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Evaluation of consciousness level
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| Conscious |
| When a patient is alert and aware of space. |
| A patient is conscious when: |
| - He/she can say his/her name and last name. |
| - He/she can say his/her age (±2 years) or birth date (month and year). |
| A patient is aware of space when: |
| - He/she knows he/she is in the hospital. |
| - He/she knows the current month. |
| If the patient does not clearly meet these four requirements, he/she cannot be considered conscious. If the patient is intubated and/or cannot speak or write, go to the next item. |
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| Collaborative |
| A patient will be considered collaborative if he/she fulfills at least two simple orders of the following type: |
| - Open and close eyes. |
| - Hold and release the hand. |
| - Move the head or extremities. |
| If the professional is not sure the patient’s movements are a response to the request (check the patient’s auditory perception), go to the next item. |
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| Reactive |
| A patient is reactive when his/her response to a painful stimulus is: localizes pain, removes pain, flexion or extension. If the flexion or extension is very tenuous and dubious, go to the next item. |
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| Unreactive |
| Patients whose response to pain is very dubious and mild or nonexistent. This item also includes patients who perform decerebration or decortication movements. |
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Evaluation of hemodynamic status
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| No support |
| Patients without infusion of vasoactive drugs, without expansion with serum or red cells (not including platelets and plasma) 6 hours before the evaluation. Vasoactive drugs are: dopamine, dobutamine, adrenaline, and noradrenaline. |
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| With expansion |
| Patients without infusion of vasoactive drugs, but with expansion with serum or red cells 6 hours before the evaluation. |
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| With infusion of dopamine and dobutamine |
| Patients who, regardless of receiving serum or red blood cells, maintain dose-independent dopamine or dobutamine intravenous infusion. |
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| With infusion of adrenaline and noradrenaline |
| Patients who, at the time of evaluation, maintain dose-independent adrenaline or norepinephrine infusion. |
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Evaluation of respiratory status
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| Low demand for oxygen |
| Patients who remain with spontaneous breathing, extubated, without tracheostomy and in ambient air or with a nasal catheter. |
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| High demand for oxygen |
| Include in this section patients who: |
| - are extubated, with an oxygen mask, with reservoir or venturi. |
| - are intubated (oral or nasal) or has been submitted to tracheostomy using heat and moisture exchanger (filter), T-tube or any other type of simple oxygen support. |
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| With respiratory support |
| Patients who: |
| - are intubated or have been submitted to tracheostomy and require CPAP (continuous positive airway pressure), pressure support (PS) or any other system that does not eliminate full effort of the patient. |
| - are not intubated, but are submitted to any type of non-invasive ventilation. |
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| With mechanical ventilation |
| Patients who require any type of mechanical ventilation that fully replaces their respiratory function: CMV (controlled mandatory ventilation), VCPLV (volume-controlled, pressure-limited ventilation), PCV (pressure-controlled ventilation), IPPV (intermittent positive pressure ventilation), A/C (assisted/controlled), etc. |
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Mobility
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| Independent |
| Patients who are able to move by themselves, adopting the desired position in bed. |
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| Dependent, but moving |
| Patients who: |
| - cannot move alone, but tolerate all 3 positions (HDD, RLD, LLD). Consider at least the shift before the assessment. |
| - can be placed in an armchair, even if no decubitus changes are made or the patient is unable to perform them alone. The assessment shift or the shift before should be considered. |
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| Poor mobility |
| Patients who: |
| - did not tolerate changes from decubitus in the previous shift, or who cannot be placed in all positions (due to atelectasis, fractures, etc.). |
| - are changed from decubitus, even if returning to the previous position, and to the position of horizontal dorsal decubitus. |
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| No mobility |
| Patients who do not tolerate change from decubitus, or who have not been changed in the previous shift. |
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Other
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Temperature
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| Add one point to patients who have an axillary temperature of 38º C or higher. |
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Oxygen saturation
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| Add one point to patients with capillary oxygen saturation below 90% at any moment during the evaluation. |
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Blood pressure
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| Add one point to patients with systolic blood pressure below 100 mmHg during the evaluation. It can be an isolated measurement while monitoring non-invasive pressure. In case of continuous monitoring, consider recording low pressure during the evaluation. |
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Skin condition
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| Add one point if the patient clearly presents any of the following skin alterations: |
| - general edema (fovea sign, positive Godet or Cacifo sign in hands and feet). |
| - peripheral and/or central cyanosis (evidence in the fingers and toes, lips or extremities). |
| - very dehydrated or very delicate skin. |
| - excessive skin moisture or maceration. |
| - diarrhea (liquid and abundant evacuation, with more than 500 ml in the previous shift). |
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Patient in prone position
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| Add one point if patient is in prone position at the time of evaluation. |
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F. Add in item “Other” 0.5 point to total score for every full week the patient spent in the ICU*. Max. 2 points.
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