NURSING CARE ANALYSIS IN A COVID-19 PATIENT WITH TRACHEOSTOMY IN THE INTENSIVE CARE UNIT: A CASE REPORT

Denissa Faradita Aryani, Dian Rahmawati, Shedy Maharani Nariswari

Abstract


Background: The coronavirus disease (COVID-19) pandemic has posed significant challenges in critical care, particularly for patients with severe acute respiratory distress syndrome (ARDS), ventilator weaning failure, and septic shock requiring tracheostomy.  Case Presentation: This report presents the clinical course and nursing management of Mrs. X, a COVID-19 patient who presented to the emergency department with severe dyspnea, hypoxia (SpO2 69%), and tachypnea (30 breaths/min).  Despite initial noninvasive ventilation (NIV), her condition deteriorated, requiring endotracheal intubation and intensive care unit (ICU) admission.  She was diagnosed with moderate ARDS (P/F ratio: 146 mmHg) and ventilator weaning failure after 15 days, leading to tracheostomy. Results: Key nursing diagnoses included impaired spontaneous ventilation and impaired gas exchange. ICU nurses implemented comprehensive tracheostomy care, adhered to ventilator-associated pneumonia (VAP) prevention bundles, and performed continuous assessments to minimize infection risks. These interventions successfully prevented common tracheostomy-related complications such as ulcers and site infections. However, the patient developed septic shock and multiple organ dysfunction syndrome (MODS), ultimately resulting in death on the 27th day of admission.  Conclusion:  This case highlights the essential role of ICU nursing in managing complex COVID-19 patients with tracheostomy.  Effective tracheostomy care, stringent infection control, and timely nursing interventions are crucial to optimizing patient outcomes.  Nevertheless, the progression to septic shock underscores the challenges of managing critically ill patients with COVID-19.

Keywords: COVID-19, nursing care, critical care, ventilator weaning, tracheostomy, ARDS


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Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M. (2021). Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates - E-Book. St. Louis, Missouri: Mosby.

Ahmadinegad, M., Lashkarizadeh, M. R., Ghahreman, M., Shabani, M., Mokhtare, M., & Ahmadipour, M. (2014). Efficacy of Dressing with Absorbent Foam versus Dressing with Gauze in Prevention of Tracheostomy Site Infection. Tanaffos, 13(2), 13-19.

Alhazzani, W., Møller, M. H., Arabi, Y. M., Loeb, M., Gong, M. N., Fan, E., ... & Rhodes, A. (2020). Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Intensive Care Medicine, 46, 854-887.

Alipoor, S. D., Jamaati, H., Tabarsi, P., & Mortaz, E. (2020). Immunopathogenesis of Pneumonia in COVID-19. Tanaffos, 19(2), 79-82.

Alnajar, M. K., Shudifat, R., Mosleh, S. M., Ismaile, S., N'Erat, M., & Amro, K. (2021). Pain Assessment and Management in Intensive Care Unit: Nurses' Practices, Perceived Influencing Factors, and Educational Needs. The Open Nursing Journal, 15, 170-178. https://doi.org/https://doi.org/10.2174/1874434602115010170

Aslan, A., Aslan, C., Zolbanin, N. M., Jafari, R. (2021). Acute respiratory distress syndrome in COVID-19: possible mechanisms and therapeutic management. Pneumonia (Nathan), 13(1), 14.

Bardwell, J., Brimmer, S., & Davis, W. (2020). Implementing the ABCDE Bundle, Critical-Care Pain Observation Tool, and Richmond Agitation-Sedation Scale to Reduce Ventilation Time. AACN advanced critical care, 31(1), 16-21. https://doi.org/10.4037/aacnacc2020451

Bhimraj, A., Morgan, R. L., Shumaker, A. H., Lavergne, V., Baden, L., Cheng, V. C. C., …, & Falck-Ytter, Y. (2020). Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, ciaa478.

Bain, W., Yang, H., Shah, F. A., Suber, T., Drohan, C., Al-Yousif, N., …, & Kitsios, G. D. (2021). COVID-19 versus non-COVID-19 acute respiratory distress syndrome: Comparison of demographics, physiologic parameters, inflammatory biomarkers, and clinical outcomes. Annals of the American Thoracic Society, 18(7), 1202-1210.

