Nursing Documentation Essay

Nursing Documentation Essay-35
The aim of this paper is to evaluate the individual components of the APIE and the approach in its entirety with respect to nursing practice.

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Contemporary nursing practice is a diverse and challenging field.

Nurses are increasingly involved in complex decision-making as their roles expand in the health system (Cherry and Jacob, 2016).

This includes the core components of respect and dignity of the patient, which should be preserved at all times, as well as the delivery of culturally-sensitive care (NMC, 2018).

Indeed, nurses who are compassionate and considerate of other cultures and patient beliefs are more likely to develop strong therapeutic relationships, which have been shown to promote adherence to treatment plans and improve outcomes (Hagerty and Patusky, 2003).

The assessing process is not a list of presenting problems, but a more systematic integration of quantitative and qualitative data.

Quantitative data include the physiological status of the patient, including routine observations (temperature, weight, blood pressure, pulse) and more specific assessments, such as physical examination and interpretation of investigations (Lewis et al., 2016).Furthermore, careful consideration of available resources and support is needed to ensure that the care plan is suitable for the individual patient and their environment (e.g. Self-care ranges from the simple act of a patient managing their own medication to more complex processes, whereby patients are responsible for symptom identification and changes to lifestyle/behaviours.The Nursing and Midwifery Council (2018) publishes a code for nurses, which includes the role of the nurse in supporting self-care in a sensitive and compassionate manner.Nurses may involve other members of the care team in decision-making at this point in order to maximise the potential benefits to the patient.Furthermore, a combination of personal experience and evidence-based guidance can be used to inform the optimal planning approach, suggesting that nurses need to apply critical thinking and a combination of intuition and guidelines in formulating appropriate care goals (Blais et al., 2006).These models provide a deeper context for applying the principles of the APIE, taking into account the necessity to generate patient-centred care planning and goals that are achievable and measurable with respect to the status of the patient (Flagg, 2015).Similarly, planning should take into consideration the ability of the patient to self-care, a crucial aspect of everyday function and wellbeing (Orem, 1985).Therefore, to ensure adherence to practice standards and professional codes of conduct, the implementing process in the APIE scheme should balance the need for nurse-led therapies and strategies to promote individual wellbeing and empowerment in self-care.Furthermore, the APIE problem-solving approach emphasizes the need for suitable implementation of a plan, but wider roles of nurse and the patient need to be considered to deliver personalised care.The assessing process can be considered a fundamental part of patient care planning and forms the main data collection phase of the nurse-patient interaction (Lewis et al., 2016).Nurses use multiple techniques and approaches to collect data, including history taking, examination and ordering investigations, all of which may inform the decision-making process.

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