N2529 Noncompliance

Define Noncompliance
• 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:
• 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
• 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
• 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
NANDA Noncompliance
• 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.
Carpenito Non-Compliance
• 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.
McFarland Non-Compliance
• 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.
Patient in Non-Compliance
• NON-COMPLIANCE
o PATIENT:
desires to comply, but factors prevent from,in or terfere with, doing so.
Nurse in Non-Compliance
• NON-COMPLIANCE
o NURSE:
reduce/eliminate these factors
Therefore, the patient’s intentions and abilities must be assessed before this diagnosis is made.
Conclusion
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
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:
• 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
• 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.
Difference between Informed Decision and Noncompliance
• 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.
NANDA Ineffective Management of 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
Carpenito Ineffective Management of Therapeutic Regimen
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
McFarland Ineffective Management of Therapeutic Regimen
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 Examples
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).
Noncompliance Example
Wants to be a compliant diabetic but is unable to read the units on the syringe because they have bad eyes.
Defining Characteristics of Ineffective Management of Therapeutic Regimen
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 for Ineffective Management of Therapeutic Regimen
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
Ineffective Management of Therapeutic Regimen EO
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 for Ineffective Management of Therapeutic Regimen
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 Ackley
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 McFarland; Carpenito
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
PPT Impaired Adjustment
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 for Impaired Adjustment
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 for Impaired Adjustment
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’s for Impaired Adjustment
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 for Impaired Adjustment
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
Noncompliance is…
• 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 is…
• 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 is…
• Impaired Adjustment:
o needs an attitude adjustment
o won’t
o denies
Knowledge Deficit is…
• 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
• Interrelated Nursing Diagnoses:
o Anxiety r/t noncompliance
o Noncompliance r/t noncompliance
Expected Outcomes for Noncompliance
• Expected Outcomes for Noncompliance:
o will report compliance without difficulty
o the expected/hoped for result/outcome will be noted
Interventions for Noncompliance
• 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).
Nursing Diagnosis
• 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:
• 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:
• 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).
Nursing Diagnosis
• 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:
• 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:
• 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).
Nursing Diagnosis
• 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:
• 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:
• 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