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1. MONITORING AND TITRATION
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1a. Hourly vital signs, regular registration and calculation of fluid balance Patients who requireNORMAL monitoring, according to the ICU routine, of vital signs, application of assessment scales (pain, RASS, Glasgow), water balance control (including nasogastric and nasoenteral tubes) and who do not need frequent alterations in treatment, therapy or monitoring intensification. Assisted oral feeding. |
4.5 |
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1b. Present at bedsideandcontinuous observation or active for 2 hoursormore in any shift, for reasons of safety, severity or therapy, such as: non-invasive mechanical ventilation, weaning procedures, restlessness, mental disorientation, prone position, donation procedures, preparation and administration of fluids and/or medication, assisting specific procedures. Patients who require intensified monitoring (MORE THAN NORMAL) due to alterations in the clinical condition, hemodynamic instability, oliguria, bleeding, dyspnea, fever, alteration in the level of consciousness, measurements in the assessment scales higher than the ICU standard, measurement of central venous pressure, invasive arterial pressure, intra-abdominal pressure, use of sedatives or long-term use of insulin, ventilator support, non-invasive mechanical ventilation or alteration of the ventilator parameters, preparation of fluids and emergency medication. Patient is stable after the therapeutic behavior adopted. Immediate post-operative care after cardiac surgery or major surgery, where the patient remains stable. Invasive procedures with intercurrences. Extubation without intercurrences. Assisted oral feeding that demands more time than normal. |
12.1 |
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1c. Present at bedsideandactive for 4 hours or more in any shift for reasons of safety, severity or therapy, such as those examples above (1b). Critical patients who require MUCH MORE THAN NORMAL monitoring, in at least one shift in 24 hours, without stabilization after the therapeutic interventions adopted, requires continuous nursing presence. Alterations described in the “MORE THAN NORMAL” category, however with a greater frequency and the need for interventions. Hemodialysis with intercurrence, requiring nursing intervention (when hemodialysis is performed by ICU staff). Unstable patients in immediate postoperative care after cardiac surgery or major surgery. |
19.6 |
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2. LABORATORY: Biochemical and microbiological investigations. Patients submitted to any biochemical or microbiological exam, regardless of the quantity, performed at bedside by a nursing professional, including capillary glucose. E.g.: HGT, glycosuria, tracing cultures, blood gas analysis, among others. This item should not be scored if the laboratory collector or physician performs the collection. |
4.3 |
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3. MEDICATION: Vasoactive drugs excluded. Patients who received any type of medication, regardless of the route and dose. Vasoactive drugs will be scored in a specific item (item 12). |
5.6 |
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4. HYGIENE PROCEDURES Performing hygiene procedures such as: dressing of wounds and intravascular catheters, changing linen, washing patient, incontinence, vomiting, burns, leaking wounds, complex surgical dressing with irrigation, special procedures (e.g. barrier nursing, cross-infection related, room cleaning following infections, staff hygiene) and especially obese patients, etc.
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4a. NORMAL Patients who were submitted, inNORMAL frequency (ICU routine), to one of the hygiene procedures mentioned above in at least one shift in 24 hours. Also including dressings closed in vascular catheter once a day. |
4.1 |
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4b. The performance of hygiene procedures took more than 2 hours in any shift. Patients who were submitted, inMORE THAN NORMAL frequency, to one of the hygiene procedures mentioned above in at least one shift in 24 hours. Vascular catheter dressing twice a day; medium dressing for pressure ulcer, dressing a surgical incision twice a day, medium dressing (with suture dehiscence); changing linen twice in 24h; washing of unstable patients by three professionals; body hygiene twice per shift. Fecal incontinence three times a day. Patients in isolation. |
16.5 |
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4c The performance of hygiene procedures took more than 4 hours in any shift. Patients who were submitted, inMUCH MORE THAN NORMAL frequency, to one of the hygiene procedures mentioned above in at least one shift in 24 hours. Extensive, complex, open cavity dressing or ≥three times a day. |
20.0 |
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5. CARE OF DRAINS - All (except gastric tube). Patients with any type of drain or tube with the aim of draining. Including long-term catheter, external ventricular drain (EVD), thorax drain, among others. EXCLUDING gastric tubes (nasogastric, nasoenteral, gastrostomies and others), which should be considered in item 1 or 21. |
1.8 |
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6. MOBILIZATION AND POSITIONING Including procedures such as: turning the patient; mobilization of the patient; moving from bed to chair; team lifting (e.g. immobile patient, traction, prone position).
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6a. Performing procedure(s) up to 3 times per 24 hours. Patients who require mobilization and positioning up to three times in 24 hours. |
5.5 |
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6b. Performing procedures(s) more frequently than 3 times per 24 hours, or with 2 nurses – any frequency.Patients who require mobilization and positioning, as described in item 6, which have been performed more than three times in 24 hours or by two members of the nursing staff in at least one shift in 24 hours. |
12.4 |
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6c. Performing procedure with three or more nurses – any frequency. Complex mobilization and positioning as per the procedure described in item 6, which have been performed by three or more members of the nursing staff, in any frequency, in at least one of the shifts in 24 hours. |
17.0 |
| 7. SUPPORT AND CARE OF RELATIVES AND PATIENT Including procedures such as telephone calls, interviews, counseling. Often, the support and care of either relatives or patient allow staff to continue with other nursing activities (e.g.: communication with patients during hygiene procedures, communication with relatives whilst present at bedside and observing patient). |
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7a. Support and care of either relatives or patient requiringfull dedicationfor about one hour in any shift such as: to explain clinical condition, dealing with pain and distress, difficult family circumstances. This item receives a score when guidance or instructions are given to patients and/or their families, providing emotional support with full dedication of a nurse from the staff, with NORMAL duration, according to the routine established in the unit, in at least one shift in 24 hours. |
4.0 |
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7b. Support and care of either relatives or patient requiringfull dedicationfor 3 hours or more such as: to explain clinical condition, dealing with pain and distress, difficult family circumstances. This item receives a score when guidance or instructions are given to patients and/or their families, providing emotional support with full dedication of a nurse from the staff, with MORE THAN NORMAL duration, according to the routine established in the unit, in at least one shift in 24 hours. |
32.0 |
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8. ADMINISTRATIVE AND MANAGERIAL TASKS
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8a. Performing routine tasks such as: processing of clinical data, ordering examinations, professional exchange of information (e.g.: ward rounds). Including records performed as nursing process and/or shift change, multidisciplinary rounds or administrative and managerial tasks related to patients, with NORMAL duration. |
4.2 |
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8b. Performing administrative and managerial tasks requiringfull dedicationfor about 2 hours in any shift such as: research activities, protocols in use, admission and discharge procedures. Including records performed as part of nursing process and/or shift change, multidisciplinary rounds or administrative and managerial tasks related to patients, with MORE THAN NORMALduration. Admission of patients in immediate postoperative period, unstable patients who require more extensive records. Need for providing materials and equipment. Assembly of the hemodialysis machine, application of protocols such as ECLS, transplantation, others. When the nurse needs help from a colleague to perform his/her activities. E.g.: the nurse continues assisting a patient and a colleague takes over the administrative tasks. |
23.2 |
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8c. Performing administrative and managerial tasks requiringfull dedicationfor about 4 hours or more of the time in any shift such as: death and organ donation procedures, co-ordination with other disciplines. Including any administrative and managerial task related to the patient, with MUCH MORE THAN NORMAL duration, according to the routine established in the unit. Critical, unstable patients who require intense records. Detailed shift change records, multidisciplinary rounds, organization of special materials and equipment for patient care, surgical procedures at bedside, protocols such as transplantation, ECLS, ventricular assist devices, teaching and supervising education/training. |
30.0 |
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VENTILATORY SUPPORT
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9. Respiratory support: Any form of mechanical ventilation/assisted ventilation with or without positive end-expiratory pressure, with or without muscle relaxants; spontaneous breathing with positive end-expiratory pressure (e.g. CPAP or BiPAP), with or without endotracheal tube; supplementary oxygen by any method. Patients making use of any respiratory support, from nasal catheter to mechanical ventilation. |
1.4 |
| 10. Care of artificial airways. Endotracheal tube or tracheostomy cannula. Patients making use of orotracheal or nasotracheal tube or tracheostomy. |
1.8 |
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11.Treatment for improving lung function. Lung physiotherapy, incentive spirometry, inhalation therapy, intratracheal suctioning. Patients who underwent treatment to improve their pulmonary function, performed in any frequency by the nursing staff. Aspiration with open or closed system and nebulization. |
4.4 |
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CARDIOVASCULAR SUPPORT
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12. Vasoactive medication, irrespective of type or dose. Patients who have received any vasoactive medication, regardless of the type and dose and who need intensive monitoring in their endovenous use: Sodium Nitroprusside, Vasopressin, Prostaglandin, Norepinephrine, Epinephrine, Dopamine, Dopexamine, Dobutamine, Isoproterenol, Phenylephrine, Nitroglycerin, Clonidin hydrochloride. Metoprolol and Propranolol (beta blockers) should be scored. |
1.2 |
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13. Intravenous replacement of large fluid losses. Fluid administration >3 l/m2/day, irrespective of type of fluid administered. Patients who have received fluid replacement greater than 4.5 liters of solution per day, irrespective of the type of fluid administered. |
2.5 |
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14. Left atrium monitoring. Pulmonary artery catheter with or without cardiac output measurement. Patients making use of pulmonary artery catheter (Swan-Ganz catheter). Including the use of cardiac pacemaker, intra-aortic balloon pumping, cardiac output monitoring, extracorporeal life support (ECLS), ventricular assist devices. |
1.7 |
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15. Cardiopulmonary resuscitation after arrest; in the past 24 hours (single precordial thump not included). Patients who suffered a heart problems and were submitted to cardiopulmonary resuscitation, independently of the environment where the cardiac arrest took place. This item should be scored only once in 24 hours. |
7.1 |
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RENAL SUPPORT
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16. Hemofiltration techniques. Dialysis techniques. Patients who have received any type of intermittent or continuous dialytic procedure. |
7.7 |
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17. Quantitative urine output measurement (e.g.: by indwelling urinary catheter). Patients who require diuresis control, in milliliters, with or without any type of urinary device. |
7.0 |
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NEUROLOGICAL SUPPORT
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18. Measurement of intracranial pressure. Patients submitted to intracranial pressure monitoring, jugular bulb catheter or microdialysis. Do consider this item if the patient has external ventricular drainage and assessment of ICP. |
1.6 |
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METABOLIC SUPPORT
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19. Treatment of complicated metabolic acidosis/alkalosis. Patients who made use of specific medication to adjust metabolic acidosis or alkalosis, such as administration of sodium bicarbonate in continuous or bolus infusion. Respiratory acidosis and alkalosis should not be scored in this item, neither should ventilator correction. The item considers those conditions requiring the permanent presence of a nurse for monitoring severe physiological deregulation and for titrating (fine-tuning) the therapy in acute conditions. During hemofiltration, if correction is necessary, additional score is indicated. |
1.3 |
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20. Intravenous hyperalimentation. Patients who receive central or peripheral venous infusion of parenteral nutrition. |
2.8 |
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21. Enteral feeding. Through gastric tube or other gastrointestinal route (e.g., jejunostomy). Patients who receive enteral feeding through tubes, by any route of the gastrointestinal tract. Measurement of aspiration/retention included. |
1.3 |
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SPECIFIC INTERVENTIONS
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22. Specific intervention(s) in the intensive care unit. Endotracheal intubation, insertion of pacemaker, cardioversion, endoscopies, emergency surgery in the past 24 hours, gastric lavage. Routine interventions without direct consequences for the clinical condition of the patient, such as: X-rays, echography, electrocardiogram, dressing, or insertion of venous or arterial catheters, are not included. Patients submitted to a diagnostic or therapeutic intervention listed above in the ICU. Specific procedures performed in the unit and which require active intervention of the staff can be considered in this item, including the insertion of venous or arterial catheters and spinal puncture. Procedures performed by the nurse, such as passing a relief or indwelling urinary catheter, a nasoenteral or gastric tube, a peripherally inserted central catheter (PICC), installation of intra-abdominal pressure, among others, that might be particular complex and require more nursing time for their execution can also be considered. |
2.8 |
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23. Specific interventions outside the intensive care unit. Surgery or diagnostic procedures. Patients who require diagnostic or therapeutic interventions performed outside the ICU. E.g.: tomography, radionuclide imaging, magnetic resonance, hemodynamics (take or pick up a patient), surgical procedures (take or pick up a patient), patient transfer to any hospitalization unit or discharge, and sending the body to the morgue. |
1.9 |
