Nursing diagnosis: Self-Care Deficit related to cognitive decline, physical limitations; frustration over loss of independence, depression
Possibly evidenced by
Impaired ability to perform activities of daily living (ADLs)—frustration; forgetfulness; misuse or misidentification of objects;
inability to bring food from receptacle to mouth; inability to wash body part(s), regulate water temperature; impaired ability
to put on/take off clothing; difficulty completing toileting tasks
Desired Outcomes/Evaluation Criteria—Client Will
Perform self-care activities within level of own ability.
Caregiver Home Care Readiness
Identify and use personal and community resources that can provide assistance; support client’s independence.
Nursing intervention with rationale:
1. Identify reason for difficulty in self-care related to physical limitations in motion, depression, cognitive decline, or environment.
Rationale: Underlying cause affects choice of interventions and strategies. Clients reported to be unable to perform specific ADLs are often able to do so given the right circumstances, such as adequate and knowledgeable caregiver support.
2. Determine hygienic needs and provide assistance as needed with activities, including care of hair, nails, and skin; brushing teeth, and cleaning glasses.
Rationale: As the disease progresses, basic hygienic needs may be forgotten. Infection, gum disease, disheveled appearance, or harm may occur when client or caregivers become frustrated, irritated, or intimidated by degree of care required.
3. Inspect skin regularly.
Rationale: Presence of such lesions as ecchymoses, lacerations, or rashes may require treatment as well as signal the need for closer monitoring and protective interventions.
4. Incorporate usual routine into activity schedule as possible. Wait or change the time to initiate dressing and hygiene if a problem arises.
Rationale: Maintaining routine may prevent worsening of confusion and enhance cooperation. Because anger is quickly forgotten, another time or approach may be successful.
5. Be attentive to nonverbal physiological symptoms.
Rationale: Sensory loss and language dysfunction may cause client to express self-care needs in nonverbal manner, such as thirst by panting, need to void by holding self or fidgeting, and pain by facial grimacing.
6. Be alert to underlying meaning of verbal statements.
Rationale: May direct a question to another, such as, “Are you cold?” meaning “I am cold and need additional clothing.”
7. Supervise but allow as much autonomy as possible.
Rationale: Eases the frustration over lost independence.
8. Allot plenty of time to perform tasks.
Rationale: Tasks that were once easy, such as dressing or bathing, are now complicated by decreased motor skills or cognitive and physical changes. Time and patience can reduce chaos resulting from trying to hasten this process.
9. Assist with neat dressing and provide colorful clothes.
Rationale: Enhances esteem; may diminish sense of sensory loss and convey aliveness.
10. Offer one item of clothing at a time in sequential order. Talk client through each step of the task. Allow the wearing of extra clothing if client demands.
Rationale: Simplicity reduces frustration and the potential for rage and despair. Guidance reduces confusion and allows autonomy. Altering the “normal” may lessen rebellion.