NDx: Altered Health Maintenance

sugarmagnoliaRN · Apr 21, 2012

Anybody? Please! I need help!

Esme12, ASN, BSN, RN · Apr 21, 2012

Why is the patient non compliant? What is the history? What are they non compliant with? I need a little more information to help.

sugarmagnoliaRN · Apr 21, 2012

My etiology is "perceived powerlessness." This patient is a paraplegic and has been in the hospital a very long time; while I was helping take care of him, he refused things like repositioning to avoid further skin breakdown (he already had numerous decubitus ulcers), medications (almost everything except pain meds), dressing changes, being put on an Envision bed... based on his mood/affect, he seemed like he was losing hope that things would get better for him.

Thanks for your reply!!

sugarmagnoliaRN · Apr 21, 2012

Another tidbit - something I really liked about that diagnosis was that one of the interventions is including the pt in planning their care. There was one nurse that I saw take care of him (he was my patient in clinical more than once) who was most effective in getting him to follow some kind of treatment plan, and the difference between her and the other nurses was that she would oppose him when he refused treatments and she would try to make him more comfortable with it by offering him some other options and coordinating with the doctor if she needed to. The other nurses I saw expected him to refuse things (he had already been at this particular hospital ~ 3 weeks) and just said "welp, everyone has the right to refuse treatment" and went on their way without really trying to persuade him or adjust the treatments a little so that he would be comfortable with them.

Esme12, ASN, BSN, RN · Apr 21, 2012

ok you are falling into the same trick bag that all new students fall into. you are picking a nursing diagnosis and trying to make your patient fit into it because you like it. that is not what you do.

the biggest thing about a care plan is the assessment, of the patient. the second is knowledge about the disease process. first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms.

the medical diagnosis is the disease itself. it is what the patient has not necessarily what the patient needs. the medical diagnosis is what the patient has and the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. it is trying to teach you how to think like a nurse.

think of them as a recipe to caring for your patient. your plan of care.

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
planning (write measurable goals/outcomes and nursing interventions)
implementation (initiate the care plan)
evaluation (determine if goals/outcomes have been met)

a dear friend to an, daytonite (rip) always had the best advice.......check out this link.

https://allnurses.com/nursing-student...is-290260.html

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). [thanks daytonite]

take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). what i would suggest you do is to work the nursing process from step #1

the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

with the little information you have here lets see......

this patient is a paraplegic and has been in the hospital a very long time; while i was helping take care of him, he refused things like repositioning to avoid further skin breakdown (he already had numerous decubitus ulcers), medications (almost everything except pain meds), dressing changes, being put on an envision bed... based on his mood/affect, he seemed like he was losing hope that things would get better for him.

his powerlessness isn't perceived, this patient is depressed. put yourself in his position. how would you feel? what would you do to care for him in a better way?

is his non compliance based in hopelessness? does his situational low self esteem contribute to his feelings if powerlessness? all due to his paralysis and impaired physical mobility?

noncompliance

nanda-i definition: behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional. in the presence of an agreed-on health-promoting or therapeutic plan, person's or caregivers behavior is fully or partially non adherent and may lead to clinically ineffective or partially ineffective outcomes

situational low self-esteem

nanda-i definition: development of a negative perception of self-worth in response to current situation (specify)

hopelessness

nanda-i definition: subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf

impaired physical mobility

nanda-i definition: limitation in independent, purposeful physical movement of the body or of one or more extremities

powerlessness

nanda-i definition: perception that one's own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening

these are prioritized according to think maslow's hierarchy of needs. maslow's hierarchy of needs - enotes.com virginia henderson's need theory

maslow’s hierarchy of needs is a based on the theory that one level of needs must be met before moving on to the next step.

self-actualization – e.g. morality, creativity, problem solving. (to be filled last)
esteem – e.g. confidence, self-esteem, achievement, respect.
belongingness – e.g. love, friendship, intimacy, family.
safety – e.g. security of environment, employment, resources, health, property.
physiological – e.g. air, food, water, sex, sleep, other factors towards homeostasis. (greatest need to be filled first)

assumptions

maslow’s theory maintains that a person does not feel a higher need until the needs of the current level have been satisfied.

b and d needs

deficiency or deprivation needs

the first four levels are considered deficiency or deprivation needs (“d-needs”) in that their lack of satisfaction causes a deficiency that motivates people to meet these needs

growth needs or b-needs or being needs

the needs maslow believed to be higher, healthier, and more likely to emerge in self-actualizing people were being needs, or b-needs.
growth needs are the highest level, which is self-actualization, or the self-fulfillment.
maslow suggested that only two percent of the people in the world achieve self actualization. e.g. abraham lincoln, thomas jefferson, albert einstein, eleanor roosevelt.
self actualized people were reality and problem centered.
they enjoyed being by themselves, and having deeper relationships with a few people instead of more shallow relations with many people.
they tended to be spontaneous and simple.

application in nursing

maslow's hierarchy of needs is a useful organizational framework that can be applied to the various nursing models for assessment of a patient’s strengths, limitations, and need for nursing interventions.

these resources may help.

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

understanding the essentials of critical care nursing

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

cns: problem oriented nursing care plans

nurseprnRN, BSN, RN · Apr 21, 2012

hopelessness and powerlessness come to mind for this sort of situation. "altered health maintenance" does not appear in the nanda-i nursing diagnoses, so you can't actually use that. there are "ineffective health maintenance," and "ineffective self-health management," either or both of which may include defining characteristics you identified in your patient-- you would have to check them and see.

remember-- it's always "data first, diagnosis second."

sugarmagnoliaRN · Apr 22, 2012

Thank you both for your help!! I ended up using both Hopelessness and Ineffective Health Maintenance r/t perceived powerlessness. Thanks again y'all! Esme, I'm copy & pasting your response into a sticky note on my computer for future reference :)