Nursing Outcome Classification

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John Mark L. Bocarile, RN Nursing Outcome Classification

Transcript of Nursing Outcome Classification

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John Mark L. Bocarile, RN

Nursing Outcome Classification

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“What is the client’sresponse to the nursing intervention?”

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Nursing Process6-step process (ADOPIE)

ASSESSMENTDIAGNOSISOUTCOME IDENTIFICATIONPLANNINGIMPLEMENTATIONEVALUATION(ANA, Standards of Clinical Practice, 2008)

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Outcome Identification

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Outcome Identificationrefers to formulating and documenting

measurable, realistic and client-focused goals that will provide the basis for evaluating nursing diagnosis.

Expected Outcome or the anticipated goal of the identified care interventions and actions needed to treat the patients’ conditions. 

Establish client’s goals and outcome criteria

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Example of Verbs Used in Goal SettingCalculateClassifyCommunicat

eCompareDefineDemonstrateDescribeConstructContrast

DistinguishDrawExplainExpressIdentifyListNameMaintainPerformParticular

PracticeRecallReciteRecordStateUseVerbalizeAmbulates

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ExampleAmbulates safely with one-person

assistance.

Identifies actual & risk environmental hazards.

Demonstrates signs of sufficient rest before Surgery.

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General Qualifiers to Predict Care OutcomesTo Improve patient's condition

To Stabilize patient's condition

To Support Deterioration or Death of patient's condition

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ExampleGoal – The client will report a decreased anxiety level

regarding Surgery.

Possible Criteria>After client teaching, the client verbalizes decreased anxiety.The client discusses fears & concern regarding surgical

procedure after client teaching.The client identifies a support system and strategies to use to

reduce stress and anxiety related to the surgical experience.

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ExampleGoal – The client will demonstrate safety

habits when performing activities of daily living.

Possible Criteria_____________________________________________

_____________________________________________________________________________________________________________________________.

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Possible Outcome CriteriaImmediately after instruction by the nurse, the

client uses call light system for assistance when needs to use the bathroom.

The client demonstrates safety practices when dressing and doing personal hygiene.

The client uses over-the-bed lights, non-skid slippers when transferring to chair or getting out of bed.

The client identifies modification for home safety (removal of throw pillows, installation of hand rails in hallway, better lighting of hallway and stairway), 12 hours after nurse’s instruction about home safety.

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ExampleGoal – The client will mobilize lung

secretions.

Possible Outcome Criteria_____________________________________________

_______________________________________________________________________________________________________________.

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Possible Outcome CriteriaAfter teaching session, the client

demonstrates proper coughing techniques.The client drinks at least 6 glasses of water

per day while in the hospital.The caregiver or significant other

demonstrates proper technique of chest physiotherapy including percussion, vibration and postural drainage before discharge.

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Evaluation

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EvaluationNurses’ make decisions all throughout

patient (client) care situations. Within the context of the nursing process, evaluation— the sixth phase—is a concurrent and a terminal process. It is concurrent or on-going because the nurse evaluates and makes decision during the implementation phase of the process.

Actual Outcome depicting the outcome of care resulting from the interventions and action types used to treat the patient. 

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Types of EvaluationStructure Evaluation – Environment

Process Evaluation – Nurse

Outcome Evaluation - ???????

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Outcome Evaluation“Outcome evaluation” occurs when the

client becomes the focus of evaluation.Here the nurse is concerned with changes

in the client that occur as an effect of the nursing interventions.

Outcome evaluation answers the question “To what degree are the client goal and predicted outcomes achieved?”

