NCP Self Care Deficit

Nursing Care Plan
Nursing
Diagnosis
Goal
Nursing
Intervention
Rationale
Evaluation
Self-Care Deficit related to musculoskeletal impairment as claimed by the client that she experiences difficulty in performing simple tasks such as combing of hair, brushing of teeth and putting on of gown and as evidenced by stiffness in the joints of the wrist and fingers and reddened and edematous bilateral knees, right ankle, right hand and fingers.
Within 3 days of nursing intervention, client will be able to interdependently perform self-care activities consistent with individual capabilities.

Objectives:
Within 8 hours of nursing intervention, the client will be able to:
1. Perform self-care activities at a level consistent with individual capabilities.

2. Demonstrate techniques to meet self-care needs.

3. Identify personal or community resources that can provide needed assistance.

INDEPENDENT:
1. Allow client sufficient time to complete tasks to fullest extent of ability.

2. Determine usual level of functioning using Functional Level Classification 0-4 for status before onset of illness and potential changes now anticipated.

Collaborative:
3. Arrange for consult with other agencies, such as home-care service or nutritionist.

1. May need more time to complete tasks but provides an opportunity for greater sense of self-confidence and self-worth.

2. May be able to continue usual activities with necessary adaptations to current limitations.

3. May need additional kinds of assistance to continue in home setting.
Goal met. Client can interdependently perform self-care activities such as combing of hair, brushing of teeth and putting on of gown with passive assistance as minimum as possible consistent to the capability of client and maintained client’s sense of independence.