COVID-19 DELTA VARIANT

____________________

A Case Analysis Presented to

the Faculty of the Nursing Department
Ms. Amie S. Perez, RN

____________________

In Partial Fulfillment of
the Requirements in NCM 218 – RLE
PRIMARY NURSING ROTATION

By
Amoroso, Tristan Jay
Europa, Edgard Laurent
Billones, Kristine Joy
Escobido, Vianah Eve
Layague, Jearielyn

Group 1 – Subgroup 1
BSN 4D

November 15, 2021

 TABLE OF CONTENTS

I. Introduction
II. Objectives
III. Pathophysiology
A. Disease Process
B. Narrative Discussion
C. Prognosis
IV. Nursing Diagnoses
V. Discharge Planning
VI. Related Nursing Theory (3)
VII. Review of Related Studies (3)
VIII. References
 I. INTRODUCTION
Primary nursing is a critical component of the global response against coronavirus
disease 2019 (COVID-19) defined as a disease caused by a novel coronavirus which is
now called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; which was
formerly called 2019-nCoV) that can be spread from person-to-person. It was first
identified amidst an outbreak of respiratory illness cases in Wuhan City, China on
December 31, 2019 which then progressed on January 30, 2020 when the World Health
Organization declared COVID-19 outbreak a global health emergency and later on March
11, 2020 when WHO then declared it as a global pandemic. This virus that caused this
pandemic is a new strain of coronavirus that has spread easily worldwide. This virus
spreads primarily through droplets of saliva or discharge from the nose of an infected
person when he/ she sneezes or coughs. Most people who are infected with COVID-19
may experience and show symptoms that can range from mild (or no symptoms) to severe
respiratory illness and recover without requiring special treatment. It has been known that
everyone is at risk of getting COVID-19 and that older adults and people with serious
underlying medical conditions like cardiovascular diseases, diabetes mellitus, chronic
respiratory diseases or cancer are more likely to develop serious diseases.
With this, Primary Nursing plays an important role in gatekeeping and clinical
responses, including recognizing and triaging potential COVID-19 cases, establishing an
early diagnosis, assisting vulnerable patients with their anxiety about the virus, and
minimizing the demand for hospital services. As cities enforced rigorous control
measures, including non-pharmaceutical therapies, and larger hospitals closed their
outpatient clinics during periods of high transmission, the role of primary nursing has
grown in importance.
In statistics, according to JHU CSSE COVID-19 Data as of October 31, 2021, there
are presently 235 million cases globally, with 211 million recovering and 4.8 million dying.
In the same source, approximately 2.78 million people had been confirmed as infected
with the COVID-19 virus in the Philippines. Of those, over 2.6 million had recovered and
around 43, 044 thousand died. According to the Department of Health, there are 103
thousand cases in the Davao area, with 48,271 patients recovering and 1579 cases dying.
In addition, according to Rappler Ph the highly contagious Delta COVID-19 variant has
been detected in all regions in the Philippines with 2,068 cases as of September 6, 2021
where 10 cases were from Davao Region.
This study on Coronavirus illness (COVID-19) is critical since we are presently
dealing with a pandemic of the disease. Conducting numerous research on this sickness
is important to our education since these studies may provide knowledge with correct
information on how to care for such patients and also educate students nurses like us, as
well as nurses and front line workers who face this virus every day. As student nurses
restricted within our four walls, we must be provided with at least the necessary
information in order to be competent in the future. In terms of nursing practice, we could
not yet utilize this on our journey since we are not yet authorized to have clinical exposure,
but with the appropriate information, we may implement the relevant nursing treatments
that may improve our patients' wellness in the near future. This study not only assists
nurses during practice and education, but it also helps researchers on a daily basis since
we are now dealing with a pandemic and it is critical to undertake research that may
benefit our front-liners as well as ourselves as student nurses.
 II. OBJECTIVES

General Objective:
That within 4 weeks of Primary Nursing Rotation, the student nurses of BSN 4D
Group 1 Subgroup 1 will be able to formulate a thorough case analysis regarding COVID-
19 Delta Variant that will enable them to absorb more knowledge, improve skills and
develop better attitude on Primary Nursing and apply learned theories and principles in
handling patients under the said concept.

Specific Objectives:
In order to achieve the general objectives, the group specifically aims to:
a. present concept and statistics of the disease, and the nursing implication of the
said topic in the introduction;
b. formulate general and specific objectives;
c. identify the precipitating and predisposing factors affecting the condition;
d. state the symptomatology;
e. trace the pathophysiology of the disease process through the schematic diagram;
f. determine the possible diagnostic or laboratory confirmatory tests for clients with
COVID-19 based on its signs and symptoms along with its rationale and clinical
significance;
g. present appropriate medical, surgical, and nursing management for the condition;
h. identify the prognosis of the disease;
i. generate a discharge plan with the use of METHOD;
j. relate chosen nursing theories to the case;
k. gather specific review of related studies of the condition;
l. formulate appropriate nursing care plans;
m. cite books, references, and internet websites that were used as a source of
information using APA format; and
n. present the student nurses‘case study through a zoom presentation
III. Pathophysiology
A. Disease Process
 B. Narrative Discussion

According to the World Health Organization (2021), coronavirus disease (COVID-

19) is a transmissible disease caused by the SARS-CoV-2 virus. The majority of those
infected with the virus will have mild to moderate respiratory problems and will recover
without the need for special treatment. When a virus replicates or duplicates itself, it often
evolves considerably, which is natural for a virus. "Mutations" are the term for these
modifications. A "variant" of the original virus is defined as a virus with one or more
additional mutations. SARS-CoV 2 virus has mutated itself into different variants and
those are the Alpha, Beta, Gamma, and Delta. The SARS CoV-2 "delta variant," also
known as B.1.617, is a coronavirus variant that played a major role in the second wave
of infections in India and since then has spread to a number of other countries, including
the United Kingdom. It's currently considered a variant of concern because it is highly
transmissible. The variant developed several mutations that allowed the virus to widely
spread from person to person. The first known mutation is the K417N which is a mutation
that reduces the virus’ sensitivity towards the antibodies, next is the E484Q mutation
which is an escape mutation because it helps the virus evade the immune system, and
lastly the L452R which indirectly affects the binding of ACE-2 receptors during the
infection (Le Page, 2021).

