Lewis Chapters 27, 65, 67, 68

LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION CHAPTER 27 - LOWER RESPIRATORY PROBLEMS CHEST TRAUMA BLUNT TRAUMA: chest strikes or is struck by an object; shearing & compression PENETRATING TRAUMA: injury in which a foreign object impales or passes through the body tissue Also known as a sucking chest (paradoxical chest movement) wound since air enters the pleural space through the chest wall during inspiration FRACTURED RIBS: ➢ Pain at the site of injury, especially during inspiration and with coughing ➢ Goal of treatment is to decrease pain so the patient can breathe adequately and clear secretions ➢ PT teaching should emphasize deep breathing, coughing, incentive spirometry, and appropriate use of pain meds DISEASE PATHO MANIFESTATIONS PNEUMOTHORAX Air in the pleural space (collapsed lung) Caused by: ➢ Trauma ➢ Too much PEEP → (barotrauma) ➢ Rupture bleb 3 TYPES: ➢ Closed - air enters through airways & cannot escape, occurs internally ○ Inc intrathoracic chest pressure ○ Inc pressure on lungs & heart -> leads to tension pneumothorax ➢ Tension - life threatening ○ Air accumulates in pleural space & cannot escape ○ Pressure collapses lung ○ Decreased capacity, decreased compliance ○ Can lead to PEA arrest ➢ Open - air is entering chest upon inspiration ➢ Spontaneous & Iatrogenic - medically induced Dyspnea, SOB Decreased movement of involved chest wall Decreased or absent breath sounds on the affected side ➢ Hyperresonance to percussion ➢ Hypoxemia ➢ Tachycardia ➢ Cyanosis - late sign Diagnostics - evident on CXR Subclavian central line placement -> highest risk for pneumothorax ➢ ➢ ➢ HEMOTHORAX Blood in pleural space ➢ May or may not be in conjunction with pneumothorax When it occurs in the pneumothorax it’s called hemopneumothorax. ➢ ➢ ➢ ➢ ➢ Dyspnea Decreased or absent breath sounds Dullness to percussion Decreased Hgb Shock (depending on volume loss) TENSION PNEUMOTHORAX Air in pleural space that does not escape ➢ Increased air in the pleural space shifts organs and increases intrathoracic pressure TENSION IS BUILDING UP IN CHEST AND CAN’T ➢ ➢ ➢ ➢ Severe dyspnea Cyanosis Air hunger Extreme agitation Occurs with open or INTERVENTIONS ➢ ➢ ➢ Chest tube insertion with chest drainage system Thoracentesis - drain fluid from surrounding tissue Pleurodesis - adheres lung tissue OPEN PNEUMO FROM PENETRATION: NOT 4 SIDES OF TAPE ➢ The chest wall is open ➢ Prevent air ➢ Occlusive dressing taped on 3 sides (as you breathe in the dressing will stick to skin which allows some pressure to escape) ○ Inspiration - pulls dressing in ○ Expiration - allows air to escape ➢ ➢ ➢ ➢ Chest tube insertion with chest drainage system Autotransfusion of collected blood Treatment of hypovolemia as needed with IV fluid Packed red blood cells Medical emergency (can be fatal) ➢ Needle decompression (will hear air escape, & HR will go up & BP will lower) ➢ Chest tube insertion with chest drainage system LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION closed pneumothorax LEAVE, SO ALL OTHER ORGANS ARE COMPRESSED. ➢ Can result from an open or closed pneumothorax ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ FLAIL CHEST Fracture of 2 or more adjacent ribs in 2 or more places with loss of chest wall stability ➢ ➢ ➢ ➢ ➢ Subcutaneous emphysema Neck vein distention (JVD only in tension pneu) Hyperresonance to percussion Tracheal deviation away from the affected side late sign! Decreased /absent breath sounds on affected side Bradycardia BP Drops Mediastinum shifts toward the unaffected side, compressing the “good” lung, which further compromises oxygenation. Hemodynamic instability ○ JVD ○ Heart is squished If PT is de-sating: reposition first (semi fowlers or on injured side) Paradoxical movement of chest wall Respiratory distress May be associated with hemothorax, pneumothorax, or pulmonary contusion Diagnostic test: CXR Subcutaneous emphysema - air gets trapped within subcutaneous layer of skin - feels like rice krispies ➢ ➢ ➢ ➢ ➢ O2 as needed to maintain O2 saturation Analgesics Stabilize flail segment with positive pressure ventilation Treat associated injuries Possible surgical fixation DRAINING SYSTEMS CHEST TUBES - PURPOSE INSERTION/REMOVAL COMPARTMENTS FOR DRAINAGE Chest tubes: drain the pleural space, reestablish negative pressure, and allow for proper lung function ➢ Size depends on PT’s condition ○ Large: drain blood ○ Medium: drain fluid ○ Small: drain air Pig Tails: very small tubes with a curly end designed to keep them in place - effective alternative to larger-bored chest tube for treatment of pneumothorax. Get sutured into skin on the outside Flutter or Heimlich Valve: used to remove air from pleural space. During inspiration, when pressure in chest decreases, the valve closes. During expiration, when intrathoracic pressure increases, valve closes. PT can go home with this - allows for increased pt mobility. For small pneumothorax INSERTION: PT is positioned with arm raised above head on affected side, area is cleansed with antiseptic solution , small incision is made, then the chest tube is advanced up and over the tip of the rib to avoid intercostal nerves and blood vessels that are behind the rib inferiorly. Once inserted the HCP secures the tube in place and closes the incision with sutures & the tube is