PALAWAN STATE UNIVERSITY

COLLEGE OF NURSING AND HEALTH SCINCES

Puerto Princesa City

NURSING CARE PLAN

CUES Objective cues: Discomfort Unpleasant odor Unfixed Hair Dry Hair Presence of Dandruff Halitosis noted NURSING DIAGNOSIS RATIONALE OBJECTIVES After 1hour of nursing intervention patient may able to maintain his proper grooming and hygienic care and also patient may perform activity of daily living such as groom, bathe, toilet, comb hair, tooth brushing and changing clean clothe daily. INTERVENTION Independent: Assess ability to carry out ADLs (e.g., grooming, bathing, toileting, tooth brushing and changing clothe daily) on regular basis Assess specific cause of each deficit (e.g., weakness, visual problems, cognitive Impairment). Provide positive reinforcement for all activities attempted by the patient. To know the ability of the patient and to determine the aspects of self care that is problematic to the patient. RATIONALE EVALUATION After 1hour of nursing intervention patient was consistently appear clean and well-groomed and will independently manage personal grooming and hygiene. Patient will have clean and reasonably appropriate clothes,

Self-care deficit Changes in genes (grooming, dressing, and chemicals in the brain and feeding) related to (neurotransmitters) psychological impairment, difficulty in concentrating and making decisions: as evidenced by Psychological inappropriate dress, impairment unpleasant odor, unfixed Hair, dry Hair Presence of Dandruff Impaired thought Halitosis process

Different etiological factors may require more specific interventions to enable self-care Provides the patient with an external source of positive Reinforcement.

Lack of concern with hygiene or grooming

Self-care deficit (grooming, dressing, and feeding) related to

Assist with bathing and hygiene daily only when patient has difficulty. Allow ample of time for patient to perform bathing, grooming,

To encourage independency and self reliance.

Rushing creates unnecessary stress and promotes failure.

psychological impairment, difficulty in concentrating and making decisions: as evidenced by inappropriate dress, unpleasant odor, unfixed Hair, dry Hair Presence of Dandruff Halitosis

toileting, tooth brushing and changing clothes. Direct patient in bathing, toileting, grooming, toileting, and tooth brushing and hygiene measure, giving simple instruction one at a time. Collaboration: These extra resources Refer patient to a will reinforce activities psychiatric liaison planned to meet nurse, support group, or patients needs. home health care agency, as needed. Such clothing makes Encourage family independency dressing member to provide easier. clothing patient can easily manage. Patient may benefit from clothing slightly larger than regular size. Instruct patient and family members in dressing and grooming technique (you can give family members written instruction). Have patient and family members demonstrate dressing and grooming technique under supervision. Return demonstration reveals problem areas and increase selfconfidence To aid comprehension of the patient.