Learning Objectives
By the end of this section, you will be able to:
- Describe the categories of patient care used in the implementation phase
- Compare different interventions used to implement care
- Recall the focus of interventions based on nursing diagnosis
- Describe how to effectively prioritize nursing interventions
- Define delegation rules regarding assigning interventions
A well-structured care plan is pivotal to ensuring patient well-being and recovery. At the heart of this plan are interventions—actions designed to either mitigate harmful outcomes or promote beneficial health results. More than tasks or procedures, interventions are the active components of nursing care that are tailored to address specific patient needs and health goals.
This module will cover the diverse range of interventions, which may be dependent, independent, and interdependent. It will explain how various interventions are employed during the implementation phase of the nursing process. It will also explore how to align interventions with nursing diagnoses, ensuring that each action taken is purposeful and grounded in clinical reasoning, and identify how to prioritize and delegate interventions as needed. These topics highlight the importance of understanding the scope of practice and the dynamics of working within an interdisciplinary team. First, the section takes a closer look at the categories of patient care.
Categories of Patient Care
During the implementation phase of patient care, different categories of interventions are used to address the patient’s needs effectively. Medical interventions are treatments and procedures that are performed by healthcare providers, such as administering medications or conducting diagnostic tests. Nursing interventions encompass a broad range of actions that are performed by nurses to meet their patients’ physical, emotional, and psychosocial needs. These interventions may include administering prescribed medications, providing wound care, assisting with activities of daily living (ADLs), and educating patients and families about self-care techniques.
Imagine following a nurse through a typical shift in the hospital. The nurse’s day begins with a handover from the previous shift, during which they review patient notes and plan their schedule. Then, the nurse heads to patient rooms for the beginning of shift assessments, checking vital signs, administering medications, and chatting with each patient about how they feel. The nurse updates care plans based on observations and discussions with patients to ensure their needs are met.
Throughout the shift, the nurse performs various tasks—from changing dressings on a postsurgical wound and assisting a patient with mobility exercises to providing patient education on managing conditions. Between these activities, the nurse coordinates care by consulting with providers about changes in a patient’s condition, coordinating diagnostic tests, and participating in multidisciplinary team meetings to discuss patient care strategies. Think about how the nurse might categorize the activities they do (Figure 14.2). Some actions involve direct interaction with patients, addressing their immediate needs and providing comfort. Actions not performed at bedside are equally important for patient care and require coordination and planning behind the scenes. Direct care and indirect care are two categories that form the basic dichotomy during the implementation phase of the nursing process (FVI School of Nursing and Technology, n.d.).
Direct Care
Interventions that involve personal contact or interaction with patients, whether in person, over the phone, or digitally, are known as direct care. This type of care is a key component of the implementation phase, as it allows nurses to assess patients’ conditions firsthand, respond to their needs, and provide immediate comfort and support. Examples of direct care interventions include administering medications, performing physical assessments, assisting with daily living activities, treating wounds, and educating patients about their health conditions. These interactions are essential for the physical aspects of patient care and building rapport and trust—two essential elements in the therapeutic relationship between a nurse and a patient.
Indirect Care
Tasks and interventions that are performed away from the patient but are still vital to their overall care are called indirect care. This type of care is crucial for the successful implementation of a patient’s care plan, and it requires organizing, managing, and coordinating healthcare services. Indirect care interventions may include documentation, collaborating with other healthcare professionals, arranging referrals or follow-up care, and managing resources. For example, the nurse’s consultations with providers and participation in care planning meetings are forms of indirect care. These activities, though not always visible to patients, significantly affect the quality and efficacy of the care provided.
Life-Stage Context
Tailoring Direct and Indirect Care for Different Age Groups
Both direct and indirect nursing care needs to be adapted according to the age of the patient to ensure it is appropriate and effective. Understanding these variations is crucial for nursing students as they prepare to cater to a diverse patient population.
- Neonatal patients: In neonatal care, direct care involves delicate handling, as these patients are extremely vulnerable. Tasks such as bathing, feeding, and physical assessments require gentle and precise techniques. Indirect care includes coordinating with pediatricians and lactation consultants and educating parents about neonatal care. The focus is on providing a safe, nurturing environment conducive to growth and development.
- Pediatric patients: With older children, direct care includes age-appropriate communication to explain procedures and engage them in their care. This might involve using play therapy for assessments or distraction techniques during uncomfortable procedures. Indirect care includes collaborating with family members and school officials to support the child’s health needs, both in the hospital and upon their return to school.