connected to a pleural drainage system. Then the wound is covered with occlusive dressing. Sealed with petroleum gauze. Placement confirmed by x-ray. Insertion equipment: ➢ Chest tube insertion tray ➢ Chest drainage unit ➢ Chest tube ➢ Bottle of sterile water ➢ 1% lidocaine (to numb area) ➢ Suction tubing and collection chamber DRAINAGE COLLECTION CHAMBER - C: receives fluid or air from the pleural space ➢ Must be below chest level (gravity duh) ➢ Monitor drainage color and amount - documentation! ➢ Within 1st hour of insertion you call HCP if more than 200 ml/hr, any hr after that if more than 100 mL/hr, call HCP ATI SAYS 70 - FOR PROCTOR ➢ If ¾ full, consider replacing it - NEVER RE-USE. ➢ Measure Q1Hr WATER SEAL CHAMBER - B: 2cm water that acts as a 1 way valve, this shit bubbles and prevents backflow of air into the PT ➢ Expect bubbling on forced expiration or coughing -> Tidaling will occur if in lungs Tidaling represents inspiration/expiration ➢ If water is not fluctuating: occlusion in chest tube or lung has re-expanded Tape all connections between chest tube and drainage system to LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION ensure the system is airtight and prevent the chest tubing from accidentally disconnecting Can be inserted at operation table, bedside, ER, anywhere ➢ Occlusive dressing ➢ Suture kit/pain medication ➢ Hemostat ➢ Oxygen REMOVAL: When lungs are fully re expanded and fluid drainage has ceased or is minimal. Give pain medication before removal. Needs petroleum jelly and dry gauze dressing. Suture is cut, PT is bearing down (valsalva), tube is removed. Site is immediately covered with airtight dressing to prevent air from entering the pleural space. CXR to evaluate, observe drainage, and vitals. ➢ Suture kit bedside ➢ Prn meds - 30 mins prior ➢ 4 sided occlusion tape ➢ Suction prn (pt is d-sating, crackles, wheezing, gagging) As lungs reinflate & expand, you won’t see as much bubbling AIR LEAK MONITOR: ➢ Don’t want bubbling here ➢ If excessive bubbling -> air leak ➢ Pneumothorax can cause intermittent bubbling ➢ Worse the air leak, the higher the number SUCTION CONTROL CHAMBER - A: can be wet or dry - applies suction to the chest drainage unit ➢ Dry: no bubbling - bellow needs to be past line indicator ○ Extra compartment - suction monitor bellows ➢ Wet suction -> gentle bubbling (normal) ○ 20 mL sterile water Ensure there's water, bc it will evaporate!! (think boiling water) ➢ NURSING MANAGEMENT: ➢ Dislodged: ○ Check PT for respiratory status ○ Cover w/occlusive sterile dressing taped on 3 sides (petroleum gauze) ➢ System Breaks or gets disconnected: ○ Check PT respiratory status ○ Place distal end into sterile water (1 inch) and get a new system ➢ Blood Clot? ○ TPA ○ New chest tube ➢ IF you are clamping to change unit: ○ Time is of the essence ○ Prepare tube before removal (sterile water) NO MILKING/STRIPPING OF TUBING DON’T CLAMP -> increased risk for tension pneumothorax (only clamp briefly when changing unit) DON’T RE-USE! MEASURE HOURLY! RESTRICTIVE LUNG DISORDERS DISORDER ETIOLOGY CLINICAL MANIFESTATIONS PULMONARY EMBOLISM Blockage of 1 or more pulmonary arteries by a fat (long bone fractures) or air embolus or tumor tissue or thrombus (DVT most common) Risk Factors: immobility, surgery, hx of DVT, DVT, VTE, obesity, birth control, smoking, HF, pregnancy, S/S: ➢ ➢ ➢ ➢ Mental status changes New onset dyspnea/SOB Anxiety Changes in LOC NURSING/INTERPROFESSIONAL CARE ➢ ➢ Semi-fowler's to facilitate breathing Support cardiopulmonary status: ○ intubation/mechanical vent ○ Fluids, vasopressors ○ Diuretics LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION A-fib (blood pooled in heart - quivers) ➢ If pt has A-line or CVC -> risk for air embolism Virchow’s Triad: ➢ Venous stasis - being immobile, fractures to bone, hips, orthopedic surgery, obesity, pregnancy, HF ➢ Hypercoagulability - PT’s with lung cancer & malignancy, women on estrogen, smokers, sickle cell anemia, dehydration, sepsis ➢ Vasculature integrity - IV drug use, varicose veins, atherosclerosis, etc ➢ Impending doom ➢ Hypotension ➢ Chest pain ➢ Tachycardia/tachypnea ➢ Crackles, wheezing COMPLICATIONS: ➢ Pulmonary infarction - death of lung tissue ➢ Pulmonary hypertension - from hypoxemia ➢ Pleural effusion - causes right ventricular hypertrophy DIAGNOSTICS: ➢ Spiral CT Scan (Gold Standard)/CTA - AKA HELICAL ○ IV contrast to determine where clot is ○ Determine shellfish or iodine allergy ■ Pre-medicate with benadryl ○ Metformin - C/I; wait 24-48 hrs after holding ➢ D-dimer - doesn’t tell us where clot is ○ Normal: < 0.04 ➢ V/Q scan (for those who can’t have CT scan) ○ Not for intubated PTs - need to follow directions ○ Perfusion & Ventilation scanning ➢ Pulmonary angiogram ○ Not a lot of hospitals can afford this ASSESSMENT: ➢ Doppler ultrasound ➢ Red, swollen, pain, reduced mobility If PT can’t have VQ or CT -> D-dimer, ABG, EKG RANDOM SHIT FROM LECTURE: ➢ Allen’s Test done for ABGs - looking for perfusion (if good to go, we can perform venipuncture for ABGs) ➢ Go over ABG’s ○ Normal Values: ■ pH: 7.35 - 7.45 ■ CO2: 35-45 mmHg ■ HCO3: 22-26 mEq/L ■ PaCO2: 80-100 mmHg (saturation of oxygen in our blood stream) ➢ Thoracentesis: fluid buildup around the lungs ○ Invasive procedure that drains fluid surrounding the pts lungs, so they can fully