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Alteration in Family Processes

Alteration in Family Processes

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Illness of a family member:_____________________
(_) Loss/gain of family member due to:______________
____________________________________________
(_) Change in family roles:_______________________
(_) Conflict:___________________________________
(_) Financial crisis:_____________________________
(_) Other:____________________________________
____________________________________________
____________________________________________
As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Family system cannot or does not adapt constructively to crisis or family system cannot or does not communicate openly and effectively between family members.
Minor:
(
May be present)
(_) Family system cannot or does not:

  • meet physical needs of all its members
  • meet emotional needs of all its members
  • meet spiritual needs of all its members
  • express or accept a wide range of feelings
  • seek or accept help appropriately
Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The family member or patient will:(_) Frequently verbalize feelings to professional nurse and each other.

(_) Maintain functional system of mutual support for each member.

(_) Seek appropriate external resources when needed.

(_) Other:

(_) Assess causative and contributing factors.(_) Meet with patient/family to identify:

  • strengths/weaknesses
  • resources available
  • needs
  • priorities
  • alternative arrangements
  • Other:

(_) Encourage verbalization of guilt, anger, hostility, etc. and subsequent recognition of these feelings to:

  • nursing staff
  • family members

(_)Direct family to hospital/community agencies:

  • home health care
  • nurse discharge planners
  • social workers
  • other:

(_) Other:________________
________________________
________________________
________________________

__________________________
Patient/Significant other signature

__________________________
RN signature

Alteration in Health Maintenance Care Plan

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

Alteration in Nurtition: More Than Body Requirements

Alteration in Nurtition: More Than Body Requirements

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Altered satiety patterns
(_) Medications (steroids)
(_) Lack of knowledge
(_) Decreased activity
(_) Decreased metabolic needs
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Overweight (weigh 10% to 20% over ideal for height and frame.
(_) Obese (weigh over 20% of ideal).
Minor:
(
May be present)
(_) Reported undesirable eating patterns.
(_) Intake in excess of metabolic requirements.
(_) Sedentary activity patterns.

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:(_) Decrease total calories ingested.(_) Increase activity level.

(_) Loose weight:
(_____ pounds by discharge).

(_) Other:

(_) Assess and document patient’s dietary history, patterns of ingestion, activity patterns.(_) Discuss with patient potential causative factors for weight gain.(_) Assess motivation to correct overweight.

(_) Consult with dietician regarding balanced plan for weight loss. Reinforce teaching. Discuss realistic weight loss of not more than 2 pounds per week.

(_) Provide positive reinforcement for weight loss.

(_) Record intake.

(_) Weigh q ___ days at ____ am/pm.

(_) Other:________________
________________________
________________________
________________________

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature

Alteration in Nutrition: Less Than Body Requirements

Alteration in Nutrition: Less Than Body Requirements

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Dysphagia caused by:_________________
(_) Absorptive disorders
(_) Anorexia
(_) Allergy
(_) Burns
(_) Cancer
(_) Chemotherapy
(_) Chemical dependence
(_) Crash or fad diet
(_) Depression
(_) Inability to obtain food
(_) Infection
(_) Lack of knowledge of adequate nutrition
(_) Nausea and vomiting
(_) Radiation Therapy
(_) Social isolation
(_) Stress
(_) Trauma
(_) Other:___________________________
__________________________________
__________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Reported inadequate food intake less than recommended daily allowance with or without weight loss and/or actual or potential metabolic needs in excess of intake.
Minor:
(
May be present)
(_) Weight 10% to 20% or more below ideal for height and frame.
(_) Tachycardia on minimal exercise and bradycardia at rest.
(_) Muscle weakness and tenderness.
(_) Mental irritability or confusion.
(_) Decreased serumm albumin.

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:(_) Experience adeuqate nutrition through oral intake.(_) Experience an increase in the amount or type of nutrients ingested.

(_) Gain weight.

(_) Other:

(_) Assess and document patient’s dietary history, patters of ingestion, intolerance to foods.(_) Assess patient likes and dislikes. Inform dietary.(_) Teach techniques to maintain adequate nutritional intake and stimulate appetite:

  • administer/instruct pt. on good oral hygiene before and after feedings
  • maintain pleasant environment for patient

(_) Determine proper denture fit and profice adhesive as necessary.

(_) Increase social contact with meals by:____________________
_______________________

(_) Plan care so that unpleasant/painful tests/tx’s don’t take place before meals.

(_) Medicate pt. for pain 2 hrs before meals per physician’s orders.

