Impaired Home Maintenance Management

Impaired
Home Maintenance Management

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
Chronic
debilitating disease:
(_) Arthritis
(_) Cancer

(_) CHF
(_) COPD
(_) Diabetes mellitus
(_) Multiple sclerosis
(_) Muscular dystrophy

Injury
to individual or family members:
(_) Addition of family member
(_) Loss of family member
(_) Impaired mental status
(_) Insufficient finances
(_) Lack of knowledge

(_) Substance abuse
(_) Surgery
(_) Unavailable support system
(_) Other:_____________________________
____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(Must be
present
)

(_)
Outward expressions by individual or family of difficulty
in maintaining the home or in caring for self or family
members.
Minor:

(May be
present
)

(_) Poor
hygiene practice.
(_) Unwashed cooking/eating utensils.
(_) Impaired caregiver.
(_) Inadequate support system.

 

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

Achieved:

  The
patient or caregiver will:

(_) Identify factors that restrict self
care and home management.

(_) Demonstrate the
ability to perform skills necessary for the care of the
individual or home.

(_) Express
satisfaction with home.

(_) Other:

 

  (_)
Assess for factors that might impair home management.

(_) Explore with patient and/or
significant other, factors that will facilitate home
management and provide appropriate health teaching. (See
Discharge Plan)

(_) Procure necessary
equipment or aids:____________________
________________________

________________________

(_) Refer to/consult
with appropriate agencies for:

  • insufficient
    funds:
  • cooking:
  • transportation:
  • housework:
  • home maintenance:
  • other:

 

(_)
Other:________________
________________________

________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature