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Introduction

Since it first emerged in China in late 2019, the SARS-CoV-2 strain of coronavirus has spread worldwide, causing over 760 million confirmed cases and nearly 7 million deaths globally. Over 1 million United States citizens have died from the disease and, despite expanded knowledge of the disease, improved testing, and widely available and effective vaccines, the virus still remains a front runner of public health concern (10).  

Much has changed since the beginning of the pandemic, and this module aims to provide the most up to date and comprehensive overview of nursing considerations for COVID-19. 

What is the Coronavirus?

Coronaviruses are a family of viruses that have been known to cause mild to moderate respiratory symptoms that may mimic influenza. A few strains of coronavirus have been known to cause much more severe or even fatal illness; SARS-CoV (often referred to as just SARS) occurred in 2002, MERS in 2012, and most recently SARS-CoV-2 in 2019, commonly referred to as COVID-19 (10).  

Coronaviruses are aptly named for the crown-like appearance the virus has when examined under a microscope; “corona” is Latin for “crown” and the virus appears to be covered in crowns which are actually spike proteins used to latch onto healthy cells, typically beginning in the respiratory tract. Once attached and inside host cells, coronaviruses take control of the cells and turn them into factories for more viruses to be produced and released into the body (10).  

Mutations and Variants

All viruses mutate over time as they adapt to their environment and try to find the best way to move from host to host. Large mutations, called antigenic shift, result in a large jump in genetic material and a new virus or the ability to infect a new species. This is how SARS-CoV-2 first came to infect humans (9).  

Smaller, less drastic mutations occur much more frequently and result in different variants of the same virus. Different variants can be identified through genetic testing and can help track the spread of the disease across regions or globally. Different variants may result in slightly different symptoms, ease of transmission, or severity of illness. SARS-CoV-2 has mutated steadily throughout the pandemic and there are currently over 10 variants in circulation (9).  

One of the main concerns with mutations is whether any of the variants could affect treatment and prevention. Mutations may allow the coronaviruses to escape the antibodies in currently available therapies and those induced by vaccines. Vaccine boosters for widely circulating strains have been developed (9).  

Signs and Symptoms

Over the course of 2 to 14 days, the virus replicates and spreads rapidly throughout the body, causing symptoms that are anywhere from mild to severe. Inflammation of the respiratory tract can lead to cough, difficulty breathing, and even respiratory failure. The most common symptoms of COVID-19 include:  

• Fever 
• Cough 
• Shortness of breath 
• Fatigue 
• Body aches 
• Chills 
• Sore throat 
• Congestion or rhinorrhea 
• Loss of taste or smell 
• Vomiting or diarrhea
  

Complications

The coronavirus disease affects each person differently. Many patients will experience mild disease, while others may develop more severe respiratory symptoms that require hospitalization. Patients with conditions such obesity, diabetes, asthma, chronic lung conditions, sickle-cell disease, or immune system deficiencies are at increased risk of developing severe disease and experiencing complications such as acute respiratory distress syndrome (ARDS). ARDS occurs when the tissue and blood vessels of the lungs’ alveoli are damaged and fill with debris.

This then causes:  

• Tachycardia 
• Dizziness or confusion 
• Hypotension 
• Diaphoresis 
• Severe shortness of breath and/or irregular breathing patterns 
• Blood gas imbalance 
• Organ dysfunction 

Severe illness and respiratory distress requires higher levels of care including hospitalization and mechanical ventilation.  

COVID-19 and Pregnancy

Accumulating data continues to indicate that pregnant patients are at an increased risk of serious illness and complications from COVID-19. Pregnancy has been shown to increase the risk of serious disease, including hospitalization, mechanical ventilation, and use of extracorporeal membrane oxygenation (ECMO). Pregnant patients are five times more likely to be admitted to the ICU than non-pregnant patients of the same age and have a 76% increase in risk of mechanical ventilation and ECMO. Infection during pregnancy also affects the fetus and increases the risk of preterm delivery or stillbirth. Recent studies have shown that COVID-19 affects the health of the placenta, even after maternal symptoms begin to improve. This reduces oxygen perfusion to the fetus and can impact growth and development or lead to intrauterine death (1).  

Long Covid

Although it may feel like COVID-19 has been around for quite a long time, the reality is that our understanding of the disease is just getting underway. As the pandemic continues to progress, there is a growing recognition that people are experiencing the long-term repercussions of the SARS-CoV-2 virus, which may persist for months or even years. It is very likely that we will not know the full extent of long term effects for many years to come.  