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NOC

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SituationThe health care environment in which nurses

deliver care is experiencing constant change characterized by decreased lengths of stay in acute care settings, increased use of technology, increasing emphasis on computerized patient records and care planning options, increasing markets dominated by managed care, and an emphasis on outcomes rather than process. These changes dictate that nursing as a profession ensures that the work of nursing is visible in this health care environment and included in the data used to make health policy decisions (Moorhead et. al., Journal of Nursing Care Quality, 1998)

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Nursing Outcome ClassificationIt is a comprehensive, standardized system to classify

outcomes of nursing interventions. It is a clinical tool developed by a research team at the University of Iowa that describes and defines the knowledge base for nursing curricula and practice. NOC outcomes have been linked to NANDA diagnoses. At present, NOC includes 385 nursing outcomes for use for individual patients or individual family caregivers in the home. It is considered part of the clinical decision making of the nurse to decide and document the nursing diagnoses, desired outcomes, interventions used, and outcomes achieved. (Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier)

 

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Outcome ClassificationHealth care providers have appreciated the

importance of outcomes as requirements for measuring economic efficiency and system effectiveness in a cost-control environment. In addition to the term "result", eight terms are commonly used in the literature to modify, an outcome: patient, nurse-sensitive, desired, effective, expected, predicted, projected, and actual outcome. Outcomes may defined as the end results of care, yet when quality of care is being measured outcomes are linked to diagnoses. From this perspective, outcomes are indicators of problem resolution or progress toward resolution (Gordon, The Online Journal of Issues in Nursing, 1998)

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Historical Perspective: Outcome Classification

Aydelotte (1962) was an early pioneer in the measurement of patient outcomes. She was the first in nursing to use changes in characteristics of patients to evaluate nursing care delivery.

In 1988 Heater, Becker, and Olson completed a meta-analysis of studies that suggested a growing interest in nursing goals and outcomes during the previous decade. Outcomes at this time were general, such as "the patient's self care skills" (Hover and Zimmer, 1978).

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Historical Perspective: Outcome ClassificationJohnson and Maas summarized the multiple reports of

outcome generation that were characteristic of the 1980s and early 1990s and concluded that identification of outcomes was based mainly on literature reviews and practical experience rather than research or conceptual frameworks" (1997, p.5). These authors also note that nursing outcomes differ in content from medical outcomes. Nursing includes client knowledge and behaviors, safety ,use of resources, home maintenance, and caregiver status (1997, p.5).

In a large, funded project Johnson and Maas (1997) and a team of investigators at the University of Iowa developed a set of outcomes and proposed their linkages to nursing diagnoses. Outcomes and their indicators are the concepts, or elements, to be used in classification.

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Nursing Outcome ClassificationThe Nursing Outcomes Classification (NOC)

describes patient outcomes sensitive to nursing intervention. NOC evaluates the effects of nursing care as a part of health care. Standardized patient outcomes are essential to ensure that nursing becomes a full participant in clinical evaluation science along with other health disciplines. (Johnson, 1997)

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Nursing Outcome ClassificationThe Nursing Outcomes Classification (NOC) is a

comprehensive taxonomy of patient outcomes influenced by nursing care. Each outcome is stated as a variable concept measured on a five point Likert scale and includes a definition, indicators, and references. The classification provides outcomes that can be used across the care continuum to assess patient status following nursing interventions. The classification has a number of advantages, including being research based, standardized, comprehensive, and flexible for clinical use. It was developed lay a large research team that included clinical experts and has been subjected to testing (Marion and Meridean, Journal of Nursing Quality, 1998)

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Standardized outcomes are necessary for documentation in electronic records, for use in clinical information systems, for the development of nursing knowledge and the education of professional nurses. An outcome is a measurable individual, family, or community state, behavior or perception that is measured along a continuum and is responsive to nursing interventions. The outcomes are developed for use in all settings and with all patient populations.

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Brief History of NOCThe Nursing Outcomes Classification contains

190 outcomes listed alphabetically during the year it was published by Mosby in 1997 (Iowa Outcomes Project, 1997). Since publication, an additional 28 outcomes and the taxonomy have been developed. For this work, an outcome is stated as a variable concept representing a patient or family caregiver state, behavior, or perception that is measurable along a continuum and responsive to nursing interventions. Stating the outcomes as variable concepts, rather than as goals, allows for the identification of positive or negative changes or no change in a patient's status. Each NOC outcome has a definition, a list of indicators that are useful in evaluation of patient status, a measurement scale, and a short list of references used in development of the outcome

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Brief History of NOCSince August 1991, a research team consisting

of 43 nurses representing service agencies and nursing education has been conducting a study of nursing-sensitive patient outcomes. The purposes of the research are to:

1) identify, label, validate, and classify nursing-sensitive patient outcomes and indicators

2) evaluate the validity and usefulness of the classification in clinical field testing

and 3) define and test measurement procedures for the outcomes and indicators.

