NCP Self care deficit - Lecture notes 1 PDF

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Assessment Subjective Cues: “Dili man gud ko makalakaw maam kay dili na malihok akong pikas na lawas” As verbalized by the client

Objective cues:  Inability to dress self independentl y  Inability to bathe and groom self independentl y  Inability to perform toileting tasks independently  Inability to ambulate independently

Diagnosis Self Care Deficit related to cerebrovascular accident as evidenced by hemiplagia

Objectives Short term objectives: At the end of 1 hour of nursing intervention the client will be able to:  Verbalize proper hygienic practices  Identify alternative action to perform Activity of Daily living

Long term goal: At the end of 2 days of nursing intervention the patient will be able to:  Perform

Implementation 1. Assess the patient overall condition

Rationale 1. To determine the patient capability to perform ADL. 2. Give tepid 2. The client sponge bath cannot take a Bath independently. Tepid sponge can be an alternative way to clean the client’s body 3. Encourage 3. Proper hygiene the client and is the most the family to important way provide a tepid to prevent sponge bath occurrence everyday and and severity of other hygienic disease. practices like hand washing, tooth brushing, combing, nail cutting. 4. Give health 4. Emphasizing teaching about this health

Evaluation At the end of 1 hour of nursing intervention the client was able to verbalize the importance of proper hygienic practices like bathing, proper hand washing, nail cutting, tooth brushing.

Long term goal: The patient verbalized “dili man nako kaya buhaton ang pagligo, pag nailcutter nga ako ra isa maam.

Activity of daily living with minimal  assistance     

the importance of the following: Tooth brushing Hand washing Combing Nail cutting Take a bath Regular exercise of ambulation

5. Provide the client assistive devices such as cane or crutches. 6. Instruct the client the proper way of using cane or crutches.

teaching help to remind the client and the family why it is necessary to do Tooth Brushing, Hand washing, Combing, Nail cutting, Take a bath and to have an exercise or ambulation in the regular basis of our lives. 5. To support the patient in walking and doing the ADL. 6. For the client to use the cane or crutches appropriately.

Kailangan to nako ako anak nga tabangan ko” Goal’s not met...