ROOM # _______ DATE _______________

STUDENT NAME _______________________________________

NURSING DIAGNOSIS

Nursing Problem

Ineffective Health
Maintenance

PLANNING

related to
ETIOLOGY or RISK
FACTORS

evidenced by
DEFINING
CHARACTERISTICS

Cognitive
impairment, lack of
health-seeking
behavior; reported or
observed impairment
of personal support
systems; demonstrated
lack of adaptive
behaviors to internal
and external
environmental
changes; reported or
observed inability to
take responsibility for
meeting basic health
practices in any or all
functional pattern areas

Subjective: Client
stated that she
needs glasses but
has not way to get
them due to lack of
support system;
however she is seen
as an outpatient for
her history of
mental illness.
Objective: Client
verbalized no
awareness of
community
resources available
to her or knowledge
of how to obtain
information of
available resources.

GOALS
(SHORT & LONG TERM)

INTERVENTION
WITH JUSTIFICATION

Short: Discuss fear or

blocks to obtaining
needed community
health resources by
end of shift today.

Assessing for family

patterns, economic issues,
and cultural patterns that
influence compliance with a
given medical regimen
enables the nurse to gain an
understanding of clients'
lives and to cultivate their
connections to a responsive
community, encouraging
clients to not get into
"receiving" behaviors.

Effective
teaching/learning is
demonstrated by the client
verbalizing available
community resources,
how to contact these
resources and support
persons to call when
assistance is needed.

Short: Help client

determine how to
arrange a daily
schedule that
incorporates the new
health care regimen by
discharge 6/9/16. (e.g.,
taking pills before
meals or list of who to
contact for what issue
posted by the
telephone).

Increased social support and

personal autonomy has been
related to a reduction in
hospital admissions and an
increase in individual
wellbeing for persons with
physical and mental illness.

The client will be able to

verbalize and demonstrate
plan and/or strategies that
will enable them to
properly follow their daily
care plan and access their
support system when
needed.

EVALUATION

Realistic goals for changes

Long: Patient will
in health maintenance will
follow mutually
be discussed with the client
agreed on healthcare
every Tuesday afternoon at
maintenance plan as
the individual therapy
measured by one week sessions.
of documentation of
participation in
healthcare
maintenance activities
by July 8, 2016.

Effective compliance will

be evidenced by repeated
weekly documentation of
clients verbalization and
use of effective strategies
and tools provided in the
care plan at time of
discharge.

ROOM # ________ DATE _______________ STUDENT NAME ________________________________________

NURSING DIAGNOSIS

Nursing Problem

related to
ETIOLOGY or RISK
FACTORS

evidenced by
DEFINING
CHARACTERISTICS

PLANNING

GOALS
(SHORT & LONG TERM)

INTERVENTION
WITH JUSTIFICATION

EVALUATION