Acute pain (n=142) |
To record pain as the 5th vital sign |
83 |
58.5 |
To request assessment |
26 |
18.3 |
To calm down the patient |
20 |
14.1 |
To take vital signs |
10 |
7 |
To request the presence of a family member |
2 |
1.4 |
To assess pain using the intensity scale |
1 |
0.7 |
|
Impaired tissue integrity (n=133) |
To rotate the site of subcutaneous injections |
65 |
48.9 |
To perform dressings |
22 |
16.5 |
To sit patients on the chair |
13 |
9.8 |
To protect the skin of bony prominences |
7 |
5.3 |
To rotate the site of capillary glucose monitoring |
7 |
5.3 |
To monitor bleeding |
6 |
4.5 |
To observe puncture site and sites of catheter insertion |
3 |
2.3 |
To maintain specialty mattress, as appropriate |
2 |
1.5 |
To observe signs of infection |
2 |
1.5 |
To perform a compressive dressing |
2 |
1.5 |
|
Impaired tissue integrity (n=133) |
To implement care with venipuncture |
1 |
0.8 |
To observe perineal status |
1 |
0.8 |
To change patient’s position in bed |
1 |
0.8 |
To take vital signs |
1 |
0.8 |
|
Imbalanced nutrition: more than body requirements (n=87) |
To take vital signs |
75 |
86.2 |
To take patient’s weight |
9 |
10.3 |
To stimulate the patient to walk |
1 |
1.1 |
To guide the patient |
1 |
1.1 |
To provide health education and performing referrals |
1 |
1.1 |
|
Impaired physical mobility (n=83) |
To sit patients on the chair |
20 |
24.1 |
To stimulate the patient to walk |
18 |
21.7 |
To maintain specialty mattress, as appropriate |
8 |
9.6 |
To take vital signs |
7 |
8.4 |
To stimulate the patient to leave the bed |
5 |
6 |
To keep the bell within reach of patients |
5 |
6 |
To keep the head of the bed elevated |
3 |
3.6 |
To keep the bed rails |
3 |
3.6 |
To hydrate patient’s skin |
2 |
2.4 |
To provide a comfortable position to the patient |
2 |
2.4 |
To change patient’s position in bed |
2 |
2.4 |
To evaluate circulatory status |
1 |
1.2 |
To report changes in limbs |
1 |
1.2 |
To stimulate active movements |
1 |
1.2 |
To give pain medication before the procedures |
1 |
1.2 |
To guide patients and family members on changes in lifestyle |
1 |
1.2 |
To make patient’s body hygiene in the shower |
1 |
1.2 |
To record pain as the 5th vital sign |
1 |
1.2 |
To calm down the patient |
1 |
1.2 |
|
Impaired comfort (n=73) |
To measure waist circumference |
23 |
30.7 |
To provide safety and comfort |
18 |
24 |
To report abdominal distension |
17 |
22.7 |
To keep the bell within reach of patients |
10 |
13.3 |
To provide a comfortable position to the patient |
3 |
4 |
To stimulate respiratory exercises |
2 |
2.7 |
|
Bathing/hygiene self-care deficit (n=20) |
To stimulate oral hygiene |
4 |
20 |
To make patient’s bodily hygiene in the shower |
3 |
15 |
To take the patient to the shower |
2 |
10 |
To give pain medication before the procedures |
2 |
10 |
To perform oral hygiene |
2 |
10 |
To assist in showering |
1 |
5 |
To assist the patient in performing oral hygiene |
1 |
5 |
To stimulate self-care |
1 |
5 |
To keep the perineum clean and dry |
1 |
5 |
To comb patient’s hair |
1 |
5 |
To perform a bed bath |
1 |
5 |
To take vital signs |
1 |
5 |