| Pain Level (2102) |
Reported pain (210201) |
It is characterized by the self-report of the painful experience. The response may be spontaneous or requested(88 Lunney M, McGuire M, Endozo N, McIntosh-Waddy D. Consensus-validation study identifies relevant nursing diagnoses, nursing interventions, and health outcomes for people with traumatic brain injuries. Rehabil Nurs [Internet]. 2010 [cited 2018 Oct 30];35(4):161-66. Available from: https://doi.org/10.1002/j.2048-7940.2010.tb00042.x
https://doi.org/10.1002/j.2048-7940.2010...
). |
Apply the Verbal Numerical Scale (VNS), asking how much the patient rates his pain from 0 to 10. |
- Ten (10) = Unbearable intensity pain.
- Seven to Nine (7 to 9) = Strong intensity pain.
- Four to Six (4 to 6) = Moderate intensity pain.
- One to Three (1 to 3) = Low intensity pain.
- Zero (0) = No Pain. |
| Length of pain episodes (210204) |
It is characterized by the duration of pain episodes(99 Silva MB. Aplicabilidade clínica dos resultados de enfermagem em pacientes com mobilidade física prejudicada submetidos à artroplastia total de quadril [Dissertation on the Internet]. Porto Alegre (RS): Universidade Federal do Rio Grande do Sul, Escola de Enfermagem, Programa de Pós-Graduação em Enfermagem; 2013 [cited 2018 Nov 3]. 109 p. Available from: https://lume.ufrgs.br/handle/10183/87223
https://lume.ufrgs.br/handle/10183/87223...
). |
To ask the patient the duration of the pain episodes, considering a 24-hour period. |
- The pain episodes last all the time.
- The pain episodes last most of the time.
- The pain episodes last for more than 1 hour.
- The pain episodes last up to 1 hour.
- No pain episodes. |
| Facial expressions of pain (210206) |
It is characterized by changes in facial mime during painful episodes(1010 Pamol MIR. A empatia e a ansiedade no julgamento das expressões faciais de dor [Dissertation on the Internet]. Évora (PT): Universidade de Évora, Escola de Ciências Sociais, Departamento de Psicologia; 2014 [cited 2018 Nov 3]. 114 p. Available from: https://dspace.uevora.pt/rdpc/bitstream/10174/12967/1/A%20Empatia%20e%20a%20Ansiedade%20no%20Julgamento%20das%20Express%c3%b5es%20Faciais%20de%20Dor.pdf
https://dspace.uevora.pt/rdpc/bitstream/...
). |
To observe if the patient presents a change in the facial expression of the face, such as: wrinkled brow, twisted mouth, crying face, eyebrow contraction, tongue reaction, chin tremor, lip opening during assessment. |
- Presents facial expressions of pain continuously during the assessment.
- Presents facial expressions of pain 5 to 6 times during the assessment.
- Presents facial expressions of pain 3 to 4 times during the assessment.
- Presents facial expression of pain 1 to 2 times during the assessment.
- Does not present facial expressions of pain during the assessment. |
| Agitation (210222) |
Restless state of motion, disturbance, excitement(1111 Almeida TM, Azevedo LC, Nosé PM, Freitas FG, Machado FR. Risk factors for agitation in critically ill patients.. Rev Bras Ter Intensiva [Internet]. 2016 [cited 2018 Oct 30];28(4):413-419. Available from: doi: 10.5935/0103-507X.20160074
https://doi.org/10.5935/0103-507X.201600...
). |
To observe if the patient shows signs of agitation, such as: fidgeting, twisting hands, pulling clothes and inability to sit still. |
- Dangerous agitation (e.g., attempts to remove catheters).
- Very agitated, does not show calm after verbal command.
- Moderate agitation, calmness after verbal command.
- Light agitation, calm and cooperative after verbal command.
- No agitation. |
| Irritability (210223) |
Excessive reaction to the stimuli, translated by discomfort that generates a certain impatience to anger and hatred(1111 Almeida TM, Azevedo LC, Nosé PM, Freitas FG, Machado FR. Risk factors for agitation in critically ill patients.. Rev Bras Ter Intensiva [Internet]. 2016 [cited 2018 Oct 30];28(4):413-419. Available from: doi: 10.5935/0103-507X.20160074
https://doi.org/10.5935/0103-507X.201600...
). |
To observe if patient shows signs of irritation (impatience, hatred, fury, aggressive response, demonstration of annoyance) during assessment. |
- Hazardous Irritation (e.g., attempting to assault).
- Very irritated (irritates with all the stimuli and does not show calm in any moment).
