Self-care deficit emerges when individuals find themselves unable to perform activities of daily living (ADLs) adequately, affecting their health and well-being. Rooted in Dorothea Orem’s Self-Care Deficit Theory, self-care is viewed as a learned behavior aimed at maintaining life, health, and overall wellness. Effective self-care bolsters structural integrity, human function, and development. Orem’s theory identifies three types of self-care requisites: developmental, health deviation, and universal self-care requisites, with universal self-care requisites commonly known as activities of daily living (ADLs). Deficits in these universal requisites manifest as challenges in everyday tasks like bathing, dressing, toileting, and positioning, significantly altering daily life (Queiros et al., 2021).
Understanding Activities of Daily Living (ADLs)
Activities of daily living (ADLs) are the fundamental, routine tasks individuals undertake daily to maintain their health and well-being. These encompass essential self-care tasks such as eating, bathing, dressing, grooming, working, managing a household, and engaging in leisure activities. These actions are typically performed autonomously to preserve and enhance overall well-being. However, various circumstances can lead to a self-care deficit. These deficits can be temporary, resulting from situations like post-surgical recovery, or progressive, stemming from a gradual decline in physical or cognitive abilities, diminishing a person’s capacity or desire to engage in self-care. Crucially, psychosocial factors, such as depression, profoundly impact self-care motivation. Individuals struggling with depression often experience a significant lack of motivation and energy, further compounding self-care deficits. This connection highlights why self-care deficit can indeed be considered a psychosocial nursing diagnosis, as mental and emotional states directly influence the ability to perform essential daily tasks.
Instrumental activities of daily living (IADLs) represent more complex skills necessary for independent living. These include meal preparation, grocery shopping, household management, financial handling, and transportation. IADLs demand higher-level cognitive and organizational abilities compared to basic ADLs. The ability to perform IADLs significantly determines an individual’s capacity to live independently and maintain a satisfactory quality of life. For older adults and individuals with disabilities, proficient performance of IADLs allows them to sustain autonomy and reside in their own homes longer, potentially delaying or preventing the need for assisted living or long-term care facilities.
Nurses play a vital role in recognizing and addressing self-care deficits, providing crucial support for individuals to regain independence and enhance their physical and mental health. Through targeted interventions and necessary support, nurses empower individuals to resume and maintain their self-care and ADLs, emphasizing the psychosocial dimensions of care.
Nursing Care Plans and Holistic Management
Managing self-care deficits and ADLs requires a collaborative approach involving healthcare professionals, patients, and caregivers. Nurses are central to this process, guiding patients toward optimal self-care, teaching essential skills, and offering assistance while fostering independence. Integrating family members and caregivers into the care planning process strengthens the patient’s support network and ensures consistent care beyond clinical settings. This collaborative model recognizes the multifaceted nature of self-care deficits, acknowledging both physical and psychosocial elements.
Prioritizing Nursing Problems
In addressing patients with self-care needs and ADL limitations, nurses prioritize the following:
- Limited Physical Mobility: Restricted mobility significantly impairs a patient’s ability to perform ADLs and self-care tasks. Interventions aimed at improving mobility and providing assistive devices are paramount.
- Self-Care Deficits: Direct and focused attention is required for patients struggling with self-care activities. Nursing interventions may include teaching adaptive techniques, supplying necessary aids, and addressing cognitive or physical barriers to self-care.
- Psychosocial Concerns: Patients with self-care and ADL limitations often face psychosocial challenges, including coping difficulties and diminished self-esteem. Conditions like anxiety and depression can severely impact a patient’s motivation and capacity to engage in self-care and ADLs. Recognizing and addressing these psychosocial issues enables timely intervention by the nursing team. This underscores the importance of considering self-care deficit as a psychosocial nursing diagnosis, requiring interventions that target both physical and emotional well-being.
Comprehensive Nursing Assessment
Assessment is fundamental in identifying self-care deficits and guiding effective nursing care. A thorough evaluation of the patient’s health, functional abilities, environment, and support systems enables nurses to develop personalized care plans, prevent potential complications, and promote recovery. Collaborative discussions and regular reassessments are essential for a holistic approach to self-care management.
Assess for the following subjective and objective data:
- Decreased or absent motivation in performing self-care or ADLs
- Reported weakness or fatigue
- Complaints of pain or discomfort
- Presence of perceptual or cognitive impairment
- Inability to perceive a body part
- Neuromuscular or musculoskeletal impairments
- Medically indicated restrictions (e.g., complete bed rest)
- Therapeutic procedures limiting mobility (e.g., cast, IV therapy)
- Severe anxiety or depression
- Observed poor personal hygiene
- Forgetfulness; misuse or misidentification of objects
Formulating Nursing Diagnoses
Following a comprehensive assessment, nursing diagnoses are formulated to specifically address self-care deficits. These diagnoses are guided by the nurse’s clinical judgment and a deep understanding of the patient’s unique condition. While nursing diagnoses provide a structured framework for care, their application can vary across different clinical settings. Ultimately, the nurse’s expertise and clinical reasoning shape the care plan, ensuring it is tailored to prioritize each patient’s individual needs. Recognizing the interplay of physical and mental health, nursing diagnoses for self-care deficit often incorporate psychosocial components, reflecting the holistic nature of patient care.
