Nursing Documentation Essay

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).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.

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).

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).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).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.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 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).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.

SHOW COMMENTS

Comments Nursing Documentation Essay

The Latest from diploms-mba.ru ©