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Brief HistoryThe research to develop NOC began with

the formation of the outcomes research team in 1991 and has progressed through the following phases.

Phase I - Pilot Work to Test Methodology (1992-1993)Phase II - Construction of the Outcomes (1993-1996)Phase III - Construction of the Taxonomy and Clinical Testing (1996-1997)Phase IV - Evaluation of Measurement Scales (1998-2002)Phase V - Refinement and Clinical Use (1997 - Present)

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Clinical sites used to test the NOC included tertiary care hospitals, community hospitals, community agencies, nursing centers, and a nursing home. The outcomes are developed for use in all settings and can be used across the care continuum to follow patient outcomes throughout an illness episode or over an extended period of care. Since the outcomes describe patient/client status, other disciplines may find them useful for the evaluation of their interventions.

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Nursing Outcome ClassificationThe classification contains patient outcome categories

and indicators at four levels of abstraction and empirical measurement scales. The taxonomy of domains and labels can be obtained from the NOC project office at the University of Iowa.

Most Abstract Nursing-Sensitive Outcomes DomainsHigh-Middle Level Abstraction Nursing-Sensitive

Outcome ClassesMiddle Level Abstraction Nursing-Sensitive Outcome

LabelsLow Level Abstraction Nursing-Sensitive Outcome

IndicatorsEmpirical Level Measurement Activities for Outcomes

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Nursing Outcome ClassificationThe outcomes have been linked to NANDA

International diagnoses, to Gordon's functional patterns, to the Taxonomy of Nursing Practice, to Omaha System problems, to resident admission protocols (RAPs) used in nursing homes, to the OASIS System used in home care and to NIC interventions.

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THE CENTER FOR NURSING CLASSIFICATION

Classification research conducted at Iowa is unique and crucial to the documentation and study of nursing care and to the articulation of nursing care with that of other providers. For nearly a decade the University of Iowa College of Nursing has been a leader in developing standardized languages to describe the work of nursing. The Center for Nursing Classification, established in 1995, facilitates the continued development of this important work.

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BenefitsThe Classifications will benefit health care providers,

patients, and third-party payers in many ways. They will:

· Provide a standardized language for nursing.· Facilitate appropriate selection of nursing interventions.· Define and predict outcomes nurses can achieve with

patients.· Facilitate communication of nursing treatments to

other nurses and other providers.· Standardize and define the knowledge base for nursing

curricula and practice.· Facilitate the teaching of clinical decision-making to

novice nurses.

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BenefitsAssist administrators in effectively planning for

staff and equipment resources.· Enable researchers to examine the effectiveness

and cost of nursing care.· Assist educators in developing curricula that

better conform with clinical practice.· Promote the development of a reimbursement

system for nursing services.· Facilitate the development of computerized

information systems.· Communicate the nature of nursing to the public.

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NOC - DescriptionThe 330 NOC outcomes in Nursing Outcomes

Classification (NOC) (3rd ed.) are listed in alphabetical order. Each outcome has a definition, a list of indicators that can be used to evaluate patient status in relation to the outcome, a target outcome rating, place to identify the source of data, a five-point Likert scale to measure patient status, and a short list of references used in the development of the outcome. For 76 of the outcomes an additional measurement scale was added to the outcome based on feedback from our research in 10 clinical sites. Examples of scales used with the outcomes are: 1=Extremely compromised to 5= Not compromised and 1=Never demonstrated to 5=Consistently demonstrated.

