Nursing Documentation Essay

Nursing Documentation Essay-22
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.

Therefore, the initial stage of the APIE can be considered a valid approach to gathering data to inform care planning of the individual patient.

Only once a systematic and comprehensive assessment phase is complete is it possible to engage in effective care planning.

Specific consideration needs to be made regarding the achievement of care goals and the suitability of these goals in future care episodes, based on patient factors and nurse factors.

However, the evaluation process is not simply a process of clinical review, but can be considered a core aspect of the overall professional development of the nurse and a key learning process (Barrett et al., 2014).

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.The assessment, planning, implementing and evaluating approach, also known as APIE (Yura and Walsh, 1967), is a commonly used approach to care planning in nursing practice.This approach encourages a systematic and rigorous approach to patient care, incorporating a holistic perspective of the care process.However, the APIE approach focuses more precisely on the role of nurse-led interventions and overlooks the importance of supportive nursing roles during the implementation process.In addition to nurse-led interventions, patients should be supported and educated to promote self-care (Wilkinson and Whitehead, 2009).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).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.The APIE approach culminates in an evaluation of the implementation of the care plan, which is essential in ensuring goals of care have been met, while allowing adjustment of the care plan where needs remain unmet.This evaluation process was initially conceptualised as a single assessment during patient follow-up or management review, but has developed into more extensive process of monitoring therapy and adjusting interventions over time (Barrett et al., 2014).

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