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Examine lung conditions;
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Auscultate respiratory sounds, observing areas of reduced or absent ventilation and the presence of adventitious sounds;
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Record chest movements, noting symmetry, use of accessory muscles, and supraclavicular and intercostal muscle retractions.
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| Nutrition |
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Decreased Appetite/Positive Appetite;
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Impaired Ability To Manage Dietary Regime/Improved Ability To Manage Dietary Regime;
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Compulsive Eating Behaviour/Impaired Eating Behaviour;
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Lack Of Knowledge of Dietary Regime/Improved Knowledge of Dietary Regime;
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Risk For Impaired Nutritional Status/Positive Nutritional Status;
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Impaired Weight/Weight Within Normal Limits.
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Assess anthropometric data;
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Investigate complaints about food;
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Question about swallowing;
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Observe if patient uses dental prosthesis;
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Advise on the need for a daily oral care routine;
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Guide the person to brush their teeth, gums and tongue;
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Recommend a healthy diet; Investigate a person’s food preferences;
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Monitor the mucous membranes, skin turgor;
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Assess insufficient water intake;
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Monitor evolution of patient data: weight in all consultations.
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| Elimination |
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Low Fluid Output/Improved Fluid Output;
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Fluid Imbalance/Fluid Balance Within Normal Limits;
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Fluid Retention/ Effective Fluid Volume;
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Nausea/No Nausea;
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Effective Constipation/Gastrointestinal System Function;
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Risk For Constipation/Effective Gastrointestinal System Function;
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Frequent Pain During Urination/No Pain During Urination;
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Decreased Urinary Frequency/Normal Urinary Frequency;
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Decreased Urinary Elimination/Improved Urinary Elimination; Proteinuria/Effective Urinary System Function.
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Investigate bowel control;
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Instruct the person to avoid retaining urine, urinating whenever they feel like it;
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Encourage the person to always maintain proper personal hygiene;
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Identify the risks for developing constipation;
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Investigate insufficient water intake;
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Ask about pain when urinating;
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Assess signs of hypovolemia, such as bleeding, diarrhea, vomiting and other losses;
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Check for signs of low cardiac output;
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Investigate low food intake;
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Look for signs of dehydration and poor tissue perfusion;
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Assess the 24-hour urinalysis;
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Assess laboratory tests;
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Monitor laboratory tests, paying attention to electrolyte disturbances.
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| Activity and Rest |
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Impaired Ability to Manage Exercise Regime/Ability to Manage Exercise Regime improved;
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Hypoactivity/Effective Pathological Process Related Activity Tolerance;
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Fatigue/Reduced Fatigue;
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Leg Cramps/Improved Leg Cramps;
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Risk For Fall/ Risk For Fall Control;
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Impaired Sleep/Adequate Sleep;
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Improved Discomfort/Comfort.
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Monitor the person’s satisfaction with pain control at specified intervals.
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Identify factors that trigger fatigue;
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Guidance on the practice of physical activity;
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Supervise polypharmacy and drug under prescription;
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Strengthen a healthy diet;
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Encourage lifestyle changes;
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Periodically review and adjust the prescription of medications that increase the risk for falling;
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Check the use of diuretics, laxatives;
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Assess sleep pattern;
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Investigate customs of sleep schedules;
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Assess medical prescriptions about medications that can alter sleep and cause drowsiness;
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Ask about sleep interruptions.
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| Protection |
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Impaired Skin Protection Capacity/Effective Skin Protection Capacity;
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Impaired Skin Integrity/Improved Skin Integrity;
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Dry Skin/Improved Dry Skin;
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Risk For Impaired Skin Integrity Risk/Skin Integrity Control;
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Rash/Improved Rash;
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Impaired Medication Schedule/Improved Medication Schedule;
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Impaired Dentition/Improved Dentition;
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Hyperthermia/Positive Thermoregulation;
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Contamination Exposure/Decreased Contamination Exposure;
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Risk For Urinary Tract Infection/Risk For Urinary Tract Infection Control;
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Susceptibility To Infection/Infection Control;
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Chronic Inflammation/Improved Chronic Inflammation.
