00109 Self -Care Deficit On The Dress

Domain 4: activity/rest
class 5: self -care
Diagnostic Code: 00109
Nanda label: self -care deficit in the dress
Diagnostic focus: self -care: dress
Approved 1980 • Revised 1998, 2008, 2017 • Level of evidence 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « self -care deficit in the dress is defined as: inability to wear and remove clothes independently.

Definite characteristics

  • Difficulty choosing clothes
  • Difficulty to fasten clothes
  • Difficulty gathering clothes
  • Difficulty to maintain the appearance
  • Difficulty in taking clothes
  • Difficulty in dressing the lower part of the body
  • Difficulty in dressing the upper body
  • Difficulty in dressing some clothing garments
  • Difficulty with withdrawal clothes
  • Difficulty using an assistance device
  • Difficulty using zippers

Related factors

  • Anxiety
  • Cognitive dysfunction
  • Decreased motivation
  • DISCONFORT
  • Limitations of the environment
  • Fatigue
  • Neurocomportal manifestations
  • Pain
  • Weakness

Associated problems

  • Musculoskeletic deterioration
  • 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>

The functional level must be classified using a standardized scale, such as the following:
0 = totally independent
1 = You need to use equipment or some device
2 = You need the help of another person to receive 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

The patient will be able to:

  • Accept the help of a caregiver
  • Express satisfaction with clothing
  • Use adaptation devices to dress more easily
  • Select clothes and take it from cabinets or drawers
  • Use zippers and button the clothes
  • Dress neatly
  • Be able to take off your clothes, socks and shoes

NIC Interventions

  • Support for self -care: Dress/Personal arrangement: Help the patient to dress and make up
  • Management of the environment: manipulation of the patient’s environment to obtain therapeutic benefit, sensory attraction and psychological well -being

Nursing Activities

Valuations

  • Evaluate the ability to use auxiliary devices
  • Monitor the energy level and activity tolerance
  • Monitor whether the ability to dress and combs improve or deteriorates
  • Monitor sensory, cognitive, or physical deterioration, which could cause patient difficulties to dress

Patient and family education

  • Demonstrate the use of auxiliary devices and adaptive activities
  • Teach alternative methods to dress and comb; Specify the methods

Collaboration activities

  • Offer analgesics to the patient before dressing or grooming
  • Channel to the patient and relatives to social services to obtain home health care, as required
  • Resort to occupational and physical therapy to plan patient care and the use of auxiliary devices
  • (NIC) Support for self -care: Person

Others

  • Promote independence to dress and groom, and help the patient only if necessary
  • Adapt to cognitive deterioration in the following ways:
    • Apply nonverbal indications (for example, give the patient a garment at the same time and in the right order)
  • Talk slowly and give simple instructions
  • Use sailboat closures when possible
  • Create opportunities to obtain small achievements; Specify
  • Motivate the patient to dress and fix themselves at their own rhythm
  • Help the patient choose baggy clothes and be easy to put
  • Ensure security by maintaining an orderly and well -lit environment
  • (NIC) Support for self -care: Dress/Personal Arrangement:
    • Place the patient’s clothes in an accessible place (for example, near the bed, and in the order in which it should be put)
    • Maintain privacy while the patient dresses
    • Help with laces, buttons and zippers, as required
    • Use extension equipment (for example, a long shoeker, a hitch for buttons, a zipper shooter) to put on clothes, if adequate
    • Strengthen any effort to dress only

At home

  • The above activities are suitable for home care
  • Channel to the patient to receive health services at home, if necessary

Babies and Children

  • Allow the child to perform self -care as far as possible, to increase their self -concept
  • Allow the child to choose the clothes you want to wear

Older people

  • Evaluate the ability to perform daily activities independently, with the use of approved scales
  • Evaluate and adjust to cognitive or physical changes that may contribute to the deficit of self -care
  • Encourage the patient to walk and perform exercises to increase the force
  • Promote independence as the patient’s abilities