Nursing Process
Complete the nursing process diagram below and then explain it.           Type?
                                                                  …………………………………………
                                                                    …………………………………………
                                   …………………………………..                    …………………………………………
                                                                             How?
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                                          Data Source(s)?                      …………………
                                                                               ………………………
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                                                                         ……
                                                                         ……………………………………
                                                                         ……
                                                              Data Clustering: Process of putting
                                                              data together in order to identify
                                                              areas of the client's problems and
                                                              strengths.
                                                                    Problem?
                            S     …………………………………..
                        S                                           Etiology?
                            O                                       Defining Characteristics?
           ……       S   O
           ……               A                                                       Type?
           ……       O   A                                                          ………………………
           ……               P                                                      ………………………
                                                                                   …………………
                                  …………………………………..           Type?
           ……       A   P                                                          …………………
                                                                                   ………………………
           ……               I                                                      …………………
           …..      P   I                           ………………………
                            E                       ……………………..
                        E                           …………..…………
                            R
                                  …………………………………..           Type?
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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).
S6.M6.WS.NCP/P2B/2018