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Nursing Diagnosis Self- Care Deficit (Grooming and dressing) Possible Etiologies: (Related to) Difficulty in completing tasks/

loss of previous capabilities Defining characteristics: (Evidenced by) Subjective: Mama seems to forget herself nowadays. So, I help her clean herself and wear her clothes every day. As verbalized by daughter. Objective:
Inability to maintain her appearance unlike before Forgetfulness (time and place where she is) Inability to recall previous tasks Presence of urinary incontinence as claimed by daughter Difficulty articulating needs Poor judgement when

Objectives Short term goal: Client will be able to maintain physical care with less assistance and on the level of her ability, after 2 weeks of intervention. Long term goal: Client will be able to participate in activities that would promote her level of functioning and learn and recall previous capabilities, at the end of nursepatient social interaction.

Nursing Interventions 1. Assess if how is the client able to meet her basic needs, who is she residing with, presence of visual or hearing disabilities, and her usual daily routine. 2. Observe and assess for her appearance i.e. appropriate dressing, disturbances in gait or movement, presence of injuries.

Rationale - It will provide important information as to how the client functions at home and indicate the need for the degree of assistance required by the client.

Evaluation Client is able to groom and dress herself with minimal assistance or with assistance as necessary. Client is participative in activities like fixing and feeding self at her own level of ability, reminiscing previous roles and capabilities, and learning or relearning tasks (enhancing memory) needed for her to accomplish her ADLs.

- Clients with cognitive impairment often have some changes in appearance because of inability to assume previous role or functioning. 3. Check her judgement, -These are indicators to orientation, memory and the proper functioning of cognitive abilities. a person as client with dementia usually would 4. Build rapport with require prompting to client through a calm, complete tasks. supportive approach in - Trust is the main key interaction. point in establishing relationship with the 5. Organize a client. It would prevent structured, routine the client from becoming schedule of activities suspicious or delinquent considering clients from asking assistance. abilities while - It would help client maximizing her resume her ADLs independence. without overstimulation. 6. Reorient client frequently by putting her - This would help her name in bold big letters enhance her memory in her door or by calling and it would create a her by name always, comfortable environment


putting a clock and some familiar pictures in her room and even putting the schedule of activities for a given day. 7. Provide a safe, nonrestrictive environment for the client through proper and adequate lighting, etc.

for her. -This would ensure her safety and would help prevent harm/ injury since client may be disoriented and confused at times. -This will help client regain strength and energy and would minimize mood changes like irritability and some agitation. - This will promote positive self- concept and her ability to solve or accomplish simple tasks. -By doing this, client will be able to lessen dependency and be able to function with integrity.

8. Encourage enough resting periods and adequate sleep. 9. Encourage client to engage in activities like music therapy and dancing; involve client in simple decision making. 10. Assist client in her ADLs but as much as possible let her regain independence depending on her abilities.