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(SOLVED)Nursing Process Project: Implementation/Take Action

(SOLVED)Nursing Process Project: Implementation/Take Action

The nursing process is a systematic, rational method of planning that guides all nursing actions in delivering holistic and patient-focused care. The nursing process is a form of scientific reasoning and requires the nurse’s critical thinking to provide the best care possible to the client.
What is the purpose of the nursing process?
The following are the purposes of the nursing process:

To identify the client’s health status and actual or potential health care problems or needs (through assessment) (through assessment).
To establish plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs.
To apply the best available caregiving evidence and promote human functions and responses to health and illness (ANA, 2010). (ANA, 2010).
To protect nurses against legal problems related to nursing care when the standards of the nursing process are followed correctly.
To help the nurse perform in a systematically organized way their practice.
To establish a database about the client’s health status, health concerns, response to illness, and the ability to manage health care needs.
Characteristics of the nursing process
The following are the unique characteristics of the nursing process:
Nursing Process Project: Implementation/Take Action
Patient-centered. The unique nursing process approach requires respectful and responsive care to the individual patient’s needs, preferences, and values. The nurse advocates by keeping the patient’s right to practice informed decision-making and maintaining patient-centered engagement in the health care setting.
Interpersonal. The nursing process provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals, learning and growing due to the interaction. It involves the nurse and patient interaction with a common goal.
Collaborative. The nursing process functions effectively in nursing and inter-professional teams, promoting open communication, mutual respect, and shared decision-making to achieve quality patient care.
Dynamic and cyclical.
The nursing process is a dynamic, cyclical process in which each phase interacts and is influenced by the other phases.
Requires critical thinking. The nursing process requires critical thinking, a vital skill for nurses in identifying client problems and implementing interventions to promote effective care outcomes.
Nursing Process Steps
The nursing process consists of five steps: assessment, diagnosis, planning, implementation, and evaluation. The acronym ADPIE is an easy way to remember nursing process components. Nurses need to learn how to apply the process step-by-step. However, as critical thinking develops through experience, they learn how to move back and forth among the steps of the nursing process.

The steps of the nursing process are not separate entities but overlapping, continuing subprocesses. Apart from understanding nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the selected nursing diagnoses, and the interventions suited for treating the diagnoses.

The steps of the nursing process are detailed below:

1. Assessment: “What data is collected?”
The first phase of the nursing process is assessment. It involves collecting, organizing, validating, and documenting the clients’ health status. This data can be obtained in a variety of ways. Usually, when the nurse first encounters a patient, the nurse is expected to assess to identify the patient’s health problems as well as the physiological, psychological, and emotional state and to establish a database about the client’s response to health concerns or illness and the ability to manage health care needs. Critical thinking skills are essential to the assessment, thus requiring concept-based curriculum changes.

Collecting Data
Data collection is gathering information regarding a client’s health status. The process must be systematic and continuous in collecting data to ensure the information concerning the client is accurate.

The best way to collect data is through head-to-toe assessment. Learn more about it at our guide: Head to Toe Assessment: Complete Physical Assessment Guide.

Types of Data
Data collected about a client generally falls into objective or subjective categories, but data can also be verbal and nonverbal.

Objective Data or Signs
Objective data are overt, measurable, tangible data collected via the senses, such as sight, touch, smell, or hearing, and compared to an accepted standard, such as vital signs, intake and output, height and weight, body temperature, pulse, and respiratory rates, blood pressure, vomiting, distended abdomen, presence of edema, lung sounds, crying, skin color, and presence of diaphoresis.

Subjective Data or Symptoms
Subjective data involve covert information, such as feelings, perceptions, thoughts, sensations, or concerns that are shared by the patient and can be verified only by the patient, such as nausea, pain, numbness, pruritus, attitudes, beliefs, values, and perceptions of the health concern and life events.

Verbal Data
Verbal data are spoken or written data such as statements made by the client or by a secondary source. Verbal data requires the listening skills of the nurse to assess difficulties such as slurring, tone of voice, assertiveness, anxiety, difficulty in finding the desired word, and flight of ideas.

Nonverbal Data
Nonverbal data are observable behavior transmitting a message without words, such as the patient’s body language, general appearance, facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture, and clothing. Nonverbal data obtained can sometimes be more powerful than verbal data, as the client’s body language may not be congruent with what they think or feel. Obtaining and analyzing nonverbal data can help reinforce other forms of data and understand what the patient feels.

