Nursing Process

Complete the nursing process diagram below and then explain it. Type
Comprehensive Initial Assesment

Focused Assesment
ASSESMENT
Emergency Assesment
Methods of Collecting Data :
Interview.
Observation.
Data Source(s)? Physical examitation.
Primary source
Secondery source

Data Clustering: Process of putting data together in order to identify areas of the c

S Problem
S NURSING DIAGNOSIS Etiology
O Defining Characteristics
…… S O Type
…… A
…… O A Actual Nursing
…… P …………………………………..
Diagnosis.
PLANNING
…… A P Type Risk Nursing
Diagnosis.
…… I -Independent Nursing Possible Nursing
….. P I ………………………
Intervention Diagnosis.
E ……………………..
- Interdependent Nursing
E Intervention
…………..…………
- Dependent Nursing
R Intervention

IMPLEMENTATION
Type

EVALUATION Implementing nursing care

S6.M6.WS.NCP/P2B/2018
 LANGUAGE FOCUS
Here are some tenses used in Nursing Care Plan.

Nursing Process Grammatical Features

1. Assessment Objective Data: Statement
 Example: Mr. G, 45 years old, has got chest pain since a week
ago. His blood pressure was 135/90 mmHg at 09.00
a.m.
Subjective Data:
 Direct Speech
- Example: The patient said, “I vomited three times this morning.”
 Indirect Speech
- Example: The patient said that he had vomited three times this
morning.
2. Diagnosis Simple Present Tense and adjective clause
 Pattern: The problem is …(nursing diagnosis label)…
related to…(etiology)…as evidenced by …(defining
characteristics).
 Example: The problem is ineffective airway clearance related to excessive
mucus as evidenced by shortness of breath and coughing up blood for an
hour +/- 5 tbsp, ronchi breathing, and RR 30 breaths/min.
3. Planning Outcome Future Tense (will + V1)
 Example: The client will achieve respiratory status: airway patency (0410),
as evidenced by: ….
4. Planning Intervention Instruction (V1/infinitive verbs)
 Example: Open the airway.
Position patient to maximize ventilation potential.
Perform chest physical therapy, as appropriate.
5. Implementation Simple Past Tense (S +V2)
 Example: The client ate low calories diet.
The client practiced breathing relaxation technique.
6. Evaluation Present Perfect Tense (S + has/have + V3)
 Example: The client has passed bowel movement.
The client’s blood pressure has decreased from 135/90 mmHg to
120/80 mmHg.

Practice
Open English for Nursing 3 book page 5 (Mr. Ahmad case).