- Moderate irritation (irritates with some stimuli, but does not calm down easily).
- Mild irritation (irritates with certain stimuli, but calms down easily).
- No irritation. |
| Vital Signs (0802) |
Respiratory rate (080204) |
Number of breathing cycles (inspiration and expiration) that the body performs involuntarily per minute(1212 De Carvalho RT. Dispneia, tosse e hipersecreção de vias aéreas. In: de Carvalho RT, Parsons HA. Manual de cuidados paliativos ANCP. 2 ed. São Paulo: Sulina, 2012. p. 151-67.). |
To check respiratory rate parameters. |
- > 26 mpm
- 25 to 26 mpm
- 23 to24 mpm
- 21 to 22 mpm
- 16 to 20 mpm |
| Blood Pressure (080205/080206) |
Refers to the pressure exerted by the blood against the artery wall during ventricular systole and diastole(1313 Sociedade Brasileira de Cardiologia. 7a Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol [Internet]. 2016 [cited 2018 Nov 3];107(Supl. 3):1-103. Available from: http://publicacoes.cardiol.br/2014/diretrizes/2016/05_HIPERTENSAO_ARTERIAL.pdf
http://publicacoes.cardiol.br/2014/diret...
). |
Verificar parâmetros da pressão arterial. |
- ≥ 180/110mmHg
-179/109 160/100mmHg
- 159/99 140/90mmHg
- 139/89 130/85mmHg
- 129/84 120/80 mmHg |
| Pain Control (1605) |
Recognizes pain onset (160502) |
The ability of the patient to recognize when the pain starts(1414 Mateus AM, Ferreira BMA, Monforte EMM, Ferreira FMB, Alvarenga MICSF, Silva MFV et al (coords). Dor: guia orientador de boa prática. [Internet]. Lisboa (PT): Ordem dos Enfermeiros; 2008 [cited 2018 Nov 3]. 57 p. Available from: https://suporte.ordemenfermeiros.pt/arquivo/publicacoes/Documents/cadernosoe-dor.pdf
https://suporte.ordemenfermeiros.pt/arqu...
). |
To ask if the patient can identify when the pain started. |
- Never recognizes.
- Rarely recognizes the onset of pain.
- Sometimes you recognize the onset of pain.
- Often recognizes the onset of pain.
- Always recognize the onset of pain. |
| Pain Control (1605) |
Describes primary causal factors (160501) |
It is characterized by the patient describing the factors causing the pain(1414 Mateus AM, Ferreira BMA, Monforte EMM, Ferreira FMB, Alvarenga MICSF, Silva MFV et al (coords). Dor: guia orientador de boa prática. [Internet]. Lisboa (PT): Ordem dos Enfermeiros; 2008 [cited 2018 Nov 3]. 57 p. Available from: https://suporte.ordemenfermeiros.pt/arquivo/publicacoes/Documents/cadernosoe-dor.pdf
https://suporte.ordemenfermeiros.pt/arqu...
). |
To ask the patient to describe the factors that cause pain, such as: change of position; excess heat; excess of cold; movements; cough; breath; inadequate analgesic; rest; impaired; lesion / tumor. |
- Cannot describe the factors.
- Can describe 1 to 2 of the factors.
- Can describe 3 to 4 factors.
- Can describe 5 to 7 of the factors.
- Can describe 8 or more items. |
| Uses non-analgesic relief measures (160504) |
It is characterized in that the patient uses methods or techniques for prevention and / or treatment of pain that does not involve the administration of drugs(1414 Mateus AM, Ferreira BMA, Monforte EMM, Ferreira FMB, Alvarenga MICSF, Silva MFV et al (coords). Dor: guia orientador de boa prática. [Internet]. Lisboa (PT): Ordem dos Enfermeiros; 2008 [cited 2018 Nov 3]. 57 p. Available from: https://suporte.ordemenfermeiros.pt/arquivo/publicacoes/Documents/cadernosoe-dor.pdf
https://suporte.ordemenfermeiros.pt/arqu...
). |
To observe/ask whether patient uses methods or techniques for pain prevention and/or treatment that do not involve drug administration, such as: relaxation (decrease muscle tension); strategies to divert attention; application of cold and heat; performing exercises (stretching and resistance movements); restriction and limitation of movements when necessary; massage on body parts. |
- Does not use measures.
- Use 1 to 2 measures.
- Uses 3 to 5 measures
- Use 6 to 8 measures.
