*ACUITIES* Indicator #1 - ADL Self/Minimal Care Select for a patient who independently performs activities of daily living (feeding,

, bathing, toileting, mobility, and dressing) or needs minimal assistance. Patient may still need the nurse to setup their tray or setup their bath, but they are able to perform the activities without assistance. Indicator #2 ADL Partial Care Select for a patient who requires assistance in performing any activities of daily living. Use this for patients that need help getting in/out of bed or ambulating. Patients who require some assistance in bathing or feeding. Indicator #3 ADL Complete Select for a patient who is dependent on staff for all activities of daily living. Indicator #4 Rehabilitative You are assisting the patient to learn how to do his/her ADLs independently. Select for a patient who requires staff assessment and intervention to restore/achieve the highest level of ADL attainable. o A patient who is an amputee learning to use a prosthesis o A CVA patient relearning motor activities or speech o Patient learning to use a walker to ambulate (Note: The patient cannot be completely dependent on nursing staff for everything; they must be able to perform some of their ADLs without assistance.) Indicator #5 ADL 2 or more Select for a patient who requires two or more caregivers to complete any activity of daily living. o Patient needs two caregivers to turn or get out of bed This is not for a physiologic crisis. #6 Communication Support Does this patient try to communicate with you but has a barrier? Deaf, blind, HOH without effective hearing aid, illiterate or has a language barrier. If ETT or Trach, patient must be trying to communicate with you. Do not use for sedated or comatose patients or those recovering from anesthesia. #7 Cognitive Support This patient needs orientation to person, place, time and situation due to alteration in cognitive function (not because he is recovering from anesthesia or sedation). This patient is confused, disoriented or developmentally challenged. You may also use this for restrained or ETOH withdrawal patients. #8 Close Observation Can only be used for safety reasons! This patient needs assessment by staff every 30min for at least 12 hours out of a 24 hour period (for safety reasons only).

#9 Close Observation 1 to 1 Can only be used for safety reasons! A staff member (i.e. sitter) must be present at the bedside for 12 hours out of a 24 hour period or the majority of their length of stay (for safety reasons only). May be used for the patient on Suicide precautions #10 Isolation Precautions Select for a patient who, due to known or suspected risk for transmissible infection or susceptibility to transmissible infection, requires additional precautions beyond Standard Precautions. This includes Airborne, Droplet and/or Contact Precautions. Examples: MRSA, VRE, TB/AFB precautions, Lice/Scabies or Chicken Pox (Note: If a patient needs isolation precautions the nurses interventions need to be above and beyond standard precautions i.e. gowning, gloves or bonnets.) #11 Fluid Management This patient needs an I&O. May or may not have a continuous IV. Patient may be on daily weights. May have an intermittent infusion. This patient needs an I&O intervention less than every 2 hours. Active calorie counts. In ICU this patient is probably just waiting on a bed in another unit. #12 Fluid Management Intermediate This patient needs a fluid assessment every 2 hours for at least 12 hours of a 24 hour period (or the majority of their stay). Patient must have at least one continuous infusion. #13 Fluid Management Complex This patient requires a fluid assessment every 1 hour for at least 12 hours in a 24 hour period. Must have at least one continuous infusion. Most ICU patients fit here. Although it is policy to monitor the patients I&O every hour some patients do not require this. Use this indicator only if the patient needs a qhr I&O assessment. (The key is to choose the fluid indicator that your patient truly needs.) #14 - Medication Management This patient requires an assessment every 4 hours (for at least 12 hours of a 24 hour period) to assess for response to a medication he is receiving. This med may be given via any route. This may include assessment of an IV site due to toxicity of the med being infused. This indicator can be selected for AC & HS accuchecks and any other medication that requires an assessment or intervention related to its administration every 4 hours. #15 Medication Management Complex This patient requires an assessment every 1 hour (for at least 12 hours of a 24 hour period) to assess for response to a medication he is receiving. This med may be given via any route.

This may include assessment of an IV site due to the toxicity of the med being infused. Most continuous medication drips can be captured here (i.e. vasopressors, insulin as well as drips for pain, anxiety or paralytics).

