Validation of a Guideline for Nurses Taking Care of Patients With Liver Cirrhosis in the Context of COVID-19 in the Emergency Department

Abstract

The objective of this study was to prepare and validate the content of a guideline for nursing care of adult patients with liver cirrhosis and COVID-19 treated in the emergency department. The study was conducted in two stages: first, the guideline was developed based on an integrative literature review and existing guidelines on the topic. The guideline was prepared with six domains and 64 care items. In the second stage, 15 specialists in urgency and emergency services performed content validation of the guideline. The data were analyzed using the Content Validity Index, with reliability assessed through Cronbach's α. The judges validated the guide regarding language clarity, objectivity, theoretical relevance, and practical pertinence. The value of the guideline's Content Validity Index was 0.96. Cronbach's α reliability reached a value of 0.93. The judges validated all domains and items of the guideline for theoretical relevance and practical pertinence, to be used by researchers and clinical practice professionals in the nursing area.

In December 2019, pneumonia of unknown etiology in China was identified and later characterized as a new coronavirus (World Health Organization, 2020a). The virus referred to as severe acute respiratory syndrome 2 (SARS-CoV-2) became known for its high transmissibility and potential infection due to its pathogenicity that can cause coronavirus disease-2019 (COVID-19). COVID-19 is manifested in different clinical outcomes, and may present signs and symptoms that are developed in a mild, moderate, severe, or critical form (Deng, 2020; Wang et al., 2020; Wang, Tang, & Wei, 2020).

In January 2020, the World Health Organization declared COVID-19 a public health emergency of international interest and, in March, a pandemic (World Health Organization, 2020b,2020c). Since its inception, COVID-19 has already presented as more than 300 million confirmed cases, including 5,486,304 deaths as of January 9, 2022 (World Health Organization, 2022).

Background

Given COVID-19's potential severity, it is not surprising that patients with associated comorbidities are more likely to develop the severe form of the respiratory disease and require hospitalization (Docherty et al., 2021; Escosteguy et al., 2020). Many patients with chronic liver diseases, such as cirrhosis, also have underlying comorbidities such as chronic obstructive pulmonary disease, obesity, diabetes, cardiovascular disease, kidney disease, and cancer, with more chances of developing severe COVID-19 complications (Jeon, Son, & Choi, 2021; Simon et al., 2021).

In this sense, patients with liver cirrhosis, who are in an immunodeficiency state, can be more susceptible to SARS-CoV-2 infection (Irvine, Ratnasekera, Powell, & Hume, 2019; Marjot et al., 2020). When infected with the virus, diverse evidence indicates that people with liver cirrhosis have worse clinical outcomes, with increased hepatic decompensation and increased hospitalization and death risks (Marjot et al., 2020; Singh & Khan, 2020).

Liver cirrhosis is widely prevalent worldwide, causing nearly 1 million deaths per year, and can be developed with different etiologies such as hepatitis B or C infection, harmful alcohol consumption, obesity, and autoimmune diseases. With the progression of the disease, cirrhosis can evolve from the compensated, asymptomatic phase to the decompensated phase that characterizes the presence of clinical manifestations, which often results in hospitalization, decreased quality of life, and worse prognosis (Gines et al., 2021).

In Brazil, acute hospital care is performed by direct admission, medical referral, or mobile patient emergency care services to the emergency department (Marques, Lucca, Alves, Fernandes, & Nascimento 2020). When a patient with liver cirrhosis and suspected or confirmed COVID-19 is admitted to the emergency service, the nurse frequently makes the first contact for clinical evaluation.

Nurses play an important role in the care of patients with liver cirrhosis to help prevent disease complications. However, it is noted that nurses' knowledge and training about liver diseases are still limited when compared to other specialties. This is challenging due to the importance of cirrhosis as a disease that affects the entire world (Fabrellas et al., 2020).

The prognosis of patients with liver cirrhosis in the emergency department depends on factors such as the severity of liver dysfunction and the association of extrahepatic organ failure. Knowledge of these factors and immediate treatment are essential strategies to provide adequate care and reduce complications (Javaud et al., 2019).

Nurses in the emergency department need to provide quality nursing care when assisting people with cirrhosis and COVID-19. This requires scientific and theoretical knowledge to perform emergency procedures and planning for safe care, considering the specificities of the underlying chronic disease, as well as the new acute situation presented by the novel coronavirus (Dağ, Bişkin, & Gözkaya, 2019; Sharma, Nuttall, Kalyani, & Hemlata, 2020).

From this perspective, instrument validation studies become important care tools as they verify the reliability and validity of the content. In addition to subsidizing a safer practice, validated tools standardize care based on scientific knowledge (Alexandre & Coluci, 2011; Medeiros et al., 2015).

Therefore, due to the health emergency experienced in the world and the severe consequences evidenced in the population with liver cirrhosis, the objective of this study was to prepare and validate the content of a nursing care guideline for adult patients with liver cirrhosis and COVID-19 treated in the emergency department, as hospital nurses play an essential role in the care of patients with cirrhosis.

Methods

A methodological study was conducted from July 2020 to January 2021 in two stages according to Pasquali's model (Pasquali, 1999): development of the guideline and content validation by expert judges in the construct area. https://www.wolterskluwer.com/en/solutions/ovid/platforms-products/ovid-synthesis. The Committee of Ethics and Research with Human Beings of the Federal University of Catarina approved the study.

Stage 1: Development of the Instrument

A literature search was conducted on nurse's care guidelines for patients with liver cirrhosis and COVID-19. From an integrative review conducted in 11 databases (PubMed/MEDLINE, SCOPUS, Literatura Latino-Americana and do Caribe em Ciências da Saúde [LILACS], Banco de Dados em Enfermagem [BDENF], Cumulative Index of Nursing and Allied Health [CINAHL], Scientific Electronic Library Online [SciELO], Web of Science [WoS], EMBASE, BDTD, CAPES Thesis Database, and ProQuest) and using the following descriptors: “Nursing Care,” “Liver Cirrhosis,” “Hepatic Insufficiency,” “Coronavirus,” and “COVID-19,” 38 scientific research studies were selected.

The scientific basis of the 38 studies selected for the integrative review was used to develop the guideline, as well as existing guidelines on the theme under study. The first version of the instrument included six domains and 64 care items.

Stage 2: Content Validation

Content validation of the guideline took place from December 2020 to January 2021. In this stage, it is important that a committee of judges specialized in the construct area analyzes and validates the content from their technical, theoretical, and scientific judgment (Alexandre & Coluci, 2011).

The expert judges in the urgency and emergency services were selected through the curricula available in the Lattes Platform, a Brazilian body belonging to the Ministry of Science, Technology, and Innovation (Brasil, Ministério da Ciência, Tecnologia e Inovação, 2020). A randomly chosen reading of the specialists' curricula was performed; the classification of potential judges was obtained from the classification criteria for curricula by Guimarães, Pena, Lopes, Lopes, and Barros (2016), which adopts scores according to titration, specialization, and clinical experience. A total of 131 potential judges were selected to validate the instrument.

Subsequently, an invitation letter for participation in the study was sent to the potential judges' e-mail addresses, providing the access link to the guideline. The time allotted for receiving responses was 30 days. Among the potential judges, 15 evaluated the instrument within the established deadline.

The evaluation data collection was structured in an online Google Forms form. Formatting of the guideline was organized for the judge to have access to the Free and Informed Consent Form, where an agreement to participate in the research conditioned continuation of the validation process. Data such as age, gender, professional training, and length of experience were collected to describe the specialist judges. Finally, the guideline prepared with its domains and items was made available, and the steps for completion were indicated.

Each item was rated on a 4-point Likert scale (1 = totally disagree; 2 = disagree; 3 = agree; and 4 = totally agree). According to their technical and theoretical judgment, the judges evaluated four criteria: language clarity, objectivity, theoretical relevance, and practical pertinence (Alexandre & Coluci, 2011; Hulley, Cummings, Browner, Grady, & Newman, 2015). A space for concerns and suggestions was provided at the end of each item.

Statistical Analysis

The Content Validity Index (CVI) was the method employed to analyze the judges' agreement in evaluating the guideline and its items. The formula used to evaluate each item separately was as follows: the number of specialists who assessed the items with a 3 or a 4, divided by the total number of judges. In the evaluation of the instrument as a whole, the formula used was the mean of the values of the items calculated separately; that is, adding up all the CVIs calculated separately and dividing by the number of items considered in the evaluation (Alexandre & Coluci, 2011). For an item to remain in the guideline, a CVI ≥ 0.80 was considered. The items evaluated with a CVI < 0.80 were excluded.

When assessing the reliability of the guideline's items, Cronbach's α coefficient was used, which analyzes the internal consistency of each dimension by verifying the uniformity of each item in the instrument compared to the rest of the items in the same instrument (Pasquali, 2013). For this study, the accepted minimum Cronbach's α value for each item calculated separately was ≥0.70.

