Part Three Nursing
I. Nursing Care for Patients Receiving High-Flow NasalCannula (HFNC) Oxygen Therapy
1、Assessing
Provide detailed information of the HFNC oxygen therapy to get the patient's cooperation
before implementation. Use low dose sedative with close monitoring if necessary. Choose a
proper nasal catheter based on the diameter of the patient's nasal cavity. Adjust the head
strap tightness and use decompression plaster to prevent device-related pressure injuries
on the facial skin. Maintain the water level in the humidifier chamber. Titrate the flow rate,
the fraction of inspired oxygen (FiO2), and the water temperature based on the patient's
respiratory demands and tolerance.
2、Monitoring
Report to the attending physician to seek medical decision of replacing HFNC by mechani
cal ventilation if any of the followings occur: hemodynamic instability, respiratory distress
evidenced by obvious contraction of accessory muscles, hypoxemia persists despite
oxygen therapy, deterioration of consciousness, the respiratory rate > 40 breaths per
minute continuously, significant amount of sputum.
3、Treatment of Secretions
Patients' drool, snot, and sputum should be wiped with tissue paper, be disposed in a
sealed container with chlorine-containing disinfectant (2500 mg/L). Alternatively,
secretions can be removed by oral mucus extractor or suctioning tube and be disposed in
a sputum collector with chlorine-containing disinfectant (2500 mg/L).
II. Nursing Care for Patients with Mechanical Ventilation
1、Intubation Procedures
The number of the medical staff should be limited to the minimum number that can ensure
the patient's safety. Wear powered air-purifying respirator as PPE. Before intubation,
perform administration of sufficient analgesia and sedative, and use muscle relaxant if
necessary. Closely monitor the hemodynamic response during intubation. Reduce
movement of staff in the ward, continuous purify and disinfect the room with plasma air
purification technology for 30 min after completion of intubation.
2、Analgesia, Sedation and Delirium Management
Determine the target pain management goal every day. Assess pain with every 4 hours
(Critical-Care Pain Observation Tool, CPOT), measure sedation with every 2 hours
(RASS/8I55). Titrate the infusion rate of analgesics and sedatives to achieve pain
management goals. For the known painful procedures, preemptive analgesia is admin
istered. Perform CAM-ICU delirium screening in every shift to ensure an early diagnosis
of COVID-19 patients. Apply centralization strategy for delirium prevention, including
pain relief, sedation, communication, quality sleep, and early mobilization are used.
3、Prevention of Ventilator-Associated Pneumonia (VAP)
The ventilator bundle is used to reduce VAP, which includes hand washing; raising the tilt
angle of the patient's bed by 30-45° if no contradiction is presented; oral care every 4 to
6 hours by using a disposable oral mucus extractor; maintain endotracheal tube (ETT)
cuff pressure at 30-35 cmH,O every 4 hours; enteral nutrition support and monitor
gastric residual volume every 4 hours; evaluating daily for ventilator removal; using
washable tracheal tubes for continuous subglottic suctioning combined with 10 ml
syringe suctioning every 1 to 2 hours, and adjusting the suctioning frequency according
to the actual amount of secretions. Dispose retentate below the glottis: the syringe
containing the subglottic secretions is immediately used to aspirate an appropriate
amount of chlorine-containing disinfectant (2500 mg/L), then be re-capped and
disposed of in a sharp container.
4、Sputum Suction
(1) Use a closed sputum suction system, including closed suction catheter and closed
disposable collection bag, to reduce the formation of aerosol and droplets.
(2) Collection of sputum specimen: use a closed suction catheter and a matching
collection bag to reduce exposure to droplets.
5、Disposal of Condensation from Ventilators
Use disposable ventilator tubing with dual-loop heating wire and automatic humidifier
to reduce the formation of condensation. Two nurses should cooperate to dump the
condensation promptly into a capped container with chlorine-containing disinfectant
(2500 mg/L). The container can then be directly put in a washing machine, which can be
heated up to 90 °C, for automatic cleaning and disinfection.
6、Nursing Care for the Prone Position Ventilation (PPV)
Before changing the position, secure the position of tubing and check all the joints to
reduce the risk of disconnection. Change the patient's position every 2 hours.
