- Actual
- Risk for (Potential)
Related To: [Check those that apply]
- Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
- Musculoskeletal disorder such as rheumatoid arthritis
- Cognitive impairment
- Energy deficit
As evidenced by: [Check those that apply]
- 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
Patient’s Diagnosis: –
Date:-
CLICK HERE for Free NCLEX –RN & CGFNS Practice Questions
- safely performs (to maximum ability) self-care activities.
- identify resources which are useful in optimizing autonomy and independence.
- Others
Note: you need to indicate time frame/target as objective must be measurable.
| Nursing Interventions | Scientific Rationale |
|---|---|
| Assess ability to carry out ADLs 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 etiologic factors may require more specific interventions to enable self-care. |
| Assess patient's need for assistive devices | To increase independence in ADLs performance. |
| 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. | To facilitate learning and decrease frustration. |
| Encourage independence, but intervene when patient cannot perform. | To decrease 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. |
| Ensure that patient wears dentures and eyeglasses if needed. | Deficits may be exaggerated if other senses or strengths are not functioning optimally. |
| Provide patient with appropriate utensils (e.g., drinking straw, food guard) to aid in self-feeding. | These items increase opportunities for success. |
| 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. |
| Provide frequent encouragement and assistance as needed with dressing. | To reduce energy expenditure and frustration. |
| Place the patient in wheelchair or stationary chair. | To assist with support when dressing. Dressing can be fatiguing. |
| Encourage use of clothing one size larger. | To ensure easier dressing and comfort. |
| Suggest elastic shoelaces or loop and pile closures on shoes. | To eliminate tying. |
| Provide make-up and mirror; assist as needed. | Fine motor activities may take more coordinated actions and may be beyond the abilities of the patient. |
| Ensure that needed utensils are close by. | To conserve energy and optimize safety. |
| Instruct patient to select bath time when they are rested and unhurried. | Hurrying may result in accidents and the energy required for these activities may be substantial. |
| Offer frequent encouragement. | Patients often have difficulty seeing progress. |
| Provide privacy while patient is toileting. | Lack of privacy may inhibit the patient's ability to evacuate their bowel and bladder. |
| 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. |
| Offer bedpan or place patient on toilet every 1 to 1.5 hours during day and three times during night. | To eliminate incontinence. Time intervals can be lengthened as the patient begins to express the need to toilet on demand |
CLICK HERE for more Free Nursing Care Plans
___________________________________
Patient/Significant other signature
___________________________________
RN Signature