Setting Nursing Goals
Goals and expected outcomes for patients with self-care deficits may include:
- Patient will demonstrate measurable improvement in performing ADLs, evidenced by increased independence in self-care tasks (bathing, dressing, grooming) within a specified timeframe.
- Patient will verbalize understanding of self-care management techniques and effectively implement them, demonstrated by adherence to medication regimens, dietary guidelines, and therapeutic exercises within a reasonable timeframe.
- Patient will actively engage in self-care education and training, indicated by consistent attendance, participation in educational sessions, asking pertinent questions, and proactively seeking resources to enhance self-care abilities.
Nursing Interventions and Actions
Nursing interventions for self-care deficits are multifaceted, encompassing assessment of current abilities, setting achievable goals, providing education and training, developing individualized care plans, and offering ongoing support and monitoring. Involving family and caregivers, collaborating with interdisciplinary healthcare teams, evaluating the effectiveness of interventions, and providing emotional support are also critical components. Therapeutic nursing interventions and actions for patients with self-care deficits are detailed below:
1. Comprehensive Client Assessment
Nurses must diligently observe and assess a patient’s capacity to perform ADLs to ascertain their level of independence in self-care and determine the specific nursing interventions required. Identifying the underlying causes of these limitations is essential for tailoring appropriate interventions to meet individual patient needs.
1.1. Functional Ability Assessment
Utilize a validated assessment tool, such as the Functional Independence Measure (FIM), to evaluate the patient’s strength and efficiency in performing ADLs daily. The FIM assesses 18 self-care items related to eating, bathing, grooming, dressing, toileting, bladder and bowel management, transfers, ambulation, and stair climbing. Scoring is based on a seven-point scale, quantifying the patient’s level of independence. The Alpha FIM, a shorter version, is often used within 72 hours of admission in acute care settings to measure functional independence and assistance needs.
Evaluate the patient’s need for assistive devices. Assistive devices can significantly boost confidence in performing ADLs. If a patient struggles with an ADL, an adaptive or assistive device can be beneficial. These devices can be commercially obtained or custom-made by nurses, occupational therapists, patients, or family members.
Verify the necessity for home healthcare post-discharge. Shorter hospital stays often result in patients being discharged in a more debilitated state, requiring increased support at home. Occupational therapists are valuable resources for accessing a wide array of self-help devices. A primary rehabilitation goal is to facilitate the patient’s return to their home environment after learning to manage their disability. Discharge planning should commence upon admission, prioritizing the patient’s functional potential.
Determine the patient’s level of independence. Document the patient’s independence level by observing their performance in specific activities, such as eating or dressing. Record the time taken, mobility, coordination, endurance, and the level of assistance needed. The Barthel Index can be used to measure independence in ADLs, continence, toileting, transfers, and ambulation.
Assess cultural and belief systems that influence self-care practices. Pre-existing cultural norms can significantly influence a patient’s willingness to consider various self-care approaches. Cultural and ethnic beliefs about hygiene vary widely. Nurses must recognize these beliefs, address any related concerns with the patient and family, and communicate relevant findings to the healthcare team to ensure culturally sensitive care.
Evaluate the patient’s gait and alignment. Alignment assessment includes observing the patient’s posture while standing to identify variations and learning needs for maintaining good posture. Gait assessment determines mobility and injury risk. Observe gait as the patient walks into the room or down a hallway.
Identify factors hindering capabilities and movement limitations. Gather data indicating hindrances or restrictions to movement and the need for assistance. Observe how illness affects movement ability and if the patient’s condition contraindicates any exertion, position, or movement. Assess for mechanical barriers such as IV lines, casts, or drainage tubes.
Closely monitor vital signs. By determining an appropriate activity level, nurses can predict a patient’s strength and endurance for energy-demanding activities. Vital signs are crucial indicators, measured before, during, immediately after activity, and three minutes post-activity after rest.
1.2. Etiology and Patient Preference Identification
Recognize patient choices regarding food, personal care items, and other preferences. Patients are more likely to adhere to treatment regimens that align with their individual preferences. Self-care interventions should enhance choice and autonomy by being accessible, acceptable, and affordable, promoting self-determination, self-efficacy, autonomy, and health engagement for patients and caregivers (World Health Organization, 2021).
