Cross mapping between clinical indicators for assistance in intensive care and nursing interventions

Camargo, Maryanni Magalhães; Furieri, Lorena Barros; Lima, Eliane de Fátima Almeida; Lucena, Amália de Fátima; Fioresi, Mirian; Romero, Walckiria Garcia

doi:10.1590/0034-7167-2019-0728

Acessibilidade / Reportar erro

Brasil

Revista Brasileira de Enfermagem

Español English

Brasil

Español English

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Sumário

REVIEW • Rev. Bras. Enferm. 73 (6) • 2020 • https://doi.org/10.1590/0034-7167-2019-0728 copy

Cross mapping between clinical indicators for assistance in intensive care and nursing interventions

Mapeo cruzado entre indicadores clínicos para la asistencia en terapia intensiva e intervenciones de enfermería

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

Identify the main clinical indicators for assistance in the Intensive Care Unit (ICU) and map them in the nursing interventions described by the Nursing Interventions Classification (NIC).

Methods:

Integrative literature review study, followed by cross-mapping between clinical indicators for assistance in the ICU care and NIC nursing interventions and activities.

Results:

36 articles were identified, which resulted in 285 clinical indicators for ICU care, with mechanical ventilatory assistance, pain, sedation, psychomotor agitation, delirium, anxiety, altered heart rate, diet by naso tube / oroenteral and diarrhea the clinical indicators for assistance in the ICU the most prevalent. These were mapped in 12 Nursing Interventions Classification interventions and 130 nursing activities.

Final considerations:

It is concluded that the clinical indicators for ICU care associated with Nursing Interventions Classification are concrete data that assist intensive care nurses in their clinical practice.

Descriptors:
Signs and Symptoms; Intensive Care Units; Nursing Care; Health Status Indicators; Standardized Nursing Terminology

