To gain a better understanding of the problem solving approach it is useful to explore how it can be used to demonstrate an understanding of patients' experiences and behaviours. This essay will look at the A.P.I.E approach to care planning, what A.P.I.E is and how it is used in the nursing process.
A.P.I.E is a problem solving process used to direct individuals in a systematic approach to problem solving, using the development of Assess, Planning, Implement and Evaluate, although this process is used by many professions, it will be explored from a nursing perspective. It is used to provide individual care planning in nursing and looks not just at the illness or disease but at the patient from a holistic view, in order to provide effective care giving (Slevin 2001).
Each element of the model will be explored and discussed to give an understanding of how the model works, the strengths, limitations of using the problem solving approach in delivering care, it will also explore theories that can be used to plan care relating to a patients behaviour or even how care can affect the patients behaviour. It will look at whether each stage is independent of the next or if they are interrelated.
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From the audiovisual that was presented to use Joe is a patient in a care setting, it will be useful to use each stage of A.P.I.E to explain how care planning would have improved Joe's experiences, enabling him to receive improved care.
The nursing process is a systematic approach to delivering care, Yura and Walsh (1978) identified four main stages to the process (Roper, Logan, Tierney 2003). Assessment was the first, however Roper et al (2000) suggested that assessing would be more appropriate as this is an ongoing process and not a once only activity. Assessing a patient is not the same as admitting a patient and this can be confused at times in a clinical setting, although they can be used in conjunction with each other. Admitting a patient is to welcome them to the area they will be staying, introducing yourself to a patient, making them feel comfortable and dealing with any immediate needs. Assessing is more complex and not just a list of problems the patient may have, it needs to be objective, accurate and a detailed account of the individual (Barrett, Wilson, Woollands 2009).
During assessing, data is gathered in two parts, quantitative information which may consist of height, weight, temperature, pulse and blood pressure, qualitative data is in the form of mental state, social background, family status, the patients likes and dislikes, although there are lots of other factors that may be considered during the assessing process (Slevin 2001). Data is collected by different ways, and nurses use interview techniques, direct observations, measurements, previous medical history and present, coping strategies and also how the patient perceives their health patterns. Furthermore the nurse should consistently validate the data with the patient ensuring that the nurse's interpretation is complete and accurate. However during assessing there are some considerations that need to be addressed, a patients physical state, this could be how tired they are, their stress levels and hormones. Psychological state, social and cultural backgrounds also need to be considered (Barrett, Wilson, Woollands 2009). Data can come from a multi disciplinary team that may be involved and family (Arnold 2003). This serves as a baseline throughout the nursing process, base lines offer descriptions and measurements allowing for the nursing team to evaluate if the patient is making progress or failing to reach their goals, leading to a change in care that is given. Baselines need to be a clear description of what is happening now with regards to health, they need to incorporate objective and subjective information. Deliberation has to be taken from the medical diagnosis and the effects the consequences will have on the patient in their everyday lives, nurses need to look beyond a medical diagnosis and take into account the social, psychological, spiritual and physical issues related to their illness (Barrett, Wilson, Woollands 2009). Critical thinking skills are used to differentiate what is essential, relevant and what is irrelevant data, to organise and plan care (Kenney 1995). Nurses must identify not only the actual problem but also potential problems that may arise.
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During Joe's assessment he was asked what he likes to eat, his wife had always made him fried eggs and sausage sandwiches for breakfast and he put that he would like this to eat, but had only ever been given porridge. Although this maybe suitable at times, peoples preferences must be taken into account, this may lead to patients not eating and getting the nutritional intake they need. Maintaining sufficient intake needs to be assessed and monitored, so having relevant knowledge of what is correct for a patient of Joe's age, his activity and height to weight ratio is very important (Arnold 2003). Nurses need to ask questions that are relevant for him and centred around the care he needs, asking questions about nutrition to a diabetic would be totally different to asking Joe about his diet, he is not a diabetic and this would be irrelevant for any care planning.
