NURSING PROCESS COMPLETE.pdf

NURSING PROCESS INTRODUCTION The nursing process is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty. “The nursing process...

NURSING PROCESS INTRODUCTION The nursing process is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty. “The nursing process provides the basis for critical thinking in nursing” The purpose of the nursing process Is to identify a client's health status and actual or potential health care problems or needs To establish plans to meet the identified needs To deliver specific nursing interventions to meet those needs. The client may be an individual, a family, or a group. Phases of the Nursing Process Although nurse theorists may use different terms to describe the phases of the nursing process, the activities of the nurse using the process are similar. For example, diagnosing may also be called analysis, and implementing may be called intervention or intervening. Phases of the Nursing Process cont’d The phases of the nursing process are not separate entities but overlapping, continuing sub processes. For example, assessing, which may be considered the first phase of the nursing process, is also carried out during the implementing and evaluating phases. For instance, while actually administering medications (implementing), the nurse continuously notes the client's skin color, level of consciousness, and so on. Phases of the Nursing Process cont’d Each phase of the nursing process affects the others; they are closely interrelated. For example, if inadequate data are obtained during assessing, the nursing diagnoses will be incomplete or incorrect; inaccuracy will also be reflected in the planning, implementing, and evaluating phases. CHARACTERISTICS OF THE NURSING PROCESS The nursing process has distinctive characteristics that enable the nurse to respond to the changing health status of the client. These characteristics include its Cyclic and dynamic nature Client centeredness Focus on problem solving and decision making, Interpersonal and collaborative style Universal applicability Use of critical thinking Cyclic and dynamic nature Data from each phase provide input into the next phase. Findings from evaluation feed back into assessment. Hence, the nursing process is a regularly repeated event or sequence of events (a cycle) that is continuously changing (dynamic) rather than staying the same (static). Client centeredness The nurse organizes the plan of care according to client problems rather than nursing goals. In the assessment phase, the nurse collects data to determine the client's habits, routines, and needs, enabling the nurse to incorporate client routines into the care plan as much as possible.  Focus on problem solving and decision making The nursing process is an adaptation of problem solving and systems theory. It can be viewed as parallel to but separate from the process used by physicians (the medical model). Both processes (a) Begin with data gathering and analysis (b) Base action (intervention or treatment) on a problem statement (nursing diagnosis or medical diagnosis) (c) Include an evaluative component Focus on problem solving and decision making cont’d However, the medical model focuses on physiological systems and the disease process, whereas the nursing process is directed toward a client's responses to disease and illness. Focus on problem solving and decision making cont’d Decision making is involved in every phase of the nursing process. Nurses can be highly creative in determining when and how to use data to make decisions. They are not bound by standard responses and may apply their repertoire of skills and knowledge to assist clients. This facilitates the individualization of the nurse's plan of care. Interpersonal and collaborative style It requires the nurse to communicate directly and consistently with clients and families to meet their needs. It also requires that nurses collaborate, as members of the health care team, in a joint effort to provide quality client care. Universal applicability The universally applicable characteristic of the nursing process means that it is used as a framework for nursing care in all types of health care settings, with clients of all age groups. Use of critical thinking Nurses must use a variety of critical-thinking skills to carry out the nursing process. The five overlapping phases of the nursing process. Each phase depends on the accuracy of the other phases. Each phase involves critical thinking. ASSESSING Collect data Organize data Validate data Document data DIAGNOSING Analyze data Identify health problems, risks, and strengths- Formulate diagnostic statements PLANNING Prioritize problems/diagnoses Formulate goals/desired outcomes Select nursing interventions Write nursing interventions IMPLEMENTING Reassess the client Determine the nurse's need for assistance Implement the nursing interventions Supervise delegated care Document nursing activities EVALUATING Collect data related to outcomes Compare data with outcomes Relate nursing actions to client goals/outcomes Draw conclusions about problem status Continue, modify, or terminate the client's care plan  ASSESSMENT Assessment is the first step in the nursing process. Assessing is the systematic and continuous collection, organization, validation, and documentation of data (information). In effect, assessing is a continuous process carried out during all phases of the nursing process.. For example, in the evaluation phase, assessment is done to determine the outcomes of the nursing strategies and to evaluate goal achievement. ASSESSMENT CONT’D The completeness and correctness of the information obtained during assessment are directly related to the accuracy of the steps that follow. There are four different types of assessments: initial assessment, problcm-focuscd assessment, emergency assessment, and time-lapsed reassessment.  