NURSING PROCESS which help in patient care

nursing process is a process used in patient care for assessment, diagnosis and prognosis

1. NURSING PROCESS

3. The American Nurses Association (ANA) in
2010 defined the nursing process as a critical
thinking process that nurses use to apply the
best available evidence to caregiving and
promoting human functions and responses to
health and illness.
Nursing process is a systematic method of care to
clients.

4. DEFINITION
Nursing process is a systematic organized pattern of
determining the health status, defined as alterations in
human need fulfillment, making plans to solve them,
initiating and implementing the plan, evaluating the
extent to which the plan was effective in promoting
optimum wellness and resolving the problems identified.
Yura & Walsh (1988)

5. Cont……

Nursing process is an organized systematic process
of giving individualized nursing care that focuses on
identifying and treating unique nursing problems of
individual/group actual/potential health problems.

7. PURPOSE OF THE NURSING
PROCESS
To identify the client’s health status and actual or
potential health care problems or needs (through
assessment).
To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet those
needs.
To apply the best available care giving evidence and
promote human functions and responses to health and
illness (ANA, 2010).

8. CONT…
To protect nurses against legal problems related
to nursing care when the standards of the
nursing process are followed correctly.
To help the nurse perform in a systematically
organized way their practice.
To establish a database about the client’s health
status, health concerns, response to illness, and
the ability to manage health care needs.

9. CHARACTERISTICS OF NURSING
PROCESS
Patient-centered. Care respectful of and responsive to the
individual patient’s needs, preferences, and values.
Interpersonal. The nursing process provides the basis for the
therapeutic process in which the nurse and patient respect each
other as individuals, both of them learning and growing due to the
interaction. It involves the interaction between the nurse and the
patient with a common goal.
Collaborative. The nursing process functions effectively in nursing
and inter-professional teams, promoting open communication,
mutual respect, and shared decision-making to achieve
quality patient care.

10. CONT…..
Dynamic and cyclical. The nursing process is a
dynamic, cyclical process in which each phase
interacts with and is influenced by the other
phases.
Requires critical thinking. The use of the
nursing process requires critical thinking which
is a vital skill required for nurses in identifying
client problems and implementing interventions
to promote effective care outcomes.

11. BENEFITS OF NP
Organized and systematic nursing care
Prevents communication barrier
Deliver holistic care
Aids continuity of care
Prevents duplication
Identifies unique problem strength and weakness
Promotes flexibility
Improves patient safety
Improves patient satisfaction
Promotes quality patient care
Increases the likelihood of achieving positive patient outcomes
Saves time, energy, and frustration by creating a care plan or path
to follow

12. CRITICAL THINKING
Before learning how to use the nursing process, it
is important to understand some basic concepts
related to critical thinking and nursing practice.
 Let’s take a deeper look at how nurses think.

13. Definition
Critical thinking in nursing is a discipline specific,
reflective reasoning process that guides a nurse in
generating, implementing, and evaluating approaches
for dealing with client care and professional concerns.
National league for nursing - 2000

14. WHAT IS CRITICAL THINKING
• Chafee (2002) – Active, organized, cognitive process
used to examine one’s thinking and that of others
• Settersten and Lauver (2004) – It involves
recognizing an issue exists, analyzing information about
the issue, evaluating the issue, and making conclusions.

15. CRITICAL THINKING AND
CLINICAL REASONING
 Critical thinking is a broad term used in
nursing that includes “reasoning about clinical
issues such as teamwork, collaboration, and
streamlining workflow.” Using critical thinking
means that nurses take extra steps to maintain
patient safety and don’t just “follow orders.”
It also means the accuracy of patient information
is validated and plans for caring for patients are
based on their needs, current clinical practice,
and research.
 Creativity is the major component of critical
thinking