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Record allergies in the medical record;
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Assess medical prescription in order to assess drug interactions;
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Maintain skin hydration;
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Identify signs such as cold skin, edema and lung congestion;
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Observe peripheral pulse;
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Monitor dryness and excessive moisture of the skin;
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Monitor skin color;
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Monitor skin temperature;
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Advise not to use drugs without a prescription.
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| Senses |
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Acute Pain/Reduced Pain;
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Chronic Pain/Reduced Pain;
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Musculoskeletal Pain/Improved Musculoskeletal Pain;
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Impaired Sensory Perception: Hearing/Improved Sensory Perception;
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Impaired Sensory Perception: Sight/Improved Sensory Perception;
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Impaired Tactile Perception/Effective Tactile Perception.
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Encourage rest in an environment with low light and silence;
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Conduct a comprehensive pain survey to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors;
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Assure the person the precise care of analgesia;
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Assess with the person and the health care team the effectiveness of pain control measures that have been used;
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Encourage self-monitoring of pain and intervene appropriately;
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Assess the need for neurological assessment;
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Promote the use of prescribed medication;
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Control underlying diseases;
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Discuss measures to prevent accidents at home;
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Forward to the otorhinolaryngology service;
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Forward to the ophthalmology service;
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Investigate causes for loss of sensitivity.
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| Fluids and Electrolytes |
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Risk For Altered Blood Pressure Risk/Blood Pressure Control;
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Risk For Arrhythmia /No Arrhythmia;
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Impaired Fluid Volume/Effective Fluid Volume; Hypervolemia/Fluid Balance Within Normal Limits;
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Peripheral Oedema/No Peripheral Oedema;
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Presence Of Hyperphosphatemia/Improved Electrolyte Balance;
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Presence Of Hypernatremia/Improved Electrolyte Balance;
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Presence Of Hyperkalaemia/Improved Electrolyte Balance;
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Presence Of Hypocalcemia/Improved Electrolyte Balance;
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Presence Of Hypophosphatemia/Improved Electrolyte Balance;
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Risk For Electrolyte Imbalance/Improved Electrolyte Balance;
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Metabolic Acidosis/Improved Acid Base Balance;
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Impaired Kidney Function/Effective Kidney Function;
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Impaired Heart Function/Effective Heart Function;
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Altered Blood Pressure/Blood Pressure Within Normal Limits;
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Impaired Cardiac Output/Effective Cardiac Output;
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Risk For Impaired Cardiac Function/Effective Cardiac Function;
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Risk For Fluid Volume Imbalance/Fluid Volume Control;
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Advise on the use of diuretics and anti-inflammatory drugs;
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Encourage dietary change with fruits and vegetables;
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Note hyperkalemia;
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Monitor serum creatinine at each appointment;
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Control volume of net gains; Assess kidney function;
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Assess sodium intake;
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Investigate water loss in large quantities;
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Assess dosage of serum calcium and ionized calcium, phosphorus, PTH, calcitriol;
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Assess calcium replacement with the medical team;
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Inform the person of normal blood pressure values;
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Monitor serum electrolyte levels;
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Identify possible causes of electrolyte imbalances;
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Monitor nausea, vomiting and diarrhea;
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Identify treatments capable of altering the electrolyte status;
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Look for symptoms of uremia;
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Assess the control of drug treatment;
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Assess need for hydration;
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Forward to the nutrition service for adequacy of dietary regime.
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| Neurological Function |
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Impaired Memory/Effective Memory;
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Impaired Learning/Improved Learning;
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Impaired Communication/Effective Communication;
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Dizziness/No Dizziness.
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Assess mental state, level of development and cognitive ability;
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Assess the psychological state;
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Assess communication about conservative treatment care;
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Check the person’s cognitive learning regarding their health; Assess barriers in communication in the person’s daily life;
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Listen carefully to the person and family and respond in a simple and understandable way;
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Ensure that the person understands the guidance provided about their health status;
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Allow the person to show their expectations about their health condition;
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Institute measures that provide for the memorization of the person’s treatment; Identify signs and symptoms before vertigo.
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| Endocrine Function |
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Impaired Blood Glucose Self-Monitoring/Improved Blood Glucose Self-Monitoring;
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Hyperglycaemia/Blood Glucose Level Within Normal Limits; Hypoglycaemia/Blood Glucose Level
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Within Normal Limits;
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Risk for Altered Blood Glucose/Blood Glucose Level Within Normal Limits;
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Hypovitaminosis/Improved Hypovitaminosis.
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Encourage hand hygiene;
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Educate about sharps and their disposal;
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Guidance on device calibration and general care;
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Guidance on hypertension and diabetes treatment;
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Assess blood glucose tests;
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Research on the feeding regime;
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Monitor evolution of patient data: weight in all consultations;
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Provide guidance on weight reduction measures;
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Calculate BMI in consultations;
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Assess insufficient control of diabetes;
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Assess signs of hyperglycaemia and hypoglycaemia.
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| SELF CONCEPT MODE |
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Negative Self Image/Positive Self Image;
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Stigma/Reduced Stigma;
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Impaired Sexual Performance/Improved Sexual Performance; Anxiety/Reduced Anxiety; Self Esteem/Positive
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Self Esteem;
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Conflicting Spiritual Belief/Improved Spiritual Belief;
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Impaired Adaptation/Improved Adaptation;
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Aggressive Behaviour/No Aggressive Behaviour; Improved Hopelessness/Hope;
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Difficulty Coping With Illness/Reduced Difficulty Coping With Illness;
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Depressed Mood/Decreased Depressed Mood;
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Lack Of Resilience/Improved Resilience;
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Suffering/Reduced Suffering;
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Sadness/Reduced Sadness;
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Crying/No Crying;
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Spiritual Distress/Decreased Spiritual Distress;
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Fear About Death/Decreased Fear About Death;
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Fear About Abandonment/Decreased Fear About Abandonment;
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Fear About Being A Burden To Others/Decreased Fear About Being A Burden To Others.
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Identify suffering;
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Assess expression of guilt;
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Establish integration with significant people;
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Assess expression of anger or despair;
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Assess the person’s expectations;
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Listen to complaints that make anxiety possible;
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Encourage self-confidence;
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Help the person adapt to their disabilities;
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Listen carefully to the person’s expectations;
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Define activities for self-care;
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Recognize situations in which the person can self-manage their treatment;
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Assess family relationships;
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Assess level of education;
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Reinforce presence in consultations;
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Maintain respect and let the person rant about their motives;
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Assess help from other professionals to better manage the situation;
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Promote good interaction;
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Create a safe environment for the person;
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Awaken feelings of hope;
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Know the values of religion for the person;
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Question the reasons for their unmotivated belief;
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Promote measures for the integration of religion and health care;
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Identify reasons that lead to the difficulty of follow-up;
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Assess treatment dissatisfaction;
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Promote multidisciplinary measures that contribute to improving body image;
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Assess possible measures to improve body image in the community;
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Promote biopsychosocial work with the person and family;
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Involve the sexual partner in the treatment;
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Provide information about treatment that is appropriate for each patient, considering the cultural level of each one and how much the person wants to be informed;
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Value personal hygiene for a better quality of life;
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Promote adaptation to new lifestyles;
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Assess the person’s and family’s beliefs, attitudes and values;
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Assess measures that support the person’s confidence;
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Identify the spiritual aspects that affect suffering;
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Offer emotional support;
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| ROLE FUNCTION MODE |
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Stress/Decreased Stress; Risk For Dissatisfaction With Healthcare/Satisfaction With Healthcare;
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Tobacco Abuse/No Tobacco Abuse;
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Ineffective Health Self Control/Improved Self Control;
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Self Care Deficit/Able To Perform Self Care;
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Impaired Ability To Manage Medication Regime/Positive Ability To Manage Medication Regime;
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Impaired Ability To Dress And Groom Self/Improved Ability To Dress And Groom Self;
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Impaired Ability To Prepare Food/Improved Ability To Prepare Food;
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Impaired Acceptance Of Health Status/Effective Acceptance Of Health Status;
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Denial About Illness Severity/No Denial;
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Unrealistic Expectation About Treatment/Improved Expectation About Treatment;
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Low Follow-Up Appointment Attendance/Improved Follow-Up Appointment Attendance;
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Continuity Of Care Problem/Effective Continuity Of Care;
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Impaired Role Performance/Effective Role Performance;
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Impaired Safety Role/Improved Safety Role;
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Impaired Work Role/Improved Work Role;
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Impaired Family Role/Improved Family Role.
