Physical security/Environment:
Risk of infection, Risk of adverse drug reactions |
|
|
| Dressing the central venous catheter |
103 |
(68.7) |
| Replacing valves - oxygen extender |
100 |
(66.7) |
| Implement care in accordance with the patient fall care protocol |
96 |
(64.0) |
| Apply arterial catheter dressing |
95 |
(63.7) |
| Change aspirator bottle and extender |
94 |
(62.7) |
| Disinfect connections with a 70% alcohol sachet after each handling |
94 |
(62.7) |
| Implement precautionary measures for aerosols |
93 |
(62.0) |
| Implement precautionary measures for droplets |
91 |
(60.7) |
| Change blood pressure transducer |
91 |
(60.7) |
| Change equipment, extenders and cannulas as per routine |
89 |
(59.3) |
| Change closed suction system |
88 |
(58.3) |
| Change the ventilatory system’s bacterial filter |
87 |
(58.0) |
| Apply standard disinfectant to equipment and surfaces |
85 |
(56.7) |
| Apply 2% aqueous chlorhexidine to the body, followed by changing the set of cardiac electrodes |
81 |
(54.0) |
| Dressing the peripheral venous catheter |
80 |
(53.3) |
| Implement care in the collection of laboratory tests |
70 |
(46.7) |
| Change diet infusion pump set |
70 |
(46.7) |
| Implement contact precaution measures |
44 |
(29.3) |
| Restrict visits |
39 |
(26.0) |
| Implement care with the mechanical containment of the adult patient |
34 |
(22.7) |
| Dressing the central catheter for hemodialysis |
26 |
(17.2) |
Oxygenation:
Impaired spontaneous ventilation, Ineffective breathing pattern, Impaired gas exchange |
|
|
| Keep headboard elevated |
111 |
(74.4) |
| Measure cuff pressure |
93 |
(62.0) |
| Check oximetry |
91 |
(60.7) |
| Implement oxygen therapy care - mechanical ventilation |
81 |
(54.0) |
| Implement care with tracheal and oropharyngeal aspiration |
77 |
(51.3) |
| Aspirate secretions |
72 |
(48.0) |
| Communicate ventilatory pattern changes |
67 |
(44.7) |
| Implement oxygen therapy care - nasal catheter |
63 |
(42.0) |
| Upkeep face mask with reservoir |
60 |
(40.0) |
| Upkeep eye protection |
60 |
(40.0) |
| Implement care with nasopharynx and oropharynx aspiration |
55 |
(36.7) |
| Alternate eye occlusion |
28 |
(18.7) |
| Implement oxygen therapy care - non-invasive mechanical ventilation |
21 |
(14.0) |
| Body care: |
|
|
| Self-care deficit syndrome, Self-care deficit: bathing and/or hygiene |
|
|
| Perform bed bath |
120 |
(80.0) |
| Perform oral hygiene by applying standard mouthwash |
119 |
(79.3) |
| Perform oral hygiene applying 0.12% aqueous chlorhexidine |
112 |
(74.7) |
| Perform urinary meatus hygiene |
107 |
(71.3) |
| Check external measurement of gastric/enteral tube |
101 |
(67.3) |
| Change disposable diapers |
83 |
(55.3) |
| Maintain nasoenteric tube care |
83 |
(55.3) |
| Apply medium-chain triglyceride |
81 |
(54.0) |
| Perform facial trichotomy |
81 |
(54.0) |
| Change probe fixture |
79 |
(52.7) |
| Perform eye hygiene |
75 |
(50.0) |
| Sanitize scalp; perform perineal hygiene |
72 |
(48.0) |
| Wash enteric/gastric tube with 20 ml of water |
59 |
(39.3) |
| Warm the patient with a thermal blanket or blankets |
30 |
(20.0) |
| Vascular: |
|
|
| Risk of bleeding, Ineffective tissue perfusion: cardiopulmonary, Decreased cardiac output, Risk of shock, Risk of vascular dysfunction |
|
|
| Check vital signs |
114 |
(76.0) |
| Administer saline flush in the arterial vascular access |
85 |
(56.7) |
| Evaluate extremity perfusion |
56 |
(37.3) |
| Salinate peripheral venous catheter |
54 |
(36.0) |
| Implement venipuncture care |
52 |
(34.7) |
| Communicate change in level of consciousness |
47 |
(31.3) |
| Warm lower limbs with laminated cotton |
28 |
(18.7) |
| Monitor for signs of bleeding |
25 |
(16.7) |
| Implement full anticoagulation care |
13 |
(8.7) |
| Skin and mucosal integrity: |
|
|
| Risk of pressure injury, Impaired skin integrity, Impaired tissue integrity, Risk of impaired skin integrity, Impaired physical mobility |
|
|
| Implement care protocol for the prevention and treatment of PI |
97 |
(64.3) |
| Perform position change |
92 |
(61.3) |
| Protect the skin on bony prominences |
79 |
(52.3) |
| Upkeep airflow mattress |
76 |
(50.7) |
| Moisturize the skin |
56 |
(37.3) |
| Use a malleolus heel protective boot |
41 |
(27.3) |
| Elevate limb(s) - change swimmer position - when prone |
10 |
(6.6) |
| Hydration: |
|
|
| Change in tissue perfusion: renal, Excessive fluid volume, Risk of electrolyte imbalance |
|
|
| Check the patient's weight |
112 |
(74.7) |
| Perform a complete water balance |
94 |
(62.7) |
| Perform a partial water balance |
80 |
(53.3) |
| Implement care in preparing for hemodialysis installation |
25 |
(16.7) |
| Implement care in the installation of hemodialysis in the double-lumen catheter |
22 |
(14.7) |
| Implement care at the end of the hemodialysis session |
19 |
(12.7) |
| Excretion: |
|
|
| Impaired urinary excretion, Diarrhea |
|
|
| Measure diuresis |
112 |
(74.7) |
| Implement care with indwelling urinary catheter |
98 |
(65.3) |
| Record aspects and frequency of excretions |
61 |
(40.7) |
