Friday, November 26, 2010

Self-Care Deficit Bathing/Hygiene; Dressing/Grooming; Feeding; Toileting

Self-Care Deficit
Bathing/Hygiene; Dressing/Grooming; Feeding; Toileting

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

Discussion of the Problem
Dorethea Orem’s theory, first published in 1971, includes three related concepts: self care, self-care deficit, and nursing systems. Self-care theory is based on four concepts: self-care, self-care agency, self-care requisites, and therapeutic self. Self-care refers to those activities an individual performs independently throughout life to promote and maintain personal well-being. Self-care agency is the individual’s ability to perform self-care activities. It consists of two agents: a self-care agent (and individual who performs self-care independently) and dependent care agent (a person other than the individual who provides the care.) Self care requisites, also called self-care needs, are measures or actions taken to provide self-care. Therapeutic self-care demand refers to all self-care activities required to meet existing self-care requisites, or in other words, actions to maintain health can and well being. Self-care deficit results when self-care agency is not adequate to meet the known self-care demand. Orem’s self-care deficit theory explains not only when nursing is needed but also how people can be assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and pr0viding an environment that promotes health. Medical conditions that could lead to self care deficit are as follows: cerebrovascular accident, stroke, multiple sclerosis, renal dialysis, rheumatoid arthritis, and a lot more. In addition, 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 caring for himself or herself. The nurse may encounter the patient with a self-care deficit in the hospital or in the community. 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.  Orem identifies three types of nursing systems: 1. Wholly compensatory systems are required for individuals who are unable to control and monitor their environment and process information. 2. Partly compensatory systems are designed for individuals who are unable to perform some, but not all, self-care activities. 3. Supportive-educative (developmental) systems are signed for persons who need to learn to perform self-care measure and need assistance to do so. The goal of management is maximizing the patient’s self care activities, particularly, bathing, hygiene, dressing, grooming, feeding and toileting, while promoting patient’s independence.

Nursing Interventions Classification (NIC)
  • Dressing/Grooming
  • Environment Management
  • Self-Care Assistance
  • Self-Care Assistance: Bathing/Hygiene
  • Self-Care Assistance: Feeding
  • Self-Care Assistance: Toileting

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

Goal and Objectives
  • Patient will identify useful resources in optimizing the autonomy and independence.
  • Patient will recognize individual weakness or needs.
  • Patient will safely execute self-care activities to utmost capability.
  • Patient will show lifestyle changes to meet self-care needs.

Subjective and Objective Data
  • Difficulty finishing toileting tasks
  • Disheveled or unkempt appearance, strong body odor
  • Frustration
  • Impaired capability to put on or take off clothing
  • Inability to ambulate autonomously
  • Inability to bathe self independently
  • Inability to control temperature of water
  • Inability to do common tasks such as telephoning and writing
  • Inability to dress self autonomously
  • Inability to feed self independently
  • Inability to move from bed to wheelchair
  • Poor personal hygiene

Related Factors
  • Cognitive impairment
  • Decreased motivation
  • Decreased strength and endurance
  • Depression
  • Environmental barriers
  • Fatigue
  • Impaired mobility or transfer ability
  • Intolerance to activity
  • Memory loss
  • Motor impairment, tremors
  • Musculoskeletal disorder such as rheumatoid arthritis
  • Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
  • Pain or discomfort
  • Perceptual or cognitive impairment
  • Severe anxiety

Assessment (Dx)
  • Determine exact cause of each deficit. For instance, weakness, visual problems, and cognitive impairment. Varied etiological factors may require more specific interventions to enable self-care.

  • Evaluate capability and level of deficit (0–4 scale) to perform ADLs such as feeding, dressing, grooming, and bathing, toileting, transferring, and ambulating on regular basis. The patient may only need support with some self-care measures. Also help in anticipating and development for managing patient needs.

  • Monitor impulsive behavior or actions indicative of altered judgment. May signify the need for supplementary interventions and management to ensure safety or security.

  • Note the need for assistive devices. This enhances autonomy in performing Activities of Daily Living.

  • Observe preference for individual care objects, food, and other stuffs. These sustain patient’s personal preferences.

  • Verify for need of home health care assistance following discharge. Shortened hospice confinement signifies that patients are more incapacitated upon release from the institution, and that they need additional support subsequent to discharge.

Therapeutic Interventions (Tx)
  • Avoid performing things for patient that patient could accomplish for self, but offer help as appropriate. Permit as much independence as feasible. Even though assistance is necessary in avoiding frustration, these individual may become afraid and dependent. It is imperative for patient to do as much as possible for self to sustain self-esteem and uphold recuperation.

  • Collaborate with rehabilitation specialists like occupational therapist. Useful in determining assistive devices to achieve individual needs.