Determine the specific cause of each self-care deficit (e.g., visual problems, weakness, cognitive impairment). Different etiologies necessitate tailored interventions to facilitate self-care. A detailed functional assessment of secondary conditions related to the disability, such as muscle atrophy, deconditioning, skin integrity, bowel and bladder control, and sexual function, alongside identifying residual strengths, is crucial.
Evaluate gag reflex or the need for swallowing assessment by a speech therapist before initial oral feeding. Absence of gag reflex or difficulty chewing or swallowing increases choking or aspiration risk. Elicit gag reflex by gently touching the back of the pharynx with a cotton-tipped applicator on each side of the uvula. A positive response includes equal uvula elevation and gagging upon stimulation.
Monitor for impulsive behavior or altered judgment. These behaviors may indicate a need for additional interventions and safety measures. Self-care involves attitude, intention, and self-determined choice. Motivation alone is insufficient; capacity is also essential for successful self-care (LeBlanc & Jacelon, 2018).
Evaluate recent changes or difficulties in mobility affecting activity levels. An activity and exercise history is typically part of a comprehensive nursing history. If a patient reports recent changes or mobility issues, a detailed history is needed, including the problem’s nature, onset, frequency, causes, impact on daily living, coping strategies, and their effectiveness.
Assess personal factors influencing self-care. Studies link personal factors to self-care. Age is a statistically significant predictor of self-care maintenance, management, confidence, symptom monitoring, and behavior. Other factors include gender, employment status, marital status, family income, and education (Koirala et al., 2018).
Assess adequacy of social support. Family, caregiver, or social support significantly correlates with better self-care. Caregiver or family presence has been linked to lower self-care maintenance, while strong support systems are associated with improved self-care.
2. Promoting Independence and Enhancing Self-Esteem
Empowering patients to maintain independence cultivates dignity and self-worth, reducing the need for long-term institutional care.
Establish short-term, realistic goals with the patient. Setting achievable goals minimizes frustration. Desired self-care outcomes include stability, symptom control, complication prevention, functional status preservation, sustained self-care ability, and care direction based on self-determined choices. Self-care must be appropriate for the individual’s condition to realize these outcomes.
Guide the patient in accepting necessary dependence. Patients may need help recognizing safe limits of independence versus when to seek assistance. For severe disabilities, complete self-care independence may be unrealistic. Nurses help patients accept self-care dependency while emphasizing independence in other areas, like social interaction, to promote a positive self-concept.
Provide positive reinforcement for all attempted activities; acknowledge partial achievements. External positive reinforcement encourages continued effort. Patients often struggle to recognize progress. Simplify daily activities into short, achievable steps to foster a sense of accomplishment.
Supervise each activity until skill proficiency and safe independent care are demonstrated; regularly re-evaluate skill level and environmental safety. Self-care abilities can fluctuate, requiring regular assessment. Occupational therapists can suggest task simplification or adaptive equipment. Direct supervision may be needed, but preserving dignity and autonomy is crucial. Encourage patient choice and participation in self-care as much as possible.
Implement measures to promote independence, but intervene when the patient cannot function. Appropriate assistive care prevents injury without causing frustration. Nurses help patients accept temporary or permanent dependence. Simple tasks may require intense concentration and effort for disabled patients; self-care interventions should be adapted to lifestyle.
Maximize independence. Rehabilitation aims for the highest possible independence level. Self-care can be achieved in various ways, using common sense and ingenuity. For example, encourage a patient who cannot reach their head to lean forward.
Establish regular routines and allow adequate time for task completion. Routines become automatic, requiring less effort, aiding self-care skill organization and execution. Repetition, practice, and demonstrations maximize independence in personal care. Identify optimal activity times, encourage concentration, address endurance issues affecting safety, and provide cues and reminders.
Motivate patient participation in self-care. Impaired mobility and family/cultural expectations can hinder self-care. Nurses must motivate patients to learn and embrace self-care responsibility, fostering an “I’d rather do it myself” attitude.
Focus on patient strengths and optimal function level. Guide, educate, and support patients in learning self-care, emphasizing their strengths and functional level. Consistent instructions and assistance from healthcare professionals facilitate this process. Record patient performance to track progress and build morale.
Encourage participation in support groups or self-care programs. Support groups help patients discover creative self-care solutions. Self-care programs are structured educational forums teaching skills for managing medical conditions independently (Agency for Healthcare Research and Quality, 2020).
3. Interventions for Bathing Self-Care Deficit
Difficulties in bathing may involve washing the body or parts, accessing water, and regulating water temperature or flow. Bathing removes oil, perspiration, dead skin cells, and some bacteria, promoting well-being.
Determine the type of bath needed. Baths are categorized as cleansing or therapeutic. Cleansing baths (complete bed baths, self-help bed baths, partial baths, bag baths, towel baths, tub baths, showers) are for hygiene. Therapeutic baths treat skin irritation or specific areas, often with added medications.
