INTRODUCTION
The World Health Organization (WHO) declared COVID-19, an infectious disease caused by the SARS-CoV-2 coronavirus, a pandemic in March 2020 following its emergence in Wuhan, China in December 2019. Globally, by July 2022, the pandemic had resulted in approximately 574 million cases and 6.39 million deaths [1].
While many COVID-19 infections present as asymptomatic or mild, characterized by symptoms such as cough, fever, fatigue, and respiratory issues, severe cases can lead to pneumonia, acute respiratory distress syndrome (ARDS), and multiple organ failure. Adding to the complexity, a growing body of evidence highlights neurological manifestations associated with COVID-19, including headache, loss of smell (anosmia), altered taste (dysgeusia), dizziness, seizures, and cognitive impairment [2].
COVID-19 infection can trigger a cascade of complications, such as encephalitis, systemic inflammation, and cerebrovascular changes, potentially leading to long-term neurological sequelae. These after-effects can exacerbate pre-existing conditions or initiate new neurological and cerebrovascular diseases, including stroke. Studies indicate that a significant proportion of COVID-19 survivors experience cognitive or motor impairments upon hospital discharge, particularly those in high-risk groups [3].
In navigating the complexities of COVID-19 and its aftermath, the role of nurses in applying the Nursing Process (NP) is paramount. The NP is crucial for identifying and addressing the unique care needs of patients affected by COVID-19, aiming to mitigate complications and long-term sequelae [4]. Nurses provide holistic care, tailoring nursing interventions to the specific challenges presented by coronavirus infection.
The Nursing Process, a systematic framework for patient care, comprises five distinct stages: assessment, Nursing Diagnosis (ND), planning, implementation, and evaluation [5]. Its application in daily nursing practice, especially during pandemics, is essential for ensuring high-quality, safe, and effective care in complex and challenging situations.
Given the limited research on the implementation of the Nursing Process for post-COVID-19 patients, there is a clear need for studies to enhance the quality of care provided to this population. This study aims to address this gap by examining the sociodemographic profile, nursing diagnoses, and nursing care provided to post-COVID-19 patients. This research is particularly relevant as nursing teams require evidence-based care plans tailored to the specific needs of COVID-19 survivors to minimize disease-related deficits [3, 4]. Therefore, this study seeks to answer the critical question: What are the sociodemographic profiles, diagnoses, and nursing care needs of post-COVID-19 patients admitted to a university hospital in southern Brazil between January 2020 and January 2021?
OBJECTIVES
This study aims to analyze the sociodemographic profile, nursing diagnoses, and nursing care provided to post-COVID-19 patients admitted to a university hospital in southern Brazil.
METHODS
Ethical Considerations
The research protocol was reviewed and approved by the Nursing School Research Commission (COMPESQ) and the Research Ethics Committee (REC) of the Hospital de Clínicas de Porto Alegre (HCPA). This ensured adherence to ethical guidelines for research involving human subjects, including those related to virtual research environments [6, 7, 8]. As this study utilized secondary data from medical records, informed consent from patients was waived.
Study Design, Setting, and Period
This retrospective cohort study [9] adhered to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines. The study was conducted in the Post-COVID-19 Clinical Inpatient Units of HCPA. Hospital de Clínicas is a public university hospital affiliated with the Ministry of Education and the Universidade Federal do Rio Grande do Sul (UFRGS), featuring 919 beds and a workforce of 6,843 employees. During the COVID-19 pandemic, HCPA served as a key referral center for critically ill COVID-19 patients. The hospital includes a 62-bed Adult Intensive Care and Coronary Care Unit and an additional 135 beds dedicated to COVID-19 adult Critical Care Units (CCUs) [10].
Data Collection, Sample, and Criteria
The study sample comprised 1467 medical records of COVID-19 survivors hospitalized in HCPA Clinical Units between January 2020 and January 2021.
Data were obtained through queries of the clinical database linked to HCPA’s COVID-19 Biobank [11] between April and July 2022. Inclusion criteria were: survival of COVID-19, age 18 years or older, and prior admission to a CCU. Exclusion criteria were: COVID-19 survivors under 18 years of age, patients not admitted to the CCU, and records with incomplete data.
Data Analysis
Qualitative variables were presented as absolute and relative frequencies [n (%)], while quantitative variables were described using means, standard deviations, interquartile ranges (quartile 1 – quartile 3), minimum and maximum values, and counts of missing data. The distribution of quantitative variables was assessed using histograms and quantile-quantile plots. Due to the skewed distribution of the variables, group differences were analyzed using the Kruskall-Wallis test. All analyses were performed using R software, version 4.2.0, with the tidyverse package, version 1.3.1 [12, 13]. Figures were generated in Scalable Vector Graphics format.
RESULTS
The study analyzed 1467 medical records of patients who tested positive for SARS-CoV-2 and were discharged from the CCU between January 2020 and January 2021.
Sociodemographic analysis revealed a predominance of males (52.9%), with an average age of 58.9 years. The majority of patients were white (81.1%), married (42.9%), and retired (11.2%). Table 1 details the sociodemographic characteristics of post-CCU COVID-19 survivors. Regarding clinical variables, the most common diagnostic test for COVID-19 was PCRVR (respiratory virus PCR), performed in 44% (646 patients). The average patient weight was 82.9 kg, ranging from 37 kg to 180 kg.
Table 1 illustrates the prevalence of Nursing Diagnoses (NDs) in post-hospitalization COVID-19 survivors from the CCU. The most prevalent ND was Impaired Physiological Balance Syndrome (77.3%), followed by (00004) Risk for Infection (48%), (00155) Risk for Falls (46.5%), (00249) Risk for Pressure Injury (29%), (00032) Ineffective Breathing Pattern (24.4%), and (00044) Impaired Tissue Integrity (22%).
Less frequent diagnoses, each prescribed only once by nurses, included: (00105) Interrupted Breastfeeding; (00126) Deficient Knowledge; (00124) Hopelessness; (00256) Delivery Pain; (00052) Impaired Social Interaction; (00131) Impaired Memory; (00096) Sleep Deprivation; (00301) Maladaptive Grieving; (00139) Risk for Self-Mutilation; (00104) Ineffective Breastfeeding; (00290) Risk for Elopement Attempt; (00218) Risk for Adverse Reaction to Iodinated Contrast Media; and (00038) Risk for Physical Trauma.
Notably, 9.9% of patients exhibited altered levels of consciousness, including confusion, lethargy, coma, and agitation. Table 2 presents the association between level of consciousness/neurological regulation and specific NDs: (00128) Acute Confusion; (00129) Chronic Confusion; (00049) Decreased Intracranial Adaptive Capacity; (00201) Risk for Ineffective Cerebral Tissue Perfusion; (00103) Impaired Swallowing; (00123) Unilateral Neglect; and (00131) Impaired Memory.
Figure 1 illustrates the association between Glasgow Coma Scale (GCS) scores and the NDs: (00128) Acute Confusion; (00129) Chronic Confusion; (00049) Decreased Intracranial Adaptive Capacity; (00201) Risk for Ineffective Cerebral Tissue Perfusion; (00103) Impaired Swallowing; (00123) Unilateral Neglect; and (00131) Impaired Memory. The average GCS score was 14, with scores ranging from 8 to 15.
Figure 1: Analysis of Glasgow Coma Scale scores in relation to nursing diagnoses for post-ICU COVID-19 patients, highlighting the correlation between neurological status and identified nursing needs.
The Mann-Whitney U test revealed a significant difference in Glasgow scores (p<0.001) between patients with and without these neurological NDs.
Figure 2 shows the correlation between the SAK Fall Risk Scale score and the ND “Risk for Falls”. The mean SAK score in the sample was 5.3, with scores varying from 0 to 16.
Figure 2: Examining the relationship between SAK Fall Risk Scale scores and the nursing diagnosis “Risk for Falls” in post-ICU COVID-19 patients, demonstrating the scale’s effectiveness in identifying fall risk.
The Mann-Whitney U test indicated significant differences in SAK scores (p<0.001) between patients diagnosed with “Risk for Falls” and those without.
Table 3 presents the prevalence of nursing care interventions prescribed for post-COVID-19 patients. A total of 564 distinct nursing care procedures were identified. The most prevalent interventions included: implementing aerosol precautions (94.5%); implementing droplet precautions (93.4%); monitoring vital signs (91.9%); applying standard disinfectant to equipment and surfaces (89.6%); implementing contact precautions (88.8%); and implementing care according to the falls prevention protocol (82.9%).
The high prevalence of aerosol and droplet precautions (94.5% and 93.5%, respectively) is notable. Approximately 47% of the prescribed nursing care procedures were related to infection prevention, highlighting the institutional and nursing team’s focus on managing the “Risk for Infection,” the second most frequently identified nursing diagnosis in this patient population.
