Sunday, April 29, 2012

Self-Care Deficit - Nursing Diagnosis and Interventions

Bathing/Hygiene; Dressing/Grooming; Feeding; Toileting

NANDA Definition: Impaired ability to perform or complete activities of daily living, such as feeding, dressing, bathing, toileting

The nurse may encounter the patient with a self-care deficit in the hospital or in the community. The deficit may be the result of transient limitations, such as those one might experience while recuperating from surgery; or the result of progressive deterioration that erodes the individual’s ability or willingness to perform the activities required to care for himself or herself. Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing at self-care because of a lack in material resources or a problem with arranging the environment to suit the patient’s physical limitations. The nurse coordinates services to maximize the independence of the patient and to ensure that the environment that the patient lives in is safe and supportive of his or her special needs.


Defining Characteristics:
  • Inability to feed self independently
  • Inability to dress self independently
  • Inability to bathe and groom self independently
  • Inability to perform toileting tasks independently
  • Inability to transfer from bed to wheelchair
  • Inability to ambulate independently
  • Inability to perform miscellaneous common tasks such as telephoning and writing

Related Factors :
  • Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
  • Musculoskeletal disorder such as rheumatoid arthritis
  • Cognitive impairment
  • Energy deficit
  • Pain
  • Severe anxiety
  • Decreased motivation
  • Environmental barriers
  • Impaired mobility or transfer ability

Expected Outcomes
  • Patient safely performs (to maximum ability) self-care activities.
  • Resources are identified which are useful in optimizing the autonomy and independence of the patient.

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
  • Self-Care: Eating
  • Self-Care: Bathing
  • Self-Care: Dressing
  • Self-Care: Grooming
  • Self-Care: Hygiene
  • Self-Care: Toileting

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
  • Self-Care Assistance: Bathing/Hygiene
  • Self-Care Assistance
  • Dressing/Grooming
  • Self-Care Assistance: Feeding
  • Self-Care Assistance: Toileting
  • Environment Management
Ongoing Assessment
  • Assess ability to carry out ADLs (e.g., feed, dress, groom, bathe, toilet, transfer, and ambulate) on regular basis. Determine the aspects of self care that are problematic to the patient. The patient may only require assistance with some self-care measures.
  • Assess specific cause of each deficit (e.g., weakness, visual problems, cognitive impairment). Different etiological factors may require more specific interventions to enable self-care.
  • Assess patient’s need for assistive devices. This increases independence in ADLs performance.
  • Assess for need of home health care after discharge. Shortened hospital stays mean that patients are more debilitated on discharge from the hospital, and that patients need more assistance after discharge.
  • Identify preferences for food, personal care items, and other things. These support patient’s individual and personal preferences.