Check water temperature before bathing. Water should feel comfortably warm, generally 43℃ to 46℃ (110℉ to 115℉). Patients with decreased circulation or cognitive issues cannot reliably verify temperature; nurses must check to prevent burns.
Assist patients needing therapeutic baths. These are typically taken in a tub filled one-third to one-half full. Instruct patients to soak for 20-30 minutes, ensuring treated areas are immersed.
Use skin care agents appropriate for the patient’s condition. Some patients have sensitive skin. Common agents include chlorhexidine gluconate, soap, or bath oils. Soap reduces surface tension, aiding cleansing, and may contain antibacterials. Chlorhexidine gluconate is often used in critical care for antimicrobial purposes, applied with disposable cloths saturated with solution and moisturizers.
Exercise caution with patients undergoing IV therapy. Use easy-to-remove gowns with Velcro or snaps. If unavailable, carefully change gowns post-bath and reassess IV site security.
Use universal precautions. Practice universal precautions, especially during perineal care. Gloves are not always necessary for bathing; use clinical judgment and explain glove use to the patient.
Provide privacy. Hygiene is personal; draw curtains or close doors. Facilities may have privacy signs.
Prepare the patient. Involve family members or significant others as desired. Offer a bedpan or urinal before bathing, as warm water and activity can stimulate voiding, enhancing comfort. Voiding before perineal care is also advisable.
Prepare the environment. Close windows and doors to ensure a comfortable room temperature. Air currents can cause chilling.
Encourage maximum self-care. Promote independence and self-esteem, but caution against excessive bathing, which can strip skin sebum, causing dryness, especially in older adults.
3.1. Providing a Bed Bath
Position the patient and bed appropriately. Adjust bed to a comfortable working height. Lower the near side rail and raise the far one. Move the patient closer to avoid reaching and straining, promoting good body mechanics.
Use a bath mitt. Mitts retain water and heat better and prevent washcloth ends from dragging on the skin. Create a mitt by folding a washcloth around your hand and tucking in the corner.
Wash the face first. Start with the cleanest area, the face, moving downward. Place a towel under the head. Wash eyes with water only, drying thoroughly. Use a separate washcloth corner for each eye, wiping inner to outer canthus to prevent microorganism transmission. Wash, rinse, and dry face, ears, and neck.
Wash arms and hands. Place a towel lengthwise under the arm. Use long, firm strokes from wrist to shoulder, including axilla, to promote venous blood return. Rinse and dry. The patient may also wash their arms in a basin. Repeat for the other arm and hand.
Wash chest and abdomen. Place a bath towel lengthwise across the chest, folding the bath blanket to the pubic area to maintain warmth and privacy. Lift the towel to wash chest and abdomen with firm strokes, paying attention to under-breast areas and skinfolds. Rinse and dry thoroughly.
Wash legs and feet. Expose the leg farthest from you, keeping the perineum covered. Lift the leg and place a towel underneath. Wash, rinse, and dry using firm strokes from ankle to thigh to promote circulation. Repeat for the other leg. Feet can be soaked in a basin and dried, focusing on between toes.
Wash back and perineum. Position the patient prone or side-lying, facing away. Place a towel alongside the back and buttocks. Wash and dry back from shoulders to buttocks and upper thighs, paying attention to gluteal folds. Assess if the patient can perform perineal care themselves.
3.2. Providing a Tub Bath or Shower
Prepare patient and tub/shower. Fill tub one-third to one-half full with water at 43℃ to 46℃ (110℉ to 115℉), enough to cover the perineal area. Cover IV catheters and dressings with plastic. Place a rubber mat or towel in the tub or shower to prevent slipping.
Assist patient in shower or tub. Some patients need a shower chair due to weakness. Check water temperature and pressure. Instruct on signaling for help and place an occupied sign. Never leave patients at risk for seizures or cognitive impairment unattended.
3.3. Providing Perineal Care
Position the patient comfortably. For females, supine with knees flexed and spread apart. For males, supine with knees slightly flexed and hips slightly externally rotated.
Ensure patient privacy. Drape the patient with a bath blanket to minimize exposure and embarrassment.
Clean female perineal area thoroughly. Clean labia majora first, then spread labia to wash folds between labia majora and minora. Use separate washcloth quarters for each stroke, wiping pubis to rectum to prevent microorganism transmission. Rinse and dry well.
Clean male perineal area thoroughly. Wash and dry penis with firm strokes. If uncircumcised, retract foreskin to clean glans, then replace. Removing smegma under foreskin is crucial to prevent bacterial growth.
4. Interventions for Dressing and Grooming Self-Care Deficit
Dressing and grooming difficulties include inability to obtain, put on, remove, fasten clothing, and maintain satisfactory appearance.
Identify appropriate assistance level. Enable patients to dress as independently as possible. Healthcare professionals should aim to maintain patients’ quality of life (Tsai, 2018).
