Nursing Process: The Patient With Self-Care Deficit in Activities of Daily Living

NURSING PROCESS: THE PATIENT WITH SELF-CARE DEFICITS IN ACTIVITIES OF DAILY LIVING

ADLs are those self-care activities that the patient must accom-plish each day to meet personal needs. ADLs include personal hygiene/bathing, dressing/grooming, feeding, and toileting. Many patients are unable to perform such activities easily. An ADL pro-gram is started as soon as the rehabilitation process begins, because the ability to perform ADLs is frequently the key to independence, return to the home, and reentry into the community.

Assessment

The nurse must observe and assess the patient’s ability to perform ADLs to determine the level of independence in self-care and the need for nursing intervention. The activity of bathing requires obtaining bath water and utensils, washing, and drying the body after bathing. Dressing requires getting clothes from the closet, putting on and taking off clothing, and fastening the clothing. Self-feeding requires using utensils to bring food to the mouth, and chewing and swallowing the food. The activity of toileting includes removing clothing to use the toilet, cleansing oneself, and readjusting clothing. Grooming activities include combing hair, brushing teeth, shaving or applying makeup, and washing the hands. Patients who can sit up and raise their hands to their head can begin self-care activities.

In addition, the nurse needs to be aware of the patient’s med-ical conditions, the effect that they have on the ability to perform ADLs, and the family’s involvement in the patient’s ADLs. This information is valuable in setting goals and developing the plan of care to maximize self-care.

Nursing Diagnosis

Based on the assessment data, major nursing diagnoses for the pa-tient may include the following:

•          Self-care deficit: bathing/hygiene, dressing/grooming, feed-ing, toileting

Planning and Goals

The major goals of the patient include bathing/hygiene indepen-dently or with assistance, using adaptive devices as appropriate; dressing/grooming independently or with assistance, using adaptive devices as appropriate; feeding independently or with as-sistance, using adaptive devices as appropriate; and toileting independently or with assistance, using adaptive devices as ap-propriate. Another goal is that the patient with a self-care deficit expresses satisfaction with the extent of independence in self-care activities.

Nursing Interventions

FOSTERING SELF-CARE ABILITIES

To learn methods of self-care effectively, the patient must be mo-tivated. An “I’d rather do it myself ” attitude is encouraged. The nurse must also help the patient identify the safe limits of inde-pendent activity; knowing when to ask for assistance is particu-larly important.

The nurse teaches, guides, and supports the patient who is learning or relearning how to perform self-care activities. Consis-tency in instructions and assistance given by health care providers facilitates the learning process. Recording the patient’s perfor-mance provides data for evaluating progress and may be used as a source for motivation and morale building (Chart 11-2).

Often, a simple maneuver requires concentration and the ex-ertion of considerable effort on the part of the patient with a dis-ability; therefore, self-care techniques need to be adapted to accommodate the individual patient’s lifestyle. There is usually more than one way to accomplish a self-care activity, so common sense and a little ingenuity may promote increased independence. For example, a person who cannot quite reach his or her head may be able to do so by leaning forward. Encouraging the patient to participate in a support group may also help the patient to dis-cover inventive or creative solutions to self-care problems.

RECOMMENDING ASSISTIVE DEVICES

If the patient has difficulty in performing an ADL, an adaptive or assistive device (self-help device) may be useful. A large variety of assistive devices are available commercially or can be fab-ricated by the nurse, the occupational therapist, the patient, or the family. The nurse should be alert to “gadgets” coming on the market and evaluate their potential for usefulness. Of course, the nurse must exercise professional judgment and caution in rec-ommending devices, because unscrupulous vendors have mar-keted unnecessary, overly expensive, or useless items to patients in the past.

A wide selection of computerized assistive devices is avail-able, or devices can be designed to help individual patients with severe disabilities to function more independently. The ABLE-DATA project (see Resources list) offers a computerized listing of commercially available aids and equipment for patients with disabilities.

HELPING THE PATIENT ACCEPT LIMITATIONS

If the patient has a severe disability, independent self-care may be an unrealistic goal; in this situation, the rehabilitation nurse teaches the patient how to direct his or her own care. The patient may require a personal attendant to perform ADLs. Family members may not be appropriate for providing bathing/hygiene, dressing/grooming, feeding, and toileting assistance, and a spouse may have difficulty providing bowel and bladder care for the patient and maintaining the role of sexual partner. If a personal caregiver is needed, the disabled person or family members must learn how to manage an employee effectively. The nurse assists the patient in accepting self-care dependency. Independence in other areas, such as social interaction, should be emphasized to promote positive self-concept.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1.        Demonstrates independent self-care in bathing/hygiene or with assistance, using adaptive devices as appropriate

a.        Bathes self at maximal level of independence

b.        Uses adaptive devices effectively

c.         Reports satisfaction with level of independence in bathing/hygiene

2.        Demonstrates independent self-care in dressing/grooming or with assistance, using adaptive devices as appropriate

a.        Dresses/grooms self at maximal level of independence

b.       Uses adaptive devices effectively

c.         Reports satisfaction with level of independence in dressing/grooming

d.        Demonstrates increased interest in appearance

3.        Demonstrates independent self-care in feeding or with as-sistance, using adaptive and assistive devices as appropriate

a.        Feeds self at maximal level of independence

b.        Uses adaptive and assistive devices effectively

c.         Demonstrates increased interest in eating

d.        Maintains adequate nutritional intake

4.        Demonstrates independent self-care in toileting or with as-sistance, using adaptive and assistive devices as appropriate

a.        Toilets self at maximal level of independence

b.        Uses adaptive and assistive devices effectively

c.         Indicates positive feelings regarding level of toileting independence

d.        Experiences adequate frequency of bowel and bladder elimination

e.         Does not experience incontinence, constipation, uri-nary tract infection, or other complications