## Level 3 -- Bedridden

All the good care in Level 2 has not worked and things are getting worse. Doesn't mean you did anything wrong, just keep going. Except now the patient isyou're getting weaker. He or she is often too weakweaker, and you're not just coughing anymore, but you feel like absolute crap (doctors call that "general malaise"), things hurt, and you want to get out ofbe in bed and may need extra encouragementmost of the time. It's easy to forget to eat and drink.

### If the patient is you{{ site.data.tags.breakout.begin }}

This is when you start telling other people around youNow that you are really ill and are mostly in bed. Talkgetting ill, it's time to someonelet your regular General Practitioner / doctor / primary care physician know if you trust about how theyhaven't spoken to him/her already earlier. The doctor may do house visits or have a protocol to take care of you. Have this person or these people read this document. Ifassess you have people in your environment who have already had COVID-19 (something that will be increasingly common as time goes on), such people would naturally makeover the best caregivers as they presumably willphone or via videochat. There may be COVID-19-immune. Otherwise try to judge what is wisest inadditional advice or guidelines your circumstances. By all means do not wait with this until the very last moment, because if the disease progresses, youdoctor will get short of breath which inevitably will also affect your ability to talkgive you. Doctors know their patients and can tailor advice to think clearly.the case at hand. So follow any advice, also if it contradicts any of the more general information given here.

![](/images/sick-in-bed.png)Ask the doctor or otherwise try to use reliable local information to see what, if anything, is expected of people with worsening symptoms where you are. The health authorities may have a website, app, or other mechanism to register a worsening of symptoms. This could be important for keeping an eye on the pandemic, but also to figure out who needs additional care.

### In any caseIf you have no primary care doctor, you will need to seek up-to-date local information on what help is available to you. If all lines everywhere are busy -- which is certainly a possibility during the peaks of this crisis -- do not panic, just keep trying.

* Stay in bed. At this point rest is very important. The patient should sleep as much as possible. At least in the beginning, patients will still be able to get out of bed for limited amounts of time. Toilet, a quick rinse-off shower, weighing once a day (note in [diary](/images/covid-diary.pdf)). Put new sheets on the bed as often as possible and wash the old sheets at 60 degrees Celsius or warmer.
* Ventilate the room as often as possible.
* Drink more water! (more than 2 liters and less then 5 liters a day).
* Try to eat vitamin-rich foods, but multi-vitamin drink is also ok.
* Inhale more often.{{ site.data.tags.breakout.end }}

At this point, read ahead for all the signs### Now thatindicate Level 4. The purpose of care in Level 3 is also to monitor the patient more and more closely so as to catch early any signs that the patient is moving to Level 4. For instance: If the patient is not able to drink at least 2 liters of fluids per day, you should (kindly) insist. Dehydration is a medical condition, and without this daily bare minimum you're quickly in Level 4.are sick

* **Rest**. At this point, rest is very important. Sleep as much as possible. At least in the beginning, you will still be able to get out of bed for limited amounts of time. Toilet, a quick rinse-off shower, weighing once a day (note in [diary](/assets/images/covid-diary.pdf)). Put new sheets on the bed when you can, and make sure the old sheets are washed at 60° Celsius (140° Farenheit) or warmer.
* **Get fresh air**. Ventilate the room as often as possible. 
* **Drink more water!** More than 2 liters and less then 5 liters a day, or at least 8.5 cups. Remember your body needs more fluids than usual when you're sweating from a fever. If you have a chronic condition that could worsen with excess fluids (e.g., heart failure or chronic kidney disease), consult a doctor. 
* **Eat something**. Try to eat vitamin-rich foods, but multi-vitamin drink is also ok.
* **Use those lungs**. See Level 2 on breathing deeply in and out, moving your arms above your head to help your chest fully expand, and even exercising your lung capacity if possible by blowing up a balloon or using another toy that requires blowing every hour.

### A typical day

At this stage, a typical day might look something like this: 

You get up, weigh, and note weight in illness diary. You might also want to take your temperature first thing, before eating or drinking, especially if you are taking temperature orally -- and note it in the illness diary, too. 

