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Nursing Process: Implementation Phase

The document discusses the implementation phase of the nursing process. It explains that implementation involves performing nursing interventions outlined in the care plan. There are five activities in the implementation phase: 1) reassessing the client, 2) determining if assistance is needed, 3) implementing nursing interventions, 4) supervising delegated care, and 5) documenting nursing activities. Guidelines for properly implementing interventions include basing them on evidence, adapting to individual clients, ensuring safety, providing education and support, and encouraging client participation.

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41 views3 pages

Nursing Process: Implementation Phase

The document discusses the implementation phase of the nursing process. It explains that implementation involves performing nursing interventions outlined in the care plan. There are five activities in the implementation phase: 1) reassessing the client, 2) determining if assistance is needed, 3) implementing nursing interventions, 4) supervising delegated care, and 5) documenting nursing activities. Guidelines for properly implementing interventions include basing them on evidence, adapting to individual clients, ensuring safety, providing education and support, and encouraging client participation.

Uploaded by

Kyle Vargas
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES


Nabua, Camarines Sur

BACHELOR OF SCIENCE IN NURSING


College of Health Sciences
1ST SEMESTER S/Y 2021-2022
NURSING PROCESS
Module 4: IMPLEMENTATION
Learning Outcomes:
After completing this chapter, you will be able to:
1. Explain how implementing relates to other phases of the nursing process.
2. Describe three categories of skills used to implement nursing interventions.
3. Discuss the five activities of the implementing phase.
4. Identify guidelines for implementing nursing interventions.

Introduction
The nursing process is action oriented, client centered, and outcome directed. After developing a plan of
care based on the assessing and diagnosing phases, the nurse implements the interventions and evaluates the
desired outcomes. On the basis of this evaluation, the plan of care is either continued, modified, or terminated.
As in all phases of the nursing process, clients and support persons are encouraged to participate as much as
possible.

Implementing
Is the action phase in which the nurse performs the nursing interventions. Using Nursing Interventions
Classification (NIC) terminology, implementing consists of doing and documenting the activities that are the
specific nursing actions needed to carry out the interventions. The nurse performs or delegates the nursing
activities for the interventions that were developed in the planning step and then concludes the implementing
step by recording nursing activities and the resulting client responses.

Process of Implementing
• Reassessing the client
• Determining the nurse’s need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities.
Reassessing the Client
Just before implementing an intervention, the nurse must reassess the client to make sure the
intervention is still needed. Even though an order is written on the care plan, the client’s condition may have
changed. For example, a client has a nursing diagnosis of Disturbed Sleep Pattern related to anxiety and
unfamiliar surroundings. During rounds, the nurse discovers that the client is sleeping and therefore defers the
back massage that had been planned as a relaxation strategy.
Determining the Nurse’s Need for Assistance
When implementing some nursing interventions, the nurse may require assistance for one or more of the
following reasons:
 The nurse is unable to implement the nursing activity safely or efficiently alone (e.g., ambulating
an unsteady obese client).
 Assistance would reduce stress on the client (e.g., turning a person who experiences acute pain
when moved)
 The nurse lacks the knowledge or skills to implement a particular nursing activity (e.g., a nurse
who is not familiar with a particular model of traction equipment needs assistance the first time it
is applied).
Implementing the Nursing Interventions
It is important to explain to the client what interventions will be done, what sensations to expect, what
the client is expected to do, and what the expected outcome is.
When implementing interventions, nurses should follow these guidelines:
 Base nursing interventions on scientific knowledge, nursing research, and professional standards
of care (evidence-based practice) when these exist.
 Clearly understand the interventions to be implemented and question any that are not
understood.
 Adapt activities to the individual client. A client’s beliefs, values, age, health status, and
environment are factors that can affect the success of a nursing action.
 Implement safe care. For example, when changing a sterile dressing, the nurse practices sterile
technique to prevent infection; when giving a medication, the nurse administers the correct
dosage by the ordered route
 Provide teaching, support, and comfort.
 Be holistic
 Respect the dignity of the client and enhance the client’s self-esteem. Providing privacy and
encouraging clients to make their own decisions are ways of respecting dignity and enhancing
self-esteem.
 Encourage clients to participate actively in implementing the nursing interventions.
Supervising Delegated Care
 If care has been delegated to other health care personnel, the nurse responsible for the client’s
overall care must ensure that the activities have been implemented according to the care plan.
 The nurse validates and responds to any adverse findings or client responses. This may involve
modifying the nursing care plan.
Documenting Nursing Activities
After carrying out the nursing activities, the nurse completes the implementing phase by recording the
interventions and client responses in the nursing progress notes. The nurse may record routine or recurring
activities (e.g., mouth care) in the client record at the end of a shift.