Bhutta, B. S., Alghoula, F., Berim, I. (2022). Hypoxia. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK482316/

Blakeley, S. Tracheostomy care in critical care. Retrieved from: https://www.portsmouthicu.com/resources/2017-06-30-TracheCare(2017).pdf

Breik, O., Nankivell, P., Sharma, N., Bangash, M. N., Dawson, C., Idle, M., ... & Tasker, L. (2020). Safety and 30-day outcomes of tracheostomy for COVID-19: a prospective observational cohort study. British Journal of Anaesthesia, 125(6), 872-879.

Brosnahan, S. B., Jonkman, A. H., Kugler, M. C., Munger, J. S., & Kaufman, D. A. (2020). COVID-19 and respiratory system disorders: Current knowledge, future clinical and translational research questions. Arteriosclerosis, thrombosis, and vascular biology, 40(11), 2586-2597.

Carrillo-Esper, R., Mejia-Gomez, L., Monares-Zepeda, E., Chavarria-Martinez, U., Diaz-Carrillo, A., Ayala-Leon, M., ... & Perez-Calatayud, A. A. (2020). Hemodynamic and mechanical ventilation approach in patients with COVID-19. Cirugía y cirujanos, 88(6), 805-817.

Chao, T. N., Harbison, S. P., Braslow, B. M., Hutchinson, C. T., Rajasekaran, K., Go, B. C., ... & Rassekh, C. H. (2020). Outcomes after tracheostomy in COVID-19 patients. Annals of surgery, 272(3), e181-e186.

Danin, P. E., Girou, E., Legrand, P., Louis, B., Fodil, R., Christov, C., Devaquet, J., Isabey, D., & Brochard, L. (2015, Jan). Description and microbiology of endotracheal tube biofilm in mechanically ventilated subjects. Respir Care, 60(1), 21-29. https://doi.org/10.4187/respcare.02722

Dian, R., & Faradita, A. D. (2024). One-hour sepsis bundle in patients with sepsis shock: A case report of nursing care implementation. The Journal of Palembang Nursing Studies, 3(2), 109-116.

Dixon, L. M., Mascioli, S., Mixell, J. H., Gillin, T., Upchurch, C. N., & Bradley, K. M. (2018). Reducing tracheostomy-related pressure injuries. AACN advanced critical care, 29(4), 426-431.

Everitt, E. (2016). Caring for patients with a tracheostomy. Nurs Times, 112(19), 16-20.

Evrard., D., Jurcisin, I., Assadi, M., Patrier, J., Tafani, V., Ullmann, N., …, & Rozencwajg, S. (2021). Tracheostomy in COVID-19 acute respiratory distress syndrome patients and follow-up: A parisian bicentric retrospective cohort. PLoS One, 16(12), e0261024.

Farlow, J. L., Park, P. K., Sjoding, M. W., Kay, S. G., Blank, R., Malloy, K., M., …, & De Cardenas, J. (2021). Tracheostomy for COVID-19 respiratory failure: Timing, ventilatory characteristics, and outcomes. J Thorac Dis, 13(7), 4137-4145.

Fumagalli, J., Panigada, M., Klompas, M., Berra, L. (2022). Ventilator-associated pneumonia among SARS-CoV-2 acute respiratory distress syndrome patients. Current opinion in critical care, 28(1), 74-82.

Gagnier, J. J., Kienle, G., Altman, D. G., Moher, D., Sox, H., & Riley, D. (2014, Jan). The CARE guidelines: consensus-based clinical case report guideline development. J Clin Epidemiol, 67(1), 46-51. https://doi.org/10.1016/j.jclinepi.2013.08.003

Ghafoor, H., Abdus Samad, A., Bel Khair, A. O. M., Ahmed, O., & Khan, M. N. A. (2022). Critical Care Management of Severe COVID-19 in Pregnant Patients. Cureus, 14(5), e24885. https://doi.org/10.7759/cureus.24885

Guarino, M., Perna, B., Cesaro, A. E., Maritati, M., Spampinato, M. D., Contini, C., & De Giorgio, R. (2023). 2023 Update on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department. J Clin Med, 12(9), 3188. https://doi.org/10.3390/jcm12093188

Hashimoto, D. A., Axtell, A. L., & Auchincloss, H. G. (2021, 2021/02//). Percutaneous Tracheostomy. The New England journal of medicine, 384(8), 780-781. https://doi.org/10.1056/nejmc2035339

Hess, D. R., & Altobelli, N. P. (2014). Tracheostomy Tubes. Respiratory Care, 59(6), 956-971.

