Security/Protection |
Hospitalization |
Risk of infection |
23 |
95.8 |
Peripheral venous access |
22 |
91.6 |
Hemoglobin (5.5g/dL, 10.8g/dL) |
21 |
87.5 |
Chemotherapy |
18 |
75 |
Neutrophils (0.000/mm3-1,220/mm3) |
11 |
45.8 |
Deep venous access |
4 |
16.6 |
Bone marrow biopsy |
3 |
12.5 |
Catheter and probe |
2 |
8.3 |
Platelets (5 x 83 x
103mm3-103mm3) |
Impaired oral mucous |
16 |
66.6 |
Hemoglobin (5.3g/dL, 10.8g/dL) |
15 |
62.5 |
Chemotherapy |
14 |
58.3 |
Neutrophils (0.000/mm3-0.800/mm3) |
9 |
37.5 |
Pale (+3/+4) |
9 |
37.5 |
Coated tongue |
7 |
29.1 |
Mucositis |
6 |
25 |
Bleeding gums (Gingivitis) |
5 |
20,8 |
Odynophagia |
2 |
8.3 |
Dehydrated (+2/+4) |
2 |
8.3 |
High body temperature (37.8º C-39.6º C) |
Hyperthermia |
15 |
62.5 |
Medicines |
Risk of impaired skin integrity |
4 |
16.6 |
Emaciate |
2 |
8.3 |
Hemoglobin (5.3g/dL, 6.4g/dL) |
2 |
8.3 |
Platelets (5 x 20 x
103mm3-103mm3) |
2 |
8.3 |
High body temperature (37.6º C-39.6º C) |
2 |
8.3 |
Pallor (+3/+4) |
2 |
8.3 |
Neutrophils (0.700) |
1 |
4.16 |
Skin turgor and elasticity decreased |
1 |
4.16 |
Hypo-hydrated skin |
1 |
4.16 |
Bedridden |
Impaired skin integrity |
2 |
8.3 |
Chemotherapy |
1 |
4.16 |
Decreased turgor |
1 |
4.16 |
Deep venous access |
1 |
4.16 |
Lesion in the right lower limb |
1 |
4.16 |
Pressure ulcers |
1 |
4.16 |
Absence of some teeth |
Impaired dentition |
3 |
12.5 |
Poor oral hygiene |
1 |
4.16 |
Teeth (in disrepair) |
1 |
4.16 |
Syncope with fall |
Risk of falling |
3 |
12.5 |
Hemoglobin (6.2g/dL, 7.9g/dL) |
2 |
8.3 |
Medications (furosemide and captopril) |
2 |
8.3 |
Cough |
Ineffective airway clearance |
1 |
4.16 |
Tachypnea (24-44 breaths per minute) |
1 |
4.16 |
Scattered crackles in both lungs |
1 |
4.16 |
Reports the suicidal tendency to nurses |
Suicide risk |
1 |
4.16 |
Perception/cognition |
Confused |
Acute Confusion |
1 |
4.16 |
Agitated |
1 |
4.16 |
Periods of disorientation |
1 |
4.16 |
Does not perceive hospitalization reason |
Impaired knowledge |
1 |
4.16 |
Elimination/protection |
Absent evacuation for at least three days |
Constipation |
8 |
33.3 |
Bedridden |
5 |
20.8 |
Medications: Rivotril, Tramal, Lasix, Morphine |
4 |
16.6 |
Little appetite for dietary compliance |
4 |
16.6 |
Nausea and vomiting |
3 |
12.5 |
Rectal bleeding after a bowel movement |
2 |
8.3 |
Rectal Pain (hemorrhoids) |
1 |
4.16 |
Distended abdomen with decreased bowel sounds |
1 |
4.16 |
Bedridden |
Constipation risk |
1 |
4.16 |
Rectal sensitivity with difficult of evacuation |
1 |
4.16 |
Pain in the perianal region |
1 |
4.16 |
10 hours without urinating |
Urinary retention |
1 |
4.16 |
Activity/rest |
Platelets (4 x 69 x
103mm3-103mm3) |
Risk of bleeding |
15 |
62.5 |
Petechiae |
5 |
20.8 |
Oral bleeding |
3 |
12.5 |
Nosebleed |
3 |
12.5 |
Hematoma |
2 |
8.3 |
Palatal ecchymosis |
1 |
4.16 |
Melena |
1 |
4.16 |
Continuous epistaxis |
1 |
4.16 |
Enterorrhagia |
1 |
4.16 |
Metrorrhagia |
1 |
4.16 |
Hematemesis |
1 |
4.16 |
Hemorrhage in the left eye sclera |
1 |
4.16 |
Hemoglobin (5.3g/dL, 9.6g/dL) |
Fatigue |
11 |
45.83 |
Fatigue and dyspnea upon exertion |
9 |
37.5 |
Emaciate |
5 |
20.8 |
Eager |
5 |
20.8 |
Weakness and malaise |
3 |
12.5 |
Multiples complaints |
1 |
4.16 |
Depressed |
1 |
4.16 |
Bedridden |
Impaired physical mobility |
1 |
4.16 |
Moves up wheelchair |
1 |
4.16 |
On bed rest for deep vein thrombosis |
1 |
4.16 |
Emaciate |
Impaired Mobility in bed |
1 |
4.16 |
Prostrate, necessitating changing positions |
1 |
4.16 |
Bedridden, bed bath held |
1 |
4.16 |
Assistance with ambulation due to edema in right foot |
Impaired ambulation |
1 |
4.16 |
Lesion in right foot with devitalized tissue |
1 |
4.16 |
Reports unsatisfactory night sleep due to oral pain |
Pattern of sleep disturbance |
1 |
4.16 |
Health Promotion |
Leukemias |
Ineffective protection |
24 |
100 |
Hemoglobin (5.5g/dL-11.8g/dL) |
21 |
87.5 |
Chemotherapy |
18 |
75 |
Platelets (5 x 83 x
103mm3-103mm3) |
11 |
45.8 |
Neutrophils (0.000/mm3-0.800/mm3) |
11 |
45.8 |
Depressed mood |
Self-neglect |
1 |
4.16 |
Refused to make hygienic |
1 |
4.16 |
Scabious |
1 |
4.16 |
Comfort |
Leukemia |
Acute pain |
15 |
62.5 |
Pain in upper and lower limbs |
7 |
29.1 |
Abdominal pain |
6 |
25 |
Intense pain in the lower back and posterior chest |
4 |
16.6 |
Pain in the dorsal region |
2 |
8.3 |
Painful swallowing |
2 |
8.3 |
Generalized myalgia |
2 |
8.3 |
Rectal pain during evacuation |
1 |
4.16 |
Bone pain in the thoracolumbar region |
1 |
4.16 |
Pain at the site of venipuncture |
1 |
4.16 |
Chemotherapy |
Nausea |
8 |
33.3 |
Refers anorexia and nausea |
8 |
33.3 |
Vomit |
3 |
12.5 |
Widespread pain (more than 6 months) |
Chronic Pain |
1 |
4.16 |
Pain "twinge" in his left calf with phlogosis, erythema, pain, local
redness (over 6 months) |
1 |
4.16 |
Pain in the left inguinal region and left lower limb during ambulation
(over 6 months) |
1 |
4.16 |
Nutrition |
Leukemia |
Imbalanced nutrition: less than daily
needs |
16 |
66.6 |
Accepting diet partially |
14 |
58.3 |
Mucositis |
3 |
12.5 |
Loss of appetite |
2 |
8.3 |
Fatigue and dyspnea upon exertion (tumor that prevents him from food and
drinking water) |
1 |
4.16 |
Odynophagia |
1 |
4.16 |
Coping/tolerance to stress |
Anxious/concerned with the diagnosis |
Anxiety |
5 |
20.8 |
Hospitalization |
1 |
4.16 |
Tachycardia (> 124 beats per minute) |
1 |
4.16 |
Left hospital without proper discharge |
Behavior prone to health risk |
1 |
4.16 |
Reports feeling homesick, pets, showing sad and tearful, prolonged
treatment |
Chronic sorrow |
1 |
4.16 |
Life principles |
Refused to receive haemotransfusion for religious reasons |
Noncompliance |
1 |
4.16 |
Total |
|
507 |
- |