N2529 Noncompliance – Flashcards

• Noncompliance o The state in which an individual who has expressed the desire and intent to adhere to a therapeutic recommendation does not adhere to the recommendation.

• Defining Characteristics of Noncompliance: o (MUST be present) verbalization of desire to comply, but difficulty with compliance or confusion about therapy o observations of noncompliant behaviors o missed appointments o partially unused meds o occurrence of undesired outcomes pregnancy obesity regression during rehab o persistence of symptoms o exacerbation of symptoms

• Compliance with any therapeutic regimen depends on various factors, including desire/motivation, perception of vulnerability, and beliefs about controlling illness, environment, quality of health instruction, cost and accessibility.

• Therapeutic Regimen: o set of rules or habits of diet, exercise, and manner of living, intended to improve or maintain health and/or treat/cure disease; o activities or habits of medication therapy, treatments, diet, exercise, stress management, problem solving, symptom management, or other strategies that improve health and well-being

• NON-COMPLIANCE o No amount of choices or altering can fix this. o Can I choose to do something differently? o NANDA: behavior that fails to coincide with a health-promoting or therapeutic plan agreed on by the person and the health care professional. In the presence of an agreed-on, health-promoting or therapeutic plan, the person's behavior is fully or partially non-adherent and may lead to clinically ineffective or only partially effective outcomes.

• NON-COMPLIANCE o Carpenito: the state in which an individual desires to comply, but factors are present that deter adherence to agreed-upon health-related advice given by health professionals.

• NON-COMPLIANCE o McFarland: the state in which an individual who has expressed the desire and intent to adhere to therapeutic recommendations does not [BH,RN: or cannot] adhere to the recommendations.

• NON-COMPLIANCE o PATIENT: desires to comply, but factors prevent from,in or terfere with, doing so.

• NON-COMPLIANCE o NURSE: reduce/eliminate these factors Therefore, the patient's intentions and abilities must be assessed before this diagnosis is made.

o Conclusion: A patient-centered approach involves transferring power and authority away from health care professionals and towards patients. We encourage nurses to take a leadership role by changing the way in which health care is delivered towards a focus on patients' lives. Learning about patients' lives may assist nurses to offer health.

Related Factors for Noncompliance: • impaired ability to perform tasks (sensory, cognitive/memory, mobility) o can't see insulin syringe measurement lines o can't open pill bottle or use equipment properly o can't remember the time, can't get out of bed/chair • cost/financial (can't afford meds, can't afford supplies, can't afford fresh fruit/healthy foods) • complex/unsupervised/prolonged therapy • lack of child care • lack of knowledge or understanding • transportation o can't get to the store to purchase fresh food o can't get to therapy (weather, fatigue, side effects [n/v, fatigue, decreased appetite]) • spiritual values

• Subjective Component in Noncompliant Behavior: o (MUST be present) verbalization of desire to comply, but difficulty with compliance or confusion about therapy

• Nurses and 'difficult' patients: negotiating non-compliance o There is a large body of nursing literature on patient non-compliance. o While some articles address non-compliance as a patient problem to be resolved by nursing interventions, there is also a growing number that critique this approach. o This reflects the discomfort many nurses feel about the practice of labeling patients as non-compliant. o The aim is to encourage nurses to learn about how health care treatments affect patients' lives, and not merely their health.

• Noncompliance- not able to change to be compliant • Informed decision not to adhere to health related advising- just choosing not to follow the therapeutic regimen.

INEFFECTIVE MANAGEMENT (of Therapeutic Regimen) (Ineffective Self Health Management) Can make changes to be compliant. NANDA: pattern of regulating and integrating into daily living a [program or] therapeutic regimen for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals

INEFFECTIVE MANAGEMENT (of Therapeutic Regimen) (Ineffective Self Health Management) Carpenito: a pattern in which the individual experiences difficulty integrating into daily living a program for treatment of illness and the sequelae of illness and a reduction of risk situations

INEFFECTIVE MANAGEMENT (of Therapeutic Regimen) (Ineffective Self Health Management) McFarland states the following: The concept of Management of Therapeutic Regimen was developed as an alternative to the concept of compliance and adherence. Ineffective MTR can be used for many situations for which the nurse would use Noncompliance. The difference, however, is that the emphasis of non-compliance is on the prescribed regimen as recommended by the health care provider and the factors preventing the patient from complying. IMTR, however, focuses on difficulty the patient experiences integrating illness treatment or prevention into activities of daily living, thus requiring ongoing interaction between the patient and the nurse. Describes when an individual is experiencing difficulty in achieving a positive outcome

INEFFECTIVE MANAGEMENT (of Therapeutic Regimen) (Ineffective Self Health Management) Examples: timing of FSBS ac meals, but no regular meal times culture/social conflicts (teens eating with friends) peer/family conflicts "want to take meds but I can't because I'm too tired"- move to a more convenient time (lunch).

