1. Implementation By Patricia M. Dillon Updated Spring 2010 Prof. Unn Hidle

2. Copyright 2002 by Delmar, a division of Thomson Learning 2 Review of the Nursing Process ASSESSMENT ASSESSMENT ANALYSIS ANALYSIS PLANNING PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION EVALUATION

3. Copyright 2002 by Delmar, a division of Thomson Learning 3 Implementation Implementation is the fourth step of the nursing process. It involves the execution of the nursing plan of care derived during the planning phase of the nursing process. Implementation is the fourth step of the nursing process. It involves the execution of the nursing plan of care derived during the planning phase of the nursing process.

4. Copyright 2002 by Delmar, a division of Thomson Learning 4 Purposes of Implementation Fulfilling client needs which results in health promotion, prevention of illness, illness management, or health restoration Fulfilling client needs which results in health promotion, prevention of illness, illness management, or health restoration Delegate tasks to staff members and assistive personnel Delegate tasks to staff members and assistive personnel Document specific activities executed by the nurse and the client’s responses to these activities to maintain communication among team members. Document specific activities executed by the nurse and the client’s responses to these activities to maintain communication among team members.

5. Copyright 2002 by Delmar, a division of Thomson Learning 5 Requirements For Effective Implementation Cognitive skills Cognitive skills Psychomotor skills Psychomotor skills Interpersonal skills Interpersonal skills

6. Copyright 2002 by Delmar, a division of Thomson Learning 6 Implementation Activities Ongoing assessment Ongoing assessment  Necessary to validate the relevance of proposed interventions  Allows for adaptations to be made to better individualize care

7. Copyright 2002 by Delmar, a division of Thomson Learning 7 Priorities Establishment of priorities is based on Establishment of priorities is based on  Which problems are deemed most important by the nurse, the client, and family or significant others  Activities previously scheduled by other departments  Available resources

8. Copyright 2002 by Delmar, a division of Thomson Learning 8 Allocation of resources Delegation of tasks Delegation of tasks Types of management systems Types of management systems  Functional nursing  Team nursing  Primary nursing  Total patient care nursing  Case management

9. Copyright 2002 by Delmar, a division of Thomson Learning 9 Initiation of nursing interventions Initiation of nursing interventions An action or actions performed by the nurse that help the client to achieve the results specified by the goals and expected outcomes An action or actions performed by the nurse that help the client to achieve the results specified by the goals and expected outcomes Nursing Interventions

10. Copyright 2002 by Delmar, a division of Thomson Learning 10 Types of Nursing Interventions  Independent interventions:  Involve carrying out nurse-prescribed orders written on the nursing plan of care, and any other actions that nurses initiate without the direction and supervision of another health care professional. These actions are the result of their assessment of patient needs.  Dependent interventions :  Involve carrying out physician-prescribed orders.  Nurses are accountable for the dependent orders they implement and are thus responsible for the clarification of any questionable order.  Collaborative (interdependent) interventions :  Those performed jointly by nurses and other members of the healthcare team.

11. Copyright 2002 by Delmar, a division of Thomson Learning 11 Protocols and Standing Orders  Protocols:  Written plans that detail the nursing activities to be executed in specific situations.  Standing orders:  Empower the nurse to initiate actions that ordinarily require the order or supervision of a physician.  These orders are typically seen in critical care and emergency situations where the nurse must act quickly to save a life.

12. Copyright 2002 by Delmar, a division of Thomson Learning 12  Coordination of Care  Carrying Out the Plan of Care Utilizing therapeutic interventions therapeutic interventions  Determining the need for assistance  Delegation of care (supervision)  Responsibility and Accountability  Promoting self care (teaching & discharge planning) planning)  Communication (verbal & written)  Monitoring and surveillance of response to care (evaluation) Nursing intervention activities

13. Copyright 2002 by Delmar, a division of Thomson Learning 13 Nurse as Coordinator One of nursing's major contributions to the healthcare team is that of coordinator. Care can easily become fragmented when patients are seen by numerous people. One of nursing's major contributions to the healthcare team is that of coordinator. Care can easily become fragmented when patients are seen by numerous people. Patients may complain that no one really knows them and can talk with them about what is going on with them. Also, the orders of different specialists may conflict with one another and be counterproductive. Patients may complain that no one really knows them and can talk with them about what is going on with them. Also, the orders of different specialists may conflict with one another and be counterproductive. Therefore, it is important for nurses to make rounds with other healthcare professionals and to read the results of consultations that patients have had with various members of the healthcare team. Therefore, it is important for nurses to make rounds with other healthcare professionals and to read the results of consultations that patients have had with various members of the healthcare team. The nurse is in an ideal position to serve as liason between the patient and members of the healthcare team. The nurse is in an ideal position to serve as liason between the patient and members of the healthcare team.

14. Copyright 2002 by Delmar, a division of Thomson Learning 14 Determining the Need for Assistance Although most people are capable of independently meeting basic human needs, illness and the stress of diagnostic and therapeutic measures may interfere with a person's usual practice of self-care. A careful nursing assessment of the patient’s abilities to independently meet human needs is indicated. Although most people are capable of independently meeting basic human needs, illness and the stress of diagnostic and therapeutic measures may interfere with a person's usual practice of self-care. A careful nursing assessment of the patient’s abilities to independently meet human needs is indicated. Nursing has often failed patients by doing too much for them and by encouraging negative, sick role behaviors. Nursing has often failed patients by doing too much for them and by encouraging negative, sick role behaviors. Conversely, there is a time and a place for the "tender loving care" that says to a patient "I know you may be able to do this for yourself, but just this once, how about if I do it and we'll talk ". Conversely, there is a time and a place for the "tender loving care" that says to a patient "I know you may be able to do this for yourself, but just this once, how about if I do it and we'll talk ".

