Nurse's Pocket Guide

• Note concomitant medical problems/existing conditions that
may be factors for care (e.g., high BP, heart disease, renal failure,
spinal cord injury, CVA, MS, malnutrition, pain,
Alzheimer’s disease).
• Review medication regimen for possible effects on alertness/mentation,
energy level, balance, perception.
• Note other etiological factors present, including language barriers,
speech impairment, visual acuity/hearing problem,
emotional stability/ability. (Refer to NDs impaired verbal
Communication; impaired Environmental Interpretation;
risk for unilateral Neglect; dusturbed Sensory Percption
(specify) for related interventions.)
• Assess barriers to participation in regimen (e.g., lack of information,
insufficient time for discussion; psychological and/or
intimate family problems that may be difficult to share; fear of
appearing stupid or ignorant; social/economic, work/home
environment problems).
NURSING PRIORITY NO.2.To assess degree of disability:
• Identify degree of individual impairment/functional level
according to scale (as listed in ND impaired physical Mobility).
• Assess memory/intellectual functioning. Note developmental
level to which client has regressed/progressed.
• Determine individual strengths and skills of the client.
• Note whether deficit is temporary or permanent, should
decrease or increase with time.
NURSING PRIORITY NO. 3.To assist in correcting/dealing with
situation:
• Perform/assist with meeting client’s needs when he or she is
unable to meet own needs (e.g., personal care assistance is
part of nursing care and should not be neglected while promoting
and integrating self-care independence).
• Promote client’s/SO’s participation in problem identification
and desired goals and decision making. Enhances commitment
to plan, optimizing outcomes, and supporting recovery
and/or health promotion.
• Develop plan of care appropriate to individual situation,
scheduling activities to conform to client’s usual/desired
schedule.
• Plan time for listening to the client’s/SO’s feelings/concerns to
discover barriers to participation in regimen and to work
on problem solutions.
• Practice and promote short-term goal setting and achievement
to recognize that today’s success is as important as any
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 577
SELF-CARE DEFICIT: bathing/hygiene, dressing/grooming, feeding, toileting