Problem # : Self-care deficit related to body weakness

Assessment Nursing Scientific Objectives Nursing Rationale Expected

Diagnoses Explanation Interventions Outcome

S> Self-care deficit Activities of daily Short term : > Assess the > The patient Short term :
related to body living or ADLs patient’s may only need
are defined as After 2-3 hours of After 2-3 hours
weakness nursing strength to help with some of nursing
“the stuff we
O> The patient intervention the accomplish self-care intervention the
regularly do
may manifests: patient will ADLs efficiently measures. FIM patient shall
such as feeding
patient patient
ourselves, and cautiously measures 18
 Generalized recognizes recognizes
bathing, individual on a daily basis self-care items individual
weakness
dressing, weakness or using a proper related to weakness or
 Prolonged
grooming, work, needs. needs.
bed rest assessment eating, bathing,
homemaking,
 Pain and leisure. Long term : tool, such as the grooming, Long term :
 Imbalanced However, there After 1-3 days of Functional dressing, After 1-3 days
oxygen are some that nursing Independence toileting, of nursing
supply and might have intervention the Measures (FIM). bladder and intervention the
demand difficulties in patient will patient shall
bowel
performing self- patient safely patient safely
 Insufficient management,
care. Self-care executes executes
sleep self-care transfer, self-care
refers to those
 Shortness of activities an
activities to activities to
ambulation,
breath utmost capability. utmost
individual and stair capability.
 Abnormal performs climbing.
independently
blood
throughout life > Consider the
pressure
to promote and patient’s need
response to > Assistive
maintain for assistive
activity personal devices
devices.
well-being. On improve
the confidence in
contrary, Self-C
performance of
are Deficit is the
ADLs.
inability of an
individual to > Establish
perform short-term goals
self-care. The > Helping the
with the patient.
deficit may be
patient with
the effect of
temporary setting realistic
limitations, such goals will
as those one reduce
might >Guide the frustration.
experience patient in
while recovering > Patient may
accepting the
from surgery, or require help in
the result of needed amount determining the
gradual of dependence safe limits of
deterioration trying to be
that erodes the independent
individual’s versus asking
ability or for assistance
willingness to when
necessary.
perform the
activities
required to care
for himself or > Establish
herself. Also, regular activities
patients who are so the patient is > A plan that
suffering rested before balances
from depression activity. periods of
may not have
activity with
the interest to
periods of rest
engage in
self-care can help the
activities. patient
complete the
Assisting in
activities of daily desired activity
living are skills without
required in undue fatigue a
nursing and as > Educate family nd frustration.
well as other and significant
professions others to > This displays
such as nursing promote caring and
assistants. The autonomy and to concern but
nurse intervene if the does not hinder
coordinates patient becomes with patient’s
services to tired, not efforts to attain
capable of autonomy.
maximize the
carrying out
independence
task, or become
of the patient extremely
and to ensure aggravated.
that the
environment the
patient lives is
safe and
supportive of his >Consider or
or her special use >This saves
needs. energy-conserv energy,
ation decreases fatig
techniques. ue, and
improves
patient’s
capability to
execute tasks.

>Aid patient in
eliminating or
changing
unnecessary >Clothing that
clothing. is not easy to
get in and out
of may
compromise a
patient’s
capability to be
continent.

> Aid with

ambulation;
direct the use of > These
ambulation methods
devices such as promote patient
canes, walkers, safety and aid
and crutches. with balance
and support.