The diverse information collected from the expert judges was analyzed using simple descriptive statistics. All the collected data were organized in Microsoft Excel and analyzed using the Statistical Package for the Social Sciences (SPSS) statistical software, Version 22.

Results

Expert Judges

The participants of the content validation stage were 15 expert judges who were nurses and had experience in the study theme. Nearly 12 (80%) of the judges had already taken care of patients with liver cirrhosis, eight (53%) had assisted patients with COVID-19, and two (13%) had the experience of caring for patients with liver cirrhosis and COVID-19.

Among them, there was a predominance of female gender (87%), age between 31 and 40 years (47%), single marital status (67%), and master's degrees (60%). The mean time of professional practice was 13 years, currently working in direct patient care (60%), academic/teaching (33.3%), research (33.3%), and management (26.6%) areas.

Validation of the Guideline

Regarding validation, the judges evaluated the guideline comprised of six domains and 64 care items. As for the “language clarity” and “objectivity” evaluative variables, the CVI result was 0.96 with an α of 0.98. In the evaluation, three judges analyzed items in which they “totally disagreed” with these criteria. On the other hand, three judges “totally agreed” with the criteria on all the items evaluated, in addition to eight judges who emphasized that they “agreed” and “totally agreed.”

Concerning the theoretical relevance criterion, the analysis showed an excellent CVI (0.98) and high α reliability (0.99), with the predominance of agreement and total agreement for the items evaluated, as well as the practical pertinence criterion, with a CVI of 0.97 and an α of 0.98. The values of the evaluative criteria for the guideline can be seen in Table 1.

TABLE 1. Evaluative Criteria for the Guideline.

Judge	Language Clarity CVI, M	Objectivity CVI, M	Theoretical Relevance CVI, M	Practical Pertinence CVI, M
1	1	1	1	1
2	1	1	1	1
3	1	1	1	1
4	1	1	1	1
5	0.97	1	1	1
6	1	1	1	1
7	0.67	0.69	0.94	0.91
8	0.94	0.91	0.97	0.89
9	0.98	0.98	0.94	0.92
10	1	1	0.98	1
11	0.97	0.98	1	0.98
12	0.94	0.94	0.94	0.94
13	1	1	1	1
14	1	1	1	1
15	0.95	0.95	0.92	0.92
CVI	0.96	0.96	0.98	0.97
Cronbach's α	0.98	0.98	0.99	0.98

Note. CVI = Content Validity Index. Source: Prepared by the author.

The judges' suggestions for the items were directed to adding relevant information or adjusting confusing and inappropriate terms. For example, in the first domain, a judge suggested adding the description of the personal protective equipment necessary for the care of patients with COVID-19 to clarify the item. In domain 6, another judge suggested that item 61 improved the description to highlight the pertinence of monitoring fluids and electrolytes, thus adding the information “to avoid dehydration, hypovolemia, and hydroelectrolyte disorders.” These suggestions aimed to make the guideline clearer, more objective, relevant, and pertinent, with the ability to provide more accurate and quality information.

In the evaluation of the guideline as a whole, a mean CVI of 0.96 and high internal reliability (0.93) were found. After the necessary adjustments, it was evidenced that the guideline did not require changes regarding the domains and the number of items devised, making it possible to consider the guideline valid by the expert judges' analysis. Table 2 shows the CVI and Cronbach's α values for each domain and item of the guideline.

TABLE 2. Content Validity Index and Cronbach's α Values of the Guideline.

