Angelite Nurses: 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

Angelite Nurses