Self-Care Deficit: Nursing Diagnosis, Care Plans, and Interventions

What is Self-Care Deficit?

In the realm of nursing, understanding self-care is paramount. Rooted in Dorothea Orem’s Self-Care Deficit Theory, self-care is defined as the deliberate actions individuals undertake to maintain their life, health, and overall well-being. Effective self-care is crucial for structural integrity, optimal human functioning, and healthy development. Orem identified three categories of self-care requirements: developmental, health deviation, and universal self-care requisites. Universal self-care requisites are commonly known as Activities of Daily Living (ADLs). When an individual experiences a deficit in these universal self-care requisites, it significantly impacts their daily life, affecting fundamental tasks such as bathing, dressing, toileting, and maintaining proper body positioning. These changes highlight the importance of recognizing and addressing self-care deficits in patient care.

Understanding Activities of Daily Living (ADLs) and Instrumental ADLs (IADLs)

Activities of Daily Living (ADLs) are the cornerstone of independent living, encompassing the everyday routines individuals perform. These include essential self-care tasks such as eating, bathing, dressing, grooming, working, managing a home, and engaging in leisure activities. ADLs are fundamental actions individuals autonomously perform to maintain and enhance their health and well-being. However, various circumstances can lead to self-care deficits. These deficits can be temporary, such as during recovery after surgery, or progressive, hindering an individual’s ability or motivation to meet their self-care needs. Mental health conditions, such as depression, can significantly impact self-care by diminishing motivation and energy levels, further exacerbating self-care deficits. Recognizing the spectrum of ADLs and the factors that can impair them is crucial for effective nursing care planning.

Beyond basic ADLs, Instrumental Activities of Daily Living (IADLs) represent a more complex set of skills essential for independent living. IADLs encompass tasks like meal preparation, grocery shopping, household management, financial management, and transportation. These activities demand higher-level cognitive and organizational abilities compared to basic ADLs. The ability to perform IADLs significantly influences an individual’s capacity to live independently and maintain a high quality of life. For older adults and individuals with disabilities, efficient performance of IADLs is crucial for maintaining autonomy and aging in place, potentially delaying or preventing the need for assisted living or long-term care facilities. Therefore, assessing both ADLs and IADLs is vital for a comprehensive understanding of a patient’s self-care capabilities and needs.

Nurses play a pivotal role in recognizing and addressing self-care deficits. By identifying these deficits, nurses can provide essential support to help individuals regain independence and promote their physical and mental well-being. Implementing targeted interventions and offering necessary assistance are key nursing responsibilities. Through these actions, nurses empower patients to resume and maintain their self-care practices and activities of daily living, contributing to improved patient outcomes and quality of life.

Nursing Care Plans for Self-Care Deficit

Managing self-care deficits and supporting Activities of Daily Living (ADLs) requires a collaborative approach involving healthcare professionals, patients, and their caregivers. Nurses are central to this process, guiding patients toward optimal self-care, teaching essential skills, and providing necessary assistance while fostering independence. Incorporating family members and caregivers into the care planning process is crucial for building a robust support system and ensuring continuity of care beyond the healthcare setting. This collaborative strategy strengthens the patient’s overall care and promotes long-term self-care management.

Nursing Problem Priorities for Self-Care Deficit

When caring for patients with self-care deficits and ADL limitations, nurses prioritize the following:

Limited Physical Mobility: Impaired mobility is a primary concern as it directly affects a patient’s ability to perform ADLs and self-care tasks. Interventions focused on enhancing mobility and providing assistive devices are critical to address this priority. Improving mobility is often the foundational step in enabling patients to regain self-care independence.
Self-Care Deficits: Addressing the self-care deficits themselves is a core nursing priority. Patients struggling with self-care activities require focused and individualized attention. Nursing interventions in this area include teaching adaptive techniques, providing appropriate assistive aids, and addressing underlying cognitive or physical barriers that hinder self-care abilities. The goal is to directly support patients in overcoming their specific self-care challenges.
Psychosocial Concerns: Self-care and ADL limitations often lead to psychosocial issues. Patients may experience difficulties in coping, decreased self-esteem, anxiety, and depression. These emotional and psychological factors can significantly impact a patient’s motivation and ability to engage in self-care and ADLs. Recognizing and addressing signs of psychosocial distress is crucial for nurses to provide holistic care and ensure timely interventions to support the patient’s mental and emotional well-being.

Nursing Assessment for Self-Care Deficit

A thorough nursing assessment is fundamental for identifying self-care deficits and planning effective nursing care. By comprehensively evaluating a patient’s health, functional abilities, environment, and support systems, nurses can develop tailored care plans. This holistic assessment approach is essential for preventing complications, promoting healing, and maximizing patient independence. Collaborative discussions with the patient and family, coupled with regular reassessments, are integral to ensuring a patient-centered and dynamic approach to self-care management.

During assessment, nurses should gather both subjective and objective data.

Subjective and Objective Data to Assess:

Decreased Motivation: Observe for a lack of enthusiasm or initiative in performing self-care or ADLs. This can manifest as reluctance to participate in hygiene routines or a general disinterest in personal care tasks.
Weakness or Fatigue: Assess for reports of generalized weakness or persistent fatigue. These symptoms can significantly impair a patient’s ability to perform ADLs and require further investigation to determine underlying causes.
Pain or Discomfort: Evaluate the presence, location, and intensity of pain or discomfort. Pain can be a major barrier to self-care, limiting movement and willingness to engage in ADLs.
Perceptual or Cognitive Impairment: Assess for any cognitive deficits, such as confusion, disorientation, or memory problems, as well as perceptual issues. Cognitive and perceptual impairments can directly impact a patient’s ability to understand and perform self-care tasks safely and effectively.
Inability to Perceive a Body Part: Determine if the patient exhibits an inability to sense or be aware of a body part. This may be due to neurological conditions and can significantly affect self-care, particularly tasks involving the affected area.
Neuromuscular or Musculoskeletal Impairment: Assess for limitations in muscle strength, coordination, range of motion, or skeletal abnormalities. These impairments directly impact physical abilities needed for ADLs.
Medically Indicated Restrictions: Identify any medical orders that restrict mobility, such as complete bed rest. These restrictions will dictate the level of assistance required for self-care.
Therapeutic Procedures Limiting Mobility: Note any therapeutic procedures or devices, such as casts or IV therapy, that restrict movement and impact self-care abilities.
Severe Anxiety or Depression: Evaluate the patient’s emotional state for signs of severe anxiety or depression. These conditions can significantly reduce motivation and energy for self-care.
Poor Personal Hygiene: Observe for visible signs of poor hygiene, such as unkempt appearance, body odor, or uncleanliness. This is a direct indicator of self-care deficit.
Forgetfulness and Misuse of Objects: Assess for forgetfulness or instances of misusing or misidentifying common objects. These signs can indicate cognitive impairment affecting safety and self-care capacity.

