00108 Self -Care Deficit In The Bathroom

Domain 4: activity/rest
Class 5: self -care
Diagnostic Code: 00108
Nanda label: self -care deficit in the bathroom
Diagnostic focus: self -care: bathroom
Approved 1980 • Revised 1998, 2008, 2017 • Level of evidence 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « self -care deficit in the bathroom is defined as: deterioration of the ability to perform or complete the hygiene activities for oneself.

Definite characteristics

  • Difficulty accessing the bathroom
  • Difficulty accessing water
  • Difficulty drying the body
  • Difficulty gathering bath supplies
  • Difficulty to regulate bath water
  • Difficulty washing the body

Related factors

  • Anxiety
  • Cognitive dysfunction
  • Decreased motivation
  • Limitations of the environment
  • deterioration of physical mobility
  • Neurocomportal manifestations
  • Pain
  • Weakness

Risk population

  • Older adults

Associated problems

  • Deterioration of the ability to perceive a part of the body
  • Deterioration of the ability to perceive spatial relationships
  • Musculoskeletic diseases
  • Neuromuscular diseases

Suggestions of use

The self -care deficit describes a state in which the person experiences inability to carry out self -care activities such as bathing, dressing, eating and going to the toilet. If the person is unable to perform any self -care, the situation is described as a total self -care deficit. However, diagnoses are classified as more specific problems, each with their defining characteristics. These problems can occur alone or in several combinations, such as self -care deficit: food, bathroom, dress and use of the toilet.
Self -care deficits are usually caused by intolerance to activity; deterioration of physical mobility ’, pain, acute or chronic; Anxiety, or perceptual or cognitive deterioration (for example, self -care deficit: food + 2 related to disorientation). As an etiology, the deficit of self -care can cause depression, fear of becoming dependent and impotence [for example, fear of becoming totally dependent related to total self -care deficit + 2 secondary to residual weakness due to stroke (stroke])].

The self -care deficit should be used to label only those conditions in which the objective is to support or improve the patient’s self -care skills. The results and evaluation criteria of these labels must reflect an improvement in operation. Therefore, if the diagnosis is used for states that cannot be treated, the achievement of the results raised cannot be expected. Nursing interventions in this case have a double approach: (a) improve the patient’s ability to perform self -care, and (b) help patients with limitations and carry out the care that the patient cannot perform. P>

In order to promote efforts to restore operation, the functional level of the patient should be classified by a standardized scale as the following:

0 = totally independent
1 = You need to use equipment or some device
2 = You need the help of another person for support, supervision or teaching
3 = You need the help of another person and team or some device
4 = It is dependent, does not participate in the activity

Suggested alternative diagnostics

Other examples

  • Accept help or the complete care of a caregiver, if it requires it
  • Verbally express body cleaning and satisfactory oral hygiene
  • Maintain the necessary mobility to move to the bathroom and obtain the toilet utensils
  • Open the water key and regulate its flow and temperature
  • Wash and dry the body
  • Perform oral hygiene
  • Deodorant is applied

NIC Interventions

  • Other NIC interventions are selected that are suitable for the deficit of the patient’s specific self -care (for example, nail care, hair care, feet care). Here are some examples.
  • Support for self -care: bath/hygiene: Help the patient to perform personal hygiene
  • Bathroom: Body cleanliness to achieve relaxation, cleanliness and healing
  • Oral health maintenance: maintenance and promotion of oral and dental hygiene of the patient at risk of developing mouth or teeth injuries

Nursing Activities

Valuations

  • Evaluate the ability to use auxiliary devices
  • Examine the cleaning of the body and mucous membranes daily
  • Examine the status of the skin during the bathroom
  • Monitor changes in functional capacities
  • (NIC) Support for self -care: bath/hygiene: monitor the cleaning of the nails, according to the patient’s self -care capabilities

Patient and family education

  • Teach the patient and relatives alternative methods for bathroom and oral hygiene

Collaboration activities

  • Offer analgesics before the bathroom
  • Channel to the patient and family members to social services to obtain home assistance
  • Resort to physical and occupational therapy as a resource to plan patient care activities (for example, for adaptation equipment)

Others

  • Promote independence for bathroom and oral hygiene; Help the patient only if necessary
  • Encourage the patient to perform the self -care at their own pace
  • Include family in care
  • Adapt to the preferences and needs of the patient as much as possible (for example, bath or shower, and at what time of day)
  • (NIC) Support for self -care: bath/hygiene:
    • Provide help until the patient is completely capable of performing self -care
    • Place towels, soap, deodorant, shave equipment and other necessary accessories, next to the bed or in the bathroom
    • Facilitate the patient brushing their teeth, as required
  • Shaving the patient, as indicated
  • Indicate the patient to wash the hands after going to the bathroom and before each meal

At home

  • In addition to the activities of this section, most of the previous activities are adequate to apply at home
  • Recommend the installation of clamping bars and non -slip surfaces in the bathrooms
  • Channel to the patient to home health services, as required
  • Instruct caregivers on toilet strategies, as required
  • Do not insist on bathing a terminal patient if you don’t want it

Babies and Children

  • Allow the child to perform self -care as much as possible to improve their self -concept

Older people

  • Evaluate the patient’s ability to perform daily activities independently through acceptable scales
  • Evaluate and adjust to cognitive or physical changes that contribute to self -care deficits
  • Encourage the patient to walk and perform exercises that increase their strength
  • Make sure there are clamping bars and non -slip surfaces in the bathroom
  • Use a non -soapy cleaner instead of soap; Apply warm water
  • Keep the bath atmosphere hot; Expose only the body of the body that will be washed
  • Provide a full bath once or twice a week and make partial bathrooms for other days to avoid dry skin
  • Wash and dry the patient softly to protect fragile skin
  • Promote independence as the patient’s abilities