  • Establish short-term goals with patient. Supporting the patient to lay down realistic goals will lessen frustration.

  • Give affirmative reinforcement for efforts and for all activities done. This supplies an external source of positive reinforcement for the patient Develops sense of self-worth, encourages autonomy, and persuades patient to continue accomplishments.

  • Help patient in recognize needed amount of dependence. Patient may require grieving prior to accepting that dependence is necessary if ailment, injury, or illness may lead to self-care deficit.

  • Uphold a supportive, firm attitude and provide enough time for patient to accomplish tasks. This aids patient put in order and perform self-care skills. Patients could do with empathy and to be assured that caregivers will be constant in their assistance.

Bathing or hygiene:
  • Foresee hygienic requirements and calmly support as necessary with care of nails, skin, and hair, mouth care, shaving. Significant other’s illustration can provide a matter-of-fact tone for handling needs that many be awkward to patient or repulsive to significant other.

  • Help out patient with care of fingernails and toenails as needed. Patients may need podiatric care to avoid harm to feet when trimming nails

  • Make sure that necessary utensils are within reach. This saves energy and ensures safety.

  • Offer patient with proper assistive devices such as long-handled bath sponge, shower chair, safety mats for floor, grab bars for bath. This helps out bed bathing.

  • Persuade patient to fix own hair. Recommend hairstyles that are not difficult to maintain. This allows the patient to uphold independence for as long as possible.

  • Provide privacy when bathing as suitable. Necessitate for privacy is basic for most patients.

  • Support patient in performing minimal oral-facial hygiene after rising as feasible. Lend a hand with brushing teeth and shaving, as necessary.

  • Teach patient to choose bath time when energy is high. The energy necessary for these activities can be significant. Rushing may lead to accidents.

Dressing or grooming:
  • Give privacy during dressing. Patients possibly will take longer time to dress and might be fearful of violations in privacy.

  • Give proper assistive devices for dressing as evaluated by nurse and occupational therapist. The utilization of a button hook or of loop and pile closures on clothes could make it feasible for a patient to maintain autonomy in this self-care activity.

  • Offer makeup and mirror; help out as necessary. Fine motor activities may take additional coordinated actions and may be further than the capabilities of the patient.

  • Offer regular support and help as required with dressing. These decrease energy spending and disappointment.

  • Persuade utilization of clothing one size bigger. This facilitates simpler dressing and comfort.

  • Propose front-opening brassiere and half slips. These may be simpler to manage.

  • Put the patient in wheelchair or stationary chair. This helps with support when dressing because dressing can be tiring.

  • Recommend elastic shoelaces or loop and pile closures on shoes. These get rid of tying.

  • Guarantee that consistency of diet is proper for patient’s capability to masticate and swallow, as needed. Mechanical problems could hinder the patient from eating.

  • Make sure that patient uses dentures and eyeglasses if necessary. If other senses or strengths are not functioning maximally, deficits may be exacerbated.

  • Offer patient with appropriate utensils to assist in self-feeding. These materials augment chances for success.

  • Persuade patient to feed self as soon as possible if appropriate, using unaffected hand. Help out with setup as necessary. It is possible that the dominant hand will also be the affected hand if the upper extremity is involved.

  • Put patient in appropriate position for feeding, if possible sitting up in a chair; prop up arms, elbows, and wrists as necessary.

  • Recommend to patient the position of food on the plate if has visual alterations. Subsequent to stroke, patients may have unilateral neglect, and may overlook half the plate.

  • Take into consideration suitable place for feeding where patient has accommodating assistance yet is not embarrassed. Fear of spilling food on self may embarrass patient, thus hindering patient’s attempts to feed self.

  • Assess or record prior and present patterns for toileting; introduce a toileting routine that factors these habits into the program. The efficacy of the bowel or bladder program will be improved if the natural and personal patterns of the patient are taken into consideration.

  • Evaluate patient’s capability to verbalize necessitate to void and/or capacity to use urinal, bedpan. Bring patient to the bathroom at regular or intermittent intervals for voiding if suitable. Patient may have neurogenic bladder, is lacking concentration, or be able to verbalize needs in acute recovery phase, but often is able to recover independent control of this function as recovery develops.

  • Give bedpan or put patient on toilet every 1 to 1½ hours throughout day and three times throughout night. This eradicates incontinence. Time intervals can be prolonged as the patient starts to verbalize the need to toilet on demand.

  • Give privacy while patient is toileting. Lack of privacy may reduce the patient’s ability to empty bowel and bladder.

  • Give suppositories and stool softeners. May be essential at first to help in instituting normal bowel function.

  • Help patient in eliminating or changing unnecessary clothing. Clothing that is not easy to get in and out of may compromise a patient’s capability to be continent.