A person's risk of acquiring the coronavirus disease is influenced by a number of

factors and is divided into the predisposing and precipitating factors. For the predisposing
factors, first is the advanced age. Older adults are more likely to get severely ill from
COVID-19. People over the age of 65 account for more than 81% of COVID-19 deaths.
Deaths among individuals over 65 are 80 times higher than deaths among those aged 18
to 29. Next is gender, which states that men are at higher risk in acquiring the virus. Men
and women have different innate and adaptive immunological responses, which may be
related to X-chromosomal-inherited sex-specific inflammatory responses. Women's
innate and adaptive immune responses are often stronger than men's due to the high
density of immune-related genes on the X chromosome. In addition, men have greater
plasma ACE-2 levels than women, and a study conducted on patients with heart failure
found that plasma ACE-2 levels were higher in men than women, presumably suggesting
higher tissue expression of the ACE-2 receptor for SARS-CoV 2 infections (Centers for
Disease Control and Prevention, 2021).
 According to the Centers for Disease Control and Prevention (2021), Hispanics
had 1.9 times the number of cases while American Indians, non-Hispanics had 3.5 times
the number of hospitalizations. Both races have a higher mortality rate than the other
races, ranging from 2.3 to 2.4 times. Several underlying elements that affect health, like
socioeconomic status, access to health care, and workers exposed to the virus, are risk
factors for race and ethnicity. There are underlying medical conditions that make a person
at risk for COVID-19 and those are inherited blood disorders and down syndrome. There
are also medical comorbidities like existing lung problems, heart conditions, kidney
diseases, liver problems, diabetes, cancer and cerebrovascular disease. For inherited
blood disorders, there’s sickle cell anemia and thalassemia. Sickle cell anemia makes the
red blood cells deformed causing its early death, thus oxygen cannot be transported
around the body. Thalassemia on the other hand doesn't produce enough hemoglobin
and this affects how well the red blood cells can carry oxygen. Both Sickle Cell Anemia
and Thalassemia are among the most common monogenic illnesses in humans, involving
significant burden, multisystem involvement, and the need for intense life-long therapy
and follow-up, making existing symptoms worse once infected with the COVID-19 virus.
People with Down syndrome are more likely to get lung infections in general, therefore
COVID-19 puts them at a higher risk. In addition, due to congenital and associated
disorders, people with Down syndrome frequently have problems with their upper
airways, lower airways, and pulmonary vasculature (Huls et. al., 2021). People with
kidney disease, liver problems, cancer and other severe chronic medical conditions are
at higher risk for more severe illness like COVID-19 because aside from the deterioration
of their system functions, the treatments involved make their immune system weaker
(CDC, 2019). For the lung problems, it may have already established scarring,
inflammation, or lung damage that makes respiratory symptoms, once contracted, likely
to get even worse (Maragakis, 2020). Although COVID-19 most commonly affects the
lungs and airways, these organs work in tandem with the heart to supply oxygen to the
body's tissues. Maragakis (2020), stated that when the lungs are strained as a result of
illness, the heart needs to work harder, posing problems for patients who already have
heart disease. According to the American Heart Association, viral diseases like COVID-
19 can increase the risk of a heart attack in those who have plaque buildup in their blood
vessels. People with diabetes are at a higher risk of becoming seriously ill as a result of
the new coronavirus. Poor blood sugar control can make viral illnesses, such as COVID-
19, more serious, presumably because elevated blood sugar creates an environment
conducive to virus growth. Furthermore, diabetes causes inflammation and affects the
immune system, making it more difficult for people with diabetes to fight off disease in
general (Maragakis, 2020). Those are for the underlying medical conditions, and the next
factor includes poverty. To begin with, people who are economically disadvantaged are
more likely to live in an overcrowded environment, which is a potential risk for lower
respiratory tract infections. compliance with social distancing. Furthermore, financially
disadvantaged people are more likely to be employed in jobs that do not allow them to
work from home, and their work conditions and salaries are more likely to be uncertain.
These conditions that individuals like them can’t take control of increases their risk in
acquiring the virus.

Obesity is the first in line for the precipitating factors. People with obesity are more
likely to have other diseases that are independent risk factors for severe COVID-19. Fat
tissues in the abdomen push the diaphragm which impinge the lungs and restrict airflow.
In addition, immunity is also weakened because fats can infiltrate organs where immune
cells are produced making the immune system less effective in protecting the body from
pathogens (Wadman, 202). Next factor is pregnancy since it brings about a variety of
physiological changes that can make them more vulnerable to respiratory viruses hence
making them more susceptible to the severe manifestations of this virus (Sheffield, 2021).
Next is immunocompromised people which indicates that one's immune system has been
weakened by disease, treatment, or a specific surgery. It makes one more susceptible to
infection and, if infected, to a severe disease than someone with a healthy immune
system (CDC, 2021). Another risk factor would be smoking. Smoking decreases lung
function, making it more difficult for the body to fight off infections like coronavirus.
Furthermore, tobacco is a key risk factor for non-communicable diseases such as
cardiovascular disease, cancer, respiratory disease, and diabetes, putting people with
these illnesses at a higher risk of developing severe disease if they are infected with
COVID-19 (WHO, 2020). People who have substance abuse problems are at risk. to
become infected with COVID-19 and develop major complications. Long-term drug use
has been proven to have particularly negative consequences on pulmonary function,
other major organ systems, and the immune system, causing COVID-19 symptoms to
become severe (Wen et. al., 2020). Poor hygiene which is another risk factor increases
a person's vulnerability to contract COVID-19 since regular hand washing is necessary to
prevent the virus from spreading. Environmental factors also play a significant role in virus
transmission. In laboratory studies, increased solar radiation, temperature, and humidity
were found to negatively affect the COVID-19 virus's survival rate in the air and on
surfaces. Air pollution can damage lung function, making a person more susceptible to
respiratory infections (WHO, 2020). Lastly, the frontline workers like the medical
professionals who've been dealing with sick individuals for more than 8 hours a day are
at higher risk of acquiring the COVID-19 virus.

