NURSING SCIENTIFIC

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS RATIONALE
SUBJECTIVE: Self – Care Deficit Self-Care Deficit is the SHORT TERM GOAL: INDEPENDENT: SHORT TERM GOAL:
- “Danay diri ako related inability to inability of an individual After 3 days of nursing  To obtain cooperation
 Establish rapport.
nakakagliwan hin trust evidenced by to perform self-care. The interventions, the
Inability or patient will be GOALS PARTIALLY MET
akon la kay gusto ko deficit may be the effect
 Underlying cause of
hi mana teying la it unwillingness to of temporary limitations, able to  Identify reason for As evidenced by:
establish ADL affects choice of
mag aareglar ha carry out toileting such asthe result of difficulty in self – care; e.g.
with assistance interventions/ strategies.
procedures without gradual deterioration cognitive decline.
akon.” as verbalized Problem may be
assistance that erodes the as evidenced by:
by the patient. minimized by e.g.,  Being able to verbalize
individual’s ability or changes in environment or the understanding about
willingness to perform • Verbalize adaptation of clothing, or the importance of
OBJECTIVE: the activities required to understanding about may be more complex, performing ADL.
care for himself or the importance of requiring consultation from
Presents symptoms of herself. Also, patients performing ADL other specialists.  Patient reportedly
dependence to the unit who are suffering from Important to distinguish observed to perform
parent. any kind of psychosis • Perform self – care between partial and total bathing independently
activities within the dependence to avoid but with stand-by
may not have the
level of own creating excess disability. assistance from the unit
interest to engage in
ability parent.
self-care activities.
• Patient will participate
in feeding, dressing,  Determine hygienic  As the disease
toileting, and bathing needs and provide progresses, basic hygienic
activities detaching a assistance as needed with needs may be forgotten.
little of assistance to activities, including care of Infection, gum disease,
promote hair/nails/ skin, brushing disheveled appearance, or
dependence. teeth, cleaning glasses. harm may occur when
client/ caregivers become
frustrated, irritated or
intimidated by degree of
care required.

 Presence of such
lesions as ecchymoses,
 Inspect skin regularly.
lacerations, rashes may
require treatment, as well
as signal the need for
close monitoring/
protective interventions.

 Incorporate usual  Maintaining routine may

routine into activity prevent worsening of