CVICU A.C.E. Pilot Program
Nursing Role with CPT
I CPT ordered
+
I
for your pt
I
RN Notify RT
+
RT performs Airway Clearance Evaluation (A.C.E.)
(Assessment incl. discussing with bedside RN)
RT to discuss A.C.E. result with MD
(A.C.E. printout will be filed in the Order section of patient's chart)
I
+
~
A.C.E. score> 16
RT PERFORMs CPT
A.C.E. score < 16
NURSE PERFORMs CPT
•
A.C.E. score 1 - 5
May use:
1.
2.
3.
4.
5.
Bubbles
Incentive spirometer
Deep breathing & coughing
Positioning
Ambulation
Frequency: PRN
•
I
A.C.E. score 6 - 15
Order to be written for RN to perform:
1.
Percussion
2.
Bubbles
Incentive spirometer
3.
Deep breathing & coughing
4.
Positioning
5.
6. Ambulation
Frequency: BID or TID only
Nursing must document when, type of CPT, location (e.g. L side percussion)
and how patient tolerate CPT in flowsheet.
.:.•...••.••...•...•.....•.........•...................•...............................•.............•.•.....................•.................•.•.....•...
_
,.
I Pt's Airway Clearance Evaluation result is also I
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w.Yung
Octo9; approved by S. Roth, D. Giley, and V. Arnolde
Airway Clearance Evaluation Tool
for nursing reference
Evaluate
o points
1 point
2 points
Respiratory
No previous hx of
pulmonary disease
Stable pulmonary
disease I no home
respiratory therapy
Stable Pulmonary
Exacerbation of
Disease, on home 02 pulmonary disease
&lor tx regimen
Severe exacerbation of
~urgeries (during
urrent
encounter)
No surgery
General Surgery
(includes
racheostomy)
Abdominal surgery
ThoracidCardiac
Scoliosis surgery
iw/pulmonary disease
Ability to
Alert and cooperative
Follows some
Less than 2 yrs age,
ommands or unable klr inability to follow
o cooperate is at
~irections
baseline status
History
cooperate
Activity
Level
~ctivity appropriate
or age
Normal rate for age
Work of Breathing
Unlabored or in phase Abdominal
~th mechanical
support
[Tachypnea
pulmonary disease
[Ihoracic/Cardiac
~coliosis Surgery
Decreased activity
level for age
Respiratory
Pattern
4 points
3 points
Unable to cooperate due
o decreased LaC,
sedation
Unable to cooperate (not
baseline)
Moves involuntarily wIno
change in LaC from
baseline
Unable to move, ie. SMA,
~uadriplegic, paralytics
Pt. on Mechanical
Support (VentlBiPAP),
not overbreathing
Intercostal retractions Intercostal retractions,
&lor nasal flaring
nasal flaring,
Irregular pattern
~runting
administered
Irregular with apneic
periods
Intercostal &
supraclavicular
retractions, nasal flaring,
use of accessory muscles
and grunting
Breath Sounds
Clear or at baseline
Unilateral crackles &
honci
Bilateral crackles &
rhonchi
Unilateral absent &lor
~iminished
Bilateral absent &lor
diminished
~hestX-ray
Clear
Unilateral: Infiltrate,
Atelectasis or pleural
effusion; no CXR
available
Bilateral: Infliltrate,
Atelectasis or pleural
effusion
Unilateral: collapse or
consolidation
Bilateral: collapse or
consolidation
None
Can't evaluate--
Excessive
most recent)
~ecretions
Thick bronchial secretions
swallows
~ough
Strong, spontaneous
~eak spontaneous cough Absent cough &lor
mechanical support
~th stimulation only
Strong cough with
stimulation only
Weak spontaneous
cough
Total Score
Total score
Severity Assessment
Treatment
1-5
Unremarkable
As needed: deep breathing and
coughing, incentive sprirometer,
bubble therapy, positioning,
ambulation
6-15
Mild
81D& TID
16-20
Moderate
OlD & prn
21 -29
Severe
06H around the clock
> 29
Critical
04H - contact MD if severity has
increased from previous evaluation
Frequency
LPCH policies and procedures:
1.
Assessment: Chest physiotherapy I Airway Clearance
2.
Orders: Chest physiotherapy I Airway Clearance
w.Yung
Oct09; approved by S. Roth, D. Giley, and V. Arnolde