Then, start drinking fluids. Not too much caffeine or sugar. As much water and herbal tea as you like. Remember you want to drink at least 2 liters (around 8.5 cups) and up to 5 liters a day. 

Air out your home as much as possible, perhaps while the water for your morning tea or coffee is boiling.  If you have the energy (and enough sheets), consider changing your bed linens if they got sweaty / otherwise soiled. Next, have a quick shower if you're able. Staying clean can help you feel better mentally and emotionally, as well as physically. 

Eat a small, nutritious meal (piece of fresh fruit? handful of salted nuts?) -- something that sounds good to you. This is also a good time to take paracetamol (also known as acetaminophen) for fever / pain if you really need it, and note the dose and time in your illness diary.

If that was already enough exertion, take a rest. Nap whenever you can -- sleep is crucial for healing. If you're not sleepy but need to rest, then try to rest sitting up to give your lungs a better chance to drain. If you're still upright, now is a good time to steam to help your sinuses / airways open and mucus to drain. 

Speaking of being upright, remember to ventilate your room and breathe in the fresh air. Lift your arms over your head to fully expand your lungs on the inhale. Try blowing up a balloon to fully exhale. 

Keep drinking throughout the day. Some people find it helpful to empty and refill a liter bottle of water or a teapot that holds approximately a liter, so that it's easier to keep track of roughly how much you have drunk. This also makes it easier to keep water by the sofa or bed while you are resting. 

Throughout the day, check in with yourself about fatigue (sleep as much as possible), hunger (eat small, nutritious meals), thirst (drink whenever you feel like it), and temperature (take care to keep warm enough). If you feel up to it, and only if you feel up to it, move your body (e.g., go for a short walk as long as it's still permitted where you are, or get up and dance to a favorite song). 

Finally, you want to be alert to signs that your condition may be worsening and you may need more care. So after taking basic care of yourself, then check in with other people around you who know that you are really ill. Let them know how you are doing -- and if you need help, ask. Especially let someone know if you start experiencing more severe symptoms (see the next section).

### The fork in the road

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Current guidance in many places is that COVID-19 patients who cannot take care of themselves (anymore) are treated elsewhere. Given that the patient's condition can worsen quickly, there are good reasons to be cared for by medically trained professionals who can keep an eye on you -- while (hopefully) having adequate protection and training to not get infected themselves. Letting the experts do it instead of staying home also protects your loved ones from infection. 

We are seeing this break down in places where there are a lot of cases, with some very ill patients deemed "not sick enough" to go to the hospital, and no other sorts of centralized quarantine facilities with medical staff (yet?) available. This text will continue assuming the COVID-19 patient needs to be cared for at home. This is not the optimal situation. If possible, you should consult with a doctor when you feel you need help before risking anyone becoming infected while they take care of you.

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Tell other people around you that you are really ill and are mostly in bed. Talk to someone you trust about how they may have to take care of you. Have this person or these people read this document. If you have people in your environment who have already had COVID-19 (something that will be increasingly common as time goes on), such people would naturally make the best caregivers as they presumably will be (at least partially) COVID-19-immune. Otherwise try to judge what is wisest in your circumstances. By all means do not wait with this until the very last moment, because if the disease progresses, you will get short of breath -- which inevitably will also affect your ability to talk and think clearly. Everyone at this level, especially patients who live alone, should really have someone checking on them regularly, because the deterioration in respiratory function can be very fast, especially in the second week. 

[](/assets/images/sick-in-bed.png)

### Others taking care of you

If non-medical people are going to need to take care of you (or if you need to take care of someone who is ill), make sure adequate protection is used to the extent possible. At this point, patient and caregiver need to be closer together, so use all the protection you can have: respirator / mask, protective gown / raincoat, protective glasses / face shield, gloves. Train the proper procedures for putting these on and taking them off, going through that in your head over and over again.

From now on in this text, we will assume that you're the caregiver. Read ahead for signs that indicate Level 4. The purpose of care in Level 3 is also to monitor the patient more and more closely so as to catch early any signs that the patient urgently needs expert medical care. For instance: If the patient is not able to drink at least 2 liters of fluids per day, you should (kindly) insist. Dehydration is a medical condition, and without a daily minimum, you're quickly in Level 4.