Hoevenaar, M., & Goossens, D. (2020). Fever & COVID-19-Complications. https://doi.org/10.13140/RG.2.2.34099.17445/2

Imo, I. C. (2020). Improving Ventilator Acquired Pneumonia Bundle Compliance in Mechanically Ventilated Patients in an Intensive Care Unit [Doctoral Dissertation]. Grand Canyon University, Arizona, United States. https://www.proquest.com/dissertations-theses/improving-ventilator-acquired-pneumonia-bundle/docview/2445584941/se-2?accountid=17242

Karamchandani, K., Dalal, R., Patel, J., Modgil, P., & Quintili, A. (2021). Challenges in sedation management in critically ill patients with COVID-19: a brief review. Current Anesthesiology Reports, 11, 107-115.

Keski, H. (2021). Hematological and inflammatory parameters to predict the prognosis in COVID-19. Indian Journal of Hematology and Blood Transfusion, 37(4), 534-542.

Khan, R. M., Al-Juaid, M., Al-Mutairi, H., Bibin, G., Alchin, J., Matroud, A., Burrows, V., Tan, I., Zayer, S., Naidv, B., Kalantan, B., & Arabi, Y. M. (2019). Implementing the comprehensive unit-based safety program model to improve the management of mechanically ventilated patients in Saudi Arabia. American Journal of Infection Control, 47(1), 51-58. https://doi.org/https://doi.org/10.1016/j.ajic.2018.06.022

Kimmoun, A., Novy, E., Auchet, T., Ducrocq, N., & Levy, B. (2015, Apr 9). Hemodynamic consequences of severe lactic acidosis in shock states: from bench to bedside. Crit Care, 19(1), 175. https://doi.org/10.1186/s13054-015-0896-7

Klompas, M., Branson, R., Eichenwald, E. C., Greene, L. R., Howell, M. D., Lee, G., …, & Berenholtz, S. M. (2014). Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(8), 915-936.

Kristina, K., Sasmito, P., Bawa, N. N. R., Azizah, L. N., Suratmiti, N. N., Sari, N. M. S., Muhalla, H. I., Surasta, I. W., & Sari, P. M. P. (2024). Buku Ajar Asuhan Keperawatan Medikal Bedah: Menggunakan SDKI, SIKI, SLKI. Jambi: Sonpedia Publishing Indonesia.

Maes, M., Higginson, E., Pereira-Dias, J., Curran, M. D., Parmar, S., Khokhar, F., …, & Morris, A. C. (2021). Ventilator-associated pneumonia in critically ill patients with COVID-19. Crit Care, 25(1), 25.

Mattioli, F., Fermi, M., Ghirelli, M., Molteni, G., Sgarbi, N., Bertellini, E., …, & Marudi, A. (2020). Tracheostomy in the COVID-19 pandemic. European archives of oto-Rhino-Laryngology, 277, 2133-2135.

Mishra, P., Jedge, P., Kaushik, M., Artham, P., & Kumari, S. (2022). Our experience of tracheostomy in COVID-19 patients. Indian Journal of Otolaryngology and Head & Neck Surgery, 74, 1-4.

Morris, P. E., Berry, M. J., Files, D. C., Thompson, J. C., Hauser, J., Flores, L., …, Young, M. P. (2016). Standardized rehabilitation and hospital length of stay among patients with acute respiratory failure: A randomized clinical trial. JAMA, 315(24), 2694-2702.

O’Toole, T. R., Jacobs, N., Hondorp, B., Crawford, L., Boudreau, L. R., Jeffe, J., …, & LoSavio, P. (2017). Prevention of tracheostomy-related hospital-acquired pressure ulcers. Otolaryngology–Head and Neck Surgery, 156(4), 642-651.

Parker, L. C. (2014). Tracheostomy care. Nursing2020 Critical Care, 9(6), 38-41.

Prinzi, A., Parker, S. K., Thurm, C., Birkholz, M., & Sick-Samuels, A. (2021). Association of Endotracheal Aspirate Culture Variability and Antibiotic Use in Mechanically Ventilated Pediatric Patients. JAMA Network Open, 4(12), e2140378-e2140378. https://doi.org/10.1001/jamanetworkopen.2021.40378

Rali, A. S., Butcher, A., Tedford, R. J., Sinha, S., Mekki, P., Spall, H. V., & Sauer, A. J. (2022). Contemporary Review of Hemodynamic Monitoring in the Critical Care Setting. US Cardiology Review 2022;16:e12. https://doi.org/10.15420/usc.2021.34

Rodrigues, S. O., Cunha, C. M. C. D., Soares, G. M. V., Silva, P. L., Silva, A. R., & Gonçalves-de-Albuquerque, C. F. (2021). Mechanisms, Pathophysiology and Currently Proposed Treatments of Chronic Obstructive Pulmonary Disease. Pharmaceuticals (Basel, Switzerland), 14(10), 979.

Ryder, J. H., & Kalil, A. C. (2022). The puzzles of ventilator-associated pneumonia and COVID-19: Absolute knowns and relative unknowns. Critical Care Medicine, 50(5), 894-896.

Shah, F. A., Meyer, N. J., Angus, D. C., Awdish, R., Azoulay, É., Calfee, C. S., Clermont, G., Gordon, A. C., Kwizera, A., & Leligdowicz, A. (2021). A research agenda for precision medicine in sepsis and acute respiratory distress syndrome: an official American Thoracic Society research statement. American journal of respiratory and critical care medicine, 204(8), 891-901.

Staibano, P., Levin, M., McHugh, T., Gupta, M., & Sommer, D. D. (2021). Association of tracheostomy with outcomes in patients with COVID-19 and SARS-CoV-2 transmission among health care professionals: a systematic review and meta-analysis. JAMA Otolaryngology–Head & Neck Surgery, 147(7), 646-655

Tang, Y., Liu, J., Zhang, D., Xu, Z., Ji, J., Wen, C. (2020). Front Immunol, 11, 1708.

Tsolaki, V., Zakynthinos, G. E., & Makris, D. (2020). The ARDSnet protocol may be detrimental in COVID-19. Critical Care, 24(1), 351.

Tzotzos, S. J., Fischer, B., Fischer, H., & Zeitlinger, M. (2020). Incidence of ARDS and outcomes in hospitalized patients with COVID-19: A global literature survey. Critical Care, 24, 1-4.

Vena, A., Taramasso, L., Di Biagio, A., Mikulska, M., Dentone, C., De Maria, A., …, & group, G. s. (2021). Prevalence and Clinical Significance of Persistent Viral Shedding in Hospitalized Adult Patients with SARS-CoV-2 Infection: A Prospective Observational Study. Infectious Diseases and Therapy, 10(1), 387-398. https://doi.org/10.1007/s40121-020-00381-8

World Health Organization. (2021). Care of COVID-19 patients after acute illness (new chapter). In Clinical Management of COVID-19: Living guidance, 60-61. Retrieved from http://www.jstor.org/stable/resrep30113.28

Xu, J. B., Xu, C., Zhang, R. B., Wu, M., Pan, C. K., Li, X. J., …, & Zhu, S. (2020). Associations of procalcitonin, C-reaction protein and neutrophil-to-lymphocyte ratio with mortality in hospitalized COVID-19 patients in China. Scientific reports, 10(1), 15058.

Yue, M., Lei, M., Liu, Y., & Gui, N. (2019). The application of moist dressings in wound care for tracheostomy patients: A meta‐analysis. Journal of Clinical Nursing, 28(15-16), 2724-2731.

Yoo, E. J., Edwards, J. D., Dean, M. L., & Dudley, R. A. (2016, Jun). Multidisciplinary Critical Care and Intensivist Staffing: Results of a Statewide Survey and Association With Mortality. J Intensive Care Med, 31(5), 325-332. https://doi.org/10.1177/0885066614534605

Zhang, J., He, X., Hu, J., & Li, T. (2020). Failure of early extubation among cases of coronavirus disease-19 respiratory failure: case report and clinical experience. Medicine, 99(27), e20843.




DOI: http://dx.doi.org/10.32419/jppni.v10i1.605

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