Nursing Documentation Essay

Nursing Documentation Essay-26
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.The first stage of the APIE is ‘assessing’, which entails a thorough analysis of the presenting complaint and the overall account of the individual patient (Hill, 2015).

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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 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).

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.

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.

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).

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