Clinical Indicators for ICU Assistance	n
Mechanical ventilatory assistance⁽²2 Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes [Internet]. 2015 [cited 2019 Feb 02];8(1). Available from: https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-015-1275-9 https://bmcresnotes.biomedcentral.com/tr... ^,¹⁴14 Souza RCS, Garcia DM, Sanches MB, Gallo AMA, Martins CPB, Siqueira ILCP. Nursing team knowledge on behavioral assessment of pain in critical care patients. Rev Gaúcha Enferm. [Internet]; 2013 [cited 2019 Feb 14] 34(3):55-63. Available from: http://www.scielo.br/pdf/rgenf/v34n3/en_a07v34n3.pdf http://www.scielo.br/pdf/rgenf/v34n3/en_... 15 Iyigun E, Pazar B, Tastan S. A study on reliability and validity of the Turkish version of the Face Anxiety Scale on mechanically-ventilated patients. Intensive Crit Care Nurs. 2016; 37:46-51. doi: 10.1016/j.iccn.2016.05.002 https://doi.org/10.1016/j.iccn.2016.05.0... 16 McCaughey C, Blackwood B, Glackin M, Brady M, McMullin MF. Characteristics and outcomes of haematology patients admitted to the intensive care unit: characteristics and outcomes of haematology patients. Nurs Crit Care. 2013; 18(4):193-9. doi: 10.1111/nicc.12005 https://doi.org/10.1111/nicc.12005... 17 Öztürk Birge A, Tel Aydin H. The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses. Intensive Crit Care Nurs. 2017; 41:33-42. doi: 10.1016/j.iccn.2016.08.009 https://doi.org/10.1016/j.iccn.2016.08.0... 18 Selim AA, Ely EW. Delirium the under-recognised syndrome: survey of healthcare professionals’ awareness and practice in the intensive care units. J Clin Nurs. 2017;26(5-6):813-24. doi: 10.1111/jocn.13517 https://doi.org/10.1111/jocn.13517... 19 Bashar FR, Vahedian-Azimi A, Hajiesmaeili M, Salesi M, Farzanegan B, Shojaei S, et al. Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium. J Crit Care. 2018; 43:88-94. doi: 10.1016/j.jcrc.2017.08.034 https://doi.org/10.1016/j.jcrc.2017.08.0... 20 Dehghan M, Fatehi poor A, Mehdipoor R, Ahmadinejad M. Does abdominal massage improve gastrointestinal functions of intensive care patients with an endotracheal tube?: a randomized clinical trial. Complement Ther Clin Pract. 2018; 30:122-8. doi: 10.1016/j.ctcp.2017.12.018 https://doi.org/10.1016/j.ctcp.2017.12.0... 21 Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M. Effects of hypercapnia and hypercapnic acidosis on hospital mortality in mechanically ventilated patients. Crit Care Med. 2017;45(7):e649-56. doi: 10.1097/CCM.0000000000002332 https://doi.org/10.1097/CCM.000000000000... 22 Jakob SM, Bütikofer L, Berger D, Coslovsky M, Takala J. A randomized controlled pilot study to evaluate the effect of an enteral formulation designed to improve gastrointestinal tolerance in the critically ill patient-the SPIRIT trial. Crit Care [Internet]. 2017 [cited 2019 Feb 14];21(1). doi: 10.1186 /s13054-017-1730-1 https://doi.org/10.1186 /s13054-017-1730... 23 Sundararajan K, Wills S, Chacko B, Kanabar G, O’Connor S, Deane AM. Impact of delirium and suture-less securement on accidental vascular catheter removal in the ICU. Anaesth Intensive Care. 2014 [cited 2019 Feb 14];42(4):473-9. doi: 10.1177/0310057X1404200408 https://doi.org/10.1177/0310057X14042004... 24 López-López C, Murillo-Pérez MA, Morales-Sánchez C, Torrente-Vela S, Orejana-Martín M, García-Iglesias M, et al. Valoración del dolor en la aspiración de secreciones traqueales en pacientes con traumatismo craneal mediante la Escala de conductas indicadoras de dolor (ESCID). Enferm Intensiva. [Internet]; 2014 [cited 2019 Feb 14] 25(3):114-21. doi: 10.1016/j.enfi.2014.03.001 https://doi.org/10.1016/j.enfi.2014.03.0... 25 Coyer F, Gardner A, Doubrovsky A. An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: a before and after study. Intensive Crit Care Nurs. 2017; 40:1-10. doi: 10.1016/j.iccn.2016.12.001 https://doi.org/10.1016/j.iccn.2016.12.0... 26 Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs. 2018 [cited 2019 Feb 16];27(9-10):2109-19. doi: 10.1111/jocn.14365 https://doi.org/10.1111/jocn.14365... 27 Crespo JCL, Gomes VR, Barbosa RL, Padilha KG, Secoli SR. Haemodialysis, nutritional disorders and hypoglycaemia in critical care. Br J Nurs Mark Allen Publ. 2017; 26(5):281-6. doi: 10.12968/bjon.2017.26.5.281 https://doi.org/10.12968/bjon.2017.26.5.... 28 Cordeiro ALPC, Silva R, Prado CBC, Oliveira KF, Barbosa MH. Laryngotracheal mucosa injury and associated factors after endotracheal extubation: a pilot study. Acta Paul Enferm. [Internet]; 2017 [cited 2019 Feb 16] 30(3):316-22. Available from: http://www.scielo.br/pdf/ape/v30n3/en_1982-0194-ape-30-03-0316.pdf http://www.scielo.br/pdf/ape/v30n3/en_19... ^-²⁹29 Plani N, Becker P, van Aswegen H. The use of a weaning and extubation protocol to facilitate effective weaning and extubation from mechanical ventilation in patients suffering from traumatic injuries: a non-randomized experimental trial comparing a prospective to retrospective cohort. Physiother Theory Pract. 2013; 29(3):211-21. doi: 10.3109/09593985.2012.718410 https://doi.org/10.3109/09593985.2012.71... ⁾.	17
Pain⁽⁴4 da Costa C, da Costa Linch GF, Nogueira de Souza E. Nursing diagnosis based on signs and symptoms of patients with heart disease. Int J Nurs Knowl. 2016; 27(4):210-4. doi: 10.1111/2047-3095.12132 https://doi.org/10.1111/2047-3095.12132... ^,¹⁴14 Souza RCS, Garcia DM, Sanches MB, Gallo AMA, Martins CPB, Siqueira ILCP. Nursing team knowledge on behavioral assessment of pain in critical care patients. Rev Gaúcha Enferm. [Internet]; 2013 [cited 2019 Feb 14] 34(3):55-63. Available from: http://www.scielo.br/pdf/rgenf/v34n3/en_a07v34n3.pdf http://www.scielo.br/pdf/rgenf/v34n3/en_... ^,¹⁷17 Öztürk Birge A, Tel Aydin H. The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses. Intensive Crit Care Nurs. 2017; 41:33-42. doi: 10.1016/j.iccn.2016.08.009 https://doi.org/10.1016/j.iccn.2016.08.0... ^,²⁴24 López-López C, Murillo-Pérez MA, Morales-Sánchez C, Torrente-Vela S, Orejana-Martín M, García-Iglesias M, et al. Valoración del dolor en la aspiración de secreciones traqueales en pacientes con traumatismo craneal mediante la Escala de conductas indicadoras de dolor (ESCID). Enferm Intensiva. [Internet]; 2014 [cited 2019 Feb 14] 25(3):114-21. doi: 10.1016/j.enfi.2014.03.001 https://doi.org/10.1016/j.enfi.2014.03.0... ^,³⁰30 Candiota CSS, Queluci GC, Cavalcanti ACD, Pereira JMV. Problem-situations and its complexity degrees - lower, medium and higher - in customers with acute coronary syndrome. Rev Enferm UFPE. [Internet]; 2016 [cited 2019 Feb 16] 10(1):112-8. Available from: https://pdfs.semanticscholar.org/d0e8/ea7c4ee243912eda96a9513c38c1b386da6f.pdf https://pdfs.semanticscholar.org/d0e8/ea... 31 Boitor M, Martorella G, Arbour C, Michaud C, Gélinas C. Evaluation of the preliminary effectiveness of hand massage therapy on postoperative pain of adults in the intensive care unit after cardiac surgery: a pilot randomized controlled trial. Pain Manag Nurs. 2015; 16(3):354-66. doi: 10.1016/j.pmn.2014.08.014 https://doi.org/10.1016/j.pmn.2014.08.01... 32 Nyholm L, Steffansson E, Fröjd C, Enblad P. Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study. J Neurosci Nurs. 2014; 46(5):285-91. doi: 10.1097/JNN.0000000000000077 https://doi.org/10.1097/JNN.000000000000... 33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... 34 Echegaray-Benites C, Kapoustina O, Gélinas C. Validation of the use of the Critical-Care Pain Observation Tool (CPOT) with brain surgery patients in the neurosurgical intensive care unit. Intensive Crit Care Nurs. 2014; 30(5):257-65. doi: 10.1016/j.iccn.2014.04.002 https://doi.org/10.1016/j.iccn.2014.04.0... ^-³⁵35 Giner M, Heras SB, Rosa LR, Díaz JA, Malpica ALB. Monitorización de la nutrición enteral como indicador clínico para la evaluación de la calidad en Unidades de Cuidados Intensivos. Nutr Hosp [Internet]. 2018 [cited 2019 Feb 23]; 35(1):6-10. Available from: http://scielo.isciii.es/pdf/nh/v35n1/1699-5198-nh-35-01-00006.pdf http://scielo.isciii.es/pdf/nh/v35n1/169... ⁾.	10
