NANDA-Nursing Plan 00102 Feeding self-care dificit

Area 4 Activity/Rest
production, storage, consumption, or balance of energy resources
Category 5 Self-care
Ability to carry out activities to care for one’s body and bodily functions

Feeding self-care difficit 00102

Feeding self-care difficit 00102

Nursing Diagnosis: Feeding self-care difficit
Definition: Self-assured sequence of eating behaviors. or a condition in which the ability to complete is impaired

Thank you for always watching.
This time it’s the eating version of the lack of self-care series.
I think there are personal factors and environmental factors in the lack of self-care. Let’s look along NANDA.

1.Adaptation of feeding self-care dificit

・ Decreased motivation (psychiatric disorders, dementia, etc.)
・Cognitive decline
-cannot recognize food
・I don’t know the season or day or night
・I don’t know if I ate or forget what I ate. i don’t know i haven’t eaten
・Lack of appetite
・Mental illness (can’t eat due to delusions or hallucinations: poisoned, etc.)
・Swallowing dysfunction
·paralysis
・Motor paralysis: there is a limit to feeding on one’s own
・Motor paralysis: self-help devices required
·fracture
・Spatial neglect (limited visibility)
・Neuromuscular disease (weakness, involuntary movements, etc.)
・Difficulty sitting or standing
·pain
・Cardiac dysfunction (difficulty eating, palpitations, chest pain)
・Respiratory dysfunction (breathing becomes difficult due to exertion such as eating, inhalation of oxygen)
・Exhaustive fatigue★1

*1 For exhaustive fatigue, please refer to the nursing diagnosis “Exhaustive Fatigue”.

★ For problems in the oral cavity, refer to the nursing diagnosis “dental disorders” and “oral mucosal disorders”.

★If you already have swallowing dysfunction, please refer to “Dysphagia” and “Aspiration risk status”.

2. aim setting

1) Goal setting by linkage (published in the second half of NOC)

*Linkage has the role of connecting NANDA (diagnosis) and NOC (results).
・Self-care: meals
・Swallowing state
Nutritional status: food and water intake
・Adaptation to physical disabilities
・Sensory function: vision
・Cognition
・Neurological condition: Central motor nervous system adjustment ・Peripheral nerves
・Psychomotor energy

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・Able to use self-help tools suitable for remaining function and take them by themselves.
• Caregivers can prepare meals that consider swallowing function.

*Nurse goals include:

・Prepare self-help tools according to ADL and disability to maintain eating self-care.
・For lack of eating health care due to declining cognitive function, engage in a relationship that reminds people of the season and date.
　Provide support so that they can eat according to the time, place, and occasion.
・Be careful of aspiration and provide safe meal assistance. Guidance on how to assist with meals to caregivers and family members.
・Listen to the complainants and their families, and try to alleviate their concerns.
・Give advice to the person and their family members and have them acquire knowledge and skills so that they can live with their remaining functions.

3. nursing plan

1) Observation Plan 《OP》

(1) Physical factors

・age
・Cognitive function: MMSE score of 21 or less, Hasegawa score of 20 or less, dementia suspected
・Changes in body weight
・Food intake and water intake
・Presence or absence of appetite
・Meal form
・Whether or not someone prepares meals
・Results of swallowing function test
・Medical history, current disease history, etc.:
　* Dysphagia
　* Near-skeletal system disease: range of motion and joint disorders
　* Rheumatoid arthritis, scleroderma: Impairment of fingertip movement
　* Cerebrovascular disease, intracerebral lesion: paralysis, motor dysfunction
　*Pulmonary diseases such as pulmonary hypertension and COPD: respiratory distress, need for oxygen inhalation
　*Fracture
　* Consuming diseases: severe infections, anemia, dehydration, hypoproteinemia, etc.
　* Cancer: Various symptoms such as pain, neurological symptoms, and respiratory distress appear depending on the place of metastasis. There is also an impact on life.
・ADL, IADL: How far you can do eating by yourself, and whether you are willing to do it yourself
・Caregiver’s ability to care, degree of intervention
・vital signs
・Blood pressure, pulse pressure, left-right difference, pulse deficit
・Heart rate (bradycardia, tachycardia), pulse rate (bradycardia, tachycardia), difference between heartbeat and pulse
・SPO2
・pain:
・ Degree of pain: face scale, pain scale, etc.
・Timing of pain appearance: pain at rest, pain on exertion
・Pain area
Types of pain; stabbing pain, sudden pain, pain that feels like pressure, etc.
・Presence or absence of analgesics
・Paralysis: site, range, complete paralysis, partial paralysis
・ Residual function in case of paralysis
・Presence or absence of caregiver, caregiver’s ability to care
・Peripheral sensations (fingertips and toes)
・Image inspection
・XP, CT: Pleural effusion, ascites, bone fracture, brain injury site, etc.
・Strength: MMT
・Joint range of motion
・Subjective symptoms:
・Dyspnea, chest pain, palpitations
・dizzy
・Venous blood data
・Anemia (RBC, Hb, HT)
・Infection (procalcitonin, CRP, WBC, granulocytes/lymphocytes) As inflammation progresses, the coagulation system also
・Hypoproteinemia (Alb, TP)
Cardiogenic shock symptoms
・Low blood pressure, loss of consciousness, decreased urine output, etc.
·electro-cardiogram
·arrhythmia
・ Oral medicine (Try following the 6Rs. Check what you are taking and what risks you are taking.)

