Ineffective Health Maintenance Nursing Care Plan Diagnosis and Interventions
Ineffective Health Maintenance NCLEX Review and Nursing Care Plans
Ineffective Health Maintenance is a NANDA nursing diagnosis that refers to the changes in one’s ability to maintain or manage his or her healthcare requirements, whether they may be physical, mental, social, or spiritual needs. This can be a result of the patient’s lack of ownership of their health or it can be out of their control, such as cognitive impairment.
A number of factors can be linked to ineffective health maintenance, which may include changes in physical health status such as having a lifelong illness or a debilitating disorder. A person’s mental health status can also be suspected to affect health maintenance, such as depression, confusion, hopelessness, and helplessness.
In addition to these, changes in social health status such as lack of family and/or friends, and spiritual health status such as spiritual distress may contribute to this.
As these cases are mostly cognitive and psychosocial in nature, the nurse can help the patients in presenting information and resources, support and empowerment in making a plan and setting goals, however, the patients play a significant active role in the maintenance and improvement of their health status.
People from older age groups are mostly vulnerable to experience ineffective health maintenance and are especially at risk for management of the therapeutic plan.
Causes And Related Factors of Ineffective Health Maintenance
The causes and related factors of ineffective health maintenance include:
- Developmental delay (complete or partial lack of fine or gross motor skills to perform tasks)
- Cognitive or Mental health impairment
- Depression
- Deficient knowledge
- Lack of social support and Complicated family dynamics
- Insufficient finances
- Lack of access to resources
- Poor choices in one’s lifestyle (e.g., smoking, poor diet, sedentary lifestyle, or substance abuse)
- Deteriorating health status (e.g., cancer and osteoporosis)
- Life crisis (e.g., Unemployment)
- Ineffective coping
- Lack of motivation
Signs And Symptoms of Ineffective Health Maintenance
Signs and symptoms of Ineffective Health Maintenance comprise of subjective and objective data. Subjective data are those that the patient reports, while objective data are those that the nurse assesses.
Subjective data:
- Verbalization of a lack of interest or motivation in improving personal health
- Verbalization of a lack of knowledge about health maintenance
- significant others’ verbal report of the patient’s ineffective health maintenance
Objective data:
- Worsening of health status
- History of poor health-seeking behaviors
- Low mood or appearance of being depressed
- Disheveled look
- Difficulty in making decisions
- Physical impairment causing difficulty in performing activities related to health maintenance
- Lack of support system
Ineffective Health Maintenance Nursing Diagnosis
Ineffective Health Maintenance Nursing Care Plan 1
Nursing Diagnosis: Risk for Ineffective Health Maintenance secondary to Pressure Ulcer related to the need for long term pressure ulcer management
Desired Outcome: The patient and the caregiver will demonstrate understanding of the following aspects of care related to pressure ulcer management: relief of pressure, wound care, nutrition, and incontinence management.
| Ineffective Health Maintenance Nursing Interventions | Rationale |
| Assess the patient and the home caregiver’s knowledge of and ability to provide local wound care. | The patient may need to have long-term care after being discharged from the hospital, therefore the need for local wound care may continue at home for weeks to months. Assessing the caregiver and the patient’s knowledge will provide baseline information on how to educate the patient and the caregiver in managing pressure ulcer wounds. |
| Assess the patient and the caregiver’s understanding of and ability to provide a high-calorie, high-protein diet throughout the course of healing. | Nutrition is a vital part of the wound healing process. Assessment of the patient and caregiver’s knowledge on diet and nutrition will provide a better meal plan for the patient, thus, promoting fast recovery and healing from pressure ulcers. |
| Teach the client and the caregiver to observe: report the signs of wound infection: fever or high temperature, general malaise, malaise, chills, foul-smelling odor, purulent drainage. | Early detection of the signs and symptoms of an impending infection would prompt immediate intervention to avoid complications and further tissue injury. |
| Educate the patient and the caregiver on the importance of pressure reduction and relief (e.g., turning schedule, use of specialty beds, use of relief surface where the client sits). | Providing information to the caregiver and the patient will enhance adherence to pressure ulcer treatment guidelines. Proper education of Interventions will promote relief and will help in fast wound recovery. |
| Educate the patient and the caregiver regarding local wound care, and allow for a return demonstration. | The teach-back method is the most effective way to measure the patient and caregiver’s knowledge, thus enhancing retention. Immediate feedback allows the learner to make corrections in real-time. |
Ineffective Health Maintenance Nursing Care Plan 2
Terminal or End-stage Cancer
Nursing Diagnosis: Risk for Ineffective Health Maintenance related to anxiety secondary to terminal cancer.
