Nursing outcomes and interventions for Self Care Deficit

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    Hi! I am a first year nursing student in my first semester. We have a care plan due and I am having problems coming up with Goals, outcomes and interventions for my nursing Dx- Self care deficit rt cognitive decline AEB inability to perform ADL'S. My client is elderly, and suffers from Dementia. She is A&O X1 (not oriented to place, time or situation) This is my first care plan and I am stressed to the max! I am having a hard time finishing this last part. I have completed a complete asessment complete with GFHP on my client. Any help would be much appreciated! Thank you!
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  4. 7 Comments so far...

  5. 0
    so, your complete assessment revealed inability to perform adl's? you have to have more specific definition of the self care deficit than "inability to perform adl's". they have to be stated, such as, "unable to button blouses", "unable to pick matching socks", "can't find the dining room", "eats food with fingers rather than using utensils" etc.

    goals are based upon the abnormal assessment data and how you predict it will change as a result of your nursing interventions. for information on how to construct goal statements, see post #157 on this thread:
    http://allnurses.com/general-nursing...se-121128.html

    what does gfhp mean? i do not know this abbreviation.
  6. 0
    Gordon's functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing asessment of the patient:
    1. Health perception and management
    2. Activity and exercise
    3. Nutrition and metabolism
    4. Elimination
    5. Sleep and rest.
    6. Cognition and perception
    7. Self-perception and self-concept
    8. Roles and relationships
    9. Coping and stress management
    10. Sexuality and reproduction
    11. Values and beliefs
  7. 1
    thanks for explaining the abbreviation. i just needed to know what it meant. i have actually met ms. gordon and know what the 11 functional health patterns are. you are not really being very forthcoming in posting any information about this patient or these adls that the patient is unable to perform. until you do that, i can offer very little help. i am sorry.

    there is care planning information on this sticky thread: http://allnurses.com/general-nursing...ns-286986.html
    - help with care plans
    Mommy23kiddos likes this.
  8. 0
    i am sorry, i didn't mean to sound pretentious in my reply...i just copied and pasted the gordons info. i appreciate your help, here is some more info as well as what i have so far:
    medical dx: dementia, pneumonia, hypertension, atrial fibrillation, situational depression. resident has limited mobility-wheelchair bound, unable to stand unassisted. her skin is intact-warm pink and dry. a&o x1 sometimes 2 (to person and occasionaly place) she has excellent long term memory but drifts from past to present during conversation sometimes. she is incontinent of bowel and bladder. the reason i chose self-care deficit is that is what is keeping her at the facility. she is unable to perform adl's unassisted. i understand i need to find one specific adl to pinpoint? such as "bathing or toileting?" we did care plans at the very beginning of the semester and now our big assignment for the end of semester is....a care plan! here is what i have thus far:

    nursing diagnosis

    self care deficit r/t cognitive decline, aeb inability to independently and appropriately bathe.

    signs and symptoms

    memory problems; forgetfulness (gfhp #5 cognitive/perceptual)
    loss of bladder or bowel control (gfhp #3 elimination)
    change in personality and mood, such as depression (gfhp #1 health maintenance management)


    goal

    resident will perform self-care bathing (with assistance as needed) 3x by april 21, 2009

    outcome

    resident will regulate water temperature by verbalization to the nursing student and assistive personell and wash upper body with assistance when needed (to facilitate independence and provide appropriate help in hygiene) every tuesday during her bath.