Therapeutic Interventions

  • Assist patient in accepting necessary amount of dependence. If disease, injury, or illness resulting in self-care deficit is recent, patient may need to grieve before accepting that dependence is possible.
  • Set short-range goals with patient. Assisting the patient to set realistic goals will decrease frustration.
  • Encourage independence, but intervene when patient cannot perform. An appropriate level of assistive care can prevent injury with activities without causing frustration.
  • Use consistent routines and allow adequate time for patient to complete tasks. This helps patient organize and carry out self-care skills.
  • Provide positive reinforcement for all activities attempted; note partial achievements. This provides the patient with an external source of positive reinforcement.
  • Feeding: Encourage patient to feed self as soon as possible (using unaffected hand, if appropriate). Assist with setup as needed. It is probable that the dominant hand will also be the affected hand if there is upper extremity involvement.
  • Ensure that patient wears dentures and eyeglasses if needed. Deficits may be exaggerated if other senses or strengths are not functioning optimally.
  • Assure that consistency of diet is appropriate for patient’s ability to chew and swallow, as assessed by speech therapist. Mechanical problems may prohibit the patient from eating.
  • Provide patient with appropriate utensils (e.g., drinking straw, food guard, rocking knife, nonskid place mat) to aid in self-feeding. These items increase opportunities for success.
  • Place patient in optimal position for feeding, preferably sitting up in a chair; support arms, elbows, and wrists as needed.
  • Consider appropriate setting for feeding where patient has supportive assistance yet is not embarrassed. Embarrassment or fear of spilling food on self may hinder patient’s attempts to feed self.
  • If patient has visual problems, advise the patient of the placement of food on the plate. Following CVA, patients may have unilateral neglect, and may ignore half the plate.
  • Dressing/grooming: Provide privacy during dressing. Patients may take longer to dress and may be fearful of breaches in privacy.
  • Provide frequent encouragement and assistance as needed with dressing. These reduce energy expenditure and frustration.
  • Plan daily activities so patient is rested before activity.
  • Provide appropriate assistive devices for dressing as assessed by nurse and occupational therapist. The use of a button hook or of loop and pile closures on clothes may make it possible for a patient to continue independence in this self-care activity.
  • Place the patient in wheelchair or stationary chair. This assists with support when dressing. Dressing can be fatiguing.
  • Encourage use of clothing one size larger. This ensures easier dressing and comfort.
  • Suggest front-opening brassiere and half slips. These may be easier to manage.
  • Suggest elastic shoelaces or loop and pile closures on shoes. These eliminate tying.
  • Provide makeup and mirror; assist as needed. Fine motor activities may take more coordinated actions and may be beyond the abilities of the patient.
  • Bathing/hygiene: Maintain privacy during bathing as appropriate. The need for privacy is fundamental for most patients.
  • Ensure that needed utensils are close by. This conserves energy and optimizes safety.
  • Instruct patient to select bath time when he or she is rested and unhurried. Hurrying may result in accidents and the energy required for these activities may be substantial.
  • Provide patient with appropriate assistive devices (e.g., long-handled bath sponge; shower chair; safety mats for floor; grab bars for bath or shower). These aid in bed bathing.
  • Encourage patient to comb own hair (a one-handed task). Suggest hairstyles that are low-maintenance. This enables the patient to maintain autonomy for as long as possible.
  • Encourage patient to perform minimal oral-facial hygiene as soon after rising as possible. Assist with brushing teeth and shaving, as needed.
  • Assist patient with care of fingernails and toenails as required. Patients may require podiatric care to prevent injury to feet during nail trimming or because special implements are required to cut nails.
  • Offer frequent encouragement. Patients often have difficulty seeing progress.
  • Toileting: Evaluate or document previous and current patterns for toileting; institute a toileting schedule that factors these habits into the program. The effectiveness of the bowel or bladder program will be enhanced if the natural and personal patterns of the patient are respected.
  • Provide privacy while patient is toileting. Lack of privacy may inhibit the patient’s ability to evacuate bowel and bladder.
  • Keep call light within reach and instruct patient to call as early as possible. This enables staff members to have time to assist with transfer to commode or toilet.
  • Assist patient in removing or replacing necessary clothing. Clothing that is difficult to get in and out of may compromise a patient’s ability to be continent.
  • Encourage use of commode or toilet as soon as possible. Patients are more effective in evacuating bowel and bladder when sitting on a commode. Some patients find it impossible to toilet on a bedpan.
  • Offer bedpan or place patient on toilet every 1 to 1½ hours during day and three times during night. This eliminates incontinence. Time intervals can be lengthened as the patient begins to express the need to toilet on demand.
  • Closely monitor patient for loss of balance or fall. Keep commode and toilet tissue near the bedside for nighttime use. Patients may rush readiness to ambulate to the toilet or commode during the night because of fear of soiling themselves and may fall in the process.
  • Transferring/ambulation: Plan teaching session for transferring/walking when patient is rested. Tasks require energy. Fatigued patients may have more difficulty and may become unnecessarily frustrated.
  • Assist with bed mobility by doing the following:
    • Encourage patient to use the stronger side (if appropriate) as best as possible. Stroke patients experience weakness in their dominant side; therefore it will be necessary for them to develop muscle strength and coordination on the stronger side.
    • Allow patient to work at own rate of speed. Many factors may influence a patient’s ability to move freely, and each of these factors must be considered when developing/teaching a patient a new system for self-care. It will take time for the patient to learn and then gain confidence in his or her ability to perform these new self-care measures.
    • When patient is sitting up at side of bed, instruct him or her not to pull on caregiver. This may cause caregiver to lose balance and fall.
    • This prevents disabling contractures, pressure sores, and muscle weakness from disuse.
  • When transferring to wheelchair, always place chair on patient’s stronger side at slight angle to bed and lock brakes. Patient will weight-bear on the stronger side.
  • When minimal assistance is needed, stand on patient’s weak side and place nurse’s hand under patient’s weak arm. (CAREGIVER: Keep your feet well apart; lift with legs, not back, to prevent back strain.)
  • For moderate assistance, place caregiver’s arms under both armpits with caregiver’s hands on patient’s back. This forces patient to keep his or her weight forward.
  • For maximum assistance, place right knee against patient’s strong knee, grasp patient around waist with both arms, and pull him or her forward; encourage patient to put weight on strong side. This stance maximizes patient support while protecting the care provider from back injury.
  • Assist with ambulation; teach the use of ambulation devices such as canes, walkers, and crutches:
    • Stand on patient’s weak side. This enhances patient safety.
    • If using cane, place cane in patient’s strong hand and ensure proper foot-cane sequence. This assists with balance and support.
  • Miscellaneous skills: Telephone: Evaluate need for adaptive equipment through therapy department (e.g., pushbutton phone, larger numbers, increased volume). Patients will require an effective tool for communicating needs from home.
  • Writing: Supply patient with felt-tip pens. These mark with little pressure and are easier to use. Evaluate need for splint on writing hand. This assists in holding the writing device.
  • Provide supervision for each activity until patient performs skill competently and is safe in independent care; reevaluate regularly to be certain that the patient is maintaining skill level and remains safe in environment. The patient’s ability to perform self-care measures may change often over time and will need to be assessed regularly.
  • Encourage maximum independence.

Education/Continuity of Care

  • Plan teaching sessions so patient has time to practice tasks.
  • Instruct patient in use of assistive devices as appropriate.
  • Teach family and caregivers to foster independence and to intervene if the patient becomes fatigued, is unable to perform task, or becomes excessively frustrated. This demonstrates caring and concern but does not interfere with patient’s efforts to achieve independence.

Nursing Diagnosis for Self-Care Deficit
Source :
http://nandadiagnosis.blogspot.com/2011/08/nursing-diagnosis-for-self-care-deficit.html
 http://nursingcareplan.blogspot.com

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