Impaired Home Maintenance Management

Impaired Home Maintenance Management

(_)Actual (_) Potential

Related To:
[Check those that apply]
Chronic debilitating disease:
(_) Arthritis
(_) Cancer
(_) CHF
(_) COPD
(_) Diabetes mellitus
(_) Multiple sclerosis
(_) Muscular dystrophy
Injury to individual or family members:
(_) Addition of family member
(_) Loss of family member
(_) Impaired mental status
(_) Insufficient finances
(_) Lack of knowledge
(_) Substance abuse
(_) Surgery
(_) Unavailable support system
(_) Other:_____________________________
____________________________________
____________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Outward expressions by individual or family of difficulty in maintaining the home or in caring for self or family members.
Minor:
(
May be present)
(_) Poor hygiene practice.
(_) Unwashed cooking/eating utensils.
(_) Impaired caregiver.
(_) Inadequate support system.

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

(_) Identify factors that restrict self care and home management.

(_) Demonstrate the ability to perform skills necessary for the care of the individual or home.

(_) Express satisfaction with home.

(_) Other:

(_) Assess for factors that might impair home management.

(_) Explore with patient and/or significant other, factors that will facilitate home management and provide appropriate health teaching. (See Discharge Plan)

(_) Procure necessary equipment or aids:____________________
________________________
________________________

(_) Refer to/consult with appropriate agencies for:

  • insufficient funds:
  • cooking:
  • transportation:
  • housework:
  • home maintenance:
  • other:

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

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