|
Nursing Diagnosis Statement
|
| Impaired Cardiac Output (10025557) |
| Dyspnoea (Specify Type) (10029433) |
| Pain (Specify Type) (10023130) |
| Edema (Specify Degree) |
| Decreased Body Mass Index |
| Pressure Ulcer (Specify Stage) (10025798) |
| Nausea (10000859) |
| Ineffective Tissue Perfusion (10001344) |
| Ineffective Peripheral Tissue Perfusion (10044239) |
| Risk for Aspiration (10015024) |
| Risk for Cardiogenic Shock |
| Risk for Infection (10015133) |
| Risk For Deep Vein Thrombosis (10027509) |
| Cough (10047143) |
| Hypervolaemia (10042012) |
|
Nursing Intervention Statement
|
1. Administering and monitoring oxygen therapy;
2. Administering nutritional supplement (10037037);
3. Suctioning the airway (10044890);
4. Listening to and assess intestinal noises daily;
5. Listening to heart rate paying attention to the presence of 3rd heart sound;
6. Listening to breathing noises before and after aspiration;
7. Assessing the cause of impaired sleep pattern;
8. Assessing oral cavity condition;
9. Assessing nutritional status;
10. Assessing discomfort (type, orientation, intensity);
11. Assessing pain (presence, orientation, onset, duration, intensity);
12. Assessing intestinal eliminations (frequency, quantity, fecal aspects);
13. Assessing pressure ulcer staging;
14. Assessing previous pain experiences, including individual and family history of chronic pain or resulting disability;
15. Assessing and monitoring the presence and degree of edema;
16. Assessing and monitoring pulmonary artery pressure;
17. Assessing and monitoring central venous pressure or right atrial pressure;
18. Assessing and monitoring signs of dehydration (decreased skin turgor, dry mucosa);
19. Assessing and monitoring person's level of consciousness;
20. Assessing and monitoring skin (color, temperature, pain, edema, sensitivity, humidity, signs of infection);
21. Assessing and monitoring cough reflex, nausea and ability to swallow;
22. Monitoring vital signs (10032113);
23. Assessing urinary bladder functioning and integrity;
24. Assessing body mass index;
25. Assessing dietary fiber intake;
26. Assessing the lesion (degree, color, secretion, foul odor, pain, temperature);
27. Assessing upper and lower limbs (temperature, color, pulse rate);
28. Assessing moving the pain/discomfort to other locations;
29. Assessing the need for airway aspiration;
30. Assessing the need for wound dressing and coverage;
31. Assessing tissue perfusion;
32. Monitoring weight (10032121);
33. Assessing the presence of flatus;
34. Assessing oral problems that make eating and chewing difficult (prosthesis, wound);
35. Evaluating response to fluid therapy (10007176);
36. Interpreting arterial blood gas result (10010503);
37. Assessing signs of pulmonary edema (respiratory rate, sputum);
38. Assessing situations that cause discomfort;
39. Assessing type of dyspnea (night, intermittent, decubitus, at rest);
40. Assessing cough (sputum, discharge);
41. Catheterising urinary bladder (10030884);
42. Determining person's degree of dependence;
43. Determining degree of jugular vein distension;
44. Implementing enteral feeding (10046178);
45. Implementing artificial airway;
46. Investigating person's food preferences;
47. Washing hands before and after care;
48. Keeping person's head sideways;
49. Keeping person on bed rest;
50. Maintaining airway clearance (10037351);
51. Monitoring fasting person's abdominal circumference daily;
52. Monitoring decreased mobility in bed;
53. Monitoring urinary elimination (frequency, quantity, color, pain and foul odor);
54. Monitoring electrolyte balance;
55. Monitoring fluid balance, if greater than 2.5 liters;
56. Monitoring fluid balance, if less than 2.5 liters;
57. Monitoring fluid balance (10040852);
58. Monitoring degree of urinary bladder distension;
59. Monitoring blood oxygen saturation using pulse oximeter (10032047);
60. Monitoring sedation;
61. Offering small portions of meal often;
62. Offering drink (10050313);
63. Placing person on the bed with a raised headboard (30°, 45° or 60°);
64. Preventing injury during transfer technique (elevation);
