Nursing Process:

Implementation

Moh. Afandi, SKep.,Ns.,MAN.,HNC
E-mail: mohafandi2003@yahoo.com.
+6281-908-134-304
Nursing Process
Specific to the nursing profession
A framework for critical thinking
Its purpose is to:

Diagnose and treat human responses to
actual or potential health problems
Nursing Process
Organized framework to guide practice
Problem solving method - client focused
Systematic- sequential steps
Goal oriented- outcome criteria
Dynamic-always changing, flexible
Utilizes critical thinking processes

Scientific Method of problem solving
ID problem
Collect data
Form hypothesis
Plan of action
Hypothesis testing
Interpret results
Evaluate findings
Advantages of Nursing
Process
Provides individualized
care
Client is an active
participant
Promotes continuity of
care
Provides more effective
communication among
nurses and healthcare
professionals

Develops a clear and
efficient plan of care
Provides personal
satisfaction as you
see client achieve
goals
Professional growth
as you evaluate
effectiveness of your
interventions
5 Steps in the Nursing Process
Assessment
Nursing
Diagnosis
Planning
Implementing
Evaluating
Assessment
First step of the Nursing Process
Gather Information/Collect Data
Primary Source - Client / Family
Secondary Source - physical exam, nursing history,
team members, lab reports, diagnostic tests..
Subjective -from the client (symptom)
I have a headache
Objective - observable data (sign)
Blood Pressure 130/80
Assessment-collecting data
Nursing Interview (history)
Health Assessment -Review of Systems
Physical Exam
Inspection
Palpation
Percussion
Auscultation


Assessment-collecting data
Make sure information is complete &
accurate
Validate prn
Interpret and analyze data
Compare to standard norms
Organize and cluster data


Example of Assessment
Obtain info from nursing assessment,
history and physical (H&P) etc...

Client diagnosed with hypertension
B/P 160/90
2 Gm Na diet and antihypertensive
medications were prescribed
Client statement I really dont watch my
salt Its hard to do and I just dont get
it
Nursing Diagnosis
Second step of the Nursing Process

Interpret & analyze clustered data

Identify clients problems and strengths

Formulate Nursing Diagnosis (NANDA :
North American Nursing Diagnosis
Association)-Statement of how the client is
RESPONDING to an actual or potential
problem that requires nursing intervention
Nsg Dx vs MD Dx
Within the scope of
nursing practice
Identify responses
to health and illness
Can change from
day to day
Within the scope of
medical practice
Focuses on curing
pathology
Stays the same as
long as the disease
is present
Formulating a Nursing
Diagnosis
Composed of 3 parts:
Problem statement- the clients
response to a problem
Etiology- whats causing/contributing to
the clients problem
Defining Characteristics- whats the
evidence of the problem
Nursing Diagnosis
Problem( Diagnostic Label)-based on
your assessment of client(gathered
information), pick a problem from the
NANDA list...
Etiology- determine what the problem is
caused by or related to (R/T)...
Defining characteristics- then state as
evidenced by (AEB) the specific facts the
problem is based on...
Example of Nursing Dx
Ineffective therapeutic regimen
management
R/T difficulty maintaining lifestyle changes
and lack of knowledge
AEB B/P= 160/90, dietary sodium
restrictions not being observed, and client
statements of I dont watch my salt Its
hard to do and I just dont get it.
Types of Nursing Diagnoses
Actual
Imbalanced nutrition; less than body
requirements RT chronic diarrhea, nausea,
and pain AEB height 55 weight 105 lbs.
Risk
Risk for falls RT altered gait and generalized
weakness
Wellness
Family coping: potential for growth RT
unexpected birth of twins.
Collaborative Problems
Require both nursing interventions and
medical interventions
EXAMPLE: Client admitted with medical dx
of pneumonia
Collaborative problem = respiratory
insufficiency
Nsg interventions: Raise HOB, Encourage
C&DB
MD interventions: Antibiotics IV, O2 therapy

Planning
Third step of the Nursing Process
This is when the nurse organizes a nursing
care plan based on the nursing diagnoses.
Nurse and client formulate goals to help the
client with their problems
Expected outcomes are identified
Interventions (nursing orders) are selected to
aid the client reach these goals.

Planning Begin by prioritizing
client problems

Prioritize list of clients
nursing diagnoses
using Maslow
Rank as high,
intermediate or low
Client specific
Priorities can change

Planning
Developing a goal and outcome statement
Goal and outcome
statements are client
focused.
Worded positively
Measurable, specific
observable, time-limited,
and realistic
Goal = broad statement
Expected outcome =
objective criterion for
measurement of goal
Utilize NOC as standard

EXAMPLE
Goal:
Client will achieve
therapeutic management
of disease process.
Outcome Statement:
AEB B/P readings of
110-120 / 70-80 and
client statement of
understanding
importance of dietary
sodium restrictions by
day of discharge.


