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