Nutrition is just as important in older age as it is in young adults, having good diet and nutritional intake can help with living longer and having fewer disabilities. Nutrition is used for energy levels and although this declines with age it can be associated with less physical activity, however it could also be related to the basal metabolic rate declining by one to two per cent per decade, this is due to lean body mass and thyroid hormones diminishing. The loss of muscle mass can lead to loss of movement and balance, making falls more likely (DeBruyne et al, 2011). Therefore making sure Joe is getting a nutritional diet and sufficient intake is vital to help him maintain an active life, as this can lead to social disengagement. Cumming and Henry (1961) cited in Upton (2010), argued that social disengagement occurs when relationships between an individual and other members of society are severed or altered in quality, this could happen if Joe has a fall because it could lead to him being in bed and not being able to engage in any social activity. Society also accepts withdrawal from an elderly person normal life as an inevitable move towards death (Upton 2010). It is argued that elderly people do withdraw from society, but not voluntary, it is due to ageist policies, low retirement income and also dependency creating services, this restricting to remain active citizens (Chambers 2010). When this has be identified as a potential problem, it can be assessed and planned for so it does not occur and every possible step has been taken to make sure elderly patients are still socially involved and not made to feel inadequate (Upton 2010).
Once actual and potential problems have been identified care can be planned, making sure that it is patient led and goals are set that the patient understands, also makes them aware of who is going to implement them and what role they have in achieving those goals (Roper et al, 2000). Plans are made to solve the actual problem; goals are set so that potential issues do not turn in to actual problems. It needs to identify the priority in which treatment is going to happen, the most important issue being dealt with first, this may not be the same from nurse to patient, the patient may have their own ideas of how they would like issues dealt with and in what order, however life threatening or problems that may become more serious if left need to be a priority, keeping the patient safe is always the first priority (Barrett, Wilson, Woollands 2009).
Planning care with a patient needs to take into account their life style; values, economics and also personal preference will influence individual's goals (Henson 1997, cited in Arnold 2003).Without carrying a comprehensive assessing stage out the nurse would not be able to progress through the planning stage easily. It also needs to be able to able to change at any given time according to how the patient responds to treatment, the patients responses to goal setting and planning of care should also be documented, this is being accountable for nursing practice and is a legal document, it is evidence based of care and treatment the patient is to receive from the health care team (Walsh 2002, cited in Roper et al, 2003).
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Goals set during the planning stage should be directive, having a baseline of where the patient is now in relation to the problem, goals will give an indication of where the patient is heading after direct nursing care. Goals need to be evaluated by the patient and nursing team, so have to be measurable, observable and recordable so it can been seen if the patient is making progress towards or away from the goal. Goals can be short term or long term depending on the patients needs, however short term goals are better for the patient as they can maintain motivation for achieving the outcome they desire (Barrett, Wilson, Woollands 2009). When deciding goals it would be beneficial to consider who is going to achieve the goals either the patient or nurse, what they are actually meant to be achieving, how they are going to achieve it and when they are going to do this by. One way of setting goals is to use a tool this could be the MACROS criteria, Hogston (2007) argued these should be done under the headings of PRODUCT, patient centred, recordable, observable, directive, understandable, credible and time related in reference to the resources available (Hayes and Llweellyn 2010).
Joe had always been a smart dresser and when he was younger made every effort to dress in a particular way and ensure his hair was always combed. It would appear from the audiovisual that this is not happening now and he is left in his pyjamas, and does not seemed to have had his hair combed, or a shave.
Society would perceive that Joe is ill and was adopting the sick role, however this is not the case Joe is not ill he just needs some extra care and support; unfortunately his basic care needs are not being met by the care staff. To adopt the sick role there are certain rights and obligations that need to be met, the patient must be exempt from normal social role responsibilities, is not responsible for their illness and would not be able to get well without seeking medical advice, they must also want to get better and adhere to any medical advice or treatment, Parsons (1979) argues that those who claim to be sick without truly being ill are deviant (Earle 2010). Joe is not being deviant as he is being kept in this role by the care staff; he likes to get dressed and have his hair done nice, but accepts this will not happen because the health care team are so busy. Nurses have a professional responsibility to the patient to provide safe and competent nursing, this being evidence based not just biologically, but also taking into account the sociology and psychology perspectives, if this had been addressed Joe would not have felt a burden to the staff just because he wanted to get dressed, he would have been taken out of what society would have said was the sick role (Arnold and Boggs 2003).
