Initial Discussion Post: •How will the RN update the plan of care? The RN would first review the goals and outcomes of the patient care plan. The next step would be to collect Reassessment Data, " Assess the client response to the interventions."(pg. 128 Treas, Wilkinson) in which include vitals, auscultation of breath sounds, observation of activity, and asking the patient how they are feeling and family for observation. The RN would record the evaluation summary in the nursing note or care plan about the conclusion whether the outcome was achieved and the reassessment data supports the judgment. In order to revise a care plan, an RN must " review all the steps of the nursing process."(pg. 130 Treas, Wilkinson). Include one intervention to address each of the nursing diagnoses that are still applicable. In 24 hours the patient goal was not met regarding Impaired Gas Exchange. The patient oxygen saturation was at 94 percent …show more content…
The expected outcomes are standards against which nurse judges if goals have been met. Evaluation of client response to nursing care requires the use of evaluative measure simply as the reassessment of patient symptoms. Vital signs and auscultation of breath sounds. Observation of client skill performance and discussion of how they feel. Lab results such as chest x-ray to confirm whether pneumonia diagnosis is still present. Labs such as Arterial blood gas gives information about a patient oxygenation, ventilation, and acid-base balance. Assess collaboration of client with healthcare team such as the physician, respiratory therapist. Last, you would interpret and summarize finding you would match evaluative measure with expected outcome to determine if client status improving or not improving. If goals have been met discontinue the portion of the care