Nurse assisting elderly patient with walking

Nursing Diagnosis for Self-Care Deficit

Following a comprehensive assessment, nurses formulate nursing diagnoses to specifically address the challenges of self-care deficit. These diagnoses are based on the nurse’s clinical judgment and understanding of the patient’s unique condition. While nursing diagnoses provide a structured approach to care, their application may vary across clinical settings. Ultimately, the nurse’s expertise and clinical reasoning guide the care plan to prioritize each patient’s individual needs. Common nursing diagnoses relevant to self-care deficit include:

Self-Care Deficit (Bathing)
Self-Care Deficit (Dressing)
Self-Care Deficit (Feeding)
Self-Care Deficit (Toileting)
Impaired Physical Mobility
Fatigue
Activity Intolerance
Risk for Falls
Disturbed Body Image
Hopelessness
Powerlessness

Nursing Goals for Self-Care Deficit

Establishing clear and measurable goals is essential for guiding nursing interventions and evaluating patient progress. Goals and expected outcomes for patients with self-care deficits may include:

Improved ADL Performance: The patient will demonstrate measurable improvement in performing Activities of Daily Living (ADLs). This is evidenced by increased independence in completing self-care tasks such as bathing, dressing, and grooming, ideally without assistance, or with minimal assistance and within a reasonable timeframe.
Understanding of Self-Care Management: The patient will verbalize and demonstrate understanding of effective self-care management techniques relevant to their specific needs. This includes correctly adhering to prescribed medication regimens, dietary guidelines, therapeutic exercises, or use of assistive devices within a reasonable timeframe.
Active Participation in Self-Care Education: The patient will actively engage in self-care education and training sessions. This active participation is demonstrated by consistent attendance, engagement in educational sessions focused on self-care techniques, asking pertinent questions, and proactively seeking resources and information to enhance their self-care abilities within a reasonable timeframe.

Nursing Interventions and Actions for Self-Care Deficit

Nursing interventions for self-care deficit are multifaceted and patient-centered. They involve a range of actions including thorough client assessment, setting realistic and achievable goals, providing comprehensive education and training, developing personalized care plans, offering consistent support and monitoring patient progress, involving family and caregivers in the care process, collaborating effectively with other healthcare professionals, regularly evaluating the effectiveness of interventions, and providing crucial emotional support to the patient and their family. These therapeutic nursing interventions aim to empower patients, maximize their independence, and improve their overall quality of life.

1. Client Assessment: Foundation of Self-Care Deficit Management

Comprehensive and ongoing assessment is the cornerstone of effective nursing care for self-care deficits. Nurses must diligently observe and evaluate a patient’s current ability to perform ADLs to accurately determine their level of independence in self-care and identify specific needs for nursing interventions. Furthermore, identifying the underlying causes of these limitations is critical. Understanding the etiology of the self-care deficit enables nurses to develop individualized care plans and implement appropriate interventions tailored to each patient’s unique circumstances.

1.1. Assessment of Functional Ability

Utilize a standardized assessment tool to evaluate the client’s strength and ability to perform Activities of Daily Living (ADLs) safely and efficiently daily. A tool like the Functional Independence Measure (FIM) is highly recommended. The FIM is a widely recognized and validated tool that measures 18 self-care items, including eating, bathing, grooming, dressing, toileting, bladder and bowel management, transfers, ambulation, and stair climbing. Scoring on the FIM is based on a seven-point scale that quantifies the patient’s level of independence and the amount of assistance required for each ADL. The Alph FIM, a shorter version, is frequently used in acute care settings within 72 hours of admission to quickly assess functional independence and assistance needs.

Evaluate the client’s need for assistive devices. Assistive devices play a crucial role in enhancing a patient’s confidence and ability to perform ADLs. If a patient demonstrates difficulty with a particular ADL, consider whether an adaptive or assistive device could be beneficial. These devices can be commercially purchased or custom-made by occupational therapists, nurses, patients, or family members. Examples include reachers, dressing sticks, long-handled shoehorns, button hooks, and specialized utensils.

Determine the necessity for home healthcare services after hospital discharge. Due to shorter hospital stays, patients are often discharged in a more debilitated state, requiring greater assistance at home. Occupational therapists are valuable resources for accessing a wide array of self-help devices and can play a vital role in discharge planning. A primary goal of rehabilitation is to facilitate the patient’s return to their home environment while equipping them to manage their disability effectively. Discharge planning should commence upon admission, prioritizing the patient’s functional potential and home support needs.

Quantify the client’s level of independence. Systematically document the patient’s degree of independence by directly observing their performance of specific activities, such as eating or dressing. Record the time taken to complete tasks, assess their mobility, coordination, and endurance, and meticulously document the amount and type of assistance required. The Barthel Index is another useful tool for measuring independence in ADLs, continence, toileting, transfers, and ambulation.

Assess cultural and belief systems that may influence self-care practices. Pre-existing cultural norms and beliefs can significantly influence a patient’s willingness to engage in certain self-care practices. Cultural and ethnic beliefs about hygiene and personal care vary widely. Nurses must be sensitive to and respectful of these beliefs. Address any cultural issues or concerns with the patient and family and communicate pertinent findings to the healthcare team to ensure culturally competent care.

Evaluate the client’s gait and body alignment. Alignment assessment includes careful inspection of the patient’s posture while standing to identify any postural variations or learning needs for maintaining proper posture. Gait assessment focuses on evaluating the patient’s walking pattern to determine their mobility level and assess their risk for injury. Observe gait as the patient walks into the room or during a short walk down the hallway.

Identify any factors that impede the client’s abilities or impose limitations on movement. Gather data to pinpoint hindrances or restrictions to the patient’s movement and the need for assistance. Observe how the patient’s illness affects their ability to move and determine if their condition contraindicates any specific exertion, positions, or movements. Assess for mechanical barriers to movement such as intravenous lines, casts, drainage tubes, or traction devices.

Closely monitor the client’s vital signs. Vital signs provide valuable insights into a patient’s physiological response to activity. By establishing an appropriate activity level, nurses can predict a patient’s strength and endurance for activities requiring similar energy expenditure. Measure vital signs before, during, immediately after activity cessation, and three minutes post-activity after rest. These measurements help assess activity tolerance and guide activity progression.

1.2. Identification of Etiology and Client Preferences

Acknowledge and respect the client’s preferences regarding food, personal care items, and other choices. Patients are more likely to adhere to treatment regimens that align with their individual preferences and values. Self-care interventions are more effective when they are accessible, acceptable, and affordable, promoting greater self-determination, self-efficacy, autonomy, and engagement in health management for both patients and caregivers.

Pinpoint the specific cause of each self-care deficit. Examples include visual impairments, muscle weakness, or cognitive impairment. Different underlying etiologies necessitate tailored interventions to effectively address self-care deficits. A comprehensive functional assessment should evaluate secondary conditions related to the patient’s disability, such as muscle atrophy and deconditioning, skin integrity issues, bowel and bladder control problems, and sexual dysfunction. Simultaneously, identify residual strengths and abilities unaffected by the disease or disability to build upon patient capabilities.

Assess the client’s gag reflex and determine the need for a swallowing assessment by a speech therapist before initiating oral feeding. An absent gag reflex or impaired chewing and swallowing abilities significantly increase the risk of choking and aspiration. The gag reflex is assessed by gently stimulating the posterior pharynx with a cotton-tipped applicator, first on one side of the uvula and then the other. A normal response is symmetrical uvular elevation and a gag reflex upon stimulation.