Ill. Daily Management and Monitoring of ECMO (Extra Corporeal
1、ECMO equipment should be managed by ECMO perfusionists and the following items
should be checked and recorded every hour: Pump flow rate/rotation speed; blood flow;
oxygen flow; oxygen concentration; ensuring that the temperature controller is flowing;
temperature setting and actual temperature; preventing clots in circuit; no pressure to the
cannulae and the circuit tubing is not kinked, or no "shaking" of ECMO tubes; patient's
urine color with special attention to red or dark brown urine; pre & post membrane pressure
as required by the doctor.
2、The following items during every shift should be monitored and recorded: Check the
depth and fixation of cannula to ensure that the ECMO circuit interfaces are firm, the water
level line of the temperature controller, the power supply of the machine and the connection of the oxygen, the cannula site for any bleeding and swelling; measure leg circumference and observe whether the lower limb on the operation side is swollen; observe lower
limbs, such as dorsalis pedis artery pulse, skin temperature, color, etc.
3、Daily monitoring: Post membrane blood gas analysis.
4、Anticoagulation management: The basic goal of ECMO anticoagulation management is
to achieve a moderate anticoagulation effect, which ensures that certain coagulation
activity under the premise of avoiding excessive activation of coagulation. That is to
maintain the balance among anticoagulation, coagulation and fibrinolysis. The patients
should be injected with heparin sodium (25-50 IU/kg) at the time of intubation and
maintained with heparin sodium (7.5-20 IU/kg/h) during the pump flow period. The
dosage of heparin sodium should be adjusted according to APTT results which should be
held between 40-60 seconds. During the anticoagulation period, the number of skin
punctures should be reduced as less as possible. Operations should be taken gently. The
status of bleeding should be observed carefully.
5、Implement the "ultra-protective lung ventilation" strategy to avoid or reduce the
occurrence of ventilator-related lung injury. It is recommended that the initial tidal
volume is< 6 ml/kg and the intensity of spontaneous breathing is retained (breathing
frequency should be between 10-20 times/min).
6、Closely observe the vital signs of patients, maintain MAP between 60-65 mmHg,
CVP < 8 mmHg, 5pO2 > 90%, and monitor the status of urine volume and blood electrolytes.
7、Transfuse through the post membrane, avoiding infusion of fat emulsion and propofol.
8、According to the monitoring records, evaluate the ECMO oxygenator function during
every shift.
IV. Nursing Care of ALSS {Artificial Liver Support System)
ALSS nursing care is mainly divided into two different periods: nursing care during treatment and
intermittent care. Nursing staff should closely observe the conditions of patients, standardize the
operating procedures, focus on key points and deal with complications timely in order to success
fully complete ALSS treatment.
1、 Nursing Care during Treatment
It refers to nursing during each stage of ALSS treatment. The overall operation process can be
summarized as follows: operator's own preparation, patient evaluation, installation,
pre-flushing, running, parameter adjustment, weaning and recording. The following are the
key points of nursing care during each stage:
(1) Operator's own preparation
Fully adhere to Level Ill or even more strict protective measures.
(2) Patient assessment
Assess the patient's basic conditions, especially allergy history, blood glucose, coagulation
function, oxygen therapy, sedation (for sober patients, pay attention to their psychological
state) and catheter function status.
(3) Installation and pre-flushing
Use consumables with closed-loop management while avoiding the exposure to patient's
blood and body fluids. The corresponding instruments, pipelines and other consumables
should be selected according to the planned treatment mode. All basic functions and
characteristics of the consumables should be familiarized.
(4) Running
It is recommended that the initial blood draw speed is s; 35 ml/min to avoid low blood
pressure which might be caused by high speed. Vital signs should be monitored as well.
(5) Parameter Adjustment
When the patient's extracorporeal circulation is stable, all treatment parameters and alarm
parameters should be adjusted according to the treatment mode. A sufficient amount of
anticoagulant is recommended in the early stage and the anticoagulant dose should be
adjusted during the maintenance period according to different treatment pressure.
(6) Weaning
Adopt "liquid gravity combined recovery method"; the recovery speed s; 35 ml/min; after
weaning, medical waste should be treated in accordance to the SARS-Cov-2 infection
prevention and control requirements and the treatment room and instruments should be
cleaned and disinfected as well.