Provide privacy during dressing. Privacy is essential. Patients may take longer to dress and fear privacy breaches. Assess patient comfort level with caregiver gender. Respect modesty and provide sensitivity.
Allow clothing style choice when possible; respect preferences. Respect patient style. Some value being well-dressed; others do not. Ask about preferences from the patient or family if the patient cannot communicate (Prizer & Zimmerman, 2018).
Offer simple clothing choices. Simplify choices based on ability. Organize clothing in order of use. Encourage choice freedom. Offer comfortable, simple clothing like front-opening cardigans instead of pullovers. Ensure only seasonally appropriate clothes are available.
Give simple instructions. Provide short, simple instructions while handing items, e.g., “Put on your shirt.” Sometimes, just handing an item is sufficient. Limit choices and directions to avoid confusion and decision-making burden.
Use assistive devices as assessed by nurses and occupational therapists. Buttonhooks or loop-and-pile closures can maintain independence. Adaptive devices like reachers and dressing sticks help reach feet. Hospital bed functions can also aid dressing. (Buzaid et al., 2013).
Choose comfortable, simple dressing options. Substitute buttons and zippers with Velcro or elastic waistbands. Some families resist adaptive clothing fearing it will make loved ones look like nursing home residents. However, Velcro can be hidden and is practical (Mahoney et al., 2015).
Suggest elastic shoelaces or Velcro closures on shoes. Eliminate tying frustration. Adaptive footwear includes non-slip grips, easy closures, comfortable fabric, easy cleaning, and cushioned soles (Khatri & Matsushita, 2023).
Provide frequent encouragement and dressing aid as needed. Assistance reduces energy expenditure and frustration. Avoid rushing, negating patient attempts. Train in energy conservation and pacing.
Use a wheelchair or stationary chair. Sitting saves energy. A supportive chair is better than sitting on the bed edge. Occupational therapists may suggest clothing modifications or dressing from bed level.
Establish regular activities; ensure rest before activity. Balanced activity and rest periods help complete tasks without fatigue. Pacing involves spreading activities throughout the day, week, or month to ease fatigue.
Consider larger clothing sizes. Larger sizes ensure easier dressing and comfort. Loose clothing allows more movement. Tight clothing is challenging, especially with limited dexterity.
Recommend front-opening bras and half-slips. Easier clothing enhances self-care. Limited mobility requires easy-wear clothing that doesn’t hinder movement. Easy access snaps, stretchy fabric, and designs accommodating healthcare aids are beneficial.
Encourage maximum dressing involvement. Involve patients in dressing as much as possible. Encourage choosing clothes and accessories to foster independence.
Assist with undressing as needed. Techniques and assistance are needed for safe undressing without pain, discomfort, or falls. Support extremities while undressing. Undress unaffected side first, then affected side.
Assist bed dressing. Good communication and a colleague are needed to prevent injuries. Dress patients sitting up in bed if possible. Otherwise, turn side to side for upper garment dressing (McKnight, 2017). Turn to unaffected side, place affected arm through sleeve, turn to other side, gather clothing, slide under to unaffected arm, and close garment.
Assist with lower garment dressing in bed. If the patient can sit, ask them to move during dressing (Reuter, 2022). Put pants on both legs, starting with the affected side. If able, ask them to raise buttocks. If not, raise side rails, assist turning, and pull pants up.
Assist with anti-embolism stockings. Immobile patients may need these to reduce swelling and clots. They are tight and difficult to apply/remove. Instruct able patients to turn stocking tops to heel, put foot in, and pull up taut. For unable patients, stand at bed foot, turn tops to heel, put foot in, and pull up taut, standing beside the thigh.
Allow ample dressing time; avoid rushing. Ensure sufficient time. If resistance occurs, stop and try later. Sometimes, sleeping in clothes and changing in the morning is easier.
Engage in conversation during dressing. Use clothing as a conversation starter. Compliment clothes or ask opinions on patterns to involve the patient.
Avoid arguing with dressing resistance. Recognize irritability coping. Step back, simplify, and maintain calm tolerance.
5. Interventions for Toileting Self-Care Deficit
Toileting problems include difficulty accessing the toilet or commode, sitting, rising, manipulating clothing, hygiene, flushing, or emptying commodes.
Assess prior and present toileting patterns; establish a routine incorporating these habits. Bowel or bladder program efficacy improves with consideration of natural patterns. Health history explores function, symptoms, risk factors, micturition perception, and functional capabilities. Voiding patterns and records are helpful in care planning.
Assess ability to verbalize voiding needs and use urinal/bedpan. Bring the patient to the bathroom regularly if suitable. Patients may have neurogenic bladders or lack concentration initially but often regain control during recovery. Bathroom access, clothing manipulation, and toilet use are important functional factors related to incontinence. Cognitive function also needs assessment.
Provide privacy during toileting. Lack of privacy reduces bowel/bladder emptying ability, diminishes dignity and self-worth.