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NOC - DescriptionThe NOC (3rd ed.) includes 311 individual level outcomes,

10 family and 9 community level outcomes. The NOC outcomes are grouped in a coded taxonomy that organizes the outcomes within a conceptual framework to facilitate locating an outcome. The 330 outcomes are grouped into thirty-one classes and seven domains for ease of use. The seven domains are: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge & Behavior, Perceived Health, Family Health, and Community Health. Each outcome has a unique code number that facilitates its use in computerized clinical information systems and allows manipulation of data to answer questions about nursing care quality and effectiveness. The classification is continually updated to include new outcomes and to revise older outcomes based on new research or user feedback and is published on a 4 year cycle.

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Coding

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StrengthsComprehensive – The NOC contains outcomes

for individuals, caregivers, families, and communities that can be used with all clinical specialties in numerous settings.

Research-based – The research, conducted by a large team of University of Iowa College of Nursing faculty and students in conjunction with clinicians from a variety of settings began in 1991. Both qualitative and quantitative strategies were used to develop the classification.

Developed inductively and deductively –Research team focus groups reviewed outcomes in eight (8) broad categories that were drawn from the Medical Outcomes Study and nursing literature.

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Strengths Grounded in clinical practice and research –

Developed initially from nursing texts, care plan guides, and clinical information systems, the outcomes were reviewed by clinical experts and many were tested in clinical field sites. Feedback from clinicians and educators is solicited through a defined feedback process.

Uses clear, clinically useful language – Throughout the development of the NOC, clarity and usefulness of the language has been emphasized.

Has easy to use organizing structure – The taxonomy has five (5) levels: domains, classes, outcomes, indicators and measurement scales. All five levels have been coded for use in practice.

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Strengths Outcomes can be shared by all

disciplines – Although the NOC emphasizes outcomes that are most responsive to nursing interventions, the outcomes describe patient, family, or community states at a conceptual level.

Optimizes information used for the evaluation of effectiveness – The outcomes and indicators are variable concepts. They allow for measurement of the patient, family or community outcome at any point on a continuum from most negative to most positive and at different points in time.

Funded by extramural grants – To date, the NOC research has received nine (9) years of peer-reviewed grant funding: one (1) year from Sigma Theta Tau International and eight (8) years from the National Institute of Nursing Research (NINR).

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Strengths Tested in clinical field sites – Testing of the NOC

has been conducted in a variety of clinical field sites

Dissemination emphasized – Information about the classification, its development, and use is available.

Linked to other nursing languages – Linkages have been developed by the NIC and NOC research teams to assist nurses with the use of the classifications and to facilitate use in clinical information systems. Linkages with NANDA-International diagnoses and Gordon’s Functional Health Care Patterns are included in the book. Linkages among NANDA diagnoses, NOC outcomes, and NIC interventions are available in the book NANDA, NIC, and NOC linkage:

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Strengths Included in initiatives for electronic clinical record Developed as companion to the NIC – Experience with the

NIC at Iowa has aided the NOC research. Recipient of national recognition – NOC is recognized by

the American Nurses Association (ANA), included in the Metathesaurus for a Unified Medical Language at the National Library of Medicine, included in the CINAHL index, and listed as one of the languages that meets the standards set by ANA’s Nursing Information and Data Set Evaluation Center (NIDSEC).

Structure for continued development and refinement – The classification continues to be evaluated, developed, and refined by the NOC research team. Continued refinement will be facilitated through the Center for Nursing Classification and Clinical Effectiveness, the College of Nursing, and the University of Iowa.

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Activity Example

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NOC

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IndicatorsHave respiratory rate within normal limits,

compared with baseline (14-20/min)Express relief of (or improvement in)

feelings of shortness of breathRelate causative factors and ways of

preventing or managing them. (Carpenito-Moyet, 2008)

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ExampleCase Scenario: Medical Diagnosis: CHF Mr. Art Faylur, 68/MSubjective:The patient verbalized, “Madali nga talaga akong mapagod

ngayon at di ko magawa yung mga gusto kong gawin”Objective:>Conscious, Coherent, Conversant>Weak-looking>Easy fatigability >Experiencing discomfort after an activity as evidenced by facial

grimace>Increased in RR 24 to 30cpm and HR 108 to 124bpm every

activity>O2 saturation: 95%>Cold Clammy on Peripherals

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Nursing Diagnosis: Activity Intolerance related to

imbalance of oxygen supply and demand secondary to

CHF

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Outcome CriteriaGoal:

Objectives:

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Outcome CriteriaGoal:Client can perform the activity without

complicationsAfter 8 hours to a week of nursing

intervention the patient will maintain activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue.

