Self-Care Deficit | Nursing Care Plan for Cerebrovascular Accident

Nursing diagnosis: Self-care deficit related to neuromuscular impairment, decreased strength and endurance, loss of muscle control and coordination; perceptual or cognitive impairment; pain, discomfort; depression

Possibly evidenced by

Impaired ability to perform ADLs, such as inability to bring food from receptacle to mouth; inability to wash body part(s) or regulate temperature of water; impaired ability to put on and take off clothing; difficulty completing toileting tasks

Desired Outcomes/Evaluation Criteria—Client Will

Self-Care: Activities of Daily Living (ADLs)

Demonstrate techniques and lifestyle changes to meet self-care needs.

Perform self-care activities within level of own ability.

Identify personal and community resources that can provide assistance as needed.

Nursing intervention with rationale

1. Assess abilities and level of deficit (0 to 4 scale) for performing ADLs.

Rationale: Aids in anticipating and planning for meeting individual needs.

2. Avoid doing things for client that client can do for self, providing assistance as necessary.

Rationale: These clients may become fearful and dependent, and although assistance is helpful in preventing frustration, it is important for client to do as much as possible for self to maintain self-esteem and promote recovery.

3. Be aware of impulsive behavior or actions suggestive of impaired judgment.

Rationale: May indicate need for additional interventions and supervision to promote client safety.

4. Maintain a supportive, firm attitude. Allow client sufficient time to accomplish tasks.

Rationale: Clients need empathy and to know caregivers will be consistent in their assistance.

5. Provide positive feedback for efforts and accomplishments.

Rationale: Enhances sense of self-worth, promotes independence, and encourages client to continue endeavors.

6. Provide self-help devices, such as button or zipper hook, knifefork combinations, long-handled brushes, extensions for picking things up from floor, toilet riser, leg bag for catheter, and shower chair. Assist and encourage good grooming and makeup habits.

Rationale: Enables client to manage for self, enhancing independence and self-esteem; reduces reliance on others for meeting own needs; and enables client to be more socially active.

7. Encourage SO to allow client to do as much as possible for self.

Rationale: Reestablishes sense of independence and fosters self-worth and enhances rehabilitation process. Note: This may be very difficult and frustrating for the SO/caregiver, depending on degree of disability and time required for client to complete activity.

8. Assess client’s ability to communicate the need to void and ability to use urinal or bedpan. Take client to the bathroom at frequent and scheduled intervals for voiding if appropriate.

Rationale: Client may have neurogenic bladder, be inattentive, or be unable to communicate needs in acute recovery phase, but usually is able to regain independent control of this function

as recovery progresses.

9. Identify previous bowel habits and reestablish normal regimen. Increase bulk in diet. Encourage fluid intake and increased activity.

Rationale: Assists in development of retraining program (independence) and aids in preventing constipation and impaction (longterm effects).

10. Consult with rehabilitation team, such as physical or occupational therapist.

Rationale: Provides assistance in developing a comprehensive therapy program and identifying special equipment needs that can increase client’s participation in self-care.