Republic of the Philippines

Mindanao State University - College of Health Sciences

Marawi City

A Case study about

PEDIA WITH VARIANTS 19 INFECTION
Presented to
Prof. Julius M. Mirafuentes, RN,LPT,MN,MAN,EdD,PhDN

In Partial Fulfillment of the Requirements for

NSG 124.6 Pedia Ward Duty

Presented by:
Section D

ABDULBASHER, Norhidaya GUBATEN, Sittie Mariam

ABDURAJA, Hamsida GURO, Alaynah
ADAP, Sahanie IBRAHIM, Junaid
AKIATAN, Tricia Mae IMAM, Sittie Nashra
ALAG, Yasrien ISMAEL, Mohammad Ya’ser
ALI, Aleah Salivia LOMUNDAYA, Ayobkhan
ALIMODEN, Basima LUCMAN, Amal-Jahedah
AMPA, Mofedah TUMAROMPONG, Samsia
DATU-DACULA, Zuhriyah

May 29, 2021

 Introduction

The large outbreak of COVID-19 disease started in Wuhan, China. It has now spread

with many countries worldwide. COVID-19 has developed into a serious public health problem

since the year 2019 throughout the world and has become a major pandemic. Despite the

increase in the number of outlets to inform, educate, promote prevention, and increase public

awareness about this variants, there are still many who continue to become infected, battle with,

and die from this disease. According to WHO, globally, as of May 28, 2021, there have 168, 599,

045 confirmed cases of COVID-19, including 3,507,477 deaths. As of May 20, over 3.94 million

children have tested positive for COVID-19 since the onset of the pandemic.

The department of Health confirmed the first COVID-19 case in the Philippines on

January 30, 2020, followed by a report of first casualty on February 2. As the number of cases

continued to rise and threat if the disease became more imminent, the government declared on

March 8, 2020 a state of national health emergency throughout the country. A 7 years old girl

was the first paediatric patient died who died from coronavirus disease.

World Vision immediately started providing information, prevention, and control

messages to communities, in coordination with local governments unit. The organization

launched its COVID-19 emergency response and supported frontliners and health facilities with

protective equipments, isolation tents, and disinfectant kits. Roughly ten weeks after declaration

state of health emergency, World Vision conducted a rapid assessment aimed at providing

broader picture of the impact of COVID-19 to children, their families and communities in the

country and to identify needs and gaps that would require humanitarian support. (World

[Link])
 Children of all ages can become ill with coronavirus disease, but most kids who are

infected typically don’t become as sick as adults and some might not show any symptoms at all.

Most children infected with the disease have mild symptoms or no symptoms. However, some

children become severely ill with COVID-19 might need to be hospitalized, treated in the

intensive care unit or placed on a ventilator to help them breath. In addition, children with

underlying conditions, such as obesity, respiratory problems, congenital heart disease, genetic

conditions or conditions affecting the nervous system or metabolism are in higher risk of serious

illness with COVID-19.

Children reacts differently to COVID-19 because there are other coronaviruses that

spread in the community and cause diseases such as common colds. Since children often get

colds, there immune system might be primed to provide them with some protection against

COVID-19. It is also possible that children’s immune systems interact with the virus differently

than do adults’ immune system. On the other hand, babies under age 1 might be at higher risk of

severe illness with COVID-19 than older children. This likely due to their immature immune

systems, smaller airways, which make them more likely to develop breathing issues with

respiratory virus infections.

In this study, the students are going to study about the paediatric patient previously

healthy 3 years old female with no significant past medical history prior to several admissions to

the emergency department for worsening pancytopenia, decreased appetite, and abdominal pain.

The patient is known to be asymptomatic.

 Purpose and Objective

The results of the case study will redound the benefit of the society, especially on pediatric

health management, considering that COVID-19 plays a vital role on health issues of today’s

time. The greater demand for information of COVID-19 justifies the need for effective and life-

changing lifestyle approach. The purpose of the study is to identify the issue that is weighing up

to this current situation. It will specifically address the need of the children with COVID-19

positive.

The study aims to identify and determine general viral health problem and appropriately address

the need of the pediatric patient with a diagnosis of COVID-19 positive. This study also intends

to help promote health and medical understanding on such condition throughout the application

of nursing skills to pediatrics. The following are the specifics for the objective:

 To enhance knowledge and acquire more information about pediatric COVID patients.

 To provide ideas of how to render proper nursing care for clients with this condition.

 To gather the needed data that can help understand the nature of the condition.

 To identify clinical manifestation or findings of the condition and to provide prompt

intervention.
 Significance of the Study

This research study will be vulnerable to the succeeding research health care officials and

students who will take in-depth study about variant 19 infections in relation to children. This will

serve as their reference material throughout their research. This study will be helpful also to

those who seek knowledge about variant 19, for firmer faith.

This study express the understanding and the significance of variant 19 infections in this

new normal lifestyle so that everyone will know how this is in living.

This study is significance to the following:

Medical student

The study may serve as a guide and reference to the medical student who are acquiring

knowledge and understanding related studies.

Physician and Health Care Provides

This study will help them determine the etiology and the treatment of the virus.

