| ND/NO* statement |
(%) §
|
| Dyspnoea (Specify Type) |
100 |
| Oedema (Specify Degree) |
100 |
| Cough |
100 |
| Risk For Cardiogenic Shock |
100 |
| Decreased Cardiac Output |
98.3 |
| Nausea |
98.3 |
| Ineffective Peripheral Tissue Perfusion |
98.3 |
| Ineffective Tissue Perfusion |
98.3 |
| Risk For Deep Vein Thrombosis |
98.3 |
| Increased Liquid Volume |
96.6 |
| Risk For Infection |
96.6 |
| Pressure Injury (Specify Stage) |
93.1 |
| Risk For Aspiration |
91.4 |
| NI statement †
|
(%) |
| Evaluate fiber food intake |
100 |
| Evaluate the presence of flatus |
100 |
| Monitor fluid balance (or water balance) as per routine |
100 |
| Prevent injury during transfer technique |
100 |
| Evaluate intestinal eliminations (feces frequency, quantity, aspects) |
100 |
| Assess upper and lower limbs (temperature, color, pulse rate, ankle-arm index) |
100 |
| Evaluate past pain experiences, including individual and family history of chronic pain or resulting disability |
100 |
| Monitor urinary output (frequency, quantity, color, pain and foul odor) |
100 |
| Prevent accidental extubation (fix artificial airway) |
100 |
| Assess discomfort (type, location, intensity, triggering factors) |
98.4 |
| Suction airway, as appropriate |
98.3 |
| Auscultate breathing noises before and after Aspiration, as per routine |
98.3 |
| Assess person’s level of consciousness |
98.3 |
| Evaluate the function and integrity of the urinary catheter |
98.3 |
| Assess response to fluid (or hydration) therapy |
98.3 |
| Determine degree of jugular vein distention, as appropriate |
98.3 |
| Investigate person’s food preferences |
98.3 |
| Lateralize person’s head, according to the risk for aspiration of vomit |
98.3 |
| Keep via area unobstructed |
98.3 |
| Monitor mobility in bed |
98.3 |
| Monitor electrolyte balance as per routine |
98.3 |
| Position person in bed with the headboard elevated (30º, 45º or 60º), as appropriate |
98.3 |
| Provide change of position, according to person’s routine and hemodynamic state |
98.3 |
| Record sleep pattern in hours |
98.3 |
| change dressing |
98.3 |
| Auscultate heart rhythm, paying attention to the presence of the 3rd heart sound |
98.3 |
| Assess nausea |
98.3 |
| Assess vital signs (heart rate, respiratory rate, blood pressure, pulse rate, temperature, and pain) |
98.3 |
| Assess skin (color, temperature, pain, swelling, perfusion, tenderness, moisture, texture, and signs of infection) |
98.3 |
| Assess signs of dehydration (decreased skin turgor, dry mucosa) |
98.3 |
| Monitor blood oxygen saturation using pulse oximetry as per routine |
98.3 |
| Supervise the insertion site of invasive devices (temperature, color, pain, secretion) |
98.3 |
| Administer oxygen therapy, as appropriate |
96.6 |
| Administer nutritional supplement, as appropriate |
96.6 |
| Auscultate bowel sounds as per routine |
96.6 |
| Identify cause of impaired sleep |
96.6 |
| Restrict/offer fluids, as appropriate |
96.6 |
| Check body temperature of lower limbs |
96.6 |
| Assess central venous pressure or right atrial pressure, as appropriate |
96.6 |
| Assess oral cavity condition (prosthesis, injury, teeth, pain) |
96.6 |
| Evaluate the type of dyspnea (nocturnal, intermittent, lying down, resting, others) |
96.6 |
| Assess nutritional status |
94.8 |
| Evaluate pain with scales (verbal, facies, visual, numeric) about the place, beginning, duration, intensity, triggering/relieving factors |
94.8 |
| Catheterize urinary bladder, if necessary |
94.8 |
| NI statement †
|
(%) |
| Install non-invasive artificial airway |
94.8 |
| Evaluate cough (sputum, secretion, color, frequency, intensity, murmurs and noises) |
93.3 |
| Evaluate shift of pain/discomfort to other locations |
93.1 |
| Assess weight as per routine |
93.1 |
| Evaluate person’s acid-base balance through arterial blood gases |
93.1 |
| Monitor person’s response to sedation |
93.1 |
| Offer oral or parenteral liquid, as appropriate |
93.1 |
| Identify signs of pulmonary congestion (breathing rate, heart rate, peripheral oxygen saturation, expectoration, murmurs, noises, others) |
93.1 |
| Irrigate nasogastric catheter during continuous feeding and before intermittent feeding, as per routine |
93.1 |
| Check nasogastric catheter residues (volume, color) |
93.1 |
| Evaluate the lesion (degree, cause, dimensions, location, color, secretion, fetid odor, pain, temperature) |
91.4 |
| Educational Process |
| ND/NO statement |
(%) |
| Impaired Self Care |
96.6 |
| Conflicting Attitude Toward Medication Management |
93.1 |
| NI statement |
(%) |
| Guide the family/caregiver on the importance of encouraging person’s self-care |
100 |
| Explain to person/family/caregiver the causes of fatigue |
100 |
| Encourage person’s autonomy in self-care, according to the degree of capacity |
98.3 |