(2) Environmental factors

・Presence or absence of self-help tools for eating
・Is there a situation where meals are set?
・ Financial factors: unable to buy food, unable to buy self-help tools
・There is no helper

2) Action plan 《TP》

・Provide care that considers safety, comfort, and independence. (utilize remaining functions)
・Improve the dining environment
・Set up a calendar so that you can see the seasons.
・Open the curtains or set up a clock so that you can tell the time.
・Adjust your diet. Use of chopping, thickening, etc.
・Adjust your eating habits.
・Prepare a pulse oximeter and blood pressure monitor just in case
・Help with feeding
・Set up in a position where it is easy to take meals.
・While explaining the use of self-help tools, provide assistance when necessary.
・Confirm that the child is scooping food, and change the spoon or plate appropriately according to their physical function.
・If you can carry it to your mouth, consider using a spoon with a curved handle, etc., according to your physical function.
・Observe if the amount is appropriate, if the food is chewed properly, and if the gag reflex is activated, and confirm that the food is eaten safely.
・If choking is observed, stop eating and perform suction.
・If you cannot secure enough oral intake, consult a doctor.
You may be asked to divide your meals into multiple meals or consider supplements.
If there is an addition such as an infusion, confirm and administer according to the 6Rs so that it can be safely administered.
Manage appropriately. Organize routes and devise ways to prevent self-extraction.
・Arrange to maintain proper posture while eating. Do not tilt your neck backwards.
・If you get tired on the way, switch to meal assistance.
・Provide assistance while checking for the appearance of palpitations, discomfort, nausea, dizziness, lightheadedness, headache, etc.
Use analgesics when self-care is lacking due to pain. Administer 30 minutes before exertion.
・Perform joint range of motion exercises to maintain ADL.
・Provide an environment to support what you can do on your own at home. Futon → bed life etc. Consult with a social worker or care manager to make adjustments so that you can receive the services you need.

3) Education plan 《EP》

・Instruct the patient not to discontinue taking the medicine on his/her own, but to take the medicine prescribed (internal medicine is important to maintain a recuperative life at home).
・Please let us know if you have any subjective symptoms (pain, palpitations, shortness of breath, breathing difficulty, etc.).
・Explain that pain should not be tolerated and should be reported. Explain that analgesics can be used if needed.
・Explain how to use self-help tools.
・Give advice on adapting to lifestyle changes.
・Explain the necessity of lifestyle rehabilitation and joint range of motion training to maintain ADL and prevent bedriddenness. After discharge from the hospital, ask the patient and their family to explain from the rehabilitation staff so that they can continue on their own.
・Explain to the family not to help too much and to provide assistance to preserve the remaining functions. (what to where)
Explain to the family how to help with meals.
・Consult with a social worker or care manager so that you can receive the services you need to live at home.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yutaka Okaniwa. (2003). Disease can be seen VOL.2 Cardiology. Medic Media Co., Ltd.
Yutaka Okaniwa. (2007). Illness can be seen VOL.4 Respiratory organs. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Toyoaki Yamauchi. (Date unknown). Physical Assessment Guidebook. Igaku Shoin.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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