Nursing Diagnosis: total self-care deficit

Related to: perceptual and cognitive impairment

AEB: observation of inability to eat, bathe, toilet, dress or groom self

Goals:
Short: patient will eat half to one third of each meal plus one snack between meals with aid
from nurse
Long: patient will sleep 6-8 hours per night

Interventions:
1. Encourage frequent rest periods during the day
Rationale: lack of sleep can lead to exhaustion and death (patient complains of
insomnia)
2. Monitor intake, output and vital signs.
Rationale: ensure adequate fluid and calorie intake, minimize dehydration and cardiac
collapse (pt has heart problems and complains of fatigue)
3. Give simple step-by-step reminders for hygiene and dress
Rationale: distractibility and poor concentration are countered by simple, concrete
instructions
Pathos Card

Name: Bipolar Disorder

Definition: mental illness characterized as mood disorder. consist of prolonged episodes of

depression, interrupted by or coexisted with episodes of mania/hypomania

Cause:
Genetic
Neurobiology
Psychosocial

Sign/Symptoms:

Periods of deep, prolonged, and profound depression

Periods of excessively elevated/irritable moods (mania)
Grandiosity
Diminished need for sleep
Excessive talking or pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Loss of energy or fatigue
Decreased concentration ability
insomnia

Treatment:
Look at areas of stress and find ways to handle them
Monitor and support the medication
Develop and maintain the therapeutic alliance
Provide education
What are you teaching?
1. Educate family and significant others to promote autonomy and to intercede if the patient
becomes tired, are not capable to carry out task, or become extremely aggravated.

2. Persuade independence, but intercede when the patient is not able carry out self-care
activities.

3. Persuade or use energy-conservation techniques.

4. Persuade patient input in planning schedule.

5. Persuade significant other to permit patient to perform self-care measures as much as

possible.

Why is it appropriate?
1. This displays caring and concern but does not hinder with patient’s efforts to attain
autonomy.

2. A suitable level of assistive care can avoid harm with activities without causing
disappointment.

3. Saves energy, decreases fatigue, and improves patient’s capability to execute tasks.

4. Patient’s worth of life is improved when wishes or likes are taken into consideration in daily
activities.

5. Reinstitutes feeling of independence and promotes self-esteem and improves rehabilitation

process. Note: This may be very hard and discouraging for the significant other or caregiver,
depending on extent of disability and time needed for patient to accomplish activity.

Content:

How will you teach it?

Evaluate understanding