NURSING DIAGNOSIS: Self-care deficit

related to:
  1. activity limitations imposed by current diagnosis and/or treatment plan;
  2. weakness and fatigue associated with factors such as inadequate nutritional status, cardiac deconditioning, loss of muscle strength, and difficulty resting and sleeping.
Desired Outcome
The client will perform self-care activities within physical limitations and activity restrictions imposed by current diagnosis and treatment plan.
Nursing Actions and Selected Purposes/Rationales
  1. With client, develop a realistic plan for meeting daily physical needs.
  2. Implement measures to facilitate client's ability to perform self-care activities:
    1. schedule care at a time when client is most likely to be able to participate (e.g. when analgesics are at peak effect, after rest periods, not immediately after meals or treatments)
    2. keep needed objects within easy reach
    3. perform actions to prevent activity intolerance (see Diagnosis 5, action b) in order to help maintain client's strength and prevent weakness and fatigue
    4. perform actions to maintain optimal joint mobility and muscle function (see Diagnosis 6, action a)
    5. consult occupational therapist about assistive devices available if indicated
    6. allow adequate time for accomplishment of self-care activities.
  3. Encourage client to perform as much of self-care as possible within physical limitations and activity restrictions imposed by the current diagnosis and treatment plan.
  4. Assist the client with activities he/she is unable to perform independently.
  5. Inform significant others of client's abilities to perform own care. Explain importance of encouraging and allowing client to maintain an optimal level of independence within prescribed activity restrictions and physical capabilities.