Nursing Documentation Essay

Nursing Documentation Essay-14
While quantitative data alone can provide a clue as to the diagnosis of the patient, the holistic nature of nursing care demands consideration of subjective wellbeing and qualitative aspects of the patient, including ideas, expectations and concerns.

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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).

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).

Planning involves formulating suitable interventions and strategies to address the presenting problem, with consideration of the biological elements of the condition as well as the preferences of the patient (Doenges et al., 2016).

Furthermore, care planning should include clear goal setting to ensure that the plan can be successfully implemented.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.These goals should be patient-centred, recordable, observable, directive, understandable, credible and time-related regarding available resources (Hayes and Llewellyn, 2010).However, planning within the problem-solving APIE approach may be limited without consideration of additional models of nursing, including the activities of living model by Roper, Logan and Tierney (1985) and the self-care model of nursing by Orem (1985).Underlying any care decision is the need to identify the source of the problem and then to develop a suitable approach to addressing this problem.To assist in decision-making, it is recommended that nurses adopt frameworks or models of problem-solving and care planning (Johansen and O’Brien, 2016).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).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.

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