16. Skills involved in critical thinking
•Critical analysis- application of set of questions to a
particular situation to determine essential
information and discard superfluous information.
•Inductive reasoning- generalization are formed from
set of observation or facts
•Deductive reasoning- specific conclusions are made
from general premise

17. Levels of
critical
thinking

18. Kataoka-Yahiro and Saylor (1994) developed a critical
thinking model.
Basic Critical Thinking
At the basic level of critical thinking a learner trusts that
experts have the right answers for every problem.
Thinking is concrete and based on a set of rules or
principles. For example, as a nursing student use a
hospital procedure manual to confirm how to insert a
Foley catheter. Students likely follow the procedure step
by step without adjusting it to meet a patient’s unique
needs (e.g., positioning to minimize the patient’s pain or
mobility restrictions). 

19. Complex Critical Thinking
Complex critical thinkers begin to separate themselves
from experts. They analyze and examine choices
more independently. The person’s thinking abilities
and initiative to look beyond expert opinion begin to
change. A nurse learns that alternative and perhaps
conflicting solutions exist.
Commitment
The third level of critical thinking is commitment, At
this level a person anticipates when to make choices
without assistance from others and accepts
accountability for decisions made.

20. Critical thinkers” possess certain attitudes that foster
rational thinking.
 Independence of thought: 
Thinking on your own
Fair-mindedness: 
Treating every viewpoint in an unbiased,
unprejudiced way
Insight into egocentricity and sociocentricity: 
Thinking of the greater good and not just thinking
of yourself. Knowing when you are thinking of yourself
(egocentricity) and when you are thinking or acting for the
greater good (sociocentricity)
Intellectual humility: 
Recognizing your intellectual limitations and
abilities
Intellectually Humble:

21. Nonjudgmental: Using professional ethical
standards and not basing your judgments on your own
personal or moral standards
Integrity: Being honest and demonstrating strong
moral principles
Perseverance: Persisting in doing something despite
it being difficult
Confidence: Believing in yourself to complete a task
or activity
Interest in exploring thoughts and feelings: 
Wanting to explore different ways of knowing
Curiosity: Asking “why” and wanting to know more

25. Standards for critical thinking
Intellectual standards professional standards
Clear ethical criteria for nursing
Precise judgement
Specific
Accurate criteria for evaluation
Relevant
Plausible (reasonable) professional responsibility
consistent
Logical
Deep
Broad
Complete
Significant
Adequate
fair

26. STEPS IN NURSING PROCESS
The acronym ADPIE 
A-Assessment
D- Diagnosis
P- Planning
I- Implementation, and 
E- Evaluation.

27. ASSESSMENT
 According to Carpenito :-Assessment is the deliberate and
systematic collection of data to determine a client’s current
and past health status, functional status and to determine
the client’s present and coping patterns.
Atkinson and murray(1991) :- Assessment is a part of each
activity the nurse does for and with the patient.

28. PURPOSE OF ASSESSMENT
To gather information regarding client’s health.
To determine client’s normal function.
To organize the collected information.
To enhance investigation of nursing problems.
To frame nursing diagnosis.
It increases greater managing skill of handling patient’s
problem.
To identify the health problems.
 To identify client’s strengths.
 To identify need for health teaching.

30. ASSESSMENT
The first phase of the nursing process
is assessment. It involves collecting, organizing,
validating, and documenting the clients’ health status.
D – Data collection
V – Validation
O – Organize
I – Identify the patterns
C – Communicating / recording

31. Collecting Data
Data collection is the process of gathering
information regarding a client’s health status. The
process must be systematic and continuous in
collecting data to prevent the omission of important
information concerning the client.
Objective data (Sign)are overt, measurable, tangible
data collected via the senses, such as
sight, touch, smell, or hearing, and compared to an
accepted standard, such as vital signs, intake and
output, height and weight, body temperature, pulse,
and respiratory rates, blood pressure, vomiting,
distended abdomen, presence of edema, lung sounds,
crying, skin color, and presence of diaphoresis.

