Implementation is the actual performance of the nursing interventions identified
in the care plan. The implementations are co ordinated with other members of
the health care team who have direct care of the client. These interventions
include , but are not limited to; health teaching, direct client care, medical
treatments, medications, and dressing changes. Nurses provide care to achieve
established goals of care and then communicate the nursing interventions by
documenting and reporting.
Not all interventions are planned. The nurse must use her critical thinking skills to respond to an unexpected crisis.
Mr. K is a 45 year old polish male. Married with three children. He is currently unemployed. He has worked in the service industry for his entire life. He has been socially drinking since he was 13 yrs. He has a family history of alcoholism an diabetes. He has been admitted to ICU on three previous occasions for liver disease.
Nursing
Diagnosis |
Goals and
Outcome Criteria |
Implementation(Interventions) |
Imbalance
Nutrition: Less than Body Requirements related to anorexia, metabolic
imbalance |
Adequate nutrition:
Stable body weight, consumes meals |
Explain the
need for adequate food intake. Small frequent meals. Arrange for dietician
consult. Record daily weight. |
Activity
Intolerance related to fatigue |
Improved
activity tolerance: Performs activities of daily living without excessive
fatigue |
Schedule
nursing care for rest periods. Elevate head of bead to facilitate breathing.
Deep breathing and exercise extremities. |
Risk for
Impaired Skin Integrity related to edema, immobility, pruritis, hypoproteinemia |
Intact skin: No
redness or breaks in skin. No scratching |
Gentle bathing
with mild soap and warm water. Client's nails should be kept short. If
itching severe ask Doc. for medications to relieve the discomfort. Administer
medications as ordered. |
Ineffective
Breathing Patterns related to ascites |
Effective
breathing: Respiratory rate of 12-20 per minute without dyspnea. |
Elevate head of
bed to relieve pressure of abdomen. Chair sitting may be more comfortable,
with elevated feet .If allowed. |
Risk for Injury
related to impaired coagulation |
Absence of
bleeding: No blood in emesis or stool, vital signs consistent with patient
norms |
Handle client
gently to avoid trauma. Apply pressure to injection sites. Note stool
characteristics. |
Disturbed
Thought Processes related to elevated blood ammonia |
Normal
cognitive functions: Mentally alert, oriented |
Monitor mental
, cognitive and neurological statis. Provide basic information. Notify doc.
if changes in statis. Health teaching for family members on dietary
restrictions. Be alert for drug therapy adverse side effects i.e.: diarrhea,
vitamin K deficiency and otoxicity. |
Nursing Process: Definition |
Critical Thinking
| Guidelines
Critical Thinking:
Characteristics
| Skills, Elements, Standards
Nursing Process: Assessment
| Nursing
Diagnosis | Planning | Implementation | Evaluation
John
Philip Tiongco, MD