Monitor for impulsive behaviors or actions indicative of impaired judgment. Impulsivity and altered judgment may necessitate additional interventions and safety measures. Self-care is not solely a physical act but also an affective process involving attitude, intention, and self-determined choice. While a patient may have the desire and motivation for self-care, cognitive or judgment deficits can hinder their ability to fully and safely engage in self-care activities.

Evaluate any recent changes or difficulties in mobility that impact activity levels. An activity and exercise history is typically included in the comprehensive nursing history. If a patient reports recent changes in mobility patterns or difficulties with movement, a more detailed history is essential. This detailed history should include the specific nature of the problem, onset, frequency, known causes, impact on daily living, coping strategies used, and the effectiveness of these strategies.

Assess personal factors that may influence self-care abilities. Research has highlighted the correlation between personal factors and self-care practices. Age is a statistically significant predictor of self-care maintenance, management, confidence, symptom monitoring, and overall self-care behavior. Other factors such as gender, employment status, marital status, family income, and education level also influence self-care practices. Consider these personal factors in the assessment and care planning process.

Evaluate the adequacy of the client’s social support system. A strong social support network, including family, caregivers, and community resources, is significantly associated with improved self-care outcomes. The presence of a caregiver or family member can influence the level of self-care maintenance, while overall social support is often linked to better self-care management. Assess the availability and quality of social support to identify potential resources and address support deficits.

2. Promote Independence and Enhance Self-Esteem

Empowering patients to maintain their independence is crucial for fostering dignity, self-worth, and minimizing the need for long-term institutional care. Nursing interventions should actively promote independence in self-care activities whenever safely possible.

Establish short-term, achievable goals collaboratively with the client. Setting realistic, short-term goals is vital to prevent frustration and promote a sense of accomplishment. Desired outcomes of self-care interventions include stability, effective symptom management, prevention of complications, preservation of functional status, sustained ability to self-care, and the capacity to direct care decisions based on personal choices. To achieve these outcomes, self-care plans must be tailored to the individual patient’s specific condition and abilities.

Guide the client in accepting necessary levels of dependence. Patients may need assistance in recognizing the safe boundaries between striving for independence and requesting assistance when needed. For patients with severe disabilities, complete independence in self-care may be unrealistic. Nurses play a crucial role in helping patients accept necessary self-care dependence without diminishing their self-worth. Emphasize independence in other areas, such as social interaction and decision-making, to foster a positive self-concept.

Provide consistent positive reinforcement for all self-care activities attempted, even partial achievements. External positive reinforcement is a powerful motivator for continued effort. Patients often struggle to recognize their own progress. Simplify daily activities by breaking them down into small, manageable steps to facilitate a sense of accomplishment upon task completion. Celebrate even small victories to encourage continued participation.

Provide supervision during self-care activities until the client demonstrates skill proficiency and safety in independent care. Regularly reassess skill levels and environmental safety. A patient’s self-care abilities can fluctuate over time and require ongoing assessment. Occupational therapists can offer valuable suggestions for task simplification and recommend adaptive equipment to enhance independence and safety. Direct supervision may be necessary initially, but always prioritize maintaining personal dignity and autonomy. Encourage patient choice and active participation in self-care activities to the maximum extent possible.

Implement strategies to promote independence, but intervene promptly when the client cannot function safely. Providing an appropriate level of assistive care is essential to prevent injury during self-care activities without causing undue frustration. Nurses are key in helping patients accept both temporary and permanent dependence as needed. Recognize that even seemingly simple self-care tasks can require intense concentration and considerable effort for individuals with disabilities. Adapt self-care interventions to accommodate the patient’s lifestyle and abilities.

Maximize the client’s level of independence. The overarching goal of rehabilitation is to achieve the highest possible level of independence. Self-care activities can be accomplished in various ways using common sense and creativity to promote increased independence. For example, encourage a patient who has difficulty reaching their head to lean forward to facilitate washing their hair.

Establish regular routines and allocate sufficient time for the client to complete self-care tasks. Established routines become automatic and require less conscious effort, promoting efficiency and reducing fatigue. Routines help patients organize and execute self-care skills more effectively. Repetition, practice, and clear demonstrations are essential for patients to achieve maximum independence in personal care activities. Identify the patient’s optimal time of day for self-care activities, encourage focused concentration, address endurance limitations that may impact safety, and provide cues and reminders as needed for patients with specific cognitive or physical disabilities.

Actively motivate the client to participate in self-care. Impaired mobility, psychological factors, and family or cultural expectations can influence a patient’s willingness to engage in self-care. Nurses must actively motivate patients to learn and accept responsibility for their self-care. Encourage patients to adopt an “I’d rather do it myself” attitude, fostering self-efficacy and independence.

Focus on the client’s strengths and optimal level of function. Emphasize the patient’s existing strengths and functional abilities when guiding, educating, and supporting them in learning and performing self-care activities. Consistency in instructions and assistance provided by all healthcare professionals is crucial for facilitating the learning process. Document the patient’s performance to track progress and use it as a motivational tool for morale building and positive reinforcement.

Encourage the client to join a support group or participate in a self-care program. Support groups offer valuable peer support and allow patients to discover creative solutions to self-care challenges from others with similar experiences. Self-care programs are typically structured educational forums where patients can acquire skills and knowledge to better manage their health conditions independently. These programs empower patients and enhance self-management abilities.

3. Providing Interventions for Self-Care Deficit in Bathing

Bathing difficulties can arise from challenges in washing the body or specific body parts, accessing a water source, and regulating water temperature and flow. Bathing is essential for removing accumulated oil, perspiration, dead skin cells, and bacteria, promoting hygiene and a sense of well-being.

Determine the most appropriate type of bath for the client’s needs. Baths are broadly categorized as cleansing or therapeutic. Cleansing baths are for hygiene purposes and include complete bed baths, self-help bed baths, partial baths, bag baths, towel baths, tub baths, and showers. Therapeutic baths are administered for specific physical effects, such as soothing irritated skin or treating localized areas. Medications may be added to therapeutic baths to enhance their effects.

Always verify the water temperature before initiating a bath. Bathwater should feel comfortably warm to the patient. Individual sensitivity to heat varies. Generally, water temperature should be between 43℃ to 46℃ (110℉ to 115℉). While a patient may be able to verify temperature, those with decreased circulation or cognitive impairments may not accurately assess water temperature. The nurse must check the temperature to prevent burns from excessively hot water.

Provide assistance to clients requiring a therapeutic bath. Therapeutic baths are typically administered in a tub filled to one-third or one-half capacity. Instruct the patient to remain in the bath for a prescribed duration, usually 20 to 30 minutes. If the treatment is for the back, chest, or arms, ensure these areas are adequately immersed in the medicated solution.

Utilize skin care agents appropriate for the client’s skin condition. Some patients have sensitive skin that reacts to chemicals in certain skin care products. Commonly used bathing agents include chlorhexidine gluconate, soap, and bath oils. Soap reduces surface tension and aids in skin cleansing, with some soaps containing antibacterial agents. Chlorhexidine gluconate is frequently used in critical care settings for its antimicrobial properties, often in the form of disposable cloths saturated with the solution and skin-moisturizing substances.