| Guide the family member/caregiver about post-discharge care in disease management |
98.3 |
| Advise on procedures and sensations that person may experience |
98.3 |
| Facilitate communication with person about conflicts in medication management |
96.6 |
| Psychosocial Support For Patient And Family |
| ND/NO statement |
(%) |
| Hopelessness |
100 |
| Spiritual Distress |
98.3 |
| Anxiety |
98.3 |
| Impaired Ability Of Caregiver To Perform Caretaking |
98.3 |
| Conflicted Spiritual Belief |
96.6 |
| Fear |
96.6 |
| Situational Low Self Esteem |
94.8 |
| Unfavorable Religious Coping |
94.8 |
| Lack Of Family Support |
94.8 |
| NI statement |
(%) |
| Help person identify situations that trigger anxiety |
100 |
| Help person identify situations that cause hopelessness |
100 |
| Help person identify situations that provoke fear |
100 |
| Identify barriers to effective communication with person |
100 |
| Identify person’s spiritual beliefs |
100 |
| Identify factors that cause low self-esteem |
100 |
| Encourage the family/caregiver to participate in the care plan |
100 |
| Encourage effective family communication |
100 |
| Guide person about techniques to reduce anxiety (relaxation, rest, reading, music therapy, others) |
100 |
| Provide activities that increase person’s self-esteem (hygiene, reading, music therapy, others) |
100 |
| Provide a suitable environment for meals |
98.3 |
| Offer an adapted and obstacle-free environment |
98.3 |
| Assess person’s anxiety level (using scales) |
98.3 |
| Observe feelings of sadness, irritability, fear, anxiety and loneliness, seeking to offer support in communication |
98.3 |
| Provide adequate environment for person (comfortable bed, noise and odor control, lighting and temperature) |
98.3 |
| Provide alternative techniques for relieving anxiety (image building, relaxation, others) |
98.3 |
| Provide techniques to perform spirituality (reading, music therapy, others) |
98.3 |
| Provide visits by religious entities with the person’s consent |
98.3 |
| Support person in accepting their health condition |
96.6 |
| Facilitate communication with person about needs related to self-esteem |
96.6 |
| Facilitate communication with person about needs related to spiritual demands |
96.6 |
| Facilitate communication with person about needs related to care management |
96.6 |
| Facilitate communication with person/family/caregiver about feelings related to hospitalization |
96.6 |
| Provide privacy for spiritual/religious behavior |
96.6 |
| Respect person’s spiritual/religious beliefs |
96.6 |
| Provide distraction technique (dialogue, reading, music therapy) |
91.4 |
| Supervised Cardiovascular Rehabilitation Program |
| ND/NO statement |
(%) |
| Impaired Skin Integrity |
100 |
| Risk For Impaired Skin Integrity |
100 |
| Decreased Bowel Motility |
96.6 |
| Risk For Pressure Injury |
94.8 |
| Impaired Sleep And Rest‡
|
94.8 |
| Impaired Mobility In Bed |
94.8 |
| Increased Body Weight |
94.8 |
| Increased Nocturnal Urinary Frequency |
94.8 |
| Decreased Bladder Volume |
94.8 |
| Discomfort (Specify Location) |
93.1 |
| Altered Blood Pressure |
93.1 |
| Decreased Risk For Bowel Motility |
93.1 |
| NI statement |
(%) |
| Help a person to eat |
100 |
| Assist person in finding a comfortable body position |
100 |
| Help person to get dressed in bed |
100 |
| Evaluate the need for assistance in self-care |
100 |
| Determine person’s degree of dependency |
100 |
| Keep person’s skin clean, dry and moisturized |
100 |
| Identify factors that trigger dyspnea |
100 |
| Monitor person’s degree of ability to perform self-care |
100 |
| Protect regions over bony prominences with cushions allowing adequate tissue perfusion |
100 |
| Assist person to bathe in bed/toilet |
98.3 |
| Help person to better position themselves to eat in bed |
98.3 |
| Stimulate person’s autonomy in self-care, according to the degree of capacity |
98.3 |
| Offer help until person is able to perform autonomous self-care |
98.3 |
| Use a special mattress (pneumatic, pyramidal, foam, other) |
98.3 |
| Maintain a sodium-restricted diet |
96.6 |
| Assist person in oral hygiene, according to routine |
94.8 |
| Provide intimate hygiene |
94.8 |
| Apply elastic stockings for compression therapy, as appropriate |
94.8 |
| Therapy Based On Exercise |
| ND/NO statement |
(%) |
| Fatigue |
100 |
| Activity Intolerance ‡
|
96.6 |
| Impaired Physical Mobility |
94.8 |
| NI statement |
(%) |
| Assist person to stand and walk |
100 |
| Assist person to sit up in bed for postural management |
100 |
| Identify factors that cause fatigue |
100 |
| Guide on light to moderate exercise after discharge, as appropriate |
100 |
| Provide passive exercise therapy (range movements, standing) if indicated |
100 |
| Monitor activity tolerance |
98.3 |
| Provide active exercise therapy (ambulation) if indicated |
96.6 |
