In a quote from a nurse on the frontlines of the COVID crisis, “I have witnessed innumerable deaths in my career. But I’ve never watched this many, relatively young, otherwise healthy people become this sick, this quickly and die alone.
As of today, the CDC reports 12 million cases and 257,000 deaths from COVID-19. Every day we learn a little bit more about COVID-19. But still, we do not know much about COVID-19 and how it affects different populations. Let’s talk about the virus itself and how it attacks the body. We found that COVID-19 is attacking many other systems in the body, not just the lungs, although many of the symptoms are from the respiratory complications of COVID-19. Our patients end up on ventilators; they need oxygen for extended periods; they have long-term coughing and other respiratory symptoms even if they have a mild case of the disease. As the disease worsens, we need to use a high flow nasal cannula or intubation and mechanical ventilation in those patients.
However, the virus also attacks other parts of the body as well. The neuromuscular system, neurological system, and even some psychiatric long-term complications are resulting from COVID-19. Interestingly, there is also a perception of inadequate care for patients who have COVID-19. And this arises from several different factors. First is the increased acuity with more sick patients in the hospital that need higher levels of care. And that obviously, is going to make it more challenging to be able to provide a high level of care. There is decreased staff availability because we have more patients, and the acuity is higher. And because healthcare workers are getting sick, and because the relationship and communication with patients are decreased.
We communicate how we care for patients through the relationship that we build with the patient and our communication. That includes the family — not just the patient but the patient’s family. In COVID-19, we’re running into situations where we can’t have that relationship or the communication the way that we have in the past, as a result of isolation. This ends up having some adverse effects on our End Of Life discussions too. And we have more patients who are ending up dying alone, which also lends to that perception of possible inadequate care.
So what we want to do is to be able to rapidly detect problems in their early stages in our patients who have COVID-19, keeping in mind that one of the first places it’s going to attack is the lung. It’s an aerosol type of virus. The patient inhales the virus, goes down into the lung, and starts to affect right away. This virus is going to attack the lung tissue and will cause some direct alveolar damage. By damaging the alveolus, the virus will cause an inflammatory response. The inflammation starts in the lung, and we start getting some bronchoconstriction and mucus production. This leads to decreased lung compliance, the lung’s elasticity, how well the lung can move back and forth, and how elastic it is. When we have reduced lung elasticity, we will have a hard time moving air in and out. And, of course, the alveoli are being damaged, so they are not going to work as well either. We have bleeding occurring and fibrosis as a result.
As this inflammation is occurring in the lung, it is causing damage. Think about having inflammation somewhere else in your body. You get a cut on your hand, and you’re going to have some inflammation there, redness, swelling, and eventually, there’s going to be scar tissue that forms, and the scar tissue is fibrotic. That is why fibrotic tissue in the alveolus will interfere with how well the patient can have the gas exchange. There can even be long-term problems with the gas exchange because of the fibrotic tissue that is starting to build.
Two things happen as the virus starts to get into the bloodstream because the lungs are very vascular. The virus can be able to move into the bloodstream from the lung and circulate throughout the body. An overwhelming, out of control, inflammatory response is occurring and may start to travel outside of the lung as well. There is too much inflammation in the lung. The inflammatory mediators and the inflammation mechanisms move into the bloodstream and go to other parts of the body. And that is where we start to have some problems with other organ systems. Although it is difficult to pinpoint how much of the damage to organs is caused by a systemic inflammatory response and how much damage is caused by direct damage by the virus. But current thinking is that it may be both mechanisms.
There seems to be some direct damage to myocardial tissue from the virus, myocyte death, the muscle itself is dying. There also is some damage to the inside of the blood vessels. And we see some vasculitis and thrombosis occurring in our patients who have COVID-19. This can lead to ischemia injury, and then the patient can end up with cardiomyopathy, dysrhythmias, or myocardial infarction.
In addition to the lungs and the heart, we can also see symptoms in the GI tract. Although more common in children and less common in adults, a viral load can be cultured from the GI tract because of this infection. So maybe not attacking the GI system as much in adults, although we probably see more symptoms and patients who already have underlying GI disease.
In the liver and the kidneys, we see some direct destruction. Remember, these are the body’s filters, and we see some direct attacks on the liver and the kidney. Also, because the virus is attacking these organs, we will see some lymphocytic infiltration. White blood cells are going down there, they are trying to neutralize the virus, but they are getting clogged in the filter, too, because lymphocytes are large cells. We can also see some microthrombi.
If you remember, three things happen from the inflammatory process: vasodilation, capillary permeability, and clotting. Clotting will lead to the microthrombi occurring in the liver and the kidney, which further decreases our liver and kidney function. That leads to cellular degeneration. Treatments, including antivirals and steroids, add to more liver dysfunction because, of course, they are filtered out by the liver too. So that may lead to even more liver dysfunction as well.
Lastly, we could see that there will be some neurological changes: cognitive symptoms and psychiatric symptoms. We are not quite sure exactly how this is occurring. But we see it more pronounced in patients who have a severe illness. If the patient has a severe illness, that they will be on a ventilator, they’re going to be in the ICU, they’re going to have prolonged mechanical ventilation. Most of these patients are mechanically ventilated for an average of 16.5 days. That means a long time on sedation and neuromuscular blockade. Those things can lead to a post-ICU syndrome, where patients have delirium, mental confusion, and difficulty processing cognitively after they have left the ICU. Whether that’s due to post-ICU syndrome or due to some direct damage from the virus, we’re not clear on yet. Still, about 50% of our patients who have severe illnesses will end up having some kind of neuromuscular disorder as a result. About 70% will have some delirium, at least while they’re in the intensive care unit.
There is a very prolonged recovery period that happens because of COVID-19 as well. Of those patients who have a severe illness, a third cannot return to work, and another third cannot return to their previous employment level. Fully 66% of patients who have had a severe illness will not go back to the job they left before they got sick. We must implement early interventions with these patients to keep them mobilized, beginning with early passive range of motion, even while they’re unstable. Start getting them back into some strength training as soon as they can do that to avoid losing that neuromuscular ability and, hopefully, combating some of that fatigue that they have.
For more information about the nursing care of COVID patients, please see our YouTube videos on the Nursing Care of COVID Patients part one and part two.
In closing, COVID-19 attacks all the body systems and stimulates the systemic inflammatory response syndrome, leading to multiorgan dysfunction. A thorough assessment can find problems early on and prevent complications.
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