Alteration in Health Maintenance

Alteration in Health Maintenance

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Loss of independence
(_) Changing support systems
(_) Change in finances
(_) Lack of knowledge
(_) Poor learning skills (illiteracy)
(_) Crisis situation
(_) Inadequate health practice
(_) Substance abuses:_______
__________________________
(_) Lack of accessibility to health care services
(_) Health beliefs
(_) Religious beliefs
(_) Cultural/folk beliefs
(_) Alterations in self image
(_) Age related conditions
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Reports or demonstrates an unhealthy practice or life style.
(_) Reckless driving of vehicle.
(_) Substance abuse.
(_) Overeating.
(_) Reports or demonstrates frequent alterations in health. eg:
_________________________________________________

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:

(_) Incorporate principles of health promotion into lifestyle:

(_) Other:

(_) Assess for factors that contribute to the promotion and maintenance of health or that result in alterations in health.

(_)Provide pertinent information concerning screening for: breast cancer, BP, other:______________________

(_) Explore health promotion behaviors that patient is willing to incorporate into lifestyle.

(_) Initiate health teaching and referrals as indicated:

  • review daily health practices
  • dental care
  • food intake
  • fluid intake
  • exercise
  • use of tobacco, alcohol, and drugs
  • knowledge of safety practices, fire prevention, water safety, automobile safety, bicycle safety, and poison control
  • other:

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

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