Risk of hemorrhage/Control of the risk of hemorrhage |
Identify risk of hemorrhage; monitor fluid output; monitor fluid balance (or water balance); manage bleeding; measure (or check) fluid output |
0.895/0.952 |
1.00/1.00 |
Agitation/Agitation, reduced |
Assess signs of agitation; gather data on the environment; assess the presence of noise; gather data on stress level; monitor pain; position patient; monitor vital signs; reduce noise; manipulate according to the need for care |
0.837/0.896 |
1.00/1.00 |
Pain/Pain control |
Implement pain management guide; monitor pain; position patient; administer pain medication; nurse-controlled analgesia; assess response to the medication; assess response to pain management (control) |
0.856/0.963 |
1.00/1.00 |
Risk of infection/Control of the risk of infection |
Invasive device site care; monitor signs and symptoms of infection; use aseptic technique; prevent infection; obtain data on signs and symptoms of infection |
0.843/0.879 |
1.00/1.00 |
Infection/Infection, absent |
Invasive device site care; monitor signs and symptoms of infection; use aseptic technique; prevent infection; obtain data on signs and symptoms of infection |
0.989/0.997 |
1.00/1.00 |
Hypothermia/Control of hypothermia |
Promote positive thermoregulation; obtain data on risk of negative thermoregulation; monitor body temperature; evaluate response to thermoregulation |
0.893/0.869 |
1.00/1.00 |
Thermoregulation, impaired/Thermoregulation, effective |
Promote positive thermoregulation; obtain data on risk of negative thermoregulation; monitor body temperature; evaluate response to thermoregulation |
0.826/0.863 |
1.00/1.00 |
Bradycardia/Bradycardia, absent |
Measure (or check) heart rate; monitor heart condition; monitor physiological condition; obtain data on heart condition |
0.803/0.987 |
1.00/1.00 |
Edema/Edema, absent |
Invasive device site care; implement skin care regimen; maintain skin integrity; monitor fluid balance (or water balance); monitor tissue perfusion; measure (or check) fluid output |
0.863/0.875 |
1.00/1.00 |
Hematoma/Hematoma, absent |
Invasive device site care; implement skin care regime; maintain skin integrity; apply cold compress |
0.896/0.863 |
1.00/1.00 |
Skin integrity, impaired/Skin integrity, effective |
Invasive device site care; implement skin care regime; maintain skin integrity |
0.803/0.987 |
1.00/1.00 |
Trauma due to invasive device/Response to trauma due to invasive device |
Invasive device care regime; perform safety measure; prevent mechanical injury |
0.894/0.901 |
1.00/1.00 |
Tissue integrity, impaired/Tissue integrity, effective |
Maintain skin integrity; monitor skin integrity; obtain data on skin integrity; skin care regime; treat skin condition |
0.891/0.962 |
1.00/1.00 |
Peripheral tissue perfusion, impaired/Peripheral tissue perfusion, effective |
Assess tissue perfusion; monitor tissue perfusion; obtain data on peripheral tissue perfusion |
0.806/0.861 |
1.00/1.00 |
Risk of embolism/Control of the risk of embolism |
Assess the presence of air in infusion device; manage symptoms of embolism; monitor blood oxygen saturation using pulse oximeter; prevent embolism; handle invasive device carefully; avoid infusion therapy in invasive device with resistance; evaluate invasive device removal |
0.802/0.896 |
1.00/1.00 |
Risk of necrosis |
Assess invasive device condition; treat skin condition; implement skin care regime; obtain data on the risk of ineffective tissue perfusion |
0.801/0.979 |
1.00/1.00 |
Function of the respiratory system, impaired/Function of the respiratory system, effective |
Measure (or check) invasive device; order (or request) examination from X-ray service; assess location of invasive device by examination; stabilize invasive device with dressing; prevent venous thrombosis |
0.809/0.951 |
1.00/1.00 |
Vital sign(s), altered/Vital sign(s), at the normal limit |
Identify physiological condition; monitor physiological condition; monitor vital signs |
0.844/0.943 |
1.00/1.00 |
Risk of impaired function of the nervous system/Control of the risk of impaired function of the nervous system |
Measure (or check) invasive device; order (or request) examination from X-ray service; assess location of invasive device by examination; monitor vital signs |
0.807/0.868 |
1.00/1.00 |
Risk of impaired function of the respiratory system/Control of the risk of impaired function of the respiratory system |
Measure (or check) invasive device; order (or request) examination from X-ray service; assess location of invasive device by examination; stabilize invasive device with dressing, monitor vital signs; monitor blood oxygen saturation using pulse oximeter; assess symptoms of dyspnea; assess heart rate; prevent shock; auscultate lungs; monitor blood oxygen saturation using pulse oximeter; monitor vital signs |
0.803/0.962 |
1.00/1.00 |
Risk of ineffective tissue perfusion/Control of the risk of ineffective tissue perfusion |
Monitor vital signs; monitor blood oxygen saturation using pulse oximeter; assess symptoms of dyspnea; assess heart rate; prevent shock |
0.817/0.878 |
1.00/1.00 |
Risk of impaired neurological condition/Control of the risk of neurological condition |
Measure (or check) invasive device; order (or request) examination from X-ray service; assess location of invasive device by examination; monitor vital signs |
0.806/0.975 |
1.00/1.00 |
Risk of impaired cardiac function/Control of the risk of impaired cardiac function |
Measure (or check) invasive device; order (or request) examination from X-ray service; assess location of invasive device by examination; stabilize invasive device with dressing; monitor vital signs; monitor blood oxygen saturation using pulse oximeter; assess symptoms of dyspnea; assess heart rate; prevent shock |
0.815/0.920 |
1.00/1.00 |
Heart rate, impaired/Heart rate, effective |
Measure (or check) invasive device; order (or request) examination from X-ray service; assess location of invasive device by examination; stabilize invasive device with dressing; monitor vital signs; monitor blood oxygen saturation using pulse oximeter; assess symptoms of dyspnea; assess heart rate; prevent shock |
0.828/0.913 |
1.00/1.00 |
Allergy to latex/Allergy to latex, controlled |
Identify allergy in the patient; avoid contact with latex; monitor skin integrity |
0.804/0.862 |
1.00/1.00 |
Allergy/Allergy, absent |
Identify allergy in the patient; identify allergy at the patient's bedside |
0.827/0.875 |
1.00/1.00 |
Risk of allergy to the medication/Control of the risk of allergy to the medication |
Confirm (or verify) allergy; evaluate medication list; evaluate need for laboratory test; report to physician; evaluate need for diagnostic test |
0.832/0.950 |
1.00/1.00 |
Complication associated with health care/Complication associated with health care, absent |
Perform safety measure; promote hand hygiene; use aseptic technique; evaluate dressing; implement invasive device care regime; monitor signs and symptoms of infection |
0.808/0.978 |
1.00/1.00 |
Catheter obstruction/Catheter obstruction, absent |
Evaluate invasive device; flush invasive device with isotonic solution; implement regime to flush invasive device before and after medications |
0.899/0.961 |
1.00/1.00 |
Risk of adverse medication/Risk of adverse medication, absent |
Implement safety regime; manage medication's side effect risk; obtain data on risk of adverse drug interaction |
0.813/0.987 |
1.00/1.00 |
Adverse drug interaction/Adverse drug interaction, absent |
Evaluate medication list; consult pharmacist about medication list; consult health care provider about medication's side effects; obtain data about medication's side effects; change medication schedule according to multiprofessional guidance |
0.816/0.915 |
1.00/1.00 |