Coronavirus disease is caused by a variety of factors including those that are

mentioned above. But the main etiology as to why COVID-19 is being acquired is because
of the transmission of the SARS-CoV-2 virus. A person can acquire the disease through
direct contact via mucous membranes, some droplets are being aerosolized and become
airborne, and sometimes viral particles adhere to inanimate objects like door knobs and
jeepney handles which are termed as fomites. When a person manages to obtain the
virus through these different transmissions, the virus spreads in the body and enters the
respiratory system. The viral envelope of coronaviruses is typically made up of three
proteins that include the membrane protein (M), the envelope protein (E), and the spike
protein (S). SARS-CoV has been found to have a functional receptor, ACE-2, which is
strongly expressed on pulmonary epithelial cells. It is through this host receptor that the
S protein attaches initially to start the host cell invasion by the virus. The receptor then
brings the virus inside the cell through endocytosis and begins to invade and enter the
type 2 alveolar epithelial cells (Parasher, 2021). Once inside, the virus particles are
uncoated and its genome enters the cell’s cytoplasm. Since coronaviruses have a positive
single stranded RNA (+SSRNA) genome, they can directly produce their proteins and
new genome in the cytoplasm by attaching to the host ribosomes. The host ribosome will
translate the viral RNA to make proteins that will make RNA polymerase. The RNA
polymerase will read the +SSRNA of the virus again to make a negative RNA strand. The
negative strand will be used by the RNA polymerase again to make a positive RNA strand
as well as other small +RNA strands. These small +RNA strands will be read by the host
ribosomes again in the endoplasmic reticulum to help make the structural components of
the virus. On the other hand, after binding of SARS-CoV-2 to the ACE-2, the S protein
undergoes activation via a two-step protease cleavage and will then go on to synthesize
new proteins in the cell cytoplasm. After that, the endoplasmic reticulum will transfer these
in to the Golgi apparatus where it will be nicely packaged up with the +SSRNA formed to
form an essentially new virus. These progeny viruses are then released from the host cell
by exocytosis through secretory vesicles. While the virus is self-replicating in the alveolar
cells, it also damages it and this will initiate the inflammatory response Injured alveolar
cells release inflammatory mediators like interferons and cytokines. The inflammatory
process occurring in the lung parenchyma stimulates nerve endings responsible for
initiating cough reflex, thus dry cough is manifested and is noticed through physical
assessment. This is an early sign of COVID-19 and an increase in oral fluid intake, rest,
and promotion of infection prevention and control is one way to manage it. Hand hygiene,
encouraging to wear facemasks, and isolation for 14 days also prevents viral
transmission. (Hasudungan, 2020).

Interferons act in a paracrine manner and have numerous effects in the

surrounding cells preparing them to ward off viral infection. The primary function is to
induce protection against viruses in neighboring non-infected cells. But as inflammatory
mediators are released to ward off the virus, an excessive response from them can also
affect the cells in the surrounding systems, thus leading to systemic inflammatory
response. Aside from the systemic inflammatory response, the replication and spread of
the virus also affects the system as several systems in the body contain ACE-2 receptors
as well. The release of inflammatory mediators increases the activity of procoagulants
and decrease the natural coagulant mechanisms of the blood components which can lead
to multiple clot formation and will eventually cause disseminated intravascular
coagulation, which shows signs of shortness of breath and hypotension since blood flow
is already blocked by the clot formation. These symptoms are assessed through physical
assessment and vital signs monitoring and is managed by giving Heparin, an
anticoagulant drug or blood thinners to alleviate symptoms. Aside from the increase of
white cell count due to the cytokine storm, SARS-CoV-2 might directly attack the
lymphocytes which will eventually cause a WBC complication called lymphopenia and is
assessed through blood tests. Gastrointestinal functions are also affected causing
diarrhea which is one of the hallmark signs of COVID-19. This symptom is diagnosed
through blood tests and stool examination and is managed by increasing oral fluid intake.
Another systemic complication is the spread of infection in the pharyngeal mucosa. And
an inflammation in the pharynx causes sore throat and is managed by gargling warm
water with salt. ACE-2 receptors are found in skeletal muscles and viruses can bind with
them causing an increase in skeletal muscle damage leading to myalgia (muscle pain)
and can be managed with OTC pain relievers and rest. Interleukin-6 is a proinflammatory
cytokine which causes changes that can relate to local or systemic inflammatory
processes. A study found that the olfactory and gustatory dysfunctions had a higher score
in patients with higher levels of IL-6. Also, the patients with the association of both
disorders had even higher levels of IL-6. Because of the release of inflammatory
responses, the release of interleukin-6 is elevated, thus affecting olfactory and gustatory
function. An olfactory cell damage causes anosmia which is a loss of the sense of smell,
and nasal mucosa inflammation causes rhinorrhea. An infection in the gustatory cells on
the other hand causes ageusia which is a loss of taste function of the tongue. Olfactory
and gustatory dysfunction are assessed through physical assessment and verbalization
of the patient. However, these are only managed by treating the underlying condition
that’s causing these symptoms. And that’s for systemic inflammatory response.

Going back, the effect of inflammatory mediators causes alveolar macrophage to

detect cell injury and respond to the cytokines that are being released by injured cells.
This causes the alveolar macrophages themselves to secrete cytokines such as TNFα,
IL-1, IL-6, and IL-8 as well as other chemokines (cytokine storm). Cytokine storms cause
several reactions and one of them is the production of reactive oxygen species. As a
result of cellular response to cytokines, reactive oxygen species and proteases are
produced to destroy the source of infection. However, at the same time, it also damages
the type 1 and type 2 pneumocytes. Because of this accumulation of inflammatory
molecules, lung consolidation happens, which is manifested through productive cough
and increased in tactile fremitus which are managed by giving expectorants, increasing
fluid intake, promoting rest, and doing chest physiotherapy like breathing exercises. Lung
consolidation could increase the distance for oxygen to diffuse from alveoli to capillary.
When this happens, the process of gas exchange in the lungs slows down. The heart
compensates by increasing its workload to increase cardiac output as this action could
lead to hypoxemia. This could result in a strain on the myocardium which can result in an
arrhythmic state of the patient.
 During the release of inflammatory cytokines, TNFα and IL-1 which are
proinflammatory cytokines are released and cause an increase in expression of adhesion
molecules. This allows recruitment of more immune cells including neutrophils and
monocytes. They will bind to the adhesion proteins and enter the site of injury. On the
other hand, IL-8 which was also produced during the cytokine storm recruits more
neutrophils, and other chemokines will attract monocytes. A massive release of these will
increase vascular permeability which causes the leakage of the fluids into the interstitial
space, causing interstitial edema. Then it leaks back into the alveoli causing pulmonary
edema.