Researchers, Health Care officials & Scientist

This study will help to understand how these affects the virus behavior to children

including their impact on the effectiveness of vaccines, if any

Authority

This study is useful for the parents or someone older to protect and give care to the children from

virus.
 Scope and Limitation

This case study focuses on the medical and nursing management for an effective care to

the condition of 3 year old female pediatric patient who had several admissions to the emergency

department (ED) regarding to her past medical history for deteriorating pancytopenia, decreased

appetite, abdominal pain, and who got tested for being positive for SARS-coV-2, but shown

asymptomatic at the time of discharge and who was re admitted for fatigue, vomiting, cough,

malaise and gastrointestinal symptoms after 3 days of discharged in the hospital

This case study is limited only to the Nursing interventions and responsibilities that are

established on the pediatric patient with a diagnosis of COVID 19 positive such as medications,

nursing management, health teaching, and plan of care at the time of admission to the time she

was discharged.
 Background of the Study

The SARS-CoV-2 infection is consider as the leading cause of mortality in CoVid-19

patient, This pandemic poses an urgent and lasting threat to the health and well-being of people

all over the world. When we face unprecedented uncertainty, clinicians, patients both adult and

pediatric, policy makers, and many others need urgent answers to questions to help them make

decisions and guide them to take the most appropriate actions. Severe acute respiratory syndrome

Corona Virus 2 (SARS-CoV-2), causing the corona virus diseases 2019 (Covid19) was first

reported with pneumonia like symptoms in Wuhan, China, in late 2019. It is considered one of

the major problems around the world. The important of this topic though several investigation

articles on the pediatric patients with variants 19 infection also helped increase general

awareness about the phenomenon. Limited data exist on severe acute respiratory syndrome

SARS-CoV-2 in children. We describe infection rate and symptoms profiles among pediatric

patient infected with SARS-CoV-2.

Persistent SARS-CoV-2 contamination in immunosuppressed hosts is getting more and

extra attention. This host can serve as a reservoir for the emergence of new strains that can avoid

the accumulation of mutations and subsequent immune responses. In fact, infection with SARS-

CoV-2 primarily cause respiratory illness ranging from mild disease to severe disease and death

also caused by fatigue and vomiting as well as cough, malaise and gastrointestinal symptoms.

With the case given, the pediatric patient was admitted due to tachycardia and pancytopenia

which was accompanied with pulmonary infiltrates as evidenced by respiratory distress and was

tested positive for SARS-CoV-2 by PCR and even during follow up screens for her
chemotherapy; the patient’s vital signs was being monitored and a chemotherapy regimen was

initiated. As a matter of fact, the SARS-CoV-2 attack respiratory mucosal epithelial cells and

spread to other cells, infect peripheral white blood cells and immune cells, particularly T

lymphocytes. But some pediatric patients infected with virus never develop symptoms.

The study showed the impact of severe acute respiratory syndrome SARS-CoV-2 in

children. The researchers chose this client for the case because her case is different to the usual

pediatric cases that deals with variant 19 infection. This will serve as a tool to give awareness to

people of what is it like having acute respiratory syndrome Corona Virus 2 (SARS-CoV-2). The

importance of this study is to enable the families to validate the finding of the studies and

confirm the prevalence and the danger of (SARS-CoV-2) among the pediatric who admitted and

consistently tested positive for acute respiratory syndrome Corona Virus 2 (SARS-CoV-2).

Furthermore , it is important for findings and insights derived from the study of these newly

available works to reach everyone who can benefit from it and to provide a forum and a gateway

to make the collective knowledge more accessible, timely and effective. We will welcome

contributions that can shed lights on our understanding of the COVID-19 disease and research in

a broader context of Corona Virus towards pediatric patients.

 General Description

Coronavirus is a kind of common virus that causes an infection in your nose, sinuses, or

upper throat. Most coronaviruses aren't dangerous. In early 2020, after a December 2019

outbreak in China, the World Health Organization identified SARS-CoV-2 as a new type of

coronavirus. The outbreak quickly spread around the world. COVID-19 is a disease caused by

SARS-CoV-2 that can trigger what doctors call a respiratory tract infection. It can affect your

upper respiratory tract (sinuses, nose, and throat) or lower respiratory tract (windpipe and lungs).

It spreads the same way other coronaviruses do, mainly through person-to-person contact.

Infections range from mild to deadly. SARS-CoV-2 is one of seven types of coronavirus,

including the ones that cause severe diseases like Middle East respiratory syndrome (MERS) and

sudden acute respiratory syndrome (SARS). The other coronaviruses cause most of the colds that

affect us during the year but aren’t a serious threat for otherwise healthy people.

There are different types of disease presentation based on the age of the person who is

infected by this virus. Luckily, children and adolescents tend to have more mild disease

compared to adults. Most people who are infected with the SARS-CoV-2 virus have respiratory

symptoms. They start to feel a little bit unwell, they will have a fever, they may have a cough or

a sore throat or sneeze. In some individuals, they may have gastrointestinal symptoms. Others

may lose the sense of smell or the sense of taste. Especially in the youngest children, they tend to

be more mild, which means they don't have as many symptoms as adults do. Some children may

have gastrointestinal symptoms like diarrhea or vomiting, but they tend to be more mild. And
even most children tend to have asymptomatic infection, which means they don't have any

symptoms at all.

