Impaired
Adjustment
(_)Actual (_)
Potential
(_) Illness (_) Other:_____________________________ ____________________________________ ____________________________________ |
Major: (Must be present) |
(_) Verbalization of non-acceptance of health status change. (_) Inability to be involved in problem solving or goal setting. |
Minor: (May be present) |
(_) Lack of movement toward independence. (_) Extended period of shock, disbelief, or anger regarding health status change. (_) Lack of future oriented thinking. |
Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
The patient will: (_) (_) Differentiate (_) Other: |
(_) Asses the patient’s:
(_) Assist patient to (_) Explore feelings (_) Identify factors
(_) ________________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature