Implementing Nursing Interventions PDF

Implementing  Is the action phase in which the nurse performs the nursing interventions.  Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.  NIC (Nursing Intervention Classification)  Tax...

Implementing  Is the action phase in which the nurse performs the nursing interventions.  Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.  NIC (Nursing Intervention Classification)  Taxonomy of nursing interventions  Developed by the Iowa Intervention Project  First published in 1992  Updated every 4 years  Consists of three levels:  Level 1 domains  Level 2 classes  Level 3 interventions  More than 514 interventions developed  Each intervention includes:  A label (name)  A definition  A list of activities that outline key actions  Linked to NANDA diagnostic labels  Select appropriate intervention from suggested list of intervention.  Relationship of implementing to other Nursing Process phases  Based on first three phases (Assessment, Diagnosis, Planning)  Implementing phase provides the actual nursing activities  Nursing activities and client responses examined during evaluating phase  Nursing activities individualized based on assessment data  While the nurse implementing nursing care, the nurse also performing an assessment (auscultate breath sound q 4h).  To implement care successfully, nurses need:  Cognitive skills  Interpersonal skills  Technical skills Cognitive Skills (Intellectual)  Problem solving  Decision making  Critical thinking  Creativity  Interpersonal Skills  Are all the activities, verbal and nonverbal, people use when interacting directly with one another (Ability to communicate with others)  Effectiveness depends largely on the ability to communicate  Necessary for all nursing activities ( caring, referring, counseling, and supporting)  Include conveying knowledge, attitudes, feelings, interest, and appreciation of the client’s cultural values and lifestyle  Technical Skills  Are “hands-on” skills  Often called tasks, procedures, or psychomotor skills  Psychomotor refers to physical actions that are controlled by the mind, not reflexive (for example, the need to communicate with the client)  Require knowledge and frequently manual dexterity  Process of Implementing  Reassessing the client  Determining the nurse’s need for assistance  Implementing nursing interventions  Supervising delegated care  Documenting nursing activities 1. Reassessing the client:  to make sure that the intervention is still needed, or new data may indicate a need to change the priorities of care 2. Determining the nurse’s need for assistance: the nurse may require assistance for one or more of the following reasons: A. Unable to implement the nursing activity safely or efficient alone (positioning an obese patient) B. Assistance would reduce stress on client (turning a person who experiencing pain with movement) C. The nurse lacks the knowledge or skills to implement a particular nursing activity. 3. Implementing the nursing interventions:  explain the procedure or the intervention to the patient before implementation.  For many nursing interventions it is important to ensure patient’s privacy  Nurses coordinate clients care (scheduling the clients contacts with other departments) 4. Supervising Delegate Care:  The nurse responsible for the client’s overall care must ensure that the activities have been implemented according to the care plan. Other caregivers may be required to communicate their activities to the nurse by: 1. Documenting them on the patient’s records 2. Reporting verbally 3. Filling out a written form The nurse can validate the intervention implemented and respond to any adverse findings or client response. 5. Documenting Nursing Activities:  After the activities carried out, the nurse completes the implementing phase by recording the interventions and client responses in the nursing progress note.  Nursing care must not be recorded in advance because the nurse may determine on reassessment of the client that the intervention should not or cannot be implemented  The nurse may record routine or recurring activities (mouth care) in the client record at the end of the shift  It is very important to record the nursing intervention immediately after it is implemented (treatment and medications) which helps safeguard the client (prevent duplicating dose of medication)  Recorded data about the client must be up to date, accurate, and available to other nurses and health care professionals.  Nursing activities are communicated verbally as well as in writing (reporting the client status at changing the shift verbally  Guidelines for Implementing nursing Intervention  Evidence Based practice  Clearly understand intervention  Adapt activities to the individual client  Implement safe care  Provide teaching, support and comfort  Be holistic  Respect the dignity of the client and enhance self esteem  Encourage active client participation