NANDA-Nursing Plan 00109 Dressing 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

Dressing self-care deficit 00109

Dressing self-care deficit 00109

Nursing Diagnosis: Dressing self-care deficit
Definition: To perform a dressing action for oneself. or a condition that impairs the ability to complete

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

1. Lack of dressing self-care

・ Decreased motivation (psychiatric disorders, dementia, etc.)
・Cognitive decline
・Don’t worry about yourself
・I don’t know the season or day or night
・I don’t know how to put the button on and take it off
・I don’t know how to raise and lower the zipper
・Mental illness (some people with mental illness dislike clean behavior extremely)
·paralysis
・Motor paralysis: there is a limit to changing clothes on your 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 (difficult to bathe, palpitations, chest pain)
・Respiratory dysfunction (difficulty in breathing when bathing, inhalation of oxygen)
・Exhaustive fatigue
– Can’t get clothes

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

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: changing clothes
・Mobility
・Body balance
・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 change clothes on their own using clothes and self-help tools that match their remaining functions.
・Clothes can be selected according to temperature, location, and occasion.
・Be able to state points to note on the paralyzed side.

*Nurse goals include:

・Prepare self-help tools suitable for ADLs and disabilities to maintain self-care while dressing.
・To address the lack of changing healthcare due to declining cognitive function, engage in activities that remind people of the season and date.
Provide support so that the clothes can be selected according to the temperature, location, and occasion.
・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
・ 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 changing clothes
　* Near-skeletal system disease: range of motion and joint disorders
　* Rheumatoid arthritis, scleroderma: Impairment of fingertip movement
　* Cerebrovascular disease, intracerebral lesion: paralysis, motor dysfunction
　*Heart disease, valve disease: 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
　* Consuming diseases: severe infections, anemia, dehydration, hypoproteinemia, etc.
・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
・ Cyanosis, peripheral coldness
・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
・Joint range of motion
·Subjective symptoms:
・Dyspnea, chest pain, palpitations
・dizzy
・Venous blood data
・Anemia (RBC, Hb, HT)
・As infection (procalcitonin, CRP, WBC, granulocytes/lymphocytes) 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 wearing clothes
・Presence or absence of clothes that fit
・Monetary factors

2) Action plan 《TP》

・Provide care that considers safety, comfort, and independence. (utilize remaining functions)
・Improve the changing environment
・Set up a calendar so that you can see the seasons.
・Adjust the room temperature so that it is not too cold.
・Prepare a chair so that you can sit down and change your clothes.
・Prepare a pulse oximeter and blood pressure monitor just in case
– Assistance with clothing preparation
· Help with the preparation of necessary items (Help while remembering what is in where and what to prepare)
・Help with changing clothes
・Maintenance of standing position, maintenance of sitting position
・Bend down
・Unfastening the button
・Putting on and taking off pants and socks
・Put your sleeves through. take off the sleeves
・ Use of self-help tools (magic hands, button aids, etc.)
・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)
・Consult with a social worker or care manager so that you can receive the services you need to live at home.

Please also refer to the state of readiness to promote self-care.

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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