65. Preventing spontaneous extubation (fix artificial airway with adhesive tape);
66. Providing food not accompanied by liquids;
67. Providing food with a high nutritional index;
68. Providing oral hygiene in bed every 6 hours;
69. Providing decubitus change every 2 hours;
70. Use transfer technique (10041135);
71. Performing physical examination of the chest (inspection, palpation, percussion and auscultation);
72. Performing abdominal physical examination (inspection, auscultation, percussion and palpation);
73. Rotating venipuncture site;
74. Recording sleep pattern in hours;
75. Nighttime fluid restriction;
76. Liquid restriction or supply;
77. Supervising insertion site of invasive devices (temperature, coloration, pain, secretion);
78. Wound dressing change (10045131);
79. Wound dressing change (10045131);
80. Use pain scales (verbal, facies, visual, numerical);
81. Wearing gloves according to standard precautions;
82. Use antimicrobial soap for hand hygiene;
83. Use aseptic technique (10041784);
84. Measuring height (10037000);
85. Checking and monitoring body temperature of the lower limbs;
86. Checking for residues from the nasogastric catheter or gastrostomy and irrigate every 4-6 hours during continuous feeding and before intermittent feeding;
87. Checking residual enteral catheter volume; |
|
EDUCATIONAL PROCESS
|
|
Nursing Diagnosis Statement
|
| Conflicting Attitude Toward Medication Management (10022299) |
| Self Care Deficit (10023410) |
| Impaired Family/Caregiver's Ability to Manage Care |
|
Nursing Intervention Statement
|
88. Assessing person's knowledge about disease and treatment;
89. Encouraging person's autonomy in self-care, according to the degree of ability;
90. Facilitating person's ability to communicate conflicts in medication management;
91. Informing medication side effect;
92. Explaining to person/family/caregiver the causes of fatigue;
93. Teaching family/caregiver about the importance of stimulating the person's self-care;
94. Teaching family /caregiver about post-discharge care in managing the disease;
95. Teaching family/caregiver about illness and treatment;
96. Teaching family about treatment regimen (10024656);
97. Teaching about eating not accompanied by liquids;
98. Teaching about procedures, including sensations that the person can experience during procedures;
99. Teaching about moisturizer use;
100. Teaching breathing technique (10039213);
101. Provide an explanation about care to be performed;
102. Teaching pain (10039115);
103. Providing routine times for administering medications together with the person;
104. Providing techniques to minimize medication side effects (relaxation, rest, schedule);
105. Strengthening communication about disease and treatment; |
|
PSYCHOSOCIAL SUPPORT FOR PATIENTS AND FAMILIES
|
|
Nursing Diagnosis Statement
|
| Spiritual Distress (10018583) |
| Anxiety (10000477) |
| Situational Low Self Esteem (10000844) |
| Conflicting Spiritual Belief (10022769) |
| Hopelessness (10000742) |
| Unfavorable Religious Coping |
| Lack of Family Support (10022473) |
| Intervention Statement |
| Fear (10000703) |
|
Nursing Intervention Statement
|
106. Helping to identify situations that cause anxiety;
107. Helping to identify situations that cause hopelessness;
108. Helping to identify situations that cause fear;
109. Assessing anxiety level;
110. Encouraging Bible reading;
111. Promoting acceptance of health status (10037783);
112. Teach relaxation techniques (reading, music therapy);
113. Facilitating person's ability to communicate needs related to self-esteem;
114. Facilitating person's ability to communicate needs related to spiritual demands;
115. Facilitating person's ability to communicate feelings related to hospitalization;
116. Facilitating family/caregiver's ability to communicate needs related to care management;
117. Facilitating family/caregiver's ability to communicate feelings related to hospitalization;
118. Identifying obstruction to communication (10009683);
119. Identifying spiritual beliefs;
120. Identifying factors that cause low self-esteem;
