00110 Self -Care Deficit In The Use Of Toilet

Domain 4: activity/rest
class 5: self -care
Diagnostic Code: 00110
Nanda label: self -care deficit in the use of the toilet
Diagnostic focus: Self -care: Use of the toilet
Approved 1980 • Revised 1998, 2008, 2017 • Level of evidence 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « self -care deficit in the use of the toilet is defined as: inability to independently carry out the activities related to intestinal and urinary elimination. >

Definite characteristics

  • Difficulty completing hygiene in the toilet
  • Difficulty pulling the toilet chain
  • Difficulty manipulating clothes to go to the toilet
  • Difficulty to reach the bathroom
  • Difficulty to get up from the toilet
  • Difficulty sitting at the toilet

Related factors

  • Anxiety
  • Cognitive dysfunction
  • Decreased motivation
  • Limitations of the environment
  • Fatigue
  • deterioration of physical mobility
  • Deterioration of the ability to translation
  • Neurocomportal manifestations
  • Pain
  • Weakness

Associated problems

  • Musculoskeletic deterioration
  • Neuromuscular diseases

Suggestions of use

Self -care deficit: Use of the toilet may be the etiology (that is, the related factor) of deterioration of skin integrity or social isolation. See also the analysis of the self -care deficit. The functional level of the patient should be classified by 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

NOC Results

  • Ostomy self -care: Personal actions to keep the stoma for elimination
  • Self -care: Use of the toilet: Ability to use the toilet independently, with or without help devices

Evaluation objectives and criteria

  • It demonstrates self -care: use of the toilet, as manifested by the following indicators (specify from L to 5: severely, substantially, moderately, slightly or not compromised):
    • He plays for himself in the toilet or comfortable
    • Empty the bladder (or the intestine)
    • He gets up from the toilet or comfortable
    • Clothing is fixed after wearing the toilet
  • Other examples

    • Accept the help of a caregiver
    • Recognize that you need help to use the toilet
    • Recognize and respond to the need to urinate or defecate
    • It is able to go and return from the toilet
    • It is cleaned after using the toilet

    NIC Interventions

    • Support for self -care: Use of the toilet: Help another with the elimination
    • Ostomy care: Maintenance of elimination through a stoma and care of the surrounding tissue
    • Teaching: Individual: Planning, application and evaluation of a teaching program designed to solve the specific needs of a patient
    • Intestine management: establishment and maintenance of a regular pattern of intestinal elimination

    Nursing Activities

    Also see nursing activities for the diagnosis of fecal incontinence and urinary incontinence: functional, rightening, effort and urgency.

    Valuations

    • Evaluate the ability to wander independently and safely
    • Assess the ability to handle clothes
    • Assess the ability to use auxiliary devices (for example, walkers, canes)
    • Monitor the energy level and activity tolerance
    • Assess whether there is an improvement or deterioration that limits the use of the toilet independently
    • Monitor sensory, cognitive or physical deficit, which could limit the use of the toilet independently

    Patient and family education

    • Instruct the patient and relatives about transfer and wandering techniques
    • Demonstrate the use of auxiliary equipment and adaptive activities
    • (NIC) Support for self -care: Use of the toilet: instruct the patient and the closest people, on strategies to apply in the toilet routine

    Collaboration activities

    • Offer analgesics before the use of the toilet
    • Channel to the patient and family members to social services to obtain health services
    • Apply occupational and physical therapy to plan the care of the patient and obtain the necessary auxiliary equipment

    Others

    • Specify the functional level and help to use the toilet or provide basic care, as required
    • Avoid the use of permanent probes and condom catheters, if possible
    • Recommend the patient to wear easy -to -handling clothes; help you dress if necessary
    • Have the urinal or comfortable within reach of the patient
    • (NIC) Support for self -care: Use of the toilet:
      • Help the patient use the toilet, comfortable and urinal, at specific intervals
      • Facilitate hygiene after using the toilet
      • pull the toilet chain; Clean the utensils used for elimination (comfortable, urinal)
      • Change clothes to the patient after elimination
      • Provide privacy during elimination
    • Eliminate objects that prevent access to toilet (for example, loose rugs and small furniture)
    • Use environmental aromatizers if necessary
    • Ensure that the patient can call the nursing professional or other caregivers, and inform the patient and relatives who will immediately respond

    At home

    • Most previous activities are also suitable for home care
    • (NIC) Environment Management: Inform the family and the closest person about the ways of maintaining a safe environment for the patient at home

    Older people

    • Adapt to cognitive impairment (for example, give short and simple verbal instructions)
    • Give enough time for the use of toilet in order to avoid fatigue and frustration
    • Recommend and help perform exercises that increase strength
    • Help the patient walk a few minutes when lifts to use the toilet
    • Place a restraint next to the comfortable or toilet, as required, to raise the knees above the hips