Nursing interventions
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Applying compression/contention bandage.
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Applying wound bandage.
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Applying wound bandage that exerts slight pressure on wound.
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Applying bandage.
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Applying skin moisturizer.
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Applying silver nitrate.
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Evaluating wound healing.
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Evaluating venous ulcer healing.
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Evaluating wound in patient’s return.
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Evaluating wound for decision making regarding dressing.
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Evaluating infection.
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Evaluating need for antibiotics administration.
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Evaluating need for protective dressing.
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Evaluating need for wound debridement.
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Evaluating Blood Pressure.
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Evaluating skin temperature.
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Evaluating skin turgor.
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Evaluating ulcer for decision making regarding dressing.
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Confirming allergy.
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Describing wound characteristics.
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Describing ulcer characteristics.
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Describing wound size and depth.
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Documenting ulcer history.
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Referring to medical care.
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Stimulating the establishment of daily habits of body and environmental hygiene.
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Examining skin condition.
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Performing debridement.
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Measuring ankle-brachial index (ABI) in both legs by hand Doppler.
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Identifying eczema-causing mechanism.
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Identifying erythema-causing mechanism.
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Identifying hyperemia-causing mechanism.
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Identifying the onset of allergic reactions resulting from topical treatment implemented.
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Encouraging increased fluid intake.
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Teaching about skin care.
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Teaching about wound care.
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Keeping the wound moist.
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Monitoring skin condition.
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Monitoring the appearance of edges.
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Monitoring skin color.
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Monitoring skin color, temperature, humidity and appearance.
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Monitoring edema and moisture on edges.
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Monitoring the infection.
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Monitoring signs and symptoms of wound infection.
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Monitoring signs and symptoms of ulcer infection.
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Monitoring humidity at edges.
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Guiding hygiene and restricted use of agressive soaps to the skin.
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Guiding the patient about making the dressing at home.
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Guiding the patient about care for preventing ulcer recurrence.
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Guiding regarding the risk of infection.
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Guiding regarding the importance of raising legs at constant intervals.
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Guiding regarding the use of moisturizers.
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Guiding regarding allergic reaction.
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Prescribing the use of perilesional skin moisturizer.
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Prescribing the use of skin moisturizer.
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Removing strange body from the wound bed.
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Removing wound debris with water spray or saline solution.
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Requesting laboratory tests for evaluation.
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Suspending use of possible allergen.
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Treating allergic reaction.
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Psychobiological Needs - nutrition
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Nursing diagnosis/outcomes
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Impaired nutritional status Hyperlipidemia status Obesity status Hyperglycemia |
Insufficient food intake Excessive food intake Risk of nutritional deficit |
Nursing interventions
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Evaluating the need to change eating habits.
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Assisting patient to receive help from appropriate nutritional programs of the community.
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Evaluating the need to change eating habits.
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Evaluating food acceptance.
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Calculating Body Mass Index for nutritional status evaluation.
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Discussing with patient a plan to change eating habits. · Referring for medical care.
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Encouraging adherence to diet.
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Encouraging adherence to a physical activity plan.
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Encouraging adherence to a plan for changing eating habits.
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Encouraging intake according to nutritional needs and food preferences.
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Establishing a goal for weight control.
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Identifying possible causes of hyperglycemia.
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Identifying possible causes of hyperlipidemia.
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Informing the patient about the importance of the plan for changing eating habits for glycemic control.
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Informing the patient about the importance of the plan for changing eating habits for lipemic control.
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Investigating possible causes of obesity.
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Investigating food preferences.
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Measuring patient’s height.
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Monitoring nutritional status.
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Monitoring capillary glycemia.
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Monitoring weight.
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Guiding the patient about response to medication.
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Guiding the patient about possible complications of hyperglycemia.
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Guiding the patient about possible complications of hyperlipidemia.
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Guiding the patient about expected positive results of joining the plan of change of eating habits in the short, medium and long term.
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Weighing the patient.
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Requesting laboratory tests for evaluation. Continue...
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Continuation. Psychobiological needs - regulation
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Nursing diagnosis/outcomes
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Impaired wound healing Peripheral edema Large/moderate/low volume exudate Purulent exudate Bloody exudate |
Serous exudate Serous-bloody exudate Infection Lipodermatosclerosis Impaired vascular process Risk of fall |
Nursing interventions
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Applying wound dressing.
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Evaluating evolution of wound healing.
