Nursing diagnosis: Self-Care Deficit related to Neuromuscular or perceptual impairment; intolerance to activity; decreased strength and endurance; motor impairment, tremors, Pain, discomfort, fatigue, Memory loss, Depression
Possibly evidenced by
Frustration, inability to perform tasks of self-care, poor personal hygiene
Desired Outcomes/Evaluation Criteria—Client Will
Self-Care: Activities of Daily Living (ADLs)
Identify individual areas of weakness, needs.
Demonstrate techniques and lifestyle changes to meet self-care needs.
Perform self-care activities within level of own ability.
Identify personal and community resources that provide assistance.
Nursing intervention with rationale:
1. Determine current activity level or physical condition. Assess degree of functional impairment using a scale of 0 to 4.
Rationale: Functional assessment provides information to develop plan for rehabilitation. Note: Motor symptoms are less likely to improve than sensory ones.
2. Encourage client to perform at optimal level of function; however, do not rush client.
Rationale: Encouragement promotes independence and sense of control. It may decrease feelings of helplessness.
3. Provide assistance with physical limitations. Allow as much autonomy as possible.
Rationale: Client participation in self-care can ease the frustration over perceived loss of independence.
4. Encourage client input in planning schedule.
Rationale: Client’s quality of life is enhanced when preferences are considered in daily activities.
5. Note presence of and accommodate for fatigue.
Rationale: Fatigue can be very debilitating and greatly impacts ability to participate in ADLs. The subjective nature of reports of fatigue can easily be misinterpreted as manipulative or a form of secondary gain.
6. Encourage scheduling activities early in the day or during peak energy levels.
Rationale: Completing ADLs requires high energy expenditure. Poor planning of activities can cause early fatigue, persisting through the rest of the day.
7. Allow sufficient time to perform task(s). Display patience when movements are slow.
Rationale: Decreased motor skills and spasticity may interfere with ability to manage simple activities.
8. Anticipate hygiene and grooming needs. Calmly assist with the care of nails, skin, hair, and mouth and with shaving (use electric razor), as necessary.
Rationale: The care provider can model matter-of-fact attitude toward assistance with toileting and grooming activities. This facilitates client and SO to accept changing roles and abilities.
9. Provide assistive devices as indicated: shower chair, elevated toilet seat with arm supports, and others.
Rationale: Assistive devices reduce fatigue and enhance participation in care.
10. Frequently reposition the immobile, bed- or chair-bound client. Provide skin care to pressure points, such as sacrum, ankles, and elbows. Position or encourage sleeping in prone position, as tolerated.
Rationale: Repositioning reduces pressure on susceptible areas and prevents skin breakdown. It minimizes flexor spasms at knees and hips.