Planning- Types of goals
Short term goals
Long term goals
Cognitive goals
Psychomotor goals
Affective goals

Goals are patient-centered and
SMART
Specific
Measurable
Attainable
Relevant
Time Bound
Pt will walk 50 ft.
Pt will eat 75% of meal
Pt will be OOB 2-4hrs
Pt will maintain HR<100
Pt will state pain level is acceptable 6 (0-10)
Planning-select interventions
Interventions are selected and written.
The nurse uses clinical judgment and
professional knowledge to select
appropriate interventions that will aid the
client in reaching their goal.
Interventions should be examined for
feasibility and acceptability to the client
Interventions should be written clearly
and specifically.

Interventions 3 types
Independent ( Nurse initiated )- any
action the nurse can initiate without
direct supervision
Dependent ( Physician initiated )-
nursing actions requiring MD orders
Collaborative- nursing actions
performed jointly with other health care
team members
Implemention
The fourth step in the Nursing Process
This is the Doing step
Carrying out nursing interventions
(orders) selected during the planning
step
This includes monitoring, teaching,
further assessing, reviewing NCP,
incorporating physicians orders and
monitoring cost effectiveness of
interventions
Utilize NIC as standard
Implementing- Doing
Monitor VS q4h
Maintain prescribed diet
(2 Gm Na)
Teach client amount of
sodium restriction,
foods high in sodium,
use of nutrition labels,
food preparation and
sodium substitutes
Teach potential
complications of
hypertension to instill
importance of
maintaining Na
restrictions
Assess for cultural
factors affecting
dietary regime
Implementing Doing
Teach the client-
hypertension cant be
cured but it can be
controlled.
Remind the client to
continue medication
even though no S/S
are present.

Teach client
importance of life style
changes: (weight
reduction, smoking
cessation, increasing
activity)
Stress the importance
of ongoing follow-up
care even though the
patient feels well.


Evaluation- To determine
effectiveness of NCP
Final step of the Nursing Process but
also done concurrently throughout client care
A comparison of client behavior and/or
response to the established outcome criteria
Continuous review of the nursing care plan
Examines if nursing interventions are working
Determines changes needed to help client
reach stated goals.

FOCUS
Types of interventions: Direct/Indirect
Protocols and Standing Orders
Collaborating with the Client
What is a personalized plan of care?
Implementation process
reassessing.
reviewing and revising existing care plans.
organizing and care delivery.
anticipating and preventing problems.
knowledge, skills, and qualifications.
requiring support and assistance.
Provision of care
Communicating nursing interventions



IMPLEMENTATION
The step in the nursing process
where the nurse provides care to
the clients. The nurse initiates or
completes interventions
necessary for achieving goals and
expected outcomes.

Begins after the care plan has
been designed.
Implementation
Implementation includes nursing
interventions (any treatment
based upon clinical judgment and
knowledge that the nurse
performs to enhance client
outcomes).
May involve assisting and
directing client ADLs, providing
direct care, delegating,
supervising and evaluating staff
work, exchanging and
documenting information.
Types of Nursing
Interventions
Direct Care Interventions:
Treatments performed
through interaction with
the client i.e. medication
administration, IV
infusion, grief counseling.
Indirect Intervention
Treatments performed
away from the client but
on behalf of the client or
group of clients (i.e.
documentation,
interdisciplinary
collaboration).
CYCLICAL PROCESS
The nursing process is cyclical.
Implement, evaluate and then
you may have to review and
adjust your assessment, plan and
implementation based on new
information/data.
Nursing Intervention: PROTOCOLS
Nursing interventions can be
developed, communicated, and
organized on the basis of
protocols or standing orders.
Protocol: Provides a standard of
care or clinical guideline that can
be individualized for each client
depending on how an institution
recommends protocol
implementation (i.e. protocol for
admission, discharge, pain
management, initiating CPR).
Standing Order
Pre-printed document containing
orders for the conduct of routine
therapies, monitoring guidelines,
and/or diagnostic procedures for
specific clients with identified
clinical problems.
Must be signed by a licensed
prescribing physician or HCP in
charge of care.
Commonly found in critical care
setting where clients status can
change quickly.
SIX FACTORS TO CONSIDER WHEN
SELECTING INTERVENTIONS
Desired or expected outcome:
Each outcome should have an
intervention.
Characteristics of the nursing
diagnosis: Intervention will alter
the related factor or treat the
signs and symptoms (defining
characteristics).
Evidence base for the
intervention: Research or proven
practice guidelines that indicate
effectiveness.
SIX FACTORS TO CONSIDER WHEN
SELECTING INTERVENTIONS
Feasibility for performing the intervention:
cost/time and how it affects other interventions.
Acceptability to the client: Explain how the client
is to participate, what the intervention involves,
and how the client might be affected. Important
to collaborate with the client, as they need to
make informed decisions Consider values,
beliefs and culture leads to a personalized plan
of care
Capability of the nurse: knowledge of the
scientific rationale, necessary skills, function
within the setting, consultation is critical.