121. Facilitating family ability to participate in care plan (10035927);
122. Observing feelings of sadness, irritability, fear, anxiety and loneliness, seeking to offer support;
123. Providing a suitable environment for meals;
124. Providing an adapted environment without obstacles;
125. Teaching techniques to reduce anxiety (relaxation, rest, reading, music therapy);
126. Promoting effective family communication (10036066);
127. Providing an adequate environment (comfortable bed, noise and odor control, lighting and temperature);
128. Providing a calm and safe environment;
129. Providing activities that increase self-esteem (hygiene, reading, music therapy);
130. Providing active communication to interpret the conflict;
131. Providing prayer time;
132. Providing privacy for spiritual behavior (10024504);
133. Providing privacy for religious behavior in bed;
134. Providing routine care so as not to interrupt the person's sleep and rest;
135. Distraction (10039232);
136. Providing alternative techniques for anguish relief (image building, relaxation);
137. Providing techniques to perform spirituality (reading, music therapy);
138. Providing visits by religious entities;
139. Respecting spiritual beliefs;
140. Respecting religious beliefs; |
|
SUPERVISED CARDIOVASCULAR REHABILITATION PROGRAM
|
|
Nursing Diagnosis Statement
|
| Discomfort (Specify Location) (10023066) |
| Increased nocturnal urinary frequency |
| Deficient food intake (10000607) |
| Damaged skin integrity (10001290) |
| Decreased intestinal motility |
| Impaired mobility in bed (10001067) |
| Increased body weight |
| Altered blood pressure (10022954) |
| Risk for impaired skin integrity (10015237) |
| Risk for pressure ulcer (10027337) |
| Risk for decreased intestinal motility |
| Impaired sleep and rest |
| Hypovolaemia |
|
Nursing Intervention Statement
|
141. Applying elastic stockings (10030486);
142. Assisting with the search for comfortable body position;
143. Assisting with mobility in bed (10045972);
144. Assistance with food in bed;
145. Assisting with bed/bathroom bath;
146. Assisting with better positioning for eating in bed;
147. Assisting with get dressed in bed;
148. Assisting with oral hygiene in bed every 6 hours;
149. Evaluating lower limb edema;
150. Assessing the need for help in self-care;
151. Identifying factors that alleviate/worse pain;
152. Identifying factors that cause pain;
153. Identifying factors that cause dyspnea;
154. Skin care (10032757);
155. Maintaining a sodium-restricted diet for increased blood pressure;
156. Maintaining intimate hygiene;
157. Keeping lower limbs elevated;
158. Keeping skin hydrated;
159. Keeping skin clean and dry;
160. Monitoring medication adherence (10043878);
161. Monitoring person's degree of ability to perform self-care;
162. Teaching about not eating too hot or too cold food;
163. Promoting and assisting skin hygiene;
164. Protecting bony body regions, allowing adequate tissue perfusion;
165. Providing assistance until the person is fully capable of performing autonomous self-care;
166. Providing daily body hygiene;
167. Providing routine times for medication administration together with the person avoiding diuretic medications at night;
168. Providing exchange of equipment for person's care; Use special mattress (pneumatic, pyramidal) |
|
EXERCISE-BASED THERAPY
|
|
Nursing Diagnosis Statement
|
| Fatigue (10000695) |
| Activity intolerance (10000431) |
| Impaired mobility (10001219) |
|
Nursing Intervention Statement
|
169. Helping person to stand up and walk around;
170. Helping person to sit on the edge of the bed for postural management;
171. Educating about physical exercise regimen;
172. Encouraging autonomous walking;
173. Identifying factors that cause fatigue;
174. Monitoring activity tolerance (10036622);
175. Teaching light to moderate exercise;
176. Providing person's body alignment during the transfer technique;
177. Providing active exercise therapy (walking);
178. Providing therapy with passive physical exercises (range movements, standing, stretching). |