expand ➢ ➢ ➢ ○ Opioids Prevention: ○ Cough and deep breathing ○ Ambulation ○ SCDs (not for PTs w DVT) ○ Repositioning q2hr ○ Compression socks Medication: ○ Anticoagulants ■ Lovenox-Enoxaparin (heparin) ● Doesn’t dissolve clots, only prevents new ones from forming ● aPTT: 30-40 seconds ■ Warfarin (Coumadin) ● Monitor PT/INR ● INR 0.7-1.8 - Normal ○ 2-3 mmL- Therapeutic lvl ● Continued for 3 months after must get blood tests ○ tPA or alteplase ■ C/I for hemorrhagic strokes Surgical Therapy - for pts C/I for thromboembolic therapy ○ Pulmonary embolectomy (massive PE) ○ IVC Filter (if anticoagulants are C/I - i.e. liver probs, GI bleeding) ■ This prevents clots from traveling filter is inserted thru femoral veins ■ Mesh filter that sits on top of vena cava LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION Thoracotomy - surgical incision into chest Exploratory thoracotomy: ○ Opening of the thoracic cavity ■ Look at pts coags and INR ○ Post-Op: Visualize what the sites look like under the dressing; check for bleeding and saturation & wound margins ➢ Video Assisted Thoracic Surgery (VATS) ○ Video that goes into pleural space that can visualize cancer and clots - can cut into or take out ○ Most pts have a chest tube so we can drain post-op ➢ EMPYEMA - collection of pus in pleural space ○ Move this shit out & treat with ABX CHAPTER 65 ICU - meet special needs of acutely and critically ill pts PCU - intermediate care or step down units = transition between ICU and general unit. Pts are at risk for serious complications, but risk is lower than ICU pts CC Nurse - in depth knowledge of anatomy, physiology, patho, pharmacology; advanced assessment skills, and ability to use advanced technology ➢ Difference: nurse to pt ratio, unstable physiological probs, push & titrate meds, certs - CCRN - validates cc nursing, advanced skills/technology RAPID RESPONSE VS CODE BLUE: ➢ RAPID RESPONSE: ○ Sudden deterioration in VS (BP, pulse, respiratory status) ○ Stabilize pt & figure out what’s going on ○ Prevention of code blue ○ Reduce mortality rates in pts ➢ CODE BLUE: ○ When pt is pulseless/apneic ○ CPR & rhythms HEMODYNAMIC MONITORING: measurement of pressure, flow, and oxygenation within the CV system. Purpose is to assess heart function, core temperature, fluid balance, and effects of fluids and drugs on CO. Both invasive & noninvasive parameters are used. ➢ Cardiac Output: SV x HR / 1000 ○ Amount of blood the heart pushes out in 1 minute - determined by preload, afterload, & contractility ○ SV = CO / HR x 1000 ~ volume ejected with each heartbeat; determined by preload, afterload, and contractility (how strong heart contracts - squeeze - i.e. increase contractility: epi, norepi, digoxin, positive inotropes (dopamine), dobutamine; dec: BBs, CCB) ■ Normal SV = 60-150 ■ SVI - takes into consideration BSA ○ Normal CO = 4-8 L/min ➢ Cardiac index: used to determine if CO is sufficient for PT’s size (pt’s body surface area - BSA) ○ Cardiac Index = CO / Total BSA ○ Normal CI: 2.2-4 ○ Less than 2.2 = cardiogenic shock CARDIAC INDEX IS MUCH MORE RELIABLE BC IT TAKES INTO CONSIDERATION BSA ➢ Pulse Pressure: difference between SBP & DBP ➢ ➢ LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION ➢ Mean Arterial Pressure (MAP): average pressure in larger vessels in body ○ Normal MAP: 70-105 HEMODYNAMIC MONITORING TYPE AFFECTS WHICH LOAD? WTF IS IT? SHIT TO UNDERSTAND CENTRAL VENOUS PRESSURE (CVP) PRELOAD ventricles filling up (diastole) amount of blood filling right side of heart Volume in R side of heart Right ventricular preload or right ventricular end-diastolic pressure when there is no dysfunction. Refers to fluid status Normal CVP: 2-8 mmHg ➢ > 8 mmHg: too much fluid (CHF pts, HTN) ➢ < 3 mmHg: too dry (hypovolemia, hypotension) Describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. Reflects the amount of blood returning to the heart and the ability of the heart to pump blood into the arterial system HIGH CVP & PAWP: pt is too wet (fluid overload) ➢ Pt has too much preload: ○ Diuretics ○ Vasodilators ○ Fluid restriction ○ CCBs ➢ D/T: fluid overload, HF PRELOAD ventricles filling up (diastole) amount of blood filling left side of heart Measurement of pulmonary capillary pressure which reflects left ventricular end diastolic pressure under normal conditions. Measures pressure in the lungs - left ventricular preload pressure. Rules out cardiac-related problem or it is capillary membrane issue Normal PAWP: 25/10 mmHg (systolic & diastolic BP in lungs) ➢ High PAWP: HF, cardiomyopathy ➢ < 18 mmHg = ARDS ➢ > 18 mmHg = cardiac issue Refers to the pressure in the lungs and left side of heart AFTERLOAD systolic BP (force opposing ejection) How much force the body uses to push blood out think about what the body needs SVR - opposition encountered by left ventricle. PVR - opposition encountered by right ventricle. Resistance to blood flow by the vessels Normal SVR: 800-1200 dynes/sec/cm ➢ 800 = dilated ➢ 1200 = constricted Normal PVR: < 250 dynes/sec/cm Reflects afterload RIGHT SIDE PULMONARY ARTERY WEDGE PRESSURE (PAWP) LEFT SIDE SYSTEMIC VASCULAR RESISTANCE (SVR) or PULMONARY VASCULAR RESISTANCE (PVR) HOW TO DECREASE PRELOAD: ➢ Diuretics (furosemide, lasix) ➢ Beta blockers (-lol) ➢ Vasodilators ➢ Fluid restriction HOW TO INCREASE PRELOAD: ➢ Bolus of IV fluids/blood