Sedation⁽¹⁴14 Souza RCS, Garcia DM, Sanches MB, Gallo AMA, Martins CPB, Siqueira ILCP. Nursing team knowledge on behavioral assessment of pain in critical care patients. Rev Gaúcha Enferm. [Internet]; 2013 [cited 2019 Feb 14] 34(3):55-63. Available from: http://www.scielo.br/pdf/rgenf/v34n3/en_a07v34n3.pdf http://www.scielo.br/pdf/rgenf/v34n3/en_... ^,¹⁷17 Öztürk Birge A, Tel Aydin H. The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses. Intensive Crit Care Nurs. 2017; 41:33-42. doi: 10.1016/j.iccn.2016.08.009 https://doi.org/10.1016/j.iccn.2016.08.0... ^-¹⁸18 Selim AA, Ely EW. Delirium the under-recognised syndrome: survey of healthcare professionals’ awareness and practice in the intensive care units. J Clin Nurs. 2017;26(5-6):813-24. doi: 10.1111/jocn.13517 https://doi.org/10.1111/jocn.13517... ^,²⁴24 López-López C, Murillo-Pérez MA, Morales-Sánchez C, Torrente-Vela S, Orejana-Martín M, García-Iglesias M, et al. Valoración del dolor en la aspiración de secreciones traqueales en pacientes con traumatismo craneal mediante la Escala de conductas indicadoras de dolor (ESCID). Enferm Intensiva. [Internet]; 2014 [cited 2019 Feb 14] 25(3):114-21. doi: 10.1016/j.enfi.2014.03.001 https://doi.org/10.1016/j.enfi.2014.03.0... ^,²⁶26 Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs. 2018 [cited 2019 Feb 16];27(9-10):2109-19. doi: 10.1111/jocn.14365 https://doi.org/10.1111/jocn.14365... ^,²⁹29 Plani N, Becker P, van Aswegen H. The use of a weaning and extubation protocol to facilitate effective weaning and extubation from mechanical ventilation in patients suffering from traumatic injuries: a non-randomized experimental trial comparing a prospective to retrospective cohort. Physiother Theory Pract. 2013; 29(3):211-21. doi: 10.3109/09593985.2012.718410 https://doi.org/10.3109/09593985.2012.71... ^,³²32 Nyholm L, Steffansson E, Fröjd C, Enblad P. Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study. J Neurosci Nurs. 2014; 46(5):285-91. doi: 10.1097/JNN.0000000000000077 https://doi.org/10.1097/JNN.000000000000... ^,³⁶36 Elliott SR. ICU delirium: a survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit. Intensive Crit Care Nurs. 2014; 30(6):333-8. doi: 10.1016/j.iccn.2014.06.004 https://doi.org/10.1016/j.iccn.2014.06.0... ^-³⁷37 Chianca TCM, Gonçales PC, Salgado PO, Machado BO, Amorim GL, Alcoforado CLGC. Incontinence-associated dermatitis: a cohort study in critically ill patients. Rev Gaúcha Enferm [Internet]. 2016 [cited 2019 Feb 23];37(spe):1-9. Available from: http://www.scielo.br/pdf/rgenf/v37nspe/en_0102-6933-rgenf-1983-14472016esp68075.pdf http://www.scielo.br/pdf/rgenf/v37nspe/e... ⁾.	9
Psychomotor agitation⁽¹⁴14 Souza RCS, Garcia DM, Sanches MB, Gallo AMA, Martins CPB, Siqueira ILCP. Nursing team knowledge on behavioral assessment of pain in critical care patients. Rev Gaúcha Enferm. [Internet]; 2013 [cited 2019 Feb 14] 34(3):55-63. Available from: http://www.scielo.br/pdf/rgenf/v34n3/en_a07v34n3.pdf http://www.scielo.br/pdf/rgenf/v34n3/en_... ^,¹⁸18 Selim AA, Ely EW. Delirium the under-recognised syndrome: survey of healthcare professionals’ awareness and practice in the intensive care units. J Clin Nurs. 2017;26(5-6):813-24. doi: 10.1111/jocn.13517 https://doi.org/10.1111/jocn.13517... ^,³⁰30 Candiota CSS, Queluci GC, Cavalcanti ACD, Pereira JMV. Problem-situations and its complexity degrees - lower, medium and higher - in customers with acute coronary syndrome. Rev Enferm UFPE. [Internet]; 2016 [cited 2019 Feb 16] 10(1):112-8. Available from: https://pdfs.semanticscholar.org/d0e8/ea7c4ee243912eda96a9513c38c1b386da6f.pdf https://pdfs.semanticscholar.org/d0e8/ea... ^,³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ^-³⁴34 Echegaray-Benites C, Kapoustina O, Gélinas C. Validation of the use of the Critical-Care Pain Observation Tool (CPOT) with brain surgery patients in the neurosurgical intensive care unit. Intensive Crit Care Nurs. 2014; 30(5):257-65. doi: 10.1016/j.iccn.2014.04.002 https://doi.org/10.1016/j.iccn.2014.04.0... ^,³⁶36 Elliott SR. ICU delirium: a survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit. Intensive Crit Care Nurs. 2014; 30(6):333-8. doi: 10.1016/j.iccn.2014.06.004 https://doi.org/10.1016/j.iccn.2014.06.0... ^,³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ^-³⁹39 Da Silva R, Amante LN, Salum NC, Martins T, Werner J. Adverse events during intrahospital transport of critically ill patients in a large hospita. Rev Enferm UFPE. [Internet]; 2016 [cited 2019 Mar 02] 10(12):4459-65. Available from: http://www.scielo.br/pdf/rbti/v31n1/en_0103-507X-rbti-20190003.pdf http://www.scielo.br/pdf/rbti/v31n1/en_0... ⁾, delirium⁽¹⁷17 Öztürk Birge A, Tel Aydin H. The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses. Intensive Crit Care Nurs. 2017; 41:33-42. doi: 10.1016/j.iccn.2016.08.009 https://doi.org/10.1016/j.iccn.2016.08.0... 18 Selim AA, Ely EW. Delirium the under-recognised syndrome: survey of healthcare professionals’ awareness and practice in the intensive care units. J Clin Nurs. 2017;26(5-6):813-24. doi: 10.1111/jocn.13517 https://doi.org/10.1111/jocn.13517... ^-¹⁹19 Bashar FR, Vahedian-Azimi A, Hajiesmaeili M, Salesi M, Farzanegan B, Shojaei S, et al. Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium. J Crit Care. 2018; 43:88-94. doi: 10.1016/j.jcrc.2017.08.034 https://doi.org/10.1016/j.jcrc.2017.08.0... ^,²³23 Sundararajan K, Wills S, Chacko B, Kanabar G, O’Connor S, Deane AM. Impact of delirium and suture-less securement on accidental vascular catheter removal in the ICU. Anaesth Intensive Care. 2014 [cited 2019 Feb 14];42(4):473-9. doi: 10.1177/0310057X1404200408 https://doi.org/10.1177/0310057X14042004... ^,²⁶26 Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs. 2018 [cited 2019 Feb 16];27(9-10):2109-19. doi: 10.1111/jocn.14365 https://doi.org/10.1111/jocn.14365... ^,³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ^,³⁶36 Elliott SR. ICU delirium: a survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit. Intensive Crit Care Nurs. 2014; 30(6):333-8. doi: 10.1016/j.iccn.2014.06.004 https://doi.org/10.1016/j.iccn.2014.06.0... ^,³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾.	8
Anxiety⁽⁴4 da Costa C, da Costa Linch GF, Nogueira de Souza E. Nursing diagnosis based on signs and symptoms of patients with heart disease. Int J Nurs Knowl. 2016; 27(4):210-4. doi: 10.1111/2047-3095.12132 https://doi.org/10.1111/2047-3095.12132... ^,¹⁴14 Souza RCS, Garcia DM, Sanches MB, Gallo AMA, Martins CPB, Siqueira ILCP. Nursing team knowledge on behavioral assessment of pain in critical care patients. Rev Gaúcha Enferm. [Internet]; 2013 [cited 2019 Feb 14] 34(3):55-63. Available from: http://www.scielo.br/pdf/rgenf/v34n3/en_a07v34n3.pdf http://www.scielo.br/pdf/rgenf/v34n3/en_... ^-¹⁵15 Iyigun E, Pazar B, Tastan S. A study on reliability and validity of the Turkish version of the Face Anxiety Scale on mechanically-ventilated patients. Intensive Crit Care Nurs. 2016; 37:46-51. doi: 10.1016/j.iccn.2016.05.002 https://doi.org/10.1016/j.iccn.2016.05.0... ^,¹⁹19 Bashar FR, Vahedian-Azimi A, Hajiesmaeili M, Salesi M, Farzanegan B, Shojaei S, et al. Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium. J Crit Care. 2018; 43:88-94. doi: 10.1016/j.jcrc.2017.08.034 https://doi.org/10.1016/j.jcrc.2017.08.0... ^,²⁹29 Plani N, Becker P, van Aswegen H. The use of a weaning and extubation protocol to facilitate effective weaning and extubation from mechanical ventilation in patients suffering from traumatic injuries: a non-randomized experimental trial comparing a prospective to retrospective cohort. Physiother Theory Pract. 2013; 29(3):211-21. doi: 10.3109/09593985.2012.718410 https://doi.org/10.3109/09593985.2012.71... ^,³¹31 Boitor M, Martorella G, Arbour C, Michaud C, Gélinas C. Evaluation of the preliminary effectiveness of hand massage therapy on postoperative pain of adults in the intensive care unit after cardiac surgery: a pilot randomized controlled trial. Pain Manag Nurs. 2015; 16(3):354-66. doi: 10.1016/j.pmn.2014.08.014 https://doi.org/10.1016/j.pmn.2014.08.01... ^,³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ⁾, altered heart rate⁽²2 Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes [Internet]. 2015 [cited 2019 Feb 02];8(1). Available from: https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-015-1275-9 https://bmcresnotes.biomedcentral.com/tr... ^,⁴4 da Costa C, da Costa Linch GF, Nogueira de Souza E. Nursing diagnosis based on signs and symptoms of patients with heart disease. Int J Nurs Knowl. 2016; 27(4):210-4. doi: 10.1111/2047-3095.12132 https://doi.org/10.1111/2047-3095.12132... ^,²¹21 Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M. Effects of hypercapnia and hypercapnic acidosis on hospital mortality in mechanically ventilated patients. Crit Care Med. 2017;45(7):e649-56. doi: 10.1097/CCM.0000000000002332 https://doi.org/10.1097/CCM.000000000000... ^,³¹31 Boitor M, Martorella G, Arbour C, Michaud C, Gélinas C. Evaluation of the preliminary effectiveness of hand massage therapy on postoperative pain of adults in the intensive care unit after cardiac surgery: a pilot randomized controlled trial. Pain Manag Nurs. 2015; 16(3):354-66. doi: 10.1016/j.pmn.2014.08.014 https://doi.org/10.1016/j.pmn.2014.08.01... ^,³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ^,³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ^-³⁹39 Da Silva R, Amante LN, Salum NC, Martins T, Werner J. Adverse events during intrahospital transport of critically ill patients in a large hospita. Rev Enferm UFPE. [Internet]; 2016 [cited 2019 Mar 02] 10(12):4459-65. Available from: http://www.scielo.br/pdf/rbti/v31n1/en_0103-507X-rbti-20190003.pdf http://www.scielo.br/pdf/rbti/v31n1/en_0... ⁾.	7
Naso/oroenteral tube diet⁽²⁰20 Dehghan M, Fatehi poor A, Mehdipoor R, Ahmadinejad M. Does abdominal massage improve gastrointestinal functions of intensive care patients with an endotracheal tube?: a randomized clinical trial. Complement Ther Clin Pract. 2018; 30:122-8. doi: 10.1016/j.ctcp.2017.12.018 https://doi.org/10.1016/j.ctcp.2017.12.0... ^,²²22 Jakob SM, Bütikofer L, Berger D, Coslovsky M, Takala J. A randomized controlled pilot study to evaluate the effect of an enteral formulation designed to improve gastrointestinal tolerance in the critically ill patient-the SPIRIT trial. Crit Care [Internet]. 2017 [cited 2019 Feb 14];21(1). doi: 10.1186 /s13054-017-1730-1 https://doi.org/10.1186 /s13054-017-1730... ^,²⁵25 Coyer F, Gardner A, Doubrovsky A. An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: a before and after study. Intensive Crit Care Nurs. 2017; 40:1-10. doi: 10.1016/j.iccn.2016.12.001 https://doi.org/10.1016/j.iccn.2016.12.0... ^,²⁷27 Crespo JCL, Gomes VR, Barbosa RL, Padilha KG, Secoli SR. Haemodialysis, nutritional disorders and hypoglycaemia in critical care. Br J Nurs Mark Allen Publ. 2017; 26(5):281-6. doi: 10.12968/bjon.2017.26.5.281 https://doi.org/10.12968/bjon.2017.26.5.... ^,³⁵35 Giner M, Heras SB, Rosa LR, Díaz JA, Malpica ALB. Monitorización de la nutrición enteral como indicador clínico para la evaluación de la calidad en Unidades de Cuidados Intensivos. Nutr Hosp [Internet]. 2018 [cited 2019 Feb 23]; 35(1):6-10. Available from: http://scielo.isciii.es/pdf/nh/v35n1/1699-5198-nh-35-01-00006.pdf http://scielo.isciii.es/pdf/nh/v35n1/169... ^,⁴⁰40 Bispo MM, Dantas ALM, Silva PKA, Fernandes MICD, Tinôco JDS, Lira ALBC. The nursing diagnosis of aspiration risk in critical patients. Esc Anna Nery [Internet]; 2016 [cited 2019 Mar 02] 20(2):357-362. Available from: http://www.scielo.br/pdf/ean/v20n2/en_1414-8145-ean-20-02-0357.pdf http://www.scielo.br/pdf/ean/v20n2/en_14... ⁾, diarrhea⁽²²22 Jakob SM, Bütikofer L, Berger D, Coslovsky M, Takala J. A randomized controlled pilot study to evaluate the effect of an enteral formulation designed to improve gastrointestinal tolerance in the critically ill patient-the SPIRIT trial. Crit Care [Internet]. 2017 [cited 2019 Feb 14];21(1). doi: 10.1186 /s13054-017-1730-1 https://doi.org/10.1186 /s13054-017-1730... ^,²⁵25 Coyer F, Gardner A, Doubrovsky A. An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: a before and after study. Intensive Crit Care Nurs. 2017; 40:1-10. doi: 10.1016/j.iccn.2016.12.001 https://doi.org/10.1016/j.iccn.2016.12.0... ^,³⁵35 Giner M, Heras SB, Rosa LR, Díaz JA, Malpica ALB. Monitorización de la nutrición enteral como indicador clínico para la evaluación de la calidad en Unidades de Cuidados Intensivos. Nutr Hosp [Internet]. 2018 [cited 2019 Feb 23]; 35(1):6-10. Available from: http://scielo.isciii.es/pdf/nh/v35n1/1699-5198-nh-35-01-00006.pdf http://scielo.isciii.es/pdf/nh/v35n1/169... ^,³⁷37 Chianca TCM, Gonçales PC, Salgado PO, Machado BO, Amorim GL, Alcoforado CLGC. Incontinence-associated dermatitis: a cohort study in critically ill patients. Rev Gaúcha Enferm [Internet]. 2016 [cited 2019 Feb 23];37(spe):1-9. Available from: http://www.scielo.br/pdf/rgenf/v37nspe/en_0102-6933-rgenf-1983-14472016esp68075.pdf http://www.scielo.br/pdf/rgenf/v37nspe/e... ^-³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ^,⁴¹41 Valls-Matarín J, del Cotillo-Fuente M, Ribal-Prior R, Pujol-Vila M, Sandalinas-Mulero I. Incidencia de lesiones cutáneas asociadas a la humedad en una unidad de cuidados intensivos. Enferm Intensiva. 2017; 28(1):13-20. doi: 10.1016/j.enfi.2016.11.001 https://doi.org/10.1016/j.enfi.2016.11.0... ⁾.	6
