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Nursing Interventions for Self-Care Deficit - Bathing / Hygiene

Self-Care Deficit - Bathing / Hygiene Definition Circumstances where individuals have failed to implement or complete ability bathing / hygiene activities. Data: Lack of ability to bathe themselves (including washing the whole body, combing hair, brushing teeth, doing skin care and nails as well as the use of makeup) Can not or no desire to wash the body or body parts. Can not use the source water. Inability to feel the need for hygiene measures. Lack of ability to wear his own clothes (including underwear routine or special clothing, not the clothes the night) Failure of the ability to use or release of clothes. Inability to fasten clothing. Inability to dress themselves satisfactorily. Expected outcomes are: Individuals will 1. Identifying the love of self-care activities. 2. Demonstrated that optimal hygiene in care after assistance is given. 3. Participate in physical and or verbal self-care activities Carry out the shower activity at its optimal level. Reported satisfaction with the achievements despite the limitations. Connecting a feeling of comfort and satisfaction with the cleanliness of the body. Demonstrate ability to use adaptive assistive devices. Describe the factors that cause of the lack of ability to bathe.

Nursing Interventions for Self-Care Deficit - Bathing / Hygiene: 1. Encourage individuals to use corrective lenses or assistive devices are prescribed. 2. Keep the temperature warm bath; make sure the preferred water temperature of the individual. 3. Provide privacy for bathing routine. 4. Give all toiletries in a convenient boundary. 5. Provide security in the bathroom (eg, the floor is not slippery, handle bars, bells). 6. If the individual is able to physically push using the bath or shower, depending on the hospital facilities in preparation for return home. 7. Provide adaptive equipment if needed Seat or no back seat while bathing The holder of spongy long reach back or lower extremities Place the handle on the bathroom wall

Board to move to a bath seat Pad or mat that is not slippery Dishwashing gloves with pockets for soap Toothbrush that has been adapted Shavers

Shower spray handle 8. To individual eyesight deficiencies Place toiletries in the most appropriate location for the individual Keep the call bell within easy reach Give the same degree of privacy Verbally inform yourself before entering or leaving the bath Observation of the individual's ability to put all toiletries Observation of the individual's ability to perform oral care, brushing her hair.

Provide a place to clean clothing that is easily accessible. 9. For individuals with missing limbs or pain Bathe in the early morning or before bed at night. Encourage individuals to use the mirror over the bath to observe the area of skin that have paralise Encourage individuals who experience limb amputation to observe the integrity of the skin is left for good. Give only some supervision or assistance needed to learn to re-use or adaptation of limb defects 10. For individuals with cognitive decline Give time to bathe consistent routine as part of a structured program to help reduce anxiety Keep instructions simple and avoid distractions; orientation purposes of toiletries. If the individual is unable to bathe the whole body, allow individuals to bathe a part of her body until it is; give positive feedback on the success Monitoring activities carried out until the individual can safely perform tasks that are not supported Encourage attention to the task, but be wary of fatigue that may increase anxiety 11. Ensure that the shower facilities available at home and help in determining if there are different needs for adaptation. 12. refer to the occupational therapy or social services to assist in obtaining necessary equipment.

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Self-Care Deficit Nursing Interventions Symptoms of Anemia According to John Hopkins Point-of-Care Information Technology Center, (The John Hokins POC-IT Center), the most common causes of anemia include: dizziness, weakness and fatigue, shortness of breath with activity, dizziness, occasional chest pains, and cold, clammy skin.

Having nerve pain may also point to the presence of this problem. Causes of Anemia There are several causes of anemia, which include: Iron deficiency Kidney disease Pregnancy Poor nutrition Deficiency of vitamin B12 known as pernicious anemia Sickle cell anemia Thalassemia Alcohol Bone marrow related anemia Aplastic anemia Hemolytic anemia Active bleeding, eg. heavy bleeding during menstration.

Treatments of Anemia Once the doctor determines the cause he or she will initiate a treatment program for you. Here are some causes along with their treatment protocol. Blood Loss: the source of the bleeding will be determined and stopped. For example you may be given a blood transfusion and iron to build up your red blood cell count. Iron Deficiency: If you have inadequate iron levels you most likely will be prescribed iron supplements. Do not do this on your own but under the care of a physician because consuming too much iron can be dangerous. Red blood cell destruction: Known as hemolytic anemia, there are various causes for it. So the treatment would of course depend on the cause. Follow up care: You need to stay under your doctor's care and have repeated blood work done to determine if the anemia has gone away. Your response to the treatments prescribed will determine what the next steps are to take. The hopeful outcome is that you have overcome your anemia. If not, with continued care over time you should be able to do so. Before doing any dietary or lifestyle changes always consult with your health care provider, particularly if you have been diagnosed with a disease or are taking any prescription medication.

2 Diagnosis Nursing Interventions for Anemia 1. Ineffective Tissue Perfusion Objectives: Adequate tissue perfusion Nursing Intervention for Anemia :

Monitor vital signs, capillary refill, skin color, mucous membranes. Exalt the position of head of in bed Examine and document the presence of pain. Observation of a delay in verbal response, confusion, or restlessness Observe and document the presence of the cold. Maintain the ambient temperature to keep warm the body needs. Provide oxygen as needed.

2. Activity Intolerance Objectives: Tolerant of activity Nursing Intervention: Assess the capability of doing the activity

Monitor vital signs during and after activity, and noted a physiological response to activity (increased heart rate increased blood pressure, or rapid breathing). Provide information to the patient or family to stop doing activities if teladi symptoms of increased heart rate, increased blood pressure, rapid breathing, dizziness or fatigue). Provide support to perform their daily activities according to the ability of the child. Creating a schedule of activities involving other health team. Symptoms of Anemia According to John Hopkins Point-of-Care Information Technology Center, (The John Hokins POC-IT Center), the most common causes of anemia include: dizziness, weakness and fatigue, shortness of breath with activity, dizziness, occasional chest pains, and

cold, clammy skin. Having nerve pain may also point to the presence of this problem. Causes of Anemia There are several causes of anemia, which include: Iron deficiency Kidney disease Pregnancy Poor nutrition Deficiency of vitamin B12 known as pernicious anemia

Sickle cell anemia Thalassemia Alcohol Bone marrow related anemia Aplastic anemia Hemolytic anemia

Active bleeding, eg. heavy bleeding during menstration. Treatments of Anemia Once the doctor determines the cause he or she will initiate a treatment program for you. Here are some causes along with their treatment protocol. Blood Loss: the source of the bleeding will be determined and stopped. For example you may be given a blood transfusion and iron to build up your red blood cell count. Iron Deficiency: If you have inadequate iron levels you most likely will be prescribed iron supplements. Do not do this on your own but under the care of a physician because consuming too much iron can be dangerous. Red blood cell destruction: Known as hemolytic anemia, there are various causes for it. So the treatment would of course depend on the cause. Follow up care: You need to stay under your doctor's care and have repeated blood work done to determine if the anemia has gone away. Your response to the treatments prescribed will determine what the next steps are to take. The hopeful outcome is that you have overcome your anemia. If not, with continued care over time you should be able to do so. Before doing any dietary or lifestyle changes always consult with your health care provider, particularly if you have been diagnosed with a disease or are taking any prescription medication.

Nursing Care Plan for: Constipation


Mr. Ahmad A 40-years-old male patient is admitted to the hospital on 15 April 2012 suffering from distended abdomen, dry and hard stool passed with difficulty. He states I dont pass stool since three days, I feel pain in my abdomen, I eats little amount of fiber diet and drink little fluid

Assessment:
Subjective data: The patient states I dont pass stool since three days, I feel pain in my abdomen, I eats little amount of fiber diet and drink little fluid Objective data: Mr. Ahmad A 40-years-old male has distended abdomen, dry and hard stool passed with difficulty

Nursing Diagnosis:
Constipation related to little amount of fiber diet and drink little fluid manifested by distended abdomen, dry and hard stool since three days

Planning
Short-term goal: The patient will pass bowel movement by on 16 April 2012 Nursing order: On 15 April 2012 1. Encourage fluid intake up to 3 liters per day 2. Encourage high- fiber diet intake 3. Encourage the patient practice exercises

Intervention :
1. The patient drank orange juice about one litter ,water and some soup about 1.5 liters 2. The patient ate high- fiber diet 3. The patient practice some exercises as walking

Evaluation:
On 16 April 2012 the patient pass bowel movement with little amount of pain =====================================================================================

Nursing Care Plan for: Hyperthermia, Fever, High Temperature


20 years old male patient admitted to the medical ward with acute tonsillitis. His Temperature 39.5 C .His skin is flushed and hot. He stated I feel myself very hot, and I am thirsty.

Assessment:
Subjective data: He stated I feel myself very hot, and I am thirsty Objective data: His Temperature 39.5 C .His skin is flushed and hot

Nursing Diagnosis:
Hyperthermia related to infection as evidence by Temperature 39.5 C., His skin is flushed and hot and the patient feels thirsty

Planning
Short-term goal: Pts temperature will between 36. C and 37.5 C within 24 hours of hospitalization. Nursing order: 1. The nurse will assess every four hours the patients oral temperature 2. The nurse will ask the patient to remove blankets or heavy clothes 3. The nurse will use cool compress to the forehead, behind neck, and between the axilla and inguinal skin folds for the patient 4. The nurse will administer ordered antipyretics to the patient for a temperature greater than 38 C 5. The nurse will encourage and offer oral fluid intake every two hours to the patient 6. The nurse will encourage low caloric diet intake 7. The nurse will instruct the patient to limit activates 8. Fan can be used 9. Sponge bathe will be applied if temperature still high

Evaluation:
The patients temperature return to normal range