SELF CARE

Interventions (Nursing Interventions Classification)

The nurse may encounter the patient with a self-care deficit in the hospital or in the community. The deficit may be the result of transient limitations, such as those one might experience while recuperating from surgery; or the result of progressive deterioration that erodes the individual’s ability or willingness to perform the activities required to care for himself or herself. Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing at self-care because of a lack in material resources or a problem with arranging the environment to suit the patient’s physical limitations. The nurse coordinates services to maximize the independence of the patient and to ensure that the environment that the patient lives in is safe and supportive of his or her special needs.

Defining Characteristics:
■Inability to feed self independently
■Inability to dress self independently
■Inability to bathe and groom self independently
■Inability to perform toileting tasks independently
■Inability to transfer from bed to wheelchair
■Inability to ambulate independently
■Inability to perform miscellaneous common tasks such as telephoning and writing
Related Factors:
■Neuromuscular impairment, secondary to cerebrovascular accident (CVA)
■Musculoskeletal disorder such as rheumatoid arthritis
■Cognitive impairment
■Energy deficit
■Pain
■Severe anxiety
■Decreased motivation
■Environmental barriers
■Impaired mobility or transfer ability
Expected Outcomes
■Patient safely performs (to maximum ability) self-care activities.
■Resources are identified which are useful in optimizing the autonomy and independence of the patient.