Nursing Care Plan for Self Care Deficit

Nursing Care Plan for Self Care DeficitThe nursing care plan for Self Care Deficit is used when there is impaired ability to perform or complete bathing/hygiene,dressing/grooming,feeding,or toileting activities for oneself.

Nursing Care Plan for Self Care Deficit Related To (Etiology)

  • Perceptual or cognitive impairment
  • Decreased or lack of motivation (anergia)
  • Severe anxiety
  • Severe preoccupation
As Evidenced By (Assessment Findings/Diagnostic Cues)
  • Consuming insufficient food or nutrients to meet minimum daily requirements
  • Awakening earlier or later than desired
  • Decreased ability to function secondary to sleep deprivation
  • Weight loss
  • Persistent insomnia or hypersomnia
  • Body odor/hair unwashed and unkempt
  • Inability to organize simple steps in hygiene and grooming
  • Constipation related to lack of exercise, roughage in diet, and poor fluid intake

Nursing Care Plan for Self Care Deficit Outcome Criteria

  • Performs all tasks of self-care consistently (all ADL*)
  • Experiences normal elimination
  • Sleeps 6 to 8 hours a night without medication
Long-Term Goals
Client will:
  • Gradually return to weight consistent for height and age or baseline before illness by (date)
  • Sleep between 6 to 8 hours per night within 1 month
  • Demonstrate progress in the maintenance of adequate hygiene and be appropriately groomed and dressed (shave/makeup, clothes clean and neat)
  • Experience normal elimination with the aid of diet, fluids, and exercise within 3 weeks
Short-Term Goals
Client will:
  • Gain 1 pound a week with encouragement from family, significant others, and/or staff if significant weight loss exists.
  • Sleep between 4 and 6 hours with aid of medication and/or nursing measures.
  • Groom and dress appropriately with help from nursing staff and/or family.
  • Regain more normal elimination pattern with aid of foods high in roughage, increased fluids, and exercise daily (also with aid of medications).

Nursing Care Plan for Self Care Deficit Interventions and Rationales


Imbalanced Nutrition
  1. Encourage small, high-calorie, and high-protein snacks and fluids frequently throughout the day and evening if weight loss exists. R: Minimize weight loss, dehydration, and constipation.
  2. Encourage eating with others. R: Increase socialization, decrease focus on food.
  3. Serve foods or drinks the client likes. R: Client are more likely to eat the foods they like.
  4. Weigh the client weekly and observe the client’s eating patterns. R: Give the information needed for revising the intervention.
Disturbed Sleep Pattern
  1. Provide rest periods after activities. R: Fatigue can intensify feelings of depression.
  2. Encourage the client to get up and dress and to stay out of bed during the day. R: Minimizing sleep during the day increases the likelihood of sleep at night.
  3. Encourage relaxation measures in the evening (e.g., back-rub, tepid bath, or warm milk). R: These measures induce relaxation and sleep.
  4. Reduce environmental and physical stimulants in the evening; provide decaffeinated coffee, soft lights, soft music, and quiet activities. R: Decreasing caffeine and epinephrine levels increases the possibility of sleep.
  5. Teach relaxation exercises. R: Besides deeply relaxing the body, relaxation exercises often lead to sleep.
Bathing/Hygiene Self-Care Deficit
  1. Encourage the use of toothbrush,washcloth, soap, makeup, shaving equipment, and so forth. R: Being clean and well groomed can temporarily raise self-esteem.
  2. Give step-by-step reminders, such as “Wash the right side of your face, now the left..” R: Slowed thinking and difficulty concentrating make organizing simple tasks difficult.
Constipation
  1. Monitor intake and output, especially bowel movements. R:Many depressed clients are constipated. If this condition is not checked, fecal impaction can occur.
  2. Offer foods high in fiber and provide periods of exercise. R: Roughage and exercise stimulate peristalsis and help evacuation of fecal material.
  3. Encourage the intake of nonalcoholic/non caffeinated fluids, 6 to 8 glasses/day. R: Fluids help prevent constipation.
  4. Evaluate the need for laxatives and enemas. R: These prevent the occurrence of fecal impaction.

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