32. Subjective Data or Symptoms
Subjective data involve covert information, such
as feelings, perceptions, thoughts, sensations, or
concerns that are shared by the patient and can
be verified only by the patient, such
as nausea, pain, numbness, pruritis, attitudes,
beliefs, values, and perceptions of the health
concern and life events.

33. WHAT’S UP? GUIDE TO SYMPTOM
ASSESSMENT
W—Where is it?
H—How does it feel? Describe the quality.
A—Aggravating and alleviating factors. What makes it
worse? What makes it better?
T—Timing. When did it start? How long does it last?
S—Severity. How bad is it? This can often be rated on a
scale of 0 to 10.
 U—Useful other data. What other symptoms are present
that might be related?
 P—Patient’s perception of the problem.

34. VERBAL DATA
Verbal data are spoken or written data such as
statements made by the client or by a secondary
source.
Verbal data requires the listening skills of the
nurse to assess difficulties such as slurring, tone
of voice, assertiveness, anxiety, difficulty in
finding the desired word, and flight of ideas.

35. NONVERBAL DATA
Nonverbal data are observable behavior
transmitting a message without words, such as
the patient’s body language, general appearance,
facial expressions, gestures, eye contact, touch,
posture, clothing.
Nonverbal data obtained can sometimes be more
powerful than verbal data, as the client’s body
language may not be congruent with what
they really think or feel. Obtaining and
analyzing nonverbal data can help reinforce
other forms of data and understand what the
patient really feels.

37. SOURCES OF DATA
Primary Source
The client is the only primary source of data and the only one who
can provide subjective data.
Secondary Source
A source is considered secondary data if it is provided from someone
else other than the client but within the client’s frame of reference.
Information provided by the client’s family or significant others are
considered secondary sources of data if the client cannot speak for
themselves, is lacking facts and understanding, or is a child.
Additionally, the client’s records and assessment data from other
nurses or other members of the healthcare team are considered
secondary sources of data.

38. Tertiary Source
Sources from outside the client’s frame of
reference are considered tertiary sources of
data. Examples of tertiary data include
information from textbooks, medical and nursing
journals, drug handbooks, surveys, and policy
and procedural manuals.

39. TYPES OF ASSESSMENT
Initial assessment; is performed shortly after
patient admission to a health agency or hospital .
Focused assessment; the nurse gathers data
about a specific problem that has already been
identified.
Emergency assessment, the nurse performs
this type of assessment on a physiological or
psychological crisis to identify the life –
threatening problems.
Time – lapsed assessment, this assessment
done to compare a patient's current status to the
base line data obtained earlier .

41. Data collection methods
Interview
Observation
 physical examination

51. VALIDATING DATA
Validation is the process of verifying the data to
ensure that it is accurate and factual. One way to
validate observations is through “double-
checking,” and it allows the nurse to complete
the following tasks:
Ensures that assessment information is double-
checked, verified, and complete.
Ensure that objective and related subjective data
are valid and accurate.
Documenting the data

52. Ensure that the nurse does not come to a
conclusion without adequate data to support the
conclusion.
Ensure that any ambiguous or vague statements
are clarified.
Acquire additional details that may have been
overlooked.
Distinguish between cues and inferences.

53. NOTE: Assessment does not end with the initial
interview and physical examination.
Assessment is dynamic and continues with each
nurse-client interaction.

55. Nursing Diagnosis: Is a clinical judgment
about individual , family or community response
to actual or potential health problem.
It provides the bases for selection of nursing
intervention.
Medical diagnosis : Is a clinical judgment by
the physician that identifies or determines a
specific disease condition, or pathological state.

57. DIAGNOSTIC PROCESS:
There are three phases
Data analysis
 Identification of the client’s health problems,
health risks, and strengths, and
Formulation of diagnostic statements.

