ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Self-care deficit related After 2 days of nursing INDEPENDENT INDEPENDENT After 2 days of
to alteration in cognitive interventions, patient nursing interventions,
 Her functioning as will be able to perform 1. Provide accurate and 1. So that client can patient had
daughter manifested by impaired self-care activities relevant information incorporate into self- improvement in
reported ability to: access within level of own regarding current and care plans while performing self-care
that: bathroom, wash or dry ability, and with future needs minimizing problems activities.
1. Patient body, and complete assistance of her 2. Perform or assist with (e.g. heightened
would toilet hygiene. daughter. meeting patient’s needs anxiety, depression
forget to go 3. Promote daughter’s and resistance) often
to the participation in problem associated with
bathroom identification and desired change.
and would goals and decision 2. Personal care
soil her making assistance is part of
clothes 4. Develop plan of care nursing care and
2. Forget to appropriate to individual should not be
brush her situation neglected while self-
hair and 5. Active-listen care independence is
teeth, and patient’s/daughter’s promoted and
take a bath concerns integrated.
6. Practice and promote 3. Enhances
short-term goal setting commitment to plan,
and achievement optimizing outcomes,
7. Provide for and supporting
communication among recovery and/or
those who are involved in health promotion.
caring for or assisting the 4. Scheduling activities
client to conform to client’s
 8. Ask daughter for input on
bathing habits or cultural
bathing preferences 5.
9. Bathe or assist patient in
bathing, providing for
any or all hygiene needs
as indicated
DEPENDENT
1. Assist with medication
regimen as necessary
6.
7.
8.
usual or desired
schedule.
Exhibits regard for
family’s values and
beliefs, clarifies
barriers to
participation in self-
care, provides
opportunity to work
on problem-solving
solutions and to
provide
encouragement and
support
To recognize that
today’s success is as
important as any
long-term goal,
accepting ability to
do one thing at a time
and conceptualization
of self-care in a
broader sense.
Enhances
coordination and
continuity of care.
Creates opportunities
for client to (1) keep
long-standing
 routines (e.g., bathing
at bedtime to improve
sleep; (2) exercise
control over situation.
This enhances self-
esteem, while
respecting personal
and cultural
preferences.
9. Type (e.g., bed bath,
towel bath, tub bath,
shower) and purpose
(e.g. cleansing,
removing odor, or
simply soothing
agitation) of bath is
determined by
individual need.

DEPENDENT

1. Encouraging timely
use of medications
(e.g., taking diuretics
in morning when
patient is more awake
and able to manage
toileting, use of pain
relievers prior to
activity to facilitate
movement,
postponing intake of
medications that
cause sedation until
self-care activities
completed.