In most cases, however, the patient will improve after a few days or at most a week. Just stay with it. Once the patient gets a little better, care may be done by the patient him- or herself again. Don't be in contact any more than you have to, minimise the risk of becoming infected wherever possible. Make sure the illness diary is kept until all symptoms are gone, and quarantine areis kept up until the patient has been completely wellsymptom-free for a while.14 days. If you have been caring for the patient, yourself-isolate again. Your own two-week self-quarantine period now begins.

### Care work

A large part of the work you are doing at this stage is care work, which may overlap with nursing but does not require specialized training. Remember that people who need help with basic self-care due to illness may be embarrassed to ask for or accept it. Be gracious. Everyone needs help sometimes. Think how to make the patient physically, mentally, and emotionally more comfortable and well; you might do this by asking yourself what you would need in their position, by watching for cues aboutthat may indicate discomfort (e.g., shivering, sweating), or by asking how you can help. 

Some possibly useful behaviors include:
* Getting at eye level and at a distance that is large enough for comfort but small enough that they do not have to strain speaking loudly to talk to you. At the same time, try to put some distance between you and the patient where possible to prevent infection.
* Simple encouragement to drink and eat. (E.g.,E.g., "Drink, honey.")honey." 
* If the patient is not drinking or eating adequately, offer alternatives. (E.g.,E.g., if solid food is unappealing, what about soup, bouillon, or electrolyte solution? If hot drinks are unappealing, what about something cold, or vice-versa?)vice-versa? If the patient can't feed himself / herself, could you spoon-feed him / her? 
* Checking that the patient is warm enough in the extremities (e.g., cold feet?) and at night.
* Setting up a fan to blow air in the patient's face can relax patients who are feeling breathless. Helping the patient breathe in a fresh breeze from an open window if possible can have the same effect. 
* Reassure the patient that it is very likely that he or she will make a full recovery.recovery (which is true). Offer relaxation techniques (calming music, humor, counting breaths). 
* If breathing is labored, try breathing techniques (e.g., pursed lips or diaphragmatic breathing techniques) and positional changes. Positional changes (e.g., leaning yourinclude: 
  * Leaning the chest forward a little or putting yourthe arms and head down on a table while sitting with feet flat on the floor; or sleepingfloor. 
  * Sleeping on yourone side with a pillow between your knees, orthe knees. Or, sleeping on your back with yourthe back, elevating the headelevated with a pillow or two).two. It is similarly a good idea to elevate the head of the bed for sleeping if possible. 
  * [Lying prone](https://www.ncbi.nlm.nih.gov/pubmed/22157493) -- flat on stomach with chest down and back up -- often raises blood oxygen levels in patients with acute respiratory distress syndrome (ARDS). But it's usually uncomfortable and **not for infants or pregnant people**. Also make sure there's no fluffy pillow, mattress topping or blanket that can (partially) block air flow.
* Keeping the illness diary (see below).


### Illness diary

As mentioned in the previous section, you might want to use this [printable form](/images/covid-diary.pdf),form](/assets/images/covid-diary.pdf), or make your own. 

At this stage, measure the vital signs often, log them in the illness diary, and watch out especially for and note symptoms that might suggest worsening. Read the next section for more detail, but these include dizziness or rapid heart rate (drink more and eat something if you can), rapid breathing (elevate head while lying down or lower it to the table while sitting up for easier breathing), and a blue tint to fingertips or lips (cyanosis --- get fresh air, get warm, and check blood oxygenation if possible).Also consider using relaxation techniques to slow a rapid respiration or heart rate that may be partially due to anxiety: Listen to soothing music, check in with a friend electronically, or see if you can slow your breathing and bring down your heart rate by counting longer for forceful exhaling than for gentle inhaling. (Some people use 4-7-8 and others prefer 5-2-5 to try slowing down their inhale-hold-exhale patterns.) 

