Powerlessness

Powerlessness

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Inability to communicate:________________________
(_) Inability to perform ADL:________________________
(_) Inability to perform role responsibilities:_____________
______________________________________________
(_) Progressive debilitating disease:_________________
(_) Hospital or institutional limitations:_________________
______________________________________________
(_) Other:______________________________________
______________________________________________
______________________________________________

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Overt or covert expressions of dissatisfaction over inability to control situation. (exg: illness, prognosis, care, recovery rate)
Minor:
(
May be present)
(_) Refuses or is reluctant to participate in decision-making (_) Apathy (_) Resignation
(_) Aggressive/violent/acting out behavior (_) Anxiety (_) Uneasiness (_) Depression

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

(_) Identify factors that can be controlled:

(_) Makes decisions regarding treatment and future when possible.

(_) Other:

(_) Assess causative or contributing factors.

(_) Assess patient's usual response to problems:

  • Internal - how individual makes own changes
  • External - expects others to control problems or leaves to fate, or luck

(_) Increase communication

  • Explain all procedures and..
  • Treatments
  • Medications
  • Results of labs/tests
  • Condition
  • All changes
  • Rules
  • Options
  • Other:

(_) Allow time to answer questions (15 min. ea shift)

(_) Realistically point out positive changes in person's condition.

(_) Allow patient to make as many decisions as possible.

(_) Provide opportunities for patient and family to participate in care.

(_) Encourage participation from patient who depends on others to make own decisions.

(_) Encourage patient to verbalize feelings and concerns.

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

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