Change in level of consciousness⁽²2 Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes [Internet]. 2015 [cited 2019 Feb 02];8(1). Available from: https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-015-1275-9 https://bmcresnotes.biomedcentral.com/tr... ^,¹⁶16 McCaughey C, Blackwood B, Glackin M, Brady M, McMullin MF. Characteristics and outcomes of haematology patients admitted to the intensive care unit: characteristics and outcomes of haematology patients. Nurs Crit Care. 2013; 18(4):193-9. doi: 10.1111/nicc.12005 https://doi.org/10.1111/nicc.12005... ^,³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ^,⁴⁰40 Bispo MM, Dantas ALM, Silva PKA, Fernandes MICD, Tinôco JDS, Lira ALBC. The nursing diagnosis of aspiration risk in critical patients. Esc Anna Nery [Internet]; 2016 [cited 2019 Mar 02] 20(2):357-362. Available from: http://www.scielo.br/pdf/ean/v20n2/en_1414-8145-ean-20-02-0357.pdf http://www.scielo.br/pdf/ean/v20n2/en_14... ^,⁴²42 Santos WC, Vancini-Campanharo CR, Lopes MCBT, Okuno MFP, Batista REA. Assessment of nurse’s knowledge about Glasgow coma scale at a university hospital. Einstein São Paulo. [Internet]; 2016 [cited 2019 Mar 02] 14(2):213-8. Available from: http://www.scielo.br/pdf/eins/v14n2/1679-4508-eins-14-2-0213.pdf http://www.scielo.br/pdf/eins/v14n2/1679... ⁾, care with central venous catheter⁽²⁴24 López-López C, Murillo-Pérez MA, Morales-Sánchez C, Torrente-Vela S, Orejana-Martín M, García-Iglesias M, et al. Valoración del dolor en la aspiración de secreciones traqueales en pacientes con traumatismo craneal mediante la Escala de conductas indicadoras de dolor (ESCID). Enferm Intensiva. [Internet]; 2014 [cited 2019 Feb 14] 25(3):114-21. doi: 10.1016/j.enfi.2014.03.001 https://doi.org/10.1016/j.enfi.2014.03.0... ^,²⁶26 Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs. 2018 [cited 2019 Feb 16];27(9-10):2109-19. doi: 10.1111/jocn.14365 https://doi.org/10.1111/jocn.14365... ^,⁴³43 Melo EM, Cavalcante HPO, Marques AM, Ferreira AMM, Abreu MAF, Lima VF, et al. Conhecimento do enfermeiro sobre as drogas vasoativas utilizadas em pacientes críticos. Rev Enferm UFPE [Internet]. 2016;10(8):2948-55. doi: 10.5205/reuol.9373-82134-1-RV1008201621 https://doi.org/10.5205/reuol.9373-82134... 44 Serafim CTR, Dell’Acqua MCQ, Castro MCN, Spiri WC, Nunes HRC. Severity and workload related to adverse events in the ICU. Rev Bras Enferm. [Internet]; 2017 [cited 2019 Mar 02] 70(5):942-8. Available from: http://www.scielo.br/pdf/reben/v70n5/0034-7167-reben-70-05-0942.pdf http://www.scielo.br/pdf/reben/v70n5/003... ^-⁴⁵45 Guimarães GL, Goveia VR, Mendonza IYQ, Corrêa A Reis, Matos SS, Guimarães JO. Nursing interventions for hemodialysis patients through central venous catheter. Rev Enferm UFPE. 2017;11(3). doi: 10.5205/reuol.10544-93905-1-RV.1103201702 https://doi.org/10.5205/reuol.10544-9390... ⁾.	5
Infusion of vasoactive drug⁽²2 Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes [Internet]. 2015 [cited 2019 Feb 02];8(1). Available from: https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-015-1275-9 https://bmcresnotes.biomedcentral.com/tr... ^,²⁵25 Coyer F, Gardner A, Doubrovsky A. An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: a before and after study. Intensive Crit Care Nurs. 2017; 40:1-10. doi: 10.1016/j.iccn.2016.12.001 https://doi.org/10.1016/j.iccn.2016.12.0... ^,²⁷27 Crespo JCL, Gomes VR, Barbosa RL, Padilha KG, Secoli SR. Haemodialysis, nutritional disorders and hypoglycaemia in critical care. Br J Nurs Mark Allen Publ. 2017; 26(5):281-6. doi: 10.12968/bjon.2017.26.5.281 https://doi.org/10.12968/bjon.2017.26.5.... ^,⁴³43 Melo EM, Cavalcante HPO, Marques AM, Ferreira AMM, Abreu MAF, Lima VF, et al. Conhecimento do enfermeiro sobre as drogas vasoativas utilizadas em pacientes críticos. Rev Enferm UFPE [Internet]. 2016;10(8):2948-55. doi: 10.5205/reuol.9373-82134-1-RV1008201621 https://doi.org/10.5205/reuol.9373-82134... ⁾, altered blood pressure⁽²2 Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes [Internet]. 2015 [cited 2019 Feb 02];8(1). Available from: https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-015-1275-9 https://bmcresnotes.biomedcentral.com/tr... ^,²¹21 Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M. Effects of hypercapnia and hypercapnic acidosis on hospital mortality in mechanically ventilated patients. Crit Care Med. 2017;45(7):e649-56. doi: 10.1097/CCM.0000000000002332 https://doi.org/10.1097/CCM.000000000000... ^,³²32 Nyholm L, Steffansson E, Fröjd C, Enblad P. Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study. J Neurosci Nurs. 2014; 46(5):285-91. doi: 10.1097/JNN.0000000000000077 https://doi.org/10.1097/JNN.000000000000... ^-³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ⁾, increased gastric residual volume⁽²⁰20 Dehghan M, Fatehi poor A, Mehdipoor R, Ahmadinejad M. Does abdominal massage improve gastrointestinal functions of intensive care patients with an endotracheal tube?: a randomized clinical trial. Complement Ther Clin Pract. 2018; 30:122-8. doi: 10.1016/j.ctcp.2017.12.018 https://doi.org/10.1016/j.ctcp.2017.12.0... ^,²⁷27 Crespo JCL, Gomes VR, Barbosa RL, Padilha KG, Secoli SR. Haemodialysis, nutritional disorders and hypoglycaemia in critical care. Br J Nurs Mark Allen Publ. 2017; 26(5):281-6. doi: 10.12968/bjon.2017.26.5.281 https://doi.org/10.12968/bjon.2017.26.5.... ^,³⁵35 Giner M, Heras SB, Rosa LR, Díaz JA, Malpica ALB. Monitorización de la nutrición enteral como indicador clínico para la evaluación de la calidad en Unidades de Cuidados Intensivos. Nutr Hosp [Internet]. 2018 [cited 2019 Feb 23]; 35(1):6-10. Available from: http://scielo.isciii.es/pdf/nh/v35n1/1699-5198-nh-35-01-00006.pdf http://scielo.isciii.es/pdf/nh/v35n1/169... ^,⁴⁰40 Bispo MM, Dantas ALM, Silva PKA, Fernandes MICD, Tinôco JDS, Lira ALBC. The nursing diagnosis of aspiration risk in critical patients. Esc Anna Nery [Internet]; 2016 [cited 2019 Mar 02] 20(2):357-362. Available from: http://www.scielo.br/pdf/ean/v20n2/en_1414-8145-ean-20-02-0357.pdf http://www.scielo.br/pdf/ean/v20n2/en_14... ⁾.	4
Endotracheal suction⁽²⁴24 López-López C, Murillo-Pérez MA, Morales-Sánchez C, Torrente-Vela S, Orejana-Martín M, García-Iglesias M, et al. Valoración del dolor en la aspiración de secreciones traqueales en pacientes con traumatismo craneal mediante la Escala de conductas indicadoras de dolor (ESCID). Enferm Intensiva. [Internet]; 2014 [cited 2019 Feb 14] 25(3):114-21. doi: 10.1016/j.enfi.2014.03.001 https://doi.org/10.1016/j.enfi.2014.03.0... ^,²⁸28 Cordeiro ALPC, Silva R, Prado CBC, Oliveira KF, Barbosa MH. Laryngotracheal mucosa injury and associated factors after endotracheal extubation: a pilot study. Acta Paul Enferm. [Internet]; 2017 [cited 2019 Feb 16] 30(3):316-22. Available from: http://www.scielo.br/pdf/ape/v30n3/en_1982-0194-ape-30-03-0316.pdf http://www.scielo.br/pdf/ape/v30n3/en_19... ^,³²32 Nyholm L, Steffansson E, Fröjd C, Enblad P. Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study. J Neurosci Nurs. 2014; 46(5):285-91. doi: 10.1097/JNN.0000000000000077 https://doi.org/10.1097/JNN.000000000000... ⁾, mental confusion⁽²⁹29 Plani N, Becker P, van Aswegen H. The use of a weaning and extubation protocol to facilitate effective weaning and extubation from mechanical ventilation in patients suffering from traumatic injuries: a non-randomized experimental trial comparing a prospective to retrospective cohort. Physiother Theory Pract. 2013; 29(3):211-21. doi: 10.3109/09593985.2012.718410 https://doi.org/10.3109/09593985.2012.71... ^,³⁶36 Elliott SR. ICU delirium: a survey into nursing and medical staff knowledge of current practices and perceived barriers towards ICU delirium in the intensive care unit. Intensive Crit Care Nurs. 2014; 30(6):333-8. doi: 10.1016/j.iccn.2014.06.004 https://doi.org/10.1016/j.iccn.2014.06.0... ^,³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. 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Laryngotracheal mucosa injury and associated factors after endotracheal extubation: a pilot study. Acta Paul Enferm. [Internet]; 2017 [cited 2019 Feb 16] 30(3):316-22. Available from: http://www.scielo.br/pdf/ape/v30n3/en_1982-0194-ape-30-03-0316.pdf http://www.scielo.br/pdf/ape/v30n3/en_19... ⁾, dysrhythmia⁽¹⁸18 Selim AA, Ely EW. Delirium the under-recognised syndrome: survey of healthcare professionals’ awareness and practice in the intensive care units. J Clin Nurs. 2017;26(5-6):813-24. doi: 10.1111/jocn.13517 https://doi.org/10.1111/jocn.13517... ⁾, abdominal distension⁽³⁵35 Giner M, Heras SB, Rosa LR, Díaz JA, Malpica ALB. Monitorización de la nutrición enteral como indicador clínico para la evaluación de la calidad en Unidades de Cuidados Intensivos. Nutr Hosp [Internet]. 