58. PARTS OF NURSING DIAGNOSIS
Problem: statement that describe the health
problem of the patient clearly & concisely.
Etiology : The reason (etiology)that identifies the
physiological , psychological ,social ,spiritual &
environmental factors related to the problem.
Defining characteristics (signs or symptoms ):
The subjective & objective data that signal the
existence of the problem.

59. COMPARISON OF MEDICAL DIAGNOSES
AND NURSING DIAGNOSES
Medical Diagnosis Nursing Diagnosis
Focuses on illness, injury, or disease
Process
Focuses on clients responses to actual
or potential health problems or life
processes.
Remains constant until a cure is
effected or client dies.
Changes as the client’s response
and/or the health problem changes.
Recognizes conditions the physician is
licensed and qualified to treat.
Recognizes situations that the nurse
is licensed and qualified to intervene.
Example: (Lung cancer, Congestive
heart failure, Brain tumor,
Exploratory surgery, Appendectomy,
Bronchial asthma).
Example: (Nausea, Acute pain,
Anxiety, Impaired physical mobility,
Ineffective breathing pattern, Risk for
imbalanced fluid volume).

60. TYPES OF NURSING DIAGNOSES
 Actual nursing diagnosis (Actual problems): Indicates that a
problem exists. Composed of (diagnostic label(problem), related
factors, and signs and symptoms).
Eg:
 Impaired Skin Integrity related to prolonged pressure on bony
prominence as manifested by stage II pressure ulcer over coccyx,
3 cm 13 in diameter.
 Anxiety related to stress as evidenced by increased tension,
apprehension, and expression of concern regarding
upcoming surgery
Acute pain related to decreased myocardial flow as evidenced
by grimacing, expression of pain, guarding behavior.

61. Activity intolerance related to
generalized weakness.
Decreased cardiac output related to abnormality
in blood profile

62. CONTINUE….
Risk nursing diagnosis (Potential problems):
Indicates that a problem does not yet exist, but special
risk factors are
A risk diagnosis is composed of the diagnostic label
preceded by the phrase “risk for” with the specific risk
factors listed.
Eg:
 Risk for Impaired Skin Integrity related to immobility
and lack of ability to reposition self.
Risk for falls related to age-related changes, decreased
vision, and muscle weakness
Risk for infection as evidenced by break in skin
integrity.

63. HEALTH PROMOTION NURSING
DIAGNOSIS: (WELLNESS
DIAGNOSIS):
Indicates the client’s expression of a desire to
attain a higher level of wellness in some area of
function.
Components of a health promotion diagnosis
generally include only the diagnostic label or
a one-part statement.
 Composed of the diagnostic label preceded by the
phrase “potential for enhanced.” For example a
client who is neither overweight nor underweight
tells the nurse that she knows she could improve
her diet in some ways.

64. She expresses a desire to know more about
how to improve her diet. Potential for
Enhanced Nutrition
“Readiness for Enhanced Breastfeeding.”
Readiness for enhanced health literacy

65. SYNDROME DIAGNOSIS
A syndrome diagnosis is a clinical judgment
concerning a cluster of problem or risk nursing
diagnoses that are predicted to present because
of a certain situation or event.
written as a one-part statement requiring only
the diagnostic label.
Chronic Pain Syndrome

66. Syndrome nursing diagnoses are clusters of
multiple related diagnoses that are best
addressed with similar interventions.
Examples include Acute Respiratory Distress
Syndrome (ARDS), which can manifest as
impaired gas exchange, ineffective breathing
pattern, and activity intolerance due to changes
in lung compliance

68. PROBLEM AND DEFINITION
The problem statement, or the diagnostic
label, describes the client’s health problem
A diagnostic label usually has two parts:
qualifier and focus of the diagnosis.
 Qualifiers (also called modifiers) are words
that have been added to some diagnostic labels to
give additional meaning, limit, or specify the
diagnostic statement. 
Exempted in this rule are one-word nursing
diagnoses (e.g.,
Anxiety, Constipation, Diarrhea, Nausea, etc.)
where their qualifier and focus are inherent
in the one term.

