Powerlessness

Powerlessness

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Inability to communicate:________________________
(_) Inability to perform ADL:________________________
(_) Inability to perform role
responsibilities:_____________

______________________________________________
(_) Progressive debilitating disease:_________________
(_) Hospital or institutional
limitations:_________________
______________________________________________
(_) Other:______________________________________
______________________________________________

______________________________________________

 

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

(
Must be
present
)
(_)
Overt or covert expressions of dissatisfaction over
inability to control situation. (exg: illness, prognosis,
care, recovery rate)
Minor:

(
May be
present
)
(_)
Refuses or is reluctant to participate in decision-making
(_) Apathy (_) Resignation
(_) Aggressive/violent/acting out behavior (_) Anxiety
(_) Uneasiness (_) Depression

 

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

Achieved:

  The
patient will:

(_)
Identify factors that can be controlled:

 

(_) Makes decisions
regarding treatment and future when possible.

(_) Other:

  (_)
Assess causative or contributing factors.

(_) Assess patient’s usual
response to problems:

  • Internal – how
    individual makes own changes
  • External –
    expects others to control problems or leaves to
    fate, or luck

(_) Increase
communication

  • Explain all
    procedures and..
  • Treatments
  • Medications
  • Results of
    labs/tests
  • Condition
  • All changes
  • Rules
  • Options
  • Other:

 

(_) Allow time to
answer questions (15 min. ea shift)

(_) Realistically
point out positive changes in person’s condition.

(_) Allow patient to
make as many decisions as possible.

(_) Provide
opportunities for patient and family to participate in
care.

(_) Encourage
participation from patient who depends on others to make
own decisions.

(_) Encourage patient
to verbalize feelings and concerns.

(_)
Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________

RN signature