Nurse's Pocket Guide

SELF-CARE DEFICIT: bathing/hygiene, dressing/grooming, feeding, toileting
long-term goal, accepting ability to do one thing at a time,
and conceputalization of self-care in a broader sence.
• Provide for communication among those who are involved in
caring for/assisting the client. Enhances coordination and
continuity of care.
• Establish remotivation/resocialization programs when indicated.
• Establish “contractual” partnership with client/SO(s) if appropriate/indicated
for motivation/behavioral modification.
• Assist with rehabilitation program to enhance capabilities/
promote independence.
• Provide privacy and equipment within easy reach during personal
care activities.
• Allow sufficient time for client to accomplish tasks to fullest
extent of ability. Avoid unnecessary conversation/interruptions.
• Assist with necessary adaptations to accomplish ADLs. Begin
with familiar, easily accomplished tasks to encourage client
and build on successes.
• Collaborate with rehabilitation professionals to identify/
obtain assistive devices, mobility aids, and home modification
as necessary (e.g., adequate lighting/visual aids; bedside commonde;
raised toilet seat/grab bars for bathroom; modified
clothing; modified eating utensils).
• Identify energy-saving behaviors (e.g., sitting instead of
standing when possible). (Refer to NDs Activity Intolerance;
Fatigue for additional interventions.)
• Implement bowel or bladder training/retraining program, as
indicated. (Refer to Constipation; Bowel Incontinence;
impaired Urinary Elimination for appropriate interventions.)
• Encourage food and fluid choices reflecting individual likes
and abilities that meet nutritional needs. Provide assistive
devices/alternate feeding methods, as appropriate. (Refer to
ND impaired Swallowing for related interventions.)
• Assist with medication regimen as necessary, encouraging
timely use of medications (e.g., taking diuretics in morning
when client is more awake/able to manage toileting, use of
pain relievers prior to activity to facilitate movement, postponing
intake of medications that cause sedation until selfcare
activites completed).
• Make home visit to assess environmental/discharge needs.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/
Discharge Considerations):
• Assist the client to become aware of rights and responsibilities
in health/healthcare and to assess own health strengths—
physical, emotional, and intellectual.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
578 Cultural Collaborative Community/Home Care