- Adult patients: Direct care for adults involves a more collaborative approach, encouraging patient autonomy and informed decision-making. This might include teaching self-care skills for chronic disease management. Indirect care involves coordinating care transitions, such as from hospital to home or rehabilitation facilities. It could also include arranging for home health services or occupational therapy.
- Older adult patients: In care for older adults, direct care often requires understanding the complexities of aging, such as managing multiple chronic conditions or addressing mobility issues. Indirect care includes working with multidisciplinary teams to coordinate care, considering factors such as home safety assessments and support systems to ensure a safe living environment.
In each age group, the nuances of direct and indirect care reflect the unique needs and challenges of the patients. Adapting these care approaches based on age is essential for providing holistic and effective nursing care.
Types of Interventions
In healthcare settings, nurses employ various interventions to implement care plans that cater to the diverse needs of patients. These interventions are categorized as dependent, independent, or interdependent. Each type of intervention plays a distinct role in promoting patient well-being and facilitating recovery. Understanding the differences between these intervention types is essential for nurses, as it allows them to deliver comprehensive and effective care tailored to individual patient needs.
Clinical Judgment Measurement Model
Take Action: Implementing Various Types of Nursing Interventions
Jarrell, a registered nurse working in a busy medical-surgical unit, is assigned to care for Mr. Johnson, a 65-year-old patient admitted with exacerbation of heart failure. During his assessment, Jarrell notices that Mr. Johnson is experiencing shortness of breath, has crackles in his lungs upon auscultation, and his oxygen saturation levels are below the target range. Interpreting these cues, Jarrell determines that Mr. Johnson requires immediate interventions to address his respiratory distress and manage his heart failure exacerbation.
Responding to the situation, Jarrell implements a variety of interventions tailored to Mr. Johnson’s needs. For dependent interventions, Jarrell contacts the healthcare provider to request orders for supplemental oxygen therapy and intravenous diuretics to reduce fluid overload and improve Mr. Johnson’s respiratory status. Additionally, he administers prescribed medications such as angiotensin-converting enzyme (ACE) inhibitors and beta blockers as ordered to optimize cardiac function and alleviate symptoms.
For independent interventions, Jarrell provides emotional support to reassure Mr. Johnson and alleviate anxiety associated with his breathing difficulties. He also assists him with ADLs, such as positioning for optimal respiratory function and facilitating mobility to prevent complications associated with immobility. Furthermore, Jarrell educates Mr. Johnson about dietary restrictions, fluid management, and medication adherence to empower him in managing his heart failure at home.
Recognizing the complexity of Mr. Johnson’s condition and the importance of interdisciplinary collaboration, Jarrell engages in interdependent interventions. He communicates with the respiratory therapist to initiate respiratory treatments, such as nebulizer therapy or chest physiotherapy, to improve Mr. Johnson’s ventilation and oxygenation. Jarrell also collaborates with the physical therapist to develop a plan for progressive mobility exercises and with the dietitian to optimize Mr. Johnson’s nutrition and fluid intake while adhering to his dietary restrictions.
There are also other ways to categorize the activities a nurse performs (Table 14.2). During a shift, the nurse performs many tasks on their own without input from providers (independent intervention). The nurse also performs some tasks only after getting instructions from a provider (dependent intervention). The nurse may also perform tasks as part of a collaborative, multidisciplinary team (interdependent intervention).
| Nursing Intervention | Description | Rationale | Examples |
|---|---|---|---|
| Independent | Actions initiated and carried out by the nurse based on their clinical judgment, without instructions from others | Addresses immediate patient needs promptly, proactively enhances comfort and well-being, and empowers nurses to use their clinical judgment | Providing emotional support, assisting with ADLs, educating patients on self-care, implementing preventive measures (e.g., pressure-relieving cushions, fall prevention) |
| Dependent | Actions carried out under the orders or direction of a healthcare provider (e.g., physician, nurse practitioner) | Ensures that medically essential treatments are delivered safely and effectively according to the provider’s orders | Administering medications, performing prescribed treatments or procedures (e.g., wound care, dressing changes), preparing patients for surgery |
| Interdependent | Collaborative actions that require coordination with other members of the healthcare team | Leverages the expertise and resources of the entire healthcare team to provide comprehensive, holistic care that addresses the patient’s physical, emotional, and social needs | Interdisciplinary rounds to discuss patient progress, coordinating transitions of care (e.g., discharge planning), participating in multidisciplinary meetings for complex case management (e.g., diabetes management with a dietitian, physical therapist, and social worker) |
Focus of Interventions Based on Nursing Diagnosis
Healthcare providers design interventions to solve or reduce the risk of health problems. Just as there are different types of interventions, there are different patient problems (Table 14.3). A nurse may start their shift in one patient’s room, administering medication to help lower high blood pressure—which is an immediate and observable health issue. In another room, the nurse may identify that a patient is at risk of developing pressure ulcers due to limited mobility. In a third room, the nurse collaborates with other healthcare professionals to manage a patient with complex diabetic needs—a situation that often includes a variety of problems, some immediate, some distant, some serious, and some minor.