    interventions

    [color=#444444]1. the student nurse will provide appropriate cognitive-enhancement techniques and social engagement.
    [color=#444444]2. the student nurse will ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
    [color=#444444] 3. the student nurse will work to maximize the resident’s functional capacity, but ensure to meet resident’s needs when she is unable to meet her own needs.
    [color=#444444]outcomes
    the student nurse will provide appropriate cognitive-enhancement techniques and social engagement
    1. [color=#444444]the resident actively and enthusiastically engages in conversation with the nurses aid. resident enjoys talking about past events and was able to recall recent events of the day. resident is relaxed and calm during the conversation aeb smiling and laughing appropriately thoughout the conversation.
    the student nurse will ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
    2. [color=#444444]the resident drank all of her juice that was given to her from the dietary aide. resident stated “that feels better” when pillow was adjusted below her head. resident states a “0” on a scale of “0-10” for pain.
    the student nurse will work to maximize the resident’s functional capacity, but ensure to meet resident’s needs when she is unable to meet her own needs[color=#444444].
    3. [color=#444444]the resident was able to bathe her upper body with minimal assistance (assistance was needed to wash and dry under the breast tissue). resident was able to comb her hair and pick out a hat to wear.
    again, i appreciate your help!
  9. 0
    you want to care plan this patient's bathing self-care deficit. the first thing you have to do is make a list of all the ways she fails to bath herself independently. your nursing diagnosis statement fails to tell us that:
    • self care deficit r/t cognitive decline, aeb inability to independently and appropriately bathe.
    it lacks symptoms (evidence) of the problem:
    • problem: bathing self-care deficit
    • etiology: cognitive decline
    • symptoms: ??? none listed
    examples of symptoms of bathing self care deficits would be:
    • unable to find the bathroom
    • can't undress without help
    • forgets to get (or remember) where the washing supplies are
    • doesn't turn the water on
    • doesn't regulate the water temperature
    • doesn't relate the water flow
    • doesn't wash face, arms, legs, private parts
    • doesn't dry self
    • doesn't turn water off
    every step of the bathing procedure needs to be broken down into a step-by-step process and the break in the links identified.

    then, your interventions specifically target those symptoms because there isn't a whole lot you can do for the cognitive decline, is there?

    interventions (that you listed)

    1. the student nurse will provide appropriate cognitive-enhancement techniques and social engagement.
    i'm not being mean, but what the heck does this mean? and why would social engagement be important during bathing activities to getting her body clean?
    2. the student nurse will ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
    none of these have anything to do with bathing.
    3. the student nurse will work to maximize the resident’s functional capacity, but ensure to meet resident’s needs when she is unable to meet her own needs.
    has nothing to do with bathing. sorry.
    an outcome is the anticipated result of our nursing interventions. now, how about this for an outcome and interventions. . .

    outcome: the patient will be assisted in showering twice per week.
    • at the same time every monday and thursday the patient will be escorted to the shower room
    • she will be assisted in undressing and preparing to shower
    • the water will be adjusted to a warmth the patient can tolerate and the washcloth and bar of soap handed to the patient
    • the patient will bathe all parts of her body while being supervised including _____.
    • after bathing, the patient will dry herself with dry towels provided.
    • patient will then put on a clean change of clothing and escorted to the day room.
  10. 0
    1. the student nurse will provide appropriate cognitive-enhancement techniques and social engagement.
    i'm not being mean, but what the heck does this mean? and why would social engagement be important during bathing activities to getting her body clean?
    2. the student nurse will ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
    none of these have anything to do with bathing.
    3. the student nurse will work to maximize the resident’s functional capacity, but ensure to meet resident’s needs when she is unable to meet her own needs.
    has nothing to do with bathing. sorry.

    you made me laugh, and i realized how simple this care plan really is. i think i am trying to make it more difficult than it is. you are absolutely right and now i have some more direction. thank you for your help. this is a great site, i'm glad i found it!

  11. 0
    I'm in a similar situation - except my pt is on full care status due to impaired mobility secondary to MS. If I want to explain why he can't bath himself, why would I have to go into anything more detailed than to state 'because he can't move' (obviously worded differently)? Basically my pt can more or less manipulate a tv remote control with his right hand while none of his other three extremities work at all. Weakness, contractures (and a stage 4 pressure wound on his buttocks to boot). Is it necessary to say that he can't unbutton his shirt, turn on water, etc, etc?


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