Maintain patient dignity during toileting. Be respectful in explaining and providing care. Use acceptable terms like “brief” instead of “diaper.” Never show reluctance or burden when assisting.
Offer bedpan or toilet every 1-1.5 hours during the day and three times at night. This reduces incontinence. Intervals can lengthen as patients verbalize needs. Habit training can be successful. For confused patients, toilet according to schedule before involuntary elimination.
Closely observe for balance loss or falls. Keep commode and toilet tissue nearby at night. Patients may rush to the toilet at night due to fear of soiling, increasing fall risk. A padded commode or bedside toilet is an alternative if a private toilet is not accessible. Elevated toilet seats can also help.
Ensure clear path to the toilet. Remove obstacles blocking the path. If patients use furniture for balance, moving it increases fall risk. Ensure well-lit and visible paths.
Keep call light within reach; teach prompt calling. Allows staff sufficient time to assist with transfers. Attempting to toilet unassisted can lead to falls.
Assist with clothing manipulation. Difficult clothing can compromise continence. Barrier-free access and clothing modification aid self-care and continence.
Assist to a comfortable position. Normal or comfortable positions enhance urine flow by gravity—standing for males, squatting or leaning forward for females.
Consider commode/toilet use as early as possible. Commode use is more effective than bedpans. Avoid bedpans if possible; if necessary, position patient on left side with legs flexed and head elevated 30-45 degrees.
Recognize prior bowel habits and restore a normal regimen. Supports retraining and prevents constipation and impaction. Record defecation time, stool character, intake, cognition, and toileting ability for 5-7 days to design a bowel program for fecal incontinence.
Increase dietary bulk, fluid intake, and activity. High-fiber diet (vegetables, fruit, bran) prevents constipation and stimulates peristalsis. 2-3 liters of daily fluid intake unless contraindicated. Prune juice (120 mL) 30 minutes before a meal can help. Physical activity increases peristaltic activity.
Do not restrict fluid intake. Sufficient intake (2000-3000 mL daily) is needed. Avoid large amounts before bed to reduce nighttime voiding.
Establish a bladder or bowel training schedule. Useful for cognitively intact patients with incontinence. Develop a voiding schedule based on assessment data. Regularity, timing, nutrition, fluids, and positioning promote predictable toileting.
Encourage pelvic floor exercises. Kegel exercises strengthen pelvic floor muscles. Instruct patients to tighten muscles for four seconds, 10 times, 4-6 times daily.
Limit incontinence pad/diaper use. Pads manage, not solve, incontinence and can have negative psychological effects.
Pay attention to nonverbal cues for toileting needs. Respond promptly to cues. Dementia patients may have accidents due to disorientation or delayed recognition of need.
6. Interventions for Feeding Self-Care Deficit
Patients needing feeding assistance include weakened older adults, visually impaired individuals, those on bed rest, or those with hand disabilities. Nursing care plans must include meal assistance.
6.1. Oral Cavity and Nutritional Status Assessment
Assess patient’s oral hygiene practices. Provides direction for etiological factors and education. Assess dental visits, self-care abilities, and mouth problems during health history. Oral hygiene data helps determine learning needs and incorporate preferences into care plans.
Assess teeth, gums, membranes, and tongue for color, moisture, texture, irritation, and infection. Use a moist, padded tongue blade to retract cheeks, lips, and gums for inspection. Normal findings are moist, smooth, soft, glistening, and elastic texture. Older adults may have dry mucosa due to reduced salivation.
Assess nutritional status. Poor food choices contribute to dental problems. Poor dentition affects food consumption, with tooth loss leading to reduced fiber intake from fruits and vegetables. Assess tobacco and alcohol use, appetite changes, eating patterns, and unexplained weight changes.
Assess dental appliance fit. Evaluation suggests causes and guides patient education. Inspect dentures for condition, broken or worn areas. Ill-fitting dentures and irritated areas are abnormal.
Assess mouth dryness and breath odor. Saliva is vital for clean teeth. Halitosis can result from dry mouth, dentition, or medical conditions. Dry mouth (xerostomia) occurs with reduced saliva. Patients with NG tubes or oxygen therapy are prone to dry membranes. Reduced saliva in older adults also causes dry mouth and thinning mucosa.
Assess ability to complete oral care. Patients with impaired coordination, cognition, energy, or activity restrictions need assistance.
Assess financial problems affecting dental hygiene. Patients may be too proud to ask for help or unaware of community services. Critical illness can lead to ventilator-associated pneumonia if oral care is inadequate, increasing hospital stay, costs, and mortality. Long-term care facilities often have regular dentist visits for special needs patients.
Assess toothache complaints. Caries and abscesses are common and painful, requiring dental evaluation. Both are linked to tartar and plaque. Plaque is a soft film adhering to teeth enamel. Unchecked plaque forms tartar, a hard deposit at gum lines.