If in the planning stage, goals had been set these issues could have been dealt with, Joe could have been dressed every time he had a wash, this would have taken a little extra time but would have made Joe feel better. Orem (1991) argues that patients function and maintain life, health and well being by caring for themselves, it was clear from the video that Joe was never at any point asked if he would like to get dressed or even if he wanted to dress himself. Orem (1991), also went on to say that self care are activities that are necessary to meet basic needs of daily living, are common to everyone and adjust throughout individuals lives depending on age, environmental and other factors. Nurses should be maintaining these activities for patients and encouraging patients to do as much self care as possible to enable a social and psychological well being (Arnold and Boggs 2003)
When goals have been decided by the patient and nurse care needs to be implemented to the patient can start to get better or adjust to the change that may need to happen. When it is talked about implementing is the 'doing' of care giving to a patient. There are lots of factors that need to be considered when a nurse implements care, such as cultural and individual differences, a patients values and beliefs will influence how care, how much will they want to do for themselves and what they expect the nurse to do for them. This should have been looked at in the planning stage so that the patient and nurse know exactly what is expected and when. When implementing care for a patient with cultural differences, it would be ideal to find out what they expect, how their culture needs to be cared for and how this may affect the care that is provide (Barrett, Wilson, Woollands 2009).
McCloskey and Bulcheck (1996) argued that implementing care is done through specific nursing interventions, a nursing intervention is any treatment given based on knowledge and clinical judgement to enhance the patients outcome. Direct or indirect care may be given in the implementing and need to take account of the physical, psychological, social and spiritual support, these may need to be looked at from a multidisciplinary team not just a nursing team (Arnold and Boggs 2003).
Nurses need to remember when implementing care that is patient led and if the patient is able to self care this is encouraged and not over taken by the nurse or even family members, but to make the patient aware they are there to support them, this is part of the Nursing and Midwifery Councils standards of conduct, performance and ethics (NMC 2010).
Furthermore the care giving needs to be individualised and patient centred, it must be safe, legal and ethical. All care must be evidence based and researched, but has to be in the limits of resources available to staff. When implementing care nurses still need to remember, that dignity and respect, which are part of the NMC code of conduct, are upheld and to gain consent. All care that is given must be documented in line with the NMC guidelines for recording keeping, it has to be accurate, comprehensive and include the patient's views, it must also be signed as this is taking accountability for the care that has been given and nurses are accountable for any care they provide to a patient (Barrett, Wilson, Woollands 2009).
The care for Joe was not implemented well, when he came to the care setting he was mobile with a frame, but was now in a wheel chair. Had steps been taken in the planning of care, it could have been implemented that Joe could still use his frame daily and goals could have been set that he would use it every day as long as he felt he was able to but would make sure the care team were aware if he was struggling and needed help. This would have been easy to implement and would still have given Joe is mobility enabling him autonomy.
Autonomy is learnt at an early age according to Erikson (1963), it is learnt from a child wanting to explore and parents allowing this to happen so they are not passive individuals. He believed that people pass through eight stages of life, and had to deal with social realities which are formed in the ego function, which allow them to adapt successfully and show a normal development pattern (Shaffer 2009). According to Erkison (1963), individuals have to pass through each stage successfully to be able to move on to the next, if this is not done the individual will not be able to progress through the next stage successfully and this can have an effect on their lives. At present Joe is at the eighth stage and this is Ego integrity versus despair, this is where the person reflects back over their lives, having lost his autonomy Joe's ego strength will decline and he will feel despair this is a crisis point in the last stage of development and could have the effect that Joe will fear death, had the assessment be carried comprehensively this could have been avoided and Joe could have kept in autonomy (Shaffer 2009)
Once these stages of the problem solving approach has been completed the care planning needs to be evaluated, this is so the nursing team can see if the care has been given correctly, the patient has progressed towards the goals set or moved away, where is the patient in line with the baselines that were discovered in assessing. The information from these issues will allow the nurses to establish if the assessing was comprehensive and holistic, and if this led to an accurate nursing diagnosis. During evaluation it needs to consider if the goals set were realistic and relevant to the patient and if the care that was planned was implemented correctly and by the correct person. When evaluating consideration needs to be taken over the goals set and whether it has alleviated or even solved the problem (Barrett, Wilson, Woollands 2009).
If Joes care had been evaluated properly it could have prevented his nutritional intake reducing, during assessing he was asked what he like to eat, this was not followed up. Being placed in the sick role through no choice of his own also needs to be addressed, and evaluation would look at this. Having a the eighth stage of development damaged needs to be evaluated and dealt with as soon as possible as this will affect his later years and the experience of death will be of despair.
Having looked at each stage and exploring it, it can be seen that each one is interrelated and interdependent of the next. Every stage has information needed to complete the next stage and if at any one stage it is not carried out comprehensively it will be impossible to move successfully on to the next stage. However emphasis must be placed on the assessing stage and how crucial it is for this stage to be done methodically, as this will make every other stage easier to progress through.
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