Virus variants mean changes in the virus and we are detecting changes in the SARS-

CoV-2 virus over time. This is expected. Many of these changes do not have any impact on the

virus in terms of its ability to transmit or the disease that it causes. But some variants we call

“variants of concern” and these viruses need more study. And scientists are looking at the way

the virus transmits, the disease that it causes, and luckily so far, these variants do not tend to

cause more severe disease across any age group. The disease presentation looks the same and the

severity looks the same as the other SARS-CoV-2 viruses circulating. In terms of transmission,

the virus variant that was identified in the United Kingdom, they noticed an increase in

transmissibility across all age groups. This includes increased transmission among younger

children as well. In the area where this virus variant was circulating, schools happened to have

been open. And the virus that was circulating, also circulated among the students and the

faculties in those schools that were open. So, there's much study that's still underway with these

virus variants, but the studies in the United Kingdom, for example, do not indicate that the virus

specifically targets young children, meaning that it's not infecting children more than would be

likely of other viruses that are circulating in the area.

 Anatomy and Physiology

RESPIRATORY SYSTEM

Respiratory system is the network of organs and tissues that help you breathe. It

includes your airways, lungs, and blood vessels. The muscles that power your lungs are also part

of the respiratory system. These parts work together to move oxygen throughout the body and

clean out waste gases like carbon dioxide.

 The respiratory system has many functions. Besides helping you inhale (breathe in) and

exhale (breathe out), it:

 Allows you to talk and to smell.

 Brings air to body temperature and moisturizes it to the humidity level your body

needs.

 Delivers oxygen to the cells in your body.

 Removes waste gases, including carbon dioxide, from the body when you exhale.

 Protects your airways from harmful substances and irritants.

The respiratory system has many different parts that work together to help you breathe. Each

group of parts has many separate components.

MOUTH AND NOSE: Openings that pull air from outside your body into your respiratory

system.

SINUSES: Hollow areas between the bones in your head that help regulate the temperature and

humidity of the air you inhale.

PHARYNX (THROAT): Tube that delivers air from your mouth and nose to the trachea

(windpipe).

TRACHEA: Passage connecting your throat and lungs.

BRONCHIAL TUBES: At the bottom of your windpipe that connect into each lung.

LUNGS: Two organs that remove oxygen from the air and pass it into your blood.
From your lungs, your bloodstream delivers oxygen to all your organs and other tissues. Muscles

and bones help move the air you inhale into and out of your lungs. Some of the bones and

muscles in the respiratory system include your:

Diaphragm: Muscle that helps your lungs pull in air and push it out

Ribs: Bones that surround and protect your lungs and heart

Conditions that can cause inflammation (swelling, irritation, and pain) or otherwise affect the

respiratory system include:

INFECTION: Infections can lead to pneumonia (inflammation of the lungs) or bronchitis

(inflammation of the bronchial tubes). Common respiratory infections include the flu

(influenza) or a cold

ALLERGIES: Inhaling proteins, such as dust, mold, and pollen, can cause respiratory

allergies in some people. These proteins can cause inflammation in your airways.

ASTHMA: A chronic (long-term) disorder, asthma causes inflammation in the airways that

can make breathing difficult.

DISEASE RESPIRATORY TRACT DISORDER: include lung cancer and chronic

obstructive pulmonary disease (COPD). These illnesses can harm the respiratory system’s

ability to deliver oxygen throughout the body and filter out waste gases.

AGING: Lung capacity decreases as you get older.

DAMAGE: Damage to the respiratory system can cause breathing problems.

LYMPHATIC SYSTEM

Lymphatic system is a network of tissues, vessels and organs that work together to move a

colorless, watery fluid called lymph back into your circulatory system (your bloodstream).

Some 20 liters of plasma flow through your body’s arteries and smaller arteriole blood

vessels and capillaries every day. After delivering nutrients to the body’s cells and tissues

and receiving their waste products, about 17 liters are returned to the circulation by way of

veins. The remaining three liters seep through the capillaries and into your body’s tissues.
The lymphatic system collects this excess fluid, now called lymph, from tissues in your body

and moves it along until it ultimately returns it to your bloodstream.

The lymphatic system consists of many parts. These include:

Bone marrow: This is the soft, spongy tissue in the center of certain bones, such as the hip

bone and breastbone. White blood cells, red blood cells, and platelets are made in the bone

marrow.

Lymph: Lymph, also called lymphatic fluid, is a collection of the extra fluid that drains from

cells and tissues (that is not reabsorbed into the capillaries) plus other substances. The other

substances include proteins, minerals, fats, nutrients, damaged cells, cancer cells and foreign

invaders (bacteria, viruses, etc). Lymph also transports infection-fighting white blood cells

(lymphocytes).

Lymph nodes: Lymph nodes are bean-shaped glands that monitor and cleanse the lymph as

it filters through them. The nodes filter out the damaged cells and cancer cells. These lymph

nodes also produce and store lymphocytes and other immune system cells that attack and
destroy bacteria and other harmful substances in the fluid. You have about 600 lymph nodes

scattered throughout your body. Some exist as a single node; others are closely connected

groups called chains. A few of the more familiar locations of lymph nodes are in your armpit,

groin and neck. Lymph nodes are connected to others by the lymphatic vessels.·

Lymphatic vessels: Lymphatic vessels are the network of capillaries (microvessels) and

large network of tubes located throughout the body that transport lymph away from tissues.

Lymphatic vessels collect and filter lymph (at the nodes) as it continues to move toward

larger vessels called collecting ducts. These vessels operate very much like your veins do:

they work under very low pressure, have a series of valves in them to keep the fluid moving

in one direction.

Collecting ducts: Lymphatic vessels empty the lymph into the right lymphatic duct and left

lymphatic duct (also called the thoracic duct). These ducts connect to the subclavian vein,

which returns lymph to your bloodstream. The subclavian vein runs below your collarbone.

Returning lymph to the bloodstream helps to maintain normal blood volume and pressure. It

also prevents the excess buildup of fluid around the tissues (called edema).

Spleen: This largest lymphatic organ is located on your left side under your ribs and above

your stomach. The spleen filters and stores blood and produces white blood cells that fight

infection or disease.

Thymus: This organ is located in the upper chest beneath the breast bone. It matures a

specific type of white blood cell that fights off foreign organisms.

Tonsils and adenoid: These lymphoid organs trap pathogens from the food you eat and air

you breathe. They are your body’s first line of defense against foreign invaders.
 Peyer’s patches: These are small masses of lymphatic tissue in the mucous membrane that

lines your small intestine. These lymphoid cells monitor and destroy bacteria in the

intestines.

Appendix: Your appendix contains lymphoid tissue that can destroy bacteria before it

breaches the intestine wall during absorption. Scientists also believe the appendix plays a role

in housing “good bacteria” and repopulating our gut with good bacteria after an infection has

cleared.

Pathophysiology

Coronaviruses are enveloped, positive-sense, single-stranded RNA viruses of ~30 kb.

They infect a wide variety of host species. They are largely divided into four genera; α, β, γ, and

δ based on their genomic structure. α and β coronaviruses infect only mammals. Human

coronaviruses such as 229E and NL63 are responsible for common cold and croup and belong to

α coronavirus. In contrast, SARS-CoV, Middle East respiratory syndrome coronavirus (MERS-

CoV) and SARS-CoV-2 are classified to β coronaviruses.

The life cycle of the virus with the host consists of the following 5 steps: attachment,

penetration, biosynthesis, maturation and release. Once viruses bind to host receptors

(attachment), they enter host cells through endocytosis or membrane fusion (penetration). Once

viral contents are released inside the host cells, viral RNA enters the nucleus for replication.

Viral mRNA is used to make viral proteins (biosynthesis). Then, new viral particles are

made (maturation) and released. Coronaviruses consist of four structural proteins; Spike (S),

membrane (M), envelop (E) and nucleocapsid (N). Spike is composed of a transmembrane
trimetric glycoprotein protruding from the viral surface, which determines the diversity of

coronaviruses and host tropism. Spike comprises two functional subunits; S1 subunit is

responsible for binding to the host cell receptor and S2 subunit is for the fusion of the viral and

cellular membranes. Angiotensin converting enzyme 2 (ACE2) was identified as a functional

receptor for SARS-CoV.

Structural and functional analysis showed that the spike for SARS-CoV-2 also bound to

ACE2. ACE2 expression was high in lung, heart, ileum, kidney and bladder. In lung, ACE2 was

highly expressed on lung epithelial cells. Whether or not SARS-CoV-2 binds to an additional

target needs further investigation. Following the binding of SARS-CoV-2 to the host protein, the

spike protein undergoes protease cleavage. A two-step sequential protease cleavage to activate

spike protein of SARS-CoV and MERS-CoV was proposed as a model, consisting of cleavage at

the S1/S2 cleavage site for priming and a cleavage for activation at the S′2 site, a position

adjacent to a fusion peptide within the S2 subunit. After the cleavage at the S1/S2 cleavage site,

S1 and S2 subunits remain non-covalently bound and the distal S1 subunit contributes to the

stabilization of the membrane-anchored S2 subunit at the prefusion state.

Subsequent cleavage at the S′2 site presumably activates the spike for membrane fusion

via irreversible, conformational changes. The coronavirus spike is unusual among viruses

because a range of different proteases can cleave and activate it. The characteristics unique to

SARS-CoV-2 among coronaviruses are the existence of furin cleavage site (“RPPA” sequence)

at the S1/S2 site. The S1/S2 site of SARS-CoV-2 was entirely subjected to cleavage during

biosynthesis in a drastic contrast to SARS-CoV spike, which was incorporated into assembly

without cleavage. Although the S1/S2 site was also subjected to cleavage by other proteases such
as transmembrane protease serine 2 (TMPRSS2) and cathepsin L, the ubiquitous expression of

furin likely makes this virus very pathogenic.

The symptom of patients infected with SARS-CoV-2 ranges from minimal symptoms to

severe respiratory failure with multiple organ failure. On Computerized tomography (CT) scan,

the characteristic pulmonary ground glass opacification can be seen even in asymptomatic

patients. Because ACE2 is highly expressed on the apical side of lung epithelial cells in the

alveolar space, this virus can likely enter and destroy them. This matches with the fact that the

early lung injury was often seen in the distal airway. Epithelial cells, alveolar macrophages and

dendritic cells (DCs) are three main components for innate immunity in the airway. DCs reside

underneath the epithelium. Macrophages are located at the apical side of the epithelium. DCs and

macrophages serve as innate immune cells to fight against viruses till adaptive immunity is

involved.

