1. Discuss aspects of nursing implementation (nursing intervention).
2. Differentiate between dependent action and interdependent action.
3. Define accountability. Discuss the legal implications of nursing accountability and responsibility.
4. Identify the three main skills used in implementing nursing care.
5. Discuss the rationale for this statement: A key to nursing care is communication.
6. Identify the component of evaluation in the nursing process. Describe methods of evaluation.
7. Discuss the statement: Discharge planning begins on admission of the client into a facility.
After collecting data, identifying nursing diagnoses, developing goals, and writing a nursing care plan, your next step is to carry out, or implement, the care plan. Implementation of a nursing care plan may also be referred to as providing nursing interventions (Fig. 36-1).
IMPLEMENTING NURSING CARE
“Do it,” “share it,” and “write it down” are the action phrases of implementation. You “do” nursing care with and for the client. You “share” the results by communicating with the client and other members of the healthcare team, individually or in a planning conference. You “write” information by documenting it so that the next healthcare provider can act with purpose and understanding. Always remember that adequate communication and documentation facilitate the continuity of care (Fig. 36-2).
Nursing Implementation—“Do It”
When implementing care, you perform nursing actions that may be dependent, interdependent, or independent. Actions that carry out a physician’s orders regarding medication or treatments are dependent actions that you must follow explicitly. Because of regulatory requirements, you may not administer medications or perform certain treatments without physician’s orders.
Interdependent actions are those that you perform collaboratively with other care providers; the physician may write orders for some of these actions. These actions are interventions for collaborative problems. For example, the physician may write an order to give an enema to a client when necessary. You use your nursing judgment to determine when the client needs an enema, although you cannot administer the enema without the physician’s order. Together, you have collaborated to provide client care.
Independent actions are nursing actions that do not require a physician’s orders. Only you—as a member of the nursing staff—perform independent nursing actions, which are based on your judgment. Independent actions are those actions that you take to assist the client with activities of daily living (e.g., bathing, toileting) or to help reduce stress (e.g., backrub).
To understand the different types of nursing actions, consider the example of the woman with pneumonia described.The physician writes an order for supplemental oxygen at a specified flow rate.
FIGURE 36-1 · During implementation or interventions, the fourth step of the nursing process, you put the client’s plan of care into action.
FIGURE 36-2 · The nurse may use the computer to document care, print out a nursing care plan, or retrieve data (e.g., laboratory or x-ray) about the client. The physician may also input orders for a client to be carried out by the nurses. Nursing students and graduates will also find a wealth of healthcare information on the Internet.
Administering oxygen, which is considered a medication, is a dependent action, as is administering the client’s intravenous (IV) fluid and antibiotic therapy. The physician also writes an order for an antipyretic as needed (PRN). Administering the medication is a dependent action. You may choose, however, to give the antipyretic medication based on the client’s temperature, for example, when the client’s temperature is greater than 100.4°F (38.0oC). This action is interdependent: you are following the physician’s orders, but you are making a decision based on your judgment about timing and effective treatment. Additionally, you may decide independently to apply cool compresses to aid in reducing the client’s fever. Independent actions may be written as nursing orders, such as “assist with getting out of bed to chair at least once daily,” “encourage frequent sips of fluid,” “assist client to assume semi-Fowler’s to high Fowler’s position and reposition frequently,” “monitor vital signs and respiratory status every 1 to 2 hours.” Ask your instructor or team leader if you are unsure about any nursing actions.
You are responsible for all actions you perform, whether they are dependent, interdependent, or independent. This responsibility is also called accountability, an important aspect of the legal requirements of nursing practice. Using critical thinking skills will greatly assist you to make the safest and most helpful choices for each of your clients.
NCLEX Alert NCLEX questions commonly seek the answer to "which of the following is the most appropriate nursing action?” It is vital for you to understand the difference between nursing actions and physician’s actions. Look for a correct response to the clinical scenario that is the priority nursing action.
Skills Used in Implementing Nursing Care
Certain skills influence the implementation of the nursing care plan. These skills include your ability to perform intellectual, interpersonal, and technical skills. Intellectual skills involve knowing and understanding essential information (e.g., basic sciences, nursing procedures and their underlying rationale) before caring for clients. Critical thinking is one type of intellectual skill essential for making quick decisions and taking swift action. Interpersonal skills involve believing, behaving, and relating to others. Solid communication techniques and client encounters that promote the development of a trusting relationship (rapport) are interpersonal skills.Behaving professionally also involves interpersonal skills. Technical skills, such as changing a sterile dressing or administering an injection, require safe and competent performance.
The Nursing Care Plan in Action
The nursing team determines if the plan, as written, makes sense. Using critical thinking, ask yourself the following questions when reviewing a care plan:
• Does this plan protect the client’s safety?
• Has the plan been developed according to a scientific problem-solving approach? Is it based on sound nursing knowledge?
• Do the nursing orders logically achieve the desired results? Are the orders arranged in an appropriate sequence?
• Do the nursing orders enhance and facilitate the client’s care and progress to recovery and goal achievement?
• Did the client have active involvement in this plan, and can the client give some ideas about whether it is appropriate? (Many facilities encourage the client to read and sign the nursing care plan after it is written.)
How you manage your time, the client’s time, and your activities are important concepts in determining what you and the client accomplish during the day. Prepare a timetable so the client can see the schedule of activities for a full day. Encourage client participation in planning the timetable. Remember to include both the client and the family in this process.
Continuing Collection of Data. As you care for clients, observe them carefully. Listen to what clients say; watch what they do; check their vital signs. Use critical thinking continually to determine if the nursing orders are effective in moving the client toward meeting his or her specified goals.
Communication With the Healthcare Team—“Share It”
Periodically, a client planning conference is held. If the client is to be discharged from healthcare services, this conference serves as a discharge planning conference. Interdisciplinary planning conferences offer an excellent way to coordinate your nursing care and to interact with other health disciplines. If you do not personally attend the conference regarding a client for whom you are providing care, you are responsible for giving both verbal and written information to those attending. By doing so, you help ensure that the plan of care is not only coordinated with those of other healthcare providers, but also is evaluated by them.
You also will document (“write it down”) all care given to your client.
Key Concept Nursing implementation means the carrying out of the nursing care plan. It includes the following steps:
• Putting the nursing care plan into action
• Continuing the collection of data
• Communicating care with the healthcare team
• Documenting care
EVALUATING NURSING CARE
Evaluation is measuring the effectiveness of assessing, diagnosing, planning, and implementing. The client is the focus of the evaluation. Steps in the evaluation of nursing care are analyzing the client’s responses, identifying factors contributing to success or failure, and planning for future care (Fig. 36-3).
You can use several means to evaluate the effectiveness of nursing care:
Client: The primary source of evaluation criteria is the client. The family may also be helpful in determining if care given was effective.
Team conference: A conference is helpful not only to plan nursing care, but also to evaluate the effectiveness of care and design a discharge plan.
Community health agencies: Another way of evaluating outcomes of care is to contact healthcare providers in community agencies who are in touch with clients after they leave your facility. Such care providers include public health nurses, school health nurses, social workers, and receptionists and nurses who work in physicians’ offices.
Analyzing the Client’s Response
The previously established goals and objectives of the nursing care plan become the standards or criteria by which to measure the client’s progress. Evaluation of care is based on these criteria. Was each goal met? The evaluation criteria should also consider whether nursing care has helped the client realize self-care goals. For example, for the woman with pneumonia described, resolution of fever, decreased use of accessory muscles, the client’s report that her shortness of breath and difficulty breathing were decreasing, changes in the color of sputum, lungs clearing on auscultation, and ability to increase activity level without the use of oxygen provide evidence that the goals identified on the nursing care plan were being met.
Identifying Factors Contributing to Success or Failure
Various factors contribute to the achievement of goals. For example, the client’s family may or may not be supportive. The client may be too sick to perform activities. The client may have been uncooperative or may refuse treatments or medications.
FIGURE 36-3 • During evaluation, the last step of the nursing process, the nurse and client jointly measure how well the client has achieved the goals that were specified in the plan of care. Any factors that contributed to the client’s success or failure are identified, and the plan of care is revised as necessary. The client’s responses to the plan of care determine whether the plan continues as is, is modified, or is ended.
Sometimes you, the nurse, may be a factor. For example, you may lack knowledge about how to perform certain actions or may be thinking about personal problems and therefore perform a procedure incorrectly. Remember: You are responsible for ensuring that your knowledge and skills are always of the highest quality.
NCLEX Alert When an NCLEX question asks you “which of the following would represent a valid evaluation be sure to review the initial written plan or goal for that client. The evaluation should reflect achievement or revision of a stated goal.