Nursing Documentation Essay

Nursing Documentation Essay-34
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).

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).

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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).As with the planning phase, implementing appropriate care plans requires input not only from the nurse, but also the patient.Nurses need to ensure that the actions needed to address the patient’s needs are appropriate and practicable, including the direct delivery of interventions and referral of the patient to specialist care, as needed (Locke and Latham, 2013).Accordingly, nurses have a duty to support and promote patients in self-care activities and should facilitate these activities wherever possible as part of the care planning process.Care plans should include highly structured and clear stages and steps that may be taken to achieving a specific goal, which may be followed by patients, nurses and other care professionals, as needed (Blais et al., 2006).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.These should be elicited to provide a basis for reassuring the patient or addressing emotional and psychological support needs early during the consultation (Hill, 2015).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).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).

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