Nursing Documentation Essay

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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).

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).

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).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).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).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.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).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).


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