DISCUSSION
Managing severe COVID-19 cases required nurses to utilize robust clinical reasoning and diagnostic judgment skills to effectively apply the Nursing Process in critical care settings [4].
The sociodemographic profile of participants showed a higher prevalence of white individuals (81%), consistent with findings from a study in Ponta Grossa, Paraná (PR), which also reported over 80% of COVID-19 patients being white [14]. This aligns with the demographic distribution in Rio Grande do Sul, where whites constitute 79% of the population [15]. However, this demographic data should not diminish the critical need to address healthcare disparities affecting minority populations, including the Black population, especially concerning access to health services [16]. Ensuring equitable access to public health policies for all populations remains a crucial societal goal.
The most prevalent Nursing Diagnoses (NDs) identified were: Impaired Physiological Balance Syndrome (77.3%); (00004) Risk for Infection (48%); (00155) Risk for Falls (46.5%); (00249) Risk for Pressure Injury (29%); (00032) Ineffective Breathing Pattern (24.4%); and (00044) Impaired Tissue Integrity (22%). According to the NANDA-I International Classification, a nursing diagnosis is defined as “a clinical judgment concerning a human response to a health condition or life process, or a vulnerability for that response, by an individual, family, group, or community” [17]. Diagnoses can be problem-focused, risk-focused, health promotion-oriented, or syndrome-specific.
In this study, the predominant NDs fall within the Safety/Protection domain (Risk for Infection, Risk for Falls, Risk for Pressure Injury, and Impaired Tissue Integrity) and the Activity/Rest domain (Ineffective Breathing Pattern). The corresponding classes are infection, physical injury, and cardiovascular/pulmonary responses [17].
The severity of the COVID-19 cases in this study highlighted a focus on patients’ psychobiological needs, potentially overshadowing their psychosocial and psychospiritual needs. This observation is consistent with findings from the Nursing Process Research Network (RePPE), which identified Risk for Infection, Risk for Pressure Injury, and Impaired Spontaneous Ventilation as common diagnoses in hospitalized critical care patients [4].
Notably, “Impaired Physiological Balance Syndrome,” a diagnosis currently under development [18], was prevalent in over 70% of patients. This high prevalence underscores nurses’ emphasis on interventions aimed at restoring physiological equilibrium. Although this diagnosis is not yet officially included in the NANDA-I Classification, nurses at HCPA advocated for its inclusion in the electronic medical record system (AGHUse) to streamline the Nursing Process for these complex cases. The inclusion of this syndrome diagnosis aims to reduce the time required for diagnostic processes and encompass the multifaceted health issues observed in severe COVID-19 cases [18].
Furthermore, several NDs were recorded infrequently, each only once within the study sample. These included: Interrupted Breastfeeding; Deficient Knowledge; Hopelessness; Delivery Pain; Impaired Social Interaction; Impaired Memory; Impaired Oral Mucous Membrane; Sleep Deprivation; Maladaptive Grieving; Risk for Self-Mutilation; Ineffective Breastfeeding; Risk for Elopement Attempt; Risk for Adverse Reaction to Iodinated Contrast Media; and Risk for Physical Trauma.
COVID-19 is known to cause both transient and permanent neurological sequelae, clinically evident during and after hospitalization. Encephalitis, systemic inflammation, organ dysfunction, and cerebrovascular disorders can contribute to long-term neurological issues, exacerbating existing conditions or initiating new cerebrovascular diseases [3]. Neurological manifestations commonly reported include headache, anosmia, dysgeusia, dizziness, seizures, and impaired consciousness [3, 19].
According to NANDA-I taxonomy, NDs frequently used for patients with neurological conditions and secondary neurological consequences included: Spiritual Distress; Hyperthermia; Acute Pain; Nausea; Imbalanced Nutrition: Less Than Body Requirements; Impaired Swallowing; Acute Confusion; Risk for Acute Confusion; Impaired Memory; Disturbed Thought Process; Impaired Social Interaction; Fatigue; Anxiety; Impaired Urinary Elimination; Constipation; Risk for Constipation; Diarrhea; Impaired Physical Mobility; Feeding Self-Care Deficit; Bathing Self-Care Deficit; Toileting Self-Care Deficit; Dressing Self-Care Deficit; Risk for Relocation Stress Syndrome; Risk for Infection; Risk for Falls; Risk for Pressure Ulcer; Risk for Impaired Skin Integrity; Impaired Skin Integrity; Ineffective Protection; Ineffective Breathing Pattern; Impaired Gas Exchange; Impaired Spontaneous Ventilation; Excess Fluid Volume; and Risk for Electrolyte Imbalance [17, 18, 20].
This study examined the association between Glasgow Coma Scale (GCS) scores and NDs related to consciousness level and neurological regulation from the NANDA-I domains. The GCS, developed in 1974, is a globally used tool for assessing neurological disorders and monitoring consciousness levels. It standardizes communication among healthcare professionals and aids in prognosis prediction. The GCS evaluates eye-opening, verbal response, and motor response, with total scores ranging from 3 to 15 [21].
The average GCS score in this study was 14, indicating that confusion was prevalent among patients, possibly linked to delirium following prolonged sedation. Approximately 9.9% of patients showed altered consciousness levels (confusion, lethargy, coma, agitation). A significant association was found between patients described as “lucid” and the presence of neurological diagnoses. While 4.0% of lucid patients had at least one of the seven neurological NDs, 13.8% of non-lucid patients had at least one of these diagnoses. The chi-square test confirmed a significant association between “lucid” status and neurological diagnoses (p<0.001), reinforcing the link between altered consciousness and specific nursing diagnoses [3, 19].
Regarding the SAK Fall Risk Scale and the ND “Risk for Falls,” the average SAK score was 5.3. The SAK scale includes variables like disorientation, frequent urination, mobility limitations, and medication count to categorize patients into low, moderate, and high fall risk categories [22]. The significant association between SAK scores and the ND “Risk for Falls” indicates that nurses effectively identified this diagnosis for patients at moderate to high risk based on SAK scale assessments.
Of the top fifteen nursing care interventions, approximately 47% were focused on infection prevention. This highlights the strong emphasis on mitigating “Risk for Infection,” which aligns with RePPE guidelines for COVID-19 patients in CCUs [4] and reflects the institutional priority on infection control during the pandemic.
Study Limitations
The findings of this study are limited by its single-center, retrospective design, which may restrict generalizability. Multi-center studies are recommended to validate these findings across broader populations. Additionally, the study identified a scarcity of research on the application of the Nursing Process during pandemics, indicating a need for further qualitative research to explore nurses’ perspectives on the under-representation of NDs related to psychosocial and psychospiritual domains.
Contributions to Nursing and Health
This study provides valuable insights into the sociodemographic profile, diagnoses, and nursing care priorities for post-COVID-19 patients. It highlights the primary focus on psychobiological needs in nursing care during the pandemic and underscores the importance of integrating psychosocial and psychospiritual considerations into the Nursing Process. These findings emphasize the need for enhanced nursing education that promotes clinical reasoning and holistic critical thinking, preparing nurses to address all dimensions of patients’ basic human needs, particularly in pandemic contexts.
CONCLUSIONS
This study reveals that COVID-19 predominantly affected white males around 58 years of age, who were married and retired in the studied population. Nursing Diagnoses and care interventions were crucial for maintaining quality care, with prevalent NDs including Impaired Physiological Balance Syndrome, Risk for Infection, Risk for Falls, Risk for Pressure Injury, and Ineffective Breathing Pattern. A key finding is the potential overemphasis on psychobiological needs at the expense of psychosocial and psychospiritual needs, representing a critical gap in holistic care delivery during pandemics.
The study underscores the necessity of cultivating clinical reasoning and holistic critical thinking skills in nursing education. This preparation is essential for nurses to conduct comprehensive patient assessments that address all dimensions of human needs, guided by nursing theories. The evidence from this study can inform clinical practice and enhance the application of the diagnostic process by nurses in pandemic situations. Accurate implementation of the Nursing Process stages, guided by critical thinking and clinical judgment, is vital for effective care. Post-ICU patients, especially those recovering from COVID-19, require meticulous and targeted care focused on potential disease-related complications.
The Nursing Diagnosis process serves as a valuable tool for nurses, enabling a critical and holistic approach to patient needs during pandemics. This research highlights the ongoing need for continuous education and training for nursing teams to foster a humanistic and holistic approach to care, ensuring that psychosocial and psychospiritual needs are not overlooked alongside psychobiological needs. Integrating diagnoses focused on the principles of life domains from the International Classification of Nursing Diagnoses (NANDA-I) in conjunction with diagnoses addressing psychobiological needs is crucial for comprehensive patient care, especially in crisis contexts.
References
[1] World Health Organization. WHO Coronavirus (COVID-19) Dashboard. Geneva: WHO; 2022 [cited 2022 Jul 27]. Available from: https://covid19.who.int/
[2] остались оригинальные ссылки, вставьте корректные если необходимо
