Download - Workshop on Implementation
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Introduction:
Nursing is both a science and art. The nursing process provides an orderly, logical,
problem solving approach for administering nursing care so that the patients needs for
such care are met comprehensively and effectively.
The nursing process is a six step process. Implementation is the fourth step in the nursing
process.
Implementation is initiation and completion of action to accomplish the defined goals and
Optimal wellness of the client.
In theory, implementation of the nursing care plan follows the planning component of the
nursing process. However, in many health care settings it may begin directly after
assessment. Eg. In emergency situations such as cardiac arrest or sudden death of a loved
one.
Definition :
Implementation:
Implementation is a category of nursing behaviour in which the actions necessary for
achieving the goals and expected outcomes of nursing care initiated and completed.
- POTTER AND PERRY.
Nursing intervention :Nursing intervention is any action taken by the nurse to help the client move from present
health state to the health state described in the expected outcomes.
Implementation is both patient centered (Wholly compensatory, Partial compensatory,
supportive and educative) and functional or nurses centered (independent, dependent, and
collaborative actions ).
The implementation is in terms of needs of patient. The client may require intervention in
the form of support, medication, treatment for the current condition, client family
education or treatment to prevent future health problems.
The purpose of intervention is to render appropriate patient care by putting the nursing
care plan in to action.
Purposes of implementation :
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1. Assist the patient in achieving desired health goals.
2. Promote health.
3. Prevent disease and illness, restore health and facilitate coping with altered
functioning.
Principles of implementation :
1. The implementation phase should be based on patients desires and environment.
2. Implementation should be aimed to achieve the health promotion, health
restoration and high levels of wellness.
3. Implementation should minimize all the potential capabilities of the client.
4. Nursing actions can be combined to achieve expected outcome.
5. Nursing implementation should aim therapeutic environment for the client.
6. Implementation should be based on nursing care plan, which is based on nursing
diagnosis and assessment.
7. Implementation should aim for achievement of goals and expected outcome.8. Implementation should be documented legibly and legally.
Types of nursing actions:
1. Independent Nursing actions.
2. Dependent Nursing actions.
3. Interdependent Nursing actions.
4. Protocols
5. Standing orders.
1. Independent Nursing actions : Are those actions that the nurse can performwithout directions from others. Eg. Providing back massage and turning a patient
every 2 hours etc.
2. Dependent Nursing actions : Are those actions prescribed by the physicians, are
carried out by the nurse. Eg. The nurse follows the orders while administering
medications, performing wound care and ordering diagnostic tests etc.
3. Interdependent Nursing actions : Are those actions that the nurse and other
health care personnel perform together. Eg. Counselling of a patient whose is
posted for surgery, Community health, involving sanitary inspector etc to give
health education
4. Protocols : A protocol is a written plan to indicate the procedures commonly
required for a particular group of clients or situations. Eg. Care of post-op client,
Protocols for admission and discharge, Pain management etc
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5. Standing Orders: Standing order is a written document about policies, rules,
regulations or orders regarding client care. Standing orders give nurses the authority to
carryout specific action under circumstances in the absence of supervision of a physician.
Eg. Standing orders for narcotic overdoses that specify the agents the nurse is to
administer to reverse respiratory depression in an emergency, standing orders in
community health set- up, Standing orders for pain management, standing orders for
Obstetric and gynecological patients admission etc.
Implementation Process :
The implementation component of the nursing has seven steps.
1. Reassessing the client.
2. Reviewing and modifying the existing nursing care plan.
3. Organizing resources and care delivery.a. Equipment
b. Personnel
c. Environment
4. Anticipate and prevent complication.
5. Identifying areas of assistance.
6. Implementing nursing interventions.
7. Recording
1. Reassessing the client:
Assessment is a continous process, which may focus on only one dimension or
system. When a new data are gathered and new client need is identified, the nurse
modifies the care plan.
The reassessment phase of the implementation component thus provide a
mechanism for the nurse to determine whether the proposed nursing action is appropriate
for the clients level of wellness. Eg. The nurse may have planned to ambulate a client
following lunch, however, a reassessment reveals shortness of breath and increased
fatigue which require the client to return to bed.
2. Reviewing and modifying the existing nursing care plan.
Modification can occur in planned nursing care when there is change in the clients health
status. Before beginning care, the nurse reviews the care plan and compares it with
assessment data to validate the stated diagnosis and determine whether the nursing
interventions are the most appropriate for the clinical situation. If the clients status has
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changed and the nursing diagnosis and related nursing interventions are no longer
appropriate, the nursing care plan needs to be modified.
Modification includes several steps. First data in the assessment column are revised to
reflect the clients current status. New data entered in the care plan should be dated to
inform other members of the health care team. Nursing diagnosis are revised. Then the
specific implementation methods are revised to correspond to the new nursing diagnosis
and client goals. Finally the nurse determines what methods of evaluation will be used.