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-
Assess the person’s alcohol/smoking abuse and its impact on health;
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Encourage demand for outpatient medical service;
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Reinforce health behaviour;
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Value resilience;
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Meaning spirituality;
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Assess self-perception about health status;
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Recognize the person’s social support;
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Promote measures for self-care;
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Encourage leisure activities;
-
Remove common sense beliefs about the disease;
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Help identify the role in the family;
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Reinforce capacities to perform the role;
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Value religious belief;
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Assess social support received in religious environments;
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Assess expectations about treatment; Provide information about health condition;
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Guide on preventive measures of the disease;
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Obtain information per person and family about acceptance of diet;
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Provide telephone contact for queries;
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Obtain data on used drugs;
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Recognize doubts about drug treatment;
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Recognize intellectual level for understanding the drugs;
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Seek information for denial of disease;
-
Enable communication of feelings;
-
Obtain data on friendship relationships;
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Obtain hobby data;
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Forward to the nutrition service;
-
Forward to the psychology service;
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| INTERDEPENDENCE FUNCTION MODE |
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Impaired Ability To Perform Leisure Activity/Improved Ability To Perform Leisure Activity;
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Impaired Access To Treatment/Improved Access To Treatment;
-
Lack Of Access To Transportation/Improved Access To Transportation;
-
Risk For Impaired Family Coping/Effective Family Coping;
-
Impaired Family Decision Making Process/Improved Family Decision Making Process;
-
Impaired Family Process/Effective Family Process;
-
Impaired Communication Between Health Care Provider And Individual/Improved Communication Between Health Care Provider And Individual;
-
Lack Of Trust In Health Care Provider/Trust In Health Care Provider;
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Impaired Social Condition/Improved Social Condition;
-
Lack Of Social Support/Effective Social Support;
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Social Isolation/Decreased Social Isolation;
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Impaired Marital Satisfaction/Improved Marital Satisfaction.
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-
Arrange transport service;
-
Assess accessible public transport;
-
Recognize the person’s transport access area;
-
Assess the family network to accompany the person to the outpatient clinic;
-
Obtain data on the risk for violence;
-
Assess psychological care;
-
Reflect together with the person the reasons for low confidence;
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Present welcoming strategies;
-
Present all spaces of the service;
-
Assess the person’s and family’s employment relationships;
-
Adapt care plan to socioeconomic condition; Recognize work strategies;
-
Assess communication failures;
-
Assess expectations;
-
Determine how the person wants to communicate;
-
Understand empathy without value judgment;
-
Assess behaviour that generates communication failure;
-
Refer the caregiver to the psychology service;
-
Identify the level of intellectual knowledge on the part of the person and the caregiver;
-
Assess the health situation of another weakened family member, which also requires care;
-
Determine psychological and/or psychiatric problems;
-
Recognize caregiver burden;
-
Assess family, social and economic support;
-
Reunite person and family;
-
Promote family communication;
-
Provide mechanisms for family members to keep in touch with each other;
-
Encourage the expression of feelings and expectations;
-
Promote family involvement;
-
Optimize binding pattern of family members;
-
Assess family coping;
-
Assess role interaction; Assess functional dynamic relationship;
-
Advise relaxation measures;
-
Assess care strategies for the person that generate stress;
-
Assess the level of satisfaction that harms the treatment;
-
Forward to Psychology service;
-
Forward to Social Service;
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