NURSING CARE PLAN

ASSESSMENT NURSING NURSING NURSING INTERVENTION RATIONALE OUTCOME ACTUAL

DIAGNOSIS GOAL CRITERIA EVALUATION

S= “Usahay Self-Care Deficit At the end of 1. Assess client's ability to bathe self > Use of observation of Week 1 – Goal was
maligo, usahay in the 2-week through direct observation (in usual function provides met. Patient was able
bathing setting only) noting specific complementary to perform self-care
dili. Kapuyan ko bathing/hygiene related
deficits and their causes. assessment data for goal activities with
maligo gud”, as related to learning and intervention planning. minimal supervision
verbalized by decreased or lack experience,
or assistance.
the patient. of motivation. patient will be 2. Plan activities to prevent fatigue > Energy conservation
able to perform during bathing increases activity Week 2 – Goal was
O>received Scientific Basis: personal tolerance and promotes met. Patient was able
patient sitting Feeling of hygiene within self-care. to do self-care
on the bench, worthlessness level of own activities without
ability. 3. Instruct patient to select bath time > Hurrying may result in someone prompting or
alone associated with
when he or she is rested and accidents and the energy telling him to do so.
> dirty clothes depression
unhurried. required for these
noted which activities may be
> dirty hair and contributes to substantial.
skin noted lack of
> with long nails interest in 4. Encourage independence, but > An appropriate level of
> unpleasant personal intervene when patient cannot assistive care can prevent
odor noted hygiene. perform. injury with activities
without causing
Source: frustration.
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5. Use consistent routines and allow > This helps patient
d.com/doc/1422 adequate time for patient to organize and carry out
6766/Additional- complete tasks. self-care skills.
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6. Provide privacy during > The need for privacy is
bathing/dressing as appropriate. fundamental for most
patients.

7. Encourage use of clothing one size > This ensures easier

larger. dressing and comfort.
8. Assist patient with care of
fingernails and toenails as required.
9. Provide supervision for each
activity until patient performs skill
competently and is safe in
independent care; reevaluate
regularly to be certain that the
patient is maintaining skill level and
remains safe in environment.
10. Provide positive reinforcement
for every accomplishment made.
> Patients may require
nail care to prevent injury
to feet during nail
trimming or because
special implements are
required to cut nails.
> The patient’s ability to
perform self-care
measures may change
often over time and will
need to be assessed
regularly.
> Positive reinforcement
enhances self-esteem and
encourages repetition of
desirable behaviors.