Immunological studies were mainly reported in severe COVID-19 patients. Patients with

severe diseases showed lymphopenia, particularly the reduction in peripheral blood T cells. In

addition to respiratory symptoms, thrombosis and pulmonary embolism have been observed in

severe diseases. This is in line with the finding that elevated d-dimer and fibrinogen levels were

observed in severe diseases.

Difference between Children and Adults:

Infants and young children are typically at high risk for admission to hospitals due to

respiratory tract infection with viruses as respiratory syncytial virus and influenza virus. In

contrast, pediatric COVID-19 patients have relatively milder symptoms in general compared to

elder patients. The reason for this difference between children and adults remains elusive.
Because the recent report suggested the correlation between the severity of COVID-19 and the

amount of viral loads (or the duration of virus-shedding period), children may have less virus

loads even if they get COVID-19. In this line, a couple of hypotheses can be considered.

1. The first possibility is that the expression level of ACE2 may differ between adults and

children.

2. The second possibility is that children have a qualitatively different response to the

SARS-CoV-2 virus to adults.

3. The third possibility is that the simultaneous presence of other viruses in the mucosa

lungs and airways, common in young children, can let SARS-CoV-2 virus compete with

them and limit its growth.

DIAGNOSTIC AND LABORATORY TESTS FOR COVID-19

1. Assessment of Vital Signs: (IF any of these is present, it may increase the suspicion for

COVID-19)

 Hypotension: Systolic of <90 mmHg Diastolic of <50 mmHg

 Hypertensive: Systolic >140 mmHg and Diastolic >90 mmHg

 Tachycardia : (> 120 bpm)

 Tachypnea: (> 40 bpm)

 Temperature: (> or = 100.4°F (38°C))

 Oxygen Saturation: <93% on room air

2. Physical Exam

 Auscultation of the lungs: listen for:

 a) Bronchial breath sounds

b) Wheezing

c) Crackles: Fine or Coarse

d) Rhonchi

e) You can do special tests like Egophony and Bronchophony

3. Nasopharyngeal or Oropharyngeal Swab Test

 It is a type of test where a swab is inserted into the nasal cavity or the back of the

throat to get a sample of cells and mucous.

 This sample will undergo through a test called Reverse Transcription-Polymerase

Chain Reaction (RT-PCR). This will isolate the RNA and convert it to DNA and

amplify it.

 This test has a sensitivity of 70%

4. Serology

 This is the test for antibodies.

 We will get a blood sample then identify if Ig M or Ig G antibodies are present.

 If Ig M antibodies are present, it means that the patient is presently infected with

the virus.

 If Ig G antibodies are present, it means that the patient was infected before and

has already recovered.

LAB TESTS

1. ABG

 An arterial blood gas test measures the amounts of arterial gases, such as oxygen

and carbon dioxide.

  This test will be conducted if oxygen saturation of the patient is low.

 What are we looking for when we do an ABG?

a) Respiratory Alkalosis

 Increased pH

 Decreased PaCO2

 Decreased PaO2

b) Respiratory Acidosis

 Increased PaCO2

 Decreased PaO2

 Decreased pH

c) Metabolic Acidosis

 Decreased pH

 Decreased HCO3

 Decreased PaO2

 Increased PaCO2

2. CBC

 What are we looking for when we do an CBC?

a) Thrombocytopenia – Low level of platelet

b) Lymphopenia – Low level of lymphocytes

3. CMP

 A comprehensive metabolic panel is a blood test that measures your sugar

(glucose) level, electrolyte and fluid balance, kidney function, and liver function.

 What are we looking for when we do a CMP?

 a) Increased urea Concentration

b) Increased Creatinine contentration

c) Elevated A.S.T. Enzymes

d) Elevated A.L.T. Enzymes

e) Elevated CK-MB (Creatinine Kynase)

f) Elevated Tn I and Tn T(Troponin)

4. Procalcitonin

 This is used to test if SARS Covid 2 is accompanied by a bacterial infection

 If it is a viral infection the level of procalcitonin is Normal

 If it is a viral infection plus bacterial infection, the level of procalcitonin is

Elevated

5. Blood culture

 To know if there is a fungus or bacterial infection accompanying the SARS Covid

2 infection

6. Other Lab Tests:

 What are we looking for?

a) Elevated PTT

b) Elevated PT/ INR

c) Decreased Fibrinogen

d) Elevated D-Dimer

e) Increased CRP

f) Increased IL-6

g) Increased Ferritin
 h) Elevated LDH

i) Elevated D-Dimer

IMAGING AND EKGTESTS:

1. 12 Lead EKG

 This test is to rule out other causes

 What are we looking for in an EKG test?

a) NSTEMI

b) STEMI

c) Arrhythmia

d) Prolonged QT. I

2. Chest X-Ray

 This is to look for signs of pneumonia because it’s a potential thing to come up if

you do a CXR of an individual with Covid-19

 What are we looking for?

a) B/L or U/L opacities

3. CT scan of the chest

 What are we looking for?

a) Ground glass opacities

b) Consolidation

c) Crazy paving pattern

4. CT PA (CT Pulmonary Angiogram)

 What are we looking for?

a) Clots in the pulmonary circulation

 5. Ultrasound

 What are we looking for?

a) Pleural line thickening

b) Increased number of Rerly B-Lines

c) Consolidation

MEDICAL MANAGEMENT

SARS appears to spread by close person-to-person contact by respiratory droplets, or

when a person touches an object contaminated with infectious droplets and then touches

his or her mouth, nose, or eyes. The illness usually begins with an elevated temperature,

chills, and headache.

