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Plano de Ação para ILPI's

NURSING

Protocol updated on 20-October-2020

For Nursing Professionals

Nurses

General Guidelines

The nurse is responsible for planning, organizing, directing,
coordinating, executing and evaluating nursing services at the ILPI, ensuring that the best care is offered to the resident 24 hours a day.

Service organization:

  • Elaborate the work  schedule of the nursing team so that professionals are well distributed to ensure the provision of care at all times, without the excess of professionals in the period – minimum staffing;
  • Relocate, if possible, nursing professionals from the risk group, with the indication that they work in places that do not attend suspected or confirmed patients of COVID-19;
  • Carry out immediate notification of suspected and confirmed cases to municipal epidemiological surveillance, in order to collaborate with epidemiological surveillance and control measures;
  • Build protocols and flow of care (including end of life care and body preparation) and make them available in an accessible way to everyone involved in assisting suspected or confirmed cases of infection with the new coronavirus;
  • Provide training and permanent education for the nursing team, realizing their needs and clarifying possible doubts. At this time of pandemic, it is convenient to carry out specific training related to hand washing, use of PPE, respiratory etiquette and biosafety;
  • Establish an entrance flow for employees of the institution so that they only have contact with the elderly after bathing or complete change of clothes (wearing the institution’s exclusive uniform, including footwear, removal of wristwatches, rings, among other ornaments);
  • Review the employees’ flow in the cafeteria, stablishing if possible, meal shifts in order to avoid crowding;
  • Contribute to the training and continuing education of other ILPI workers and volunteers;
  • Provide the materials and equipment necessary for the provision of nursing care, as well as Personal Protective Equipment (PPE) for the team;
  • Plan the nursing care to be provided by the team within 24 hours through the Nursing Care Systematization – SAE;
  • Reorganize the care routine in order to keep the elderly at a safe distance, avoiding crowds (for example, meal times, TV room, activities together);
  • Participate in multidisciplinary team and nursing team meetings, with due care to prevent infection;
  • Promote spaces for dialogue with employees, residents and family members, taking due precautions, being a vehicle for reliable updates and information, listening to questions and suggestions;
  • Suspend indefinitely all visits, encouraging family members to stay at home and to stablish communications through
    technology;
  • Restrain the exit of the institution, whether on a tour or outside services;
  • Restrain visits of external professionals who provide periodical services and volunteers, (hairdressers, podiatrists, religious groups, etc.);
  • Establish a Quick Response Team for support and guidance upon need for guidance and urgent care.

Care:

  • Conduct gerontological assessment of the elderly, reducing physical examination to what is strictly necessary;
  • Develop individual nursing care plan, observing established schedule;
  • Receive the elderly and their families, identify nursing needs through interviews, physical examination and systematic
    observations;
  • Provide direct nursing care to the elderly, in particular to the most vulnerable;
  • Update vaccination status against influenza and pneumococcal disease as indicated, for residents and employees;
  • In the case of vaccination campaigns, inform the Basic Health Unit of reference the number of residents according to sex and age, as well as employees to schedule vaccination at the institution;
  • Take care of the mental health of the elderly and employees. Affectionate personal communication can relieve anxiety. Try to keep their routines and life normal, taking precautions;
  • Maintain continuous communication channel with family members about their elderly.

Nursing assistants

General Guidelines

  • Check the vital signs (axillary temperature, pulse, breathing (TPR) and blood pressure (BP) of the resident once a day or as needed, adopting all measures to prevent infection;
  • Pay attention to changes in vital signs, signs and reactions that can be altered due to a possible respiratory infection;
  • Administer medications, provide hygiene, comfort and food care to the resident paying attention to infection prevention measures;
  • Meet residents in their needs and requests, minimizing the touch when necessary;
  • Ensure the maintenance of cleanliness and order in your work environment;
  • Do not allow residents to share objects for personal use and advise them not to do so;
  • Taking care of the mental health of the elderly, providing an affectionate personal communication that can relieve anxiety. Try to keep your routines and life normal, taking precautions;
  • Report changes in the resident’s general condition to the nurse, be it in any order;
  • Record the nursing observations and care provided in the medical record.