Assess “fear of dentists” role in avoiding care. Past negative experiences may cause fear and discomfort expectations. Accurate information can reduce fear. Inform patients about procedures to eliminate prejudices. Patients with high dental fear may need psychiatric support (Yildirim, 2016).
6.2. Oral Hygiene Interventions
Provide routine mouth care including toothbrushing with soft-bristle toothbrush and fluoride toothpaste regularly. Brush teeth at a 45-degree angle in an up-and-down motion at least twice daily, including gums and tongue. Replace toothbrushes when bristles wear down. Ultrasonic toothbrushes are alternatives for dexterity issues. Brushing prevents plaque buildup, removes food particles, and stimulates gum circulation.
Teach gentle flossing with unwaxed dental floss. Flossing promotes gum health and prevents plaque. Unwaxed floss is more effective at removing particles despite being more prone to fraying.
Instruct patient to rinse with warm saline or antiplaque mouth rinse. Promotes oral hygiene. Normal saline rinse is effective for cleaning and moisturizing. Vigorous rinsing loosens and removes particles.
Teach denture removal and cleaning nightly. Prevents mucosal irritation. Clean dentures daily, scrubbing with a toothbrush, rinsing, and reinserting. Use dentifrice or commercial cleaners.
Assist with oral hygiene post-meal and as needed. Regular brushing, especially post-meal, is vital. Good hygiene includes gum stimulation, brushing/flossing, and mouth rinsing. Nurses help patients maintain oral hygiene by assisting or teaching.
Assist with flossing. Nurses can assist patients in flossing independently or floss for alert, cooperative patients. Wrap floss around fingers, start at the back, work around, use thumbs and index fingers for upper teeth, index fingers for lower teeth. Move floss up and down, gently sliding to gum line. Rinse with water or mouthwash.
Advise avoiding high-sugar foods. Cause tooth decay. Free sugars are key in caries development. Bacteria metabolize sugars, producing acid that demineralizes enamel and dentine. Limit sugar-sweetened beverages and juices (World Health Organization, 2017).
Apply lip and oral mucosa lubricant as necessary. Lubrication promotes comfort and prevents dryness. Avoid mineral oil; use water-soluble moisturizers to hydrate tissues.
Instruct patients to obtain regular dental checkups and follow-ups. Early problem identification. Checkups every six months for adolescents and adults. Regular checkups needed for preschoolers when permanent teeth appear. Older adults with self-care deficits are at higher risk for cavities and periodontal disease.
Educate on oral hygiene importance. Knowledge prevents problems. Nurses teach specific hygienic measures and identify problems needing dentist intervention and referral.
Educate on healthy diet importance despite dentition problems. Adequate nutrition is vital. WHO initiatives to reduce caries include clear nutrition labeling, sugar marketing regulation, improved food environments in schools, and promoting clean water access.
6.3. Feeding Interventions
Allow self-feeding as soon as possible (using unaffected hand if appropriate). Assist with setup. Be sensitive to patient embarrassment and loss of autonomy. Help patients self-feed whenever possible.
Encourage independent eating and drinking as much as possible. Provide cues and time for eating and drinking.
Ensure dentures and eyeglasses are worn if needed. Optimize senses and strengths. Dentures improve chewing.
Position patient comfortably for feeding. Upright or semi-Fowler’s position reduces aspiration risk.
Provide a pleasant meal environment. Minimize noise, distractions, and complex tablecloths. Use contrasting plate colors to enhance food visibility.
Provide proper utensils (wide-grip, rocking knife, plate guard, straw). Special utensils aid self-feeding. Straws help with liquids.
Use adaptive feeding aids. Rims and plate guards help scoop food. Suction cups or damp cloths stabilize plates. No-spill mugs and two-handled cups aid impaired coordination.
Ensure diet consistency suits chewing and swallowing ability (speech therapist assessment). Thickened semi-solid foods are easier to swallow and less likely to be aspirated. Use National Dysphagia Diet (NDD) liquid and solid food levels.
Promote small, frequent meals or snacks. Select small portions. Allow ample chewing and swallowing time.
Serve finger foods. For patients unable to use utensils, offer finger foods and physically guide their hand to the food.
Provide adequate fluid intake with meals and throughout the day. Offer fluids after every few mouthfuls of solid food. Ensure fluids are always available.
If vision is affected, guide food placement. After CVA, patients may have unilateral neglect. Ask about preferred eating order. For visually impaired, describe food being given.
Use the clock system for visually impaired patients. Describe food placement as clock positions, e.g., “Potatoes at 8 o’clock.”
Provide a supportive, non-embarrassing feeding setting. Embarrassment may hinder self-feeding. Address patient depression related to needing help.
Maintain familiar feeding routines. Keep routines practical and independence-promoting. Avoid childlike feeding techniques.
