JULIA

LEONOR
HUARINGA
LAGOMARSINO, RN
SELF CARE DEFICIT (BATHING, HYGIENE,DRESSING, GROOMING)
R/T
COGNITIVE IMPAIRED.
Self Care Deficit, Dressing and Grooming
Related To
Neuromuscular Impairment
Self Care Deficit, Dressing and
 DEMOGRAPHIC DATE

• PATIENT: DC
• DOB: 08/16/1951
• ADM DATE: 10/10/2000
• NEUROLOGIST : NUNEZ FRANCISCO.
• DIAGNOSIS: ALZHEIMER
 …
ASSESSMENT/INTERVIEW
•Mr. X is a 53-year-old male who presents memory
loss and sometimes forgets entire experience.
•His wife thinks that something is wrong with him
because that over the last year, Mr. X has become
more and more forgetful, and rarely remembers later.
And she also states that he forgets appointments
and phone calls, sometimes just after he hangs up
the phone.
•He is being gradually unable to follow
written/spoken directions.
•He is gradually unable use notes as reminders.
 …
ASSESSMENT/INTERVIEW
• His wife also states he is being gradually unable to
take care for self, forgets how to wear his clothes,,
don’t want to eat, etc.
• Mrs. X states that over the last year, her husband has
had problems walking, like he can fall down easily.
• Over the last 6 months, he keep walking around the
house and going out very often.
• He also reports urinary incontinence over the last 6
months. Mr. X describes it as "not being able to control
it."
 PATIENT’S PAST
HISTORY
• Mr. X's father died at the age of 49 from a heart
attack.
• His mother is still alive and is in a nursing home,
he moved there after having a stroke 3 years ago
and now he has Alzheimer also.
• His brother and sister are in good health.
• M.r X had a head injury 10 years ago, after a car
accident.
 TREATMENT
• DRUGS
• Rivastigmine (Exelon) Twice a day.
• Donepezil (aricept) once a day
• Tacrine (Cognex) 4 times a day.
• Valium…….PRN
• SUPPLEMENTS
• Folate (Vitamin B9)
• Cyanocobalamine(vitamin B12)
• Ginko Biloba
• Vitamin E
 PHYSICAL EXAMINATION
• Temp: 98°F
• BP: 170/110
• Pulse: 95
• Resp: 19/min
• Height: 5'11" Weight 293
• HEENT: Within normal limits
• Motor
Biceps: 5/5 bilaterally
Triceps: 5/5 bilaterally
Quadriceps: 3/5 bilaterally
Hamstrings: 3/5 bilaterally
 PHYSICAL
ASSESSMENT
•Sensory:
Pin-prick and temperature sensation and simple touch are intact.
Vibration is normal in upper extremities, but diminished in lower
extremities bilaterally.
•Neurological
- Reflexes:
Biceps: 2+ bilaterally
Brachioradial: 2+ bilaterally
Patellar: 3+ bilaterally
Ankle: 4+ bilaterally
Plantar Response: Extensor bilaterally
 PHYSICAL ASSESSMENT
•Propioception and Cerebellar Function:
Finger to finger: no follow indication, abnormal
Heel to shin: no follow indication abnormal
Rapid alternating movements. Not achieve this movement.
Joint position : normal
• Gait:
Mr. X's gait is abnormal, walking in a shuffling manner. He is
mildly ataxic.
• Cranial Nerves:
II-XII are intact.
 MENTAL ASSESSMENT

Mental Status:
•Patient seems confused, restlessness and wandering
•He is oriented to person, but not place or time.
•He exhibits dyscalculia.
•Immediate recall is impaired.
• When asked to act out combing his hair or shaving, the
patient could not do so.
• Complex commands were difficult for the patient to follow.
• Judgment was impaired as was the ability to describe
simple analogies.
 NURSING DIAGNOSIS
• IMBALANCED NUTRITITON,LESS THAN BODY REQUIEREMENTS
R/T LACK OF SELF-CARE, AND INCREASED METABOLIC
DEMANDS.
• GOAL:
1.- Will maintain appropriate weight.
2.-Display normalization of laboratory values and be free of
signs of malnutrition as reflected in defining characteristics.
• INTERVENTIONS:
1.- To assess causative/ contributing factors
2.- Give him extra calories.
3.- Supervised meals and help with feeding.
• IMPLEMENTATION;
1.- Determine client’s to ability to chew, swallow, and status of
denture.
2.- Give him extra calories as indicated in balanced diet.
3.- Supervised meals and help with feeding
 NURSING INTERVENTIONS AND
RATIONALITIE
• SELF CARE DEFICIT (BATHING, HYGIENE,DRESSING,
GROOMING) R/T COGNITIVE IMPAIRED.
• GOAL:
1.- Identify individual areas of weakness/needs.
2.- Identify resources than can provide assistance..
• INTERVENTIONS:
1.- To assess causative/ contributing factors
2.- To evaluate degree of disability.
3.- To assist in correcting/dealing with situation..
• IMPLEMENTATION;
1.- Determining age and development issues
affecting/habilityof individual to participe in own care.

2.- Identify degree of individual impairment.

3.- Practice and promote short term goals settings.
 EVALUATION
1. Patient is assisted for family and a care giver (every 12
hours.)
2. Patient chew and swallow easily.
3. Patient receive balanced meals, as requirement.
4. Maintain normal weight and is being helped with feeding
5. Patient has his eyes, ears and as denture checked.
6. Patient has been helping for Family and care givers,
understanding his world.
7. Patient wear his clothes daily, helps watering plants with
assistance of family or caregiver.