 Isolate and send PCR test early (may take days to result)

○ A polymerase chain reaction (PCR) test is performed to detect genetic material from a

specific organism, such as a virus. The test detects the presence of a virus if you are

infected at the time of the test. The test could also detect fragments of virus even after

you are no longer infected.

 GOC discussion/triage

○ Goals-of-care conversations help patients with serious illness clarify what they value

most and what they hope to see happens with their medical care. Clinicians can use this

information to formulate a plan of care around a patient's values and preferences.

 Notify DOH, CDC etc.

 Infection control
  Fluid sparing resuscitation

 (+)(-) empiric antibiotics

 Intubate early under controlled conditions of possible

 Avoid HFNC or NIPPV (aerosolizes virus) unless individualized reasons exist (COPD,

DNI status, etc.)

 Mechanical ventilation for ARDS

 Consider using POCUS to monitor/evaluate lungs

o Numerous B- lines, pleural line thickening, consolidations with air bronchograms

 Investigational therapies:

1. Remdesivir – block RNA dependent polymerate

2. Chloroquine – blocks viral entry in endosome

3. Tocilizumab – block IL- 6

4. Cortocosteriod – reduce inflammation

NURSING MANAGEMENT

 Monitor temperature

○ SARS usually begins with a high temperature and chills

 Monitor lungs sounds

○ Bronchial lung sounds are evident in areas of lung consolidation. A dry, non-

productive cough is common

 Maintain respiratory isolation

1. Keep tissues at the patient’s bedside

2. Dispose secretions properly

 3. Have the patient cover mouth when coughing or sneezing

4. Use masks (particulate N95 mask is preferred)

5. Have anyone entering the patient’s room wear a PPE

6. Keep door closed at all times and place respiratory sign visible

7. If the patient is transported out of the room, have him or her a mask

8. Place respiratory stickers on chart, linens and so on.

9. Place patient in a single room, limit/restrict visitors

 Teach the patient to wash hands after coughing

○ Friction and running water effectively remove organisms

 Use appropriate therapy for elevated temperature

○ This maintains normothermia and reduces metabolic needs

 Encourage patient to cough unless cough is non-productive

○ Frequent non-productive cough results to hypoxemia

 Provide a high protein, high calorie, increased fluid diet in small frequent servings

○ This maintains frequent nutritional status while reducing risk for nausea and vomiting

PROGNOSIS

 Age and comorbidities (DM, COPD, CVD) are 16

14
significant predictors of poor clinical outcome; 12
mortality (%)

10
admission of SOFA score also predicts 8
6
mortality.
4
2
 Lab findings also predict mortality
0
<20 0-30 0-40 0-50 0-60 0-70 0-80 >80
o Increased d- dimer

o Increased ferritin
 o Increased troponin

o Increased cardiac myoglobin

 Expect prolonged MV

 Watch for complications: secondary infection

Presentation of the Client Case

Patient X is a 3 year old female, residing at Barrio Green, Marawi City.

Prior to numerous visits to the emergency department (ED) for deteriorating pancytopenia,

decreased appetite, and stomach discomfort, the Pedia patient was a previously healthy 3-year-

old female with no major past medical history. Her bone marrow biopsy indicated 58 percent

blasts, indicating B-cell ALL, and she was put on a chemotherapy treatment. At the time of

discharge, asymptomatic screening for SARS-CoV-2 using RT-PCR indicated a positive result

(day 0). On day 3, she was brought to the hospital for exhaustion and vomiting, as well as cough,

malaise, and gastrointestinal issues, and she was discharged on day 6. She tested positive for

SARS-CoV-2 through her chemotherapy follow-up tests until she ultimately tested negative on

day 91, with no noticeable respiratory symptoms.

 Analysis and Interpretation

Patient was admitted in covid ward , With presenting sign and symptoms such as fever,

cough, fatigue, vomiting, malaise and gastrointestinal symptoms. Upon screening by RC - PTR

she revealed a positive results for SARS COV -2. Afterward she consistently tested Positive

for SARS - COV-2 during follow up screen for her chemotherapy. The laboratory diagnostic

procedure was taken are; viral nucleic acid (RNA) detection, viral antigen detection, and

detection of antibodies to the virus. Viral tests (nucleic acid or antigen detection tests) are used to

assess acute infection, whereas antibody tests provide evidence of prior infection with SARS-

[Link] tests such as complete blood count, C-reactive protein (CRP), D-dimer,

clotting tests, biopsy bone marrow revealed 58% blast with consistent B-cell. So the nurse

formulate the nursing diagnosis Deficient knowledge related to unfamiliarity disease

transmission information as evidence by reoccurrence of infection of patient. Based on

assessment data, nursing interventions for COVID-19 should focus on monitoring vital signs,

maintaining respiratory function, managing hyperthermia, and reducing transmission. So nurse

doing nursing interventions in response to this are ;

 Monitor vital signs – particularly temperature and respiratory rate, as fever and dyspnea

are common symptoms of COVID-19.