2018 [cited 2019 Feb 23]; 35(1):6-10. Available from: http://scielo.isciii.es/pdf/nh/v35n1/1699-5198-nh-35-01-00006.pdf http://scielo.isciii.es/pdf/nh/v35n1/169... ⁾, abdominal pain⁽³⁵35 Giner M, Heras SB, Rosa LR, Díaz JA, Malpica ALB. Monitorización de la nutrición enteral como indicador clínico para la evaluación de la calidad en Unidades de Cuidados Intensivos. Nutr Hosp [Internet]. 2018 [cited 2019 Feb 23]; 35(1):6-10. Available from: http://scielo.isciii.es/pdf/nh/v35n1/1699-5198-nh-35-01-00006.pdf http://scielo.isciii.es/pdf/nh/v35n1/169... ⁾, health education⁽⁴⁵45 Guimarães GL, Goveia VR, Mendonza IYQ, Corrêa A Reis, Matos SS, Guimarães JO. Nursing interventions for hemodialysis patients through central venous catheter. Rev Enferm UFPE. 2017;11(3). doi: 10.5205/reuol.10544-93905-1-RV.1103201702 https://doi.org/10.5205/reuol.10544-9390... ⁾, spirituality⁽⁴⁵45 Guimarães GL, Goveia VR, Mendonza IYQ, Corrêa A Reis, Matos SS, Guimarães JO. Nursing interventions for hemodialysis patients through central venous catheter. Rev Enferm UFPE. 2017;11(3). doi: 10.5205/reuol.10544-93905-1-RV.1103201702 https://doi.org/10.5205/reuol.10544-9390... ⁾, erythema⁽⁴¹41 Valls-Matarín J, del Cotillo-Fuente M, Ribal-Prior R, Pujol-Vila M, Sandalinas-Mulero I. Incidencia de lesiones cutáneas asociadas a la humedad en una unidad de cuidados intensivos. Enferm Intensiva. 2017; 28(1):13-20. doi: 10.1016/j.enfi.2016.11.001 https://doi.org/10.1016/j.enfi.2016.11.0... ⁾, exhaustion⁽¹⁴14 Souza RCS, Garcia DM, Sanches MB, Gallo AMA, Martins CPB, Siqueira ILCP. Nursing team knowledge on behavioral assessment of pain in critical care patients. Rev Gaúcha Enferm. [Internet]; 2013 [cited 2019 Feb 14] 34(3):55-63. Available from: http://www.scielo.br/pdf/rgenf/v34n3/en_a07v34n3.pdf http://www.scielo.br/pdf/rgenf/v34n3/en_... ⁾, extubation⁽⁴⁴44 Serafim CTR, Dell’Acqua MCQ, Castro MCN, Spiri WC, Nunes HRC. Severity and workload related to adverse events in the ICU. Rev Bras Enferm. [Internet]; 2017 [cited 2019 Mar 02] 70(5):942-8. Available from: http://www.scielo.br/pdf/reben/v70n5/0034-7167-reben-70-05-0942.pdf http://www.scielo.br/pdf/reben/v70n5/003... ⁾, fatigue⁽³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ⁾, liquid stools⁽³⁷37 Chianca TCM, Gonçales PC, Salgado PO, Machado BO, Amorim GL, Alcoforado CLGC. Incontinence-associated dermatitis: a cohort study in critically ill patients. Rev Gaúcha Enferm [Internet]. 2016 [cited 2019 Feb 23];37(spe):1-9. Available from: http://www.scielo.br/pdf/rgenf/v37nspe/en_0102-6933-rgenf-1983-14472016esp68075.pdf http://www.scielo.br/pdf/rgenf/v37nspe/e... ⁾, hemodialysis⁽²⁷27 Crespo JCL, Gomes VR, Barbosa RL, Padilha KG, Secoli SR. Haemodialysis, nutritional disorders and hypoglycaemia in critical care. Br J Nurs Mark Allen Publ. 2017; 26(5):281-6. doi: 10.12968/bjon.2017.26.5.281 https://doi.org/10.12968/bjon.2017.26.5.... ⁾, oral hygiene⁽³²32 Nyholm L, Steffansson E, Fröjd C, Enblad P. Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study. J Neurosci Nurs. 2014; 46(5):285-91. doi: 10.1097/JNN.0000000000000077 https://doi.org/10.1097/JNN.000000000000... ⁾, hyperalbuminemia⁽²⁵25 Coyer F, Gardner A, Doubrovsky A. An interventional skin care protocol (InSPiRE) to reduce incontinence-associated dermatitis in critically ill patients in the intensive care unit: a before and after study. Intensive Crit Care Nurs. 2017; 40:1-10. doi: 10.1016/j.iccn.2016.12.001 https://doi.org/10.1016/j.iccn.2016.12.0... ⁾, hypercapnia⁽²¹21 Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M. Effects of hypercapnia and hypercapnic acidosis on hospital mortality in mechanically ventilated patients. Crit Care Med. 2017;45(7):e649-56. doi: 10.1097/CCM.0000000000002332 https://doi.org/10.1097/CCM.000000000000... ⁾, hypercreatinemia⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, hypernatremia⁽¹⁷17 Öztürk Birge A, Tel Aydin H. The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses. Intensive Crit Care Nurs. 2017; 41:33-42. doi: 10.1016/j.iccn.2016.08.009 https://doi.org/10.1016/j.iccn.2016.08.0... ⁾, hyperuremia⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, hypocapnia⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, hyponatremia⁽¹⁷17 Öztürk Birge A, Tel Aydin H. The effect of nonpharmacological training on delirium identification and intervention strategies of intensive care nurses. Intensive Crit Care Nurs. 2017; 41:33-42. doi: 10.1016/j.iccn.2016.08.009 https://doi.org/10.1016/j.iccn.2016.08.0... ⁾, hypoperfusion⁽²2 Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes [Internet]. 2015 [cited 2019 Feb 02];8(1). Available from: https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-015-1275-9 https://bmcresnotes.biomedcentral.com/tr... ⁾, hypoxemia⁽¹⁸18 Selim AA, Ely EW. Delirium the under-recognised syndrome: survey of healthcare professionals’ awareness and practice in the intensive care units. J Clin Nurs. 2017;26(5-6):813-24. doi: 10.1111/jocn.13517 https://doi.org/10.1111/jocn.13517... ⁾, depressed mood⁽⁴4 da Costa C, da Costa Linch GF, Nogueira de Souza E. Nursing diagnosis based on signs and symptoms of patients with heart disease. Int J Nurs Knowl. 2016; 27(4):210-4. doi: 10.1111/2047-3095.12132 https://doi.org/10.1111/2047-3095.12132... ⁾, immobility⁽³⁴34 Echegaray-Benites C, Kapoustina O, Gélinas C. Validation of the use of the Critical-Care Pain Observation Tool (CPOT) with brain surgery patients in the neurosurgical intensive care unit. Intensive Crit Care Nurs. 2014; 30(5):257-65. doi: 10.1016/j.iccn.2014.04.002 https://doi.org/10.1016/j.iccn.2014.04.0... ⁾, fecal incontinence⁽⁴¹41 Valls-Matarín J, del Cotillo-Fuente M, Ribal-Prior R, Pujol-Vila M, Sandalinas-Mulero I. Incidencia de lesiones cutáneas asociadas a la humedad en una unidad de cuidados intensivos. Enferm Intensiva. 2017; 28(1):13-20. doi: 10.1016/j.enfi.2016.11.001 https://doi.org/10.1016/j.enfi.2016.11.0... ⁾, urinary incontinence⁽⁴¹41 Valls-Matarín J, del Cotillo-Fuente M, Ribal-Prior R, Pujol-Vila M, Sandalinas-Mulero I. Incidencia de lesiones cutáneas asociadas a la humedad en una unidad de cuidados intensivos. Enferm Intensiva. 2017; 28(1):13-20. doi: 10.1016/j.enfi.2016.11.001 https://doi.org/10.1016/j.enfi.2016.11.0... ⁾, antiarrhythmic drug infusion⁽²⁶26 Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs. 2018 [cited 2019 Feb 16];27(9-10):2109-19. doi: 10.1111/jocn.14365 https://doi.org/10.1111/jocn.14365... ⁾, hypertonic glucose infusion⁽²⁷27 Crespo JCL, Gomes VR, Barbosa RL, Padilha KG, Secoli SR. Haemodialysis, nutritional disorders and hypoglycaemia in critical care. Br J Nurs Mark Allen Publ. 2017; 26(5):281-6. doi: 10.12968/bjon.2017.26.5.281 https://doi.org/10.12968/bjon.2017.26.5.... ⁾, tube intolerance⁽³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ⁾, orotracheal intubation⁽⁴⁰40 Bispo MM, Dantas ALM, Silva PKA, Fernandes MICD, Tinôco JDS, Lira ALBC. The nursing diagnosis of aspiration risk in critical patients. Esc Anna Nery [Internet]; 2016 [cited 2019 Mar 02] 20(2):357-362. Available from: http://www.scielo.br/pdf/ean/v20n2/en_1414-8145-ean-20-02-0357.pdf http://www.scielo.br/pdf/ean/v20n2/en_14... ⁾, isolation⁽³⁰30 Candiota CSS, Queluci GC, Cavalcanti ACD, Pereira JMV. Problem-situations and its complexity degrees - lower, medium and higher - in customers with acute coronary syndrome. Rev Enferm UFPE. [Internet]; 2016 [cited 2019 Feb 16] 10(1):112-8. Available from: https://pdfs.semanticscholar.org/d0e8/ea7c4ee243912eda96a9513c38c1b386da6f.pdf https://pdfs.semanticscholar.org/d0e8/ea... ⁾, contact isolation⁽³⁷37 Chianca TCM, Gonçales PC, Salgado PO, Machado BO, Amorim GL, Alcoforado CLGC. Incontinence-associated dermatitis: a cohort study in critically ill patients. Rev Gaúcha Enferm [Internet]. 