Page 16 - Altered Obstructive Nursing Care
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Self-Care Deficit
Related to
• Surgery
• Gradual deterioration that erodes the individual’s ability
• Depression
Outcomes
• Patients receive care holistically
Nursing Assessment Rationales
The patient may only need help with some
Assess the patient’s strength to accomplish self-care measures. FIM measures 18 self-care
ADLs efficiently and cautiously on a daily basis items related to eating, bathing, grooming,
using a proper assessment tool, such as the dressing, toileting, bladder and bowel
Functional Independence Measures (FIM). management, transfer, ambulation, and stair
climbing.
Determine the specific cause of each deficit Various etiological factors may need more
(e.g., visual problems, weakness, cognitive
impairment). explicit interventions to enable self-care.
Consider the patient’s need for assistive Assistive devices improve confidence in
devices. performance of ADLs.
The patient will be eager to submit himself or
Recognize choice for food, personal care items, herself to the treatment regimen that supports
and other things.
his or her individual preferences.
Evaluate gag reflex or the need for swallowing Absence of gag reflex or inability to chew or
assessment by a speech therapist prior to initial swallow properly may lead to choking or
oral feeding. aspiration.
Shortened hospital stay has resulted in
patients being more debilitated on discharge
Verify the need for home health care after
discharge. and therefore requiring more assistance at
home. Occupational therapists have access to
a wide range of self-help devices.
This may imply the demand for
Monitor impulsive behavior or actions
indicative of altered judgment. supplementary interventions and
management to guarantee safety or security.
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