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NCLEX & CGFNS Practice Questions
Self-Care Deficit
  • 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: –
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Objective/Expected Outcome;The patient will:

  • 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

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