Assessing and Diagnosing Self-Care Deficit

systoly · Dec 2, 2011

Is this a real or a textbook patient? If real, assess and obtain hx, may need to consult family if speech et communication are affected. Is there right sided neglect? If text book patient, consider changing to potential for.

OT, adaptive devices, safety measures. Teach active ROM. BTW, rarely have seen Dr. order for ROM.

BellasMommyOBRN · Dec 2, 2011

the "diagnosis" part comes from your evidence. for instance, it could be diagnosed based on the fact that she is unable to lift her hand to brush teeth/hair, adjust self w/o assistance, dress self.....or whatever (you get the point!)

you don't really need to use a specific "test" to diagnose, it's what you have witnessed/heard/smelled during your assessment that is presenting a problem with self-care.

good luck!!

classicdame, MSN, EdD · Dec 2, 2011

What can they NOT perform for themselves that they were able to do earlier and what interventions can be done? For instance, can they perform all ADL's? If not, will ROM or some tool be effective in assisting them? Do you need to involve another discipline, like PT/OT? How soon would you expect the patient to be able to do that task once the intervention has taken place?

nurseprnRN, BSN, RN · Dec 3, 2011

you don't start with a diagnosis and then go look for evidence. that's completely backwards. you start with evidence, then use it to make the diagnosis. how would you like it if you went to a physician and he said, "well, you've got cancer. let's go look and see what we can find that supports my diagnosis." screwy, right? :rolleyes: nursing diagnosis is no different-- assess first, then make your diagnosis. in school they ask you for "related to" (that would be "caused by" or "because he has...", in this case, the cva) and "as evidenced by" because they want to know how you reached that conclusion. after you graduate you will find that you don't need to write the "aeb" because real nurses will know why, and after awhile you won't even need the "r/t," for the same reason.

for example, if i admit a 55-year-old with diabetes and heart disease, i recall what i know about dm pathophysiology. i'm pretty sure i will probably see a constellation of nursing diagnoses related to these effects, and i will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. i might find readiness to improve health status, or ineffective coping, or risk for falls, too. these are all things you often see in diabetics who come in with complications. they are all things that nursing treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. but i can't put them in any individual's plan for nursing care until *i* assess for the symptoms that indicate them, the defining characteristics of each.

so... how did you get into this position? :idea:did you look at this patient and observe that s/he can't do things for him/herself? then you have supporting data for your diagnosis. take it from there.

Ted's Wife · Dec 3, 2011

This is not an actual patient. This is a case scenario...guess I should have specified that at the beginning.

The only info I have is that the patient has had a recent left-sided CVA and curently has right-sided hemiplegia and slurred speech. That's all I have to go on.

I see where you're coming from and it definitely makes sense. Were this an actual person, I would have done further assessments.