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Self -Management Support: Nurse Self Assessment Cheat Sheet by

Nurse’s Guide to Patient Self- Management and Self -Management Support
assessment     self     nursing     management     tool


Purpose of Tool: To provide parameters to assess your capacity to support patient self-m­ana­gement in your clinical practice.

Nurse Self Assessment

Esta­blish a Focus
At start of care and on an ongoing basis, I assess patient beliefs, behavior and knowledge with a standa­rdized assess­ment.
I ask open-ended questions whenever possible to learn about patients’ percep­tions and concerns, adapting the level of my conver­sation based on cognitive and language deficits.
I actively listen to my patients as they tell their illness story.
Share Inform­ation
I share inform­ation about the illness with the patient to help my patients make informed decisions on where to focus their efforts.
I provide person­alized feedback on lab values and functional status related to risks/­ben­efits and ways behaviors can affect outcomes.
I provide feedback to patients, the home health team and physicians regarding the patient’s progre­ss/­status with an emphasis on the patient’s self-d­efined goals.
Develop Shared Goals
I collab­ora­tively develop a patien­t-c­entered emergency care plan that correlates with my patient’s goals and is reinforced with each encounter.
I collab­ora­tively set goals with the patien­t/c­are­giver based on the patient’s interest and confidence in his or her ability to change the behavior.
I refer to speech therapy to identify the best possible way to present inform­ation to patients with hearing loss, cognitive deficits, memory deficits, vision issues and/or processing deficits and various learning styles.
Develop an Action Plan
I establish a patien­t/c­are­giver driven action plan with my patients to support self-m­ana­gement goals.
I provide an opport­unity for my patients to identify their confidence levels in achieving specified goals.
Identify personal barriers, strate­gies, proble­m-s­olving techniques and social­/en­vir­onm­ental support available forall patients.
Use Problem Solving Techni­ques
I offer tools and coaching to ensure medication simpli­fic­ation and reconc­ili­ation occurs effect­ively according to patient’s ability.
I support and encourage my patients to develop skills needed to commun­icate effect­ively with physic­ians.
I define plans for follow-up including setting a specific date to revisit or check in by phone to follow-up with the patient’s progress towards goals.

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