Wants to be a compliant diabetic but is unable to read the units on the syringe because they have bad eyes.

Defining Characteristics: • verbalizes the desire to, but difficulty with, managing prescribed regimens • choices of daily living are inappropriate for meeting the goals of treatment or prevention • acceleration or continuation of illness symptoms • failure to include treatment regimen in daily living • **failure to take action to reduce risk factors** (goes with choices)

Related Factors: • complexity of health care system • complexity of therapeutic regimen • decisional conflicts • economic difficulties • knowledge deficit • family conflict • conflicting health values • fears about treatment or side effects • powerlessness • perceived lack of benefit

EO: will describe (diet/fluid intake/exercise pattern/med schedule) that meets therapeutic goals will verbalize ability to manage therapeutic regimen will collaborate with health providers to decide on therapeutic regimen congruent with health goals and lifestyle will demonstrate required competency

Interventions: the primary intervention is to explore available options and educate patient as to how to implement the chosen option(s) establish a collaborative partnership, build trust, avoid pressuring; LISTEN! determine patient's understanding of health problem listen to patient's story of illness self-management review current therapy/side effects/obstacles; address collaborate with patient to set goals consider a contract self-monitoring: charts, journal help patient enhance confidence in own ability to manage illness use various formats to provide education/information about therapeutic regimen provide referral info re: support systems assist with organization make a plan encourage contract/commitment rearrange/set priorities

IMPAIRED ADJUSTMENT (RISK-PRONE HEALTH BEHAVIOR) No interest in wanting to change- "I've never taken meds in the past and I won't start now!" Need an attitude adjustment Ackley: Impaired ability to modify lifestyle/behaviors in a manner that improves health status

IMPAIRED ADJUSTMENT (RISK-PRONE HEALTH BEHAVIOR) McFarland; Carpenito: state in which an individual is unable[BH,RN: or unwilling] to modify lifestyle/behavior [in a manner] consistent with a change in health status

IMPAIRED ADJUSTMENT (RISK-PRONE HEALTH BEHAVIOR) PPT: verbalization of non-acceptance of health change, inability to be involved in problem solving chooses not to adhere, or factors interfere with adjustment to change (hopeless-, powerlessness)

Defining Characteristics: • verbalization or demonstration of non-acceptance of health status change • inability to be involved in problem-solving or goal-setting • minimizes health status change • lack of movement toward independence • lack of future-oriented thinking • failure to take action to prevent further health problems • failure to achieve optimum sense of control • extended period of shock, disbelief, or anger concerning health status change • nonexistent or unsuccessful involvement in problem solving or goal setting • lack of progress toward independence

Related Factors: disability requiring changes in lifestyle lack of motivation impaired cognition altered focus of control incomplete grieving excessive ETOH use smoking negative attitude toward health care

EO: will verbalize reality and acceptance of condition will verbalize awareness of changes in health status and their effects on lifestyle will take an active role in identifying realistic goals and means to achieve these goals will use strategies that will assist in coping with limitation or loss will request assistance in altering behaviors to adapt to change will report/demonstrate behavior changes mutually agreed upon with nurse as evidence of positive adaptation will state experience of a period of grief that is proportional to the actual or perceived effect of the loss will state personal goals for dealing with change in health status and/or means to prevent further health problems

Interventions: Always collaborate! encourage to describe perceived changes in health or feelings about changes, especially about the limitation or loss support patient in goal formulation and problem solving focus on ways patient can exhibit more independence, less dependence assess patient's definitions of health and wellness and major barriers to such use open-ended questions to allow patient free expression (e.g., tell me about your last hospitalization, how does this time compare) help patient work through the stages of grief; know denial is usually the initial response and may be an adaptive coping mechanism; acknowledge that grief takes time, give patient permission to grieve; accept crying discuss patient's current goals; have patient list goals so as to be referred to, and steps to be taken to accomplish them; support hope that the goals will be accomplished allow patient choices in daily care that result from the change in health status promote positive spiritual influences refer to community resources

• Non-Compliance: o has a plan o is trying o but is hindered by factors o not a matter of choice

• Ineffective Management of Therapeutic Regimen: o trying but having difficulty o could, but needs to try harder o a matter of choice as to how hard to try

• Impaired Adjustment: o needs an attitude adjustment o won't o denies

• Knowledge Deficit: o An individual's lack of information or inability to state or explain information or demonstrate a required skill related to disease management procedures. o It is also the inability to explain or use self-care practices recommended to restore health or maintain wellness. o It may appear as a cognitive or psychomotor deficit or a combination of the two.

