Knowledge Deficit
(_)Actual (_) Potential
| (_) New diagnosis:_____________________________ (_) Language differences:________________________ (_) Hospitalization (_) Diagnostic test:_____________________________ (_) Surgical procedure:__________________________ (_) Medications:_______________________________ (_) Pregnancy (_) Other:_____________________________ ____________________________________ ____________________________________ |
| Major: (Must be present) |
(_) Verbalizes a deficiency in knowledge or skill. (_) Requests information. (_) Expresses and inaccurate perception of health status. (_) Does not correctly perform a desired or prescribed health behavior. |
| Minor: (May be present) |
(_) Lack of integration of treatment plans into daily activities. (_) Exhibits or expresses psychological alteration, (anxiety, depression) resulting from misinformation or lack of information. |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The patient will:(_) Describe disease process, causes, factors contributing to symptoms.
(_) Describe procedure(s) for disease or symptom control. (_) Identify needed alterations in lifestyle. (_) Other: |
(_) Assess patient’s readiness to learn by assessing emotional respose to illness:
(_) Allow person to work through and express intense emotions prior to teaching. (_) Examine patient’s health beliefs: (_) Assess patient’s desire to learn. (_) Assess preferred learning mode:
(_) Assess literacy level. (_) Provide health teaching and referrals: ___________________ (_) Plan and share necessity of learning outcomes with patient – s/o. (_) Evaluate patient – s/o behaviors as evidence that learning outcomes have been achieved: (_) Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
