Unit 1: NCP

Review
S6.M9.PPT-Review
NURSING PROCESS =

SCIENTIFIC METHOD + CRITICAL

THINKING
Mention 5 steps in nursing process!
 Assessment
 Nursing Diagnosis
 Planning (Outcome & Intervention)
 Implementation
 Evaluation
 Activity 1
Identify what step in the nursing
process are the following?
Pain related to myocardial ischemia as
manifested by guarding left chest, grimacing
(expression of pain), reporting pain score of
10/10, Bp 170/80
nursing diagnosis
 At the end of the shift the patient will be able
to ambulate (move) at the end of the hallway.
 planning/expected outcome
 Pulse rate of 150 and irregular
 assessment
 Ambulate patient TID (Transient Ischemic
Dilation)
 Planning intervention
 The client has decreased the use of accessory
muscles; The client has reported a decrease in
shortness of breath and decrease in
difficultyof breathing? Goal met
 evaluation
 Teach patient how to use prescribed inhalers,
as appropriate
 Planning Intervention
 The problem is ineffective airway clearance
related to excessive mucus as evidenced by
shortness of breath and coughing up blood
for an hour
 Nursing diagnosis
 “Nurse, I feel painful right in my lower
abdomen and I have difficulty in urinating. It’s
been 2 days.”
 Assessment
 Activity 2
Rearrange these Diagnosis
Labels into good order (5 points)
and find the correct key words
(5 points)!
REQUIREMENT – BODY – NUTRITION –
IMBALANCED – MORE– THAN

IMBALANCE NUTRITION: MORE THAN BODY

REQUIREMENT
PATTERN – SEXUALITY – INEFFECTIVE

INEFFECTIVE SEXUALITY PATTERN

CARDIAC – DECREASED – OUTPUT

DECREASED CARDIAC OUTPUT

INTOLERANCE – FOR – RISK – ACTIVITY

RISK FOR ACTIVITY INTOLERANCE

FOR – RISK – SKIN – INTEGRITY –
IMPAIRED

RISK FOR IMPAIRED SKIN INTEGRITY

SENSORY – DISTURBED - PERCEPTION

DISTURBED SENSORY PERCEPTION

URINARY – IMPAIRED – ELIMINATION

IMPAIRED URINARY ELIMINATION

COMMUNICATION – VERBAL – IMPAIRED

IMPAIRED VERBAL COMMUNICATION

VOLUME – IMBALANCED – RISK – FOR –
FLUID

RISK FOR IMBALANCED FLUID VOLUME

DECREASED – FOR – TISSUE – RISK –
PERFUSSION – CARDIAC

RISK FOR DECREASED CARDIAC TISSUE PERFUSSION

 Activity 3

Practicing Diagnosing
Write good sentence for data
analysis!
(10 points)
The problem is constipation related to insufficient fiber
intake as evidenced by distended abdomen, dry and
hard stool, and pain in the abdomen.

Problem: Constipation
Etiology: insufficient fiber intake
Defining Characteristics: distended abdomen, dry
and hard stool, and pain in the abdomen.
The problem is Ineffective Airway Clearance related to
excessive mucus as evidenced by coughing up blood,
coughing up with sputum, and the RR is 30
breaths/min.

Etiology: excessive mucus

Problem: Ineffective Airway Clearance
Defining Characteristics: coughing up blood,
coughing up with sputum, RR=30 breaths/min.
The problem is acute pain related to biological agents
as evidenced by chest pain while coughing, ronchi
breathing, and shortness of breath.

Defining Characteristics: chest pain while

coughing, ronchi breathing, shortness of
breath.
Problem: Acute Pain
Etiology: Biological agents
The problem is anxiety related to change in health
status as evidenced by frightened by the appearance of
blood while coughing, face looked tense and nervous.

Problem: Anxiety
Etiology: change in heatlh status
Defining Characteristics: frightened by the
appearance of blood while coughing, face looked
tense and nervous.
The problem is ineffective breathing pattern
related to fatigue as evidenced by decreased
expiratory pressure and dyspnea.

Problem: Ineffective breathing pattern

Etiology: fatigue
Defining Characteristics: decreased expiratory
pressure, dyspnea.
The problem is sexuality dysfunction related to altered
body structure (pregnancy) as evidenced by alteration
in achieving sexual satisfaction and change of interest
in self.

Etiology: altered body structure (pregnancy)

Defining Characteristics: alteration in achieving
sexual satisfaction, change of interest in self.
Problem: Sexuality Dysfunction
The problem is complicated grieving related to
death of a significant other as evidenced by
depression, fatigue, and reports feeling empty.

Defining Characteristics: depression, fatigue,

reports feeling empty
Etiology: death of a significant other
Problem: Complicated grieving
The problem is impaired tissue integrity related
to radiation as evidenced by destroyed tissue

Defining Characteristics: destroyed tissue

Problem: impaired tissue integrity
Etiology: radiation
 Activity 4

Practicing NOC:
Write the sentence for NOC using
the provided data!
(100 points)
After doing nursing implementations for 2x24 hours, the client
will achieve Respiratory Status: Airway Patency (0410), as
evidenced by:
1. Respiratory rate will increase from level 2 to level 4.
2. Ability to clear secretions will increase from level 2 to level 4.

Time: 2x24 hours

Outcome: Respiratory Status: Airway Patency (0410)
Indicators (increase):
Indicators Present Condition Outcomes
Respiratory Rate 2 4
Ability to clear 2 4
secretions
After doing nursing implementations for 3x24 hours, the client
will achieve Bowel Elimination (0501), as evidenced by:
1. Elimination pattern will increase from level 2 to level 4.
2. Stool soft and formed will increase from level 2 to level 5.
3. Ease of stool passage will increase from level 2 to level 5.

Time: 3x24 hours

Outcome: Bowel Elimination (0501)
Indicators (increase to):
Indicators Present Condition Outcomes
Elimination pattern 2 4
Stool soft and formed 2 5
Ease of stool passage 2 5
After doing nursing implementations for 2x24 hours, the client
will achieve Appetite (1014), as evidenced by:
1. Desire to eat will increase from level 3 to level 5.
2. Food intake will increase from level 2 to level 4.
3. Nutrient intake will increase from level 2 to level 5.

Time: 2x24 hours

Outcome: Appetite (1014)
Indicators (increase to):
Indicators Present Condition Outcomes
Desire to eat 3 5
Food intake 2 4
Nutrient intake 2 5