| Problem Type | Definition | Focus of Interventions | Example |
|---|---|---|---|
| Actual | An immediate, identified issue currently affecting a patient | Resolving existing health problems and improving the patient’s current condition | Treating high blood pressure with medication, monitoring, and lifestyle education |
| Potential | A risk or condition a patient is susceptible to but is not currently manifesting | Preventing the potential problem from becoming an actual problem; implementing preventive measures | Identifying a patient with limited mobility as being at risk for pressure ulcers and implementing regular repositioning and pressure-relieving devices |
| Collaborative | A complex issue requiring the coordinated efforts of multiple healthcare professionals | Addressing complex care needs that require a multidisciplinary approach | Managing a patient with diabetes by collaborating with a dietitian, endocrinologist, and diabetes educator |
Prioritizing Nursing Interventions
In nursing practice, prioritizing interventions is a crucial skill that ensures efficient and effective patient care. This process is similar to prioritizing assessments, as discussed in Establishing Priorities During Assessment. Nurses often utilize tools such as the ABC framework (airway, breathing, circulation) (Figure 14.3) and Maslow’s hierarchy of needs to determine the order of their interventions (Figure 12.4). These frameworks remind nurses to address life-threatening problems first, then basic needs next, before proceeding to less critical issues. Prioritizing helps ensure a systematic approach to patient care (Marymount University, 2022).
For instance, if a patient is experiencing breathing difficulties and has a long-term mobility issue, the nurse should address the breathing problem first, as it poses an immediate risk to the patient’s life. Once stabilized, the nurse can focus on interventions for the patient’s mobility. By prioritizing interventions, nurses can efficiently manage their time and resources to focus on the most pressing issues first and then address other important (but less critical) aspects of patient care.
Assessing Patient Safety
Ensuring patient safety is a primary concern during the implementation phase and is integral to prioritizing nursing interventions. Nurses continually assess potential threats to patient safety, such as fall risks, medication errors, or complications from immobility. They must prioritize interventions that mitigate these risks for patients. For example, when administering medications, nurses must carefully follow protocols to prevent errors, considering risk factors such as correct dosages, patient allergies, and medication interactions. In direct patient care, a nurse may prioritize interventions that prevent falls for a patient with mobility issues, such as ensuring the environment is safe, assisting with ambulation, and educating the patient and their family about fall-prevention strategies. For a postoperative patient, a nurse typically prioritizes wound care and monitors for signs of infection to prevent complications. These actions, focused on maintaining patient safety, highlight the nurse’s role in identifying and addressing potential hazards, ensuring that care delivery is effective and safe.
Delegating Interventions
Delegation in nursing is a crucial skill involving the transfer of responsibility for certain tasks while retaining accountability for the outcome. Nurses delegate tasks to manage time effectively and ensure patient care is delivered efficiently. However, not every task can be delegated, and not every staff member can accept a request for delegation. Understanding when and why to delegate involves considering the “five rights” of delegation, which are listed in Table 14.4 (National Council of State Boards of Nursing & American Nurses Association [NCSBN & ANA], 2019). Delegation is discussed further in 15.4 Nursing Standards of Delegation.
| Right | What It Means | Example |
|---|---|---|
| Right Task | The task must be appropriate for delegation. | Delegate the monitoring of routine vital signs to a nursing assistant, a task within their competency. |
| Right Circumstance | The circumstances must be appropriate for delegation. | Ensuring the patient’s condition is stable and appropriate for delegation. |
| Right Person | The individual must be able to perform the task delegated to them. | Selecting a qualified and competent team member to perform a task, such as a licensed practical nurse for administering oral medications. |
| Right Communication | The instructions regarding the task must be clear. | Providing clear, specific instructions on the task. |
| Right Supervision | The individual performing the task must be properly supervised. | Requires the nurse to monitor the delegated task and intervene if necessary, ensuring patient safety and quality of care. |
Clinical Judgment Measurement Model
Take Action: Delegating Nursing Interventions
Taylor is a registered nurse working in a medical-surgical unit. She is responsible for caring for several patients, including Mr. Martinez, a 70-year-old patient admitted for pneumonia. During her morning rounds, Taylor notices several cues indicating a change in Mr. Martinez’s condition.