products LOW CVP & PAWP: poor perfusion/low preload/decreased CO ➢ Pt has too little preload ○ Vasopressors (Levofed, norepi, epi) ○ Vasoconstrictors ○ Fluids ➢ D/T: hypotension, dehydration, hypovolemia HIGH AFTERLOAD: cardiac system has to work harder ➢ D/T: CHF, HF If pt has: ➢ Systemic HTN = SVR ➢ Pulmonary HTN = PVR HOW TO DECREASE AFTERLOAD: ➢ Diuretics ➢ Vasodilators - so heart doesn't have to push so hard ➢ CCBs HOW TO INCREASE AFTERLOAD: ➢ Fluids LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION HEMODYNAMIC MONITORING - INVASIVE TECHNIQUES SWAN-GANZ CATHETER Starts in right atrium to right ventricle into pulmonary artery FOR PAWP & CVP ARTERIAL LINE (A-LINE) RADIAL ARTERY - do allen’s test FOR PTS IN CRITICAL POSITION & W TITRATED MEDS Catheter that sits in artery (smooth muscle is activated by ROS system) Measures hemodynamics within the body. Catheter is advanced into heart via pulmonary artery to measure pressures USES: ➢ Cardiogenic shock - ROS system is what’s killing us ➢ MI, CV FXN ➢ Pulmonary HTN ➢ ARDS ➢ TX of CHF ➢ Transplant work up ➢ Multi organ failure Goes into pulmonary artery - BALLOON DOESN’T REMAIN INFLATED ➢ Balloon allows blood to float the catheter forward & PAWP measurement ➢ IF INFLATED -> can cause pulmonary artery rupture -> internal bleeding -> DEATH Tells us: ➢ CO/CI - how well the pump is circulating blood ➢ CVP - volume status ➢ SvO2 - mixed venous sample ➢ Core temperature - usually 1 degree warmer than peripheral ➢ PAWP - reflects pressure on the left side of the heart ➢ SVR - afterload resistance (higher the number the more clamping) ➢ MvO2 - mixed saturation of blood after one circulation Balloon = 1.5 mmHg (OR ELSE RUPTURE PULMONARY ARTERY) FAMILIAR WITH PG 1542 FIG 65.8 (balloon port - deflate/inflate; thermostat connector - blood temp) How to place it: ➢ PT is supine ➢ Continuous EKG monitoring ➢ Check electrolytes, coagulation studies, ABGs, oxygenation status ➢ Transducer positioning ○ Phlebostatic Axis (4th intercostal space) ○ Zero-point reference point (home depot thing) If higher = false high BP reading If lower = false low BP reading We encourage movement, but everytime they move, we need to reposition to even level ➢ CXR done to verify placement ➢ Check markings on catheter ➢ Waveforms ➢ Balloon wedge LINES MUST BE CHANGED OUT EVERY 96 HOURS TO PREVENT INFECTION CI/ CONSIDERATIONS: ➢ Left bundle branch block ➢ Pts with tricuspid or pulmonic heart valve replacements ➢ Presence of endocardial pacing leads ➢ Lack of appropriate clinical skills or infrastructure to insert ➢ SG has metal components -> NO MRI ➢ May cause v-fib/v-tach ○ If pt has hx of vtach storm -> NO SG COMPLICATIONS: ➢ Arrhythmias - vtach/vfib (catheter touching ventricle) ➢ Balloon rupture ➢ Catheter knots or loops ➢ Local and systemic infection ➢ Pulmonary complications ➢ Air embolism ➢ Thrombosis Real-time BP monitor - most accurate way especially when titrating meds (levophed norepinephrine) constantly - obtains systolic, diastolic, & MAP For pts who are hemodynamically unstable Indications: ➢ hypo/hypertension ➢ Respiratory failure ➢ Shock ➢ Pts on continuous vasopressors ➢ Pts who need continuous ABG monitoring ○ Can get blood sampling from this line for ABGs VAMP Tells us: real time BP. In ICU we could be taking BPs every 15 mins for 1 or more weeks, this will cause soreness and pain if using a regular BP cuff consistently Pressure bag prevents blood from backing into the system, which is why it needs to be used with an arterial line. ➢ Perform Allen’s test to determine circulation adequacy ➢ Continuous flush irrigation system - delivers 1-3 mL/hr to keep line patent & limit thrombus formation (normal saline) ➢ Phlebostatic Axis (4th intercostal space) ➢ Zero-point reference point (home depot thing) NEVER GIVE MEDS THRU THIS. CONSIDERATIONS: ➢ Assess neurovascular status RISK/COMPLICATIONS: ➢ Hemorrhage ➢ Infection ➢ Thrombus formation ➢ Neurovascular impairment ➢ Loss of limb Use luer-lock connections, check arterial waveforms, and activate alarms LINES MUST BE CHANGED OUT EVERY 96 HOURS - INFECTION CTRL HAS AN ALARM Inserted into an artery, as blood flows the catheter measures the resistance against the vessel walls; sutured into skin so it doesn't dislodge (by HCP or NP) HEMODYNAMIC MONITORING - NONINVASIVE MEASUREMENTS ➢ General appearance ➢ LOC LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION ➢ Skin color/temperature ➢ Vital signs ➢ Peripheral pulses ➢ Capillary refill ➢ Urine output CIRCULATORY ASSISTIVE DEVICES (CAD) DEVICE WTF DOES IT DO? INDICATIONS/CI INTRA AORTIC BALLOON PUMP (IABP) Provides temporary circulatory assistance by reducing afterload. Sits in aortic arch. Inflation and deflation of balloon to help pass blood. COUNTERPULSATION- PROPELS BLOOD AFTER MI ➢ Inflates at beginning of diastole (pushes blood back to coronary arteries) ➢ Deflates immediately before systole (sucks blood forward, so muscle can relax) Inserted percutaneously or surgically into femoral artery, moved toward heart & placed in descending aorta. Confirmed by CXR Benefits: ➢ Dec ventricular workload ➢ Inc myocardial perfusion ➢ Reduces afterload ➢ Reduces SVR ➢ Augment circulation (oxygenate coronary vessels) TEMPORARY USE INDICATIONS: ➢ MI ➢ Unstable angina ➢ Cardiogenic shock ➢ CHF CONTRAINDICATIONS: ➢ PVD ➢ Dissecting