ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Inability to Deficient
understand Knowledge r/t
prescribed informed consent/
treatment lack of exposure or
 Inaccurate recall/ information
performance of misinterpretation/
test unfamiliarity with
 Inaccurate information
follow-through resources/ cognitive
of instruction limitation/ lack of
 Inappropriate or interest in learning
exaggerated
behavior (e.g.
hysterical,
hostile, agitated,
apathetic)
 Reports of
problem
 Request for
information;
statements
reflecting
misconceptions
 Development of
preventable
complication
 Continued use
in spite of
complications/
adverse
consequences
 Neurologic
status, including
level of
consciousness,
thought and
speech, mood
and affect,
judgment,
memory, mental
status, and
orientation
 Educational
level
 Ethnic group
 Religion
 Beliefs, values,
and attitudes
about health and
illness
 Family status,
including
marital status ,
family roles, and
family
communication
patterns
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Abdominal pain Imbalanced

or cramping, Nutrition: Less
with or without Than Body
disease Requirements r/t
 Altered taste insufficient dietary
sensation intake to meet
 Aversion to or metabolic needs/
lack of interest inability to ingest or
in eating digest food/
 Body weight inability to absorb
20% or more nutrients (biological
under ideal or psychological
weight factors)/
 Diarrhea and
steatorrhea
 Excessive hair
loss
 Increased
growth of hair
on body
(lanugo)
 Fragile
capillaries/
bruises easily?
 Hyperactive
bowel sounds
 Inadequate food
intake (less than
recommended
daily
 allowances)
 Lack of
information or
misinformation
about nutrition
 Loss of body
weight despite
adequate food
intake
 Pale
conjunctivae
and mucous
membranes
 Perceived
inability to
ingest food
 Poor muscle
tone
 Satiety
immediately
after eating
 Sore, inflamed
buccal cavity
 Weakness of
muscles
required for
chewing or
swallowing
 Abnormal
laboratory
studies
(decreased
albumin, total
 proteins; iron
deficiency;
electrolyte
imbalance)
 Height: ?
 Weight:?
 Reports of
weight
fluctuations
 Activity or
exercise level
 Body image,
including self-
perception
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

 Perception of health Low Self-Esteem

problem r/t an unexpected
 Family system, change in health
including marital status/ social
status, role in stigma attached to
family, and sibling substance abuse,
position expectation that
 Past experience one controls
with health care behavior/ negative
system role models; abuse
 Dependent on or neglect,
other’s opinions dysfunctional
 Evaluation of self as family system/ life
unable to deal with choices
events perpetuating
 Exaggerates failure; situational
negative feedback crisis with loss of
about self control over life
events/
 Excessively seeks
biochemical body
reassurance
change (e.g.
 Expressions/reports
withdrawal from
of guilt
alcohol or other
 Expressions/reports drugs)/ repeated
of shame negative
 Frequent lack of reinforcement,
success in life and failures/ lack of
events/ relationships affection, approval,
 Hesitant to try new or membership in a
situations group/ perceived
 Indecisive behavior lack of belonging
 or difficulty making or respect from
decisions others/ ineffective
 Lack of eye contact adaption to loss
 Nonassertive
behavior
 Overly conforming
 Passive
 Rejects positive
feedback about self
 Perception of self,
including self-
worth, body image,
coping mechanisms
 Past experience
with crisis
 Past history of
treatment for
psychosocial
disturbance,
including
hospitalization,
medication,
psychotherapy, and
suicidal ideation,
plans, and attempts
 Neurovegetative
signs, including
ability to experience
pleasure, appetite,
energy level, and
sleep
 Behavior
inconsistent with
 values
 Decreased control
over environment
 Evaluation of self as
unable to handle life
events
 Expression of
negative feelings
about self, such as
helplessness and
uselessness
 Expressions of
shame or guilt
 Functional
impairment
 History of abuse
 History of neglect
 Lack of recognition
 Negative self-
appraisal in
response to life
events in a patient
who previously
exhibited positive
self-evaluation