2016 [cited 2019 Feb 23];37(spe):1-9. Available from: http://www.scielo.br/pdf/rgenf/v37nspe/en_0102-6933-rgenf-1983-14472016esp68075.pdf http://www.scielo.br/pdf/rgenf/v37nspe/e... ⁾, fasting⁽²⁷27 Crespo JCL, Gomes VR, Barbosa RL, Padilha KG, Secoli SR. Haemodialysis, nutritional disorders and hypoglycaemia in critical care. Br J Nurs Mark Allen Publ. 2017; 26(5):281-6. doi: 10.12968/bjon.2017.26.5.281 https://doi.org/10.12968/bjon.2017.26.5.... ⁾, lethargy⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, leukocytosis⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, leukopenia⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, abdominal massage⁽²⁰20 Dehghan M, Fatehi poor A, Mehdipoor R, Ahmadinejad M. Does abdominal massage improve gastrointestinal functions of intensive care patients with an endotracheal tube?: a randomized clinical trial. Complement Ther Clin Pract. 2018; 30:122-8. doi: 10.1016/j.ctcp.2017.12.018 https://doi.org/10.1016/j.ctcp.2017.12.0... ⁾, cardiac monitoring⁽⁴³43 Melo EM, Cavalcante HPO, Marques AM, Ferreira AMM, Abreu MAF, Lima VF, et al. Conhecimento do enfermeiro sobre as drogas vasoativas utilizadas em pacientes críticos. Rev Enferm UFPE [Internet]. 2016;10(8):2948-55. doi: 10.5205/reuol.9373-82134-1-RV1008201621 https://doi.org/10.5205/reuol.9373-82134... ⁾, altered motor skills⁽⁴²42 Santos WC, Vancini-Campanharo CR, Lopes MCBT, Okuno MFP, Batista REA. Assessment of nurse’s knowledge about Glasgow coma scale at a university hospital. Einstein São Paulo. [Internet]; 2016 [cited 2019 Mar 02] 14(2):213-8. Available from: http://www.scielo.br/pdf/eins/v14n2/1679-4508-eins-14-2-0213.pdf http://www.scielo.br/pdf/eins/v14n2/1679... ⁾, odynophagia⁽²⁸28 Cordeiro ALPC, Silva R, Prado CBC, Oliveira KF, Barbosa MH. Laryngotracheal mucosa injury and associated factors after endotracheal extubation: a pilot study. Acta Paul Enferm. [Internet]; 2017 [cited 2019 Feb 16] 30(3):316-22. Available from: http://www.scielo.br/pdf/ape/v30n3/en_1982-0194-ape-30-03-0316.pdf http://www.scielo.br/pdf/ape/v30n3/en_19... ⁾, oliguria⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, oxygen therapy⁽²2 Schell CO, Castegren M, Lugazia E, Blixt J, Mulungu M, Konrad D, et al. Severely deranged vital signs as triggers for acute treatment modifications on an intensive care unit in a low-income country. BMC Res Notes [Internet]. 2015 [cited 2019 Feb 02];8(1). Available from: https://bmcresnotes.biomedcentral.com/track/pdf/10.1186/s13104-015-1275-9 https://bmcresnotes.biomedcentral.com/tr... ⁾, skin pallor⁽³⁰30 Candiota CSS, Queluci GC, Cavalcanti ACD, Pereira JMV. Problem-situations and its complexity degrees - lower, medium and higher - in customers with acute coronary syndrome. Rev Enferm UFPE. [Internet]; 2016 [cited 2019 Feb 16] 10(1):112-8. Available from: https://pdfs.semanticscholar.org/d0e8/ea7c4ee243912eda96a9513c38c1b386da6f.pdf https://pdfs.semanticscholar.org/d0e8/ea... ⁾, panic⁽¹⁹19 Bashar FR, Vahedian-Azimi A, Hajiesmaeili M, Salesi M, Farzanegan B, Shojaei S, et al. Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium. J Crit Care. 2018; 43:88-94. doi: 10.1016/j.jcrc.2017.08.034 https://doi.org/10.1016/j.jcrc.2017.08.0... ⁾, cardiorespiratory arrest⁽²⁶26 Öztürk Birge A, Bedük T. The relationship of delirium and risk factors for cardiology intensive care unit patients with the nursing workload. J Clin Nurs. 2018 [cited 2019 Feb 16];27(9-10):2109-19. doi: 10.1111/jocn.14365 https://doi.org/10.1111/jocn.14365... ⁾, polyneuromyopathy⁽³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ⁾, polyuria⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, drug preparation and administration⁽⁴³43 Melo EM, Cavalcante HPO, Marques AM, Ferreira AMM, Abreu MAF, Lima VF, et al. Conhecimento do enfermeiro sobre as drogas vasoativas utilizadas em pacientes críticos. Rev Enferm UFPE [Internet]. 2016;10(8):2948-55. doi: 10.5205/reuol.9373-82134-1-RV1008201621 https://doi.org/10.5205/reuol.9373-82134... ⁾, altered cerebral perfusion pressure⁽³²32 Nyholm L, Steffansson E, Fröjd C, Enblad P. Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study. J Neurosci Nurs. 2014; 46(5):285-91. doi: 10.1097/JNN.0000000000000077 https://doi.org/10.1097/JNN.000000000000... ⁾, altered intracranial pressure⁽³²32 Nyholm L, Steffansson E, Fröjd C, Enblad P. Secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study. J Neurosci Nurs. 2014; 46(5):285-91. doi: 10.1097/JNN.0000000000000077 https://doi.org/10.1097/JNN.000000000000... ⁾, altered horny reflex⁽³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ⁾, altered cough reflex⁽³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ⁾, altered sensitivity⁽⁴²42 Santos WC, Vancini-Campanharo CR, Lopes MCBT, Okuno MFP, Batista REA. Assessment of nurse’s knowledge about Glasgow coma scale at a university hospital. Einstein São Paulo. [Internet]; 2016 [cited 2019 Mar 02] 14(2):213-8. Available from: http://www.scielo.br/pdf/eins/v14n2/1679-4508-eins-14-2-0213.pdf http://www.scielo.br/pdf/eins/v14n2/1679... ⁾, sweating⁽³⁰30 Candiota CSS, Queluci GC, Cavalcanti ACD, Pereira JMV. Problem-situations and its complexity degrees - lower, medium and higher - in customers with acute coronary syndrome. Rev Enferm UFPE. [Internet]; 2016 [cited 2019 Feb 16] 10(1):112-8. Available from: https://pdfs.semanticscholar.org/d0e8/ea7c4ee243912eda96a9513c38c1b386da6f.pdf https://pdfs.semanticscholar.org/d0e8/ea... ⁾, inotropic support⁽¹⁶16 McCaughey C, Blackwood B, Glackin M, Brady M, McMullin MF. Characteristics and outcomes of haematology patients admitted to the intensive care unit: characteristics and outcomes of haematology patients. Nurs Crit Care. 2013; 18(4):193-9. doi: 10.1111/nicc.12005 https://doi.org/10.1111/nicc.12005... ⁾, altered temperature⁽²¹21 Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M. Effects of hypercapnia and hypercapnic acidosis on hospital mortality in mechanically ventilated patients. Crit Care Med. 2017;45(7):e649-56. doi: 10.1097/CCM.0000000000002332 https://doi.org/10.1097/CCM.000000000000... ⁾, altered muscle tone⁽³³33 Randen I, Lerdal A, Bjørk IT. Nurses’ perceptions of unpleasant symptoms and signs in ventilated and sedated patients: nurses’ perceptions of unpleasant symptoms and signs. Nurs Crit Care. 2013; 18(4):176-86. doi: 10.1111/nicc.12012 https://doi.org/10.1111/nicc.12012... ⁾, numbness⁽³⁸38 Garrido F, Tieppo L, Pereira MDDS, Freitas RD, Freitas WM, Filipini R, et al. Ações do enfermeiro na identificação precoce de alterações sistêmicas causadas pela sepse grave. ABCS Health Sci. 2017; 42(1):15-20. doi: 10.7322/abcshs.v42i1.944 https://doi.org/10.7322/abcshs.v42i1.944... ⁾, glycemic variability⁽⁴⁷47 Silveira LM, Basile-Filho A, Nicolini EA, Dessotte CAM, Aguiar GCS, Stabile AM. Glycaemic variability in patients with severe sepsis or septic shock admitted to an Intensive Care Unit. Intensive Crit Care Nurs. 2017; 41:98-103. doi: 10.1016/j.iccn.2017.01.004 https://doi.org/10.1016/j.iccn.2017.01.0... ⁾.	1