69. Qualifier Focus of the Diagnosis
Deficient Fluid volume
Imbalanced
Nutrition: Less Than Body
Requirements
Impaired Gas Exchange
Ineffective Tissue Perfusion
Risk for Injury

71. PLANNING

72. Meaning
It is the category of nursing process which include
outcome & goals, intervention designed to meet the
problems / needs.
Planning involves decision making and problem
solving

73. TYPES OF PLANNING
Initial Planning: which is done after the initial
assessment
Ongoing Planning: continuous planning
Discharge planning: Planning for needs after
discharge

74. Planning process Steps
Setting priorities
Setting goals/Desired outcome
Formulating the intervention
Writing individualized nursing interventions on care
plan

75. Setting priorities
Principles:
Priority rating is influenced by the following
factor
client feeling
 client general health status
 presence of potential problem
Problem likely to cause complication should be given
priority
Nurses frequently use Maslow’s hierarchy of needs
when setting priorities

76. Steps to prioritize:
Ask yourself
- Is that immediate problem
- If not initiated, what will happen?
- How to initiate treatment

77. GOAL/EXPECTED OUTCOME
 A "goal" is a broad, general statement about the
desired patient outcome, while an "expected
outcome" is a specific, measurable action that the
patient is expected to achieve within a certain
timeframe, directly resulting from nursing
intervention.

78. TYPES
Goals can be short- or long-term. The time frame
for short- and long-term goals is dependent on
the setting in which the care is provided. For
example, in a critical care area, a short-term goal
might be set to be achieved within an 8-hour
nursing shift, and a long-term goal might be in
24 hours.
In contrast, in an outpatient setting, a short-term
goal might be set to be achieved within one
month and a long-term goal might be within six
months.

79. Outcome statements are always patient-centered.
They should be developed in collaboration with
the patient and individualized to meet a patient’s
unique needs, values, and cultural beliefs. They
should start with the phrase “The patient
will…” Outcome
 statements should be directed at resolving
the defining characteristics for that nursing
diagnosis.
Additionally, the outcome  must be something
the patient is willing to cooperate in
achieving.

80. Outcome statements should contain five
components easily remembered using the “SMART”
mnemonic
Be specific. 
Keep it measurable
Keep it attainable/ Action oriented. 
Be realistic.
Keep it timely. 

81. SPECIFIC / MEASURABLE
Not specific: The patient will increase the
amount of exercise.
Specific: The patient will participate in a
bicycling exercise session daily for 30 minutes.
Not measurable:  The patient will drink
adequate fluid amounts every shift.
Measurable:  The patient will drink 24 ounces of
fluids during every day shift

82. ATTAINABLE/REALISTIC
Not action-oriented: The patient will get
increased physical activity.
Action-oriented:  The patient will list three
types of aerobic activity that he would enjoy
completing every week.
Not realistic:  The patient will jog one mile
every day when starting the exercise program.
Realistic:  The patient will walk ½ mile three
times a week for two weeks.

83. TIME ORIENTED
Not time limited:  The patient will stop
smoking cigarettes.
Time limited:  The patient will complete the
smoking cessation plan by December 12, 2025.

86. Formulating nursing intervention
Definition:
It is a specific nursing activity to work on to
prevent complication, promote and maintain physical,
psychological, social, and spiritual comfort of the
client.

87. Guidelines
Identify focus assessment
Choose intervention
Consider the goal
Consider the client strengths
Individualize the nursing intervention
Be realistic -preference –developmental age –with in
the capabilities and knowledge of nurse –use resources
appropriately – provide with in the therapeutic
environment

88. For collaborative problem
Perform frequent assessment- to note pathological
change
Alert physician
Perform preventive and corrective action as physician
order

89. Documenting the plan
Reason:
 for directing the nursing care
 legal document
 serves as written record for evaluation
Component
 brief client profile
 short and long term goals
Nsg diagnosis
Expected outcome
Nursing intervention

90. TYPES OF PLANNING
Initial Planning
Initial planning is done by the nurse who
conducts the admission assessment. Usually, the
same nurse would be the one to create the initial
comprehensive plan of care.

