Powerlessness
Powerlessness
(_)Actual (_) Potential
| (_)
Inability to communicate:________________________ (_) Inability to perform ADL:________________________ (_) Inability to perform role responsibilities:_____________ ______________________________________________ (_) Progressive debilitating disease:_________________ (_) Hospital or institutional limitations:_________________ ______________________________________________ (_) Other:______________________________________ ______________________________________________ ______________________________________________ |
| Major:
(Must be present) |
(_) Overt or covert expressions of dissatisfaction over inability to control situation. (exg: illness, prognosis, care, recovery rate) |
| Minor:
(May be present) |
(_)
Refuses or is reluctant to participate in decision-making
(_) Apathy (_) Resignation (_) Aggressive/violent/acting out behavior (_) Anxiety (_) Uneasiness (_) Depression |
| Date & Sign. |
Plan and Outcome [Check those that apply] |
Target Date: |
Nursing Interventions [Check those that apply] |
Date Achieved: |
| The
patient will: (_) Identify factors that can be controlled:
(_) Makes decisions regarding treatment and future when possible. (_) Other: |
(_)
Assess causative or contributing factors. (_) Assess patient's usual response to problems:
(_) Increase communication
(_) Allow time to answer questions (15 min. ea shift) (_) Realistically point out positive changes in person's condition. (_) Allow patient to make as many decisions as possible. (_) Provide opportunities for patient and family to participate in care. (_) Encourage participation from patient who depends on others to make own decisions. (_) Encourage patient to verbalize feelings and concerns. (_)
Other:________________ |
__________________________
Patient/Significant other signature
__________________________
RN signature
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