For the entire Care Team:

General Guidelines

  • Reinforce care regarding hand hygiene, respiratory etiquette and responsible and appropriate use of PPE’s;
  • Be aware that wearing masks when not indicated can generate unnecessary costs and create a false sense of security. In addition, the mask must be properly adjusted to the face to ensure its effectiveness and reduce the risk of transmission;
  • All professionals should be instructed on how to use, remove, dispose of PPE and the importance of hand hygiene before and after use;
  • Keep the elderly at a certain distance, avoiding crowds of people;
  • Maintain natural ventilation in the environments and reduce the use of air conditioners when strictly necessary.

Use of PPE and individual protection measures

Is the use of the mask recommended?

  • The masks must be used to avoid contamination of the professional’s mouth and nose by respiratory droplets, when he acts at a distance of less than 1 meter from the suspected or confirmed person of infection. Wearing masks when not indicated can generate unnecessary costs and create a false sense of security. In addition, the mask must be properly adjusted to the face to ensure its effectiveness and reduce the risk of transmission.

Who should use it?

  • All residents must use mask. It can be a fabric mask if there is no suspicion or confirmation of contamination by COVID-19;
  • Health professionals and institution’s staff must wear the surgical mask, and unrestrictedly the N95 mask when in contact with suspected or confirmed cases or when performing or participating in procedures that produce aerosols (orotracheal intubation, non-invasive ventilation, tracheostomy, cardiopulmonary resuscitation, manual ventilation before intubation and bronchoscopy).

Correct use of the mask

  • Place the mask carefully to cover the mouth and nose and tie securely, to minimize the gap between the face and the mask;
  • As long as you are in use, avoid touching a mask;
  • Remove the mask using the appropriate technique (ie do not touch the front, remove by loosening the straps);
  • Change the mask every 2 hours (if continued use) or when it gets wet;
  • If the mask gets wet, replace it with a new one, clean and dry;
  • Immediately dispose of the mask after removal, it is not allowed
    to reuse disposable masks.
  • Fabric masks (for example, cotton or gauze) are not recommended under any circumstances;
  • After removal, or whenever you accidentally touch the used mask, clean your hands using 70% alcoholic preparation or water and liquid soap (or foam).
  • Staff must change mask every time they leave or enter the institution.

Fabric masks cleaning

  • According to Brazilian National Surveillance Agency, the hygiene of fabric masks must follow the recommendations below:
  • • Fabric masks must be washed separately from other clothes;
    • Wash the mask previously with running water and mild soap;
    • Soak it in a solution of water with bleach or another equivalent disinfectant for 20 to 30 minutes. To prepare the solution, dilute 2 tablespoons of bleach in 1 liter of water.
    • Rinse it well under running water to remove any remaining disinfectant;
    • Avoid twisting the mask too hard and let it dry;
    • Iron it with hot iron;
    • Discard the fabric mask when observing loss of elasticity of the fixation rods, or deformity in the fabric that may cause damage to the barrier;
    • Make sure that the mask is not damaged (bad adjustment, deformation, worn out, etc.);
    • Store it in a closed container.

Correct use of gloves

Procedural gloves should be worn whenever the professional enters the room for any procedure or when there are residents with suspected or confirmed coronavirus.

  • Wear gloves when at risk of contact with blood, body fluids, secretions, excretions, mucous membranes and skin that is not intact;
  • Sanitize your hands before putting on gloves;
  • Wear gloves as a precautionary contact measure for all contacts with the resident and their environment;
  • Wear gloves to touch surfaces close to residents in contact precautions;
  • Gloves must be replaced when they become dirty, torn, between different residents;
  • Remove gloves immediately after each appointment or procedure;
  • Do not unnecessarily handle environmental surfaces and materials with gloved hands;
  • Do not handle personal items when your hands are gloved;
  • Discard gloves in infectious waste;
  • Never wash or decontaminate them;
  • Perform hand hygiene immediately after removing gloves. (São Paulo, 2016).

If there are suspected cases of Coronavirus

Precautions for the Professional

  • Respiratory isolation through the use, by the professional, of a face mask with respiratory protection filter with minimum efficiency in the filtration of 95% of particles up to 0.3 um (type PFF2, PFF3, N95, N99, N100);
  • Use of gloves, hat, disposable apron and goggles;
  • Perform hand hygiene respecting the 5 moments:
    1- before contact with the resident;
    2- before performing the aseptic procedure;
    3- after risk of exposure to body fluids;
    4- after contact with the resident;
    5- after contact with any area close to the resident;
  • Equipment for the exclusive use of the resident: stethoscope, cuff, sphygmomanometer and thermometer.