- Uses 8 or more measures. |
| Sleep (0004) |
Sleep quality (000404) |
Usual sleep characteristics(1515 Corrêa K, Ceolim MF. [Sleep quality in aged patients with peripheral vascular diseases]. Rev Esc Enferm USP [Internet] 2008 [cited 2018 Oct 30];42(1):12-18. Available from: http://dx.doi.org/10.1590/S0080-62342008000100002 Portuguese.
http://dx.doi.org/10.1590/S0080-62342008...
). |
To observe/ask if the patient has characteristics that impair the quality of sleep, such as: difficulty falling asleep; wakes up several times a night; difficulty breathing; cold during sleep; presents pain during sleep; uses sleeping pills; presents daytime drowsiness. |
- Presents 7 or more characteristics.
- It has 5 to 6 characteristics.
- Presents 3 to 4 characteristics.
- Presents 1 to 2 characteristics.
- You do not have any characteristic that decreases or impairs sleep. |
| Comfort Status (2008) |
Physical well-being (200801) |
General physical Comfort State (1616 Cuidados paliativos oncológicos: controle de sintomas. Rev Bras Cancerol [Internet]. 2002 [cited 2018 Nov 3];48(2):191-211. Available from: http://www.inca.gov.br/rbc/n_48/v02/pdf/condutas3.pdf
http://www.inca.gov.br/rbc/n_48/v02/pdf/...
). |
To observe if the patient presents characteristics of physical well-being, for example: good physical mobility; comfortable; normal breathing; fatigue control; enjoy your food; absence of nausea vomiting; good sleep quality. |
- Has no physical well-being characteristics.
- Presents 1 to 2 characteristics of physical well-being.
- Presents 3 to 4 characteristics of physical well-being.
- Presents 5 to 6 characteristics of physical well-being.
- Presents 7 or more characteristics of physical well-being. |
| Bem-Estar Pessoal (2002) |
Psychological well-being (200803) |
State in which the patient is well with himself and with others. Accepts the demands of life, knows how to deal with good and unpleasant emotions(1717 Queroz NC, Neri AL. [Emotional intelligence and psychological well-being among middle-aged and old men and women] Psicol Reflex Crit [Internet]. 2005 [cited 2018 Oct 30];18(2):292-299. Available from: http://dx.doi.org/10.1590/S0102-79722005000200018 Portuguese.
http://dx.doi.org/10.1590/S0102-79722005...
). |
To observe if the patient presents characteristics of psychological well-being, for example: positive attitudes toward oneself; growth, development and self-realization; integration and emotional response; autonomy and self-determination; accurate perception of reality; environmental domain and social competence. |
- Does not present characteristics of psychological well-being.
- Presents 1 characteristic of psychological well-being.
- Presents 2 characteristics of psychological well-being.
- Presents 3 characteristics of psychological well-being.
- Presents 4 or more characteristics of psychological well-being. |
| Personal Well-Being (2002) |
Social support from family (200806) |
There is a family member who, although a lay person, assumes responsibility for the physical and emotional needs of the other who is incapable of caring(1919 Rodrigues JSM, Ferreira NMLA, Caliri MHL. [Characterization of social support perceived for family to adult patient with cancer]. Medicina (Ribeirao Preto) [Internet]. 2013 [cited 2018 Oct 30];46(3):288-95. Available from: http://revista.fmrp.usp.br/2013/vol46n3/AO_Caracteriza%E7%E3o%20do%20apoio%20social%20percebido%20pela%20familia%20do%20doente%20adulto%20com%20c%E2ncer.pdf Portuguese.
http://revista.fmrp.usp.br/2013/vol46n3/...
). |
To ask/observe if the patient has a family that provides social support characterized by examples: administration of symptoms and comfort, with non-pharmacological approaches; search for information about the disease and treatment; use of strategies to solve problems;
providing emotional support (affection, company, counseling, practical help, or financial assistance); support in the provision of direct care (hygiene and food, support in the provision of indirect care (accepting that it is the responsibility of the family to care for its members). |
- Does not receive social support from the family.
- Receives 1 type of social support from the family.
- Receives 2 types of family social support.
- Receives 3 types of family social support.
- Receives all social support from the family. |
| Personal Well-Being (2002) |
Ability to communicate needs (200812) |
It is characterized by the patient's ability to communicate their needs(1414 Mateus AM, Ferreira BMA, Monforte EMM, Ferreira FMB, Alvarenga MICSF, Silva MFV et al (coords). Dor: guia orientador de boa prática. [Internet]. Lisboa (PT): Ordem dos Enfermeiros; 2008 [cited 2018 Nov 3]. 57 p. Available from: https://suporte.ordemenfermeiros.pt/arquivo/publicacoes/Documents/cadernosoe-dor.pdf
https://suporte.ordemenfermeiros.pt/arqu...