  • Maintain call light within reach and teach patient to call as prompt as possible. This facilitates staff members to have ample time to help with transfer to commode or toilet.

  • Observe closely patient for loss of balance or fall. Maintain commode and toilet tissue close to the bedside for nighttime utilization. Patients may hurry readiness to ambulate to the toilet or commode throughout the night due to fear of soiling themselves and may fall in the procedure.

  • Persuade utilization of commode or toilet as early as possible. Patients are more successful in emptying bowel and bladder when sitting on a commode. A number of patients find it unfeasible to toilet on a bedpan.

  • Recognize prior bowel habits and restore normal regimen. Increase bulk in diet, fluid intake, and activity. Supports in progression of retraining program and helps in avoiding constipation and impaction.

Transferring or ambulation:
  • Always set the chair on patient’s stronger side at slight angle to bed and lock brakes, when transferring to wheelchair. Patient will bear weight on the stronger side.

  • For maximum assistance, place right knee adjacent to patient’s strong knee, grab patient around waist with both arms, and pull him or her forward; persuade patient to put weight on strong side. This posture optimizes patient’s support while protecting the caregiver from back injury.

  • Help with ambulation; instruct to utilize ambulation devices such as canes, walkers, and crutches:
    1. Place cane in patient’s strong hand and make certain proper foot-cane sequence, if using cane. This aids with support and balance.
    2. Stay on patient’s weak side. This ensures patient safety.

  • Offer massage and active or passive Range Of Motion exercises on a regular timetable. Persuade utilization of splints or footboards as ordered. Avoids associated problems with muscle dysfunction and disuse. Assist in sustaining muscle tone or strength and joint mobility, and reduces risk of loss of calcium from bones.

  • Place nurse’s arms under both armpits with nurse’s hands on patient are back for moderate assistance. This forces patient to maintain his or her weight forward.

  • Schedule a learning time for transferring or ambulating when patient is well rested. Activities necessitate energy. Tired patients may possibly have more difficulty and may turn out to be unnecessarily disappointed.

  • Support with bed mobility by performing the following:
    1. Persuade patient to utilize the stronger body part as much as possible. CVA patients feel weak in their dominant side; thus it will be appropriate for them to improve muscle strength and coordination on the stronger side.

    1. Let patient work at own rate of speed. Numerous possibilities may affect a patient’s capability to be in motion liberally.  Each of these factors should be taken into consideration when planning and teaching patient new methods for self-care. It will take time for the patient to discover and then achieve confidence in his or her capacity to carry out these new self-care procedures.

    1. Explain to patient not to pull on caregiver when sitting up at side of bed. Caregiver may have the tendency to lose balance and fall.
This avoids pressure sores, disabling contractures, and muscle weakness from disuse.

  • When minimal assistance is necessary, stay on patient’s weak side and put nurse’s hand under patient’s weak arm. Nurses should keep their feet well apart, lift with legs, not back, to prevent back strain.

  • When patient is bed or chair bound or immobile, change position on a regular basis. Offer skin care to pressure points, like sacrum, ankles, and elbows. Persuade to sleep in prone position as tolerated. Decreases pressure on vulnerable areas and avoids skin breakdown. Also, it lessens flexor spasms at knees and hips.

Miscellaneous skills:
  • Offer supervision for each activity until patient can carry out skill proficiently and is safe in independent care. Reassess on a regular basis to make sure that the patient is continuing skill level and remains safe in environment. The patient’s capability to carry out self-care procedures may perhaps vary over time and will require to be checked frequently.  

  • Telephone: Assess the need for utilizing adaptive equipment through therapy department. Patients will necessitate an efficient device for communicating needs from home.

  • Writing: Provide patient with felt-tip pens. These create mark with little pressure and are easier to use. Note for the need for splint on writing hand. This helps in holding the writing device.

Educative (Edx)
  • Educate family and significant others to promote autonomy and to intercede if the patient becomes tired, are not capable to carry out task, or become extremely aggravated. This displays caring and concern but does not hinder with patient’s efforts to attain autonomy.

  • Persuade independence, but intercede when the patient is not able carry out self-care activities.  A suitable level of assistive care can avoid harm with activities without causing disappointment.

  • Persuade or use energy-conservation techniques. Saves energy, decreases fatigue, and improves patient’s capability to execute tasks.

  • Persuade patient input in planning schedule. Patient’s worth of life is improved when wishes or likes are taken into consideration in daily activities.

  • Persuade significant other to permit patient to perform self-care measures as much as possible. Reinstitutes feeling of independence and promotes self-esteem and improves rehabilitation process. Note: This may be very hard and discouraging for the significant other or caregiver, depending on extent of disability and time needed for patient to accomplish activity.


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