Stay with the patient during meals. Communicate while assisting. Engage with patients during meals. Eating is a cultural experience that builds connections.
Document food and fluid intake regularly. Documentation provides insight into patient health and well-being. Estimate intake to the nearest 25%. Document fluid intake in milliliters or cubic centimeters.
Refer to community resources for nutritional needs. Programs like Meals-on-Wheels and grocery delivery services are available. USDA’s Supplemental Nutrition Assistance Program aids the poor.
7. Interventions for Transferring/Ambulating
Transferring is moving a patient from one place to another. Assist with transfers and ambulation as soon as permitted and when the patient’s condition is stable. Regaining walking ability improves morale.
7.1. Assisting with Transferring or Ambulating
For moderate assistance, place arms under patient’s armpits with hands on their back. Forces weight forward. Support and gently assist during position changes, avoiding pulling weak extremities to prevent dislocation.
For maximal assistance, use a gait belt. Maximizes support and protects caregivers from injury. Gait belts aid transfers and ambulation. Use handles to control movement. Raise bed to a height allowing feet flat on the floor. Grasp gait belt, pull forward, place knee against weak knee, encourage weight on strong side, and encourage arm use.
Aid ambulation; direct use of canes, walkers, and crutches. Promote safety, balance, and support. Provide standby support, instruct on assistive device use, or use sit-to-stand lifts. Have patients sit up for one minute before dangling legs, then sit on the bed edge. Stand on weak side, assist to stand for one minute. Place cane in strong hand, ensure proper foot-cane sequence, and walk on the weak side.
Utilize strategies for upright sitting. Reclining wheelchairs, tilt tables, and gradual head elevation help patients assume a 90-degree sitting position, especially after prolonged recumbency.
Use adaptive devices during transfers. Lightweight wheelchairs with removable armrests and leg rests minimize obstacles. Tub seats and raised commode seats ease transfers.
Promote upper extremity muscle strengthening. Push-up exercises in bed strengthen arm and shoulder muscles.
Assist bed-to-wheelchair transfers. Weight-bearing transfer involves standing, pivoting, and sitting. Transfer boards aid non-weight-bearing transfers. Ensure finger safety during transfer board use.
Ensure transfer safety guidelines. Lock wheelchairs and beds before transfer. Remove detachable parts. Place one board end under buttocks, the other on the destination surface. Instruct patients to lean forward, push up, and slide across.
Ensure proper adaptive device fit. Crutches: 5 cm below axilla, hand grip for 20-30 degrees elbow flexion. Walkers: 20-30 degrees elbow flexion when hands are on grips. Canes: Handle level with greater trochanter, tip 15 cm lateral to the 5th toe, elbow flexed at 30 degrees.
7.2. Providing Education on Assistive Device Use
Evaluate adaptive equipment needs through therapy (e.g., large-button phones). Provide tools for home communication. Ropes attached to beds can aid movement.
Provide felt-tip pens. Assess splint needs for writing hand. Felt-tip pens require less pressure. Splints and adaptive grips aid writing.
Instruct on crutch use and gaits. Crutches are for partial or non-weight-bearing ambulation. Good balance, cardiovascular reserve, and upper extremity strength are needed. Teach 4-point, 2-point, 3-point, swing-to, and swing-through gaits.
Provide client education on ambulatory device use. Use tripod stance with crutches. Walk alongside patients using walkers, holding at waist if needed. Instruct patients not to pull up using walkers and to look up when walking. Instruct patients using canes to move opposite arm and leg together.
Instruct on gait for adaptive devices. Pick-up walkers: lift and move forward with each step. Rolling walkers: roll forward and walk automatically. Canes: advance cane with the affected leg.
Instruct on stair descent with crutches or canes. Crutches: advance crutches to lower step, affected leg first, then unaffected leg. Canes: step down on affected extremity, place cane, then unaffected extremity on the lower step.
Instruct on stair ascent with crutches or canes. Crutches: advance unaffected leg first, then crutches and affected leg. Canes: step up with unaffected extremity, then cane and affected extremity.
8. Encouraging Social Support
Lack of support can hinder self-care and ADL management. Identify support networks and involve family or community resources.
Educate family and significant others to promote autonomy and intervene when patients tire or become aggravated. Displays caring without hindering autonomy. Appropriate assistive care prevents harm without disappointment. Encourage functional independence as long as possible.
Inform family to allow maximum patient self-care. Fosters independence, self-esteem, and rehabilitation. Note: can be challenging for caregivers depending on disability extent and time needed.
Involve patient input in planning schedules. Considering patient wishes enhances their quality of life. Families benefit from anticipatory guidance and long-term planning.
Consider energy-conservation techniques. Saves energy, reduces fatigue, and improves task capability. Use pacing to spread activities throughout the day.
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
See also
Other recommended site resources for this nursing care plan:
