Introduction: Nursing is both a science and art.

The nursing process provides an orderly, logical, problem solving approach for administering nursing care so that the patients needs for such care are met comprehensively and effectively. The nursing process is a six step process. Implementation is the fourth step in the nursing process. Implementation is initiation and completion of action to accomplish the defined goals and Optimal wellness of the client. In theory, implementation of the nursing care plan follows the planning component of the nursing process. However, in many health care settings it may begin directly after assessment. Eg. In emergency situations such as cardiac arrest or sudden death of a loved one. Definition : Implementation: Implementation is a category of nursing behaviour in which the actions necessary for achieving the goals and expected outcomes of nursing care initiated and completed. - POTTER AND PERRY.

Nursing intervention : Nursing intervention is any action taken by the nurse to help the client move from present health state to the health state described in the expected outcomes. Implementation is both patient centered (Wholly compensatory, Partial compensatory, supportive and educative) and functional or nurses centered (independent, dependent, and collaborative actions ). The implementation is in terms of needs of patient. The client may require intervention in the form of support, medication, treatment for the current condition, client family education or treatment to prevent future health problems. The purpose of intervention is to render appropriate patient care by putting the nursing care plan in to action. Purposes of implementation :

1. Assist the patient in achieving desired health goals. 2. Promote health. 3. Prevent disease and illness, restore health and facilitate coping with altered functioning. Principles of implementation : 1. The implementation phase should be based on patients desires and environment. 2. Implementation should be aimed to achieve the health promotion, health restoration and high levels of wellness. 3. Implementation should minimize all the potential capabilities of the client. 4. Nursing actions can be combined to achieve expected outcome. 5. Nursing implementation should aim therapeutic environment for the client. 6. Implementation should be based on nursing care plan, which is based on nursing diagnosis and assessment. 7. Implementation should aim for achievement of goals and expected outcome. 8. Implementation should be documented legibly and legally. Types of nursing actions: 1. Independent Nursing actions. 2. Dependent Nursing actions. 3. Interdependent Nursing actions. 4. Protocols 5. Standing orders. 1. Independent Nursing actions : Are those actions that the nurse can perform without directions from others. Eg. Providing back massage and turning a patient every 2 hours etc. 2. Dependent Nursing actions : Are those actions prescribed by the physicians, are carried out by the nurse. Eg. The nurse follows the orders while administering medications, performing wound care and ordering diagnostic tests etc. 3. Interdependent Nursing actions : Are those actions that the nurse and other health care personnel perform together. Eg. Counselling of a patient whose is posted for surgery, Community health, involving sanitary inspector etc to give health education

4. Protocols : A protocol is a written plan to indicate the procedures commonly required for a particular group of clients or situations. Eg. Care of post-op client, Protocols for admission and discharge, Pain management etc

5. Standing Orders: Standing order is a written document about policies, rules, regulations or orders regarding client care. Standing orders give nurses the authority to carryout specific action under circumstances in the absence of supervision of a physician. Eg. Standing orders for narcotic overdoses that specify the agents the nurse is to administer to reverse respiratory depression in an emergency, standing orders in community health set- up, Standing orders for pain management, standing orders for Obstetric and gynecological patients admission etc.

Implementation Process : The implementation component of the nursing has seven steps. 1. Reassessing the client. 2. Reviewing and modifying the existing nursing care plan. 3. Organizing resources and care delivery. a. Equipment b. Personnel c. Environment 4. 5. 6. 7. Anticipate and prevent complication. Identifying areas of assistance. Implementing nursing interventions. Recording

1. Reassessing the client: Assessment is a continous process, which may focus on only one dimension or system. When a new data are gathered and new client need is identified, the nurse modifies the care plan. The reassessment phase of the implementation component thus provide a mechanism for the nurse to determine whether the proposed nursing action is appropriate for the clients level of wellness. Eg. The nurse may have planned to ambulate a client following lunch, however, a reassessment reveals shortness of breath and increased fatigue which require the client to return to bed. 2. Reviewing and modifying the existing nursing care plan. Modification can occur in planned nursing care when there is change in the clients health status. Before beginning care, the nurse reviews the care plan and compares it with assessment data to validate the stated diagnosis and determine whether the nursing interventions are the most appropriate for the clinical situation. If the clients status has

changed and the nursing diagnosis and related nursing interventions are no longer appropriate, the nursing care plan needs to be modified. Modification includes several steps. First data in the assessment column are revised to reflect the clients current status. New data entered in the care plan should be dated to inform other members of the health care team. Nursing diagnosis are revised. Then the specific implementation methods are revised to correspond to the new nursing diagnosis and client goals. Finally the nurse determines what methods of evaluation will be used. 3. Organizing resources and care delivery : A facilitys resources include equipment and skilled personnel. Organization of equipment and personnel make efficient , skilled client care possible. The nurse Prepares the necessary supplies and decides on the time and provide of care. Preparation of care delivery also involves preparing the environment and client for nursing intervention. a. b. c. d. Equipment. Personnel. Environment. Patient and patient visitors