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Evaluating the wound on patient’s return.
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Evaluating the wound for decision making regarding the dressing.
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Evaluating the need for antibiotics.
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Evaluating the need for wound debridement.
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Evaluating the occurrence of trauma.
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Evaluating peripheral Tissue Perfusion.
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Evaluating the presence of edema.
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Evaluating the presence of pulse.
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Evaluating the risk of ineffective capillary perfusion.
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Evaluating tactile, thermal and painful sensitivity in lower limbs.
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Describing wound characteristics.
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Discussing possible domestic accidents.
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Documenting the history of the wound.
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Referring patient for medical consultation.
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Referring for medical care.
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Measuring ankle-brachial index in both legs by hand Doppler.
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Encouraging the use of assistive aid devices for ambulation (cane, walker, wheelchair).
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Inspecting legs regarding integrity, hydration and color.
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Teaching about wound care.
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Keeping the wound moist.
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Monitoring the infection.
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Monitoring signs and symptoms of wound infection.
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Monitoring signs and symptoms of infection.
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Monitoring body temperature.
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Guiding the organization of domestic environment.
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Guiding the patient regarding care for preventing ulcer recurrence.
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Guiding the patient on the importance of raising legs at constant intervals.
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Prescribring leg elevation at constant intervals.
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Prescribing the use of compressive therapy.
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Tracking the risk of falls and other accidents.
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Removing wound debris with water spray or saline solution.
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Requesting laboratory tests for evaluation.
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Suggesting safe shoes that make walking easier.
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Using absorbent cover in dressing.
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Checking possible causes of edema.
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Psychobiological needs - perception
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Nursing diagnosis/outcomes
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Mild/moderate/severe pain Mild/moderate/severe wound pain Mild/moderate/severe fetid odor |
Impaired tactile perception Mild/moderate/severe pruritus Risk of impaired peripheral neurovascular function |
Nursing interventions
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Administering pain medication before wound care.
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Applying wound dressing.
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Evaluating need for debridement.
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Evaluating wound for decision making regarding dressing.
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Evaluating pain intensity.
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Evaluating response to pain management.
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Evaluating tactile, thermal and painful sensitivity in lower limbs.
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Describing wound characteristics.
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Referring patient for medical evaluation in case of peripheral vascular changes.
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Encouraging patients to discuss their pain experience.
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Encouraging patients to monitor their own pain and interfere properly.
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Examining the integrity of skin.
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Examining feet and legs at each return: inspection and palpation of skin, nails, subcutaneous and structure, palpation of arterial pulse and evaluation of plantar protective sensation.
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Explaining causes of pain.
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Measuring ankle-brachial index in both legs by hand Doppler.
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Managing wound odor control.
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Identifying the cause of pruritus.
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Encouraging participation of family and patient in pain control.
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Indicating the use of compressive therapy.
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Teaching about wound care.
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Investigating factors that increase pain.
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Keeping the wound moist.
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Wetting the dressing with saline solution or water before removal.
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Monitoring response to analgesic.
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Monitoring signs and symptoms of infection.
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Guiding the patient regarding moisturizer application.
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Guiding the patient to apply cold compresses for relief of irritation.
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Guiding the patient to report changes of sensitivity and the appearance of any injury.
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Guiding the patient to favor adequate rest/sleep for pain relief.
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Guiding the patient to keep nails trimmed and not scratch the skin.
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Guiding the patient not to use abrasive products on the skin.
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Guiding the patient with feet changes regarding adjustments on the type of shoes, physical activity and use of assistive aid devices for ambulation (cane, walker, wheelchair)
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Guiding the patient regarding body hygiene of the affected area.
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Guiding the patient regarding hygiene habits.
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Prescribing analgesy.
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Providing alternative methods of pain relief.
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Removing wound debris with water spray or saline solution.
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Psychobiological needs – sleep and rest
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Nursing diagnosis/outcomes
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Impaired rest behavior |
Impaired sleep |
Nursing interventions
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Evaluating the cause of altered sleep pattern.
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Encouraging rest.
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Teaching the patient about relaxation techniques.
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Stimulating the patient to maintain adequate sleep pattern.
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Alleviating pain.
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Organizing activities of daily life in order to allow rest periods during the day.
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Guiding to keep the ulcerated leg elevated when at rest.
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Guiding the patient to make changes in the environment (reduce lighting, noises, check bed and pillow conditions, check ventilation conditions).
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Guiding the patient to plan medication schedule in order not to interrupt the sleep.
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Guiding the patient regarding factors interfering in the sleep.
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Planning rest/activity periods with the patient.
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Psychobiological needs - sexuality
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Nursing diagnosis/outcomes
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Impaired sexual behavior |
Nursing interventions
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Evaluating the patient’s knowledge of his/her sexuality pattern.
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Encouraging the patient’s ability to adjust to his/her state of health.
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Encouraging the patient to share his/her feelings about sexuality.
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Stimulating the dialogue about the situation with the partner.
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Identifying determinants of unsatisfactory sexual activity.
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Guiding regarding contraceptive methods.
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Promoting the practice of safe sex with use of condoms.
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Providing counselling by considering cultural and social aspects, myths and taboos. Continue...
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Psychobiological needs – physical activity Continuation.
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Nursing diagnosis/outcomes
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Low physical exercise |
Impaired mobility |
Nursing interventions
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Evaluating adherence to the proposed exercise plan.
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Evaluating patient’s ability to perform activities of daily life.
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Evaluating the need for ambulation assistive devices.
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Psychobiological needs - hydration
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Nursing diagnosis/outcomes
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Impaired self-care in fluid intake |
Inadequate fluid intake |
Nursing interventions
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Evaluating patient’s knowledge about his/her need of fluid intake.
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Encouraging self-care.
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Encouraging the patient to inspect skin during the shower.
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Stimulating the establishment of daily habits of body and environmental hygiene.
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Monitoring hydration indicators.
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Guiding the patient regarding the need of fluid intake.
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Guiding regarding hygiene care by considering cultural and social aspects, myths and taboos.
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Planning a scheme for stimulation of fluid intake by considering specificities of the case.
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Recording fluid intake.
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Psychobiological needs – body care
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Nursing diagnosis/outcomes
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Impaired ability to perform hygiene Inadequate hygiene |
Impaired self-care in hygiene |
Nursing interventions
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Evaluating self-care.
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Evaluating family hygiene conditions in the home environment.
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Encouraging bathing before the visit to perform the dressing.
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Encouraging hygiene habits by considering cultural and social aspects, myths and taboos.
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Encouraging the patient to bathe.
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Stimulating the establishment of daily habits of body and environmental hygiene.
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Encouraging the patient to inspect skin during the shower.
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Guiding family/caregiver regarding personal hygiene care.
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Guiding regarding hygiene care by considering cultural and social aspects, myths and taboos.
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Psychobiological needs – physical security
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Nursing diagnosis/outcomes
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Alcohol abuse |
Smoking |
Nursing interventions
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Assisting patient in establishing a goal plan for reducing alcohol abuse.
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Assisting patient in establishing a goal plan for reducing smoking.
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Assisting patient in identifying triggers related to the desire and act of smoking and the way to overcome them.
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Assisting patient in identifying the moments and attitudes related to the desire to drink and the way to overcome them.
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Evaluating lifestyle and its relation with alcohol abuse.
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Evaluating lifestyle and its relation with tobacco abuse.
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Referring to a self-help group.
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Encouraging search for a self-help group.
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Identifying the family and community support network.
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Identifying the desire to quit smoking.
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Providing support for times related to abstinence.
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Guiding regarding the possibility of relapses and how to overcome them.
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Guiding regarding abstinence crisis.
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Guiding regarding doubts related to use together with drugs.
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Guiding regarding harm caused by smoking.
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Psychosocial needs
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Psychosocial needs – freedom and participation
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Nursing diagnosis/outcomes
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Impaired social condition Impaired family coping |
Impaired work role |
Nursing interventions
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Helping with identification of positive personal attributes.
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Evaluating social support and support network (work, church, family, friends).
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Discussing with the family and patient about co-responsibility in treatment and adverse reactions during treatment.
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Referring family and patient to self-help groups and/or psychological care.
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Referring to multiprofissional team if necessary.
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Encouraging the patient to identify his/her strengths and abilities.
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Indicating community social equipments for recreation and leisure.
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Investigating the family’s level of understanding and acceptance of the patient’s current state of health.
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Guiding regarding patient’s current state of health.
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Scheduling a home visit.
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Reinforcing to the family about treatment adherence.
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Psychosocial needs – emotional security, self-esteem
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Nursing diagnosis/outcomes
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Anguish Anxiety Low self-esteem Stress |
Fear Risk of low self-esteem Sadness |
Nursing interventions
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Embracement of the patient according to his/her needs.