Prepared by:
Jocyl Darrel B. Abinal, R.M, R.N, MAN
Clinical Instructor
Source: Kozier and Erb’s FUNDAMENTALS OF NURSING, concept, process and practice 10th edition Unit 3, Chapter 14

Common questions

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To maintain client dignity, nurses can provide privacy during procedures by closing doors and curtains, explaining procedures before beginning, allowing clients to express concerns and preferences, and encouraging clients to participate in their care decisions. Respectful communication, empathy, and involving clients in planning to enhance their self-esteem can also preserve dignity .

Basing interventions on scientific knowledge and research ensures that nursing care is grounded in the best available evidence, which leads to improved patient outcomes and higher standards of care. This approach helps in minimizing errors, optimizing resource use, and enhancing the safety and efficiency of healthcare practices. It enables nurses to update their practices in line with new research findings and professional standards, ensuring interventions are not only effective but also current .

Supervision of delegated care is vital to ensure that nursing interventions are carried out effectively and in alignment with the established care plan. It involves validating that tasks have been completed correctly and addressing any unexpected client responses. Proper supervision protects patient safety and ensures high-quality care. It also involves modifying the care plan if necessary based on the findings from delegated actions .

Nurses should seek clarification on any nursing interventions that are not understood. This may involve consulting with colleagues, referring to relevant literature or guidelines, or discussing with the nursing supervisor to gain a clear understanding of the intended intervention. It is important that nurses have a complete understanding of procedures for effective implementation and to ensure patient safety .

Nurses can encourage client participation by explaining interventions and expected outcomes clearly, soliciting questions and preferences from clients, involving them in decision-making processes, and encouraging self-care activities within their capacities. Providing education about the impact of interventions and reinforcing the importance of adherence can also motivate active participation .

The five activities involved in the implementation phase are: reassessing the client to determine if the interventions are still relevant, determining the nurse's need for assistance, implementing the interventions with a focus on evidence-based practice and client individuality, supervising any delegated care to ensure quality and adherence to the care plan, and documenting nursing activities and client responses to track progress and outcomes .

The three categories of skills used in implementing nursing interventions include cognitive skills, interpersonal skills, and technical skills. Cognitive skills involve critical thinking, clinical judgment, and decision-making processes that allow nurses to think through client care problems logically. Interpersonal skills are essential for effective communication with clients and team members, providing emotional support, and fostering trust. Technical skills involve the manual dexterity required to perform procedures and use equipment safely and efficiently .

Nurses can adapt their activities to individual clients by considering the client's beliefs, values, age, health status, and environmental factors. This may involve modifying the approach to care such as using culturally appropriate communication, customizing teaching methods to fit the client's learning preferences, adjusting the timing of interventions to suit the client’s personal schedule or comfort level, and using supportive devices in a way that aligns with the client's physical capabilities .

The implementation phase is where the nurse puts the developed plan of care into action, which follows the assessing and diagnosing phases and precedes the evaluation phase. It requires the nurse to apply specific nursing actions or interventions that have been developed during the planning step. This phase is critical as it translates the care plan into practical actions and involves reassessing the client's condition to ensure interventions are still needed. Thus, it directly relies on the accuracy and detail-oriented nature of previous phases such as assessment and planning and sets the stage for later evaluation phases where the effectiveness of these interventions is appraised .

Documenting nursing activities is crucial as it provides a legal record of the care provided and the client's responses. It ensures continuity of care by keeping all caregivers informed about the interventions performed and their outcomes, which is essential for team-based care and care coordination. Documentation also aids in evaluating the effectiveness of the care plan, supports communication within the healthcare team, and serves as evidence in legal situations should discrepancies arise.

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