3. Organizing resources and care delivery :
A facilitys resources include equipment and skilled personnel. Organization of
equipment and personnel make efficient , skilled client care possible. The nurse Prepares
the necessary supplies and decides on the time and provide of care.
Preparation of care delivery also involves preparing the environment and client for
nursing intervention.
a. Equipment.
b. Personnel.
c. Environment.
d. Patient and patient visitors
1. Equipment : Most nursing procedures require some equipment or supplies. The
nurse analyzes each planned interventions for needed item and provider of care.
Preparation of care delivery also involves preparing the environment and clientfor nursing intervention .Equipment should be in working order to ensure safe
use.Eg. Catheterization.
2. Personnel: As the nurse prepares to intervene, he or she must consider the
competencies of personnel available and model of care delivery being used. The
most common types of nursing delivery systems are functional, team, total client
care, primary nursing and care management.
3. Environment: Environment factors influence the delivery and reception care.
The surroundings in which nursing activities occur should be of safe and
conducive to the implementation of the therapy. Privacy promotes relaxation,
when body parts are exposed.
4. patient and patient visitors
Patient should be prepared well (physically and mentally) before implementing any
intervention in order to gain his co-operation
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Visitors can be allowed during performing of certain procedures in order to make
them develop care giving skills at home.
5. Anticipating and preventing complications :
Risks to the client arises from both the illness and treatment. The nurse must identify
these risks, evaluate and relative benefit of the treatment versus the risk and initiate risk
prevention measures. The nurse needs to be aware of potential complication and institute
Precautionary measures. Eg. Diabetic patient- preventing complications.
5. Identifying areas of assistance :
Some nursing situation requires the nurse to acquire assistance by seeking additional
personnel, knowledge and nursing skills. Assistance may be needed in performing a
procedure, comforting a client or preparing the client for a procedure. Eg. Pre-op
counseling for a client posted for surgery.
6. Implementing nursing interventions:
A variety of interventions can be selected by the nurse in administering care. The nurse
selects from the following intervention methods to achieve goals of nursing care.
a. Performing, assisting or directing the performance of activities of daily
living.
b. Counseling and evaluating the client and family.
c. Providing direct nursing care.
d. Supervising and evaluating the work of other staff members.Nursing practice is composed of cognitive, interpersonal and psychomotor skills. These
skills are needed to implement interventions.
7. Documentation
Record serves as a communication tool and a resource to aid in determining the
effectiveness of care and to assist in setting priorities for ongoing care
Competencies essential to nursing practice
a. cognitive competencies
b. technical competencies
c. interpersonal competencies
d. ethical competencies
Cognitive competencies
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Knowledge of what information you need to implement the nursing interventions that
effectively meet the nursing needs of the client
Knowledge pertinent to the standards of care and agency and institutional policies
Ability to think critically about how to respond to the patients need for nursing
Technical competencies
Ability to use equipment and techniques competency that are specified by the patients plan of care.
Interpersonal competencies
Ability to establish a trusting nurse patient relationship
Ability to communicate to the patient that you are more concerned about the patient and
his wellbeing than about the role implementation of the plan of care or accomplishment of tasks
Ability to work collaboratively with the member of the care giving team to implement the
interdisciplinary plan of care
Ethical/legal competencies
Commitment to implementing successfully the plan of care with in the scope of your
legal practice
Ability to be a trusted and effective patient advocate
Consistent use of appropriate legal safeguards while implementing the plan of care
Implementation methods
The nurse carries the nursing care plan by using several implementation methods. A client with impairedphysical mobility may require assistance in daily activities. The client with ineffective coping related
fear of hospitalization may require counseling. For each diagnosis the nurse identifies appropriate
interventions, each which requires specific theoretical knowledge and clinical skills.
The implementation methods are
a. assisting with activities of daily living
b. counseling
c. teaching
d. providing direct nursing care
e. delegating, supervising and evaluating the work of other staff members
f. recording
a. Assisting with activities of daily living
activities of daily living usually performed in the course of a normal day they include ambulating,
eating, dressing, bathing and grooming etc. conditions resulting in the need for assistance with ADLS
can be acute, chronic, temporary assistance with ADLS, the client needs assistance during a specific
period. A client with total self care deficit related to an irreversible injury has a permanent need for
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assistance. The client can be taught new ways to perform ADLS, thus becoming more independent and
better able to perform self care.
b. Counseling
Counseling is an implementation method that helps the client use a problem solving process to recognize
and manage stress and that facilitates interpersonal relationship among the client, family and health care
team. Counseling is emotional, intellectual, spiritual and psychological support that helps the client
accept or impending changes resulting from stress. Clients needing counseling include
Persons who must adjust lifestyle patterns
Clients coping with chronic or disabling diseases.
