A MERLIN Site



Nursing Care Plans: Nursing Diagnosis and Intervention, 5/e
Back to 5th edition


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 services.

Related Factors

Defining Characteristics

Expected Outcomes

Ongoing Assessment

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(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 limitations.
(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 successful outcome.
(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 instituted.
(i) Assess patient's ability to perform the desired activity.
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.

Therapeutic Interventions

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(i) Include patient in planning the treatment regimen.
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 usage.
(i) Eliminate unnecessary clinic visits.
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 calls.
(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 eliminated.
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

Actions/Interventions/Rationale
Key:
(i) independent
(c) collaborative
(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 a time.
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.

NIC

Self-Modification Assistance; Teaching: Individual

~ Care Plan Index ~ Outcomes Index ~
~ Care Plan Constructor Home ~