Exercise caution when bathing clients with intravenous (IV) therapy. Special precautions are needed when bathing patients receiving IV therapy. Easy-to-remove gowns with Velcro or snap fasteners along the sleeves are recommended. If special gowns are unavailable, exercise extra care when changing the patient’s gown after bathing. Always reassess the IV site after bathing to ensure the IV connection remains secure and intact.

Adhere to universal precautions during bathing, especially during perineal care. Practice universal precautions, particularly during perineal care, to prevent infection transmission. While routine glove use for all bathing may not be necessary, use clinical judgment to determine when gloves are indicated and explain the rationale to the patient.

Ensure client privacy throughout the bathing procedure. Hygiene is a personal matter; therefore, always maintain patient privacy. Draw curtains around the bed or close the room door when providing or assisting with bathing. Some facilities utilize privacy signages to further enhance patient privacy during personal care activities.

Prepare the client for the bathing procedure. Offer to include a family member or significant other in the bathing process if desired by the patient. Provide a bedpan or urinal or ask if the patient needs to use the toilet or commode before bathing. Warm water and activity can stimulate the urge to void, and voiding beforehand enhances patient comfort. Voiding before perineal care is also advisable.

Prepare the client’s environment for bathing. Ensure all windows and doors are closed to maintain a comfortable room temperature during bathing. Air currents can increase heat loss from the body through convection, potentially causing shivering and chilling during the procedure.

Encourage the client to perform as much self-care as possible during bathing. Promote independence, exercise, and self-esteem by encouraging patients to participate actively in bathing. However, caution patients against excessive bathing, which can strip the skin of sebum, leading to dryness. This is particularly relevant for older adults, who naturally produce less sebum.

3.1. Providing a Bed Bath

Position the client and adjust the bed to an appropriate and comfortable working height. Raise the bed to a comfortable height for the nurse, lower the side rail on the working side, and ensure the opposite side rail remains up for safety. Move the patient closer to the nurse to minimize reaching and straining, promoting good body mechanics for the nurse.

Utilize a bath mitt to wash the client. A bath mitt, created from a washcloth, retains water and heat more effectively than a loosely held cloth and prevents washcloth ends from dragging across the skin, minimizing irritation. To make a bath mitt:

Lay your hand flat on the washcloth.
Fold the top corner over your hand.
Fold the side corners over your hand.
Tuck the remaining corner under the cloth on the palm side to secure the mitt.

Begin washing with the client’s face, the cleanest area, and proceed downward to the feet. Place a towel behind the patient’s head to protect the bed linens. Wash the eyes with water only, drying them thoroughly. Use a separate corner of the washcloth for each eye, wiping from the inner to outer canthus to prevent cross-contamination and minimize the risk of infection. Then, wash, rinse, and dry the patient’s face, ears, and neck.

Wash the arms and hands. Place a towel lengthwise under the patient’s arm to protect the bed from moisture. Using long, firm strokes from wrist to shoulder, wash the elevated arm, including the axilla (armpit). Firm strokes in a distal-to-proximal direction promote circulation by enhancing venous blood return. Rinse and dry the arm thoroughly. The patient may also immerse their hands in a washbasin to wash themselves if able. Repeat these steps for the other arm and hand.

Wash the chest and abdomen. Place a bath towel lengthwise across the chest, then fold the bath blanket down to the patient’s pubic area to maintain warmth and minimize unnecessary chest exposure. Lift the towel to bathe the chest and abdomen using long, firm strokes with a bath mitt. Pay particular attention to areas under the breasts in women and any skin folds. Rinse and dry these areas thoroughly.

Wash the legs and feet. Expose the leg farthest from the nurse by folding the bath blanket towards the opposite leg, ensuring the perineum remains covered. Lift the exposed leg and place a bath towel lengthwise underneath. Wash, rinse, and dry the leg using long, firm strokes from ankle to knee to thigh to promote blood circulation. Repeat these steps for the other leg. The feet can be immersed in a basin of water for washing, then dried meticulously, paying special attention to the spaces between the toes.

Wash the back and perineum. Position the patient in a prone or side-lying position facing away from the nurse. Place a bath towel lengthwise alongside the back and buttocks. Wash and dry the patient’s back from shoulders to buttocks and the upper thighs, paying close attention to the gluteal folds. Assess the patient’s ability to perform perineal care themselves.

3.2. Providing a Tub Bath or Shower

Prepare the client and the tub or shower environment. Fill the tub with water to about one-third to one-half full, maintaining a temperature of 43℃ to 46℃ (110℉ to 115℉). Ensure sufficient water depth to cover the perineal area. Cover any intravenous catheters or wound dressings with waterproof plastic coverings to keep them dry. Place a rubber bath mat or towel on the tub or shower floor to prevent slipping.

Assist the client in and out of the shower or tub. Some patients may require a shower chair due to weakness. Others may need assistance with water temperature and pressure adjustments. Instruct the patient on how to signal for help and place an “Occupied” sign on the door for privacy. Never leave patients at risk for seizures or with decreased cognition unattended in the bath or shower.

3.3. Providing Perineal Care

Position the client comfortably and appropriately. For female patients, position them in a back-lying (dorsal recumbent) position with knees flexed and legs spread comfortably apart. For male patients, position them in a supine position with knees slightly flexed and hips slightly externally rotated.

Ensure client privacy throughout perineal care. Drape the patient appropriately to minimize exposure and maintain modesty. Cover the body and legs with a bath blanket, positioning a corner at the head, the opposite corner at the feet, and the other two corners on the sides. Drape the legs by tucking the bottom corners under the inner sides of the legs.

Thoroughly clean the female client’s perineal area. Clean the labia majora first. Then, gently separate the labia to wash the folds between the labia majora and labia minora, as secretions tend to accumulate in these folds, promoting bacterial growth. Use separate sections of a washcloth for each stroke, wiping from the pubis towards the rectum to prevent microorganism transmission. Rinse and dry the area meticulously.

Thoroughly clean the male client’s perineal area. Wash and dry the penis using firm strokes. If the patient is uncircumcised, retract the foreskin to expose the glans penis for cleaning. After cleaning, gently replace the foreskin. Retraction is essential to remove smegma, which can accumulate under the foreskin and facilitate bacterial growth.

4. Providing Interventions for Self-Care Deficit in Dressing and Grooming

Difficulties in dressing and grooming can include the inability to select, put on, remove, fasten, or replace clothing items, and to maintain a satisfactory personal appearance.

Determine the appropriate level of assistance needed for dressing. This ensures the patient can dress as independently as their abilities allow. Healthcare professionals who utilize appropriate assistance strategies recognize their role in maintaining patients’ quality of life.

Maintain client privacy during dressing. Privacy is paramount for most patients during dressing. Patients may take longer to dress and may be sensitive to privacy breaches. Assess the patient’s comfort level with the gender of the caregiver assisting with dressing. Hygienic care can be embarrassing and stressful for modest individuals. Nurses must respect patient modesty, regardless of gender, and provide adequate privacy and sensitivity.

Allow the client to choose their clothing style if possible. Respect the client’s preferences and individual style. Respect the patient’s preferred dressing style. Some patients take pride in being well-dressed, while others have different priorities. Inquire about patient preferences or consult with family members if the patient cannot communicate their choices.