(_) Consult with dietitian re:

  • calorie count
  • change in food consistency
  • spacing meals
  • provision of high caloric supplements
  • provision of high protein supplementation
  • food intolerances/preferences
  • extra fluids on tray
  • dietetic teaching, food selelction
  • therapeutic diet restrictions:
    __________________

(_)Consult with PT/PT re:

  • strengthening exercises
  • prosthetic devices
  • swallowing disorders

(_) Environmental support to improve intake:

  • be sure pt. is alert and responsive before eating
  • sit upright 60-90 degrees for 15-20 min. before, during & after eating
  • decrease distractions
  • demonstrate patience by providing specific directions until finished
  • assure good mouth care

(_) Weigh patient q______
at _______ a.m./p.m.

(_) Other:________________
________________________
________________________
________________________

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature

Alteration in Parenting

Alteration in Parenting

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Abusive
(_) Accident victim
(_) Acutely disabled
(_) Addicted to drugs
(_) Adolescent
(_) Alcoholic
(_) Breastfeeding difficulties
(_) Change in family unit
(_) Economic problems
(_) Emotionally disturbed
(_) Lack of extended family
(_) Lack of knowledge
(_) Relationship problems
(_) Separation from nuclear family
(_) Single parent
(_) Terminally ill
(_) Unrealistic expectations of self, infant, partner
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Innappropriate parenting behaviors.
(_) Lack of parental attachment behavior.
Minor:
(
May be present)
(_) Frequent verbalization of dissatisfaction or disappointment with infant/child.
(_) Verbalization of frustration of role.
(_) Verbalization of perceived or actual inadequacy.
(_) Diminished or inappropriate visual, tactile, or auditory stimulation.
(_) Evidence of abuse or neglect of child.
(_) Growth and development lag in infant/child.

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:(_) Begin to verbalize positive feelings re: child, self.(_) Demonstrate increased attachment behaviors such as holding infant close, talking to infant, eye contact.

(_) Initiate active role in child’s care.

(_) Identify activities that defer and promote successful breast feeding.

(_) Identify outside resources for support/guidance:
______________

(_) Demonstrate ability to care for infant.

(_) Identify support system.

(_) Other:

 

(_) Assess causative or contributing factors.(_) Eliminate/reduce contributing factors.(_) Promote ongoing attachment process by:_______________
________________________
________________________

(_) Assist to identify and contact appropriate outside resources.

(_) Will assist patient to identify support system and assess strengths and weaknesses.

(_) Provide support to parents/support system by:____
________________________
________________________

(_) Provide interventions that promote parents and s/o self esteem.

(_) Counsel the parent(s) on assessed needs.

(_) Consult with:______________
________________________
________________________

(_) Encourage mother/father to feed, diaper, dress, bathe child.

(_) Promote successful breastfeeding by:

  • proper positioning
  • eye to eye contact
  • feeding on demand
  • encourage rooming in
  • proper latching on of infant to breast
  • other

(_) Other:________________
________________________
________________________
________________________

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature

Alteration in Patterns of Urinary Elimination: Incontinence

Alteration in Patterns of Urinary Elimination: Incontinence

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Congenital urinary tract anomalies:
________________________________
(_) Disorders of urinary tract:_________
________________________________
(_) Drug therapy
(_) Environmental barriers to bathroom
(_) Estrogen deficiency
(_) Inability to communicate needs
(_) Lack of privacy
(_) Loss of perineal tissue tone
(_) Neurogenic disorder or injury
(_) Prostatic enlargement
(_) Stress/fear
(_) Other:__________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Urgency followed by incontinence.
(_) Other:

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:(_) Be continent at all times.(_) Be continent during waking hours.

(_) Other:

 

 

(_) Montiro I & O, including patterns of urinary incontinence.(_) Instruct to start and stop stream during urination.(_) Ask physician for pelvic floor exercises. Order and teach as follows:
_________x__________ (# of times).

(_) Limit fluids 2-3 hours prior to bedtime.

(_) No fluids after:___________

(_) Awaken patient at night to void at:_______ or q___hours.

(_) Provide urinal/bedpan/bedside commode in easy access.

(_) Place call light within reach at all times.

(_) Provide comfort measures (sitz baths: warm perineal soaks as needed).

(_) Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature

Alteration in Patterns of Urinary Elimination: Retention

Alteration in Patterns of Urinary Elimination: Retention

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Anxiety
(_) Fecal impaction
(_) Flaccid bladder
(_) Medications
(_) Packing
(_) Stones
(_) Weak or absent sensory and/or motor impulses
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Bladder distention (not related to acute, reversible etiology).
(_) Distention with small frequent voids or dribbling (overflow incontinence).
(_) 100 ml or more residual of urine.
Minor:
(
May be present)
(_) The individual states that it feels as though the bladder is not empty after voiding.

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:(_) Void in the amount of:
__________
(_) Have urine resicual less than 30cc.

(_) Verbalize knowledge of signs and symptoms of infection.

