Nursing Process : IMPLEMENTATION

BY : CATHERINE KUCKYT, RN

mplementation is the actual performance of the nursing interventions identified in the care plan. The implementations are co ordinated with other members of the health care team who have direct care of the client.These interventions include , but are not limited to; health teaching, direct client care, medical treatments, medications, and dressing changes.

Nurses provide care to achieve established goals of care and then communicate the nursing interventions by documenting and reporting.

Not all interventions are planned. The nurse must use her critical thinking skills to respond to an unexpected crisis.
Measurement Criteria:(2)

1. Interventions are consistent with the established plan of care.
2. Interventions are implemented in a safe and appropriate manner.
3. Interventions are documented according to Nursing Standards.

NOTE: For the purpose of examples of Nursing Process , I will be using the following Case Study through out this report.
Case Study:
Client with Liver Disease - Cirrhosis

Mr.K is a 45 year old polish male. Married with three children. He is currently unemployed. He has worked in the service industry for his entire life. He has been socially drinking since he was 13 yrs.He has a family history of alcoholism and diabetes. He has been admitted to ICU on three previous occassions for liver disease.

Sample Nursing Care Plan Now includes Implementation :

Nursing Diagnosis
Imbalance Nutrition:Less than Body Requirements related to anorexia, metabolic imbalance

Goals and Outcome Criteria
Adequate nutrition:Stable body weight, consumes meals


Implementation(Interventions)
Explain the need for adequate food intake. Small frequent meals. Arrange for dietician consult. Record daily weight.


Nursing Diagnosis
Activity Intolerance related to fatigue

Goals and Outcome Criteria
Improved activity tolerance:Performs actvities of daily living without excessive fatigue

Implementation(Interventions)
Schedule nursing care for rest periods. Elevate head of bead to facilitate breathing. Deep breathing and excercise extremeties.

Nursing Diagnosis
Risk for Impaired Skin Integrity related to edema, immobility, pruritis, hypoproteinemia

Goals and Outcome Criteria
Intact skin: No redness or breaks in skin.No scratching

Gentle bathing with mild soap and warm water. Client's nails should be kept short. If itching severe ask Doc. for medications to relieve the discomfort. Administer medications as ordered

Nursing Diagnosis
Ineffective Breathing Patterns related to ascites

Goals and Outcome Criteria
Effective breathing:Respiratory rate of 12-20 per minute without dyspnea.

Implementation(Interventions)
Elevate head of bed to relieve pressure of abdomen. Chair sitting may be more comfortable, with elevated feet .If allowed.

Nursing Diagnosis
Risk for Injury related to impaired coagulation

Goals and Outcome Criteria
Absence of bleeding: No blood in emesis or stool, vital signs consistent with patient norms

Implementation(Interventions)
Handle client gently to avoid trauma. Apply presure to injection sites. Note stool characteristics.

Nursing Diagnosis
Disturbed Thought Processes related to elevated blood ammonia

Goals and Outcome Criteria
Normal cognitive functions: Mentally alert, oriented

Implementation(Interventions)
Monitor mental , cognitive and neurological statis. Provide basic information. Notify doc. if changes in statis. Health teaching for family members on dietary restrictions. Be alert for drug therapy adverse side effects ie:diarrhea, vitamin K deficiency and otoxicity.