An increase in circulating macrophages and neutrophils means an increase in

white cell count. And while neutrophils are important in the acute setting by engulfing
viruses and other debris around the area, it can actually be detrimental after a while
because it releases chemicals as a by-product, damaging the surrounding tissue. And
this results in damaged alveolar cells and this means less surfactant being produced.
When you have less surfactant, this means the alveoli can easily collapse. Alveolar
collapse along with the pulmonary edema that was mentioned earlier could lead to
impaired oxygenation which can result in hypoxemia. The white blood cells and damaged
endothelial cells release other inflammatory mediators including leukotrienes and
prostaglandins which are being released through the signal of the hypothalamus to
stimulate elevation of temperature causing fever, a body’s response to inflammation.
Fever can be managed by giving a tepid sponge bath and administration of antipyretics.
Leukotrienes will cause bronchoconstriction, impairing ventilation. This impairment in
ventilation, along with the increased distance for oxygen to diffuse from alveoli to capillary
and impaired oxygenation will lead to a decrease in oxygen in the blood resulting in
hypoxemia. Hypoxemia manifests shortness of breath and hyperventilation to
compensate for the loss of oxygen in the body which will eventually result in respiratory
alkalosis. This is managed by giving supplemental oxygen, proper positioning to
maximize inhalation and teaching patients to perform proper breathing exercises
(Hasudungan, 2020).

Decreased oxygen levels in the blood will stimulate chemoreceptors in the aortic
arch, the carotids, as well as in the brain. Stimulated chemoreceptors will then stimulate
cardiopulmonary centers in the brain to tell the lungs to breathe more in order to increase
oxygen levels in the blood and also tell the heart to pump faster to deliver oxygen to the
body. And that is why patients who have hypoxemia are usually tachypneic as well as
tachycardia. On the other note, people can be infected by the virus and still remain
asymptomatic because their immune system keeps it in check or they can develop only
minor symptoms such as cough and a bit of shortness of breath and mild fever
(Hasudungan, 2020).

In summary, an injured lung, fluid accumulation in the lungs, V/Q mismatch, and
hypoxemia that’s not related to any cardiac function is what is called acute respiratory
distress syndrome (ARDS) and is the leading cause of mortality in COVID-19.

If these conditions are not managed and have successfully progressed to ARDS,
these will affect other internal organs since there’s already a decreased oxygen level
flowing in the blood. For the kidneys, this will cause a decrease in glomerular filtration
rate and a decreased active secretory rate of the nephrons leading to kidney failure which
also increases the risk in developing heart disease. For the liver, this will cause liver
derangement which increases inflammatory enzymes released by the liver which can be
seen in laboratory examinations indicating liver failure. A decreased oxygen flow in the
heart causes the heart to overwork to compensate for the lack of oxygen, and because
of the coagulation due to the decreased anticoagulant activity, this will lead to heart
complications such as myocardial infarction and cardiomyopathy. To maintain cerebral
function, the brain tries to compensate by maintaining the ratio of blood oxygen that a
tissue takes from the blood flow but this just results in another cytokine storm. These
could result in brain ischemia which is the lack of oxygen flow in the brain, necrotizing
hemorrhagic encephalopathy, and acute flaccid paralysis. When all of these systems’
functions deteriorate, a multi organ failure happens. Medical experts have said multiple
organ failure is potentially reversible with early intervention if no more than two organs
are affected. However, a delay in intervention leads to irreversible damage of the organs
simultaneously, leading to death – an implication, that survival rate in general, when left
unmanaged, is low (Adejoro, 2020).

When COVID-19 is managed and intervened before it reaches its complicated

stage, which is the ARDS, the chance of full recovery and survival rate is high. According
to the World Health Organization, as of the 4th of November 2021, 227 million cases of
COVID-19 had recovered over a total of 251 million cases worldwide and 2.74 million
cases had recovered over a total of 2.81 million cases in the Philippines. The primary
intervention of preventing the spread and aggravation of the disease is the infection
prevention and control. The need to also strengthen the immune system is necessary as
this is the one who fights and tries to compensate for the body’s difficulty to function
properly. Increased oral fluid intake and adequate rest is also necessary in the early
stages of the disease. And lastly, in order to prevent people from acquiring the disease,
especially those that already have special conditions that increase their risk to be infected,
wearing of face masks, proper hand washing or using of alcohol, and maintenance of
overall hygiene is necessary. Given that this is a highly transmissible disease, being
complacent would put a person at a much higher risk than having those mentioned risk
factors above.
 C. PROGNOSIS

The Delta is currently the predominant variant of the covid virus in the United
States. On July 27, 2021, CDC released updated guidance on the need for urgently
increasing COVID-19 vaccination coverage and a recommendation for everyone in areas
of substantial or high transmission to wear a mask in public indoor places, even if they
are fully vaccinated. CDC issued this new guidance due to several concerning
developments and newly emerging data signals.
The delta variant is concerning because it's more highly transmissible, a significant
increase in new cases reversed what had been a steady decline since January 2021. In
the days leading up to the guidance update, CDC saw a rapid and alarming rise in the
COVID-19 case and hospitalization rates. New data began to emerge that the Delta
variant was more infectious and was leading to increased transmissibility when compared
with other variants, even in some vaccinated individuals.
The prognosis of this disease, just like the first variant, is either fair or bad as it
depends on the health status of the patient prior to infection. In terms of recovery, some
patients may recover without any special treatment that may lead to fair prognosis but for
elderly and patients with underlying medical problems, they are more likely to develop
serious illnesses or second infections that may lead to poor prognosis. The good news is
that the COVID-19 vaccine is still highly protective against getting infected or ending up
in a hospital or dying from the infection.
 IV. NURSING DIAGNOSIS
CLUSTERING OF CUES: COVID 19
Name of Patient:F.O.G. Age/Sex: 47/Male Room and Bed #: 302
Physician: Dr. Elliot Diagnosis: COVID-19

Health Nutritional/ Elimination Activity/ Exercise Cognitive/ Sleep/ Self- Role/ Sexual/ Coping/ Value-
Perception/ Metabolic Perceptual Rest perception Relationship Reproductive Stress Belief
Health / Self- Toleranc
Management concept e

Complete ● Vital signs: ● Persistent fever ● “Nibaba kog

blood count: BP: 88/55 ● Body malaise barko… tapos
● WBC: mmHg ● Myalgia/muscle pagka tulo ka
12,000/mm PR: 115 bpm (N: weakness on all adlaw, nigawas ning
3 (normal: 60 – 100 bpm) extremities mga sintomas.
4,000- CR: 119 bpm (N: ● Shortness of Nibalik ko duha ka
10,000/mm 60 – 100 bpm) breath adlaw human sa
3) RR: 26 cpm (N: ● (+) Nasal flaring akong initial check-
● 67% 16 – 20 cpm) ● (+) Use of up kay nigrabe
neutrophils Temp: 39.9C (N: accessory akong kondisyon”
(PMNs) 36.1- 37.5C) muscles prior to ● “Maglisod jud ko’g
● 25% SpO2: 85% on intubation ginhawa ma’am”
lymphocyte room air ● Abnormal ● “Maglisod kog
s breathing pagawas sa akong
● 5 ● “Taas gihapon pattern plema ug mo ubo,
monocytes ● Difficulty of unya usahay gina-
akong
● Hgb/Hct: breathing pugngan nalang
normal kalintura” as ● Rapid shallow nako kay sakit sa
breathing (prior dughan”, as
verbalized by
Inflammatory to intubation verbalized prior to
markers: the patient ● Auscultation on intubation.
● C-reactive the lung fields: GCS: 10-Intubated
● Skin warm to
protein: bilateral rales (E4, V[NT], M6)
4.7mg/L touch ● Hooked to
(normal < cardiac
 3mg/L) ● Flushed skin monitor: Sinus
● LDH: 360 tachycardia
● Weak in
U/L noted
(normal: appearance ● Given 1 amp
140-280 diazepam via IV
● Muscle aches
U/L) prior to
● DizzinessRest intubation;
Organ Lethargic
less and
function: ● Hooked to
● BUN: 24 Irritable mechanical
mg/L ventilator on AC
● Dry mucous
(normal: 7- mode
20 mg/L) membrane ● Mech Vent
● Creatine: Settings:
● Loss of
1.4 mg/L FIO2:60%, TV:
(normal appetite 400 PF, PEEP:
0.5-11 5 cmH2O, Set
mg/dl) Respirations: 16
● AST/ALT: breaths/min
85/79 U/L
(normal:
10-40 U/L)
● Troponin:
0.5 ng/mL
(normal: 0-
0.4 ng/mL)

Arterial blood
gas
● pH: 7.47
(high) (N:
7.35 –
7.45)
● PaO2: 55
mmHg
(low) (N: 80
 – 100
mmHg)
● PaCO2: 32
mmHg
(alkaline)
(N: 35 – 45
mmHg)
● HCO3: 25
mmHG (N:
22 -26

● Chest CT
scan
results:
bilateral
nodules,
peripheral
ground-
glass
opacities
(bilateral).
mild
intralobular
septal
thickening
● Chest
assessmen
t results:
diffuse fine
crackles,
fair air
entry,
increased
work of
breathing
● (+) SARS-
 CoV2
nucleic acid
amplificatio
n (NAA)
assay
Chest x-ray:
bilateral
Ground-glass
opacities on
the lung fields
with
predominance
of the lower
lung lobes
V. DISCHARGE PLANNING

HEALTH TEACHINGS RATIONALE

1. Educate the patient 1. To avoid contracting

MEDICATION
how to take nutritional the condition repeatedly
supplements and
2. To offer information
vitamins
on the correct dosage of
2. Educate the patient supplements and
how to take drugs medications.
properly.

3. Encourage the
3. To prevent
patient to take his or
alterations in time.
her medication on
schedule.

4. Supply oxygen 4. To comfort difficulty in

breathing.
 1. Allow the patient to 1. To be able to exercise
EXERCISE
move on his or her independence in one's daily
own. activities.

2. Motivate the patient 2. Patients with good

to take a break and balance benefit from
relax. adequate rest.

3. Teach the patient to 3. As a result, anytime

practice breathing the patient experiences
exercises. difficulty breathing, the
patient will know how to
relax.

4. Explain to the
4. By avoiding going to
patient that instead of
the gym, patients have
going outside, he/she
less contact with the
can do simple
outer community.
exercises at home.
5. Meditation helps improve
5. Do meditation
proper breathing.
 1. Place self in 1. Isolation aids in
Isolation minimizing contact with
other people, ensuring that
TREATMENT
the infected person does
not infect others.

2. Vitamin C helps in
2. Consume Vitamin C
protecting the immune
system.

3. Take treatment to help 3. Common signs like that

with the alleviation of
symptoms of the disease.
such as fever, cough,
colds, and difficulty
breathing may also be
present. In addition, the
patient should take
treatments for it.

1. Wash hands as 1. Handwashing

HYGIENE
much as possible minimizes the spread of
the virus

2. Alcohol is an easy
2. Bring alcohol when
way of disinfecting
planning to go out
hands.

3. Disinfect furniture more

3. To prevent viruses and
often
other microorganisms from
sticking on surface areas.
 1. Follow with the 14 1. To prevent
OUTPATIENT
days quarantine transmission of the
virus.

2. To avoid direct
2. Wear face mask
contact with other
and face shield as
people.
much as possible

3. To keep from coming

3. Social distance from
into intimate contact with
others
other people

1. Increase fluid 1. To prevent

DIET
intake, preferably water dehydration

2. Avoid from skipping 2. To prevent

meals becoming unhealthy
and keeping the
immune system strong.