If you think the patient's condition might be worsening, your illness diary might expand to include the following: 
- more frequent temperature readings
- respiration rate (breaths per minute)
- heart rate
- onset of new confusion (if the person seems to have less mental capacity than normal)

If the patient's condition seems to be worsening, skip to the next section. 

### A typical day

At this stage, a typical day might look something like this: 

You (orGo bag

If your condition deteriorates to the patient) get up, weigh, and note weight in illness diary. You might also wantpoint that you / the patient needs to take your temperature first thing, before eatinggo to hospital, **you will not have time or drinking, especially if you are taking temperature orally - and note itbe in the illness diary, too. 

Then, start drinking fluids. Not too much caffeine or sugar. As much water and herbal tea as you like. Remember you wantmood to drink at least 2 liters and upthink about what to 5 literspack**. So prepare beforehand a day. 

Air out your home as much as possible, perhaps while the water for your morning tea or coffee is boiling.  If you have the energy (and enough sheets), consider changing your bed linens if they got sweaty / otherwise soiled. Next, havesmall bag with a quick shower if you're able. Staying clean can helpzipper / firm closure that contains:
* A piece of paper with, in clearly readable print:
  * Identifying information: Name, date of birth, address
  * Names, addresses, and telephone numbers of loved ones and next of kin
  * ( optional: pincode to patient's cell phone )
  * A list of any essential medications you feel better mentallyare taking (drug, time, dose)
  * A brief medical history, listing chronic health conditions and emotionally, as well as physically. 

Eat a small, nutritious meal (piecename(s) of fresh fruit? handfuldoctor(s)
* A week's supply of your essential medication, if applicable
* Government-issued ID, or a copy ofsalted nuts?) - something that
sounds good to you. This* Health-ID card, health insurance card, whatever is also a good time to take paracetamolapplicable where you are
* A set or two of simple and compact fresh clothes
* Bath slippers (also known as acetaminophen) for fever / painflip-flops)
* Spare glasses if available
* Toothbrush, toothpaste
* Patient's living will document, if applicable
* Phone charger if you need it, and notehave an extra
* USB battery pack if you have one
* Previous days of the dose and time in yourpatient illness diary. 

If that was already enough exertion, take a rest. Nap whenever you can - sleep is crucial for healing. If you're not sleepy but need to rest, then try to rest sitting up to give your lungs a better chancediary

It would be ideal to drain. If you're still upright, nowhave name and date of birth readable on the outside of the bag as well.

When it isa good time to steamgo, remember to help your sinuses / airways openput glasses, phone, charger, and mucus to drain. 

Keep drinking throughouttoday's page of the day. Some people find it helpful to emptyillness diary in the bag before you go. Remember that there will likely be no visits allowed in hospitals during peak pandemic phases, and refill a liter bottle of waterCOVID-19 patients (and others) may be in far-away makeshift hospitals or a teapot that holds approximately a liter, so that it's easier to keep track of roughly how muchquarantine facilities staffed with medical professionals. We put your own essential prescription medicines on the list, although they are generally provided for youhave drunk. This also makes it easier to keep water by the sofa or bed whilehospital when you areresting. 

Throughout the day, check in with yourself about fatigue (sleep as much as possible), hunger (eat small, nutritious meals), thirst (drink whenever you feel like it), and temperature (take care to keep warm enough). If you feel up to it, and only if you feel up to it, move (e.g., go for a short walk as long as it's still permittedthe hospital. It's just not always clear where you are,may be taken, or get up and dancewhat level of care they will be able to a favorite song). 

Finally, you wantprovide, during peak pandemic times when the hospital system is likely to be alertoverwhelmed. You may also want to signsdownload the free [Patient Communicator app](https://www.sccm.org/MyICUCare/THRIVE/Patient-and-Family-Resources/Patient-and-Family) that your condition may be worsening andcould help you may need more care. So after taking basic care of yourself, then checkcommunicate in with other people around you who know that you are really ill. Let them know how you are doing - anda hospital setting, even if you need help, ask. Especially let someone know if you start experiencing more severe symptoms (see the next section).to be intubated and therefore can't speak.