Page 15 - Advanced Communication in Nursing

a. My stomach cramps b. The client will not c. PR: 87 bpm d. Acute pain r/t
and I had to go to experience irritation of
the rest room for aspiration as esophagus from
several times. evidenced by gastric acids
certain indicators.
e. O2 Sat: 98% f. Pain g. PR: 104 bpm h. nausea
i. vomiting j. Skin warm and k. BP: 150/80 mmHg l. Risk for aspiration
moist r/t ineffective
cough
m. T: 36.9 °C n. Diarrhea r/t o. headache p. The client will
infectious process report less diarrhea
involving intestinal as evidenced by
tract certain indicators.

Step 1: Assessment Step 2: Nursing Diagnosis Step 3: Outcomes and Planning

Vocabulary: Terms used in Nursing Diagnosis

Nursing Care Plan (NCP) is a formal process that correctly identifies existing needs and recognizes a client’s
potential needs or risks.
Terms used in a Nursing Diagnosis
To state the problem and its definition
1. Deficient: lacking in some necessary quality or element
2. Imbalanced: unevenly or unfairly arranged
3. Impaired: reduced or weakened in strength, quality, etc.
4. Ineffective: having no effect; incompetent or inefficient
5. Risk for: possibility of loss or injury
To state etiology (related factors)
6. Related to: to connect (something) with (something else)
To state risk factors
7. As evidenced by: as is clearly shown by
To define characteristics
8. As manifested by: as revealed by; as proven by
9. As evidenced by: as is clearly shown by

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