Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

BACHELOR OF SCIENCE IN NURSING

College of Health Sciences
1ST SEMESTER S/Y 2021-2022
NURSING PROCESS
Module 4: IMPLEMENTATION
Learning Outcomes:
After completing this chapter, you will be able to:
1. Explain how implementing relates to other phases of the nursing process.
2. Describe three categories of skills used to implement nursing interventions.
3. Discuss the five activities of the implementing phase.
4. Identify guidelines for implementing nursing interventions.

Introduction
The nursing process is action oriented, client centered, and outcome directed. After developing a plan of
care based on the assessing and diagnosing phases, the nurse implements the interventions and evaluates the
desired outcomes. On the basis of this evaluation, the plan of care is either continued, modified, or terminated.
As in all phases of the nursing process, clients and support persons are encouraged to participate as much as
possible.

Implementing
Is the action phase in which the nurse performs the nursing interventions. Using Nursing Interventions
Classification (NIC) terminology, implementing consists of doing and documenting the activities that are the
specific nursing actions needed to carry out the interventions. The nurse performs or delegates the nursing
activities for the interventions that were developed in the planning step and then concludes the implementing
step by recording nursing activities and the resulting client responses.

Process of Implementing
• Reassessing the client
• Determining the nurse’s need for assistance
• Implementing the nursing interventions
• Supervising the delegated care
• Documenting nursing activities.
Reassessing the Client
Just before implementing an intervention, the nurse must reassess the client to make sure the
intervention is still needed. Even though an order is written on the care plan, the client’s condition may have
changed. For example, a client has a nursing diagnosis of Disturbed Sleep Pattern related to anxiety and
unfamiliar surroundings. During rounds, the nurse discovers that the client is sleeping and therefore defers the
back massage that had been planned as a relaxation strategy.
Determining the Nurse’s Need for Assistance
When implementing some nursing interventions, the nurse may require assistance for one or more of the
following reasons:
 The nurse is unable to implement the nursing activity safely or efficiently alone (e.g., ambulating
an unsteady obese client).
 Assistance would reduce stress on the client (e.g., turning a person who experiences acute pain
when moved)
 The nurse lacks the knowledge or skills to implement a particular nursing activity (e.g., a nurse
who is not familiar with a particular model of traction equipment needs assistance the first time it
is applied).
Implementing the Nursing Interventions
It is important to explain to the client what interventions will be done, what sensations to expect, what
the client is expected to do, and what the expected outcome is.
When implementing interventions, nurses should follow these guidelines:
 Base nursing interventions on scientific knowledge, nursing research, and professional standards
of care (evidence-based practice) when these exist.
 Clearly understand the interventions to be implemented and question any that are not
understood.
 Adapt activities to the individual client. A client’s beliefs, values, age, health status, and
environment are factors that can affect the success of a nursing action.
 Implement safe care. For example, when changing a sterile dressing, the nurse practices sterile
technique to prevent infection; when giving a medication, the nurse administers the correct
dosage by the ordered route
 Provide teaching, support, and comfort.
 Be holistic
 Respect the dignity of the client and enhance the client’s self-esteem. Providing privacy and
encouraging clients to make their own decisions are ways of respecting dignity and enhancing
self-esteem.
 Encourage clients to participate actively in implementing the nursing interventions.
Supervising Delegated Care
 If care has been delegated to other health care personnel, the nurse responsible for the client’s
overall care must ensure that the activities have been implemented according to the care plan.
 The nurse validates and responds to any adverse findings or client responses. This may involve
modifying the nursing care plan.
Documenting Nursing Activities
After carrying out the nursing activities, the nurse completes the implementing phase by recording the
interventions and client responses in the nursing progress notes. The nurse may record routine or recurring
activities (e.g., mouth care) in the client record at the end of a shift.

Prepared by:
Jocyl Darrel B. Abinal, R.M, R.N, MAN
Clinical Instructor
Source: Kozier and Erb’s FUNDAMENTALS OF NURSING, concept, process and practice 10th edition Unit 3, Chapter 14