(7) Recording
Make accurate records of the patient's vital signs, medication and treatment parameters for
ALSS and take notes on special conditions. 51
2、Intermittent Care
{1) Observation and treatment of delayed complications:
Allergic reactions, imbalance syndromes, etc.;
{2) ALSS Intubation Care:
Medical staff during each shift should observe the patient's conditions and make records;
prevent catheter-related thrombosis; carry out professional maintenance of the catheter
every 48 hours;
{3) ALSS Intubation and Extubation Care:
Vascular ultrasonography should be performed before extubation. After extubation, the
lower limb with the intubation side of patients should not be moved in 6 hours and the
patient should rest in bed for 24 hours. After extubation, the surface of the would to be
observed.
V. Continuous Renal Replacement Treatment {CRRT) Care
Preparation before CRRT
Preparation for patient: establish effective vascular access. Generally, central vein catheterization
is performed for CRRT, with the internal jugular vein preferred. A CRRT device can be integrated
into the ECMO circuit if the two are applied at the same time. Prepare equipment, consumables,
and ultrafiltration medication before CRRT.
2 In-treatment Care
(1) Vascular Access Care:
Perform professional catheter care every 24 hours for patients with central venous catheteriza
tion to properly fix access to avoid distortion and compression. When CRRT is integrated into
ECMO treatment, the sequence and the tightness of the catheter connection should be
confirmed by two nurses. Both the outflow and the inflow CRRT lines are suggested to be
connected behind the oxygenator.
(2) Closely monitor consciousness and the vital signs of patients; accurately calculate the
fluid inflow and outflow. Closely observe blood clotting within the cardiopulmonary bypass
circuit, respond effectively to any alarms, and ensure that the machine is operating properly.
Assess the electrolyte and acid-base balance in the internal environment through blood gas
analysis every 4 hours. The replacement liquid should be prepared freshly and labeled
clearly under strict sterile conditions.
3、 Postoperative Care
(1) Monitor blood routine, liver and kidney function and coagulation function.
(2) Wipe the CRRT machine every 24 hours if continuous treatment is applied. Consumables
and wasted liquid should be disposed in accordance with hospital requirements to avoid
nosocomial infection.
VI. General Care
1、Monitoring
Patient vital signs should be continuously monitored, especially changes in consciousness,
respiration rate and the oxygen saturation. Observe symptoms such as cough, sputum,
chest tightness, dyspnea, and cyanosis. Monitor arterial blood gas anlysis closely. Timely
recognition of any deterioration to adjust strategies of oxygen therapy or to take urgent
response measures. Pay attention to ventilator associated lung injury (VALi} when under
high positive end-expiratory pressure (PEEP) and high-pressure support. Closely monitor
changes in airway pressure, tidal volume and respiratory rate.
2、 Aspiration Prevention
(1) Gastric retention monitor: perform continuous post-pyloric feeding with a nutrition
pump to reduce gastroesophageal reflux. Evaluate gastric motility and gastric retention
with ultrasound if possible. Patient with normal gastric emptying are not recommended for
routine assessment;
(2) Evaluate gastric retention every 4 hours. Re-infuse the aspirate if the gastric residual
volume is< 1 oo ml; otherwise, report to the attending physician;
(3) Aspiration prevention during patient transportation: before transportation, stop nasal
feeding, aspirate the gastric residues and connect the gastric tube to a negative pressure
bag. During transportation, raise the patient's head up to 30°;
(4) Aspiration prevention during HFNC: Check the humidifier every 4 hours to avoid
excessive or insufficient humidification. Remove any water accumulated in the tubing
promptly to prevent cough and aspiration caused by the accidental entry of condensation
into the airway. Keep the position of the nasal cannula higher than the machine and tubes.
Promptly remove condensation in the system.
3、Implement strategies to prevent catheter-related bloodstream infection and catheter
related urinary tract infection.
4、Prevent pressure-induced skin injuries, including device-related pressure-induced injuries,
incontinence-associated dermatitis and medical adhesive-related skin injuries. Identify
patients at a high risk with the Risk Assessment Scale and implement preventive strategies.
5、 Assess all patients upon admission and when their clinical conditions change with the VTE
risk assessment model to identify those who are at a high risk and implement preventive
strategies. Monitor coagulation function, D-dimer levels and VTE-related clinical manifes
tations.
6、 Assist eating for patients who are weak, short of breath or those with an obvious fluc
tuating oxygenation index. Intensify oxygenation index monitoring on these patients
during meals. Provide enteral nutrition at early stages for those who are unable to eat by
mouth. During each shift, adjust the enteral nutrition rate and quantity according to the
tolerance of enteral nutrition.
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