#16 Medication Management Continuous Assessment Nurse needs to be at the bedside during administration of the med. This patient must be monitored for his response to (or complication of) his receiving this medication every 30 minutes (for at least 12 hours of a 24 hour period). o i.e. Hemodynamically unstable patient requiring vasopressors and needs VS monitored every 30 minutes or more often to measure the response or lack there of the medication. (The key is to document frequent VS or interventions every 30 minutes or more often if your patient truly needs continuous assessment.) #17 Pulmonary Management This patient requires a pulmonary assessment and/or intervention every 4 hours (for at least 12 hours of a 24 hour period). Assessment could include any or all of the following: Rate and quality of respirations, titration/monitoring of oxygen therapy, inhalers, CPAP/BIPAP, airway suctioning and pulse oximetry monitoring. This can be used for q4hr assessments. #18 Pulmonary Management - Complex This patient requires a pulmonary assessment and/or intervention every 1 hour or more often (for at least 12 hours of a 24 hour period). Assessment could include any or all of the following: Rate and quality of respirations, titration/monitoring of oxygen therapy, inhalers, CPAP/BIPAP, airway suctioning, monitoring of arterial blood gas levels (q1hr for at least 12 hours), ventilator monitoring/adjustments and pulse oximetry monitoring. #19 - Pulmonary Management Intensive This patient requires a pulmonary assessment/intervention every 30 minutes (for at least 12 hours of a 24 hour period). Assessment could include any or all of the following: Rate and quality of respirations, titration/monitoring of oxygen therapy, inhalers, CPAP/BIPAP, airway suctioning, monitoring of arterial blood gas levels (q1hr for at least 12 hours), ventilator monitoring/adjustments and pulse oximetry monitoring. (Tip: It is important to document frequent VS (Q30 minutes) or interventions if the patient truly needs #19 Pulmonary Management Intensive.) #20 Cardiovascular/Neurological Management This patient needs an assessment and/or intervention of cardiovascular and or neurological/vascular status every 4 hours (for at least 12 hours of a 24 hour period). Assessment can include any or all of the following: Pulse rate, Blood Pressure, telemetry monitoring, pedal pulses (or other vascular assessment sites), spinal cord assessments and neurological/neurovascular assessments (i.e. Neuro checks). May use for q4hr neuro/cardiovascular assessments.

#21 - Cardiovascular/Neurological Management Complex This patient needs an assessment and/or intervention of cardiovascular and or neurological/vascular status every 1 hour (for at least 12 hours of a 24 hour period). Assessment can include any or all of the following: Pulse rate, Blood Pressure, telemetry monitoring, pedal pulses (or other vascular assessment sites), spinal cord assessments, continuous EEGs, and neurological/neurovascular assessments (i.e. Neuro checks). Invasive monitoring may include: Arterial lines, Swan-Ganz Catheters, CVP, ICP or Balloon Pumps. #22 - Cardiovascular/Neurological Management Intensive This patient needs an assessment and/or intervention of cardiovascular and or neurological/vascular status every 30 minutes (for at least 12 hours of a 24 hour period). Assessment can include any or all of the following: Pulse rate, Blood Pressure, telemetry monitoring, pedal pulses (or other vascular assessment sites), spinal cord assessments, continuous EEGs, and neurological/neurovascular assessments (i.e Neuro-checks). Invasive monitoring may include: Arterial lines, Swan-Ganz Catheters, CVP, ICP or Balloon Pumps. CVVHD This patient should not be left unattended due to high risk for rapid exsanguination if filter cracks/leaks or if line becomes disconnected. (Note: To select this indicator it is important to document VS/interventions every 30 minutes or the inability to leave this patient alone without asking a coworker to observe him for cardiovascular/neurological reasons.) #23 Preventative Skin Care This patient has a problem that threatens skin integrity and there is documentation of interventions related to the problem. Note: There doesnt necessarily have to be a care plan as long as charting indicates a problem and that interventions are taken related to this problem. Patient may have a care plan indicating specific creams, ointments, oral hygiene products or skin care products. The patient may have sensory loss, compromised circulation, decreased mobility or nutritional deficits that necessitate assistance with positioning or special pressure relieving devices. If your patient requires turning and/or oral care q2hr, the documented problems may include: o The patient is unable to perform these activities himself o The patient is NPO o The patient has tubes (NG, OG and ETT) in the naso/oropharynx. #24 Wound/Injury Management This indicator is for simple wound care (this excludes routine IV site care). Use this indicator for central line or A-line dressing change (only on the day the dressing change is being performed). Wounds: o Surgical incision with staples or sutures o A new stoma o A wound vac where the dressing is intact and does not need to be changed

