Essay On Assessment In Nursing Practice

Essay On Assessment In Nursing Practice-88
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.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.

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.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.

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This process should be individualized and can be modified at any point to optimize the success of the patient in reaching the goals (Taylor et al, 2011).

These steps are flexible and allow the nurse to prioritize current issues, but also be prepared for changes in problems to arise as patient conditions change.

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).

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).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, 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.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).PATIENT INTERVIEW A health assessment should consist of establishing a patient profile and incorporate a full medical history (Harvey, 2004). The traditional approach includes collecting subject matter on “biographical data, present health concerns (or present illness) and the chief complaint, past history, family history, review of system and patient data” (Farrell & Dempsey, 2010, p. The assessment interview builds the foundation of the nurse and patient relationship, building good rapport with the patient will alleviate any stress, anxiety or discomfort the patient may be feeling. The purpose and focus of this assessment paper is to detail the core aspects of the nursing process and creating nursing diagnoses for patients in a formal paper.The nursing process allows nurses to identify a patient’s health status, their current health problems, and also identify any potential health risks the patient may have.

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