CRITICAL THINKING and
IMPLEMENTATION
Consider:
Interventions that have worked in the past.
Review professional and standards of practice.
Consider all possible nursing actions.
List the consequences associated with each action.
Determine the probability of consequences
associated with each action.
Judge the value of the consequence to the client.
Implementation Process
Steps in the implementation process
include:
1. Reassess- determine whether the planned
nursing action is still appropriate.
2. Review and revision of the present
nursing care plan-may need to revise
assessment data, diagnoses, specific
interventions, and methods of
evaluation.
Implementation Process

3. Organize resources and care delivery-
Determine equipment, personnel and environment
required to carry out the interventions. (privacy,
reduce distractions, adequate space and lighting,
physically and psychologically comfortable,
administering comfort measures)
4.Anticipate and prevent complications- Weigh the
benefit of the treatment with the possible risks
and initiate risk preventing measures.
Implementation Methods:
Direct Care
Assist with activities of daily living (ADLs)-
activities done through out a day. Ex. Help the
client get dressed, brush teeth, comb hair etc.
Instrumental Activities of Daily Living: skills such
as shopping, preparing meals, taking medications
ect.
Physical Care Techniques: turning and positioning
clients, administering meds, providing comfort
measures.


Direct Care
Counseling- Help the individual to use a problem
solving process to manage stress and help with
interpersonal interaction among the client, family
and the HCP. Focus on the development of new
attitudes and feelings.
Teaching- Illustrate appropriate techniques and
procedures to clients. Ex. How to use an aerosol.
Focus is on intellectual growth.
Observing for adverse reactions: Anticipate and
know potential adverse reactions, nurse actions
reduce or counteract the reaction.

Indirect Care
Actions that support the
effectiveness of direct care
Communicating nursing
interventions-orally between
nurses and other HCPs.
Unless communication is timely
and accurate, caregivers may
become uninformed,
interventions duplicated,
procedures delayed, tasks left
undone.
Delegating, supervising and
evaluating others work.
APPLICATION TO THE CARE PLAN
Nursing Interventions
The nursing care plan includes two types of
interventions nursing interventions (5
interventions), and when applicable, client
interventions (4 interventions).
Interventions can be implemented by the nurse,
client, family member, depending on the level of
skill and knowledge needed. Maintaining a
partnership is essential.
Interventions must be specific and address the
need or desire for a change in client response
with in the context of a particular situation.
While there are several
interventions derived for each
diagnosis, some interventions
can only be implemented by the
client. For example it is the client
that uses the incentive
spirometer q1h while awake, it is
the client who attends the fitness
program, it is the client who does
deep breathing and coughing
exercises q2h while awake.
Consider knowledge, skill, and
motivation.
NOTE
Client interventions do NOT mirror nursing interventions. For
example, if the nurse administers an oral medication, one
can assume the client will swallow it. If not then it would
not be appropriate for the nurse to make a diagnosis that
reflects the situation, for example, impaired
swallowingand derive the appropriate care plan. If the
nurse is going to assist the client with something (e.g.,
assist with dressing), there is no need for a corresponding
client action.
There are times however when a nursing action must
precede a client action such as when the nurse must teach
the client how to do something, and then the client can
proceed unassisted. In this case the nursing intervention is
to teach, and following the successful implementation of
this intervention, the client intervention is to do.
WRITING/FORMATTING
INTERVENTIONS
VERB-NOUN-MODIFIER
Where applicable the action verb
should be accompanied by what
(noun) as well as by how much,
how often, and/or under what
conditions/circumstances
(modifiers).

Administer Tylenol 325 mg for
temp over 38.5 degrees
Discuss clients support system.
Intervention may include , but are not limited to those listed
in the categories below:
Act for/do for: adjust, aspirate, decrease, empty, give,
assess, auscultate, examine, measure, monitor, note,
observe, palpate.
Guide: guide, inform, discuss, show, counsel, assist, etc.
Support: share, suggest, talk, promote, encourage, assist,
maintain, explain, ask, reinforce, etc.
Teach: demonstrate, discuss, explain, inform, instruct, list,
review, show, etc.
Provide and environment that promotes physical,
psychosocial and spiritual development and or positive life
style change: provide, promote, encourage, suggest, give,
etc.

SEE Nursing Care plan Guidelines
The literature based rationale for
interventions
The literature based rationale for
interventions describes the basis
or reason for the interventions.
Rationale is based on scientific
researched-based, and or
theoretical information from
current nursing and or health
related texts and journals.
Sources must be sited using APA
format.
Note: Additional rationale may emerge from situational data,
and should be included in the section whenever possible.
Summary
Types of interventions: Direct/Indirect
Protocols and Standing Orders
Collaborating with the Client
What is a personalized plan of care?
Implementation process
reassessing.
reviewing and revising existing care plans.
organizing and care delivery.
anticipating and preventing problems.
knowledge, skills, and qualifications.
requiring support and assistance.
Provision of care
Communicating nursing interventions

ALHAMDULILLAH
Terimakasih
53