Sources of Data
Sources of data can be primary, secondary, and tertiary. The client is the primary data source, while family members, support persons, records and reports, other health professionals, laboratory, and diagnostics fall under secondary sources.

Primary Source
The client is the only primary source of data and the only one who can provide subjective data. Anything the client says or reports to the healthcare team members is considered primary.

Secondary Source
A source is considered secondary data if provided by someone other than the client but within the client’s frame of reference. Information provided by the client’s family or significant others is considered a secondary data source if the client cannot speak for themselves, lacks facts and understanding, or is a child. Additionally, the client’s records and assessment data from other nurses or other members of the healthcare team are considered secondary sources of data.

Tertiary Source
Sources outside the client’s frame of reference are considered tertiary data sources. Examples of tertiary data include information from textbooks, medical and nursing journals, drug handbooks, surveys, and policy and procedural manuals.

Methods of Data Collection
The main methods used to collect data are health interviews, physical examinations, and observation.

Health Interview
The most common approach to gathering important information is through an interview. An interview is an intended communication or a conversation with a purpose, for example, to obtain or provide information, identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy. One example of the interview is the nursing health history, which is a part of the nursing admission assessment. Patient interaction is generally the heaviest during the assessment phase of the nursing process, so rapport must be established during this step.

Physical Examination
Aside from conducting interviews, nurses will perform physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Establishing a good physical assessment would, later on, provide a more accurate diagnosis, planning, and better interventions and evaluation.

Observation is an assessment tool that depends on using the five senses (sight, touch, hearing, smell, and taste) to learn about the client. This information relates to characteristics of the client’s appearance, functioning, primary relationships, and environment. Although nurses observe mainly through sight, most of the senses are engaged during careful observations, such as smelling foul odors, hearing or auscultating lung and heart sounds, and feeling the pulse rate and other palpable skin deformations.

Validating Data
Validation is verifying the data to ensure that it is accurate and factual. One way to validate observations is through “double-checking,” and it allows the nurse to complete the following tasks:

Ensures that assessment information is double-checked, verified, and complete.
For example, during the routine assessment, the nurse obtains a reading of 210/96 mm Hg from a client with no history of hypertension. To validate the data, the nurse should retake the blood pressure and, if necessary, use another piece of equipment to confirm the measurement or ask someone else to perform the assessment.
Ensure that objective and related subjective data are valid and accurate.
For example, the client’s perceptions of “feeling hot” need to be compared with the body temperature measurement.
Ensure that the nurse concludes with adequate data to support the conclusion.
A nurse assumes tiny purple or bluish-black swollen areas under the tongue of an older adult client to be abnormal until reading about physical changes of aging.
Ensure that any ambiguous or vague statements are clarified.
For example, an 86-year-old female client who is not a native English speaker says, “I have been in pain on and off for four weeks,” which would require clarification from the nurse by asking, “Can you describe what your pain is like? What do you mean by on and off?”
Acquire additional details that may have been overlooked.
For example, the nurse asks a 32-year-old client if he is allergic to prescription or non-prescription medications. And what would happen if he took these medications?
Distinguish between cues and inferences.
Cues are subjective or objective data that the nurse can directly observe; that is, what the client says or what the nurse can see, hear, feel, smell, or measure. On the other hand, inferences are the nurse’s interpretation or conclusions based on the cues. For example, the nurse observes the cues that the incision is red, hot, and swollen and infers that the incision is infected.
Documenting Data \sOnce all the information has been collected, data can be recorded and sorted. Excellent record-keeping is fundamental so that all the data gathered is documented and explained in a way that is accessible to the whole healthcare team and can be referenced during evaluation.

2. Diagnosis: “What is the problem?”
The second step of the nursing process is the nursing diagnosis. The nurse will analyze all the gathered information and diagnose the client’s condition and needs. Diagnosing involves analyzing data, identifying health problems, risks, and strengths, and formulating diagnostic statements about a patient’s potential health problem. More than one diagnosis is sometimes made for a single patient. Formulating a nursing diagnosis by employing clinical judgment assists in the planning and implementing of patient care.

The types, components, processes, examples, and writing nursing diagnosis are discussed in more detail in “Nursing Diagnosis Guide: All You Need To Know To Master Diagnosing.”

3. Planning: “How to manage the problem?”
Planning is the third step of the nursing process. It provides direction for nursing interventions. When the nurse, supervising medical staff, and the patient agree on the diagnosis, the nurse will plan a course of treatment that considers short- and long-term goals. Each problem is committed to a measurable goal for the expected beneficial outcome.

In the planning phase, goals and outcomes are formulated that directly impact patient care based on evidence-based practice (EBP) guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a direction for personalized care tailored to an individual’s unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum.

Types of Planning
Planning starts with the first client contact and resumes until the nurse-client relationship ends, preferably when the client is discharged from the health care facility.

Initial Planning
Initial planning is done by the nurse who conducts the admission assessment. Usually, the same nurse would be the one to create the initial comprehensive plan of care.

Ongoing Planning
Ongoing planning is done by all the nurses who work with the client. As nurses obtain new information and evaluate the client’s responses to care, they can further individualize the initial care plan. An ongoing care plan also occurs at the beginning of a shift. Ongoing planning allows the nurse to:

determine if the client’s health status has changed \ set priorities for the client during the shift \ decide which problem to focus on during the shift
coordinate with nurses to ensure that more than one problem can be addressed at each client contact
Discharge Planning
Discharge planning is the process of anticipating and planning for needs after discharge. To provide continuity of care, nurses need to accomplish the following:

Start discharge planning for all clients when admitted to any healthcare setting.
Involve the client and the client’s family or support persons in the planning process.
Collaborate with other health care professionals to ensure that biopsychosocial, cultural, and spiritual needs are met.
Developing a Nursing Care Plan
A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans communicate with nurses, their patients, and other healthcare providers to achieve healthcare outcomes. The nursing care planning process will preserve the quality and consistency of patient care.


The planning step of the nursing process is discussed in detail in Nursing Care Plans (NCP): Ultimate Guide and Database.

4. Implementation: “Putting the plan into action!”
The implementation phase of the nursing process is when the nurse puts the treatment plan into effect. It involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care. This typically begins with the medical staff conducting any needed medical interventions.

Interventions should be specific to each patient and focus on achievable outcomes. Actions associated with a nursing care plan include:
Monitoring the patient for signs of change or improvement.
Directly caring for the patient or conducting important medical tasks such as medication administration.
Educating and guiding the patient about further health management.
Referring or contacting the patient for a follow-up.

A taxonomy of nursing interventions referred to as the Nursing Interventions Classification (NIC) taxonomy, was developed by the Iowa Intervention Project in addition to the efforts of NANDA-I to standardize the language for describing problems. The nurse can look up a client’s nursing diagnosis to determine recommended nursing interventions.

Nursing Interventions Classification (NIC) System
There are more than 550 nursing intervention labels that nurses can use to provide the proper care to their patients. According to the Nursing Interventions Classification system, these interventions are categorized into seven fields or classes of interventions.

Behavioral Nursing Interventions
These are interventions designed to help a patient change their behavior. With behavioral interventions, in contrast, patient behavior is the key, and the goal is to modify it. The following measures are examples of behavioral nursing interventions:

Encouraging stress and relaxation techniques
Providing support to quit smoking
Engaging the patient in some form of physical activity, like walking, to reduce the patient’s anxiety, anger, and hostility
Community Nursing Interventions
These are interventions that refer to the community-wide approach to health behavior change. Instead of focusing mainly on the individual as a change agent, community interventionists recognize a host of other factors that contribute to an individual’s capacity to achieve optimal health, such as:

Implementing an education program for first-time mothers
Promoting diet and physical activities
Initiating HIV awareness and violence-prevention programs
Organizing a fun run to raise money for breast cancer research
Family Nursing Interventions
These are interventions that influence a patient’s entire family.

Implementing a family-centered approach in reducing the threat of illness spreading when one family member is diagnosed with an infectious disease
Providing a nursing woman support in breastfeeding her new baby \sEducating family members about caring for the patient
Health System Nursing Interventions
These are interventions that are designed to maintain a safe medical facility for all patients and staff, such as:

Following procedures to reduce the risk of infection for patients during hospital stays.
Ensuring that the patient’s environment is safe and comfortable, such as repositioning them to avoid pressure ulcers in bed
Physiological Nursing Interventions
These are interventions related to a patient’s physical health to ensure that any physical needs are met and that the patient is in a healthy condition. These nursing interventions are classified into two types: basic and complex.