 Monitor O2 saturation – normal O2 saturation as measured with pulse oximeter should be

94 or higher; patients with severe COVID-19 symptoms can develop hypoxia, with

values dropping low enough to warrant supplemental oxygen.

 Manage fever – use appropriate therapy for hyperthermia, including adjusting room

temperature, eliminating excess clothing and covers, using cooling mattresses, applying
 cold packs to major blood vessels, starting or increasing intravenous (IV) fluids as

allowed, administering antipyretic medications as prescribed, and readying oxygen

therapy in the event of respiratory problems resulting from the metabolic demands for

oxygen during a fever.

 Maintain respiratory isolation – isolation rooms should be well-marked with limited

access; all who enter the restricted-access room should use personal protective

equipment, such as masks and gowns.

 Enforce strict hand hygiene – to reduce or prevent transmission of coronavirus, patients

should wash hands after coughing, as should all who enter or leave the room.

 Provide information – educate the patient and patient’s family members of the

transmission of COVID-19, the tests to diagnose the disease, disease process, possible

complications, and ways to protect oneself and one’s family from coronavirus.

 Supportive therapy :Bed rest and supportive treatment such as ensuring an adequate

intake of daily calories and water;

 Performing routine blood or urine examinations or assessing other biochemical

parameters based on clinical conditions, blood gas analyses, and serial chest imaging

examinations should be provided when facilities are adequate.

The Medical Management

✓Notify DOH, CDC etc.

✓administered physical cooling or antipyretic drugs (oral ibuprofen or acetaminophen) for a

body temperature above 38.5°C

✓ Utilization of MV in the pediatric . The role of supportive treatment for maintaining breathing

and airway is provided by noninvasive MV, such as high-flow nasal cannula, continuous positive

airway pressure, or bi-level positive airway pressure.

✓ Administration of antiviral drugs

✓infection prevention and control measures and supportive care, including supplemental oxygen

and mechanical ventilator support when indicated.

✓Investigational therapies:

✓Remdesivir – block RNA dependent polymerase

✓– blocks viral entry in endosome

✓Tocilizumab – block IL- 6

✓Cortocosteriod – reduce inflammation

 Narrative Format Of The NCP

The patient was readmitted to the hospital because of complaints of fatigue and vomiting

as well as cough, malaise, and gastrointestinal symptoms and discharged on day 6. Patient

consistently tested positive for SARS-CoV-2 during follow up screens for her chemotherapy

until she ultimately tested negative on day 91.

That said, the patient was diagnosed with Deficient knowledge related to unfamiliarity

with disease transmission information as evidenced by the consistent recurrence of infection of

the patient. After the diagnosis was formulated, the nurses came up with an objective to educate

the patient and her family members about SARS-CoV-2 and its management. Suitable nursing

interventions were rendered to the patient and her family.

The nurses wore an adequate PPE first to protect themselves and the patient from

possible transmission of the said virus. After that, vital signs particularly temperature and

respiratory rate of the patient were monitored as fever and dyspnea are common symptoms of

SARS-CoV-2. Oxygen saturation was also monitored because patients with severe SARS-CoV-2

symptoms can develop hypoxia, with values dropping low enough to warrant supplemental

oxygen. Information about SARS-CoV-2 and its preventive measures were also provided to

educate the patient especially the patient’s family members of the transmission of the virus, the

tests to diagnose the disease, disease process, possible complications, and ways to protect oneself

and one’s family from coronavirus.

The patient and her family members were encouraged to obey the following preventive

measures: stay at home, wash hands often with soap and water, wear a mask, maintain a safe

physical distance of at least 6 feet when out, always cover nose and mouth when coughing and
sneezing, avoid touching nose, eyes and mouth, clean and disinfect frequently touched objects

and surfaces using a regular household cleaning spray and to call first before seeing their

provider. All these preventive measures were discussed to prevent contracting and transmission

of the virus.

The patient was also encouraged to eat a high protein, high calorie, and increased fluid

diet to maintain frequent nutritional status while reducing risk for nausea and vomiting. After

rendering all the said interventions, the patient and her family members learned more about

SARS-CoV-2 and its management. Therefore, the goal was met.

 Summary of Findings

Patient is a 3 years old female patient admitted due to a worsening pancytopenia,

decreased appetite, and abdominal pain. Prior to admission, patients was previously healthy with

no major past medical history. It was then discovered that patient have Acute Lymphoblastic

leukemia, and developed SARS-CoV-2. She was then put to chemotherapy treatment, with

asymptomatic screening for SARS-CoV-2 using RT-PCR, she was found positive for

Coronavirus. The cause of coronavirus disease 2019 (COVID-19), is reverse transcription

polymerase chain reaction (RT-PCR). On day 3, she was brought to the hospital for exhaustion

and vomiting, as well as cough, malaise, and gastrointestinal issues, and she was discharged on

day 6. She tested positive for SARS-CoV-2 through her chemotherapy follow-up tests until she

ultimately tested negative on day 91, with no noticeable respiratory symptoms.

