Nursing Diagnosis: Ineffective Health maintenance Application of NANDA, NOC, NIC

Nursing Diagnosis: Ineffective Health maintenance
Suzanne Skowronski and Gail B. Ladwig

NANDA Definition: The inability to identify, manage, or seek out help to maintain health

Defining Characteristics: History of lack of health-seeking behavior; reported or observed lack of equipment, financial, and/or other resources; reported or observed impairment of personal support systems; expressed interest in improving health behaviors; demonstrated lack of knowledge regarding basic health practices; demonstrated lack of adaptive behaviors to internal and external environmental changes; reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas

Related Factors: Disabled family coping, perceptual-cognitive impairment (complete or partial lack of gross or fine motor skills); lack of or significant alteration in communication skills (written, verbal, or gestural); unachieved developmental tasks; lack of material resources; dysfunctional grieving; disabling spiritual distress; inability to make deliberate and thoughtful judgments; ineffective coping

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Health Beliefs: Perceived Resources
·         Health-Promoting Behavior, Health-Seeking Behavior
 Client Outcomes
·         Discusses fear of or blocks to implementing a health regimen
·         Follows mutually agreed upon health care maintenance plan
·         Meets goals for health care maintenance

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Health System Guidance
·         Support System Enhancement
·         Health Education
Nursing Interventions and Rationales
·         Assess client's feelings, values, and reasons for not following prescribed plan of care. See Related Factors. A factor to assess when examining client responsibility is the level of dissatisfaction with current lifestyle and readiness for change (Clark, 1996).
·         Assess for family patterns, economic issues, and cultural patterns that influence compliance with a given medical regimen. Responsiveness to clients enables the nurse to gain an understanding of clients' lives and to cultivate their connections to a responsive community, encouraging clients to not get into "receiving" behaviors (Smith-Battle, 1997).
·         Help client determine how to arrange a daily schedule that incorporates the new health care regimen (e.g., taking pills before meals).
·         Refer client to social services for financial assistance if needed. Information-seeking behavior is a strategy that many people use as a means of coping with and reducing stress when coping with an illness such as cancer (van der Molen, 1999).
·         Identify support groups related to the disease process (e.g., Reach to Recovery for a woman who has had a mastectomy).
·         Help client to choose healthy lifestyle and to have appropriate diagnostic screening tests. This study identified that women who adopt a healthy lifestyle and practice preventive healthy behaviors can reduce the risks of some cancers and other diseases such as heart disease and sexually transmitted infections (Furniss, 2000).
·         Identify complementary healing modalities such as herbal remedies, acupuncture, healing touch, yoga, or cultural shamans that the client uses in addition to or instead of the prescribed allopathic regimen. Expenditures for alternative medicine professional services have increased 45% since 1990. Total visits to alternative medical practitioners exceeded total visits to all U.S. primary care practitioners (Eisenberg et al, 1998). A widening recognition of the mind-body-spirit connection in western medicine has resulted in a growing interest in ancient health practices such as yoga (Herrick, Ainsworth, 2000).
·         Refer client to community agencies for appropriate follow-up care (e.g., day treatment or adult day health program). Increased social support has been related to a reduction in mortality rates and incidences of physical and mental illness (Callaghn, Morrissey, 1993). This study showed a positive response when using a community youth setting, such as the girl scouts, to prevent disordered eating behaviors (Neumark-Sztainer et al, 2000).
·         Obtain or design educational material that is appropriate for the client; use pictures if possible. Verbal reinforcement of personalized written instructions appears to be the best intervention. In one study, the use of computer-generated, personalized instructions improved adherence when compared with the use of handwritten instructions (Hayes, 1998).
·         Ensure that follow-up appointments are scheduled before the client is discharged; discuss a way to ensure that appointments are kept. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences (Bohny, 1997).
·         Assess sensory deficits and psychomotor skills in terms of client's ability to comply with a health program. Barriers to health promotion in people with chronic illness were fatigue, time, safety, and lack of accessible facilities (Stuifbergen, 1997).
·         Discuss "symptoms of daily living" in addition to the major illness. Older adults are unlikely to report day-to-day symptoms such as headaches because they do not view them as illness. However, these day-to-day complaints may foretell more serious problems (Musil, 1988).
·         Recognize resistance to change in lifelong patterns of personal health care. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences (Bohny, 1997).
·         Discuss with client realistic goals for changes in health maintenance. The focus of a chronic illness may be care rather than cure. In this study of 86 people, the oldest old may have increased optimism but decreased satisfaction. They have a sense of realism about the tasks of aging and have a present-focused orientation (Lennings, 2000).
·         Consider the age of the client when suggesting screening for disease. Even assuming that the mortality reduction with screening persists in the elderly, 80% of the benefit is achieved before 80 years of age for colon cancer, before 75 years of age for breast cancer, and before 65 years of age for cervical cancer. The small benefit of screening in the elderly may be outweighed by the harms: anxiety, additional testing, and unnecessary treatment (Rich, Black, 2000).

·         Assess for the influence of cultural beliefs, norms, and values on the client's ability to modify health behavior. What the client considers normal and abnormal health behavior may be based on cultural perceptions (Leininger, 1996).
·         Discuss with the client those aspects of their health behavior/lifestyle that will remain unchanged by their health status. Aspects of the client's life that are meaningful and valuable to him or her should be understood and preserved without change (Leininger, 1996).
·         Negotiate with the client regarding the aspects of health behavior that will need to be modified. Give and take with the client will lead to culturally congruent care (Leininger, 1996).
·         Assess the role of fatalism on the client's ability to modify health behavior Fatalistic perspectives involve the belief in some African-American and Latino populations that you cannot control your own fate and influence health behaviors (Phillips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).
·         Validate the client's feelings regarding the impact of health status on current lifestyle. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995)
Home Care Interventions
·         Provide aids to assist with compliance (e.g., prepare medication schedules and put a week's medication in daily containers).
·         Provide sufficient outside supports (e.g., written notices, calendars, planned ride shares) to assist with follow-through of the agreed-upon actions. Cues play a significant role in stimulating completion of desired health actions.
·         Establish a written contract with client to follow the agreed-upon health care regimen. Written agreements reinforce the verbal agreement and serve as a reference.
·         Meet with client following the proposed actions to review the contract and determine the next course of action. Do this until the client is able to initiate and follow through independently. Successful completion of contracts promotes improved self-esteem and positive coping.
Client/Family Teaching
·         Provide family with lists of addresses for information to be obtained from the Internet. (Most libraries have Internet access with printing capabilities.) Internet-based technologies have emerged as potentially powerful tools to enable meaningful communication and proactive partnership in care for various medical conditions (Patel, 2001). A study of 469 Internet postings of patients with implantable defibrillators showed that they used the Internet for practical information seeking and support in coping (Dickerson, Flaig, Kennedy, 2000).
·         Have client and family demonstrate at least twice any procedures to be done at home. Practice of a procedure exposes problems, enhances skill levels, and promotes confidence in new behaviors.
·         Explain nonthreatening material before introducing more anxiety-producing possible side effects of the disease or medical regimen. An individual's perception of barriers and benefits has consistently been most predictive of subsequent behavior (Fenn, 1998).

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