Offer simple clothing choices to the client. Simplify clothing choices based on the patient’s ability to choose. Organize clothing items in the order they will be needed. This encourages patient autonomy and choice. Provide comfortable, simple clothing options that are easy to put on and take off, such as cardigans or front-opening shirts instead of pullovers. Ensure only seasonally appropriate clothing is available to minimize confusion.

Provide simple, step-by-step instructions when assisting with dressing. Give short, clear instructions while handing clothing items, such as “Put on your shirt.” Sometimes, simply handing an item of clothing without verbal cues can facilitate dressing. Limit choices and lengthy instructions to avoid confusion and decision-making burden.

Utilize appropriate assistive devices for dressing, as recommended by nurses and occupational therapists. Assistive devices, such as buttonhooks or loop-and-pile closures on clothing, can enable patients to maintain independence in dressing. Adaptive devices like reachers and dressing sticks can compensate for limited reach to feet during dressing. Hospital bed features, such as head and foot elevation, can also aid patients in reaching their feet in a supported position.

Select comfortable and simple dressing options. Replace buttons and zippers with Velcro closures or opt for elastic-waist pants. Some family caregivers may resist using commercially available adaptive clothing due to concerns that it may make their loved ones appear like nursing home residents. However, Velcro closures and ties can be discreet and are often not obviously designed for individuals with disabilities.

Suggest elastic shoelaces or Velcro closures on shoes. These closures eliminate the need for tying shoelaces, reducing frustration and improving ease of use. Adaptive footwear, including shoes and socks, is customized for easy wear by patients with disabilities or reduced motor skills, featuring non-slip grips, easy closures, comfortable fabrics, and cushioned soles.

Provide frequent encouragement and assistance with dressing as needed. Assistance conserves energy and reduces frustration. However, caregivers should avoid rushing tasks, which can negate the patient’s attempts at self-care. Training in energy conservation and pacing techniques is essential for both patients and caregivers. Energy conservation training includes adaptive techniques, work simplification, and the use of adaptive devices and equipment.

Utilize a wheelchair or stationary chair for dressing. Dressing requires energy. A supportive chair, compared to sitting on the edge of the bed, conserves energy during dressing. Sitting for dressing and grooming, as well as using reachers to put on pants, minimizes energy expenditure. Patients may lack the strength to stand and pull pants over their hips. Occupational therapists can suggest clothing modifications or recommend dressing from bed level.

Establish regular daily routines and ensure the client is rested before dressing activities. A balanced plan with activity and rest periods helps patients complete dressing without excessive fatigue and frustration. Pacing training involves distributing activities throughout the day, week, or month to manage fatigue effectively. For example, showering at night before bed may be preferable to showering in the morning, especially when combined with other morning tasks like grooming and breakfast preparation.

Consider using clothing one size larger than usual. Larger clothing sizes ensure easier dressing and greater comfort. Loose clothing allows for increased freedom of movement, making it easier for patients with limited dexterity to put on and remove garments. Tight or restrictive clothing can be challenging to manipulate, especially for those with mobility limitations.

Recommend front-opening bras and half-slips for women. Clothing that is easier to put on and remove enhances self-care in dressing. Limited mobility necessitates specialized clothing that is easy to wear and does not restrict movement. Easy-access snaps, stretchy fabrics, and designs accommodating healthcare and mobility aids make clothing more user-friendly for patients with mobility impairments.

Encourage the client to be as involved in dressing as tolerated. Maximize patient involvement in dressing. For example, encourage the patient to choose clothing and accessories for the day, as appropriate. This provides a sense of independence and purpose despite physical limitations.

Assist the client with undressing as needed. Patients with physical limitations require dressing techniques and assistance that allow them to undress safely without pain, discomfort, or falls. Support extremities while undressing. Undress the unaffected side first and dress the affected side last.

Assist with dressing a client in bed. Effective communication and a second caregiver are essential when dressing a client in bed to prevent injuries. If the patient is in street clothes, they can be dressed while sitting up in bed if possible. Otherwise, turn the patient side-to-side for upper garment dressing:

Turn the patient onto their unaffected side.
Gently guide the patient’s affected arm through the sleeve of the front- or back-closing garment.
Turn the patient to the other side, gathering the garment at the front or back closure.
Slide the garment under the patient towards the unaffected arm, guiding it through the sleeve, and fasten the garment.

Assist the client in putting on lower garments in bed. If the patient can sit up in bed, they can assist with lower garment dressing.

Put pants on both legs, starting with the affected side first.
If able, ask the patient to raise their buttocks to pull pants over the buttocks to the waist.
If unable to raise hips, put the side rail up on the unaffected side.
Assist the patient to turn towards the side rail, then pull pants over the buttocks and up to the waist.

Assist a client in wearing anti-embolism stockings. Patients who are immobile in bed may require anti-embolism stockings to reduce swelling and blood clot risk in the lower extremities. These stockings can be tight and difficult to put on and take off.

If the patient can move their legs, instruct them to turn the stocking tops down to the heel.
Place the foot of the stocking on the patient’s foot to the heel.
Pull the stocking up the leg until taut and wrinkle-free.
Repeat for the other leg.
If the patient cannot assist, the nurse stands at the foot of the bed with the patient’s feet facing.
Turn stocking tops down to the heel.
Place stocking foot on the patient’s foot to the heel.
Move to stand beside the patient’s upper thigh to pull the stocking up until taut.

Allow ample time for dressing and avoid rushing the client. Ensure sufficient time for dressing and avoid rushing. If resistance occurs, stop and try again later. Sometimes, allowing the patient to sleep in clothes and assisting with changes in the morning is less stressful.

Engage the client in conversation during dressing. Use clothing as a conversation starter to build rapport and comfort. Compliment clothing or ask about clothing patterns to involve the patient in the process.

Avoid arguing if the client resists dressing. Recognize that irritability during dressing is common. Time pressures and other stressors can create adverse conditions. If irritability arises, step back, simplify actions, and maintain a calm, tolerant approach.

5. Providing Interventions for Self-Care Deficit in Toileting

Toileting difficulties may include problems reaching the toilet or commode, sitting down and rising, manipulating clothing, performing toilet hygiene, flushing, or emptying a commode.

Assess prior and current toileting patterns. Establish a toileting routine incorporating these habits. The effectiveness of bowel or bladder programs improves when natural and personal patterns are considered. The health history explores bowel and bladder function, dysfunction symptoms, physiological risk factors, micturition perception, and functional toileting abilities. Voiding patterns and records of voiding times and amounts aid in care plan design.

Assess the client’s ability to verbalize voiding needs and use a urinal or bedpan. Offer bathroom assistance at regular intervals if appropriate. Patients with neurogenic bladders or concentration deficits may not verbalize needs initially but often regain control with recovery. Bathroom access, clothing manipulation, and toilet use are functional factors related to incontinence. Related cognitive function must also be assessed.

Provide privacy during toileting. Lack of privacy can inhibit bowel and bladder emptying. Privacy respects patient dignity and self-worth. Intruding on this personal activity can be embarrassing and diminish self-esteem.

Maintain client dignity during toileting. Explain and provide toileting care with sensitivity. Use respectful terms for incontinence products (briefs, pads, liners, disposable underwear, not “diapers”). Avoid reluctance or appearing burdened when providing toileting assistance.

Offer a bedpan or toilet assistance every 1 to 1.5 hours during the day and three times at night. This can help prevent incontinence. Intervals can lengthen as the patient verbalizes needs. Habit training aims to maintain dryness through strict adherence to a toileting schedule and can be effective for stress, urge, or functional incontinence. For confused patients, scheduled toileting can prevent involuntary elimination.

Closely observe for balance loss or falls. Keep commode and toilet tissue accessible at bedside for nighttime use. Patients may rush to the toilet at night due to fear of soiling themselves, increasing fall risk. If a private toilet is not nearby, a padded commode or bedside toilet is an alternative. An elevated toilet seat can simplify toilet use for patients with disabilities.

Ensure clear paths to the toilet. Remove furniture or obstacles blocking the path to the toilet. If patients use furniture for balance, moving items can increase fall risk. Ensure well-lit and visible paths to the toilet.

Keep the call light within reach and instruct the client to call promptly. This allows staff time to assist with commode or toilet transfers. For patients with mobility difficulties, unassisted toilet attempts can lead to falls. A call light enables safe assistance and prevents potential injuries.

Assist with removing or modifying difficult clothing. Clothing that is hard to manage can hinder continence. Barrier-free toilet access and clothing modifications aid functional incontinence self-care and continence.

Assist the client into a comfortable toileting position. Support normal or comfortable positions: standing for males, squatting or leaning forward while sitting for females. These positions enhance gravity-assisted urine flow.

Utilize a commode or toilet as early as possible. Patients are more successful emptying bowels and bladders on a commode. Bedpans should be avoided if possible. If a bedpan is necessary, position the patient on their left side with legs flexed and the head of the bed elevated 30-45 degrees to increase intra-abdominal pressure. Use protective padding under the buttocks.

Recognize prior bowel habits and restore a normal regimen. This supports retraining and prevents constipation and impaction. Record defecation time, stool character, nutrition, cognition, and toileting abilities for 5-7 days to design a bowel program for fecal incontinence.

Increase dietary fiber, fluid intake, and activity levels. Include high-fiber foods (vegetables, fruit, bran) to prevent constipation and stimulate peristalsis. Daily fluid intake should be 2-3 liters unless contraindicated. 120 mL prune juice 30 minutes before a meal can help with constipation. Encourage physical activity to increase peristaltic activity.

Do not restrict fluid intake. Sufficient fluid intake (2000-3000 mL daily, as tolerated) is necessary. Instruct patients to avoid large fluid intake before bedtime to reduce nighttime voiding frequency.

Establish a bladder or bowel training schedule. Bladder/bowel training benefits cognitively intact patients with incontinence. Develop a voiding/toileting schedule based on assessment data. Schedule specifies times to attempt bladder/bowel emptying using a bedpan, toilet, or commode. Regularity, timing, nutrition, fluids, and exercise, along with proper positioning, promote predictable toileting.

Encourage pelvic floor exercises (Kegel exercises). Kegel exercises strengthen pelvic floor muscles. Instruct patients to tighten pelvic floor muscles for 4 seconds, repeated 10 times, 4-6 times daily. Helpful for cognitively intact women with incontinence.

Limit incontinence pads or diapers. Pads/briefs manage, but don’t solve, incontinence. They may have negative psychological effects (perceived as “diapers”). Use only when necessary for stress or total incontinence protection.

Pay attention to nonverbal cues of toileting needs. Respond promptly to nonverbal cues. Patients with dementia may have accidents due to disorientation, not recognizing the toilet, or delayed awareness of needing to toilet.

6. Providing Interventions for Self-Care Deficit in Feeding

Patients frequently needing feeding assistance include weakened older adults, those with visual impairments, those restricted to back-lying positions, or those with hand mobility limitations. Nursing care plans must address mealtime assistance.

6.1. Assessment of the Oral Cavity and Nutritional Status

Assess the client’s oral hygiene practices. Oral hygiene information guides etiological understanding and education. Inquire about dental visits, self-care abilities, and past/current mouth problems during the health history. Oral hygiene data informs learning needs and care plan incorporation of patient needs and preferences.

Assess teeth, gums, mucous membranes, and tongue for color, moisture, texture, irritation, and infection. Use a moist, padded tongue blade to gently retract cheeks, lips, and gums for visualization. A tongue blade aids oral cavity inspection. Ask the patient to relax their mouth, and pull the lip outward and away from teeth for better visualization. Normal findings include moist, smooth, soft, glistening, and elastic texture. Dried oral mucosa may be present in older adults due to decreased salivation.

Assess the client’s nutritional status. Poor food choices contribute to dental problems. Poor dentition impacts food consumption, with tooth loss associated with reduced fiber intake (fruits and vegetables). History of tobacco and alcohol use (type, amount, duration, cessation date) should be included. Inquire about appetite changes, eating patterns, and unexplained weight loss or gain in the past year.

Assess the fit of dental appliances. Evaluation can suggest causes and guide patient education. Inspect dentures by asking the patient to remove them, noting broken or worn areas. Ill-fitting dentures and irritated areas under dentures are abnormal findings.

Assess the mouth for dryness and breath odor. Normal saliva flow is vital for teeth cleanliness. Halitosis can result from mouth dryness, dentition issues, or medical conditions. Dry mouth (xerostomia) occurs with reduced saliva. Patients with nasogastric tubes or oxygen therapy are prone to dry oral mucous membranes. Decreased saliva in older adults also causes dry mouth and thinning oral mucosa.

Assess the client’s ability to perform regular oral care. Patients may need assistance with oral care. Those with impaired hand coordination, cognitive function, low energy, or activity restrictions will require nursing assistance.

Assess for financial barriers to maintaining dental hygiene. Patients may be hesitant to ask for help or unaware of community services. Critically ill patients are at risk for ventilator-associated pneumonia, longer hospital stays, increased costs, and mortality if oral care is inadequate. Long-term care facilities often have regular dentist visits for special needs patients.

Assess for toothache complaints. Dental caries and abscesses are common and painful, requiring dental evaluation. Both are linked to tartar and plaque. Plaque is an invisible soft film on teeth enamel. Unchecked plaque forms tartar, a visible, hard deposit of plaque and dead bacteria at the gum line.

Assess the role of “fear of dentists” in avoiding dental care. Past negative dental experiences may cause fear. Accurate information can reduce fear. Inform patients about procedures to alleviate anxieties. Patients with high dental fear may benefit from psychiatric support for comfortable treatment.

6.2. Interventions for Oral Hygiene

Provide a mouth care routine with regular toothbrushing using a soft-bristle toothbrush and fluoride toothpaste.

Hold brush at a 45-degree angle to teeth.
Brush teeth in an up-and-down motion.
Brush at least twice daily.
Include gums and tongue in oral care.
Replace toothbrush when bristles wear down.
Recommend ultrasonic toothbrush for dexterity issues.

