Nursing Tasks based on Acuity Score

High Risk for CHF

Respiratory to assess patient bi-weekly & prn
Secure physician orders for 30 days: daily weights
Confirm with physician about patients home diuretics and if a change is warranted
Start Incentive spirometery (IS) on any patient with high risk for CHF and instruct patient to use IS Q4 while awake 10 times. IS physician orders can be to patient bedside
Secure physician orders for +2 Pitting Edema to elevate legs & recommend support stockings
Vital signs should be checked every 8 hours for 30 days (include Borg scale & breath sounds)
Notify MD of 3lb weight gain in 2 days and 5lb weight gain in 5 days

Low Risk for CHF

Respiratory to assess weekly & prn
Secure physician orders for weights for 30 days: 3 times a week
Vital signs should be checked every day & prn for 30 days
Notify MD of 3lb weight gain in 2 days and 5lb weight gain in 5 days
Secure physician orders for +2 Pitting Edema to elevate legs & recommend support stockings

High Risk for Pneumonia

Respiratory to assess bi-weekly & prn
Initiate oral hygiene & hand washing protocol for patient
Start incentive spirometery on any patient with high risk for pneumonia and instruct patient to use IS Q4 while awake 10 times. IS physician orders can be to patient bedside
Vital signs should be checked every 8 hours for 30 days (include Borg scale & breath sounds)

Low Risk for Pneumonia

Respiratory to assess weekly & prn
Initiate oral hygiene & hand washing protocol for patient
Vital signs should be checked every day & prn for 30 days
Start incentive spirometery on any patient with high risk for pneumonia and instruct patient to use IS Q4 while awake 10 times. IS physician orders can be to patient bedside

High Risk for COPD

Respiratory to assess bi-weekly & prn
Initiate oral hygiene & hand washing protocol for patient
Start incentive spirometery on any patient with high risk for COPD and instruct patient to use IS Q4 while awake 10 times. IS physician orders can be to patient bedside
Vital signs should be checked every 8 hours for 30 days (include Borg scale & breath sounds)
Secure physician orders for Spirometery Testing to determine COPD severity index

Low Risk for COPD

Respiratory to assess weekly & prn
Initiate oral hygiene & hand washing protocol for patient
Vital signs should be checked every day & prn for 30 days (include Borg scale & breath sounds)
Start incentive spirometery on any patient with high risk for pneumonia and instruct patient to use IS Q4 while awake 10 times. IS physician orders can be to patient bedside