The nurse is evaluating the plan of care and notes that none of the goals have been met for the client with impaired gas exchange. What should the nurse do next in this situation?

Question

1. Report the lack of achievement of the goals to the healthcare provider.
2. Review the data and modify the plan.
3. Reformulate the nursing diagnosis to a more realistic one.
4. Request a consult for the client to be seen by a pulmonologist.

Answer 1

2
Rationale 1: Reporting the lack of achievement of the goals to the healthcare provider is not appropriate, though reporting undesirable client physiologic responses may be.
Rationale 2: The plan of care should be evaluated periodically, at the established time frames, to determine achievement of the goals. If goals are not achieved, then the data need to be further assessed and the plan modified.
Rationale 3: Reformulating the nursing diagnosis to a more realistic one is not the best course of action as the diagnosis established came from subjective and objective data specific to that diagnosis.
Rationale 4: There are no data to support the need for additional medical consultations.