Scenario: You are an ICU nurse caring

Scenario: You are an ICU nurse caring for a case of a severe Covid-19 patient. A working diagnosis of community-acquired pneumonia and COVID-19 suspect is made. He was started on ceftriaxone 2 g intravenously (IV) once daily (OD) and azithromycin 500 mg OD. NPS/ORS specimens were collected and sent to the RITM. On January 27, the results of a respiratory pathogen real-time PCR detection panel performed at RITM on the NPS/OPS samples were released, reporting detection of Influenza B viral RNA and Streptococcus pneumoniae DNA. The NPS/ OPS samples were sent to the VIDRL for additional testing. Oseltamivir 75 mg BID was commenced on the basis of the influenza result. During illness days 9 and 10, his fever continued with occasional non-productive cough. He remained clinically stable apart from intermittent SpO2 desaturations of 93- 97% on 2-3 L/min of oxygen. On illness day 11, he developed increasing dyspnea with reduced SpO2 at 88% despite 8 L/min of oxygen via a face mask and haemoptysis and was noted to have bilateral chest crepitations. A chest radiograph was reported as showing hazy infiltrates in both lung fields consistent with pneumonia. Meropenem 2 g IV three times a day (TDS) was commenced. On illness day 12, he became increasingly dyspnoeic, hypoxic and agitated and was intubated and sedated with a midazolam drip. An endotracheal aspirate (ETA) and a further NPS/OPS were collected and sent to the RITM. Vancomycin, 30 mg/kg loading dose followed by 25 mg/kg BD, was commenced with a working diagnosis of severe community-acquired pneumonia due to Streptococcus pneumoniae secondary to Influenza B infection, plus consideration of COVID-19 pending the ETA result. A complete blood count showed values within the normal range. On illness day 13, he continued to be febrile (38.5-40.0 °C) with bibasal crackles. Vital signs were stable with adequate urine output. A chest radiograph was reported as showing worsening of pneumonia. On illness day 14, increased crepitations in both lung fields were noted. Blood cultures showed no growth after 24 h of incubation. An HIV test was non-reactive. On this day, the RITM reported detection of SARSCoV-2 viral RNA by real-time PCR from the NPS/OPS taken on illness day 12 and hence the 2nd confirmed COVID-19 infection in the Philippines. This result was later confirmed on February 4 on the initial admission sample sent to VIDRL. On the morning of illness day 15, the patient remained febrile at 40 °C, with BP 110/70, HR 95, RR 30, SpO2 99% with 80% FiO2, and adequate urine output. However, the patient’s condition deteriorated with the formation of thick sputum and blood clots in the ET tube. Despite frequent suctioning, the patient’s condition deteriorated. He was noted to have laboured breathing followed by a cardiac arrest. Despite several rounds of cardiopulmonary resuscitation, it was not possible to revive the patient. Present day is: Day 13 Nursing Diagnosis: Ineffective Airway Clearance related to increased amount and viscocity of secretions (thick sputum and blood clots) evidenced by presence of dyspnea, changes in depth and rate of respiration, and crackles. What specific interventions would be best suited for the diagnosis and how to evaluate it?

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