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.
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.
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
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.
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.
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.
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.
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
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