91. ONGOING PLANNING
Ongoing planning is done by all the nurses who
work with the client. An ongoing care plan also
occurs at the beginning of a shift. Ongoing
planning allows the nurse to:
determine if the client’s health status has
changed
set priorities for the client during the shift
decide which problem to focus on during the shift
coordinate with nurses to ensure that more than
one problem can be addressed at each client
contact

92. DISCHARGE PLANNING
Discharge planning is the process of anticipating
and planning for needs after discharge. To
provide continuity of care, nurses need to
accomplish the following:
Start discharge planning for all clients when they
are admitted to any health care setting.
Involve the client and the client’s family or
support persons in the planning process.
Collaborate with other health care professionals
as needed to ensure that biopsychosocial,
cultural, and spiritual needs are met.

93. Discharge goals for a client with severe
hypertension would include the following:
1. Blood pressure within acceptable limits for
individual.
2. Cardiovascular and systemic complications
prevented or minimized.
3. Disease process, prognosis, and therapeutic
regimen understood.
4. Necessary lifestyle and behavioral changes
initiated.
5. Plan in place to meet needs after discharge.

94. When outcomes are properly written, they
provide direction for planning and validating the
selected nursing interventions.

100. IMPLEMENTATION
Activities:
Continue data assessment
Set priority
Perform intervention
Documentation of nsg care
Give verbal report

106. Process of implementation
Re assessing the client
Determining the nurses need for assistance
Implementing the nsg interventions
Supervising the delegated care
Documenting nursing activities

107. Guidelines for implementing the nursing
interventions
• Nursing interventions based on scientific knowledge,
research and professional standards
•Clearly understand the interventions to be
implemented
•Provide teaching, support and comfort

108. Be holistic
Respect the dignity of the client and enhance the
clients self esteem
Encourage the client to participate actively in
implementing the nursing interventions
Never perform with out rationale
Be consistent
Explain and talk to the client
Include client and family
Be aware of hospital policies and protocals

109. FACTORS AFFECTING CARE

110. EVALUATION
Definition:
It is defined as the judgment of the effectiveness
of nursing care to meet patient goals based on the
patients behavioral responses.
Importance of evaluation:
Self satisfaction
Documentation which has legal value
To assess how for the patient is benefited
Auditing
Quality assurance

111. PURPOSES
To examine the patients behavioral responses to
nursing interventions
To compare the patients behavioral responses with
predetermined outcome criteria
To appraise the extent to which patient goals were
attained or problems resolved
To appraise involvement and collaboration of the
patient, family members , nurses and health care team
members in health care decisions
To provide a basis for the revision of the paln of care
evaluation
To collect subjective and objective data to make
judgments about nursing care delivered

112. To monitor the quality of nursing care and its
effect on the patients health status

113. TYPES
Structure
 Focuses on setting or surroundings where health
care is provided
Environmental factors directly or indirectly
influence the quality of care provided
Availability of equipment, physical lay out, nurse
patient ratios, administrative support
Process
Nurses performance and whether nsg care
provided is appropriate and competent

114. Outcome:
Outcome evaluation determines the extent to
which the patient behavioral response to
nursing intervention reflects the desired
patient goal and outcome criteria

115. Steps:
Establishing the outcome criteria
Evaluate the goal achievement
Identify the variable affecting the goal achievement
Modify the plan of care/ terminate nursing care plan.

116. REPLANNING
Gather new data to determine new problem
Delete the nsg & collaborative problem not
appropriate and add new
Examine the list & set new priority list
Check accuracy & set goal
Change if unrealistic

117. Delete goals that is inappropriate
Plan and examine intervention
Change or delete the nsg intervention which are
inappropriate
Incorporate factors that contributes for successful
achievement
Set new target for evaluation

118. DEVELOPING NURSING CARE
PLANS
The end product of the planning phase of the
nursing process is a formal or informal plan of
care.
Formal: written or computerized guide that
organizes information about pt care
Informal : strategy for action that exists in the
nurses mind

119. Standardized care plan: formal plan that specifies the
nursing care for group of clients with common needs.
Eg: all clients with myocardial infarction
Individualized care plan: is tailored to meet the unique
needs of the client

120. STANDARDIZED APPROACHES
•Protocols: preprinted to indicate the actions commonly
required for particular group of clients
Eg: care of client with epidural anesthesia
Policies and procedures: developed rules to handle the
frequently occurring situations
Eg: no of visitors allowed to stay, visitors timings

121. Standing order: written document about policies,
rules, or orders regarding client care
Formats for care plan

122. GUIDELINES FOR WRITING CARE
PLAN
Date & sign the plan
Use category heading
Use standardized or approved medical term eg: change
position q2h
Be specific
Refer to procedure books or other source rather than
including all steps in plan
Tailor the plan for the unique individual charactor

123. Incorporate the preventive, promotive aspects of
care
Ensure that the plan has interventions for
ongoing assessment
Include the intervention from collbarative and
coordinated activities
Include plan for client activities

126. Nurses are advocates for patients and
must find a balance while delivering
patient care. There are four main
principles of ethics: autonomy,
beneficence, justice, and non-
maleficence. Each patient has the right
to make their own decisions based on
their own beliefs and values.

127. 4 th step: – Execution of the nursing care plan –
Delegation –DO IT –DO IT RIGHT –DO IT
RIGHT NOW!

128. INEFFECTIVE AIRWAY CLEARANCE
May Be Related to narrowing f airway, Airway
spasm, allergic airways Excessive mucus, retained
secretions, exudates in the alveoli
Smoking/secondhand smoke
Possibly Evidenced By Dyspnea, difficulty vocalizing
Changes in depth and rate of respirations
Diminished/adventitious breath [wheezes, rhonchi,
crackles] Absent/ineffective cough Restlessness,
cyanosis
Desired Outcomes/Evaluation Criteria—Client
Will Respiratory Status: Airway Patency Maintain
patent airway with breath sounds clear or clearing.
Demonstrate behaviors to improve airway clearance

129. Auscultate breath sounds. Note
adventitious breath sounds such
as wheezes, crackles, or rhonchi.
Assess and monitor respiratory
rate. Note inspiratory-
toexpiratory ratio.
Note presence and degree of
dyspnea, for example, reports of
“air hunger,” restlessness,
anxiety, respiratory distress, and
use of accessory muscles. Use a 0
to 10 scale or American Thoracic
Society’s Grade of Breathlessness
Scale to rate breathing difficulty.
Ascertain precipitating factors
when possible. Differentiate acute
episode from exacerbation of
chronic dyspnea
Some degree of bronchospasm is present with
obstructions in airway and may or may not be
manifested in adventitious breath sounds,
such as scattered, moist crackles (bronchitis);
faint sounds, with expiratory wheezes
(emphysema); or absent breath sounds (severe
asthma). Tachypnea is usually present to some
degree and may be pronounced on admission,
during stress, or during concurrent acute
infectious process. Respirations may be
shallow and rapid, with prolonged expiration
in comparison to inspiration. Respiratory
dysfunction is variable depending on the
underlying process, for example, infection,
allergic reaction, and the stage of chronicity in
a client with established COPD. Note: Using a
scale to rate dyspnea aids in quantifying and
tracking changes in respiratory distress. Rapid
onset of acute dyspnea may reflect pulmonary
embolus