Nurse's Pocket Guide

ineffective HEALTH MAINTENANCE
• Determine whether impairment is an acute/sudden onset situation,
a progressive illness/long-term health problem, or
exacerbation or complication of chronic illness. May require
more intensive/long-lasting support.
• Note client’s age (e.g., very young or elderly) and level of
dependence/independence. May range from complete
dependence (dysfunctional) to partial or relative independence
requiring support in a single area.
• Evaluate for substance use/abuse (e.g., alcohol/other drugs).
Affects client’s desire/ability to help self.
• Ascertain recent changes in lifestyle (e.g., man whose wife dies
and he has no skills for taking care of his own/family’s health
needs; loss of independence; changing support systems).
• Note setting where client lives (e.g., long-term care facility,
homebound, homeless).
• Note desire/level of ability to meet health maintenance needs,
as well as self-care ADLs.
• Determine level of adaptive behavior, knowledge, and skills
about health maintenance, environment, and safety. Determines
beginning point for planning and interventions to
assist client in addressing needs.
• Assess client’s ability and desire to learn. Determine barriers to
learning (e.g., can’t read, speaks/understands nondominant language,
is overcome with grief or stress, has no interest in subject.)
• Assess communication skills/ability/need for interpreter. Identify
support person requesting/willing to accept information.
• Note client’s use of professional services and resources (e.g.,
appropriate or inappropriate/nonexistent).
NURSING PRIORITY NO. 2. To assist client/caregiver(s) to maintain
and manage desired health practices:
• Discuss with client/SO(s) beliefs about health and reasons for
not following prescribed plan of care. Determines client’s
view about current situation and potential for change.
• Evaluate environment to note individual adaptation needs.
• Develop plan with client/SO(s) for self-care. Allows for
incorporating existing disabilities with client’s/SO’s desires
and ability to adapt and organize care activites.
• Involve comprehensive specialty health teams when available/indicated
(e.g., pulmonary, psychiatric, enterostomal, IV
therapy, nutritional support, substance-abuse counselors).
• Provide anticipatory guidance to maintain and manage
effective health practices during periods of wellness and
identify ways client can adapt when progressive illness/
long-term health problems occur.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
368 Cultural Collaborative Community/Home Care