ASSESSMENT CONT’D Nursing assessments focus on a client's responses to a health problem. It should include the client's perceived needs, health problems, related experience, health practices, values, and lifestyles The data collected should be relevant to a particular health problem Assessments vary according to their purpose, timing, time available, and client status. TYPE TIME PERFORMED PURPOSE EXAMPLE Initial assessment Performed within To establish a complete database Nursing admission assessment specified time after for problem identification, admission to a health care reference, and future comparison agency Problem-focused Ongoing process To determine the status of a Hourly assessment of client's fluid assessment integrated with nursing specific problem identified in an intake and urinary output in an care earlier assessment ICU Emergency During any physiologic or To identify life-threatening Rapid assessment of a person's assessment psychologic crisis of the problems, airway, breathing status, and client circulation during-a cardiac arrest To identify new or overlooked problems Assessment of suicidal tendencies or potential for violence Time-lapsed Several months after To compare the client's current Reassessment of a client's reassessment initial assessment status to baseline data previously functional health patterns in a obtained home care or outpatient setting or, in a hospital, at shift change Assessment steps Collecting data from a variety of sources Validating the data Organizing data Categorizing or identifying patterns in the data Making initial inferences or impressions Recording or reporting data  COLLECTING DATA Data collection is the process of gathering information about a client's health status. It must be both systematic and continuous to prevent the omission of significant data and reflect a client's changing health status. It includes the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. COLLECTING DATA CONT’D Client data should include past history as well as current problems. For example, a history of an allergic reaction to penicillin. Past surgical procedures, and chronic diseases are also examples of historical data. Current data relate to present circumstances, such as pain, nausea, sleep patterns, and religious practices. COLLECTING DATA CONT’D Assessment provides information that will form the client database. Two types of information are collected through the assessment component: subjective objective  Subjective data Also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. Itching, pain, feelings of worry, values, beliefs, attitudes, and perception of personal health status and life situation The method of collecting subjective information is primarily the interview. Using therapeutic interviewing techniques, the nurse collects data that will begin to build the client database. Subjective data cont’d Examples of subjective information include such statements as: “I drink only coffee for breakfast.” “I have had pains in my legs for three days now.” “I go to sleep easily each night, but I wake up about two hours later and cannot go back to sleep until it is time to get up in the morning.”  Objective data Also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. Obtained through both standard assessment techniques performed during the physical examination and diagnostic tests which provides information about the function of body systems. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. Objective data cont’d Examples of objective information include: T 98.6°F, P 100, R 12, B/P 130/76 Bowel sounds auscultated in all four quadrants Gait slow, shuffling, and unsteady A discoloration of the skin.  SOURCES OF DATA Sources of data are primary or secondary. The client is the primary source of data. Family members or other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant literature are secondary or indirect sources. In fact, all sources other than the client are considered secondary sources. All data from secondary sources should be validated if possible. SOURCES OF DATA CONT’D Client Support people Client record Health professional literature  DATA COLLECTION METHODS The principal methods used to collect data are Observation occurs whenever the nurse is in contact with the client or support persons. To observe is to gather data by using the senses. Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. Although nurses observe mainly through sight, most of the senses are engaged during careful observations. DATA COLLECTION METHODS CONT’D Interviewing is used mainly while taking the nursing health history. An interview is a planned communication or a conversation with a purpose, for example, to get or give information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. One example of the interview is the nursing health history, which is a part of the nursing admission assessment. DATA COLLECTION METHODS CONT’D Examining is the major method used in the physical health assessment. The physical examination or physical assessment is a systematic data collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems. To conduct the examination the nurse uses techniques of inspection, auscultation, palpation, and percussion DATA COLLECTION METHODS CONT’D In reality, the nurse uses all three methods simultaneously when assessing clients. For example, during the client interview the nurse observes, listens, asks questions, and mentally retains information to explore in the physical examination.  