aortic/thoracic aneurysms (this can cause rupture) COMPLICATIONS: ➢ Vascular injuries ➢ Thrombus & embolus formation ➢ Thrombocytopenia ➢ Ischemia to periphery, kidney, bowel ➢ Infection ➢ Mechanical complications - improper timing of balloon inflation, balloon leak, malfunction INTERVENTIONS: ➢ Frequent assessments, keep pt immobile Provides short and long term support for failing heart and more mobility than IABP. VADs are inserted into the path of flowing blood to augment or replace the action of the ventricle TYPICALLY: ➢ VAD shunts blood from left atrium or ventricle -> device -> aorta ➢ Others provide right or biventricular support Dec cardiac work and improve organ perfusion when drug therapy is no longer adequate INDICATIONS: ➢ Failure to wean from CPB or postcardiotomy cardiogenic shock ➢ Bridge to recovery or heart transplantation ➢ Pt with new york heart association class IV heart disease who failed medical therapy Provides interim support when: ➢ Recovering from acute injury ➢ Stabilizing before surgical repair ➢ Awaiting heart transplantation ALLOWS PT TO GO HOME W DEVICE. Helps reduce systemic vascular resistance VENTRICULAR ASSIST DEVICE (VAD) DISADVANTAGES ➢ ➢ ➢ ➢ ➢ ➢ Risk for infection Educate PT that their legs need to be straight at all times (goes thru femoral artery) ○ Side lying or supine ○ HOB < 45 degrees Risk of developing pneumonia Can damage RBCs (thrombocytopenia) May cause thrombus and embolus formation Ischemia to kidneys and bowel ○ Assess urine output if balloon gets dislodged To reduce complications, do cv, neuro, and hemodynamic assessments every 15-60 minutes ➢ ➢ Many pts die awaiting transplant ○ Provide emotional support Observe for: ○ Bleeding ○ Cardiac tamponade ○ Ventricular failure ○ Infection ○ Dysrhythmias ○ Renal failure ○ Hemolysis ○ VTE LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION MODES OF VENTILATION & MANAGEMENT: NASAL CANNULA: 1-6 LPM Add humidification if > 3 L 24-40% FIO2 (concentration of oxygen) SIMPLE MASK: 6-10 LPM 35-50% FIO2 PARTIAL NON-REBREATHING MASK: 10-15 LPM 40-70% FIO2 VENTURI MASK: delivers higher total flow at a set “low” FIO2 of 40-60% NON-REBREATHER: 10-15 LPM 100% FIO2 - not intended for long-term use NONINVASIVE VENTILATION DEVICES CPAP: CONTINUOUS POSITIVE AIRWAY PRESSURE ➢ ➢ ➢ ➢ ➢ ➢ Continuous positive airway pressure - not intended for full ventilation support Constant set pressure during inhalation -> allows airways to stay open Pressure relief during exhalation One set pressure Indications: sleep apnea (snoring) No mode, no ventilation and the pt is doing all the work of breathing. Prevents the lungs from returning to zero ambient pressure BiPAP: BILEVEL POSITIVE AIRWAY PRESSURE ➢ ➢ ➢ ➢ ➢ ➢ ➢ 2 different set pressures Higher constant set pressure during inhalation Lower constant set pressure during exhalation No continuous resistance when exhaling, unlike CPAP Indications: respiratory exhaustion, COPD Assists pt to push off CO2 at the alveoli and lower expiratory positive pressure Allows for better work of breath. CONSIDERATIONS: ➢ Good seal (improper fitting mask) ➢ Oral care ➢ Skin breakdown (nose bridge) ➢ Monitor ABGs ➢ Make sure they’re clean - inf. Pts shouldn’t be in restraints and must be coherent - pt must be able to remove, bc risk if vomiting. Also not for those with tube feedings. *pts need to be AOx4 - not for confused pts/pts on restraints* INVASIVE VENTILATION DEVICES ARTIFICIAL AIRWAYS: placement of tube into trachea, bypassing upper airway and laryngeal structures ➢ Endotracheal (ET) intubation: via mouth or nose past larynx ➢ Tracheostomy: via stoma in neck (more long term) ENDOTRACHEAL TUBE (ET) Oral or nasal approach RAPID SEQUENCE INTUBATION (RSI): rapid concurrent administration of sedative & paralytic drug during emergency airway management to induce unconsciousness for INDICATIONS: ➢ Non Emergent or emergent situations ○ Emergent: protection of airway ➢ Anesthesia purposes: surgeries ➢ Short term use for positive PROCEDURE: ➢ “Sniffling” position - head extended and neck flexed (allows HCP to see vocal cords) ➢ Preoxygenate pt using BVM and 100 % O2 for 3-5 mins ➢ Each attempt limited to 30 secs ➢ Ventilate between successive attempts using BVM and 100% O2 ➢ After intubation, inflate cuff ○ Cuff pressure: 20-25 cm H2O COMPLICATIONS: ➢ UNPLANNED EXTUBATION: ○ Prevented by: ■ securing and observing and supporting ET tube during repositioning, procedures, and pt transfers ■ Giving adequate sedation and analgesia LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION intubation ➢ Dec risk for aspiration & injury ➢ Sedative -> paralytic -> analgesic (propofol-> rocuronium/succinylch oline -> fentanyl) Essentially induces unconsciousness, induces skeletal muscle paralysis, & blunts pain. Monitor O2 status w pulse ox. Propofol: short ½ life; amnesic effect. Infusion syndrome: metabolic acidosis, rhabdomyolysis, hyperlipidemia, enlarged fatty liver, monitor LFTs and renal fxn tests NOT INDICATED FOR PTS IN CARDIAC ARREST OR DIFFICULT AIRWAY pressure (mechanical ventilation) ONLY 3 WEEKS READY AT BEDSIDE: ➢ BVM bag attached to O2 ➢ Suction ➢ IV access INTUBATION EQUIPMENT: ➢ Intubation tray or box (7-8 is diameter - depends on size of pt by HCP) ➢ Working suction ➢ 10 mL syringe for cuff inflation ➢ Tape or method for securing ETT ➢ Stethoscope ➢ Monitoring equipment ➢ Ventilator ➢ BVM (ambu bag) ➢ Meds as indicated ○ ○ Record cuff pressure q8h Air leak = pt talking, wheezing or whistling sound ➢ Confirm placement while manually ventilating with BVM - use EtCO2 detector to confirm proper placement ○ 5-6 exhalations with CO2 level must be present to confirm tube placement in trach ○ Auscultate lungs for bilat breath sounds & epigastrium (tummy) for absences of sounds ○ Observe symmetric chest wall mvmt ○ SpO2 should be stable or improved ○ CXR most definitive way to confirm (2-3 cm above carina in adult) ➢ Connect ET to mechanical vent and secure tube per agency policy ○ Record & mark position of tube once placement is confirmed (use teeth or lips as reference check documentation every shift) ➢ Obtain ABGs (15-30 mins after intubation) SUCTION: ➢ PRN for only 10-15 seconds ➢ Complications: hypoxemia, bronchospasm, inc ICP, dysrhythmias, BP changes, mucosal damage, bleeding, pain, infection ➢ When to suction - high pressure alarm, if coughing, if de-sating, if you hear crackles or rhonchi TRAIN OF FOUR (TOF) ➢ Assessment of paralyzed pt using peripheral nerve stimulation ➢ Paralyzing agent may be used to provide more effective synchrony with ventilator, increase oxygenation ➢ Typically ulnar nerve - we should see 4 muscle twitches ○ Number of twitches depends on amount of neuromuscular blockade ○ 4/4 = titrate paralytic higher ○ ¼ = titrate paralytic lower ○ Usual goal = 1 or 2 twitches out of 4 currents ■ ➢ ➢ Using standard weaning protocols to decrease incidence ■ Use of restraints ○ INTERVENTIONS: ■ Call for help - stay w pt ■ Maintain pt’s airway ■ Support ventilation - manual ventilation - BVM 100% ■ Securing appropriate help to reintubate pt if vitals allow ■ Provide psychologic help ASPIRATION: ○ Secretions collect above the cuff, when cuff is deflated, secretions move into lungs ○ Prevented by: ■ Suctioning - Yankaue or sterile single-use catheter ■ Take precautions to prevent vomiting (give PPI) PNEUMONIA (INFECTION - ORAL CARE) ○ Suction toothbrush & toothpaste every 2-4 hrs ○ 0.12% chlorhexidine oral rinse ○ Mouth moisturizer ○ Oropharyngeal suctioning ○ Reposition and retape ET tube PNEUMONIA ➢ Ventilation associated pneumonia (occurs more than 48 hrs after endotracheal intubation) ➢ Contact precautions ○ HOB at least 30 degrees ○ Reposition every 2 hr ○ Promote early ambulation ○ Oral hygiene q2h - chlorhexidine q4h ○ Hand hygiene ○ Suction PRN ○ Daily sedation (sedation vacation) - assess for weaning purposes LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION ➢ ○ GI prophylaxis (protonix, -prazole, PPI) ○ Prevent DVT prophylaxis - Lovenox, subq minimal heparin Aspiration pneumonia (suction accordingly) MECHANICAL VENTILATION SETTINGS Indications for mechanical ventilation: ➢ Apnea ➢ Inability to breathe or protect airway ➢ Acute respiratory failure ➢ Severe hypoxia ➢ Respiratory muscle fatigue Vent settings are determines by pt’s vent status, respiratory drive, ABGs ALWAYS INVESTIGATE ALARM SETTINGS HIGH PRESSURE ALARMS affecting the pt itself *people use DOPE to get high* ➢ D - dislodgement ○ For dislodgement ET tubes should be placed into trachea ➢ O - obstruction ○ Classified as either fluids (blood, secretions, vomit - suction), kinks in ETT, pt biting tube - most common ➢ P - pneumothorax (tension) ○ Needle decompression/chest tube required when it’s difficult to bag pt or high pressure alarm ➢ E - equipment ventilator issues (EDEMA TOO) LOW PRESSURE ALARMS r/t machine ➢ Pt has become disconnected; partial extubation ➢ Responding to them is crucial to pt safety ➢ Respond by first assessing the pt, ventilator comes second ➢ Ventilate pt with manual resuscitation bag if necessary ➢ When pt speaks -> air leak, notify dr ➢ Leak in ET cuff tubing (less than 20-25) ○ Pt is losing oxygen -? Oxygenate immediately TERMS: ➢ FiO2 - fractional inspiratory oxygen concentration (21-100%); use lowest setting that achieves targeted oxygenation; max out FiO2 before increasing PEEP ➢ Respiratory setting - set number of ventilator breaths per minute ○ Hypoventilation may cause respiratory acidosis ○ Hyperventilation may cause respiratory alkalosis ➢ Tidal Volume (Vt) - amount of gas inhaled in on breath (6-10 mL/kg) to prevent barotrauma ➢ Positive End Expiratory Pressure (PEEP) - assoc w mode that has a rate & delivers a Vt or pressure BENEFICIAL TO ARDS PTS ○ Used to keep alveoli open and “recruit” more alveoli to improve oxygenation for pts ○ High levels can cause barotrauma, inc ICP, dec CO ■ Too much PEEP = hypotension ➢ Minute ventilation (MV) - amount of gas exchanged in one min ➢ Pressure support - 8-20 cm H2O; provides additional pressure during inspiration to ensure larger Vt with minimal pt effort; used to help overcome work of breathing thru ventilator tubing; brings air closer to pt LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION ➢ Peak inspiratory pressure (PIP) - max pressure that occurs during ventilation; measured at expiration MODE SETTINGS Negative Pressure Ventilation - NIF (neg inspiratory force); i.e iron lung Positive Pressure Ventilation - 2 categories: volume ventilation & pressure ventilation - used during expiration; beneficial to those with ARDS POSITIVE PRESSURE VENT VOLUME RT & Physician set settings: ➢ RR ➢ Tidal Volume ➢ PEEP ➢ FiO2 ASSIST-CONTROL