o Simple Decubitus care o TUR patient o Patient with severe GI Bleeding Site care associated with tubes: o G Tubes, Suprapubic cath, Chest tubes, Tracheostomies. Postpartum perineum care Infant cord care or circumcision care #25 Wound/Injury Management Complex This is an intervention that takes less than one hour cumulatively for the entire 24 hour period. This includes: o Dehiscence or evisceration requiring sterile dressing changes o A wound that requires irrigation, debridement or packing. o A simple wound vac that needs to be replaced that day, but the cumulative intervention is not greater than 1 hour. o Illizarov pin care. o A wound that requires assessment q15 minutes for at least 1 hour (i.e. Cath site post-angio or after discontinuing a central or arterial line). o The removal of a sheath that requires pressure to the site for 30 minutes or more. o Frequent simple dressing changes (at least 4 in an 8 hour period) = (12 in 24 hours) where the cumulative intervention in a 24 hour period is less than 1 hour. #26 Wound/Injury Management Extensive and Complex Use this indicator for an extensive wound with a cumulative intervention of one hour or greater in a 24 hour period. o i.e. 3 dressing changes per day that last 30 minutes each equals a total of 90 minutes or if a dressing needs 2 nurses for 40 minutes every day equals 80 minutes in a 24 hour period. This also includes: o Extensive application of ointments/creams. o Debridement, irrigations or tubbing. o The ICU bedside nurse is required to stay with the patient to assist the burn team with turning and line/tube safety during the dressing change for the full duration of the treatment. #27 Information/Instructional Needs The nurse provides information to the patient or his family today about a test or procedure he is going to have or if the patient is being supported by a new mechanical device (i.e. Ventilator or IABP). This may also be used for routine discharge information. This can be documented in the education section on the admission assessment form. #28 Education Needs Lifestyle Change The Nurse provides education to the patient or his family/caregiver/significant other today so that he can manage his medical condition after discharge. Select for a patient who requires individualized education today to manage a lifestyle change. The education must address the knowledge and/or procedures that will be necessary for post-discharge healthcare management. May apply to the patients family, caregiver or significant other. A care plan must be in place addressing teaching/learning objectives that are specific to the patients lifestyle change. Education may include management of a newly diagnosed chronic condition i.e: o Diabetes, Cardiac disease, Ulcerative colitis, Multiple sclerosis.

Surgical procedure can also be considered a lifestyle change i.e: o New ostomy, Amputation Includes new medical equipment that will be used at home i.e: V o Ventilator, Feeding pump, IV pump, Home oxygen, Apnea monitor.

You can select this indicator if a consulting service has previously provided the initial education, but the nurse is reinforcing it today (i.e. Physical Therapy instructed your patient on the use of a walker in the am, but now you are reinforcing this information and assisting the patient to use it in the afternoon). #29 Coping Support This patient or his family is unable to cope with the current healthcare situation and needs additional coping support beyond the normal amount given to every patient. This indicator is appropriate for situations that are above and beyond the norm. Examples: o Violent behavior o Behavior that is disruptive to the unit o A patient who is clinically depressed and unable to participate in their plan of care o A patient, family member or significant other that requires extensive interaction by the nurse to aid in decision making i.e. withdrawal of care or level of resuscitation. (Note: This indicator is not for daily use, it indicates an acute change in the patients/significant others coping status.) #30 Extensive Coordination Select for the patient who requires additional care due to the need for extensive assistance in the coordination of services. In a rare event this indicator may be used when the nurse must coordinate care for patients who have multiple medical specialties caring for them and these specialties are not communicating/coordinating effectively o I.e. Multiple physician teams who need a care conference to coordinate a plan of care. This may include the coordination of family conferences. If the nurse is coordinating multiple services for hospital to hospital transfers or transfer to another facility i.e: o Palliative care o Hospice Staff o Chaplain o Social Services Also this indicator may be used for patient with significant wounds, burns or injuries that require transportation to the on unit burn tubbing room. This requires the coordination of multiple services to transport the patient to the treatment room i.e. respiratory, a physician, transport assistance, a photographer and the burn team. Do not use this indicator if the Discharge planner or ICM staff is coordinating the above activities. (Note: This is indicator is not typically used on a daily basis except for the above example of patients being transported to the burn tubbing room on the unit.)