Registration Screen Nothing to say. |
International Classification of Diseases (ICD10). |
Social name; Occupation; Labor link; Marital status; Reason for admission and secondary diagnosis. |
- Form of insertion of "date of birth" and "nationality"; - Added options to the items "Organic system as cause of admission" and "Provenance". |
ANAMNESIS
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Screen 1 Environment; Therapy; Regulation (immunological, neurological); Learning; Emotional security. |
Nothing to say. |
- Options to select "previous diseases diagnosed by health professionals according to the organic systems"; - Space to describe "admissions and previous surgeries with date and reason"; - Item to describe "family history related to the disease"; - Inserted in "lifestyle choices: "Passive smoker" and "Use of illicit drugs" - Space to report "Forgetfulness related to the use of medications", as well as "Who administers the medication" and "What knowledge of the patient and family about the indication of medicines"; - Added item on "Vaccination". |
- "Alcoholism" replaced by "Alcohol consumption" with selection options; - Inserted window in "Medications in use" that allows to enter the name and posology. |
Screen 2 Communication; Time and space orientation; Sensory perception; Sleep and Rest; Hydration; Oxygenation; Physical integrity; Regulation (vascular); Cutaneous-mucosal integrity. |
Nothing to say. |
- Including information about the state of awakening "Wake up rested", "Present sleep during the activities of the day" and "There is reported to present unusual behavior during sleep"; - In "Nutrition and Water Intake", added items: "Food Preference", "Water Intake" and "Choking or Coughing with Feeding/Water Intake"; - In "Oxygen therapy", included item related to "previous difficulty breathing"; - Item that investigates the "History of edema". |
- Added options to the item "Has trouble sleeping"; - Term "Oxygen therapy" replaced by "Oxygenation and vascular regulation"; - In the item "Prior self-care deficit - Oral hygiene", the "no" and "yes" options were replaced by "Not independent", "Totally dependent" and "Partially dependent". |
Screen 3 Disposal; Motility/Locomotion; Body mechanics; Exercise and physical activity; Recreation; Leisure; Creativity; Learning;Self-esteem/self-confidence/self-respect; Self-image; Self-realization; Freedom/Participation; Acceptance; Attention; Space. |
Nothing to say. |
- Space to describe "Characteristics of urine" and "Characteristics of feces"; - Fecal incontinence with "start date" option; - Included in the topic "Motility/previous locomotion" items regarding the "History of falls"; "Ambulation aid"; "March" and "Consciousness regarding its limitation". |
Insert options in the items "Prior urinary relief" and "What he/she likes to do". |
Screen 4 Gregarious/love; Sexuality; Environment/shelter; PSPN (religious or theological/ethical or philosophy of life). |
Nothing to say. |
- Inserted item for "Preventive examinations" in day, with option of the last date and observations. |
Nothing to say. |
PHYSICAL EXAMINATION
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Screen 1 Regulation (neurological); Physical integrity; Communication; Guidance in time and space; Emotional security/love/acceptance. |
- Ramsay Scale; - Cranial assistive devices; - Intracranial pressure (ICP); - Cerebral perfusion pressure (CPP); |
Richmond Agitation Sedation Scale (RASS) |
Nothing to say. |
Screen 2 Sleep and rest; Perception (olfactory, visual, auditory, tactile, gustatory, painful); Thermal regulation. |
SwanGanz and Combitube catheters excluded from the item "Assistive devices in the spine segment and cervical region". |
- In the item referring to "Pain", inserted in "type" the option "throbbing" and field to describe observations; - Included in the field "Mouth" the option "absence of teeth". |
- Modified the items "Face", "Hair", "Eyelids", "Eyeball", "Visual acuity", "Ears", "Nose", "Paranasal sinuses", "Mouth" and "Cervical region", with options of "without commitment" and "commitment - Cite". |
Screen 3 Cutaneomucous integrity; Body mechanics; Regulation (cell growth, hydrosaline, electrolyte). |
- Excluding the option "Absence of teeth" in the item "Ability to perform oral hygiene"; - Excluded SwanGanz Catheter from Chest Assistive Devices. |
- "Type of bath" added to the options "sprinkler" and "bed"; - Addition of "Characteristics", "Frequency" and "Quantity" to the item "Vomit". |
Nothing to say. |
Screen 4 Oxygenation |
- Venous Oxygen Saturation (SVO2); - Capnography (ETCO2) |
Nothing to say. |
Nothing to say. |
Screen 5 Regulation (vascular); Motility. |
- Central venous pressure (CVP); - Intra-arterial pressure (IAP); -SwanGanz; - Disposal (IAB); - Field related to Arrhythmias. |
- Field to select "Checked pulses" as well as "Symmetry"; - In the item "Heart ausculta", added the options "hyphononic sounds" and "hyperfonéticas"; - In the item "Abdominal Percussion", added the option "increased"; - Inserted item referring to "Sudden decompression abdomen maneuver". |
- for "Pacemaker", changed the options for "absent/present and local"; - Term "Timpanism" replaced by "Percussion". |
Screen 6 Disposal |
- In the item "Dialysis", excluding type information, others, beginning, ending and volume installed; - Excluded item "Water Balance". |
- Included field to evaluate "Odor of urine" and "Goldflam's sign";- In the item "Intestinal disposal", included in aspect the options "melena" and "live blood"; - Included item to describe the "feces color". |
The term "McBurney Sign" replaced with "Blumberg Sign" and the "present" option was changed to "positive" and "absent" to "negative". |
Screen 7 Sexuality; Exercise and physical activity /locomotion; Body mechanics; Regulation (vascular); Physical integrity. |
IAB, double lumen, IAP, SwanGanz, and venous dissection venous catheter excluded from the item "Assistive Devices in the Limbs." |
- Added in the item "Genitalia" the option "normal vaginal discharge of the menstrual cycle"; - Included field to describe the "Mobility" with assistance (crutch, cane, walker and others), as well as the "Use of orthoses and prostheses". |
- Modified the system of evaluation of the edema in the members for the system of crosses (+/4+); - The term "Pressure ulcer" has been replaced by "Pressure injury". |
Screen 8 Therapy |
Nothing to say. |
- Added field for "Medication dosage" in Therapy: Intermittent medications; - Added fields for "Route of administration" and "dosage" in "Therapy: Antimicrobials, antifungals or antivirals". |
Nothing to say. |
Screen 9 (Hormonal) regulation; Therapy. |
Excluding the items "Multiple specific interventions in the ICU" and "outside the ICU". |
- In the item "Insulinotherapy", inserted the options "regular" or "NPH" to select; - Inserted space for "date of completion" in "Laboratory examinations" as well as field for laboratory results of "bilirubin", "urine" and "feces". |
- The term "insulin bolus" or "ml/h" is replaced by "units";- Changed unit of measurement for the exams: "Calcium", "Magnesium", "Sodium", "Potassium", "Platelets", "Urea" and "Creatinine". |
Screen 10 Gregarious/freedom/participation/love/acceptance; Self-esteem/self-confidence/self-respect; Recreation/leisure; Therapy/Learning;Self-realization; Space;Regulation (cell growth); Environment; Psychospiritual Needs. |
Excluding the options "IAB", "double lumen catheter", "IAP monitoring catheter", "ICP monitoring catheter", "SwanGanz catheter", "ETT" and "TCT" in the item "Accidental loss of assistive devices". |
Nothing to say. |
Nothing to say. |