VENTILATION (ACV - AC MODE) Ventilator delivers a preset Vt at a preset frequency. Pt initiates spontaneous breath, the ventilator senses a decrease in intrathoracic pressure & delivers the preset Vt. pt can breathe faster than settings, but not slower. Allows pt to have some control over ventilation while providing help. same Vt every single breath NOT GOOD FOR WEANING - VENT DOES ALL WORK FOR PT Ideal tidal volume is based on body weight. This is great bc pt will get the oxygen they need. SYNCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV) Ventilator delivers preset Vt at a preset frequency in synchrony with pt’s spontaneous breathing. Between ventilator breaths, pt can breathe spontaneously thru vent circuit. Used during continuous ventilation and during weaning from the vent. Vent will give pt intermittent breath; pt does more of the work. Good way to exercise pts muscles for breathing. Good for weaning, to get off ventilator. PRESSURE PRESSURE SUPPORT VENTILATION (PSV) Applied to airway only during inspiration and is used with pt’s spontaneous respirations. Pt must be able to initiate a breath. Level of positive airway pressure is preset so the gas flow rate is greater than the pt’s inspiratory flow rate. As pt breathes, INDICATIONS: ➢ Neuromuscular disorders (Guillain barre syndrome) ➢ Pulmonary edema ➢ Acute respiratory failure COMPLICATIONS ➢ Hyperventilation/respiratory alkalosis ○ Spontaneously breathing pt can be over ventilated -> hyperventilation ○ Nursing action: decrease respiratory rate ■ If you can’t control it from that, paralyze them with pharmacological measures ➢ Hypoventilation/respiratory acidosis ○ Volume or minimum rate is set to low & pt is apneic or weak ○ Nursing action: increase respiratory rate *these pts need constant assessment & monitoring of respiratory status, RR, ABGs, SpO2, SccO2. IMPRT that sensitivity (amount of pressure needed to start a breath) is appropriate to pt’s condition* ➢ Muscle weakness - intercostals atrophy BENEFITS: ➢ Improved pt-ventilator synchrony ➢ Lower mean airway pressure ➢ Prevention of muscle atrophy as pt takes on more of the WOB (work of breath) DISADVANTAGE: ➢ Spontaneous breathing dec when the preset rate is low ➢ Ventilation may not be adequately supported ➢ Only pts with regular, spontaneous breathing should use low-rate SIMV ➢ Weaning with SIMV demands close monitoring and may take longer bc rate of breathing is gradually reduced ➢ Can cause anxiousness in pt bc machine pushed breath into pt -> tachycardic ➢ Shallow breaths bring in small amount of tidal volume -> slowly developing respiratory acidosis USED WITH: ➢ Continuous ventilation ➢ During weaning RISK FOR: LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION machine senses spontaneous effort & supplies rapid flow of gas at the initiation of the breath and variable flow throughout breath. Pt determines inspiratory length, Vt, and rr. Vt depends on pressure level and airway compliance. KEEPS AIRWAY OPEN Continuous monitoring - make sure pt isn’t too tired Pt does all the work - inspiration & expiration. Indication - good for weaning & exercise of lungs/muscles. LONGER PT STAYS ON VENT = MORE COMPLICATIONS. Similar to cpap. Need a nif (negative inspiratory force of at least 20) ➢ Hypoventilation ➢ Apnea = acidosis -> vent will go back into assist control to combat this ➢ Weakness ➢ Lethargy ADVANTAGES: ➢ Inc pt comfort ➢ Dec WOB ➢ Dec O2 consumption ➢ Inc endurance conditioning POSITIVE END EXPIRATORY PRESSURE (PEEP) Positive pressure is applied to airway during exhalation. Normally during exhalation, airway pressure drops to near 0, and exhalation occurs passively. With PEEP, exhalation is passive but pressure falls to a preset level (3-20 cm H2O). Lung volume during expiration and between breaths is greater than normal with PEEP. Is titrated to point that oxygenation improved w/o compromising hemodynamics. Classic indication is ARDS. KEEPS ALVEOLI OPEN - CAN BE ADJUSTED. Normal people have PEEP of 5-15 cm H2O. Treats persistent hypoxia, prevents atelectasis ➢ ARDS pts -> d/t refractory hypoxemia, can inc peep to max of 20 cm H2O ○ Monitor for barotrauma & volutrauma ➢ High PEEP -> can cause dec CO/hypotension - bc of squeezing heart ➢ PEEP > 10 cm h2O -> monitor for dec CO ADVANTAGES: ➢ Improves oxygenation by restoring the lung volume that normally remains at end of passive exhalation ➢ Increased aeration of patent alveoli ➢ Aeration of previously collapsed alveoli ➢ prevention of alveolar collapse throughout resp cycle COMPLICATIONS: ➢ Increased ICP ➢ Low CO ➢ Hypovolemia ➢ Pneumothorax PRONE POSITIONING ➢ Shifts blood from base of lungs to apex - beneficial to ARDS pts ➢ Increases O2 w/o inc O2 concentration ➢ Improves VQ & airflow ➢ Moves secretions to other areas ➢ Improves atelectasis NITRIC OXIDE (NO) ➢ Vasodilation WEANING & EXTUBATION Process of: ➢ Reducing ventilator support ➢ Resuming spontaneous breathing ➢ Short term ventilation = linear weaning process ➢ Long term = alternating gains & losses Weaning: PREWEANING Assessment phase - looks at pt’s ability to breathe WEANING Awakening/breathing coordination, delirium OUTCOME PHASE Completely extubate pt LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION spontaneously ➢ Lungs should be reasonably clear on auscultation & CXR ➢ Assess muscle