Toothbrushing with fluoride toothpaste prevents plaque buildup. Mechanical brushing removes food particles and bacteria. Gum stimulation promotes circulation and healthy firmness. The sulcular technique removes plaque and cleans under gingival margins.

Teach gentle flossing with unwaxed dental floss. Flossing promotes gum health and prevents plaque buildup. Unwaxed floss is more effective at trapping particles between teeth but frays more than waxed floss.

Instruct the client to rinse with warm saline or antiplaque mouth rinse. These measures improve oral hygiene. Normal saline mouth rinse is an effective cleaner and moisturizer. Vigorous rinsing loosens and removes food particles.

Teach daily removal and cleaning of dentures. Regular denture cleaning prevents mucosal irritation. Dentures, like natural teeth, accumulate microorganisms and food. Clean dentures daily, scrubbing with a toothbrush, rinsing, and reinserting. Some use toothpaste, others use commercial denture cleaners.

Assist with oral hygiene after meals and as needed. Regular brushing, especially after meals, is vital to prevent bacterial buildup. Good oral hygiene includes daily gum stimulation, mechanical brushing and flossing, and mouth rinsing. Nurses assist patients in maintaining oral hygiene through direct help and education.

Assist the client with flossing teeth. Nurses can assist with independent flossing or floss for alert, cooperative patients:

Wrap floss around the third finger of each hand.
Start at the back right side and work around to the back left, or from center teeth to the back of the jaw on either side.
Use thumb and index finger to stretch floss for upper teeth.
Move floss up and down between teeth.
Gently slide floss into the gum-tooth space and floss away from gums in up-and-down motions.
For lower teeth, use index fingers to stretch floss.
Provide tepid water or mouthwash for rinsing.

Advise avoiding high-sugar foods. High-sugar foods cause tooth decay and hinder oral health and healing. Free sugars are the primary dietary factor in dental caries. Bacteria metabolize sugars to acid, demineralizing enamel and dentine. Sugar-sweetened beverages, including fruit juices, are primary free sugar sources.

Apply lubricant to lips and oral mucosa as needed. Lubrication promotes comfort and prevents dryness and cracking. Avoid mineral oil as a lip or mouth moisturizer due to aspiration risk and lipid pneumonia. Use water-soluble moisturizers for hydration.

Instruct clients to obtain regular dental checkups and follow-ups. Regular checkups detect problems early. Dental checkups are recommended every six months for adolescents and adults, and regularly for preschoolers when permanent teeth appear. Older adults with self-care deficits are at higher risk for dental issues and need routine dental care.

Educate the client about the importance of oral hygiene. Knowledge prevents dental problems. A key nursing role is teaching oral hygiene measures. Nurses identify problems requiring dentist or oral surgeon intervention and facilitate referrals.

Educate about maintaining a healthy diet despite dentition problems. Adequate nutrition is vital for teeth and overall health. WHO initiatives to reduce caries include nutrition labeling, regulating sugary food marketing, improving food environments in public institutions, and prioritizing clean water access.

6.3. Interventions for Feeding

Encourage self-feeding as soon as possible (using the unaffected hand if appropriate). Assist with setup as needed. If upper extremity involvement exists, the dominant hand may be affected. Be sensitive to patient embarrassment, resentment, and autonomy loss. Help patients self-feed whenever possible rather than feeding them entirely.

Encourage independent eating and drinking as much as possible. During meals, patients may need help but should be encouraged to do as much as possible independently. Provide verbal or physical cues and sufficient time to finish eating and drinking.

Ensure the client wears dentures and eyeglasses if required. Sensory deficits can worsen self-care deficits. Dentures functionally replace missing teeth, improving chewing ability and food choices. Eyeglasses optimize vision for feeding.

Position the client comfortably for feeding. Proper positioning eases feeding and reduces aspiration risk. Some patients are at risk for dysphagia. Upright positions may be needed if tolerated; otherwise, semi-Fowler’s or 30-degree head elevation is appropriate.

Provide a pleasant mealtime environment. Meals should be in a pleasant, simple setting. Minimize interruptions, noise, table clutter, and complex tablecloth patterns. Remove unnecessary items from the table. Enhance food visibility by ensuring visual contrast between plates, food, and table settings (e.g., light plates on dark placemats).

Provide proper utensils (wide-grip, rocking knife, plate guard, straw) to aid self-feeding. These aids increase success. Use normal utensils when possible, but special utensils may be needed. Straws help patients with cup or glass drinking difficulties.

Use adaptive feeding aids to promote self-management. Many adaptive aids are available to maintain feeding independence. Rimming plates and plate guards help scoop food. Suction cups or damp cloths under dishes prevent movement. No-spill mugs and two-handled cups aid those with hand coordination issues.

Ensure diet consistency suits chewing and swallowing ability, as assessed by a speech therapist. Thickened semisolid foods (pudding, hot cereal) are easier to swallow and less likely to be aspirated. The National Dysphagia Diet (NDD) includes four liquid levels (thin, nectar-like, honey-like, spoon-thick) and four semisolid/solid levels (pureed, mechanically altered, advanced/mechanically soft, regular/general).

Promote small, frequent meals or snacks. Snacking throughout the day ensures sufficient intake. Formal meals are not always necessary. Offer small portions to encourage eating. Allow ample time to chew and swallow before offering more.

Serve finger foods to increase self-feeding ability. If utensils are difficult, offer finger foods. Physically guide the patient’s hand to food to facilitate participation.

Provide adequate fluid intake with meals and throughout the day. Offer fluids as requested or after every 3-4 bites of solid food. Ensure fluids like popsicles, sherbet, fruit slushies, or water are readily available.

If vision is impaired, guide food placement on the plate. After stroke, unilateral neglect may cause patients to ignore half the plate. When feeding, ask the patient’s preferred eating order. If vision is impaired, verbally describe food being offered. Allow ample time to chew and swallow before offering more.

Use the clock system to describe food placement to visually impaired clients. Describe food positions as clock times (e.g., “potatoes at 8 o’clock, chicken at 12 o’clock, green beans at 4 o’clock”). This helps visually impaired patients choose and pick up food independently.

Provide an appropriate feeding setting with supportive assistance, avoiding embarrassment. Embarrassment or fear of spilling can hinder self-feeding. Some patients become depressed due to dependence and feeling burdensome to busy staff.

Maintain the client’s familiar feeding routines. Keep familiar eating and dining routines practical to promote eating and drinking independence. Avoid childish feeding techniques (airplane noises, etc.).

Stay with the client during meals. Communicate while assisting with feeding. Staff should sit, make eye contact, and talk to patients during meal assistance. Eating is a cultural experience that builds connections.

Document the client’s food and fluid intake regularly. Documentation provides insight into patient health and well-being. Document intake by estimating to the nearest 25% or noting “bites of food.” Convert all fluid volumes to milliliters or cubic centimeters.

Refer the client to community resources for nutritional needs. Community programs aid specific groups with nutritional needs. Meals-on-Wheels delivers meals to homebound older adults. Grocery delivery services assist those with shopping limitations. USDA’s Supplemental Nutrition Assistance Program supports the poor.

7. Providing Interventions for Transferring/Ambulating

Transferring is moving a patient from one place to another. Assist with transfers as soon as medically permitted. Regaining walking ability boosts morale. Assist with ambulation preparation when indicated and when the patient’s condition is stable.

