Dyspnea/Elevating the chest |
0.92 |
0.94 |
0.94 |
0.92 |
0.91 |
0.90 |
Impaired respiratory system function/Assessing respiratory status |
0.90 |
0.90 |
0.91 |
0.88 |
0.91 |
0.88 |
Low blood oxygen saturation/Monitoring blood oxygen saturation using pulse oximeter or arterial blood gas, if indicated |
0.89 |
0.89 |
0.90 |
0.89 |
0.90 |
0.87 |
Cough/Observing cough: frequency, onset, duration, intensity, associated signs and symptoms, precipitating factors, attenuating factors |
0.84 |
0.84 |
0.83 |
0.85 |
0.82 |
0.83 |
Unilateral peripheral edema/Obtaining data on edema: evaluating the Godet sign daily and observing associated signs and symptoms (pain, stuffing, heat, blister) |
0.88 |
0.88 |
0.88 |
0.89 |
0.89 |
0.88 |
Chronic peripheral edema/Encourage resting if there is edema or discomfort |
0.83 |
0.80 |
0.82 |
0.85 |
0.84 |
0.81 |
Impaired skin integrity/Obtaining data on skin: integrity, hydration, coloring and presence of other changes |
0.85 |
0.85 |
0.86 |
0.85 |
0.84 |
0.85 |
Risk for medication side effect/Monitor occurrence of bleeding |
0.84 |
0.84 |
0.84 |
0.82 |
0.84 |
0.85 |
Fever/Monitoring signs and symptoms of infection |
0.82 |
0.78 |
0.83 |
0.84 |
0.84 |
0.83 |
Risk for fall/Identifying patients at high risk for fall and informing the team according to institutional protocol (bracelet, identification in the medical record) |
0.88 |
0.88 |
0.88 |
0.90 |
0.87 |
0.88 |
Risk for infection/Training staff for environmental sanitation and precaution techniques, as needed |
0.85 |
0.86 |
0.86 |
0.85 |
0.83 |
0.83 |
Impaired peripheral tissue perfusion/Obtaining data on peripheral tissue perfusion (peripheral capillary perfusion, peripheral pulse, edema, cyanosis) |
0.86 |
0.88 |
0.88 |
0.85 |
0.85 |
0.86 |
Impaired vascular process/Monitoring tissue perfusion: assessing daily changes in tissue perfusion or skin; assessing ecodoppler examination result |
0.87 |
0.86 |
0.87 |
0.86 |
0.88 |
0.88 |
Tachycardia/Monitoring vital signs |
0.86 |
0.85 |
0.87 |
0.90 |
0.85 |
0.85 |
Impaired cardiovascular system/Monitoring cardiac condition during acute phase of venous thromboembolism by checking frequency, rhythm and alterations in the electrocardiographic tracing |
0.90 |
0.90 |
0.90 |
0.92 |
0.90 |
0.89 |
Altered blood pressure/Implement cardiorespiratory physical examination by considering signs of low output and respiratory pattern |
0.87 |
0.86 |
0.86 |
0.88 |
0.87 |
0.88 |
Risk for impaired cardiac function/Assessing signs of low cardiac output: oliguria, filiform pulse, cold extremities, and hypotension |
0.84 |
0.84 |
0.84 |
0.86 |
0.85 |
0.80 |
Nasal bleeding/Evaluating bleeding |
0.86 |
0.86 |
0.85 |
0.87 |
0.84 |
0.87 |
Risk for hemorrhaging/Evaluating signs and symptoms of bleeding in integumentary, intestinal, urinary and respiratory systems |
0.87 |
0.88 |
0.88 |
0.87 |
0.88 |
0.88 |
Risk for deep vein thrombosis/Teaching about anticoagulant therapy: objective, importance of adherence, duration, side effects, follow-up consultations and situations to seek health care |
0.91 |
0.91 |
0.90 |
0.92 |
0.90 |
0.90 |
Acute pain/Obtaining pain data (characteristics of pain, including location, onset, duration, frequency, quality, intensity, precipitating factors, mitigating factors, and use of pain medication) |
0.85 |
0.84 |
0.87 |
0.85 |
0.83 |
0.86 |
Chronic pain/Providing guidance for patient and family on pain management (time of pharmacological analgesia, concomitant drugs, use of non-pharmacological techniques for pain relief) |
0.85 |
0.81 |
0.85 |
0.87 |
0.86 |
0.87 |
Musculoskeletal pain/Guiding to rest and lift limbs for discomfort relief |
0.85 |
0.85 |
0.84 |
0.86 |
0.84 |
0.85 |
Impaired ability to manage medication regime/Obtaining data on ability to perform care: ability of reading, understanding orientations, motor ability |
0.91 |
0.90 |
0.91 |
0.90 |
0.92 |
0.91 |
Fear/Offering emotional support: performing active listening, user embracement, touching |
0.86 |
0.85 |
0.85 |
0.88 |
0.87 |
0.83 |
Anxiety/Obtaining data on anxiety (onset, associated symptoms, precipitating factors) |
0.87 |
0.88 |
0.87 |
0.88 |
0.86 |
0.87 |
Lack of knowledge of treatment regime/Obtaining knowledge data about treatment regime: time of treatment, dose, schedule of administration, side effects, warning signs and outpatient follow-up |
0.87 |
0.88 |
0.89 |
0.88 |
0.86 |
0.85 |
Impaired adaptation/Protect patients’ autonomy |
0.85 |
0.83 |
0.84 |
0.88 |
0.85 |
0.84 |
Negative quality of life/Promoting social support: identifying social support network, calling family and/or caregiver to participate in care; identifying basic health unit of reference, referring to social services |
0.85 |
0.87 |
0.87 |
0.85 |
0.83 |
0.84 |
Non adherence to therapeutic regime/Obtaining data on adherence barriers: difficulty with understanding, functional illiteracy, lack of social/family support |
0.89 |
0.89 |
0.89 |
0.90 |
0.90 |
0.90 |
Lack of family support/Calling the family and guiding on the importance of participation for therapeutic success |
0.80 |
0.80 |
0.80 |
0.80 |
0.82 |
0.80 |
Impaired ability of caregiver to perform caretaking/Facilitating family’s ability to participate in the care plan: including them in guidelines on disease and therapeutic regime; invite other family members to participate in orientations; teaching the form of medication administration |
0.85 |
0.84 |
0.86 |
0.85 |
0.86 |
0.85 |