West Visayas State University Ineffective Health Maintenance

West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City NURSING PROCESS Clustered Cues January 21, 2009, 8:40 AM “Permi lang bulong, wala naman ako pagayo.” “Hindi na ako anay sina, karon lang kung makatapos na ako pa dialysis.” “Hambal nila guba na akon nga kidney, wala na pagfunction. Ano pa ang pulos sina nga bulong.”

Nursing Diagnosis Ineffective health maintenance r/t avoidance of medication therapy secondary to lack of ability to make deliberate and thoughtful judgments

Rationale

Outcome Criteria

Inability to identify, manage, and/or seek out to help maintain health Source: Nurse’s pocket guide

1. The patient will be able to identify necessary health maintenance activities on January 21, 2009, 12:00PM. 2. The patient will be able assume responsibility for own healthcare needs within level of ability on January 21, 2009, 12:00PM. 3. The patient will be able to adopt lifestyle changes supporting individual healthcare goals on January 21, 2009, 12:00PM.

Nursing Interventions

Rationale

1. Determine level of adaptive behavior, knowledge about health maintenance, environment and safety.

To note individual adaptation needs

2. Evaluate environment

To note individual adaptation needs

3. Develop plan with patient

Allows for incorporating existing disabilities, adapting and organizing care as necessary

4. Provide anticipatory guidance

To maintain and manage effective health practices during periods of wellness

5. Monitor adherence to prescribed medical regimen

To alter the care plan as needed

Evaluation January 21, 2009, 12:00PM. 1. Goal met: “Amo na gale ngaa ginahatagan niyo ako sang bulong nga ina, subong naintindihan ko na kung ngaa,” as verbalized by the patient 2. Goal met: “Ari man di si nanay kag bayaw ko, mayo man ako sini kung ara sila nga nagabulig kag kamu man e,” as verbalized by the patient 3. Goal unmet: “