The development of Post COVID Conditions (PCC) or Long COVID is now widely recognized. This wide range of conditions can occur in anyone who has been infected with COVID-19, but are most likely in people who had severe illness or were not vaccinated prior to infection. Most people were aware they had COVID-19, but some people suffering from PCC may never have tested positive or known they were ill (5). The potential symptoms or conditions of PCC are broad and include:  

• Fatigue (that interferes with daily life) 
• Intermittent fevers 
• Mental fog 
• Heart palpitations 
• Shortness of breath 
• Cough 
• Chest pain 
• Headaches 
• Sleep problems 
• Dizziness 
• Loss or change in taste or smell 
• Depression or anxiety 
• Neuralgia 
• Diarrhea 
• Abdominal pain 
• Joint or muscle pain 
• Menstrual irregularities (5) 

It is likely that the extent of PCC symptoms will continue to evolve over the years as we have more experience with the disease and monitor the long term consequences.  

Nursing Considerations

All patients will present to a healthcare facility a little differently depending on their unique symptoms and health needs. Nurses have the responsibility to appropriately triage patients, based on severity of the illness and individual risk factors, to assist in the efficiency of managing a higher influx of patients, while simultaneously preventing the viral spread of the infection to those patients who have not yet been exposed to COVID-19.  

As evidenced by the early days of the pandemic, the healthcare system can become easily overwhelmed by a higher than average influx of patients, poor testing capabilities due to inadequate supplies or backlogged sample processing, and lack of resources and staff to care for high acuity patients. As such, slowed spread and prevention of serious disease are imperative for managing this illness of pandemic proportion.  

Prevention

here are several ways to help prevent the spread of COVID-19, including per the Centers for Disease Control and Prevention (CDC, 10): 

• Avoid touching the eyes, nose, and mouth 
• Avoid close contact with people who are sick or confirmed positive with COVID-19 
• Stay home when you are sick 
• Cover your cough or sneeze 
• Use a face covering such as a surgical or N95 mask 
• Clean and disinfect frequently touched objects and surfaces 
• Perform hand hygiene with soap and water or use alcohol-based sanitizer 
• For healthcare providers: wearing appropriate PPE and changing PPE and sanitizing in between patients (7) 

Understanding who is considered a close contact is important in the context of triaging and discharging patients; not all exposures are considered close contact. 

Please see the criteria below for determining a high-risk exposure(10): 

• Patient was within 6 feet of a person with confirmed COVID-19 for a total of 15+ min within a 24-hour period. 
• Patient has cared for someone at home who is sick with COVID-19. 
• Patient has shared food or drinking utensils with a person with confirmed COVID-19. 
• Patient had direct physical contact with a person with confirmed COVID-19 (hugging or kissing) (7) 

Testing

​There are several different tests available for COVID-19. They can be used for diagnosing acute infection, to guide contact tracing, and in some cases to determine if a patient has previously been infected by the SARS-CoV-2 virus. It is important for nurses to understand the limits of testing (3). 

Testing for active infection (symptomatic or asymptomatic) is an important strategy for controlling the spread of the virus. It is important to know when it is appropriate to test a patient. 

In general, testing should be considered for the following:  

• People with symptoms of COVID-19 
• People who have close contact with someone who is COVID-19 positive. 
• People who are asked or referred by their healthcare provider or local health department. 
• People who are asymptomatic but will be visiting someone high risk (3) 

*Patients with recent COVID-19 disease (past 3 months) do not require testing for subsequent exposures unless symptoms are present. 

Viral tests are diagnostic and use samples from the respiratory system, such as nasal or oral swabs, to determine the presence of infection with SARS-CoV-2. 

• This type of test tells you if a patient is currently infected with the disease. 
• Recommended to diagnose acute infection in symptomatic and asymptomatic patients. 

There are currently two types of authorized SARS-CoV-2 viral diagnostic tests that use different technological principles: nucleic acid amplification tests (NAATs) and antigen tests. Each of these detects a different part of the SARS-CoV-2 particle in acute infection (3). 

• NAATs, such as PCR tests, are more reliable particularly for people without symptoms. Samples are processed in a lab within a few hours to days and detect viral genetic material. If you have been infected within the last 90 days, you may still have viral particles in your body and could test positive via NAAT.  

• Antigen tests, or rapid tests, assess for viral particles (antigens) and produce results in about 15 minutes. These can be done in EDs, doctor’s offices, and even at home. These tests are less accurate than NAATs and may need to be repeated in a few days to ensure a negative result is accurate (3).  

Negative results mean the virus was not detected at the time of testing but do not rule out infection. Repeated testing and continued quarantining may be indicated and depends on the individual scenario. Positive results mean a person should isolate if they have not been already. For purposes of determining how long to isolate, the date of symptoms onset is day 0 for symptomatic patients, and the date the test sample was collected is day 0 for asymptomatic patients (3).  

Antibody tests can look for antibodies against SARS-CoV-2 in serum samples. After infection or vaccination, antibodies are produced and circulate through the bloodstream. The amount of time antibodies take to appear and are present after infection and/or vaccination varies by person and is not always a reliable indicator of timeline. Antibody tests are not often indicated and may sometimes be used to support a clinical assessment of persons who present in the later stages of illness when used in conjunction with viral testing (3).

Quarantine vs. Isolation: What Is the Difference?

Quarantine: refers to keeping someone who has been exposed away from others to prevent potential spread. In the beginning of the pandemic when information was just emerging and reliable testing was not widely available, anyone with a suspected exposure to COVID-19 was advised to quarantine at home for 10-14 days. Now, with the development of the vaccine and easy access to testing, there is not as much need to quarantine at home (2). Current recommendations for anyone exposed to COVID-19 include:  

• Wear a mask  
• Avoid being around high-risk individuals 
• Watch for symptoms 
• Get tested at least 5 days after exposure (testing earlier may increase the chances of a false negative) 
• Continue these precautions for 10 days from exposure (the date of exposure is day 0) 
• Isolate and retest if symptoms occur at any point (2) 

Isolation: refers to keeping those actively infected away from other individuals to reduce spread. This keeps someone infected with the virus away from others, even in their home (7). 

People with confirmed infection should isolate for 5 days as this is when they are most infectious. Staying home and remaining separate as much as possible is ideal, and wearing a high quality mask when around others is strongly encouraged.  

• For people who tested positive but have no symptoms, they may end isolation after 5 days. If symptoms start at any point during their isolation, the 5 days should be restarted.  
• For those with mild symptoms, if they are improving after 5 days they may end isolation. If symptoms are not improving, isolation needs to continue until the person is fever free for 24 hours.  
• Those who were moderately or seriously ill should isolate for a full 10 days (7).
  

Treatment

Treatment for COVID-19 infection is often supportive. For mild to moderate cases, symptoms can be effectively managed with rest, fluids, and over the counter medications like acetaminophen or ibuprofen for pain and fever (6).  

For older adults or high risk individuals who are more likely to experience severe illness, there are several FDA authorized antiviral options that may help reduce the duration or severity of illness. These include:  

• Nirmatrelvir with ritonavir (Paxlovid), which can be taken orally by adults and children over 12 years of age  
• Molnupiravir (Lagevrio), taken oral by adults 
• Remdesivir (Veklury), which is administered intravenously for adults and children (6).  

All antivirals must be taken with 5-7 days of symptom onset in order to be effective, so at-risk individuals should not delay seeking treatment with suspected or confirmed infection. Most common side effects of these medications include abdominal pain, nausea, and diarrhea (6).   

Convalescent plasma is another treatment option that may be recommended depending on a patient’s individual case. People with poor immune systems or receiving immunosuppressant medications may benefit from receiving antibody rich plasma from donors who recently recovered from COVID-19 (6).  

More severe cases of illness may require hospitalization with supplemental oxygen, IV fluids, or even mechanical ventilation. Additional diagnostics such as chest x-ray or arterial blood gasses may help determine the seriousness of the disease. Secondary infections such as pneumonia may need additional treatment such as antibiotics or steroids. Extreme complications such as Acute Respiratory Distress Syndrome (ARDS) or Multiple Organ Dysfunction Syndrome (MODS) may occur in those most at risk and require multifaceted specialty care in the ICU. Even with intensive treatment, ARDS or MODS may be fatal (6).  

COVID-19 Vaccines

One of the most unique parts of the SARS-CoV-2 pandemic, compared to pandemics of the past, is that existing technology and studies allowed scientists to develop a vaccine within a year of the first documented cases. It is estimated that the quick development of the vaccine saved many millions of lives by bolstering herd immunity, slowing the spread of disease, and lessening the severity of illness (4).  

Development

Prior to the outbreak of SARS-CoV-2, there was a large existing body of research about coronaviruses in general and decades of work on mRNA vaccines. Once the new virus’s genetics were sequenced, swift development of a vaccine was underway in early 2020. Using weakened or attenuated viruses for vaccines can take many years or even decades to develop; however producing an mRNA molecule is a much quicker process and had been trialed before in mice. This technology introduces manufactured RNA material into the body which then takes over the cells and produces SARS-CoV-2 spike proteins that are distributed throughout the body. This allows the body’s immune system to identify and destroy the spike protein and prepare for subsequent encounters with it, but because the original mRNA introduced was not that of the true SARS-CoV-2 virus, no infection occurs.  