Basic. Basic interventions regarding the patient’s physical health include hands-on procedures ranging from feeding to hygiene assistance.
Complex. Some physiological nursing interventions are more complex, such as inserting an IV line to administer fluids to a dehydrated patient.
Safety Nursing Interventions
These are interventions that maintain a patient’s safety and prevent injuries, such as:

They were educating patients about how to call for assistance if they cannot safely move around on their \sProviding instructions for using assistive devices such as walkers or canes or how to take a shower safely.
Skills Used in Implementing Nursing Care
When implementing care, nurses need cognitive, interpersonal, and technical skills to perform the care plan successfully.

Cognitive Skills, also known as Intellectual Skills, involve learning and understanding fundamental knowledge, including basic sciences, nursing procedures, and their underlying rationale before caring for clients. Cognitive skills include problem-solving, decision-making, critical thinking, clinical reasoning, and creativity.
Interpersonal skills involve believing, behaving, and relating to others. The effectiveness of a nursing action usually leans mainly on the nurse’s ability to communicate with the patient and the healthcare team members.
Technical Skills are purposeful “hands-on” skills such as changing a sterile dressing, administering an injection, manipulating equipment, bandaging, moving, lifting, and repositioning clients. All of these activities require safe and competent performance.
Process of Implementing
The process of implementation typically includes the following:

1. Reassessing the client
Before implementing an intervention, the nurse must reassess the client to ensure the intervention is still needed. The client’s condition may have changed even if an order is written on the care plan.

2. Determining the nurse’s need for assistance
Non-RN healthcare team members may also perform other nursing tasks or activities. Members of this team may include unlicensed assistive personnel (UAP) and caregivers, as well as other licensed healthcare workers, such as licensed practical nurses/licensed vocational nurses (LPNs/LVNs). The nurse may need assistance when implementing some nursing intervention, such as ambulating an unsteady obese client, repositioning a client, or when a nurse is unfamiliar with a particular traction equipment that needs assistance the first time it is applied.

3. Implementing the nursing interventions
Nurses must have a substantial knowledge base of the sciences, nursing theory, nursing practice, legal parameters of nursing interventions, and psychomotor skills to implement procedures safely. Nurses must describe, explain, and clarify to the client what interventions will be done, what sensations to anticipate, what the client is expected to do, and what the expected outcome is. When implementing care, nurses perform activities that may be independent, dependent, or interdependent.

Nursing Intervention Categories
Nursing interventions are grouped into three categories according to the role of the healthcare professional involved in the patient’s care:

Independent Nursing Interventions
A registered nurses can perform independent interventions on their own without the help or assistance from other medical personnel, such as:

Routine nursing tasks such as checking vital signs \ and educating a patient on the importance of their medication so they can administer it as prescribed
Dependent Nursing Interventions
A nurse cannot initiate dependent interventions alone. Some actions require guidance or supervision from a physician or other medical professional, such as:

prescribing new medication
inserting and removing a urinary catheter \sproviding diet
Implementing wound or bladder irrigations
Interdependent Nursing Interventions
A nurse performs as part of collaborative or interdependent interventions that involve team members across disciplines.

In some cases, such as post-surgery, the patient’s recovery plan may require a prescription medication from a physician, feeding assistance from a nurse, and treatment by a physical therapist or occupational therapist.
The physician may prescribe a specific diet to a patient. The nurse includes diet counseling in the patient care plan. To aid the patient even more, the nurse enlists the help of the dietician that is available in the facility.
4. Supervising the delegated care
Delegate specific nursing interventions to other members of the nursing team as appropriate. Consider the capabilities and limitations of the nursing team members and supervise the performance of the nursing interventions. Deciding whether delegation is indicated is another activity that arises during the nursing process.

The American Nurses Association and the National Council of State Boards of Nursing (2006) define delegation as “the process for a nurse to direct another person to perform nursing tasks and activities.” It generally concerns the appointment of the performance of activities or tasks associated with patient care to unlicensed assistive personnel while retaining accountability for the outcome.

Nevertheless, registered nurses cannot delegate responsibilities related to making nursing judgments. Examples of nursing activities that cannot be delegated to unlicensed assistive personnel include assessment and evaluation of the impact of interventions on care provided to the patient.

5. Documenting nursing activities
Record what has been done and the patient’s responses to nursing interventions precisely and concisely.