15. Copyright 2002 by Delmar, a division of Thomson Learning 15 Delegating Nursing Care Delegation is the transfer of responsibility for the performance of an activity from one individual to another while still retaining accountability for the outcome. Delegation is the transfer of responsibility for the performance of an activity from one individual to another while still retaining accountability for the outcome. With current pressure to reduce healthcare costs, many employers are increasing their utilization of unlicensed assistive personnel (UAP), or "nurse extenders". Delegated care can range from taking vital signs (temperature, pulse, respiration, blood pressure) to simple assessments to a variety of skills and procedures. Never has it been more important for nurses to critically identify which nursing interventions require professional nurses and which can be safely delegated. With current pressure to reduce healthcare costs, many employers are increasing their utilization of unlicensed assistive personnel (UAP), or "nurse extenders". Delegated care can range from taking vital signs (temperature, pulse, respiration, blood pressure) to simple assessments to a variety of skills and procedures. Never has it been more important for nurses to critically identify which nursing interventions require professional nurses and which can be safely delegated.

16. Copyright 2002 by Delmar, a division of Thomson Learning 16 Before delegating any nursing service, a number of factors should be considered: Patient's condition (if the patient is in critical or unstable condition, it may be best for the nurse to carry out the care). Patient's condition (if the patient is in critical or unstable condition, it may be best for the nurse to carry out the care). Complexity of the activity (more difficult tasks should be performed by professional staff) Complexity of the activity (more difficult tasks should be performed by professional staff) Capabilities of the UAP (when you work with unlicensed personnel on a regular basis you become familiar with their abilities and sense of responsibility. You should not delegate care when you are uncertain about the UAP’s abilities). Capabilities of the UAP (when you work with unlicensed personnel on a regular basis you become familiar with their abilities and sense of responsibility. You should not delegate care when you are uncertain about the UAP’s abilities). Availability of professional staff to accomplish the work (never delegate care so that you can take a break or ‘take it easy’. If there is professional staff available, the work should be done by the licensed personnel). Availability of professional staff to accomplish the work (never delegate care so that you can take a break or ‘take it easy’. If there is professional staff available, the work should be done by the licensed personnel).

17. Copyright 2002 by Delmar, a division of Thomson Learning 17 Responsibility & Accountability It is the RN who is responsible and accountable for nursing practice. Assistive personnel should work in a supportive role to the RN and together they will deliver safe, effective care to patients. It is the RN who is responsible and accountable for nursing practice. Assistive personnel should work in a supportive role to the RN and together they will deliver safe, effective care to patients.

18. Copyright 2002 by Delmar, a division of Thomson Learning 18 Written Communication Documentation of Interventions Documentation of Interventions  The nurse is legally required to record all interventions and observations related to the client’s response to treatment in the patient’s medical record.  The recording of information can be in the form of checklists, flow sheets, or narrative summaries.

19. Copyright 2002 by Delmar, a division of Thomson Learning 19 Legalities The rule of thumb in healthcare is: The rule of thumb in healthcare is: "If you didn't chart it, you didn't do it." "If you didn't chart it, you didn't do it." In legal situations it is extremely important for all of your nursing actions to be accurately and completely recorded. In legal situations it is extremely important for all of your nursing actions to be accurately and completely recorded. Most facilities have flow sheets for simplifying some of the routine measures Most facilities have flow sheets for simplifying some of the routine measures Each facility has policies for what will be charted, when, and where. Each facility has policies for what will be charted, when, and where. Charting (documentation) can be focused note, narratives, SOAP, SOAPIE, or other as determined by the agency. Charting (documentation) can be focused note, narratives, SOAP, SOAPIE, or other as determined by the agency. More and more charthing is now done electronically. More and more charthing is now done electronically.

20. Copyright 2002 by Delmar, a division of Thomson Learning 20 Verbal interaction among health care providers is essential for communicating current information. Verbal interaction among health care providers is essential for communicating current information. Formal reports are given between shifts; informal reports are given constantly to other nurses, members of the healthcare team, doctors, families (i.e. breaktimes). Formal reports are given between shifts; informal reports are given constantly to other nurses, members of the healthcare team, doctors, families (i.e. breaktimes). Oral Communication

21. Copyright 2002 by Delmar, a division of Thomson Learning 21  Basic patient identification information (age, sex, diagnosis)  Status of current relevant problems  Any abnormalities or changes in assessment  Results of treatments  Diagnostic tests scheduled, or those completed with the results  Needed activities completed and those remaining to be completed What should be included in verbal reports?

22. Copyright 2002 by Delmar, a division of Thomson Learning 22 SUMMARY IMPLEMTATION INCLUDES: Execution of the nursing plan of care (Interventions/nursing actions) Execution of the nursing plan of care (Interventions/nursing actions) Fulfilling client needs which results in health assessment, promotion, prevention of illness, illness management, or health restoration Fulfilling client needs which results in health assessment, promotion, prevention of illness, illness management, or health restoration Delegate tasks as necessary Delegate tasks as necessary Teaching, encouraging self care activities Teaching, encouraging self care activities Proper communication & documentation Proper communication & documentation Monitoring clients response to nursing actions Monitoring clients response to nursing actions

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