)
|
To observe how the patient communicates his physical needs; psychological; spiritual; environmental and safety measures. This communication must be perceived, both by the patient's verbal and non-verbal language, in order to understand the patient's real needs. Observe signs, gestures, movements, crying, moaning, facies, silence, own language that can express messages. |
- None, cannot communicate their needs.
- Ability to communicate 1 of your needs (ex: communication through groaning, pain facies).
- Ability to communicate 2 of your needs (ex: communication through groaning, pain facies and requests psychological support).
- Ability to communicate 3 of your needs (ex: communicating through groaning, pain facies, requests psychological support and asks for mattress improvement).
- Ability to communicate all your needs. |
| Social relationships (200203) |
It is characterized by how the patient relates to family, staff, and others(1818 Trevino KM, Fasciano K, Prigerson HG. Correlates of social support in young adults with advanced câncer. Support Care Cancer [Internet]. 2013 [cited 2018 Oct 30];21(2): 421-429. Available from: doi: 10.1007/s00520-012-1536-2
https://doi.org/10.1007/s00520-012-1536-...
). |
To observe/ask how satisfied the patient is with relationships with family members, health care staff and others. |
- No satisfaction, because the person does not have good relationship with everyone.
- Little satisfaction, because the person does not have good relationship with most people.
- Some satisfaction, because the person has good relationship with some people.
- Much satisfaction, because the person has a good relationship with most people.
- Complete satisfaction, because the person has good relationship with all. |
| Will to Live (1206) |
Expression of determination to live/hope (120601/120602) |
It is characterized by the patient expressing determination in the possibility of positive results related to events and circumstances of life(2020 Rhondali W, Yennurajalingam S, Ferrer J, Chisholm G, Filbet M, Bruera E. Association between supportive care interventions and patient self-reported depression among advanced cancer outpatients. Support Care Cancer. 2014;22(4):871-9. doi: 10.1007/s00520-013-2042-x
https://doi.org/10.1007/s00520-013-2042-...
). |
To observe in the patient expressions of determination to live and of hope, as, for example: wants to perform strategies for symptom management;
accepts treatment offered by staff; presents positive thoughts about life; makes plans for life after discharge; accepts family visits. |
1 No expression of determination to live/hope.
2 Presents 1 expression of determination to live/hope.
3 Presents 2 expressions of determination to live/hope.
4 Presents 3 to 4 expressions of determination to live/hope.
5 Presents 5 or more expressions of determination to live/hope. |
| Client Satisfaction: Pain Management (3016) |
Pain Level monitored regularly (301602) |
It is characterized by the regularity with which nursing monitors the pain level of the patient(1616 Cuidados paliativos oncológicos: controle de sintomas. Rev Bras Cancerol [Internet]. 2002 [cited 2018 Nov 3];48(2):191-211. Available from: http://www.inca.gov.br/rbc/n_48/v02/pdf/condutas3.pdf
http://www.inca.gov.br/rbc/n_48/v02/pdf/...
). |
To ask the patient about his degree of satisfaction with the nursing team regarding the regularity that the nurse monitors the level of pain. |
- Unsatisfied, no monitoring.
- Little satisfaction, very sporadic monitoring.
- Some satisfaction, monitoring at certain times of the day.
- Much satisfaction, monitoring at certain times of the day and night.
- Complete satisfaction, monitoring at various times of the day and night. |
| Client Satisfaction: Pain Management (3016) |
Actions taken to relieve pain/ provide discomfort (301604/302605) |
It is characterized by actions implemented by the nursing team to relieve the pain/discomfort of the patient(1616 Cuidados paliativos oncológicos: controle de sintomas. Rev Bras Cancerol [Internet]. 2002 [cited 2018 Nov 3];48(2):191-211. Available from: http://www.inca.gov.br/rbc/n_48/v02/pdf/condutas3.pdf
http://www.inca.gov.br/rbc/n_48/v02/pdf/...
). |
To ask the patient how satisfied they are with nursing actions to relieve and prevent their pain, such as:
The assessment of pain is performed; promotes adequate rest/sleep; encourages the patient to discuss their pain experience; controls environmental factors capable of influencing discomfort; reduces or eliminates factors that increase pain;
respects medication administration at fixed intervals; offers non-pharmacological measures; notify the doctor if the measures are not successful. |
- Unsatisfied, actions are not implemented.
- Little satisfaction with the actions that are implemented.
- Some satisfaction with the actions that are implemented.
- Much satisfaction with the actions that are implemented.
- Complete satisfaction with the actions that are implemented. |
