Nursing

Assessment Planning Interventions Rationale Evaluation

Diagnosis
Subjective: 1. Assess the patient’s overall 1. To determine the patient’s Goal met. The pt was able
Self-care deficit r/t At the end of 4 days condition. capability to perform ADL. to execute self-care safely
cerebrovascular of nursing and learned the
accident as intervention, the pt: 2. Give tepid bath sponge. 2. The client cannot take a bath importance of personal
Objective: evidenced by independently; tepid sponge can be hygiene together with the
-Inability to dress -safely executes self- an alternative way to clean the family/ S.O.
hemiplegia /
self autonomously. care activities to client’s body.
poor personal
- Inability to bathe utmost capability.
& groom self hygiene. -identifies useful 3. Encourage the client and the 3. Proper hygiene is the most
independently. resources in family to provide a tepid sponge important way to prevent
-Inability to optimizing the bath everyday and other occurrence and severity of disease.
perform toileting autonomy and hygienic practices like hand
tasks independence. washing, tooth brushing,
independently. combing, nail cutting.
- Inability to
ambulate 4.Guide the patient in accepting 4. Patient may require help in
independently. the needed amount of determining the safe limits of trying
- Poor personal dependence. to be independent versus asking for
hygiene. assistance when necessary.

5. Give heath teaching about the 5. Emphasizing this health teaching

importance of hand washing, helps to remind the client and the
tooth brushing, combing, nail family why it is necessary to do it.
cutting, regular exercise of
ambulation to the famiy.

Case: Self-Care Deficit