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Careplan

Self-Care Deficit, Adult

Jul.10.2018

Self-Care Deficit (Adult Inpatient)

Clinical Description

  • Care of the hospitalized patient experiencing limitations in the safe and independent performance of activities of daily living.

Key Information

  • It is important to consider the patient’s cultural norms, along with individual priorities and preferences when promoting self-care performance.
  • Early rehabilitation and care aimed at increasing self-care abilities are important to help prevent loss of independence and associated negative health outcomes.

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Improved Ability to Complete Activities of Daily Living

B. Patient, family or significant other will teach back or demonstrate education topics and points:
  • Education: Overview
  • Education: Self Management
  • Education: When to Seek Medical Attention

Correlate Health Status

  • Correlate health status to:

    • history, comorbidity
    • age, developmental level
    • sex, gender identity
    • baseline assessment data
    • physiologic status
    • response to medication and interventions
    • psychosocial status, social determinants of health
    • barriers to accessing care and services
    • health literacy
    • cultural and spiritual preferences
    • safety risks
    • family interaction
    • plan for transition of care

Self-Care Deficit

Signs/Symptoms/Presentation

  • active movement limitation
  • bathing ability limited
  • dressing ability limited
  • grooming ability limited
  • inability to complete BADLs (basic activities of daily living)
  • inability to complete IADLs (instrumental activities of daily living)
  • laundry performance ability limited
  • limited endurance
  • meal preparation ability limited
  • medication management ability limited
  • muscle weakness
  • pain limits activity
  • personal hygiene care ability limited
  • reluctance to perform self-care
  • requires prompting to perform self-care
  • requires assistance with self-care
  • self-feeding ability limited
  • shortness of breath
  • toileting ability limited

Problem Intervention

Promote Activity and Functional Independence

  • Evaluate ability to perform and complete BADLs (basic activities of daily living) and IADLs (instrumental activities of daily living) safely and independently.
  • Identify patient’s preferences for clothing, food and personal care items; offer and honor patient choice when possible.
  • Provide therapeutic interventions, such as modifications or adaptations to personal care tasks or routines to maximize independence and safety.
  • Encourage active participation and independence in daily activity; provide level of assistance required for safety.
  • Implement appropriate environmental modifications, such as decluttering and rearranging room to allow wheelchair access.
  • Promote use of recommended adaptive equipment, devices and orthoses.
  • Maintain patient’s preferred routines and habits; respect privacy and personal space.
  • Schedule self-care activities when pain and fatigue are at a minimum to encourage optimal performance.
  • Pace activity; allow adequate time and rest periods to conserve energy.
  • Provide frequent encouragement, along with prompting and assistance as needed.
  • Provide set-up of items if patient is unable to retrieve; store personal care items in accessible location.
  • Individualize instructions and prompts to patient’s cognitive status to promote effective communication; simplify verbal directions, give encouragement and provide demonstrated cues as needed.
  • Position the patient for optimal performance, such as sitting in a chair for meals or performing hygiene at sink.

Associated Documentation

  • Activity Assistance Provided
  • Adaptive Equipment Use
  • Self-Care Promotion

Education

CPG-Specific Education Topics

Overview

  • risk factors

  • signs/symptoms

Self Management

  • self-care

When to Seek Medical Attention

  • unresolved/worsening symptoms

General Education Topics

General Education

  • admission, transition of care

  • orientation to care setting, routine

  • advance care planning

  • diagnostic tests/procedures

  • diet modification

  • opioid medication management

  • oral health

  • medication management

  • pain assessment process

  • safe medication disposal

  • tobacco use, smoke exposure

  • treatment plan

Safety Education

  • call light use

  • equipment/home supplies

  • fall prevention

  • harm prevention

  • infection prevention

  • MDRO (multidrug-resistant organism) care

  • personal health information

  • resources for support

References

  • Bulechek, G. M.; Butcher, H. K.; McCloskey-Dochterman, J. M.; Wagner, C. (2013). Nursing Interventions Classification (NIC). St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Foster, E. R.; Bedekar, M.; Tickle-Degnen, L. Systematic review of the effectiveness of occupational therapy - related interventions for people with Parkinson's Disease. American Journal of Occupational Therapy. 2014;68(1), 39-49. [Metasynthesis,Meta-analysis,Systematic Review]
  • Legg, L.; Drummond, A.; Leonardi-Bee, J.; Gladman, J. R. F.; Corr, S.; Donkervoort, M.; Edmans, J.; Gilbertson, L.; Jongbloed, L.; Logan, P.; Sackley, C.; Walker, M.; Langhorne, P. Occupational therapy for patients with problems in personal activities of daily living after stroke:  Systematic review of randomised trials. British Medical Journal. 2007;335(7626), 922-925. doi:10.1136/bmj.39343.466863.55 [Metasynthesis,Meta-analysis,Systematic Review]
  • Martínez-Velilla, N.; Cadore, E. L.; Casas-Herrero, Á.; Idoate-Saralegui, F.; Izquierdo, M. Physical activity and early rehabilitation in hospitalized elderly medical patients:  Systematic review of randomized clinical trials. Journal of Nutrition, Health and Aging. 2016;20(7), 738-751. doi:10.1007/s12603-016-0683-4 [Metasynthesis,Meta-analysis,Systematic Review]
  • National Guideline Clearinghouse (NGC). (2012, January). Guideline summary:  Function-focused care (FFC) interventions. In Evidence-based geriatric nursing protocols for best practice.  (Summary of a guideline from Hartford Institute for Geriatric Nursing) In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ). [Quality Measures,Clinical Practice Guidelines]
  • National Guideline Clearinghouse (NGC). (2014, January). Guideline summary:  Occupational therapy practice guidelines for adults with neurodegenerative diseases. (Summary of a guideline from the American Occupational Therapy Association, Inc.) In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ). [Quality Measures,Clinical Practice Guidelines]
  • Pendleton, H. M.; Schultz-Krohn, W. (2013). Pedretti's occupational therapy: Practice skills for physical dysfunction. St. Louis: Mosby, Elsevier. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]
  • Pollock, A.; Baer, G.; Campbell, P.; Choo, P. L.; Forster, A.; Morris, J.; Pomeroy, V. M.; Langhorne, P. Physical treatment is effective in the promotion of functional recovery after stroke:  Results of a Cochrane systematic review. Cerebrovascular Diseases. 2014;37, 30. doi:10.1159/000356349 [Metasynthesis,Meta-analysis,Systematic Review]
  • Vining Radomski, M.; Trombly Latham, C. A. (2014). Occupational therapy for physical dysfunction. Baltimore: Wolters Kluwer/Lippincott Williams & Wilkins. [Review Articles,Expert/Committee Opinion,Core Curriculum,Position Statements,Practice Bulletins]

Disclaimer

Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.