VALIDATING DATA The information gathered during the assessment phase must be complete, factual, and accurate because the nursing diagnoses and interventions are based on this information. Validation is the' act of "double-checking" or verifying data to confirm that it is accurate and factual. Validating data helps the nurse complete these tasks: ▪ Ensure that assessment information is complete. ▪ Ensure that objective and related subjective data agree,  VALIDATING DATA CONT’D ▪ Obtain additional information that may have been overlooked. ▪ Differentiate between cues and inferences. Cues are subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure. ▪ Inferences are the nurse's interpretation or conclusions made based on the cues (e.g., a nurse observes the cues that an incision is red, hot, and swollen; the nurse makes the inference that the incision is infected).  VALIDATING DATA CONT’D ▪ Avoid jumping to conclusions and focusing in the wrong direction to identify problems. Not all data require validation. For example, data such as height, weight, birth date, and most laboratory studies that can be measured with an accurate scale can be accepted as factual. As a rule, the nurse validates data when there are discrepancies between data obtained in the nursing interview (subjective data) and the physical examination (objective data), or when the client's statements differ at different times in the assessment.  DOCUMENTING DATA To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client's health status. Data are recorded in a factual manner and not interpreted by the nurse. For example, the nurse records the client's breakfast intake (objective data) as "coffee 240 mL, juice 120 mL, 1 egg, and 1 slice of toast," rather than as "appetite good" (a judgment). DOCUMENTING DATA CONT’D A judgment or conclusion such as "appetite good" or "normal appetite" may have different meanings for different people. To increase accuracy, the nurse records subjective data in the client's own words, using quotation marks. Restating in other words what someone says increases the chance of changing the original meaning. EXAMPLE A 4-year-old girl is admitted following emergency surgery for a ruptured appendix. She is awake and alert, but refuses to talk. Her parents have had little sleep for over 24- hours and are extremely anxious. EXAMPLE CONT’D Gathering assessment data in this situation requires the nurse to be sensitive to the parents' needs for rest and assurance; at the same time, the nurse must collect information to compile an adequate database for appropriate nursing care decisions. Assessment will be problem focused, monitoring the condition of the child as she recovers from surgery and being alert to potential problems. EXAMPLE CONT’D The parents become the major source of subjective data, although the child should be encouraged to tell the nurse how she is feeling. Objective data collected include vital signs; level of and response to pain (often called the fifth vital sign); bleeding or discharge from the incision; mobility; integrity of dressings, intravenous lines, catheters, nasogastric tubes, or other medical devices; and affect.  DIAGNOSIS INTRODUCTION The second step in the nursing process involves further analysis (breaking the whole down into parts that can be examined) and synthesis (putting data together in a new way) of the data that have been collected. INTRODUCTION CONT’D In this phase, nurses use critical-thinking skills to interpret assessment data and identify client strengths and problems. Diagnosing is a pivotal step in the nursing process. Activities preceding this phase are directed toward formulating the nursing diagnoses; the care-planning activities following this phase are based on the nursing diagnoses INTRODUCTION CONT’D Formulation of the list of nursing diagnoses is the outcome of this process. According to the North American Nursing Diagnosis Association (NANDA) a nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. INTRODUCTION CONT’D The nursing diagnoses developed during this phase of the nursing process provide the basis for client care delivered through the remaining steps. Client problems are labeled by both medical and nursing diagnoses. The nurse uses critical-thinking and decision-making skills in developing nursing diagnoses. INTRODUCTION CONT’D This process is facilitated by asking questions such as: Are there problems here? If so, what are the specific problems? What are some possible causes for the problems? Is there a situation involving risk factors? What are the risk factors? INTRODUCTION CONT’D Is there a situation in which a problem can develop if preventive measures are not taken? What are the client’s strengths? What data are available to answer these questions? Are more data needed to answer the question? If so, what are some possible sources of the data that are needed?  Types of Nursing Diagnoses The five types of nursing diagnoses are actual, risk, health promotion nursing diagnosis, and syndrome. An actual nursing diagnosis is a client problem that is present at the time of the nursing assessmentand are supported by defining characteristics (signs and symptoms).. Examples are Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms. "Impaired Physical Mobility related to pain as evidenced by limited range of motion."  A risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. They are not evidenced by signs and symptoms because they haven't occurred yet. For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label Risk for Infection to describe the client's health status. "Risk for Infection related to compromised immune system."  Health Promotion Nursing Diagnosis: These diagnoses focus on the patient's readiness to improve their health and well-being. They are based on the patient’s expression of a desire to enhance their health behaviors. For example, "Readiness for Enhanced Nutrition as evidenced by expressed desire to learn about healthy eating."  A syndrome nursing diagnosis These diagnoses cluster together several predicted actual or high-risk diagnoses that are present due to a certain event or situation. Risk for Disuse Syndrome, for example, may be experienced by long-term bedridden clients. Clusters of diagnoses associated with this syndrome include Impaired Physical Mobility, Risk for Impaired Tissue Integrity, Risk for Activity Intolerance, Risk for Constipation, Risk for Infection, Risk for Injury, Risk for Powerlessness, Impaired Gas Exchange, and so on. "Post-Trauma Syndrome related to physical assault as evidenced by flashbacks, anxiety, and hypervigilance." NURSING DIAGNOSIS A nursing diagnosis has three components: a. The problem and its definition b.The etiology c. The defining characteristics. Each component serves a specific purpose Problem (Diagnostic Label) and Definition It describes the client's health problem or response for which nursing therapy is given. It describes the client's health status clearly and concisely in a few words. The purpose of the diagnostic label is to direct the formation of client goals and desired outcomes. It may also suggest some nursing interventions Problem (Diagnostic Label) and Definition cont’d To be clinically useful, diagnostic labels need to be specific; the nurse states the area in which the problem occurs, for example, Deficient Knowledge (Medications) or Deficient Knowledge (Dietary Adjustments). Problem (Diagnostic Label) and Definition cont’d ▪ Deficient (inadequate in amount, quality, or degree; not sufficient; incomplete) ▪ Impaired (made worse, weakened, damaged, reduced, deteriorated) ▪ Decreased (lesser in size, amount, or degree) ▪ Ineffective (not producing the desired effect) ▪ Compromised (to make vulnerable to threat) Etiology (Related Factors and Risk Factors) It identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care. For example the causes of Activity Intolerance include sedentary lifestyle, generalized weakness, and so on. Differentiating among possible causes in the nursing diagnosis is essential because each may require different nursing interventions. Defining characteristics Are cluster of signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client's signs and symptoms. For risk nursing diagnoses, no subjective and objective signs are present. Thus, the factors that cause the client to be more vulnerable to the problem form the etiology of a risk nursing diagnosis.  The diagnostic process has three steps: ❑Analyzing data ❑Identifying health problems, risks, and strengths ❑Formulating diagnostic statements ANALYZING DATA In the diagnostic process, analyzing involves the following steps: 1. Compare data against standards (identify significant cues). 2. Cluster cues (generate tentative hypotheses). 3. Identify gaps and inconsistencies.  Comparing Data with Standards Nurses draw on knowledge and experience to compare client data to standards and norms and identify significant and relevant cues. The nurse uses a wide range of standards, such as growth and development patterns, normal vital signs, and laboratory values. A cue is considered significant if it does any of the following: ❖ Points to negative or positive change in a client's health status or pattern. ❖ Varies from norms of the client population. ❖ Indicates a developmental delay. Clustering Cues Data clustering or grouping cues is a process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant. This is the beginning of synthesis. The nurse may cluster data inductively by combining data from different assessment areas to form a pattern. IDENTIFYING HEALTH PROBLEMS, RISKS, AND STRENGTHS After data are analyzed, the nurse and client can together identify strengths and problems. Determining Problems and Risks After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses. In addition the nurse must determine whether the client's problem is a nursing diagnosis, medical diagnosis, or collaborative problem. IDENTIFYING HEALTH PROBLEMS, RISKS, AND STRENGTHS Note that some data may indicate a possible problem but when clustered with other data, the possible problem disappears. "Decreased urinary frequency and amount x 2 days," suggests a possible urinary elimination problem. However, when these data are considered along with data associated with Deficient Fluid Volume, the nurse eliminates urinary elimination as a problem. Determining Strengths The nurse and client also establish the client's strengths, resources, and abilities to cope. Strengths can be an aid to mobilizing health and regenerative processes. A client's strength might be weight that is within the normal range for age and height, thus enabling the client to cope better with surgery. In another instance, a client's strengths might be absence of allergies and being a nonsmoker. Determining Strengths cont’d A client's strengths can be found in The nursing assessment record (health, home life, education, recreation, exercise, work, family and friends, religious beliefs, and sense of humor, for example), The health examination The client's records. FORMULATING DIAGNOSTIC