Patient verbalizes and uses energy-conservation techniques.

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Which NOC?A. 1308 Adaptation to Physical

Disability: Adaptive response to a significant functional challenge due to a physical disability

B. 0005 Activity Tolerance: Physiologic response to energy-consuming movements with daily activities

C. 0200 Ambulation: Ability to walk from place to place independently with or without assistive device

D. 0400 Cardiac Pump Effectiveness: Adequacy of blood volume ejected from the left ventricle to support systemic perfusion pressure

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Correct!0005 Activity Tolerance: Physiologic

response to energy-consuming movements with daily activities

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Suggested NOC0005 Activity Tolerance: Physiologic

response to energy-consuming movements with daily activities

0002 Energy Conservation: Personal actions to manage energy for initiating and sustaining activity

1813 Knowledge: Treatment Regimen: Extent of understanding conveyed about a specific treatment regimen

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Suggested NICEnergy Management

Teaching: Prescribed Activity/Exercise

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The use of standardized outcome measures, such as NOC, offers nursing the opportunity to assume accountability for the effects of nursing interventions on the health of individual patients and the patient populations it serves. The ability to quantify the effects of the care nurses provide is essential for describing the value of nurses to consumers and other providers - (Marion Johnson, 1997, University of IOWA)

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End of Report

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CHF: A case studyName: Mr. EISex: MaleAddress: Makati CityAge: 64 years oldReligious Affiliation: Roman CatholicCivil Status: MarriedRoom : MICU Chief Complaint: Difficulty of breathing and

chest painMedical Diagnosis: CHDDate of Admission: January 2012

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PAST MEDICAL HISTORYThe past illnesses of the client include

colds, cough, fever, measles, and mumps. He said that he can’t remember anything when asked about his immunizations. He has no allergy to any foods, drugs and other things. He has been hospitalized in V. Luna General Hospital on 1990 for a total deep implant of the right hip due to work related accident His second hospitalization was on 1991 in Camp Panophio for a partial implant of the left hip. He discovered his Diabetes Mellitus on 1978 and has been insulin dependent 15 years ago.

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HISTORY OF PRESENT ILLNESSOne day prior to his admission, client

experience chest pain and difficulty of breathing. According to the client, this is not his first time to be confined with this condition. The client said that these were his problems in a day. He has supply of oxygen of 180 liters in his house to be consumed in a day estimated regulation of 7.5 liters per hour. He has maintenance drugs such as Imdur, Metformin and Aspirin.

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FAMILY HISTORY

The patient has a family history of cardiovascular disease and diabetes. According to the patient, his father died because of the complication of the heart while his mother died of being aspiration because of complications. According to the client, their eldest sibling died of heart disease and three among his living siblings have Diabetes Mellitus also.

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SOCIAL HISTORYAccording to the patient he has no vices

since then. He doesn’t smoke or even drink alcoholic beverages. He is a retired captain of the Philippine Constabulary (Philippine National Police now).

According to him, he prefers variety of foods, but at the present his diet are mostly fruits, vegetables and fish he seldom eats meat.

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NURSING CARE PLAN

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Nursing Care Plan

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Nursing Care Plan

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Nursing Care Plan

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Nursing Care Plan

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Sample NIC and NOCNIC – Hemodynamic RegulationsNOC – 0400 Cardiac Pump Effectiveness- Adequacy of blood volume ejected from the

left ventricle to support systemic perfusion pressure

- Desired Outcomes>Display hemodynamic stability>Report decreased episode of dsypnea,

angina, dysrhytmmias>Demonstrate an increase in activity

intolerance