1. Equipment : Most nursing procedures require some equipment or supplies. The nurse analyzes each planned interventions for needed item and provider of care. Preparation of care delivery also involves preparing the environment and client for nursing intervention .Equipment should be in working order to ensure safe use.Eg. Catheterization. 2. Personnel: As the nurse prepares to intervene, he or she must consider the competencies of personnel available and model of care delivery being used. The most common types of nursing delivery systems are functional, team, total client care, primary nursing and care management. 3. Environment: Environment factors influence the delivery and reception care. The surroundings in which nursing activities occur should be of safe and conducive to the implementation of the therapy. Privacy promotes relaxation, when body parts are exposed. 4. patient and patient visitors Patient should be prepared well (physically and mentally) before implementing any intervention in order to gain his co-operation

Visitors can be allowed during performing of certain procedures in order to make them develop care giving skills at home.

5. Anticipating and preventing complications : Risks to the client arises from both the illness and treatment. The nurse must identify these risks, evaluate and relative benefit of the treatment versus the risk and initiate risk prevention measures. The nurse needs to be aware of potential complication and institute Precautionary measures. Eg. Diabetic patient- preventing complications. 5. Identifying areas of assistance : Some nursing situation requires the nurse to acquire assistance by seeking additional personnel, knowledge and nursing skills. Assistance may be needed in performing a procedure, comforting a client or preparing the client for a procedure. Eg. Pre-op counseling for a client posted for surgery. 6. Implementing nursing interventions: A variety of interventions can be selected by the nurse in administering care. The nurse selects from the following intervention methods to achieve goals of nursing care. a. Performing, assisting or directing the performance of activities of daily living. b. Counseling and evaluating the client and family. c. Providing direct nursing care. d. Supervising and evaluating the work of other staff members. Nursing practice is composed of cognitive, interpersonal and psychomotor skills. These skills are needed to implement interventions. 7. Documentation Record serves as a communication tool and a resource to aid in determining the effectiveness of care and to assist in setting priorities for ongoing care

Competencies essential to nursing practice a. cognitive competencies b. technical competencies c. interpersonal competencies d. ethical competencies Cognitive competencies

 Knowledge of what information you need to implement the nursing interventions that effectively meet the nursing needs of the client Knowledge pertinent to the standards of care and agency and institutional policies Ability to think critically about how to respond to the patients need for nursing Technical competencies Ability to use equipment and techniques competency that are specified by the patients plan of care. Interpersonal competencies Ability to establish a trusting nurse patient relationship Ability to communicate to the patient that you are more concerned about the patient and his wellbeing than about the role implementation of the plan of care or accomplishment of tasks Ability to work collaboratively with the member of the care giving team to implement the interdisciplinary plan of care

Ethical/legal competencies Commitment to implementing successfully the plan of care with in the scope of your legal practice Ability to be a trusted and effective patient advocate Consistent use of appropriate legal safeguards while implementing the plan of care Implementation methods The nurse carries the nursing care plan by using several implementation methods. A client with impaired physical mobility may require assistance in daily activities. The client with ineffective coping related fear of hospitalization may require counseling. For each diagnosis the nurse identifies appropriate interventions, each which requires specific theoretical knowledge and clinical skills. The implementation methods are a. assisting with activities of daily living b. counseling c. teaching d. providing direct nursing care e. delegating, supervising and evaluating the work of other staff members f. recording a. Assisting with activities of daily living activities of daily living usually performed in the course of a normal day they include ambulating, eating, dressing, bathing and grooming etc. conditions resulting in the need for assistance with ADLS can be acute, chronic, temporary assistance with ADLS, the client needs assistance during a specific period. A client with total self care deficit related to an irreversible injury has a permanent need for

assistance. The client can be taught new ways to perform ADLS, thus becoming more independent and better able to perform self care.