Desired Outcome: The patient will demonstrate the ability to cope adequately with the existing condition and adopt lifestyle changes to support health goals.
| Ineffective Health Maintenance Nursing Interventions | Rationale |
| Discuss with the patient any anxiety towards his or her condition. Offer available help to control anxiety levels. | It is important to recognize the patient’s anxiety level in relation to the condition as this may determine the reason behind ineffective health maintenance. Initiating intervention would be effective since the patient will cooperate in the plan of care if the anxiety levels are understood and addressed. |
| Communicate with the patient using easy-to-understand words and b brief statements Avoid using medical jargon, or explain what the medical term/s mean. | Simplifying the patient’s treatment plan and instruction using easy-to-understand words and brief statements s would yield increase adherence to the therapy regimen especially when the patient is experiencing moderate to severe anxiety. |
| Incorporate the patient in their health goals and recognize the patient for achieving goals. | Involving the patient in planning self-care will enhance independence and improve self-awareness. Compliments and achievements raise motivation and reinforce that the actions taken are appropriate thus, reducing anxiety. |
| Introduce anxiety-reducing skills to the patient and demonstrate as needed (e.g., relaxation, deep breathing, positive visualization, and reassuring self-statements). | Stress management with the patient having a terminal illness such as end-stage cancer may be difficult. Helping the patient discover new coping methods provides the patient with a variety of ways to manage anxiety. |
| Discuss with the patient all the parts of his or her treatment plan and procedures by utilizing non-medical terms, as well as a calm tone of voice and slow speech. Verify the patient’s understanding by asking questions. | Providing clear explanations in a non-threatening way may motivate the patient to adhere to activities that promote health. Mirroring the patient’s pace and validating knowledge of the procedure decreases anxiety. |
Ineffective Health Maintenance Nursing Care Plan 3
Nursing Diagnosis: Risk for Ineffective Health Maintenance secondary to Diabetes Mellitus related to a lack of knowledge about diabetes and its management as evidenced by inadequate follow-through of instructions.
Desired Outcomes:
- The patient will demonstrate knowledge of the diabetes disease process and potential complications.
- The patient will successfully demonstrate correct diabetes self-care measures.
| Ineffective Health Maintenance Nursing Interventions | Rationale |
| Assess and ensure the patient’s knowledge about the symptoms, causes, treatment, and prevention of hyperglycemia. | Understanding the patient’s complexities and difficulties of the disease process is significant. It serves as a starting point of intervention and diabetes management. |
| Evaluate the patient’s self-management skills, including performing procedures for blood glucose monitoring. | Assessing self-management skills determine the amount and type of education and health promotion that needs to be provided. It is important to re-assess the patient’s competency in terms of diabetes self-care and health-seeking behaviors to prevent complications. Directly observing the patients and asking open-ended questions as to why a certain step in his/her diabetes care is done is a good way to validate knowledge and skills. |
| Observe for the presence of neuropathic conditions related to diabetes, such as retinopathy and/or neuropathy. | Diabetic patients have a greater risk of getting disability as well as neuropathic conditions. For example, patients with retinopathy may have impaired vision thus, impairing the ability to prepare and administer insulin accurately. Patients with neuropathy may have limited mobility and the loss of fine motor control can interfere with the skills needed for insulin administration and blood glucose monitoring. Additionally, limited joint mobility or preexisting disability may impair the patient’s ability to inspect the bottom of the feet during foot care. |
| Use layman’s terms in explaining the treatment regimen for diabetes. Simplify instructions for self-care. | Diabetic management is a complex therapeutic intervention and sometimes it can be overwhelming and may be difficult to follow for some patients, thus, layman’s term might help for better understanding of procedure and regimens. |
| Provide positive reinforcement of changed self-care behaviors. | The provision of positive reinforcement may help motivate the patient to continue the treatment regimen and develop health-seeking behaviors towards optimal health maintenance. |
Ineffective Health Maintenance Nursing Care Plan 4
Nursing Diagnosis: Ineffective Health Maintenance related to substance abuse due to previous ineffective and inadequate coping skills as evidenced by verbalization of inability to cope for health.
