Nursing Care Plan

Return to Care Plan Listing
 






Medical Diagnoses: Ineffective health maintenance related to lack of ability to make good judgments regarding ways to obtain help 

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders

*I

Evaluation

Goals

Interventions

Ineffective health maintenance related to lack of ability to make good judgments regarding ways to obtain help as evidenced by patient statement “I’m just so stressed, I don’t know what to do anymore.”

    


Short Term:

Patient will discuss fear of or blocks to implementing health regimen as measured by identification of two fears or blocks to implementation by [date] at 3:00 pm.

     

     

     

     

Long Term:

Patient will follow mutually agreed on healthcare maintenance plan as measured by one week of documentation of participation in healthcare maintenance activities by [date] at 3:00 pm.

-Assess the client’s feelings, values, and reasons for not following the prescribed plan of care.  Assessment of an individual’s preferences for participation in decision-making will allow for enlisting involvement in decision-making at the preferred level (Ackley & Ladwig). 

-Assess for family patterns, economic issues, and cultural patterns that influence compliance with a given medical regimen.  The family’s reaction to the diagnosis has a significant influence on adherence to the treatment regimen.  There are marked differences in use of healthcare services among different cultural groups (Ackley & Ladwig).   

-Help the client to choose a healthy lifestyle and to have appropriate diagnostic screening tests completed.  Healthy lifestyle measures, such as exercising regularly, maintaining a healthy weight, not smoking, and limiting alcohol intake, help reduce the risk of cancer and other chronic illnesses (Ackley & Ladwig). 

-Discuss with the client and support person realistic goals for changes in health maintenance.  The importance of personalized goals and social support in designing health interventions for older adults is a unique predictor of health goal attainment (Ackley & Ladwig). 

     

   

     

     

     

     

Goal met on [date] at 12:30 pm.  Client has identified two blocks to implementation of health regimen.     

    

    

    

    

    

Goal is set to be measured on [date] at 3:00 pm.  Client has not made progress.  Client has not documented any participation in healthcare maintenance activities.

-The client’s feelings, values, and reasons for not following the prescribed plan of care were assessed every Tuesday afternoon.

-Family patterns, economic issues, and cultural patterns that influence compliance with a given medical regimen were assessed every Tuesday afternoon.

     

-The client was assisted in choosing a healthy lifestyle and appropriate diagnostic screening tests completed every Tuesday afternoon.

-Realistic goals for changes in health maintenance were discussed with the client every Tuesday afternoon.


Assessment

Subjective Data:

-Patient statement “I’m just so stressed, I don’t know what to do anymore.”

-Patient statement “Could you find my old doctor for me?”

Objective Data:

-Presence of several expired medications on coffee table.

-Presence of several healthcare workers’ contact information stuffed in a vase in the center of the coffee table in an unorganized fashion. 

-Patient appears to be confused while talking about health plan.

    

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing Diagnoses handbook: An evidence-based guide to planning care (8th ed.). St. Louis, MI: Mosby Elsevier




Return to Table of Contents