- Recognize Cues: Mr. Martinez appears more fatigued than usual, with increased respiratory effort. His oxygen saturation levels have dropped to 88% on room air. Mr. Martinez is coughing more frequently and producing thicker sputum. There is new-onset confusion and restlessness noted in his behavior.
- Analyze Cues: Based on these cues, Taylor analyzes the situation and considers possible reasons for the changes in Mr. Martinez’s condition. She recognizes that the decreased oxygen saturation levels, increased respiratory effort, and changes in mental status could indicate worsening pneumonia and respiratory distress. The thicker sputum production suggests a potential airway obstruction or worsening infection.
- Form a Hypothesis: Taylor forms a hypothesis that Mr. Martinez’s pneumonia may be progressing, leading to respiratory compromise and altered mental status. She suspects that prompt interventions are necessary to improve his oxygenation, clear his airway, and address the underlying infection to prevent further deterioration.
- Take Action: Taylor decides to delegate certain interventions to the certified nursing assistant (CNA) assigned to assist her. She instructs the CNA to assist Mr. Martinez with positioning to optimize his respiratory mechanics, such as elevating the head of the bed. While the CNA helps to reposition Mr. Martinez, Taylor gathers the necessary supplies and initiates supplemental oxygen therapy as prescribed by the healthcare provider to improve oxygenation.
Scope of Practice
As discussed in Scope of Practice, the nursing scope of practice refers to the defined limits and parameters within which nurses are authorized to work, make decisions, and provide services. Scope is established by regulatory bodies, licensing boards, and professional organizations such as the American Nurses Association (ANA).
The nursing scope of practice is a critical factor when making delegation decisions. It dictates what nurses are legally permitted to do and informs which tasks can be delegated to other team members. For instance, although registered nurses (RNs) can delegate noninvasive procedures such as bed bathing to nursing aides, they cannot delegate tasks that require clinical judgment, such as patient assessments (NCSBN & ANA, 2019). Understanding the scope of practice ensures that delegation aligns with legal and professional standards, safeguarding the patient and the healthcare provider.
Link to Learning
The ANA maintains a web page on the nursing scope of practice that includes an option to purchase the complete resource, currently in its fourth edition.
Interdisciplinary Team
Delegating interventions within an interdisciplinary team requires a thorough understanding of each team member’s scope of practice to ensure safe, effective, and comprehensive patient care. The scope of practice for each healthcare professional is defined by their education, training, certification, and licensure, which determines the specific tasks they are qualified to perform. When delegating interventions, it is crucial for healthcare providers to clearly communicate and collaborate, assigning tasks that match each team member’s expertise and skills. For instance, a nurse may delegate tasks such as vital signs monitoring, assisting with ADLs, and collecting specimens to a certified nursing assistant (CNA). Meanwhile, licensed practical nurses (LPNs) or licensed vocational nurses (LVNs) might be assigned more complex tasks, including administering oral medications and performing basic wound care. However, interventions that require advanced clinical judgment, such as creating and implementing care plans, performing initial health assessments, and developing treatment plans, should be reserved for registered nurses (RNs).
By adhering to the defined scopes of practice and leveraging the unique strengths of each team member, interdisciplinary delegation fosters an environment of teamwork and ensures that patient care is delivered efficiently and effectively. Effective interdisciplinary delegation requires clear communication and collaboration among team members, with a focus on patient-centered care (PCC) where decisions prioritize the patient’s needs and preferences.
Nurses also play a pivotal role in making referrals to the interdisciplinary team. They assess the patient’s condition and needs, identify when specialized care or expertise is required, and initiate or suggest referrals to other healthcare professionals (dependent upon agency policies). For example, a nurse might refer a patient to a physical therapist for mobility issues, a dietitian for nutritional counseling, or a social worker for support with discharge planning and community resources. These referrals are based on comprehensive patient assessments and the nurse’s clinical judgment, ensuring that the patient receives holistic and coordinated care. By making appropriate referrals that reflect defined scopes of practice, nurses help foster a collaborative environment that enhances the quality and efficiency of patient care.
In the context of an interdisciplinary care team, delegation fosters collaboration and maximizes the expertise of various professionals working together to care for patients. Effective delegation within an interdisciplinary team promotes comprehensive patient care, with each member bringing their specific skills and knowledge to support optimal patient outcomes.