Question

Your 79- year-old client awaiting from the hospital notifies you that their adult daughter has arrived to provide a ride home. When providing the discharge instructions to the client you note the adult daughter is unkempt,lack eye contact, and has an unusual odor present.

Identify the priority nursing intervention the RN should apply to this scenario and explain your rationale.

Answer 1

The nursing diagnosis for the adult daughter is Self care deficit as evidenced by unkempt, lack eye contact, and has an unusual odour present. Impaired ability to perform or complete tasks of daily living, such as feeding, dressing, toileting, bathing, grooming, work, homemaking and leisure.

Objective date:

Unkempt, lack eye contact, and has an unusual odour present.

Expected outcome:

• Patient demonstrates lifestyle changes to meet self-care needs.
• Patient recognizes individual weakness or needs.
• Patient safely executes self-care activities to utmost capability.

Nursing intervention:

Intervention	Rationale
Establish short-term goals with the patient	Helping the patient with setting realistic goals will reduce frustration.
Present positive reinforcement for all activities attempted; note partial achievements.	External resources of positive reinforcement may promote ongoing efforts. Patients often have difficulty seeing progress.
Boost maximum independence.	The goal of rehabilitation is one of achieving the highest level of independence possible.
Apply regular routines, and allow adequate time for the patient to complete task.	An established routine becomes rote and requires less effort. This helps the patient organize and carry out self-care skills
Encourage to perform combing own hair. Suggest some hairstyles.	Maintains autonomy.
Provide privacy during dressing.	The need for privacy is fundamental for most patients. Patients may take longer to dress and may be fearful of breaches in privacy.
Give frequent encouragement and aid with dressing as needed.	Assistance can reduce energy expenditure and frustration. However, care needs to be taken so the care provider does not rush through tasks, negating the patient’s attempts.
Establish regular activities so the patient is rested before activity.	A plan that balances periods of activity with periods of rest can help the patient complete the desired activity without undue fatigue and frustration.
Consider the use of clothing one size larger.	A large size guarantees easier dressing and comfort.
Educate family and significant others to promote autonomy and to intervene if the patient becomes tired, not capable of carrying out task, or become extremely aggravated.	This displays caring and concern but does not hinder with patient’s efforts to attain autonomy.
Inform family members to allow the patient perform self-care measures as much as possible.	Reinstitutes feeling of independence and promotes self-esteem and improves rehabilitation process.
Promote independence, but intervene when the patient is not able to carry out self-care activities.	A suitable level of assistive care can avoid harm with activities without causing disappointment.
Entertain patient input in planning schedule.	Patient’s worth of life is improved when wishes or likes are taken into consideration in daily activities.
Consider or use energy-conservation techniques.	This saves energy, decreases fatigue, and improves patient’s capability to execute tasks.