5. Evaluation: “Did the plan work?”
Evaluating is the fifth step of the nursing process. This final phase of the nursing process is vital to a positive patient outcome. Once all nursing intervention actions have taken place, the team now learns what works and what doesn’t by evaluating what was done beforehand. Whenever healthcare providers intervene or implement care, they must reassess or evaluate to ensure the desired outcome has been met. The three possible patient outcomes are as follows: the patient’s condition improved, the patient’s condition stabilized, and the patient’s condition worsened.

Evaluation Steps
The nursing evaluation consists of the following steps: (1) collecting data, (2) comparing collected data with desired outcomes, (3) analyzing client responses to nursing activities, (4) identifying factors that contributed to the success or failure of the care plan, (5) continuing, modifying, or terminating the nursing care plan, and (6) planning for future nursing care.

1. Data Collection
The nurse collects data to conclude whether or not goals have been met. It is usually necessary to gather both objective and subjective data. Data must be documented concisely and accurately to facilitate the next stage of the evaluation process.

2. Data Comparison with Desired Outcomes
The nursing care plan’s documented goals and objectives become the standards or criteria by which the client’s progress is measured, whether the desired outcome is met, partially met, or not met.

The goal has been met when the client’s response matches the desired outcome.
The goal was partially met when either a short-term outcome was achieved, but the long-term goal was not, or the desired goal was only partially attained.
The objective still needs to be met.
3. Examining the Client’s Reaction to Nursing Activities
It is also critical to determine whether the nursing activities impacted the outcomes and whether they were successful.

4. Identifying Contributing Factors to Success or Failure
More data is needed to determine whether the plan was successful or not. Various factors may contribute to goal achievement. For instance, the client’s family may or may not be supportive, or the client may be unwilling to participate in such activities.

5. Continuation, Modification, or Termination of Nursing Care Plan
Nursing is a dynamic and cyclical process. The nursing process is restarted from the beginning if the goals are not met. Depending on the general patient condition, regular reassessment and modification may be required to keep them current and relevant. Based on new assessment data, the care plan may be modified. Problems may arise or change as a result. As clients complete their objectives, new objectives are established. If goals are not met, nurses must evaluate the reasons for this and recommend revisions to the nursing care plan.

6. Discharge Preparation
The process of transitioning a patient from one level of care to the next is known as discharge planning. Discharge plans are personalized instructions given to clients as they prepare for continued care outside the healthcare facility or independent living at home. A discharge plan’s primary goal is to improve the client’s quality of life by ensuring continuity of care in collaboration with the client’s family or other healthcare workers providing ongoing care.

According to the Agency for Healthcare Research and Quality, the following are the key elements of IDEAL discharge planning:

Include the patient and family in the discharge planning process as full partners.
Discuss the following five key areas with the patient and family to prevent problems at home:
Describe your daily life at home.
Examine your medications
Highlight potential issues and warning signs
Explain the results of the tests.
Make follow-up appointments.
Throughout the hospital stay, educate the patient and family in plain language about the patient’s condition, the discharge process, and the next steps.
Examine how well doctors and nurses explain the patient’s diagnosis, condition, and next steps in care to the patient and family and how well they use teach-back.
Listen to and respect the goals, preferences, observations, and concerns of the patient and family.
A discharge plan includes specific client teaching components with documentation, such as:

Home equipment is required. Coordination of home-based care and special equipment is required.
Dietary requirements or a special diet. Talk about what the patient can and cannot eat at home.
Medication is to be administered at home. List the patient’s medications and discuss their purpose, dosage, administration method, and potential side effects.
Contact information and addresses for important people. Make a note of the name and phone number of someone to contact if there is a problem.
Danger signs require immediate action. Identify and educate patients and families about potential problems and warning signs.
Activities are related to home care. Educate the patient on what activities to do and which to avoid at home.
Summary. Discuss the patient’s condition, the discharge process, and follow-up checkups with the patient and family.


The implementation stage of the process is where you, as a nurse, apply action to your client’s care.

As a reminder, an overview of the Nursing Process Project and the project resources can be found in Module 3: Nursing Process Project: Overview.

The fourth part of the Nursing Process Project requires you to complete the implementation section on the Nursing Process Project template. Follow these steps to complete this part of the project.

Step 1: Complete the implementation section of the Nursing Process Project template by including a minimum of two interventions for each goal identified. Consider the following as you formulate client interventions:

What nursing interventions do you think are necessary to accomplish your goals?
What will assist the client in meeting the goals?
If a category is non-applicable, simply write NA in that section of the template.

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