See also: Physical Mobility & Immobility Nursing Care Plan and Management

7.1. Providing Assistance with Transferring or Ambulating

For moderate assistance, caregivers place arms under the client’s armpits with hands on the client’s back. This method encourages forward weight maintenance. Nurses often assist weak patients out of bed. Support gently during position changes, avoiding pulling on weak or paralyzed extremities to prevent shoulder dislocation.

For maximal assistance, use a gait belt. This maximizes patient support and protects caregivers from injury. Gait belts (transfer or walking belts) traditionally aid transfers and ambulation. Handles allow nurses to control patient movement during transfer or ambulation.

Raise the bed to a height allowing the client’s feet to be flat on the floor.
Grasp the gait belt with both arms and pull the client forward.
Place a knee against the client’s weak knee (if applicable) and encourage weight-bearing on the strong side during transfer.
Encourage the client to use arms for assistance, placing them on the caregiver’s forearms.

Aid ambulation; guide use of devices like canes, walkers, and crutches. These methods enhance patient safety and balance. Assistance ranges from standby support to instruction on assistive device use (cane, walker, crutches) or using sit-to-stand lifts or lifts with ambulation slings.

Have the client sit up in bed for one minute before dangling legs.
Assist the client to sit on the bed edge.
Stand on the client’s weak side and assist to stand by the bed for at least one minute.
If using a cane, place it in the strong hand and ensure proper foot-cane sequence.
Walk on the client’s weak side if appropriate.

Utilize strategies to aid upright sitting. Conditions like spinal cord injury, acute brain injury, and prolonged recumbency prevent bedside upright sitting. Strategies include:

Reclining wheelchair: Allows slow, controlled progression from supine to 90-degree sitting.
Tilt table: Tilts from horizontal to vertical in 10-degree increments, promoting vasomotor adjustment and aiding limited standing balance.
Gradual head elevation: Gradually elevate the head of the bed over 10-15 minutes for SCI patients to achieve 90-degree sitting.

Use adaptive devices during transfers. Lightweight wheelchairs with brake extensions, removable armrests, and leg rests minimize transfer obstacles. Tub seats or benches ease tub transfers. Raised, padded commode seats aid patients avoiding hip flexion over 90 degrees when toileting.

Promote upper extremity muscle strengthening exercises. Maintain muscle strength and encourage push-up exercises to strengthen arm and shoulder extensors. Push-ups involve sitting upright in bed, placing books under hands for a hard surface, and pushing down on books to raise the body, encouraging body movement in different directions.

Assist bed-to-wheelchair transfers. Transfer methods depend on patient abilities and disabilities.

Weight-bearing transfer: client stands, pivots to face the chair, and sits.
Transfer board/sliding board: bridges the gap between bed and chair for clients unable to overcome body weight resistance. Clients slide across the board with or without assistance.
Ensure fingers are not curled around the board edge during transfer to prevent crushing.

Implement safety guidelines during transfers. Safety is paramount.

Lock wheelchairs and beds before transfers.
Remove detachable arm and footrests for easy chair access.
Place one transfer board end under buttocks and the other on the transfer surface.
Instruct the client to lean forward, push up with hands, and slide across the board.

Ensure adaptive devices fit properly. For crutches, measure standing or lying down. Standing: crutch length 2 inches below axilla. Lying: measure from anterior axillary fold to sole, add 2 inches. Adjust hand grip for 20-30 degrees elbow flexion. For walkers, arms should be at 20-30 degrees elbow flexion when hands are on grips. For canes, with 30-degree elbow flexion, handle level with greater trochanter, cane tip 6 inches lateral to the 5th toe base.

7.2. Providing Education on the Use of Assistive Devices

Evaluate the need for adaptive equipment via therapy (e.g., large volume, numbers, push-button phones). Clients need communication tools at home. Home bed and chair, toilet, and tub transfers are difficult for weak patients with limited hip, knee, and ankle motion. Bed ropes aid repositioning. Footboard ropes facilitate bed entry/exit.

Provide felt-tip pens. Assess need for writing hand support or splint. Felt-tip pens require less pressure. Splints support writing hands. Adaptive grips and Velcro strap writing aids improve grip and ease writing.

Instruct on proper crutch use and gaits. Crutches aid partial or non-weight-bearing ambulation. Balance, cardiovascular reserve, upper extremity strength, and erect posture are essential.

4-point gait: Partial weight-bearing, maximal support, constant weight shift. (Right crutch, left foot, left crutch, right foot).
2-point gait: Partial weight-bearing, less support, faster than 4-point. (Left foot & right crutch, right foot & left crutch).
3-point gait: Non-weight-bearing, good balance, arm strength, faster, walker-compatible. (Left foot & both crutches, right foot).
Swing-to: Weight-bearing, stability, arm strength, walker-compatible. (Both crutches, lift feet to crutches).
Swing-through: Weight-bearing, arm strength, coordination, balance, advanced gait. (Both crutches, lift feet in front of crutches).

Educate on ambulatory device use. With crutches, use a tripod stance for stability (crutches forward and lateral to toes). With walkers, walk alongside, hold waist for balance if needed. Instruct never to pull up on walker and to look up when walking. With canes, instruct 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 affected leg.

Instruct on stair descent with crutches or canes. Crutches: walk forward, 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 to the next step, then crutches and affected leg. Canes: step up with unaffected leg first, then cane and affected leg.

8. Encouraging Social Support

Lack of support hinders self-care and ADL management. Identifying support networks and involving family/community resources is vital.

Educate family and significant others to promote autonomy and intervene if the client becomes tired, incapable, or aggravated. This shows care without hindering autonomy. Appropriate assistive care prevents harm without disappointment. Support functional independence as long as possible. Maintain dignity and encourage choice and self-care participation.

Inform family to allow maximum self-care performance. This builds independence, self-esteem, and improves rehabilitation. Note: This may be challenging for caregivers depending on disability severity and task duration.

Involve the client’s input in scheduling. Client preferences improve quality of life. Include older adults in decisions affecting them.

Consider energy-conservation techniques. Conserves energy, reduces fatigue, and improves task ability. Pacing involves spreading activities throughout the day to ease fatigue (e.g., meal prep in the morning for evening meals).

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 Evidence-based approach to nursing interventions. Uses a three-step system for assessment, diagnosis, and care planning. Includes step-by-step instructions for care implementation and outcome evaluation, building diagnostic reasoning and critical thinking skills.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition) Over 200 care plans reflecting recent evidence-based guidelines. New edition includes ICNP diagnoses, LGBTQ health, and electrolyte/acid-base balance care plans.

Alt text: Cover image of “Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)” book, highlighting its comprehensive guide for nursing professionals.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales Quick-reference tool for correct diagnoses and efficient care planning. Sixteenth edition includes recent nursing diagnoses and interventions, alphabetized listing of over 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care Identifies interventions for planning, individualizing, and documenting care for over 800 diseases and disorders. Includes subjective/objective data, clinical applications, prioritized actions/interventions with rationales, documentation sections, and more.

Alt text: Cover image of “Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care” book, emphasizing its role in nursing practice.

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health Over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with patient communication.

References

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