related to impaired physical mobility, visual and spatial-perceptual impair-ments, apraxia, unilateral neglect, and altered thought processes.
|The client will perform self-care activities within cognitive and physical limitations.|
|Nursing Actions and Selected Purposes/Rationales|
- Refer to Care Plan on Immobility, Diagnosis 7, action b, for measures to facilitate client's ability to perform self-care activities.
- Implement additional measures to facilitate client's ability to perform self-care activities:
- if apraxia is present, explain and demonstrate use of items such as toothbrush, comb, and washcloth as often as necessary
- encourage client to wear eyepatch or opaque lens if diplopia is present
- perform actions to enable client to feed self:
- place foods/fluids within client's visual field until he/she learns to effectively utilize scanning techniques
- place only a few items on the tray at one time if spatial-perceptual deficits are present
- identify where items are placed on the plate and tray and open containers, cut meat, and butter bread as indicated
- 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
- perform actions to enable client to dress self:
- encourage use of assistive devices such as button hooks, long-handled shoehorns, and pull loops for pants
- 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)
- if client has difficulty distinguishing right from left, mark outer aspect of shoes with tape
- perform actions to increase mobility (see Diagnosis 6) in order to further facilitate the client's ability to perform self-care activities
- reinforce exercises and activities recommended by the occupational therapist to improve fine motor skills.
- Assist the client with activities he/she is unable to perform independently.
- 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.