(_) Other:

(_) Palpate bladder for distention q___ hours or after each void.(_) Monitor I & O.(_) Attempt to stimulate relaxation of urethral sphincter by:

  • running water
  • providing warm water for patient to place hand/fingers in
  • other:

(_) Provide privacy.

(_) Intermittent straight cath q___ hours per physician order.

(_) Other:________________
________________________
________________________
________________________

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature

Alteration in Sensory Perceptual Care Plan

Alteration in Sensory Perceptual

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Amputation
(_) Bedrest
(_) Cast
(_) Hearing
(_) Immobility
(_) Impaired oxygen transport
(_) Medications
(_) Metabolic alterations
(_) Neurological alterations
(_) Pain
(_) Paraplegia
(_) Physical isolation
(_) Social isolation
(_) Stress
(_) Traction
(_) Visual
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Inaccurate interpretation of environmental stimuli.
(_) Negative change in amount or pattern of incoming stimuli.
Minor:
(
May be present)
(_) Disoriented about person, place, or time.
(_) Altered problem solving ability.
(_) Altered behavior or communication pattern.
(_) Sleep pattern disturbances.
(_) Restlessness.
(_) Reports auditory or visual hallucinations.
(_) Fear.
(_) Anxiety.
(_) Apathy.

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:(_) Demonstrate optimal contact with reality.(_) Demonstrate an increase in self care activities.

(_) Experience decreased symptoms of sensory overload.

(_) Other:

(_) Assess ability of patient to accurately interpret sensory stimuli.(_) Monitor electrolytes, adequacy of BP.(_) Organize nursing care to provide uninterrupted sleep at night.

(_) Reduce unessential stimuli, if possible. Orient to person, place, and time with every nurse/patient contact.

(_) Encourage interaction with familiar persons.

(_) Explain all nursing care.

(_) Other:________________
________________________
________________________
________________________

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature

Alteration in Thought Processes

Alteration in Thought Processes
(Geriatrics)

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Factors associated with aging.
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(
Must be present)
(_) Inaccurate interpretation of stimuli, internal and/or external.
Minor:
(
May be present)
(_) Cognitive defects, including abstraction, memory, suspiciousness, delusions, hallucinations, distractibility, lack of consensual validation, language, confusion/disorientation.

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:(_) Demonstrate optimum contact with reality.(_) Demonstrate an increase in self-care activities.

(_) Other:

 

(_) Assess for etiological and contributing factors:

  • physiological
  • situational

(_) Assess history of confusion (onset/duration).

(_) Determine the amount and type of stimuli needed by the patient in the context of his/her usual life style.

(_) Promote communication and sensory input.

(_) Promote a well role:

  • encourage ADL’s per patient as much as possible
  • meals out of bed yes/no_____
  • other:

(_) Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature

Alterations in Cardiac Output: Decreased Care Plan

Alterations in Cardiac Output: Decreased

(_)Actual (_) Potential

Related To:
[Check those that apply]
(_) Cardiac factors
(_) Pulmonary disorders
(_) Endocrine disorders
(_) Hematological disorders
(_) Fluid & electrolyte disturbances
(_) Surgery/anesthesia
(_) Newborn/Infant
(_) Vagal stimulation
(_) Stress
(_) Shock
(_) Allergic response
(_) Medications
(_) Other:___________________
___________________________
___________________________

 

As evidenced by:
[Check those that apply]
(_) Angina
(_) Cardiac arrythmia
(_) Cyanosis
(_) Dyspnea
(_) Edema (periph./sacral)
(_) Fatigability
(_) Hypotention
(_) Oliguria
(_) Restlessness
(_) Tachycardia

 

Date &
Sign.
Plan and Outcome
[Check those that apply]
Target
Date:
Nursing Interventions
[Check those that apply]
Date
Achieved:
The patient will:(_) Demonstrate imporved cardiac output A.E.B.:

  • vital signs within normal limits for patient. [BP____] [P___]
  • color pink
  • chest clear
  • balanced I & O
  • minimal or absent edema

(_) Other:

(_) Assess color, BP, pulse, respirations q___ hours.(_) Listen to breath sounds q___ hours.(_) Check for edema of feet, legs, and sacrum q___ hours.

(_) Daily weights at ____ a.m./p.m. using same scale.

(_) Measure intake and output q 8 hours.

(_) Organize care to maximize periods of uninterrupted rest. Needs ______ rest periods/day. (Specify:): ________________________

(_) Explore with patient potential etiological factors for decreased cardiac output and provide health teaching. (See Discharge Plan)

(_) Other:________________
________________________
________________________
________________________

(_) Discharge Plan:________
________________________
________________________
________________________

 

__________________________
Patient/Significant other signature

 

__________________________
RN signature

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