Nursing Diagnosis: Self-Care Deficit
May be related to
- Neuromuscular impairment, decreased strength and endurance, loss of muscle control/coordination
- Perceptual/cognitive impairment
Possibly evidenced by
- Impaired ability to perform ADLs, e.g., inability to bring food from receptacle to mouth; inability to wash body part(s), regulate temperature of water; impaired ability to put on/take off clothing; difficulty completing toileting tasks
- Demonstrate techniques/lifestyle changes to meet self-care needs.
- Perform self-care activities within level of own ability.
- Identify personal/community resources that can provide assistance as needed.
8 Cerebrovascular Accident (Stroke) Nursing Care Plans
- Ineffective Cerebral Tissue Perfusion — Stroke Nursing Care Plans
- Impaired Physical Mobility — Stroke Nursing Care Plans
- Impaired Verbal Communication — Stroke Nursing Care Plans
- Disturbed Sensory Perception — Stroke Nursing Care Plans
- Ineffective Coping — Stroke Nursing Care Plans
- Self-Care Deficit — Stroke Nursing Care Plans
- Risk for Impaired Swallowing — Stroke Nursing Care Plans
- Knowledge Deficit — Stroke Nursing Care Plans
Self-Care Deficit — Stroke (CVA) Nursing Care Plan (NCP)
|Assess abilities and level of deficit (0–4 scale) for performing ADLs.||Aids in anticipating/planning for meeting individual needs.|
|Avoid doing things for patient that patient can do for self, but provide assistance as necessary.||These patients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for patient to do as much as possible for self to maintain self-esteem and promote recovery.|
|Be aware of impulsive behavior/actions suggestive of impaired judgment.||May indicate need for additional interventions and supervision to promote patient safety.|
|Maintain a supportive, firm attitude. Allow patient sufficient time to accomplish tasks.||Patients need empathy and to know caregivers will be consistent in their assistance.|
|Provide positive feedback for efforts and accomplishments.||Enhances sense of self-worth, promotes independence, and encourages patient to continue endeavors.|
|Create plan for visual deficits that are present, e.g.:Place food and utensils on the tray related to patient’s unaffected side;Situate the bed so that patient’s unaffected side is facing the room with the affected side to the wall;|
Position furniture against wall/out of travel path.
|Patient will be able to see to eat the food.Will be able to see when getting in/out of bed and observe anyone who comes into the room.|
Provides for safety when patient is able to move around the room, reducing risk of tripping/falling over furniture.
|Provide self-help devices, e.g., button/zipper hook, knife-fork combinations, long-handled brushes, extensions for picking things up from floor; toilet riser, leg bag for catheter; shower chair. Assist and encourage good grooming and makeup habits.||Enables patient to manage for self, enhancing independence and self-esteem; reduces reliance on others for meeting own needs; and enables patient to be more socially active.|
|Encourage SO to allow patient to do as much as possible for self.||Reestablishes sense of independence and fosters self-worth and enhances rehabilitation process. Note: This may be very difficult and frustrating for the SO/caregiver, depending on degree of disability and time required for patient to complete activity.|
|Assess patient’s ability to communicate the need to void and/or ability to use urinal, bedpan. Take patient to the bathroom at frequent/periodic intervals for voiding if appropriate.||Patient may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function as recovery progresses.|
|Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet; encourage fluid intake, increased activity.||Assists in development of retraining program (independence) and aids in preventing constipation and impaction (long-term effects).|
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