NURSING DIAGNOSIS: Self-care deficit

related to impaired physical mobility, visual and spatial-perceptual impair-ments, apraxia, unilateral neglect, and altered thought processes.

Desired Outcome
The client will perform self-care activities within cognitive and physical limitations.
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Care Plan on Immobility, Diagnosis 7, action b, for measures to facilitate client's ability to perform self-care activities.
  2. Implement additional measures to facilitate client's ability to perform self-care activities:
    1. if apraxia is present, explain and demonstrate use of items such as toothbrush, comb, and washcloth as often as necessary
    2. encourage client to wear eyepatch or opaque lens if diplopia is present
    3. perform actions to enable client to feed self:
      1. place foods/fluids within client's visual field until he/she learns to effectively utilize scanning techniques
      2. place only a few items on the tray at one time if spatial-perceptual deficits are present
      3. identify where items are placed on the plate and tray and open containers, cut meat, and butter bread as indicated
      4. consult with occupational therapist about assistive devices available (e.g. broad-handled utensils, rocker knife, nonslip tray mat, plate guard); reinforce use of these devices
    4. perform actions to enable client to dress self:
      1. encourage use of assistive devices such as button hooks, long-handled shoehorns, and pull loops for pants
      2. encourage client to select clothing that is easy to put on and remove (e.g. clothing with zippers rather than buttons, loose-fitting clothing, shoes with Velcro fasteners or elastic laces)
      3. if client has difficulty distinguishing right from left, mark outer aspect of shoes with tape
    5. perform actions to increase mobility (see Diagnosis 6) in order to further facilitate the client's ability to perform self-care activities
    6. reinforce exercises and activities recommended by the occupational therapist to improve fine motor skills.
  3. Assist the client with activities he/she is unable to perform independently.
  4. 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.