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Helping with identification of positive personal attributes.
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Evaluating attitudes towards therapeutic regimen.
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Referring to psychological care if necessary.
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Referring to multiprofessional team if necessary.
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Encouraging the expression of perceptions, feelings and fear.
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Encouraging the patient to explain his/her doubts, desires and difficulties.
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Encouraging the patient to identify his/her strenghts and abilities.
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Encouraging the patient to verbalize feelings, perceptions and fear.
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Encouraging participation in recreational activities.
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Establishing a relationship of trust with the patient.
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Identifying determinants of Anguish.
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Identifying determinants of Anxiety.
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Identifying determinants of Sadness.
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Encouraging activities that promote their well-being.
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Investigating patient’s socio-familial context.
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Motivating patient for self-care at home.
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Guiding regarding stress management actions.
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Promoting patient’s confidence in the care provided.
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Recognizing the different moments experienced by patient when receiving new treatment guidelines.
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Checking with patient and caregiver the factors causing fear. Continue...
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Continuation. Psychosocial needs – self-image
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Nursing diagnosis/outcomes
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Impaired body image |
Nursing interventions
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Discussing body image changes with patient.
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Referring to multiprofessional team if necessary.
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Identifying with the patient the factors interfering with his/her self-image.
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Guiding patient, caregiver and families regarding possible predictable physical changes during treatment (use of bandages, large dressings, etc).
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Strengthening self-care.
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Psychosocial needs – gregarious and leisure
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Nursing diagnosis/outcomes
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Impaired ability to perform leisure activities |
Social isolation Risk of social isolation |
Nursing interventions
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Embracement of the patient according to his/her needs.
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Evaluating family and social context.
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Referring to multiprofessional team if necessary.
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Encouraging participation in recreational activities.
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Identifying with the patient the determinants for social isolation.
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Identifying community social equipments for recreation and leisure.
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Encouraging participation in social and community groups.
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Planning a simple daily routine by including recreation and leisure concrete activities.
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Scheduling a home visit.
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Psicosocial needs - love and acceptance
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Nursing diagnosis/outcomes
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Lack of family support Lack of social support |
Impaired affective bonding |
Nursing interventions
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Embracement of the patient according to his/her needs.
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Embracement of patient, caregiver and family in their needs.
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Evaluating family and social context.
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Evaluating social support.
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Discussing with the family and patient about co-responsibility in treatment and adverse reactions during treatment.
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Referring the family to self-help groups or psychological care.
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Referring to psychological care if necessary.
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Referring to multiprofessional team if necessary.
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Encouraging the verbalization of feelings, perceptions and fears.
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Identifying with patient the determinants for lack of social support.
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Encouraging participation in social and community groups.
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Investigating the family’s level of understanding and acceptance of the patient’s current state of health.
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Guiding regarding the patient’s current state of health.
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Scheduling a home visit.
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Reinforcing to the family about treatment adherence.
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Psychosocial needs – self-achievement
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Nursing diagnosis/outcomes
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Disposition for coping |
Nursing interventions
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Evaluating coping ability.
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Providing pertinent information to the current state of health.
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Referring to multiprofessional team if necessary.
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Psychosocial needs - apprenticeship
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Nursing diagnosis/outcomes
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Low health knowledge Impaired communication between nurse and patient |
Non-adherence to therapy |
Nursing interventions
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Adjusting therapeutic regimen to social and leisure activities.
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Evaluating patient’s tension.
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Evaluating response to prescribed medication.
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Describing therapeutic plan to patient in writing.
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Providing pertinent information to the current state of health.
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Establishing active listening.
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Stimulating self-care.
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Explaining actions and possible adverse effects of medication.
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Facilitate access to treatment (scheduling appointments/return, adjusting inputs and available medications).
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Speaking calmly with short sentences of easy understanding.
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Identifying the side effect of therapeutic regimen.
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Encouraging treatment adherence.
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Guiding regarding use of medication.
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Guiding regarding doubts related to prescribed treatment.
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Scheduling home monitoring with the nursing team.
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Providing a calm environment (office or home).
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Using a calm and safe approach.
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Checking if patient understood the guidelines provided.
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Psychospiritul needs
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Psychospiritual needs - religious
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Nursing diagnosis/outcomes
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Conflictual religious belief |
Nursing interventions
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