Population Prevention Measures

  • Make sure to have individual, ventilated and with closed door rooms for residents with suspicion or confirmed COVID-19 infection. If this is not possible, define temporary spaces specially reserved for collective isolation (in cohort) with beds at least one meter apart from each other;
  • Residents with suspicion and confirmed COVID-19 infection should be kept in different rooms, when in collective isolation;
  • Residents’ isolation for suspicion or confirmed cases of COVID19 should occur for a period of 14 days;
  • Residents with suspicion or confirmed infection by COVID-19, without criteria for hospital admission or those who were discharged from hospital and were instructed to return to the institution, should remain in isolation in private rooms with the door closed and properly signaled;
  • The transport or circulation of residents with COVID-19 suspicion or confirmed cases in the external areas must be prohibited;
  • Accompanying persons must wear mask, gown and gloves when they are in the room with the resident;
  • Accompanying persons must not stay in resident’s room during procedures that generate aerosols.

Confirmed Coronavirus Case

General Orientations

  • There should be visual communication at the door of the room in order to alert about respiratory isolation for droplets and contact;
  • Specific professionals should be appointed to work in the isolation area, preferably, the assistance of this team to other patients is prohibited;
  • The circulation of employees in the room should be kept to a minimum, in order to minimize the exposure of professionals;
  • Residents’ vital signs checking must be performed twice a day;
  • Symptomatic signs of the disease, as well as worsening sings (decreased level of consciousness, confusion, apathy, fever, respiratory distress, lack of appetite) must be monitored;
  • It is recommended that nutritionists carry out their assessment over the phone, or they must follow all the precautions described above, also clothing professionals and waiter/kitchen maid should not enter the room, and the delivery of the meals tray must be aligned with nursing staff.

Final Remarks

  • Keep a record of all people who came into contact with a suspected case (professionals, visitors or family members);
  • People with diseases or conditions that reduce immunity (cancer, radiotherapy, chemotherapy, transplantation, people with HIV and pregnant women) cannot be elected as companions of suspected or confirmed cases, nor as a health professional designated for patient care;
  • Symptomatic professionals for respiratory infection should be removed from work.

References

  • São Paulo. Secretaria de Estado da Saúde. Centro de Vigilância Sanitária. Divisão de Infecção Hospitalar. Recomendações sobre o uso de luvas em serviços de saúde. São Paulo, 2016.
    Disponível em http://www.saude.sp.gov.br/resources/cve-centrode-vigilancia-epidemiologica/areas-de-vigilancia/infeccao hospitalar/bmr/doc/ih16_bmr_uso_luvas.pdf
  • COREN-SP. OFÍCIO CIRCULAR Nº 001/2020/GAB/PRES/COREN-SP de 27 de Março de 2020. Disponível em: https://portal.corensp.gov.br/noticias/covid-19-coren-sp-publica-diretrizes-de-atuacaovoltadas-a-instituicoes-e-rts/
  • Agência Nacional de Vigilância Sanitária (BR). Orientações Gerais – Máscaras faciais de uso não profissional. [Internet]. 2020. [Acesso 22 abr, 2020] Available in: http://portal.anvisa.gov.br/documents/219201/4340788/NT+M%C3%A1s
    caras.pdf/bf430184-8550-42cb-a975-1d5e1c5a10f7
  • Passos KA, dos Santos MP, Campiolo EL. Healthcare workers x covid19 and population-wide use of face masks to prevent sars-cov-2 transmission and infection. InterAmerican Journal of Medicine and Health, 3. Available in https://doi.org/10.31005/iajmh.v3i0.142
  • Taminato M, Mizusaki-Imoto A, Saconato H, Franco ES, Puga ME, Duarte ML, et al. Homemade cloth face masks as a barrier against respiratory droplets – systematic review. Acta Paul Enferm. 2020: e APE20200103. Available in https://www.scielo.br/pdf/ape/v33/en_1982- 0194-ape-33-eAPE20200103.pdf
  • Santana RF, Silva MB, Marcos DASR, Rosa CS, Wetzel Jr W, Delvalle R. Nursing recommendations for facing dissemination of COVID-19 in Brazilian Nursing Homes. Rev Bras Enferm. 2020;73(Suppl2):e20200260. doi: http://dx.doi.org/10.1590/0034-7167-2020-0260
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