Instrument	CVI	Cronbach's α
Domain 1: Initial approach to the patient	0.98	0.94
Follow the flow of care and early detection of suspected or confirmed COVID-19 cases in the emergency department	0.96	0.89
Refer patients with liver cirrhosis and respiratory symptoms to the exclusive area intended for the care of suspected or confirmed COVID-19 cases	0.96	0.89
Wear personal protective equipment such as a cap, goggles or face protector, mask, waterproof apron, and procedure gloves	0.95	0.90
Carry out risk classification according to the institution's protocol	1	0.97
Identify whether it is a suspected or a confirmed COVID-19 case	1	0.98
Perform immediate notification of suspected or confirmed cases of COVID-19 infection	1	1
Evaluate the need for COVID-19 testing	1	1
Domain 2: Initial clinical evaluation by nurses in patients with liver cirrhosis in the emergency department	0.97	0.93
Perform primary evaluation and simultaneous resuscitation of patients with liver cirrhosis and COVID-19 following the ABCDE approach	0.96	0.82
Perform anamnesis/patient history	1	0.95
Collect and verify laboratory and complementary tests	1	1
Evaluate the severity of liver disease	0.96	0.86
Identify the presence of clinical complications of liver cirrhosis, such as ascites, hepatic encephalopathy, gastrointestinal bleeding, and infections	1	0.97
Classify the severity of COVID-19: mild, moderate, severe, or critical	0.96	0.91
Based on the initial clinical evaluation, list the nursing diagnoses and interventions for patients with liver cirrhosis and COVID-19 in the emergency department	0.93	1
Domain 3: General nursing care for patients with liver cirrhosis and COVID-19	0.97	0.95
Monitor vital signs, neurological status, and capillary glycemia	1	0.94
Insert peripheral venous catheter	0.90	0.91
Observe the nutritional status of the patient with liver cirrhosis and COVID-19	0.96	0.98
Evaluate the need for nasogastric or nasoenteral tubes and provide adequate nursing care to patients using feeding tubes, mainly in the pronation process	1	1
Carry out measures to prevent healthcare-associated infections	1	1
Evaluate skin integrity and use preventive measures for skin lesions and pressure ulcers	1	1
Monitor urine output, characteristics, and odor. In case of hemodynamic instability, bladder catheterization may be necessary	1	0.98
Monitor evacuations, assessing consistency and color. If lactulose is used, the ideal is two to three bowel movements/day	0.96	0.91
Carry out education in health for patients and family members	0.93	0.90
Domain 4: Nursing care for patients with liver cirrhosis and mild to moderate COVID-19	0.97	0.95
Treat the clinical manifestations as prescribed	0.93	0.99
Guide isolation and protective measures	1	1
Use score for early warning of clinical deterioration	0.96	0.92
Educate patients and caregivers concerning cirrhosis complications and early detection	1	1
Advise patients with compensated cirrhosis that elective visits to specialized centers can be postponed	0.96	0.85
Provide psychosocial support for all patients with liver cirrhosis and COVID-19	1	0.98
Domain 5: Nursing care for patients with liver cirrhosis and severe COVID-19	0.95	0.90
Administer oxygen therapy in patients with respiratory difficulty, hypoxemia, or shock, targeting SpO2 92%–96%	0.96	0.89
Evaluate signs and symptoms of deterioration in respiratory function and, when indicated, assist in the orotracheal intubation procedure	0.91	0.93
Together with the multiprofessional team, evaluate the use of the prone position in patients with liver cirrhosis and COVID-19	0.98	0.96
Administer medications according to the medical prescription for the treatment of clinical decompensation of patients with liver cirrhosis and COVID-19	0.93	0.89
Perform hemodynamic evaluation and volume resuscitation, as prescribed	0.98	0.96
Perform drug and/or mechanical prophylaxis for thromboembolism	0.98	0.80
Early identify cardiopulmonary arrest and manage it according to the cardiopulmonary resuscitation algorithm	0.98	0.98
Evaluate with the team the indications for hospitalization in the intensive care unit and, when indicated, prepare the appropriate transportation means	0.93	0.77
Domain 6: Nursing care for patients with decompensated liver cirrhosis and COVID-19	0.96	0.91
Together with the team, evaluate the need for prophylaxis against infections	0.93	0.86
Monitor and identify infection signs such as hyperthermia, tachycardia, hypotension, pain, erythema, heat, and flushing	0.95	0.83
Monitor and identify signs of systemic inflammatory response syndrome (tachypnea, hypotension, or neurological disorder)	0.96	0.86
Identify the infection source	0.96	0.84
Immediately initiate the antibiotic therapy prescribed	0.98	0.98
Evaluate and monitor for the presence of clinical manifestations of gastrointestinal hemorrhage such as hematemesis, melena, and hematochezia	0.96	0.84
Perform hemodynamic evaluation and volume replacement in cirrhotic patients with active gastrointestinal hemorrhage, as prescribed	0.98	0.84
Initiate drug therapy to control active hemorrhage, as prescribed	0.91	0.90
Assist in the emergency pre-, trans-, and post-upper digestive tract endoscopy procedure	0.95	0.72
Prevent clinical complications due to variceal bleeding	0.90	0.89
Protect and maintain airway patency	0.96	0.84
Check laboratory tests, mainly hemoglobin and coagulation factors, in cirrhotic patients with gastrointestinal bleeding	1	1
Evaluate and monitor for the presence of signs and symptoms that indicate ascites, such as fatigue, abdominal distension, lower limb edema, and oliguria	0.90	0.88
Classify the degree of ascites	0.93	0.99
Assist in the pre-, trans-, and post-paracentesis procedure	0.96	0.84
Check the amount and appearance of the ascitic fluid drained in paracentesis	0.98	0.92
Administer albumin during and/or after large volume paracentesis, as prescribed	1	1
Monitor body weight and abdominal circumference	1	1
Monitor edema in the extremities	1	1
Monitor urine output	1	1
Be aware of contraindicated medications in patients with cirrhosis and ascites, such as nonsteroidal anti-inflammatory drugs, ACE inhibitors, α-1 adrenergic receptor blockers, and aminoglycosides	0.96	0.84
Evaluate the patient's responsiveness level and identify signs of hepatic encephalopathy. Use the Glasgow Coma Scale and the West Haven Criteria	1	1
Classify hepatic encephalopathy regarding the underlying disease, the severity of the manifestations, course of time, and the existence of precipitating factors	0.93	0.99
Monitor fluids and electrolytes to prevent dehydration, hypovolemia, and hydroelectrolyte disorders	0.90	0.89
Maintain airway patency in patients with grade III–IV hepatic encephalopathy	0.96	0.82
Evaluate and implement respiratory aspiration precautions. If necessary, aspire nasopharyngeal and tracheal secretions	0.93	1
Initiate treatment for hepatic encephalopathy reversal, as prescribed	1	1

