Administration of

Nursing Service
Implementation
of Nursing Care
Plan

CARLEA C. SANA
(Reporter)

Implementation of
Nursing Care Plan
Is the step during which the nurse
performs activities necessary for the
achievement of the clients health goals.
To implement the nursing care plan
effectively, the nurse must have the
knowledge, skills, and attitudes to carry
them out.

Validating nursing care plan

Nurse reviews nursing care plan then compares
it with the assessment data to validate the
nursing diagnosis and to determine weather
the nursing interventions stated are the most
appropriate to meet the patients problems and
needs.
Validation is made with other nurses who are
more knowledgeable and experienced. Another
member of heath team such as nutritionist may
be consulted when patient needs special diet..
Nursing care plan may also be validated with
the patient, his/her family and/or significant
others.

Validating nursing care plan

nurse should consider the following areas and guidelines:

1. Individualized nursing care

Considers the patients preferences, physical and
psycho-social need.

2. Safety
Proper precaution should be observed to prevent
any accident or injury to patient.

3. Appropriateness
Plan should be congruent to the medical plan and
treatment with standard protocols and procedures
for particular health setting.

4. Effectiveness
Nursing actions should realistically help patient
achieve the intended outcomes.

Preparing for nursing

activities
Preparation of the Nurse to do the job
Nurse should review nursing action to be done
and the rationale for doing so.
Nurse determines weather any change in the
patients condition warrants modification in
nursing intervention.
Nurse should clarify any doubts with the Head
Nurse. If the doubt pertains to a medical order,
verification should be made with the ordering
physician.

Preparing for nursing

activities
Preparing the client
Patient should be fully informed about the
purpose of the nursing action, its rationale,
what he/she can expect from it and what is
expected from him/her.
Assess the patient's readiness for the procedure
to be done.
Provide assistance and privacy to prevent
unnecessary stress or discomfort.

Preparing for nursing

activities
Preparing the Equipment and
Supplies

Much time can be saved and nursing

actions can be done efficiently when
all equipment and supplies are
prepared at hand prior to the start of
the nursing intervention.

Implementing the nursing

intervention
Nurse applies her knowledge, skills,
and interpersonal relationships in
performing or delegating planned
nursing strategies. She utilizes
independent,
dependent,
and
interdependent nursing actions.

Implementing the nursing

intervention
Independent/ autonomous nursing
intervention
Consultation with physicians or another health
professionals is not necessary in performing these
nursing interventions.(e.g. health promotion etc.)
Assistance in Activities of daily living
Nurse provides health teachings to motivate
patient and family.
Counseling
Needed to help patient manage his/her
stresses as a result of actual or impending
changes brought about by illness.

Implementing the nursing

intervention
Dependent nursing intervention
Based on instructions or written orders of
physicians for treatment, therapies, and
medications.
Nurse should ensure that he/she understands
the order correctly. He/she should know a
medications action, possible reactions, dosage,
route and patient for whom it is intended.
Proper documentation should be made in
patients chart.

Implementing the nursing

intervention
Interdependent nursing intervention
Are those that are carried out in collaboration
with other health team members such as the
physical therapist, nutritionist, and physician.
Reflects overlapping of responsibilities and
relationships between health personnel.

The patients clinical

record
It is a formal legal document that provides
evidence of how the patients care was managed.
The process of making an entry to the record is
called charting, recording, or documenting.
* Patients record are treated as confidential.
* According to the Code of Ethics for Filipino
Nurses, Only those who are professionally
and directly involved in patients care and
when requested by law may see the patients
chart.

The patients clinical record

Purposes of Documentation:
1. Communication
Facilitates continuity of care, prevents duplication
of efforts, and prevents misunderstanding.

2. Planning Patient Care

Data from patients chart may be used by each
member of health team.

3. Research
The information documented in the patients chart
is a valuable source for those investigating cases
with the same condition or are given same
treatment.

The patients clinical record

Purposes of Documentation:
4. Education
Patients record becomes a valuable tool for health
care professionals as they provide comprehensive
information on the client, his illness, and the
factors that positively or negatively affect his care.

5. Audit
A review of patients chart shows weather the
health agency complies with the standards set for
patient care.
6. Reimbursement of Health Insurance
Patients chart helps health agency in receiving
reimbursements or PhilHealth etc.

The patients clinical record

Purposes of Documentation:
7. Legal
Patients record is considered a legal document
and is admissible in court evidence.

8. Health Care Analysis

Records are utilized to identify the agencys needs
in both human and material resources, cost
analysis of the resources utilized and service
rendered..

Reporting and
documenting
The quality of care received by patients,
the standards of nursing practice, the
reimbursement structure in the healthcare
system and the legal guidelines for the
practice of nursing make reporting and
documentation two of the most important
functions of the nurse.

Reporting and
GUIDELINES
FOR GOOD REPORTING
documenting
AND DOCUMENTATION:
1. Factual
Information about the patients and their
care must be based on facts that are
descriptive and objective, not on opinions.

2. Accurate
Clients record must be accurate and
reliable. Measurements should be accurate.

GUIDELINES FOR GOOD REPORTING

AND DOCUMENTATION:
3. Confidential
Code of Ethics for Filipino Nurses, Only
those who are professionally and directly
involved in patients care and when
requested by law may see the patients
chart.

4. Complete
Charting should be complete and concise
giving only essential information.
Unnecessary and lengthy words or
irrelevant details should be avoided.

GUIDELINES FOR GOOD REPORTING

AND DOCUMENTATION:
5. Current
Recording and reporting should be up-todate.

6. Organized
Information should be communicated in a
logical format or sequence. Disorganized data
may lead to confusion and errors.

7. Ethical
Negative or retaliatory remarks about a
patient or a member of health team should be
avoided as these breed ill-feeling and poor
relationships.

Precautions to Observe in
Documentation
1. Only the nurse who performs the nursing
intervention makes the entry and sign it.
2. Charting made by nursing students should be
countersigned by their clinical instructor.
3. Chart all important information before leaving
the unit. Another nurse may possibly duplicate
the giving of medications if not documented
properly.
4. Do not make erasures. Draw a line through the
error and write the word mistaken entry above
it. Sign name or initials and make the correct
entry after it.

Reports
Are Either oral, taped, or written exchanges of
information between nurses and/or members of
the health team. These include change-of-shift
reports, telephone orders and reports, and
transfer reports.

Change-of-Shift Reports
Is a system of communication aimed at transferring
essential information and holistic care for patients.
Its purpose is to provide continuity of patient care
for 24 hrs.
May be given orally, by audio-tape recording, or at
the bedside during nursing rounds.

Change-of-Shift Reports
a. Oral Report
Prior to the nursing rounds, a pre conference
is made at the nurses station or conference
room.

b. Audio-tape Report
Made by outgoing nurse and is replayed by
incoming nurse.

c. Nursing Rounds
Are made at the patients bedside. Patients
care plan is discussed. This enables the
patient and his family to participate in
discussion.

Telephone Reports and Orders

Information given through telephone should
accurately transcribed by the receiving nurse in
written form especially if this pertains to
medications or significant changes/events in clients
condition occurred.
Legal Risk in Telephone Orders
* May be misunderstood or misinterpreted by receiving
nurse. May sound unclear because of some trouble in
telephone line.
* Signature of ordering physician is not present and
this order may be denied in case errors exist or when
court litigations arise.

Telephone Reports and Orders

Only in an extreme emergency and when no other resident
or medical intern is available should a nurse receive
telephone order.
Nurse should read back such order to the physician.
Such order should be signed by physician as soon as he
arrive at the hospital.
Nurse should note the date and time the order was
made, name of physician making order, then sign own
name including designation.

Example: 2-25-14 - discontinue Iv infusion when consumed

3:20 PM
Tel. Order Dr. J.V.Santos/
P.F Roxas BSN,RN
Staff Nurse

Transfer Reports
Contains information that the nurse in the receiving
unit needs to know for continuity of care. This
includes summary of the medical progress up to the
time of transfer (usually made by physician), current
health status, critical assessment or interventions to
be completed after transfer and special equipment
necessary.
Before patient is transferred to another agency,
proper coordination must be first made to ensure that
the agency has the proper services and facilities
needed by the patient.
Nurse and a transfer report accompanies patient.
Patients medical record (chart) left at original agency.

documentation
Is anything printed or written that can be used as
a record or proof for authorization.
Standards of Nursing Practice state that
documentation of nursing care should b
pertinent and concise and should reflect
patients status.
Nursing documentation shall address the
patients needs, problems, capabilities and
limitations. Nursing interventions provided
and patients responses should be noted.

Forms for Nursing Documentation

Forms vary according to the institutions needs.
They are used to make documentation easy, quick,
and comprehensive. They present special types of
information that eliminates repeated date in the
nursing notes.

Nursing Health History and

Assessment Worksheet
This is a special form completed by the nurse when
patient is admitted to the unit.
It contains basic biographical data, present illness,
health history, physical assessment, including
nursing diagnosis on admission.

Forms for Nursing Documentation

Graphic Flow Sheet
Forms that allow nurses to record specific
measurements or observations on a repeated
basis.
Examples are graphic flow sheet that record
routine measurements at specific intervals such
as vital signs.

Medicine and Treatment Record

Contains all medication and treatments given
on a repeated basis.

Forms for Nursing Documentation

Nursing Kardex
Trademark for a card-filing system that allows
quick reference to the particular needs of each
patient for certain aspects of nursing care.
Included on the card may be a schedule of
medications, level of activity allowed, ability to
perform basic self-care, diet, any special
problems, a schedule of treatments and
procedures, and a care plan.

Is updated as necessary and is usually kept at

the nurses' station.

Forms for Nursing Documentation

Discharge Summary
Is a special progress report that helps ensure that a
clients discharge results in a desirable outcomes.
The discharge planning and summary concise and
instructive. This includes the ff data:
1. Teaching and counseling to prepare the patient for
discharge;
2. Current medications & treatments to be continued
and precautions to observe and report;
3. Activities of daily living and self-care activities
4. Support system
5. Person who will accompany patient on discharge; and
6. Destination weather at home or transferred to other
agency/hospital.

Forms for Nursing Documentation

Nursing Progress Notes
Are usually narrative description of patients
progress toward goal achievement.
Includes assessment of the clients mental and
physical condition, client activities, nursing
interventions and client responses, visits by other
member s of health team, and treatments
performed by physicians that affect nursing care.
A section for writing descriptive progress notes is
included in the patients chart.
Two most prevalent methods of writing progress
notes are the chronological narrative and the SOAP
format.

Chronological Narrative Charting

Is the traditional charting format.
Nurses write notes in paragraph form during
the shift.
Events and patients responses are written in
chronological order.

SOAP Charting
SOAP is acronym for Subjective data, Objective
data, Assessment, and Plan.
SOPIER is used by some institutions where I
represents Intervention, E for Evaluation, and R
for Revision.