Domain 1 - Physiological: Basic
Class B: Elimination Management
Clinical Indicators	Nursing Interventions	Activities
Diarrhea	Bowel Incontinence Care - 0410	- Determine physical or psychological cause of fecal incontinence. - Determine onset and type of incontinence, frequency of episodes, and any related change in bowel function or stool consistency. - Eliminate the cause of incontinence if possible. - Wash perianal area with soap and water and dry it thoroughly after each stool. - Protect the skin from excess moisture of urine, stool or perspiration with a moisture barrier cream, as needed. - Monitor perianal skin for the development of pressure ulcers and for infection. - Monitor for adequate bowel evacuation. - Avoid foods that cause diarrhea. - Administer prescribed medication for diarrhea.
	Diarrhea Management - 0460	- Determine history of diarrhea. - Identify factors that may cause or contribute to diarrhea. - Monitor for signs and symptoms of diarrhea. - Monitor skin in perianal area for irritation and ulceration. - Measure diarrhea/bowel output.
	Bowel Management - 0430	- Note date of last bowel movement. - Monitor bowel movements including frequency, consistency, shape, volume, and color, as appropriate. - Monitor bowel sounds. - Monitor for signs and symptoms of diarrhea, constipation, and impaction. - Insert rectal suppository, as needed.
Class D: Nutrition Support
Clinical Indicators	Nursing Interventions	Activities
Naso/oroenteral tube diet	Enteral Tube Feeding - 1056	- Insert nasogastric, nasoduodenal, or nasojejunal tube, according to agency protocol. - Apply anchoring substance to the skin and secure feeding tube with tape. - Monitor for proper placement of the tube by inspecting oral cavity, checking for gastric residual, or listening while air is injected and withdrawn, according to agency protocol. - Elevate head of the bed 30 to 45 degrees during feedings. - Discontinue feeding 30 to 60 minutes before putting in a head down position. - Turn off the tube feeding one hour prior to a procedure or transport if the patient needs to be less than 30 degrees. - Irrigate the tube every 4 to 6 hours as appropriate during continuous feedings and after every intermittent feeding. - Use clean technique in administering tube feeding. - Check gravity drip rate or pump rate every hour. - Slow tube feeding rate and/or decrease strength to control diarrhea.
Class D: Nutrition Support
Clinical Indicators	Nursing Interventions	Activities
Naso/oroenteral tube diet	Enteral Tube Feeding - 1056	- Monitor for sensation of fullness, nausea, and vomiting. - Check residual every 4 to 6 hours for the first 24 hours, then every 8 hours during continuous feedings. - Check residual before each intermittent feeding. - Hold tube feedings if residual is greater than 150 cc or more than 110% to 120% of the hourly rate in adults. - Keep cuff of endotracheal or tracheostomy tube inflated during feeding, as appropriate.
Class E: Physical Comfort Promotion
Clinical indicators	Nursing Interventions	Activities
Pain	Pain Management - 1400	- Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors. - Observe the nonverbal cues of discomfort, especially in those unable to communicate effectively. - Assure patient attentive analgesic care. - Use therapeutic communication strategies to acknowledge the pain experience and convey acceptance of the patient's response to pain. - Provide information about the pain, such as causes of the pain, how long it will last, and anticipated discomforts from procedures. - Control environmental factors that may influence the patient's response to discomfort. - Select and implement a variety of measures (e.g., pharmacological, nonpharmacological, interpersonal) to facilitate pain relief, as appropriate. - Provide the person optimal pain with prescribed analgesics. - Assure pretreatment analgesia and/or nonpharmacologic strategies prior to painful procedures
Domain 2 - Physiological: Complex
Class H: Drug Management
Clinical indicators	Nursing Interventions	Activities
Pain	Analgesic Administration - 2210	- Determine pain location, characteristics, quality, and severity before medicating patient. - Check medical order for drug, dose and frequency of analgesic prescribed. - Choose the appropriate analgesic or combination of analgesic when more than one is prescribed. - Determine analgesic selection, based on the type and severity of pain. - Determine the preferred analgesic, route of administration, and dosage to achieve optimal analgesia. - Choose the IV route, rather than IM, for frequent pain medication injections, when possible. - Monitor vital signs before and after administering narcotic analgesic with first-time dose or if unusual signs are noted. - Attend to comfort needs and other activities that assist relaxation to facilitate response to analgesia. - Administer analgesics around the clock to prevent peaks and troughs of analgesia, especially with severe pain. - Administer adjuvant analgesics and/or medications when needed to potentiate analgesia. - Consider use of continuous infusion, either alone or in conjunction with bolus opioids, to maintain serum levels. - Institute safety precautions for those receiving narcotic analgesic, as appropriate. - Instruct to request PRN pain medication before the pain is severe. - Evaluate the effectiveness of analgesics at regular frequent intervals after each administration, but, especially after the initial doses, also observing for any signs and symptoms of untoward effects. - Document response to analgesic and any untoward effects. - Evaluate and document level of sedation for patients receiving opioids. - Implement actions to decrease untoward effects of analgesics.
Sedation	Sedation Management - 2260	- Check for drug allergies. - Instruct the patient and/or family about effects of sedation. - Evaluate the patient's level of consciousness and protective reflexes before administering sedation. - Administer medication as per physician's order or protocol, titrating carefully, according to patient's response. - Monitor the patient's levels of consciousness and vital signs, oxygen saturation, and EKG, as per agency protocol. - Monitor the patient for adverse effects of medication, including agitation, respiratory depression, hypotension, undue somnolence, hypoxemia, arrhythmias, apnea, or exacerbation of a preexisting condition.
Class K: Respiratory Management
Clinical indicators	Nursing Interventions	Activities
Mechanical ventilatory assistance	Mechanical Ventilation Management: Invasive - 3300	- Monitor for conditions indicating a need for ventilation support. - Monitor for impending respiratory failure. - Initiate setup and application of the ventilator. - Ensure that ventilator alarms are on. - Routinely monitor ventilator settings, including temperature and humidification of inspired air. - Check all ventilation connections regularly. - Monitor for factors that increase the patient/ventilator work of breathing (e.g., morbid obesity, pregnancy, biting ET). - Monitor for symptoms that indicate increased work of breathing. - Monitor the effectiveness of mechanical ventilation on patient's physiological and psychological state. - Provide care to alleviate patient distress (e.g., positioning, sedation and/or analgesia, tracheobronchial toileting). - Provide patient with a means for communication (e.g., paper nad pencil, alphabet board).
Class K: Respiratory Management
Clinical indicators	Nursing Interventions	Activities
Mechanical ventilatory assistance	Mechanical Ventilation Management: Invasive - 3300	- Monitor ventilator pressure readings, patient/ventilator synchronicity, and patient breath sounds. - Perform suctioning based on presence of adventitious breath sounds and/or increased inspiratory pressure. - Monitor pulmonary secretions for amount, color and consistency and regularly document findings. - Monitor for adverse effects of mechanical ventilation (e.g., tracheal deviation, infection, barotrauma, gastric distention, subcutaneous emphysema). - Monitor for mucosal damage to oral, nasal, tracheal or laryngeal tissue from pressure from artificial airway, high cuff pressure, or unplanned extubations. - Use commercially tube holders rather than tape or strings to fixate artificial airways to prevent unplanned extubations. - Position to facilitate ventilation/perfusion matching, as appropriate.
Mechanical ventilatory assistance	Artificial Airway Management - 3180	- Provide an oropharyngeal airway or bite block to prevent biting on the endotracheal tube, as appropriate. - Inflate endotracheal/tracheostomy cuff using minimum occlusive volume technique or minimal leak technique. - Maintain inflation of the endotracheal/tracheostomy cuff at 15 to 25 mm Hg during mechanical ventilation and during and after feeding. - Monitor cuff pressure every 4 to 8 hours during expiration using a three-way stopcock, calibrated syringe, and manometer. - Check cuff pressure immediately after delivery of any general anesthesia or manipulation of endotracheal tube. - Change the endotracheal tapes/ties every 24 hours, inspect the skin and oral mucosa, and reposition the endotracheal tube to the other side of the mouth. - Loosen commercial endotracheal tube holders at least once a day, and provide skin care. - Auscultate for presence of lung sounds bilaterally after insertion and after changing endotracheal/tracheostomy ties. - Note the centimeter reference marking on endotracheal tube to monitor for possible displacement. - Assist with chest x-ray examination, as needed, to monitor the position of tube. - Minimize leverage and traction on the artificial airway by suspending ventilator tubing from overhead supports, using flexible catheter mounts and swivels, and supporting tubes during turning, suctioning, and ventilator disconnection and reconnection. - Monitor for presence of crackles and rhonchi over large airways. - Monitor secretions color, amount and consistency. - Perform oral care, as needed. - Monitor for decrease in exhale volume and increase in inspiratory pressure in patients receiving mechanical ventilation. - Institute measures to prevent spontaneous decannulation (i.e., secure artificial airway with tapes or ties, administer sedation and muscle paralyzing agent, use arm restraints), as appropriate. - Provide trachea care every 4 or 8 hours as appropriate: Clean inner cannula, clean and dry the area around the stoma, and change the tracheostomy tie. - Inspect skin around the tracheal stoma for drainage, redness, irritation, and bleeding. - Shield the tracheostomy from water.
Class N: Tissue Perfusion Management
Clinical indicators	Nursing Interventions	Activities
Altered heart rate	Hemodynamic Regulation - 4150	- Perform a comprehensive appraisal of hemodynamic status (i.e., check blood pressure, heart rate, pulse, jugular venous pressure, central venous pressure, right and left atrial and ventricular pressures, and pulmonary artery pressure), as appropriate. - Monitor and document blood pressure, heart rate, rhythm, and pulse. - Monitor pacemaker function, if appropriate. - Administer antiarrhythmic medications, as appropriate. - Monitor the effects of medications.
Domain 3 - Behavioral
Class T: Psychological Comfort Promotion
Clinical indicators	Nursing Interventions	Activities
Anxiety	Anxiety Reduction - 5820	- Use a calm, reassuring approach. - Explain all procedures, including sensations likely to be experienced during the procedure. - Stay with patient to promote safety and reduce fear. - Encourage verbalization of feelings, perceptions, and fears. - Identify when level of anxiety change. - Help patient identify situations that precipitate anxiety. - Administer medication to reduce anxiety, as appropriate. - Assess for verbal and nonverbal signs of anxiety.
Domain 4 - Safety
Class V: Risk Management
Clinical indicators	Nursing Interventions	Activities
Psychomotor agitation, delirium	Delirium Management - 6440	- Identify etiological factors causing delirium. - Initiate therapies to reduce or eliminate factors causing delirium. - Recognize and document the motor subtype of delirium. - Monitor neurological status on an ongoing basis.
Domain 4 - Safety
Class V: Risk Management
Clinical indicators	Nursing Interventions	Activities
Psychomotor agitation, delirium	Delirium Management - 6440	- Acknowledge the patient's fears and feelings. - Allow the patient to maintain rituals that limit anxiety. - Administer PRN medications for anxiety or agitation, but limit those with anticholinergic side effects. - Reduce sedation in general, but do control pain with analgesics, as indicated. - Remove stimuli, when possible, that create excessive sensory stimuli. - Maintain a well-lit environment that reduces sharp contrasts and shadows. - Maintain a hazard-free environment. - Use physical restrictions, as needed. - Inform patient of person, place, and time, as needed. - Provide a low-stimulation environment for patient in whom disorientation is increased by overstimulation.

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E-mail: reben@abennacional.org.br

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[1] Corresponding author: Maryanni Magalhães Camargo. E-mail: maryannicamargo@hotmail.com