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| Prevention of complications (PC) | Comfort and well-beingfor self-care (CB) |
|
| : evidence of hand sanitation according to the 5 moments recommended by the Portuguese Directorate General of Health (_) | CWS1: airway permeability (_) |
| : properly positioned side protection grids (_) | CWS2: properly prepared and sanitized secretion suction systems (_) |
| : readable ID bracelet (_) | CWS3: properly applied oxygen delivery systems (_) |
| : call bell within safe reach of the patient (_) | CWS4: evidence of explanation of procedures prior to execution (_) |
| : evidence of ensuring patient privacy when providing care (_) | CWS5: evidence that the patient is treated the way and by the name he or she likes to be called (_) |
| : properly sanitized patient’s unit (_) | CWS6: evidence that the nurse introduces himself/herself to the patient before beginning the care process (_) |
| : use of scales in accordance with the patient’s situation (_) | CWS7: evidence that the patient is comfortable and pain free (_) |
| : duly completed checklists (_) | CWS8: evidence of the use of appropriate clothing according to the patient’s clinical situation (_) |
| : evidence of the 9 rights of safe medication preparation and administration/galenical(_) | CWS9: patient safely positioned in bed or chair and in accordance with clinical situation (_) |
| | CWS10: motion limiting systems properly placed, cleaned, and adapted (_) |
| : infusion systems, taps, and tubes without evidence of clotted blood, and plugged and identified with date of replacement (_) | CWS11: evidence of clean and combed hair (_) |
| : catheter insertion sites without inflammatory signs (_) | CWS12: evidence of clean and properly sanitized eyes and mouth (_) |
| : properly secured and cleaned catheters (_) | CWS13: evidence of properly clean hands and nails (_) |
| : evidence of drainage system optimization (_) | CWS14: evidence that the patient eats the provided food (_) |
| | CWS15: evidence of feeding tube optimization (_) |
| CWS16: evidence of correct use of dressings/bandages and wound/ostomy collection devices (_) |
| CWS17: evidence of help in going to the toilet when requested (_) |
|
| Functional readaptation (FR) | Organization of care (OC) |
|
| FR1: evidence of safe discharge planning (_) | OC1: initial assessment with physical examination (_) |
| FR2: evidence of patient and significant person involvement in safe discharge (_) | OC2: nursing diagnoses appropriate to the patient’s health situation (_) |
| FR3: evidence of conducting teachings (_) | OC3: planning of interventions according to the elaborated diagnoses (_) |
| FR4: evidence of a completed discharge/transfer note according to the care plan (_) | OC4: planning of interventions according to the activated therapeutic attitudes (_) |
| FR5: evidence of delivery of hospital discharge support leaflets (_) | OC5: planning and execution of intervention “monitor vital signs” at least twice a day (_) |
| FR6: evidence of information about critical social indicators and community resources (_) | OC6: pain assessment every 8/8 hours |
| FR7: evidence of information about community resources to meet anticipated hospital discharge needs related to the current situation of disease (_) | OC7: execution of the evidenced interventions (_) |
| | OC8: evidence of objective parameters resulting from “monitor” type interventions (_) |
| FR8: evidence of information to the patient/significant person about the therapeutic plan (_) | OC9: evidence of objective parameters resulting from “ watch” type interventions (_) |
| FR9: evidence of information related to the use of supporting medical devices | OC10: consistent justification of the interventions marked as “not executed” (_) |
| | OC11: variation of diagnosis status as a result of variations in health condition (_) |
| OC12: appropriateness of planned interventions given the variation in nursing diagnosis (_) |
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