Functional Assessment:
Readiness for Enhanced Self Health Management (pgs 146, 694-695)
NANDA-I Definition: A pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and its sequalae that is sufficient for meeting health-related goals and can be strengthened.
Defining Characteristics:
- choices of daily living are appropriate for meeting goals
- describes reduction of risk factors
- expresses desire to manage illness
- expresses little difficulty with prescribed regimens
- no unexpected acceleration of illness symptoms
Client Outcomes- Client Wil:
- describe integration of therapeutic regimen into daily living
- demonstrate continued commitment to integration of therapeutic regimen into daily living routines
Nursing Interventions:
- acknowledge expertise of client and family
- review factors that contribute to the success of self care
- support all efforts to self manage therapies
- collaborate with client to identify strategies to maintain strengths and achieve success
- identify factors that may need to be improved
- educate
- help client maintain and/or seek support
- help client obtain health insurance and drug payment pans if necessary
Risk For Falls (353-359)
NANDA-I Definition: Increased susceptibility to falling that may cause physical harm
Risk Factors:
- Adults:
- age 65 or older
- history of falls
- fear of falling
- living alone
- lower limb prosthesis
- use of assistive devices (walker, cane)
- wheelchair use
- Children:
- less than 2 years of age
- bed located near window
- lack of automobile restraints
- lack of gate on stairs
- lack of window guard
- lack of parental supervision
- male gender when less than 1 year of age
- unattended infant on elevated surface
- Cognitive:
- diminished mental status
- Environment
- cluttered environment
- dimply lit room
- no anti-slip material in bath or shower
- restraints
- throw rugs
- unfamiliar room
- weather conditions
- Medications:
- Angiotensin- Converting Enzyme (ACE) inhibitors
- alcohol use
- anti-anxiety agents
- antihypertensive agents
- diuretics
- hypnotics
- narcotics/opiates
- tranquilizers
- tricyclic antidepressants
- Physiological:
- anemias
- arthritis
- diarrhea
- decreased lower extremity strength
- difficulty with gait
- foot problems
- hearing difficulties
- impaired balance
- incontinence
- neoplasms
- neuropathy
- orthostatic hypotension
- post-op
- postprandial blood sugar changes
- acute illness
- proprioceptive deficits
- vascular disease
- visual difficulties
Nursing Interventions:
- complete a fall-risk assessment for older patients (Henrich II model)
- screen pts for balance and mobility skills
- when sitting up dangle legs before standing to prevent orthostatic hypotension
- use "high-risk fall: arm band to alert staff
- evaluate meds
- place call light within reach and answer promptly
- lock wheels
- keep dim light in room at night
- assist with toiling promptly and keep path to bathroom clear
- avoid restraints
- be aware of acute change in mental status or chronic confusion
- place pt in room close to RN station
- refer to PT to improve strength, balance, flexibility, or insurance