Note. ACE = angiotensin-converting enzyme; COVID-19 = coronavirus disease-2019; CVI = Content Validity Index. Source: Prepared by the author.

The final product of the development of this guideline consisted of a guide to systematize the care provided by nurses to adult patients with liver cirrhosis and COVID-19 in the emergency department (see the Chart, Supplemental Digital Content 1, available at: http://links.lww.com/GNJ/A87, which shows the guide).

Discussion

This study presented the development and validation process of the guideline for nursing care of adult patients with liver cirrhosis and COVID-19 in the emergency department. The development of this clinical tool has become an important intervention strategy to strengthen critical thinking and comprehensive analysis of emergency nurses when caring for patients with cirrhosis given that this care became even more challenging in the context of the new coronavirus pandemic.

In a systematic review that analyzed the clinical outcomes of patients with cirrhosis and COVID-19, it was recommended that healthcare professionals be aware of the associated increased mortality from COVID-19 in patients with cirrhosis and the potential risk of associated cirrhotic decompensation (Middleton, Hsu, & Lythgoe, 2021). Considering the joint effects of cirrhosis and COVID-19, management and treatment must be rigorous in terms of medication, monitoring, and follow-up (Hu et al., 2022).

Nurses need scientific theoretical support to construct knowledge in the face of this new reality. A study on hospital readmissions of patients with cirrhosis in emergency services highlighted that identifying the modifiable factors at admission enables the development of effective interventions to reduce the readmission risk (Garg et al., 2021). With this, some suggested strategies to be implemented in the emergency services include devising tools to promote better patient safety (Lockett, Nelson, & Hales, 2021).

Guidelines assist in communication, clinical reasoning, critical thinking, and organization of the patients' information (Gimenes, Reis, da Silva, Silva, & Atila, 2016). Several studies address that clinical guidelines, based on scientific knowledge, are considered to facilitate the systematization of care, leading to best practices in health services because they provide relevant guiding sources of nursing care for evidence-based decision-making (Musayón-Oblitas, Cárcamo, Gimbel, Zarate, & Espinoza, 2020; Weber et al., 2019). The prepared guideline we developed can promote better quality and safety in nursing care provided to patients with cirrhosis and COVID-19 in emergency services.

This guideline contains recommendations for the clinical practice of nurses caring for patients with cirrhosis in the context of COVID-19. The recommendations in this guide are intended to help nurses make evidence-informed decisions to take specific actions in the care of patients with liver cirrhosis and COVID-19 in emergency departments to achieve the best health outcomes for these patients.

The guideline was developed with six domains and 64 care items. Each domain is responsible for promoting nursing care according to the initial clinical assessment. The guide does not follow a mandatory linear action of care but references scientific support to direct the intervention, enabling nurses to provide evidence-based care strategies to meet the patient's clinical needs.

The focus of the guideline applicability in practice will be to prioritize the domains of care that fit the clinical condition evidenced in each patient with cirrhosis admitted to the emergency service, thus helping the nurse establish the care plan. For example, suppose the patient with liver cirrhosis is admitted to the emergency department with a diagnosis of ascites and COVID-19. In that case, the nurse, through knowledge of the guideline, can identify this clinical threat and establish the recommended care plan, based on scientific evidence, for the patient with cirrhosis and ascites, in addition to general COVID-19 care.

There is no consensus in the literature about the ideal number of evaluating judges; some authors recommend a minimum of three and a maximum of 20 specialists (Pasquali, 2010; Rubio, Berg-Weger, Tebb, Lee, & Rauch, 2003). The importance of judges who have experience with the theme or who have already experienced care for the clinical population studied is emphasized for the validation process. Validation by expert professionals in the area provides a dynamic and attentive perspective on the topic due to theoretical and practical knowledge based on the specialists' critical judgment (Guimarães et al., 2016). The judges' suggestions were significant in facilitating reading and comprehension of the text.

In the analysis of the guideline's items, the “language clarity,” “objectivity,” “theoretical relevance,” and “practical pertinence” criteria had excellent CVI results and high α reliability. Thus, as well as in other methodological studies validated with a careful analysis process (Cruz, Faria, & Reis, 2020; Musayón-Oblitas et al., 2020), it was considered that the items provided the judges with an understanding of the language semantics, expressing the central idea and representing what was proposed.

Regarding validation of the guideline as a whole, an excellent CVI value and high internal reliability were obtained. For content validation studies, the evidence shows that values above 0.90 in an instrument's CVI are considered excellent validation indices (Alexandre & Coluci, 2011; Wynd, Schmidt, & Schaefer, 2003). Some studies that used the CVI also had similar values as this research: 0.97 (Jesus et al., 2020) and 0.95 (Pierotti, Nascimento, Rossetto, Furuya, & Fonseca, 2020).

In the analysis of Cronbach's α values, it is verified that they are above the value referenced by the literature (0.70) (Souza, Alexandre, & Guirardello, 2017), considering this guideline reliable as to its internal consistency. All the criteria evaluated in the clinical tool by the judges presented very high reliability, evidencing excellent homogeneity across the items. This satisfactory result is better than in some studies. which also used Cronbach's α index with values varying from 0.77 to 0.90 (Fairchild, Horst, Finney, & Barron, 2005), from 0.74 to 0.92 (Davoglio, Santos, & Lettnin, 2016), and from 0.71 to 0.90 (Souza, Meireles, Mira, & Leite, 2021).

This study presents some limitations. As the scientific literature on the new coronavirus is on the rise, many studies are underway, mainly related to liver cirrhosis. This suggests the guideline devised will need to undergo updates as evidence changes. Even so, to more effectively evaluate usability of the guide in practice, the tool will need to undergo clinical validation, aiming to provide greater reliability in proposed intervention. Clinical validation will be an essential step in analyzing if the guideline has the potential to raise awareness among the target audience (in this case, nurses). It will also need to be analyzed to assure it is clear in its technical-scientific approach and that nurses can understand and apply the guideline in their practice.

Implication for the Practice

This guide for nursing care of patients with cirrhosis and COVID-19 in emergency services, validated by specialists in the area, has the potential to be used by nurses in the clinical practice as an evidence-based resource for nursing care. This study contributes to promoting the quality of nursing care for patients with liver cirrhosis, especially during outbreaks of COVID-19. In addition, this study contributes to the nurse's learning process by considering continuous knowledge transformation.

Conclusion

Through the participation of expert judges, this study made it possible to elaborate and validate a clinical guideline with domains and items addressing the nursing care of adult patients with liver cirrhosis and COVID-19 treated in the emergency department, highlighting the importance of theoretical and scientific knowledge to assist nurses in the care of patients with liver cirrhosis and COVID-19.

The final version of the guideline consists of a systematic guide for the care provided by nurses. This guideline aims to direct nurses' care for patients with liver cirrhosis in the context of COVID-19 and to alert nurses to the importance of this care to assist in diagnosis and early nursing interventions. Using the guideline should also promote reduced associated complications, clinical decompensations, and readmissions, and, as a result, provide a better prognosis and, consequently, improve the patient's quality of life. Replication and evaluation of guideline use is recommended in other settings where care for patients with liver cirrhosis is provided, given its potential contribution to strengthening and qualifying nursing care for these patients.