It is important to provide proper nursing interventions and health teaching to the patient

and family. It is important that child are given vitamins such as Vitamin C to boost their immune

system and fight COVID-19 or any virus. Monitoring of lungs sounds; vital signs specially

temperature; maintaining respiration isolation; teaching hygiene such as washing hands after

coughing; appropriate therapy for elevated temperature; encourage coughing; and provide high

protein, high caloric, and increase fluid diet. These are the interventions employed to fulfill the

patient's needs.

Coronaviruses consist of four structural proteins; Spike (S), membrane (M), envelop (E)

and nucleocapsid (N). Spike is composed of a transmembrane trimetric glycoprotein protruding

from the viral surface, which determines the diversity of coronaviruses and host tropism. Spike

comprises two functional subunits; S1 subunit is responsible for binding to the host cell receptor
and S2 subunit is for the fusion of the viral and cellular membranes. Angiotensin converting

enzyme 2 (ACE2) was identified as a functional receptor for SARS-CoV. Structural and

functional analysis showed that the spike for SARS-CoV-2 also bound to ACE2. ACE2

expression was high in lung, heart, ileum, kidney and bladder. In lung, ACE2 was highly

expressed on lung epithelial cells.

The study demonstrates that children, especially immunocompromised children are

prone to SARS-CoV-2. However, if patient demonstrate strong IgA, IgG, and IgM, then

symptoms are milder. Most people who are infected with the SARS-CoV-2 virus have

respiratory symptoms. They start to feel a little bit unwell, they will have a fever, they may have

a cough or a sore throat or sneeze. In some individuals, they may have gastrointestinal

symptoms. Others may lose the sense of smell or the sense of taste. Especially in the youngest

children, they tend to be more mild, which means they don't have as many symptoms as adults

do. Some children may have gastrointestinal symptoms like diarrhea or vomiting, but they tend

to be more mild. And even most children tend to have asymptomatic infection, which means they

don't have any symptoms at all.

 Conclusion

A new strain of coronavirus (named SARS-CoV-2) began infecting patients with flu-like

symptoms. This sickness is known as coronavirus disease-19, or COVID-19. The virus is easily spreading

and has infected people, causing millions of death all around the world. To summarize case, a 3 years old

female patient admitted because of a worsening pancytopenia, decreased appetite, and abdominal pain. It

was discovered that patient have B-cell ALL or Acute Lymphoblastic leukemia, and developed SARS-

CoV-2. Patient undergo chemotherapy with 4 phases: induction, consolidation, interim maintenance, and

delayed intensification. The most common method for detecting infection with severe acute respiratory

syndrome coronavirus-2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19), is reverse

transcription polymerase chain reaction (RT-PCR). Patient was undergo asymptomatic screening for

SARS-CoV-2 by RT-PCR and tested positive. It is then notify to the other health care provider and DOH

to provide plan of care. It demonstrates that parents still lack knowledge about SARS-CoV-2, thus the

family and parents are provided health education on the virus, its symptoms, and how to prevent this such

as by performing hygiene, wearing masks, and social distance. Infection control measures are

implemented, such as the use of personal protective equipment (PPE) and the patient's instructed for

home isolation. This have provided the family or parents knowledge about the virus, and prevent the

spreading of infection to other family members or community.

On day three, the patient was re-admitted to the hospital with fatigue, vomiting, cough, malaise,

and gastrointestinal symptoms. Infection control, fluid sparing resuscitation, empiric antibiotics,

intubation preparation, avoid HFNC or NIPPV (aerosolizes), mechanical ventilation for ARDS, use of

POCUS, and investigational therapies are then implemented. The nursing management are monitoring of

and lungs sounds vital signs specially temperature; maintaining respiration isolation; teaching hygiene

such as washing hands after coughing; appropriate therapy for elevated temperature; encourage coughing;

and provide high protein, high caloric, and increase fluid diet. This intervention was employed to fulfill

the patient's needs. After day 6, the patient is discharged with no SARS-CoV-2 symptoms but still have
positive RT-PCR result. The patient is placed on home isolation and is closely monitored for any signs or

symptoms. During follow-up screening for her treatments, the patient has consistently tested positive for

SARS-CoV-2. It was examined that patient shows increased of SARS-CoV-2 on day 1 and decrease at the

following days. For the reason that patient exhibit strong IgA, IgG, and IgM that help in her recovery.

Until day 91, she tested negative without any noticeable respiratory symptoms.

In conclusion, children are prone to SARS-CoV-2 especially those who have illness or diseases.

However, it gives milder symptoms if patient demonstrate strong IgA, IgG, and IgM. Providing a proper

health teaching and nursing interventions to the patient and family is significant to help in recovery, to

stop spreading of the virus, and also to prevent further complications. It is important that child are given

vitamins such as Vitamin C to boost their immune system and fight COVID-19 or any virus.

Additionally, it is crucial that family members comply with all safety precautions for COVID-19 to

protect self and family members as well as prevent transmission of COVID-19.