b. Counseling Counseling is an implementation method that helps the client use a problem solving process to recognize and manage stress and that facilitates interpersonal relationship among the client, family and health care team. Counseling is emotional, intellectual, spiritual and psychological support that helps the client accept or impending changes resulting from stress. Clients needing counseling include Persons who must adjust lifestyle patterns Clients coping with chronic or disabling diseases. Clients with life threatening illness to cope with possibility of death. c. Teaching Teaching involves use of communication skills to effect a change in the client. The main focus of teaching is intellectual growth or the acquisition of new knowledge or psychomotor skills. Teaching is an important implementation method used to present correct principles, procedures and techniques of health care to the clients and to inform clients about their health status. The nurse is responsible for assessing the learning needs of clients and is accountable for the quality of education delivered.

d. Providing direct nursing care To achieve the therapeutic goals for the client, the nurse initiates interventions to compensate for adverse reactions. Uses precautionary or preventive measures in providing care, applies correct techniques in administering care and preparing the client for special procedures and initiates life long measures in emergency situations. Compensation for adverse reaction An adverse reaction is a harmful or unintended effect of a medication, diagnostic test or therapeutic intervention. Nursing actions that compensates for adverse reactions reduce or counteract that reaction

Preventive measures These actions are directed at promoting health and preventing illness to avoid the need for acute or rehabilitative health care. Prevention includes assessment and promotion of the clients health potential, application of prescribed measures such as immunizations, health teaching, and early diagnosis and treatment. e. Delegating, supervising and evaluating the work of other staff members

Some activities may be delegated to other members of health care team and co-coordinated by the nurse. When a nurse delegates aspects of a clients care to another staff member, the nurse assigning tasks is responsible for ensuring that each task is appropriately assigned and is completed according to the standard of care. She will supervise and evaluate the work of other staff members.

f. Recording Documentation of the implementation component involves the use of written record, the health care record and the care plan is accurately becoming a permanent part of the health care record in many agencies. Documentation describes the actions implemented by the nurse, client or others in terms of the nursing diagnosis, the clients responses to the implementation of the plan is also recorded responses consist of physical, psychological, social and spiritual behaviors. It helps the other shift nurses to quickly see what is to be done and if any intervention was omitted. It serves as a legal document. Factors affect implementation inadequate nursing staff lack of family support lack of resources-man, money, material unrealistic expectation from colleagues no financial/other incentives conflict with nursing managers being used for non nursing responsibility incomplete protocols non-acceptance of role

Self care agents are providers of self care . agents are those who can/have take care of themselves, power to regulate factors that affect their own function & development

Selfcare

Selfcare agency

Selfcare deman d Selfcare deficit

It is the totality of self care action to be performed self care requisites by using valid methods & related sets of operation & action each persons therapeutic demand varies throughout life.

The goal of nursing agency is to help people meet their dependant others therapeutic self

Nursing system

Three components of nursing agency are, 1.help client accomplish theureuutic selfcare.2. Help the client to increase independence steadily decline self-care, adjust interruption.3.hel family members in providing client care.

DOROTHEA. E. OREM SELF CARE MODEL

Self care agency

Self care agency

Age. gender. Sociocultural orientation. development stauts. health status. health care system factors. Environmental factors. Resource adequacy & availability

Self care agency

Self care agency

Self care agency

Mr.Ramesh aged 28years maintains sufficient air, I feel difficult to pass the motion, I dont feel like eating, I have severe body pain. He is prone to get hazards, as he is restless, needs medical help for health promotion.

Mr. Ramesh needs adjustment with body change. Due to fracture.

-pain due to fracture, -confined to bed, constipation. -altered elimination. -imbalanced nutritional status. -prone to injury & complications. -altered body image.

Selfcare
As Mr. Ramesh is confined to bed due to traction, so nursing personnel are needed to provide care

Selfcare agency

Selfcare deman d Selfcare deficit

-acute pain related to fracture. - impaired physical mobility r/t confinement in traction. -impaired skin integrity r/t inability to change the position secondary to traction. -self care deficit r/t traction. -imbalanced nutritional status less body requirement r/t less intake. -risk for injury r/t traction. -knowledge deficit r/t exercise, diet, follow up.

Conditioning factors.
Name: Mr. Ramesh. Age : 28 years. Sex : male. Occupation : students. Family : good support. Health status : moderately built. Diagnosis : Right femur & ulnar fracture (traction)

Nursing system

Wholly compensatory, supportive educative system

WHOLY COMPENSATORY

Accomplishes clients therapeutic self care Compensates for clients inability to engage self care. Supports and protects. PARTLY COMPENSATORY Perform some self care measures for client. Compensates for self care limitation of client. Assists client as required

Performs some self care measures Regulates self care agency Accepts care and assistance for nurse. SUPPORTIVEEDUCATIVE SYSTEM Accomplishes self care. Regulates the exercise and development of self care agency.

BASIC NURSING SYSTEM