Desired Outcomes:
- The patient will identify ineffective coping behaviors.
- The patient will demonstrate effective problem-solving skills.
- The patient will initiate necessary lifestyle changes, including participation in treatment program plan for follow-up and long-term care.
| Ineffective Health Maintenance Nursing Interventions | Rationale |
| Determine the patient’s understanding of the current situation and discuss previous methods of coping with life’s problems. | Discussing the methods of coping applicable to the patient can help him/her achieve effective health maintenance. The patient’s commitment to change and degree of denial or acceptance may help in identifying coping skills that may be applied in the patient’s current situation. |
| Encourage verbalization of feelings, fears, and anxiety in a safe and non-threatening environment. | It is important to establish the trust of the patient first before intervening in the current situation by providing a non-judgmental and non-threatening environment. The patient may begin to talk about long-unresolved issues freely without fear of judgment from the caregiver. |
| Teach the patient on how to do relaxation techniques, such as guided imagery and deep breathing exercises. | Effective coping mechanisms significantly help to deal with life crises and stress, thus, resorting to substance abuse may be prevented. Guided imagery and visualization promote relaxation and develop new ways to deal with stress and problem-solving. |
| Discuss with the patient his or her preferred diversional activities that may help towards recovery, such as playing favorite sports or starting a new hobby. | Diversional activities can remind the patient that recovery from addiction is a lifelong process and opportunity for changing patterns is available. Creating a comprehensive recovery strategy with an aim to avoid relapses helps the patient into the maintenance phase of changing behaviors away from a life of addiction and towards optimal health. |
| Encourage involvement with self-help associations (Alcoholics, Anonymous, Narcotics Anonymous) and discuss programs that are available for assistance and referral. | Long-term support is necessary to maintain optimal recovery and manage sobriety and drug-free life. Providing a list of organizations gives a great support system for the patient in managing substance abuse. |
Ineffective Health Maintenance Nursing Care Plan 5
Nursing Diagnosis: Ineffective Health Maintenance related to poor nutrition and unhealthy lifestyle secondary to hypertension as evidenced by destructive behavior toward self; overeating, lack of appetite; excessive smoking/drinking, proneness to alcohol abuse.
Desired Outcome: The patient will avoid self-destructing behaviors and identify proper diet and nutrition to improve blood pressure and overall health.
| Ineffective Health Maintenance Nursing Interventions | Rationale |
| Talk to the patient about changing modifiable risk factors such as obesity and excessive alcohol intake. | By assisting the patient to identify factors that have been shown to contribute to hypertension and cardiovascular and renal diseases, the patient will have a better understanding of foods and practices that may increase health problems in the future. |
| Discuss with the patient a common diet plan for hypertensive patients known as DASH (Dietary Approaches to Stop Hypertension) diet. Create a meal plan that involves fruits, vegetables, and low-fat dairy foods and avoids foods high in saturated fat (such as cheese, red meat, butter, and ice cream) and bad cholesterol (shrimp, organ meats, and egg yolks). | Proper instruction on food selections can greatly affect the overall health of the patient. DASH diet may help in reconsidering the need for drug therapy. |
| Discuss with patient and caregiver the important points of hypertension such as what it is and how it can affect vital organs such as the heart, blood vessels, brain, and kidneys. Explain the normal values of blood pressure level and what is considered hypertensive episode. | Health education will help the patient attain realistic goals to prevent hypertension and correlate experienced symptoms from the condition. Baseline blood pressure should be explained and understood to help the patient seek help when needed and promotes treatment compliance on drug therapy. |
| Discuss appropriate lifestyle changes to help reduce modifiable risk factors. (e.g., smoking cessation and adopting an exercise regimen). | Involving the patient to plan of care is vital in resolving the health problem. Helping the patient identify causative factors of hypertension would lead to resolution. |
| Encourage the patient to establish an individual exercise program incorporating aerobic exercise (such as walking and swimming) within the patient’s capabilities. | Aerobic exercises aid in strengthening the cardiovascular system, thus, helping to lower blood pressure. Ensure that the exercises are within the patient’s capabilities to prevent exhaustion or fatigue which may result to increase heart rate and hypertension. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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