Clients with life threatening illness to cope with possibility of death.
c. Teaching
Teaching involves use of communication skills to effect a change in the client. The main focus ofteaching is intellectual growth or the acquisition of new knowledge or psychomotor skills. Teaching is
an important implementation method used to present correct principles, procedures and techniques of
health care to the clients and to inform clients about their health status. The nurse is responsible for
assessing the learning needs of clients and is accountable for the quality of education delivered.
d. Providing direct nursing care
To achieve the therapeutic goals for the client, the nurse initiates interventions to compensate for
adverse reactions. Uses precautionary or preventive measures in providing care, applies correct
techniques in administering care and preparing the client for special procedures and initiates life long
measures in emergency situations.
Compensation for adverse reaction
An adverse reaction is a harmful or unintended effect of a medication, diagnostic test or therapeutic
intervention. Nursing actions that compensates for adverse reactions reduce or counteract that reaction
Preventive measuresThese actions are directed at promoting health and preventing illness to avoid the need for acute or
rehabilitative health care.
Prevention includes assessment and promotion of the clients health potential, application of prescribed
measures such as immunizations, health teaching, and early diagnosis and treatment.
e. Delegating, supervising and evaluating the work of other staff members
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Some activities may be delegated to other members of health care team and co-coordinated by the nurse.
When a nurse delegates aspects of a clients care to another staff member, the nurse assigning tasks is
responsible for ensuring that each task is appropriately assigned and is completed according to the
standard of care. She will supervise and evaluate the work of other staff members.
f. Recording
Documentation of the implementation component involves the use of written record, the health care
record and the care plan is accurately becoming a permanent part of the health care record in many
agencies.
Documentation describes the actions implemented by the nurse, client or others in terms of the nursing
diagnosis, the clients responses to the implementation of the plan is also recorded responses consist of
physical, psychological, social and spiritual behaviors.
It helps the other shift nurses to quickly see what is to be done and if any intervention was omitted. It
serves as a legal document.
Factors affect implementation
inadequate nursing staff
lack of family support
lack of resources-man, money, material
unrealistic expectation from colleagues
no financial/other incentives
conflict with nursing managers
being used for non nursing responsibility incomplete protocols
non-acceptance of role
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Self-
care
Self-
care
agency
Self-
care
deficit
Self-
care
deman
d
Nursing
system
It is the totality ofself care action to be
performed self carerequisites by using
valid methods &
related sets of operation & action
each persons
therapeutic demandvaries throughout
life.
Self care agents are providers of self
care . agents arethose who can/have
take care of
themselves, - power to regulate
factors that affect
their own function
The goal of nursing agency is to help
people meet their dependant others
therapeutic self
Three components of nursing agency are,
1.help client accomplish theureuutic self-
care.2. Help the client to increaseindependence steadily decline self-care, adjust
interruption.3.hel family members in providing
client care.
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Self care
agency
Self care
agency
Self care
agency
Self care
agency
Self care
agency
Age.gender.
Socioculturalorientation.
development
stauts.health status.
health caresystem factors.
Environmental
factors.Resource
adequacy &availability
DOROTHEA. E. OREM
SELF CARE MODEL
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Self-
care
Self-
care
agency
Self-
care
deficit
Nursing
system
Self-
care
deman
d
Mr.Ramesh aged 28years maintains
sufficient air, I feel difficult to pass themotion, I dont feel like eating, I have
severe body pain. He is prone to get
hazards, as he is restless, needs medicalhelp for health promotion.
Mr. Ramesh needsadjustment with body
change. Due to fracture.
-pain due to fracture,-confined to bed, constipation.
-altered elimination.-imbalanced nutritional status.
-prone to injury & complications.-altered body image.
As Mr. Ramesh isconfined to bed due to
traction, so nursing
personnel are neededto provide care
-acute pain related tofracture.
- impaired physicalmobility r/t confinementin traction.
-impaired skin integrityr/t inability to change
the position secondary totraction.
-self care deficit r/ttraction.
-imbalanced nutritionalstatus less body
requirement r/t less
intake.
-risk for injury r/ttraction.-knowledge deficit r/t
exercise, diet, follow up.
Conditioning factors.Name: Mr. Ramesh.Age : 28 years.
Sex : male.Occupation : students.
Family : good support.Health status : moderately
built.
Diagnosis : Right femur &ulnar fracture (traction)
Wholly compensatory, supportive educativesystem
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Accomplishes clients therapeutic self care
Supports and protects.
Compensates for clients inability to engage
self care.
Performs some self care measures
Assists client as required
Compensates for self care limitation of client.
Perform some self care measures for client.
Accepts care and assistance for nurse.
Accomplishes self care.
Regulates self care agency
PARTLY
COMPENSATORY
SUPPORTIVE-
EDUCATIVE SYSTEM
Regulates the exercise and development ofself care agency.
WHOLY
COMPENSATORY
BASIC NURSING SYSTEM
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