STATEMENTS Most nursing diagnoses are written as two-part or three-part statements, but there are variations of these. Basic Two-Part Statements The basic two-part statement includes the following: 1. Problem (P): statement of the client's response (NANDA label) 2. Etiology (E): factors contributing to or probable causes of the responses  Basic Three-Part Statements The basic three-part nursing diagnosis statement is called the PES format and includes the following: 1. Problem (P): statement of the client's response (NANDA label) 2. Etiology (E): factors contributing to or probable causes of the response 3. Signs and symptoms (S): defining characteristics manifested by the client  Activity intolerance related to; Bed rest Immobility Generalized weakness Sedentary lifestyle Imbalance between oxygen supply and demand Secondary to; ✓Abnormal blood pressure and heart rate response to activity ✓Exertional discomfort and/or dyspnea ✓Verbal report of fatigue and/or weakness  One-Part Statements Some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses, consist of a NANDA label only. As the diagnostic labels are refined, they tend to become more specific, so that nursing interventions can be derived from the label itself. Therefore, an etiology may not be needed. For example, adding an etiology to the label Rape-Trauma Syndrome does not make the label any more descriptive or useful.  Some nurses are confused about how to document a nursing diagnosis because they think the language is too complex. By remembering the following basic guidelines, however, you can ensure that your diagnostic statement is correct: Use proper terminology that reflects the patient’s nursing needs. Make your statement concise so it’s easily understood by other healthcare team members. Use the most precise words possible. Use a problem-and-cause format, stating the problem and its related cause. The following examples should help clarify what a nursing diagnosis is: Don’t state a need instead of a problem. – Incorrect: Fluid replacement related to fever – Correct: Deficient fluid volume related to fever Don’t reverse the two parts of the statement. – Incorrect: Lack of understanding related to noncompliance with diabetic diet –Correct: Noncompliance with diabetic diet related to lack of understanding  Don’t identify an untreatable condition instead of the problem it indicates (which can be treated). – Incorrect: Inability to speak related to laryngectomy – Correct: Social isolation related to inability to speak because of laryngectomy Don’t write a legally inadvisable statement. – Incorrect: Skin integrity impairment related to improper positioning – Correct: Impaired skin integrity related to immobility  Don’t identify as unhealthful a response that would be appropriate, allowed for, or culturally acceptable. – Incorrect: Anger related to terminal illness – Correct: Ineffective therapeutic regimen management related to anger over terminal illness Don’t make a tautological statement (one in which both parts of the statement say the same thing). – Incorrect: Pain related to alteration in comfort – Correct: Acute pain related to postoperative abdominal distention and anxiety  Don’t identify a nursing problem instead of a patient problem. – Incorrect: Difficulty suctioning related to thick secretions – Correct: Ineffective airway clearance related to thick tracheal secretions EXAMPLES dehydration Nutrition (less than body requirement) Chest pain. General body weakness. Difficulty in breathing PLANNING Is the third step of the nursing process and includes the formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses and the development of the client’s plan of care. Once the nursing diagnoses have been developed and client strengths have been identified, planning can begin.  The planning phase involves several tasks: The list of nursing diagnoses is prioritized. Client-centered long- and short-term goals and outcomes are identified and written. Specific interventions are developed. The entire plan of care is recorded in the client’s record.  Once the list of nursing diagnoses has been developed from the data, decisions must be made about priority. Critical thinking enables the nurse to make decisions about which diagnoses are the most important and need attention first. There are a number of frameworks used to prioritize nursing diagnoses; however, those diagnoses involving life-threatening situations are given the highest priority.  For example, the following nursing diagnoses would be stated in this order of priority: Ineffective Airway Clearance related to excessive and thick secretions and pain secondary to surgery and inability to cough effectively; respirations: 25, shallow, wheezing Risk for Injury (falls) related to unsteady gait Imbalanced Nutrition: Less Than Body Requirements related to nausea and vomiting  Client-centered goals are established in collaboration with the client whenever possible. A goal is an aim, intent, or end. Goals are broad statements that describe the intended or desired change in the client’s behavior. Goal statements refer to the diagnostic label (or problem statement) of the nursing diagnosis. Client-centered goals assure that nursing care is individualized and focused on the client.  Expected outcomes are specific objectives related to the goals and are used to evaluate the nursing interventions. They must be measurable, have a time limit, and be realistic. Once goals and expected outcomes have been established, nursing interventions are planned that enable the client to reach the goals.  