NANDA-Nursing Plan　Area4　activity/rest

NANDA-Nursing Plan 00108 Bathing self-care deficit

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

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

Bathing self-care deficit 00108

Nursing Diagnosis: Bathing self-care deficit
Definition: Performing bathing behavior for oneself. or a condition that impairs the ability to complete

Thank you for always watching.
I think it’s easy to imagine the lack of bathing self-care this time.
Let’s think about not only being unable to do the work due to paralysis, but also including cases where the act of “bathing” is unconscious or disliked.

1. Indications for lack of bathing self-care

・Cognitive decline (reluctance to bathe, loss of understanding of bathing)
・Mental illness (some people with mental illness dislike clean behavior extremely)
・paralysis
・ Motor paralysis: there is a limit to washing the body on one’s own
・Motor paralysis: Requires self-help equipment (slide board, anti-slip, lift, etc.)
・ Sensory numbness: not knowing the temperature of the hot water
・fracture
・Spatial neglect (limited visibility)
・Neuromuscular disease (weakness, involuntary movements, etc.)
・pain
・Cardiac dysfunction (difficult to bathe, palpitations, chest pain)
・Respiratory dysfunction (difficulty in breathing when bathing, inhalation of oxygen)

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: Cleanliness
・Self-care: Bathing
・Mobility
・Safe home environment
・Sensory function: vision
・Cognition

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 ○○.”

・The caregiver can arrange the bathing environment according to ADL and disability.
・Be able to describe a bathing method that makes use of the remaining functions and actually take a bath using that method.

*Nurse goals include:

・In order to maintain self-care, prepare a bathing environment suitable for ADLs and disabilities.
・If the patient refuses to take a bath due to a decline in cognitive function, give a sense of security and support.
・Listen to the patient’s complaints and try to alleviate their anxiety.
・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
· There is no awareness of bathing (I don’t know if I’m in or not)
・I don’t know how to get to the bathroom
・I was about to go to the bathroom, but I forgot my purpose on the way
・I can’t prepare for bathing
・Medical history, current disease history, etc.: Pick up those that are likely to have subjective symptoms due to bathing
　* Cardiac disease, valve disease…Possibility of occurrence of chest pain, palpitations, shortness of breath, dizziness, fainting, etc.
　*Pulmonary diseases such as pulmonary hypertension and COPD: respiratory distress, need for oxygen inhalation
　*Blood disease, coagulation system abnormality
　*Fracture
　*Autonomic imbalance: The autonomic nervous system is out of balance when taking a bath, causing palpitations, sweating, dizziness, hot flushes, headache, abdominal pain, nausea, and trembling. happens
・obesity
・Sensory dysfunction
　* Diabetes: Due to peripheral neuropathy, the temperature sensation of the toes and fingertips becomes dull.
・ADL, IADL: Regarding bathing actions, how much can you do on your own, and are you 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
・ Auscultation: lung murmur (pulmonary edema), heart murmur (valve disease 3.4 sounds)
・Physical findings
・Edema
・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.
・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, fracture, brain injury site, etc.
・Load test
・ Walk for 6 minutes
・Strength: MMT
·Subjective symptoms:
・Dyspnea, chest pain, palpitations
・Peripheral sensory disturbance
・Disturbed consciousness (hyperglycemia, etc.)
・dizzy
・Venous blood data
・ Bleeding tendency: PLT (platelets), PT (prothrombin time), APTT (partial thromboplastin)
・Hyperglycemia: GLU, HbA1C
・ Neutral fat, total cholesterol, HDL, LDL
・symptoms indicating high blood pressure
· Nose bleeding, increased blood pressure, etc.
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

・Does the house have a bathroom?
・Bathroom environment: steps in the bath, no handrail, far from the bathroom
・Region of life: cold zone

2) Action plan 《TP》

・Provide care that considers safety, comfort, and independence. (utilize remaining functions)
・Improve the bathing environment
・ Mark the bathroom so that you can see it
・Install a chair in the dressing room.
・Prepare a pulse oximeter and blood pressure monitor just in case
・ Eliminate steps and install handrails
· Correction of the temperature difference between the dressing room and the bathroom
・Installation of mattresses, sliding boards, etc.
・Adjustment of hot water temperature
・Help prepare for bathing
· Help with the preparation of necessary items (Help while remembering what is in where and what to prepare)
・Help with undressing
・Unfastening the button
・ Putting on and taking off trousers and pants
・Maintenance of standing position
・Help with body washing
・Make sure you wash your armpits, back, and even between your toes.
・Make sure that there is no difficulty in breathing or shortness of breath while washing the body.
・ Helping to soak in the bathtub
・Have your feet enter slowly.
・Release while checking for palpitations, discomfort, nausea, dizziness, floating sensation, headache, etc.
・Teach the location of the nurse call. Tell them to press this if anything happens.
・Call out at a suitable place so that you don’t stay in the bath for too long.
・Call out to make the water temperature appropriate.
– Helping you get out of the bathtub
· Provide assistance while checking for dizziness, discomfort, or fainting.
・Assist while explaining that the feet are wet and slippery.
・Help with changing clothes
・Is there a procedure in place?
・Check if the amount of cylinder remains.
・When using oxygen, check the oxygen administration device, dosage, and state of consciousness. Follow the route to make sure oxygen is being administered. Prepare the environment so that it will not be pulled.
・When increasing the oxygen during physical activity such as bathing, increase or decrease the amount. If you are doing it yourself, make sure you are following the correct procedure.
Use analgesics when self-care is lacking due to pain. Administer 30 minutes before exertion.
・Range of motion training for maintaining ADL, lifestyle rehabilitation
・Provide an environment to support what you can do on your own at home. 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 connect to an oxygen cylinder and how to use it.
– When using oxygen at home, the same applies to fire bans, and explain that it is necessary to keep at least 2 meters away from fire.
・Give advice on adapting to lifestyle changes.
・Explain to the family not to help too much and to provide assistance to preserve the remaining functions. (what to where)
・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.
Tomokazu Aoyagi. (2018). Assessment Skills ~. Raptor Project Co., Ltd.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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