3. Eat vegetables
3.Vegetables help to boost
immunity.
VI. RELATED NURSING THEORY

Florence Nightingale’s Environmental Theory

The Environmental Theory was developed by Florence Nightingale in the year

1859. In this theory, Nightingale believed that cleanliness of the environment is essential
to promote healing and general wellbeing of the patient. Consequently, unsanitary
environments have an impact on the health of those who live in such environment. This
is due to the presence of pathogens, pests, and germs in the environment, which cause
a variety of illnesses. She also identified key environmental factors that determine health
of the individuals in any environment, namely: ventilation, light, cleanliness, noise, variety,
warmth, and food. According to Nightingale, if any of these factors is not suitable, those
who live in that environment are more likely to become ill. The theory is based on four
interconnected concepts, namely: 1) person, which is considered the patient affected by
the surrounding; 2) environment, which includes everything in the surrounding either
social, physical, or psychological; 3) health, which is the state of well-being and is
maintained when the environment is in control and; 4) nursing, which is needed to ensure
that environmental health determinants are in the right state.

Nurses and nursing practice, as Nightingale saw them, were an integral part of
daily hospital life, as they are today. Patient well being always came first, and, as a by-
product, was closely followed by cleanliness and good sanitary practices. Nurses and
other healthcare workers today are responsible for the health and safety of their patients,
their colleagues and themselves, suggesting that basic infection control is the
responsibility of all, including individuals at the community level. Nosocomial infections
and community-acquired infections, which unfortunately are still active today, primarily
come from people themselves, often due to a lack of adherence to basic hand hygiene.
Simple tasks like hand hygiene have the potential to protect patients, visitors and
healthcare workers particularly during the current COVID-19 pandemic. Hence,
Nightingale’s concept of environmental control and basic infection control techniques,
including hand washing, wound care, quarantine and isolation have become an integral
part of the nursing practice.

Dorothea E. Orem’s Self-Care Deficit Nursing Theory

The Self-Care Deficit Nursing Theory's primary premise is that all patients intend to take
care of themselves, and that by doing so as much as they are able to, they can recover
more quickly and holistically. This theory is especially useful in rehabilitation and primary
care settings, as well as other settings where patients are encouraged to be self-sufficient.
Dorothea Orem categorizes the self-care requisites into three categories. The first are
universal self-care requisites, which are needs that everyone requires (such as air, water,
food, activity and rest, and hazard prevention). The second category is developmental
self-care requisites, which are divided into two sub-categories: maturational and
situational. Maturational requires the patient to grow to a higher degree of maturity, and
situational which enables the patient to prevent detrimental effects in development. The
third and last category is health deviation requisites, these are needs that arise as a
byproduct of the patient's condition. Thus, a "self-care deficit" develops when a patient is
unable to meet their self-care requisites. In this instance, the patient's nurse provides a
support modality in the form of total compensation, partial compensation, or education
and support. In the case of the Covid-19 pandemic, the nurse, based on nursing systems,
provides health education for virus prevention (such as proper hand-hygiene, eating
healthier meal options, exercise, and self-protection such as wearing of masks), and high-
complexity assistance when Covid-19 worsens (such as care modalities involving
tracheostomy). Furthermore, in light of Orem's theory's assumptions and conceptual
models, the role of a care agent as a person who contributes to maintaining the needs of
those who are at risk and is oriented to maintain social distancing and/or home isolation
is strongly recommended to reduce COVID-19 spread. The importance of taking care of
oneself and others is emphasized in the current management of disease spread,
corroborating collective care.

Sr. Callista Roy’s Adaptation Model Of Nursing

Sister Callista Roy defined adaptation as the process and outcome of individuals and
groups who use conscious awareness, self-reflection, and choice to create human and
environmental integration, as they positively respond to environmental changes. Roy's
Adaptation Model's key concepts are composed of four components: person, health,
environment, and nursing. A person, according to Roy's model, is a bio-psycho-social
being in constant interaction with an ever-changing environment (such as the measures
each person takes for prevention of disease acquisition or the failure to do so such as in
dealing with the Covid-19 virus and the pandemic as a whole). And to adapt, he or she
employs both innate (such as one's ability to think and act on situations) and acquired
mechanisms (such as learned health teachings through health education). Furthermore,
as stated in the Adaptation Model, health is an inevitable element of a person’s life,
represented by a health-illness continuum, and as a state and process of being and
becoming integrated and whole (in this case, the process begins during the presentation
of Covid-19 symptoms, then the isolation and in-hospital care period, and up to the
discharge period, or post-mortem care to those who have severe Covid-19) . Moreover,
the environment is divided into three parts: focal, which is internal or external and directly
confronts the person; contextual, which is all stimuli present in the situation that all
contribute to the effect of the focal stimulus; and residual, whose effects in the current
situation are unclear. All conditions, circumstances, and influences surrounding and
influencing the development and behavior of individuals and groups, with a focus on
mutuality of persons, including focal, contextual, and residual stimuli. In accordance with
Roy’s theory, Covid-19 symptoms are perceived as focal stimuli, related comorbidities as
contextual stimuli, and work stress due to high viral transmission and lack of protective
equipment, as residual stimuli. Lastly, the goal of nursing is to promote adaptation in the
four adaptive modes, thereby contributing to health, quality of life, and dying with dignity
by assessing behaviors and factors that influence adaptive abilities and intervening to
improve environmental interactions like those found in Covid-19 cases.
VII. REVIEW OF RELATED STUDIES

COVID-19 pandemic—a focused review for clinicians

The COVID-19 pandemic caused by SARS-CoV-2 was first reported December

30, 2019, from Wuhan, China. Since then, COVID-19 has been declared a pandemic,
affecting nearly every country, with over 2.3 million confirmed cases and >160 000
deaths. Data also suggests that its death rates are greater in those over the age of 60
and in those who already have comorbid diseases. As COVID-19 continues to be a
significant issue for global health, economics, and society, Cevik, Bamford, and Ho (2020)
conducted a review to provide clinicians with an update on recent developments in
virology, diagnostics, clinical presentation, viral shedding, and treatment options for
COVID-19 based on current literature. With the data presented in the study, it was
concluded that the main challenge in managing COVID-19 remains to be the patient
density; however, accurate diagnoses as well as early identification and management of
high-risk severe cases remains a daily battle for many clinicians. For improved
management of cases, the study emphasized the need to understand test probability of
serology, qRT-PCR and radiological testing, and the efficacy of available treatment
options that could be used in severe cases with high risk of mortality.

