중환자 분류도구

Ⅲ. 임상간호사에서 개발한 중환자 분류도구

*유의사항

1. 환자분류시간은 오전 11시로 한다.(전일 11AM∼당일 11AM 환자상태를 평가함)

2. 분류방법은 간호요원이 수행한 직접간호행위를 기초로 임상간호사회에서 개발한     중환자분류도구를 이용하여 환자별로 도구에 따른 ( )안의 점수를 합한 총점에     따라 환자분류군을 나누어 환자분류를 시행한다.

3. 조사자는 담당 간호사가 하며 환자분류도구와 지침서를 숙지한후 시행해야 한다.

4. 분류군별 점수는 아래와 같다.

총 점 수	분 류 군
0∼13 14∼32 33∼65 66∼98 99∼150 151이상	Ⅰ Ⅱ Ⅲ Ⅳ Ⅴ Ⅵ

항 목	내 용
VITAL SIGNS(Manual TPR,BP)	(1) Vital signs qid or less (2) Vital signs q 4h or×6 (3) Vital signs q 3h or×8 (4) Vital signs q 2h or×12 (8) Vital signs q 1h or×24 (2) Rectal or Axillary Temp or Apical pulse qid or more (2) Femoral or Pedal Pulses or fetal heart tones q 4h or more (2) Tilt Tests q 4h or more (6) Post-op, Post-partum, or post-new born Vital signs
MONITORING	(2) Intake and output q 8h or×3 (4) Intake and output q 4h or×6 (8) Intake and output q 2h or×12 (16) Intake and output q 1h or×24 (2) Circulation or fundus check q 2h or×12 (3) Neuro checks q 4h or×6 (6) Neuro checks q 2h or×12 (12) Neuro checks q 1h or×24

	(2) CVP/ICP/LAP(manual)q 2h or×12 (4) CVP/ICP/LAP(manual)q 1h or×24 (6) Cardiac/Apnea/Temp/Pressure monitor(not accumulative) (6) Transcutaneous monitor (4) A-line or ICP(monitor) or Swan Ganz set-up (2) A-line or ICP(monitor) reading q 2h or×12 (4) PAP/PCWP/RVP reading q 2h or ×12 (2) Cardiac output tid or×3
ACTIVITIES of DAILY LIVING	(6) Infant/Toddler care(<5years) (2) Self/Minimal care(Adult or child>5years) (6) Assisted care(>5years)-positions self (14) Completed care(<5years)-assists with positioning (18) Total care(<5years)-position and skin care (32) Total care(<5years)-position and skin care q 2h (4) Extra line change and partial bath per shift (14) Turning Frame(2staffs to turn q 2h) (8) Peds recreation/Observation(0-12years)
FEEDING	(5) Tube feed(bolus) q 4h or×6 (8) Tube feed(bolus) q 3h or×8 (10) Tube feed(bolus) q 2h or×12 (2) Tube feed(continuous) per bottle change (6) Adult meals>5 years-spoon feed×3 (10) Child meals<5 years spoon feed×3 (2) Infant/Neonate bottle × 1 feeding (12) Infant/Neonate bottle q 4h or×6 (18) Infant/Neonate bottle q 3h or×8 (24) Infant/Neonate bottle q 2h or×12
IV THERAPY & MEDICATIONS	(4) KVO(change bottle bid or less) (4) Heparin lock or Broviac (6) Simple(change bottle tid or qid) (8) Complex(2 or more sites or change bottle q 4h or multilumen line) (2) IV medication q 8h or×3 (3) IV medication q 6h or×4 (4) IV medication q 4h or×6 (2) Blood products(each administration) (2) Medication q 3h∼8h(up to 12trips)-exclude IV Medication (4) Medication q 2h or more(>12trips)-exclude IV medication

TREATMENTS, PROCEDURES	Simple>15 and<30 min total (2) Star IV or NG or Foley or EKG (2) OR preparation or Enema or Ace wraps/Teds (2) Lab studies×6;ABG stick or Blood cultures×3 (2) Simple dressing×2 or tube care×2 or foley care×2 (2) Irrigations or Instillations×4 or less (2) Restraints(두지점 또는 네지점) (2) Assist OOB to chair/stretcher×3 (2) Assist OOB, walk and return×1 (2) Infant circumcision or phototherapy (2) accompany patient off ward>15min but<30min (2) Other activites requiring>15min but<30min (2) Isolation(gown and glove×8) Complex>30min and<1h total (4) Chest tube insertion or lumbar puncture (4) Thoracentesis, paracentesis, pericardiocentesis (4) 단순도뇨×4회이상 (4) Complex dressing change(>30min) (4) Range of motion exercise×3 (4) Accompany patient off ward>30min (4) Other activities requiring>30min<1hr Special procedures>1h and<4h (8) 간호사에 의한 계속적 간호가 필요한 매1시간마다에 대해 (12) New admission(assessment and orientation) (4) Transfer(in-house)
RESPIRATORY THERAPY	(2) Oxygen therapy or oxyhood (2) Incentive spirometer or C&B(기침과 심호흡) q 4h (2) IPPB or Nebulizer bid or×2 (4) IPPB or Nebulizer q 6h or×4 (6) IPPB or Nebulizer q 4hr or×6 (8) Croup tent or mist tent (2) Chest PT bid or×2 (4) Chest pulmonary therapy q 6h or×4 (6) Chest pulmonary therapy q 4h or×6 (2) Suctioning q 4h or×6 (4) Suctioning q 4h or×12 (8) Suctioning q 1h or×6 (18) Suctioning q 30 min over

	(10) Ventilator (4) Tracheostomy care×3(after 48hr) (6) Tracheostomy care×3(before 48hr)
TEACHING and EMOTIONAL SUPPORT	Teaching (2) Group teaching (4) Preoperative teaching (4) Special structured teaching(Diabetic, cardiac, etc) Emotional support(>30min q 24h) (4) Patient/family support(anxiety, denial, loneliness, etc) (4) Lifestyle modification (prosthesis behavior, image, copying, etc) (6) Sensory depriviation(retarded, blind, deaf, mute, etc) (10) Maximum points for emotional support CONTINUOUS (99) Patient requiring (151) 1:1 coverage Patient requiring greater than 1:1