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Subjective:
Client indicated “I want to learn how to take care of
this heart.” “I want to take care of
myself at home.”
Objective:
-client was utilizing incentive spirometer
without prompting
-client expressed desire to manage
treatment
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Problem: Readiness for enhanced therapeutic regimen management
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Long Term:
Client will demonstrate continued commitment to integration
of therapeutic regimen into daily living.
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-Identify contributing factors
that may need to improve in future.
Health promotion and protection are complex behaviors that are difficult to implement
on a daily basis (Pender et. al, 2006) by [date], 13:00.
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*
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Client was unable to identify factors that might need improvement in the future. Goal not achieved.
Continued education required. Evaluation scheduled for [date],
13:00.
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Continued evaluation of this intervention is set for 13:00, [date]. Intervention
unsuccessful to date. Further evaluation
required.
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R/T:
Treatment regimen post cardiac transplant
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Short Term:
Client will describe integration
of therapeutic regimen into daily living by [date], 10:00.
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-Assess client’s current level of knowledge and current
home routines.
-Support all efforts to self-manage therapeutic regimens. Ongoing support and assistance from healthcare
professionals is needed to identify and enhance factors that contribute to the likelihood
of taking action for health promotion (Pender, et.al, 2006).
-Seek teachable moments to encourage health promotion. The provision of information should not
be restricted to just treatment information but also any information that prepares
the client to manage health-related issues (Timmons, et. al 2006).
-Teach client their medication schedule, go over a check-off
sheet for daily meds, how to say the names of the medications and what they are
for.
-Teach client the importance of nutrition for maintaining
health, how to guard against common community acquired infections, appropriate handwashing
techniques and timing. Education programs
based on empowerment, client participation, and adult learning principles have demonstrated
effectiveness (Kennedy, et. al, 2003).
-Teach the importance of the yearly flu vaccine
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*
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Client identified some lifestyle
changes needed to ensure protection at 10:15 on March 25, 2008.
Client also identified his medications, what they were for, and the times
of the day to take them at 10:20 on [date].
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Interventions were successful,
goal achieved on [date], .
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