Impaired Home Maintenance Management

Published on Saturday March 10th , 2007

Impaired Home Maintenance Management

(_)Actual (_) Potential

Related To:
[Check those that apply]
Chronic debilitating disease:
(_) Arthritis
(_) Cancer
(_) CHF
(_) COPD
(_) Diabetes mellitus
(_) Multiple sclerosis
(_) Muscular dystrophy
 Injury to individual or family members:
(_) Addition of family member
(_) Loss of family member
(_) Impaired mental status
(_) Insufficient finances
(_) Lack of knowledge
(_) Substance abuse
(_) Surgery
(_) Unavailable support system
(_) Other:_____________________________
____________________________________
____________________________________

 

As evidenced by:
[Check those that apply]
Major:
(Must be present)		 (_) Outward expressions by individual or family of difficulty in maintaining the home or in caring for self or family members.
Minor:
(May be present)		 (_) Poor hygiene practice.
(_) Unwashed cooking/eating utensils.
(_) Impaired caregiver.
(_) Inadequate support system.

 

Date &
Sign.		 Plan and Outcome
[Check those that apply]		 Target
Date:		 Nursing Interventions
[Check those that apply]		 Date
Achieved:
  The patient or caregiver will:

(_) Identify factors that restrict self care and home management.

(_) Demonstrate the ability to perform skills necessary for the care of the individual or home.

(_) Express satisfaction with home.

(_) Other:

 

   (_) Assess for factors that might impair home management.

(_) Explore with patient and/or significant other, factors that will facilitate home management and provide appropriate health teaching. (See Discharge Plan)

(_) Procure necessary equipment or aids:____________________
________________________
________________________

(_) Refer to/consult with appropriate agencies for:

  • insufficient funds:
  • cooking:
  • transportation:
  • housework:
  • home maintenance:
  • other:

 

(_) Other:________________
________________________
________________________
________________________

  

 

__________________________
Patient/Significant other signature

 

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RN signature