Ineffective Management of Therapeutic Regimen: Individual
Meg Gulanick, RN, PhD
NANDA: A pattern of regulating and integrating into daily living
a program for treatment of illness and the sequelae of illness that is
unsatisfactory for meeting specific health goals
With the ongoing changes in health care, patients are being
expected to be co-managers of their care. They are being discharged from
hospitals earlier, and faced with increasing complex therapeutic regimens to be
handled in the home environment. Likewise, patients with chronic illness often
have limited access to health care providers and are expected to assume
responsibility for managing the nuances of their disease (e.g., heart failure
patients taking an extra furosemide (Lasix) tablet for a 2-lb weight gain).
Patients with sensory-perception deficits, altered cognition,
financial limitations, and lacking support systems may find themselves
overwhelmed and unable to follow the treatment plan. Elderly patients, who
often experience most of the above problems, are especially at high risk for
ineffective management of the therapeutic plan. Other vulnerable populations
include patients living in adverse social conditions (poverty, unemployment,
little education), patients with emotional problems, such as depression over
the illness being treated or other life crises or problems, or patients with
substance abuse problems. Culture, ethnicity, and religion may influence one's
health beliefs, health practices (folk medicine, alternative therapies) access
to health services, and assertiveness in pursuing specific health care
- Complexity of health care
- Complexity of therapeutic regimen
- Decisional conflicts
- Economic difficulties
- Excessive demands made on individual or family
- Family conflict
- Family patterns of health care
- Inadequate number and types of cues to action
- Knowledge deficit of prescribed regimen
- Perceived seriousness
- Perceived susceptibility
- Perceived barriers
- Social support deficits
- Perceived powerlessness
- Choices of daily living ineffective for meeting the goals of
treatment or prescription program
- Increased illness
- Verbalized desire to manage illness
- Verbalized difficulty with prescribed regimen
- Verbalization by patient that he or she did not follow
- Patient describes intention to follow prescribed regimen.
- Patient describes or demonstrates required competencies.
- Patient identifies appropriate resources.
- (i) independent
- (i) Assess prior efforts to follow regimen.
- (i) Assess for related factors that may
negatively affect success with following regimen.
- Knowledge of causative factors provides direction for
subsequent intervention. This may range from financial constraints to physical
- (i) Assess patient's individual perceptions
of their health problems.
- According to the Health Belief Model, patient's perceived
susceptibility to and perceived seriousness and threat of disease affect his or
her compliance with the program. In addition, factors such as cultural
phenomena and heritage can affect how people view their health.
- (i) Assess patient's confidence in his or her
ability to perform desired behavior.
- According to the self-efficacy theory, positive conviction
that one can successfully execute a behavior is correlated with performance and
- (i) Assess patient's ability to learn or
remember the desired health-related activity.
- Cognitive impairments need to be identified so an
appropriate alternative plan can be devised. For example, the Mini-Mental
Status Examination can be used to identify memory problems that could interfere
with accurate pill taking. Once identified, alternative actions such as using
egg cartons to dispense meds, or daily phone reminders can be
- (i) Assess patient's ability to perform the
- Patients with limited financial resources may be unable to
purchase special diet foods, such as low fat or low salt. Patients with
arthritis may be unable to open child-proof pill containers.
- (i) independent
- (i) Include patient in planning the treatment
- Patients who become co-managers of their care have a
greater stake in achieving a positive outcome. They know best their personal
and environmental barriers to success.
- (i) Tailor the therapy to patient's lifestyle
(e.g., taking diuretics at dinner if working during the day).
- (i) Inform patient of the benefits of
adherence to prescribed regimen.
- Increased knowledge fosters compliance.
- (i) Simplify the regimen. Suggest long-acting
forms of medications and eliminate unnecessary medication.
- The more often patients have to take medications during the
day, the greater the risk of not following through. Polypharmacy is a
significant problem with the elderly. Attempt to reduce nonessential drug
- (i) Eliminate unnecessary
- The physical demands of traveling to an appointment, the
financial costs incurred (loss of day's work, child care), the negative
feelings of being "talked down to" by health care providers not fluent in
patient's language, as well as the frequently long waits can cause patients to
avoid follow-ups when they are required. Telephone follow-up
may be substituted as appropriate.
- (i) Develop a system for patient to monitor
his or her own progress.
- (i) Develop with patient a system of rewards
that follow successful follow-through.
- Rewards may consist of verbal praise, monetary rewards,
special privileges (earlier office appointment, free parking), or telephone
- (i) Concentrate on the behaviors that will
make the greatest contribution to the therapeutic effect.
- (i) If negative side effects of prescribed
treatment are a problem, explain that many side effects can be controlled or
- Nonadherence because of medication side effects is a
frequently reported problem. Health care providers need to determine actual
etiologic factors for side effects, and possible interplay with
over-the-counter medications. Patients likewise report fatigue or muscle cramps
with exercise. The exercise prescription may need to be revised.
- (i) If patient lacks adequate support in
following prescribed treatment plan, initiate referral to a support group
(e.g., American Association of Retired Persons [AARP], American Diabetes
Association, Senior's groups, weight loss programs, Y Me, smoking cessation
clinics, stress management classes, social services).
- Groups that come together for mutual support and
information can be beneficial.
Education/Continuity of Care
- (i) independent
- (i) Use a variety of teaching methods.
- Different people learn in different ways. Match the
learning style with the educational approach. For some patients this may
require grocery shopping for "healthy foods" with a dietitian, or a home visit
by the nurse to review a psychomotor skill.
- (i) Introduce complicated therapy one step at
- Allows learner to concentrate more completely on one topic
at a time.
- (i) Instruct patient on the importance of
reordering medications 2 to 3 days before running out.
- Although many cultures in the United States are
future-oriented and are concerned with measures to prevent illness, other
cultures are more oriented to the present. This difference in time orientation
may need to be addressed.
- (i) Include significant others in
explanations and teaching.
- To encourage their support and assistance in following
plans. This may enhance overall adaptation to the program.
- (i) Allow learner to practice new skills;
provide immediate feedback on performance.
- This allows patient to use new information immediately,
thus enhancing retention. Immediate feedback allows learner to make corrections
rather than practice the skill incorrectly.
- (i) Role-play scenarios when nonadherence to
plan may easily occur. Demonstrate appropriate behaviors.
- Relapse prevention needs to be addressed early in the
treatment plan. Helping patient expand his or her repertoire of responses to
difficult situations assists in meeting treatment goals.
Self-Modification Assistance; Teaching: Individual
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