The implementation stage of the process is where you, as a nurse, apply action to your clients care.
As a reminder, an overview of the Nursing Process Project and the project resources can be found in .
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:
If a category is non-applicable, simply write NA in that section of the template.
The goal of any nursing intervention is to help the client in achieving their goals. An intervention is something that happens within the scope of nursing care and affects the individual’s health or wellbeing. While interventions can be physical or psychosocial in nature, they can also be directed at improving patient-centered outcomes such as comfort or quality of life.
Documentation is a core nursing intervention. Documentation can be in the form of a chart, notes, or a formal report. It can be used to track progress and refer to later on if you have questions about what happened when you administered care.
Health assessment is a process that helps you to understand the client’s health and what needs to be done to help them reach their goals. It includes a physical examination, history and mental status exam, review of medications and other health problems, review of social and environmental factors.
The nurse should ask about any symptoms or problems with bowels, bladder or bowel movements; breast feeding; breathing difficulties; dizziness/lightheadedness/headaches; fatigue (acute or chronic); fever/chills/headache (acute); heavy bleeding after giving birth (postpartum hemorrhage); low blood pressure during pregnancy even though it was normal previously; poor appetite or weight loss recently or during pregnancy (inadequate nutrition).
Consultation with other health care providers is a good idea. The client may need to see a specialist, dietitian, therapist or dentist.
Review of medication information and prescriptions
The nurse should review the client’s medication information and prescriptions to ensure that they are taking their medications as prescribed.
In addition to the testing and treatment of other health problems that may interfere with goals, you may want to consider:
Documentation, consultation with other health care providers and review of medication information and prescriptions are all interventions that may assist in achieving your goals.
The interventions listed in this section are the ones that I think are necessary to help achieve your goals. As you can see, not all of them need to be done at once or in any particular order. The idea is to do what is best for your client’s health and well-being!
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