Alteration
in Health Maintenance
(_)Actual (_)
Potential
(_) Loss of independence (_) Changing support systems (_) Change in finances (_) Lack of knowledge |
(_) Lack of accessibility to health care services (_) Health beliefs (_) Religious beliefs (_) Cultural/folk beliefs (_) Alterations in self image (_) Age related conditions |
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: (_) (_) Other: |
(_) Assess for factors that contribute to the promotion and maintenance of health or that result in alterations in health. (_)Provide (_) Explore health (_) Initiate health
(_) ________________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature