ACUITY OF CARE PATIENT CLASSIFICATION

A. Activities of Daily Living C. MEDICATION & IV THERAPY 2. MAJOR NURSING PROCEDURES immediate post-invasive
Subtotal = 15 points Subtotal = 15 points 2.1. Chest tube care/ drainages/ procedures (1st 6-8 hrs.)/ post
1. FEEDING (4 points) 1. No oral medication and IVF 0 central line thoracentesis, cystoclysis/
1.1. Self 1 2. With oral medication & no IVF 2 2.2. Pulmonary toilet (suction) endoscopy/ colonoscopy/
1.2. With assistance 2 3. 1-5 oral medication and plain 3 2.3. Peritoneal dialysis/ cystoclysis/ paracentesis
1.3. On gavage feeding (NGT, 4 IVF weaning from ventilation/ 3. Immediate post-spinal (CS/ 6
gastrostomy, jejunostomy) 4. Oral medication & 2 IVFs (Plain 6 weaning from drug supports lumbar tap, etc.)
2. GROOMING (2 points) IVFs with piggy meds/ blood 4. Immediate post-general surgery 8
2.1. Without assistance 1 transfusion/ volume * 1 MINOR PROCEDURE/ 1 6 uncomplicated (thoracotomy/
2.2. With assistance 2 expanders/TPN requiring MAJOR PROCEDURE tracheostomy)
moderate observation, *2 MINOR + 1 MAJOR 12 5. Immediate post-general surgery 10
3. MOBILITY (3 points)
beneficial effects untoward PROCEDURE/ 1 MINOR +2 complicated (craniotomy/
3.1. Ambulatory 0
reaction) MAJOR PROCEDURES craniectomy/ weaning to
3.2. CBR with BRPs 1
5. With multiple NGT medication 10 *3 MINOR + 2 MAJOR 18 ventilator/ SP cardiac arrest
3.3. CBR without BRPs 2
and IVF (drug supports, blood PROCEDURES
3.4. Request for regular turning/ 3
transfusion, TPN requiring *3 OR MORE MAJOR 25
passive exercise
frequent observation of PROCEDURES H. BEHAVIOR
4. ELIMINATION (3 points) beneficial effects & untoward
4.1. Voids Freely 1
Subtotal = 5 points
reactions) 1. Alert 1
4.2. With condom cath/ foley 2 6. Same with no. 5 but requires 15
cath/ diaper/ weebag
E. COMMUNICATION 2. Anxious/ lethargic 2
intensive observation of Subtotal = 25 points 3. Comatose 3
4.3. Bowel/ urinary incontinence 3 beneficial effects & untoward 1. Orientation to hospital and 3 4. Restless, combative, confused 5
5. BATHING (3 points) reactions (includes unit policies
5.1. Self 0 thrombolytic therapy,
5.2. With assistance 1 2. Health teachings 6
autologous blood transfusion) 3. Emotion and spiritual support 10 LEVEL I = 0 – 30 POINTS
5.3. Partial bedbath 2
5.4. Complete bedbath with hair 3 LEVEL II = 31 – 60 POINTS
shampoo LEVEL III = 61 – 90 POINTS
D. NURSING PROCEDURES F. SAFETY PRECAUTIONS LEVEL IV = 91 – 100 POINTS
Subtotal = 25 points Subtotal = 5 points
1. MINOR NURSING PROCEDURES 1. Safe patient environment 2
B. ASSESSMENT AND
1.1. Enema/ O2 inhalation (nasal mask) raising of side rails
MONITORING Subtotal = 15 1.2. CBG monitoring 2. Application of restraints 3
1. Head-to-Toe Assessment 3 1.3. NGT care/ ostomy care/ gastric 3. Isolation precaution 5
2. MONITORING (12 points) lavage)
2.1. Every 4 hours 2 1.4. Tracheostomy/ ET care
2.2. Every 2 hours 4 1.5. Decubility/ pressure ulcer care/ G. GENERAL STATUS OF THE
2.3. Every 1 hour 6 wound care PATIENT
Subtotal = 10 points
1. Check-up, diagnostic procedure 2
2. Routine admission/ 4
uncomplicated pre-op events/