1) Activity of living: maintaining a safe environment
|
Faint |
No fainting |
Accompanying during bedside mobilisation and/or deambulation |
Advising not to stay in orthostatic position without the assistance of nursing professionals and/or companions |
Advising the companion to report any sensory changes |
Maintaining safe in the bed by raising the protective rails |
Ensuring airway permeability during the occurrence of fainting |
2) Activity of living: communication
|
Confusion |
No confusion |
Evaluating the risk of falls |
Evaluating the level of consciousness |
Maintaining safe in the bed by raising the protective rails |
3) Activity of living: breathing
|
Arrhythmia |
No Arrhythmia |
Auscultating for heart sounds |
Evaluating blood pressure, rhythm, heart rate, pulse rate, and frequency and depth of breaths |
Evaluating the level of consciousness |
Evaluating the heart rate shown on the multi-parameter monitor |
Maintaining airway clearance |
Monitoring the occurrence of arrhythmias and hemodynamic instability |
Monitoring signs and symptoms of low cardiac output (change in consciousness, hypotension or shock, pulmonary congestion, and anginal chest pain) |
Puncturing intravenous access |
Performing bedside 12-lead electrocardiogram |
Impaired cardiac output |
Appropriate cardiac output |
Analysing color and temperature of body extremities |
Analysing blood pressure, rhythm, heart rate, pulse rate, and frequency and depth of breaths |
Assessing the level of awareness |
Surveying the presence of chest pain |
Maintaining bed head elevated between 30º and 45º |
Performing fluid balance |
Dyspnea |
No dyspnea |
Auscultating to breathing sounds |
Analysing color and temperature of extremities |
Evaluating blood pressure, pulse rate and frequency, and frequency and depth of breaths |
Installing oxygen therapy as needed |
Maintaining bed head elevated between 30º and 45º |
Maintaining airway clearance |
Radiating pain |
No radiating pain |
Evaluating the intensity, location and duration of pain |
Evaluating blood pressure, rhythm, heart rate, pulse rate frequency, and frequency and depth of breaths |
Surveying satisfaction with medicated pain management |
Chest pain |
No chest pain |
Evaluating pain response (pain scale) after analgesic use |
Surveying satisfaction with medicated pain management |
Surveying attitude toward pain |
Maintaining bed head elevated between 30º and 45º |
Maintaining the environment calm and peaceful |
Performing bedside 12-lead electrocardiogram |
Cardiorespiratory arrest |
No cardiorespiratory arrest |
Initiating early cardiopulmonary resuscitation |
Impaired peripheral tissue perfusion |
Appropriate peripheral tissue perfusion |
Analysing color and temperature of extremities |
Installing oxygen therapy as needed |
Monitoring oxygen saturation |
Monitoring capillary refill |
4) Activity of living: eating and drinking
|
Nausea |
No nausea |
Evaluating nausea control |
Assisting in the performance of oral hygiene |
5) Activity of living: elimination
|
Impaired Kidney Function |
Effective Kidney Function |
Evaluating genitourinary status |
Installing urinary catheter if necessary |
Performing fluid balance |
6) Activity of living: washing and dressing
|
Impaired ability to perform self-care |
Appropriate ability to perform self-care |
Evaluate ability to bath |
Assisting during the change of clothes |
Assisting oral and body hygiene |
Stimulating mobility in bed |
Facilitating ability to communicate needs and feelings |
7) Activity of living: controlling body temperature
|
8) Activity of living: mobilisation
|
Fatigue |
No fatigue |
Surveying the causes of fatigue |
Maintaining the environment without intense luminous, sonorous or olfactory stimuli |
Requesting assessment from the physiotherapist service |
9) Activity of living: working and playing
|
Anxiety |
No anxiety |
Requesting evaluation from the psychology service |
Facilitating ability to communicate needs and feelings |
Negative emotion |
No negative emotion |
Requesting evaluation from the psychology service |
10) Activity of living: expressing sexuality
|
11) Activity of living: sleeping
|
Insomnia |
No insomnia |
Collecting the schedules of nursing procedures, avoiding interruption of nocturnal sleep |
Instructing on the importance of nighttime sleep for recovery |
Maintaining the environment without intense luminous, sonorous or olfactory stimuli |
Providing bedside comfort |
12) Activity of living: dying
|
Fear about death |
No fear about death |
Facilitating the family’s ability to participate in the care plan |
Facilitating the ability to communicate needs and feelings |
Promoting active listening |