Impaired Home Maintenance Management
Impaired Home Maintenance Management
(_)Actual (_) Potential
| 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:_____________________________ ____________________________________ ____________________________________ |
| 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:
(_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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