• Interrelated Nursing Diagnoses: o Anxiety r/t noncompliance o Noncompliance r/t noncompliance

• Expected Outcomes for Noncompliance: o will report compliance without difficulty o the expected/hoped for result/outcome will be noted

• Interventions: o use open ended questions o initiate trust/partnership o determine patient's perceptions/understanding o determine/assess issues interfering with regimen o assess religious beliefs/practices that affect health o provide appropriate supervision/monitoring/assistance o address negative side effects o provide information/education o make referrals o provide specific "thing" lacking

• noncompliant diabetic adolescent who eats inappropriate foods (denial). o Impaired Adjustment AEB: Verbalization of not following regimen Not participating in goal setting Lack of future oriented thinking

• noncompliant diabetic adolescent who eats inappropriate foods (denial). o Impaired Adjustment EO's: Patient will verbalize reality and acceptance of condition Patient will take an active role in identifying realistic goals and means to achieve these goals Patient will request assistance in altering behaviors to adapt to change

• noncompliant diabetic adolescent who eats inappropriate foods (denial). o Impaired Adjustment Interventions: encourage to describe perceived changes in health or feelings about changes, especially about the limitation or loss support patient in goal formulation and problem solving focus on ways patient can exhibit more independence, less dependence use open-ended questions to allow patient free expression (e.g., tell me about your last hospitalization, how does this time compare) help patient work through the stages of grief; know denial is usually the initial response and may be an adaptive coping mechanism; acknowledge that grief takes time, give patient permission to grieve; accept crying discuss patient's current goals; have patient list goals so as to be referred to, and steps to be taken to accomplish them; support hope that the goals will be accomplished allow patient choices in daily care that result from the change in health status promote positive spiritual influences refer to community resources/support group

• noncompliant adult who saves medication instead of completing the prescription (misunderstanding or knowledge deficit). o Noncompliance R/T Knowledge Deficit AEB: Patient verbalization of desire to comply, but difficulty with compliance or confusion about therapy observations of noncompliant behaviors persistence of symptoms

• noncompliant adult who saves medication instead of completing the prescription (misunderstanding or knowledge deficit). o Noncompliance R/T Knowledge Deficit EO: Patient will report compliance without difficulty The expected outcome will be noted The patient will understand the benefits of the therapeutic regimen

• noncompliant adult who saves medication instead of completing the prescription (misunderstanding or knowledge deficit). o Noncompliance R/T Knowledge Deficit Interventions: use open ended questions initiate trust/partnership determine patient's perceptions/understanding determine/assess issues interfering with regimen assess religious beliefs/practices that affect health provide appropriate supervision/monitoring/assistance address negative side effects of not complying with diet provide information/education on diabetic diet and medications make referrals to support group

• noncompliant older adult who only takes BP medicine when she "thinks" she needs it (negative effects of therapy). o Ineffective Management of Therapeutic Regimen AEB: verbalizes the desire to, but difficulty with, managing prescribed regimens acceleration or continuation of illness symptoms failure to include treatment regimen in daily living

• noncompliant older adult who only takes BP medicine when she "thinks" she needs it (negative effects of therapy). o Ineffective Management of Therapeutic Regimen EO: Patient will describe schedule that meets therapeutic goals Patient will verbalize ability to manage therapeutic regimen Patient will collaborate with health providers to decide on therapeutic regimen congruent with health goals and lifestyle

• noncompliant older adult who only takes BP medicine when she "thinks" she needs it (negative effects of therapy). o Ineffective Management of Therapeutic Regimen Interventions: establish a collaborative partnership, build trust, avoid pressuring active LISTENING determine patient's understanding of health problem listen to patient's story of illness self-management review current therapy/side effects/obstacles; address self-monitoring: charts, journal help patient enhance confidence in own ability to manage illness use various formats to provide education/information about therapeutic regimen assist with organization (pill organizer) make a plan encourage contract/commitment rearrange/set priorities