The use of the mRNA vaccine was approved for emergency use by the FDA, bypassing other vaccines and medications in the development queue. The vaccines were still trialed on sample populations and dosages adjusted to find the most effective dose while keeping side effects minimal before being made available to the general adult population and, later, children over 6 months. Additional methods of vaccine delivery have been in development in the years since the pandemic started. These include a viral vector mechanism which introduces SARS-CoV-2 proteins contained in an adenovirus shell. This introduces the body to the viral antigen, but does not replicate within the body. There are also viral subunit vaccines which introduce pieces of the virus but never a whole viral particle; these are also non-replicating within the body.  Research, adjustments for new variants, and recording of vaccination side effects for all types is still ongoing (4). 

Currently Available Vaccines

In the United States, there are four authorized vaccines available:  

• Pfizer-BioNTech (mRNA) 
• Moderna (mRNA) 
• Novavax (protein subunit) 
• Johnson & Johnson’s Janssen (viral vector) 

Side Effects and Complications

All of the authorized vaccines are given intramuscularly. Potential side effects occur because the immune system is triggered. Possible side effects include:  

• Fever  
• Chills  
• Fatigue 
• Headache

Possible complications include:  

• Allergic reaction 
• Slightly elevated risk of myocarditis following the mRNA and Novavax vaccines, particularly in males ages 12-29 years 
• Increased risk for blood clots following Johnson & Johnson’s Jannsen vaccine (4) 

Current Recommendations

The current recommendations for vaccination dosing and boosters is based on which vaccine administered and the age of the patient.

For patients 18 years and older:  

Pfizer-BioNTech  

• Primary Series
  – 1st dose
  – 2nd dose: 3-8 weeks later 
• Booster: 2 months after last dose
  *This dosage interchangeable with Moderna 

Moderna 

• Primary series
  – First dose
  – 2nd dose: 4-8 weeks later 
• Booster: 2 months after last dose
  *This dosage interchangeable with Pfizer-BioNTech 

Novavax 

• Primary dosage
  – First dose
  – 2nd dose: 3-8 weeks later 
• Booster: only available in limited situations
  *Pfizer-BioNTech or Moderna may be given for booster doses for patients who originally received Novavax 

Johnson & Johnson’s Jannsen 

• Primary dosage 
• Booster: only available in limited situations
  

The number of boosters recommended after completion of primary series varies by individual and depends on a variety of factors such as boosters for particular variants, high risk individuals, or pregnancy. It is not recommended to mix manufacturers during the primary series.  

People who may be eligible for the Novavax or Johnson & Johnson’s Jannsen boosters include those unwilling or unable to get the mRNA vaccine and 18 years or older, at least 6 months since completion of their primary series, and have not received any other booster doses.  

For children, the current recommendations vary by manufacturer.  

Pfizer-BioNTech  

Ages 6 months to 4 years 

• Primary Series
  – 1st dose
  – 2nd dose: 3-8 weeks later
  – 3rd dose: 8 weeks after 2nd dose 

Ages 5 to 11 years

• Primary Series
  – 1st dose
  – 2nd dose: 3-8 weeks later
• Booster: 2 months after last dose
   – For children age 5, this dose must be Pfizer-BioNTech
   – For children ages 6 to 11, this dosage interchangeable with Moderna 

Ages 12 to 17 years

• Primary Series
  – 1st dose
  – 2nd dose: 3-8 weeks later 
• Booster: 2 months after last dose
   *This dosage interchangeable with Moderna 

Moderna 

Ages 6 months to 5 years 

• Primary series
  – First dose
  – 2nd dose: 4-8 weeks later
• Booster: 2 months after last dose
  *For children 6 months to 4 years, boosters may only be Moderna
  *For children ages 5 years, this booster is interchangeable with Pfizer-BioNTech Booster

Ages 6 to 17 years

• Primary series
  – First dose
  – 2nd dose: 4-8 weeks later 
• Booster: 2 months after last dose
  *This dosage interchangeable with Pfizer-BioNTech

Novavax 

12 to 17 years 

• Primary dosage
  – First Dose
  – 2nd dose: 3-8 weeks later 
• Booster: not available for children under age 18
• *Pfizer-BioNTech or Moderna may be given for booster doses for patients who originally received Novavax (4)

Vaccine and Pregnancy

COVID-19 vaccines are recommended for patients who are pregnant, breastfeeding, or may become pregnant. Vaccination has been shown to reduce the risk of COVID-19 complications during pregnancy such as preterm or stillbirth and offers protection of the infant once born prior to receiving their own vaccine at 6 months of age. There is an ongoing study specifically to monitor the health of patients who received a COVID-19 vaccine during pregnancy and anyone who qualifies can register at v-safe, the CDC pregnancy and vaccine registry (4). 

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