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]
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 &
Plan and Outcome
[Check those that apply]
Nursing Interventions
[Check those that apply]
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