Modeling the Onset of Symptoms of COVID-19

COVID-19 is a pandemic viral illness with catastrophic worldwide consequences,

in which infected people are highly infectious and may spread the disease three times
more than influenza. As a result, Larsen et al. (2020) did a research in which they
compared the progression of symptoms in COVID-19 to other respiratory infections such
as influenza, SARS, and MERS to see if the diseases presented differently. Also,
identifying the sequence of symptom manifestation may aid patients and medical
providers in distinguishing COVID-19 from other respiratory diseases. The study
revealed, using the Stochastic Progression Model, that influenza begins with cough, while
COVID-19, like other coronavirus-related diseases, begins with fever. COVID-19, on the
other hand, varies from SARS and MERS in the sequence of gastrointestinal symptoms.
The study's findings support the idea that fever should be used to screen for entry into
any facility. Furthermore, the findings suggest that good clinical practice in COVID-19 and
other diseases should include recording the order of symptom occurrence.

Tracheal Intubation in Critically Ill Patients with Covid-19

In December 2019, the infectious disease Coronavirus Disease 2019 (COVID-19)

originated from the strain of the novel coronavirus (SARS-CoV-2) which appeared earliest
in the Hubei rural area of China, Wuhan. Over the course of two months, it raced
throughout the country making most infected patients exhibit mild symptoms like fatigue,
cough, fever, and these can go worse and result in acute respiratory distress syndrome,
septic shock, metabolic acidosis, and coagulopathy in critical cases. It has been studied
that the said virus can infect and progress via droplets, contact, and natural aerosols from
human to human. Thus, anesthesiologists may be put at high-risk nosocomial infections
due to aerosol-producing procedures such like endotracheal intubation. Moreover, cases
of SARS-CoV-2 infection in anesthesiologists after endotracheal intubation for infected
patients has been reported in some health facilities in Wuhan. To elucidate, the Chinese
Society of Anaesthesiology’s expert panel has plotted and discussed a recommendation
that promotes the stimulation of endotracheal intubation by anesthesiologists and critical
care physicians. In the process of airway management, an improved droplet/airborne
personal protective equipment (PPE) is highly and strictly recommended to the healthcare
workers. Furthermore, before airway intervention, a good airway assessment should be
done as to vital importance. Patients with stable airways, modified rapid sequence
induction is highly advised as to avoid awake intubation. Before intubation, a good muscle
relaxant should be prepared. And as for patients with a complicated airway, it is
recommended to prepare detailed intubation plans and a fine preparation of airway
devices.
Inhalational Anesthetic Drugs as Sedation for Ventilated COVID-19 Patients

The majority of COVID-19 patients have mild to moderate respiratory symptoms;

however, some develop severe pneumonia, and hypoxemia and are regarded as
common causes of death. COVID-19 patients who are critically ill frequently require
endotracheal intubation and mechanical ventilation. The drugs used to sedate these
patients vary widely depending on drug availability and clinical expertise. For the following
reasons, it is suggested that care providers with the necessary clinical expertise consider
the use of inhalational anesthetic drugs such as sevoflurane and isoflurane. Intensivists
and anesthesiologists are working together to treat the seriously ill COVID-19 patients. It
is reported that ventilated COVID-19 patients frequently require high doses of intravenous
sedative drugs such as propofol, midazolam, ketamine, and dexmedetomidine. Not
surprisingly, there is a growing scarcity of these medications. Moreover, studies of
patients with severe lung injury incurred by causes other than COVID-19 have shown that
inhalational anesthetic drugs improve oxygenation and reduce mortality when compared
with propofol or midazolam. The gravity of lung injury in COVID-19 patients is related to
cytokine levels and viral load. Furthermore, convincing preclinical data from studies show
that inhalational anesthetic drugs reduce lung inflammation and dilate airways. Such
effects are mediated by γ-aminobutyric acid type A (GABAA) receptors, which are found
in various types of lung cells. GABAA receptor stimulation in lung epithelial cells reduces
the production of proinflammatory cytokines; whereas GABAA receptor stimulation in
airway smooth muscle cells stimulates bronchodilation and improves oxygenation.

Anesthesia Nurses in the Treatment and Management of Patients With COVID-19

Nurses have been playing critical roles in cabin hospitals, isolation wards, and
intensive care units for critical cases as the backbone for the treatment of patients with
coronavirus disease 2019 (COVID-19). Airway management, the use and maintenance
of life support equipment, including ventilators, and the use of high-flow oxygen
equipment are all professional specialties of anesthesia nurses. Anesthesia nurses, along
with emergency nurses and critical care nurses, play critical roles in the treatment of
COVID-19 patients considering that they have extensive experience in emergency
response and nursing. However, anesthesia nurses, as with most nurses in noninfectious
disease departments, lack experience in the prevention and control of infectious
diseases. Also, anesthesia nurses routinely work in operating rooms and, as a result, may
lack experience in regular ward nursing procedures and patient communication, which
are some shortcomings. Therefore, anesthesia nurses require further training in these
aspects in order for them to be more effectively involved in the plight for the management
of patients with Covid-19.
VIII. REFERENCES

Adejoro, L. (2020, July 5). Survival rate for multiple organ failure is low -experts.
Healthwise. Retrieved November 14, 2021, from
https://healthwise.punchng.com/survival-rate-for-multiple-organ-failure-is-low-
experts/.

Cazzolla, A. P., Lovero, R., Lo Muzio, L., Testa, N. F., Schirinzi , A., Palmieri, G.,
Pozzessere, P., Procacci, V., Di Comite, M., Ciavarella, D., Pepe , M., De Ruvo,
C., Crincoli, V., &amp; Di Serio, F. (2020, August 4). Taste and smell disorders in
COVID-19 patients: Role of interleukin-6. ACS Publications. Retrieved November
14, 2021, from https://pubs.acs.org/doi/10.1021/acschemneuro.0c00447.

Centers for Disease Control and Prevention. (2021, October 4). SARS-COV-2 variant
classifications and definitions. Centers for Disease Control and Prevention.
Retrieved November 14, 2021, from https://www.cdc.gov/coronavirus/2019-
ncov/variants/variant-info.html#Concern.

Centers for Disease Control and Prevention. (n.d.). Delta variant: What we know about
the science. Centers for Disease Control and Prevention. Retrieved November
10, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/variants/delta-
variant.html?

Cevik, M., Bamford, C. G. G., & Ho, A. (2020). COVID-19 pandemic—a focused review
for clinicians. Clinical Microbiology and Infection, 26(7), 842–847.
https://doi.org/10.1016/j.cmi.2020.04.023
Elflein, J. (2021). SARS-COV-2 delta variant cases worldwide 2021. Statista. Retrieved

Henkin, R. I. (2013, July 1). Interleukin 6 in hyposmia. JAMA Otolaryngology–Head &amp;

Neck Surgery. Retrieved November 14, 2021, from
https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/1714702.

Huls, A., et. al. (2021). Medical vulnerability of individuals with down syndrome to severe
covid-19. Retrieved on September 4, 2021 from
https://doi.org/10.1016/j.eclinm.2021.100769
Katella, K. (2021, November 3). 5 things to know about the Delta variant. Yale Medicine.
Retrieved November 14, 2021, from https://www.yalemedicine.org/news/5-things-
to-know-delta-variant-covid.

Larsen, J. R., Martin, M. R., Martin, J. D., Kuhn, P., & Hicks, J. B. (2020). Modeling the
Onset of Symptoms of COVID-19. Frontiers in Public Health, 8.
https://doi.org/10.3389/fpubh.2020.00473

Le Page, M. (2021, November 9). Delta covid-19 variant (b.1.617). New Scientist.
Retrieved November 11, 2021, from
https://www.newscientist.com/definition/indian-covid-19-variant-b-1-617/.

Maragakis, L. (2020). Coronavirus and covid-19: who is at higher risk. Retrieved on

September 4, 2021 from https://www.hopkinsmedicine.org/health/conditions-
anddiseases/coronavirus/coronavirus-and-covid19-who-is-at-higher-risk

Marshall, W. F. (2020, August 13). Why is covid-19 more severely affecting people of
color? Mayo Clinic. Retrieved November 14, 2021, from
https://www.mayoclinic.org/diseases-conditions/coronavirus/expert-
answers/coronavirus-infection-by-race/faq-20488802.

Mayo Clinic. (2021). Covid-19: who‘s at higher risk of serious symptoms. Retrieved on
September 4, 2021 from https://www.mayoclinic.org/diseases-
conditions/coronavirus/indepth/coronavirus-who-is-at-risk/art-20483301
N. A. (2021). Primary care Covid-19 - WPRO Iris. Retrieved October 31, 2021, from
https://iris.wpro.who.int/bitstream/handle/10665.1/14510/Primary-care-COVID-
19-eng.pdf.
N. A. (2021). Updates on Novel Coronavirus Disease (COVID-19). Department of Health
Website. Retrieved October 31, 2021, from https://doh.gov.ph/2019-nCoV.

National Center for Chronic Disease Prevention and Health Promotion. (2020, July 16).
Men and covid-19: A biopsychosocial approach to understanding sex differences
in mortality and recommendations for practice and policy interventions. Centers for
Disease Control and Prevention. Retrieved November 14, 2021,
fromhttps://www.cdc.gov/pcd/issues/2020/20_0247.htm.
National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral
Diseases. (2021, October 14). People with certain medical conditions. Centers for
Disease Control and Prevention. Retrieved November 14, 2021, from
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-
medical-conditions.html.

National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral
Diseases. (2021, September 9). Risk for COVID-19 infection, hospitalization, and
death by Race/Ethnicity. Centers for Disease Control and Prevention. Retrieved
November 14, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/covid-
data/investigations-discovery/hospitalization-death-by-race-ethnicity.html.

National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral
Diseases. (2021, October 14). People with certain medical conditions. Centers for
Disease Control and Prevention. Retrieved November 15, 2021, from
https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-
medical-conditions.html.

National Kidney Foundation Inc. (2021, October 20). Covid-19: Kidney disease. National
Kidney Foundation. Retrieved November 14, 2021, from
https://www.kidney.org/coronavirus/kidney-disease-covid-19.
October 31, 2021, from https://www.statista.com/statistics/1245971/number-delta-
variant-worldwide-by-country/.

Parasher, A. (2021, May 1). Covid-19: Current understanding of its pathophysiology,

clinical presentation and treatment. Postgraduate Medical Journal. Retrieved
November 14, 2021, from https://pmj.bmj.com/content/97/1147/312.

Pascarella, S., Ciccozz, M., Zella, D., Bianchi, M., Benedetti, F., Benvenuto, D., Broccolo,
F., Cauda, R., Caruso, A., Angelett, S., Giovanetti, M., &amp; Cassone, A. (2021,
July 8). SARS‐ COV‐ 2 b.1.617 Indian variants ... - binasss.sa.cr. Retrieved
November 14, 2021, from https://www.binasss.sa.cr/covidago/3.pdf.

Public Health. (2020). Poverty, inequality and covid-19: the forgotten vulnerable.
Retrieved on September 4, 2021 from doi: 10.1016/j.puhe.2020.05.006
Sheffield, J. (2021). Coronavirus and pregnancy: what you should know. Retrieved on
September 4, 2021 from https://www.hopkinsmedicine.org/health/conditions-
anddiseases/coronavirus/coronavirus-and-covid-19-what-pregnant-womenneed-
to-know

Wadman, M. (2020). Why covid-19 is more deadly in people with obesity - even if they‘re
young. Retrieved on September 4, 2021 from
https://www.science.org/news/2020/09/why-covid-19-more-deadly-peopleobesity-
even-if-theyre-young

Wen, H., Barnett, M., & Saloner, B. (2020). Clinical risk factors for covid-19 among people
with substance use disorder. Retrieved on September 4, 2021 from
https://doi.org/10.1176/appi.ps.202000215

World Health Organization. (2020). Who statement: tobacco use and covid-19. Retrieved
on September 4, 2021 from https://www.who.int/news/item/11- 05-2020-who-
statement-tobacco-use-and-covid-19

Yaghi S., Ishida K., Torres J., et al. (2020). SARS2-CoV-2 and stroke in a New York
healthcare system. Stroke;51(7):2002–11.