A nursing intervention is the activity that the nurse will execute for and with the client to enable accomplishment of the goals. Nursing interventions refer directly to the related factors in the actual nursing diagnoses and the risk factors in risk nursing diagnoses. Nursing interventions also refer to the diagnostic label for possible diagnoses and focus on data needed to confirm or eliminate the diagnosis. As the nurse interacts with the client, assesses responses to interventions, and evaluates those responses, interventions may change.  There may be a number of nursing interventions. Interventions are individualized and are stated in specific terms. 1. Observation pain scale (0-10), characteristics and location of pain. 2. Let the patient take a comfortable position and increase bed rest 3. Give a gentle massage 4. Give the medicine before the activity / exercise is planned 5. Apply ice or a cold pack if necessary The list of interventions is not static, as the nurse interacts with the client, assesses responses to interventions, and evaluates those responses, interventions may change. IMPLEMENTATION The fourth step and involves the execution of the nursing plan of care derived during the planning phase. It consists of performing nursing activities that have been planned to meet the goals set with the client. Nurses may delegate some of the nursing interventions to other persons assigned to care for the client—for example, the licensed practical nurses and unlicensed assistive personnel.  Implementation involves many skills. The nurse must continue to assess the client’s condition before, during, and after the nursing intervention. Assessment prior to the intervention provides the nurse with baseline data. Assessment during and after the intervention allows the nurse to detect positive or negative responses the client may have to the intervention.  The nurse uses psychomotor skills when performing procedures such as giving injections, changing dressings, and helping the client perform range-of-motion (ROM) exercises. Interpersonal skills are necessary as the nurse interacts with the client and the family to collect data, provide information in teaching sessions, and offer support in times of anxiety. Critical thinking skills enable the nurse to think through the situation, ask the appropriate questions, and make decisions about what needs to be done.  The implementation step also involves reporting and documentation. Data to be recorded include the client condition prior to the intervention, the specific intervention performed, the client response to the intervention, and client outcomes.  Evaluation The fifth step in the nursing process, involves determining whether the client goals have been met, partially met, or not met. If the goal has been met, the nurse must then decide whether nursing activities will cease or continue in order for status to be maintained. If the goal has been partially met or not been met, the nurse must reassess the situation. Data are collected to determine why the goal has not been achieved and what modifications to the plan of care are necessary.  There are a number of possible reasons that goals are not met or are only partially met, including: The initial assessment data were incomplete. The goals and expected outcomes were not realistic. The time frame was too optimistic. The goals and/or the nursing interventions planned were not appropriate for the client.  Evaluation is an ongoing process. Nurses continually evaluate data in order to make informed decisions during other phases of the nursing process. pneumonia Ineffective Airway Clearance Nursing Diagnosis Ineffective Airway Clearance May be related to Tracheal bronchial inflammation, edema formation, increased sputum production Pleuritic pain Decreased energy, fatigue Possibly evidenced by Changes in rate, depth of respirations Abnormal breath sounds, use of accessory muscles Dyspnea, cyanosis Cough, effective or ineffective; with/without sputum production Desired Outcomes Identify/demonstrate behaviors to achieve airway clearance. Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis. Intervention Assess the rate and depth of respirations and chest movement Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes Assess the rate and depth of respirations and chest movement. Teach and assist patient with proper deep-breathing exercises. Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions  Force fluids to at least 3000 mL/day (unless contraindicated, as in heart failure). Offer warm, rather than cold, fluids. Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics Impaired Gas Exchange Nursing Diagnosis Impaired Gas Exchange May be related to Alveolar-capillary membrane changes (inflammatory effects) Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting oxyhemoglobin curve) Altered delivery of oxygen (hypoventilation)  Possibly evidenced by Dyspnea, cyanosis Tachycardia Restlessness/changes in mentation Hypoxia Desired Outcomes Demonstrate improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress. Participate in actions to maximize oxygenation. Intervention Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nail beds) or central cyanosis (circumoral). Assess respiratory rate, depth, and ease. Observe color of skin, mucous membranes, and nailbeds, noting presence of peripheral cyanosis (nail beds) or central cyanosis (circumoral).  Maintain bedrest. Encourage use of relaxation techniques and diversional activities. Elevate head and encourage frequent position changes, deep breathing, and effective coughing. Administer oxygen therapy by appropriate means: nasal prongs, mask, Venturi mask.