strength & endurance (neg inspiratory force, spontaneous Vt, vital capacity, min vent, rapid shallow breathing) ➢ Minimal secretions ➢ Ability to cough & gag ➢ Cuff leak when ET tube cuff is deflated ➢ Neuro status, hemodynamics, fluids, electrolytes, acid-base balance, nutrition, hgb monitoring/management, early mobility bundle ➢ SBT(spontaneous breathing trial) should be at least 30 mins but no more than 120 mins toleration is key ➢ SAT done by stopping all sedatives (propofol/fentanyl) ➢ Decrease ventilator days EXTUBATION: ➢ Hyperoxygenate & suction ➢ Loosen ET tapes or holder ➢ Deflate cuff & remove tube at peak of deep inspiration ➢ Have pt deep breath & cough ➢ Supplemental O2 ➢ Monitor CHAPTER 67 ACUTE RESPIRATORY FAILURE (ARF) When oxygenation, ventilation or both are inadequate. Can occur immediately. Symptom that represents lung fxn. Responds to oxygen. ➢ Assessed by ABGs and pulse S/S OF ARF: ➢ Decreased O2 ○ Restlessness ○ Confusion ○ Agitation ➢ Increased CO2 ○ Morning headache ○ Dec RR ○ Dec LOC FIRST SIGN OF RESPIRATORY FAILURE IS A CHANGE IN MENTAL STATUS! Common Cause: ➢ Intrapulmonary shunt: blood flows thru the pulmonary capillaries w/o taking part in gas exchange ➢ IVC Filter (if anticoagulants are C/I - i.e. liver probs, GI bleeding) ○ This prevents clots from traveling filter is inserted thru femoral veins ➢ Mesh filter that sits on top of vena cava V/Q mismatch HYPOXEMIA -> lack of O2 - need ventilation ➢ Oxygenation failure ➢ Inadequate exchange of O2 btw alveoli & pulmonary capillaries ➢ PaO2 /- 60% O2 ○ Normal PaO2 = 80-100 mmHg ➢ Causes: COPD, asthma, pneumonia, shunts, recurrent pulmonary emboli, pulmonary fibrosis, ARDS ➢ S/S (respiratory): ○ Dyspnea, tachypnea ○ Prolonged expiration ○ Altered LOC ○ Nasal flaring, intercostal muscle retraction ○ Use of accessory muscles ○ Paradoxic chest or abdominal movement - hallmark sign (late sign) ○ Cyanosis (late sign) ○ Dec SpO2 (< 80%) ➢ S/S (cardiac): ○ Tachycardia ○ HTN ○ Skin cool, clammy, diaphoretic ○ Dysrhythmias & hypotension (late sign) ➢ Tx: ○ Supplemental O2 ○ Mechanical ventilation ○ Meds: ■ Albuterol ■ Diuretics LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION ○ 0.8-1.2 area of lungs aren’t receiving same ratio - uneven O2 exchange RESPONDS TO OXYGEN! Nursing & interprofessional care: ➢ Positive Pressure Ventilation - intubation ➢ Noninvasive PPV - BiPAP, CPAP ➢ Respiratory therapy ➢ Drug therapy ➢ Nutritional therapy ➢ Medical supportive therapy ■ Corticosteroids ■ Mucolytics, expectorants (for thick secretions) HYPERCAPNIC -> insufficient CO2 removal ➢ Ventilatory failure ➢ Insufficient CO2 removal - body can’t compensate ➢ PaCO2 > 50 mmHg and pH < 7.35 ➢ Always find out cause for trtmt - usually pts with COPD, asthma, CNS suppression, neuromuscular conditions, drug OD ➢ S/S (respiratory): ○ Dyspnea ○ Tripod position ○ Pursed lip breathing ○ Dec RR or rapid rate w/shallow resp ○ Dec tidal volume, dec min ventilation ○ Morning headaches ➢ S/S (cardiac): ○ Tachycardia ○ HTN ○ Dysrhythmias ○ Bounding pulse ➢ Tx/intervention: ○ Inc RR to blow off CO2 ACUTE RESPIRATORY DISTRESS SYNDROME Sudden & progressive form of ARF where the alveolar-capillary membrane becomes damaged and more permeable to intravascular fluid - pt cannot produce surfactant - stiff lungs. Most common cause is sepsis. Can also develop bc of multiple organ dysfunction syndrome. Direct or indirect injury can cause ARDS. ARF can lead to ARDS Impaired gas exchange that develops from inflammation Hallmark sign: refractory hypoxemia (hallmark sign - no matter how much O2 we give its not helping), decreased lung compliance Caused by: ➢ Sepsis ➢ Multiple organ dysfunction syndrome ➢ Drowning ➢ Smoke inhalation S/S: High RR, high HR Low O2 -> refractory hypoxemia Respiratory alkalosis AT FIRST bc breathing fast, breathing out CO2 Respiratory acidosis LATER bc retaining CO2 as things progress Pulmonary edema Cyanosis, retractions Mental status changes Whiteout CXR, bilateral infiltrates Mnemonic: ○ Atelectasis ○ Refractory hypoxemia (hallmark s/s) ○ Decreased lung compliance ○ Surfactant cells damaged NURSING INTERVENTIONS: ➢ Goal: ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ ➢ LEWIS CHAPTERS 27, 65, 67, 68 PAT’S NOTES BLANK’S LECTURE ELLIE’S SESSION ERICK’S NOTES MARIO’S SESSION PF Ratio: PaO2/FiO2 Progression: ➢ Mild 200-300 ➢ Moderate 100-200 ➢ Severe < 100 Doesn’t respond to oxygen ABG best way to determine oxygenation status ➢ ➢ ➢ ➢ ➢ ➢ ○ PaO2 > 60 mmHg ○ SpO2 > 90 % Main treatment - PEEP ○ Watch for dysrhythmias or hypotension (increased intrathoracic pressure can compress the heart & decrease CO) & barotrauma ○ Normal range 5-15 cm H2O ■ 5-20 cm H2O for pts with ARDS Prone position Medications: ○ Corticosteroids - inflammation ○ Antibiotics - for sepsis ○ GI drugs - to prevent stress ulcers Prevent pressure injury, vent infections Nutrition: ○ High protein, high calorie diet ○ EN or PN in 24-48 hrs Mnemonic for treatment: ○ A - antibiotics ○ R - respiratory (nebulizer, humidifier) ○ D - diuretics ○ S - situate pt in prone position (helps with oxygenation) CHAPTER 68 Primary survey: ABC’s GLASCOW: 15 Conscious, 8 needs intubation, 3 coma, 0 - no such thing Secondary Survey: Head to toe -> SAMPLE Hypothermia - body temp 95 or less; rewarm them slowly, or else can cause cardiac arrest