Self-care deficit : Hygiene

Self-care deficit : hygiene is a condition in which individuals experience failure or ability to carry out personal hygiene activities completed (Carpenito, 1977).

Several factors influence the occurrence of Self-care deficit:
a. Developments
Family overprotective and indulgent clients that disrupts the development of the initiative and skills.
b. Biological
Chronic disease that causes the client is not able to perform self-care.
c. Social
Less support and training capabilities of the environment.

Data that needs to be studied
a. Self-care deficit.
b. Decreased motivation to self-care

Subjective Data:

• say lazy bath,
• do not want to comb the hairs,
• do not want to rub the teeth,
• do not want to cut the nails,
• do not want to make up,
• can not use a tool bathing / personal hygiene.

Objective Data:

• Body odor, dirty clothes, dirty hair and skin, long nails, dirty teeth, mouth odor, appearance is not neat, can not use a tool shower.

Nursing Diagnosis
Self-care deficit: hygiene related to decline in self-care motivation.


Interventions:

1. General Goals: The client is able to perform self-care: hygiene.

2. Specific Goals:

a. The Client can mention the definition and signs of personal hygiene.
action:

• Discuss with the client about the terms of hygiene and signs of hygiene.
• Give positive reinforcement when the client is able to do something positive.

b. The Client can mention why the client does not want to maintain personal hygiene.
action:

• Discuss with the client what the cause would not maintain personal hygiene.
• Discuss the consequences of not willing to maintain personal hygiene.

c. The Client can call the hygiene.
action:

• Discuss with the client about the benefits of hygiene.
• Help the client identify the ability to maintain personal hygiene.

d. The client can mention how to maintain personal hygiene
action:

• Discuss with the client how to maintain personal hygiene: shower 2 times a day (morning and afternoon) using soap, brush the teeth at least two times a day with toothpaste, wash the hair at least 2 times a week with a shampoo, cut the nails at least 1 time a week cutting the hair at least one time a month.
• Give positive reinforcement when the client successfully.

e. The client can implement self-care hygiene with minimal assistance.
action:

• Lead the client to do a demonstration on how to maintain personal hygiene.
• Encourage the client to perform personal hygiene with minimal assistance.

f. The client can perform self-care hygiene independently.
action:

• Give the client the opportunity to rid themselves gradually.
• Encourage the client to express feelings after self-cleaning.
• Together with the client to schedule self hygiene.
• Guided the client to conduct regular hygiene activities.

g. The client has the support of the family.
action:

• Give health education on caring for clients for personal hygiene through family gatherings.
• Give positive reinforcement on the active participation of the family.

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Self-care deficit related to Stroke

Nursing Care Plan for Stroke : Self-care deficit


Definition of Stroke

Stroke is an acute neurological dysfunction caused by impaired blood flow that occur suddenly (within seconds) or raised quickly (within hours) with symptoms and signs corresponding to the focal area disturbed.

Cerebrovascular accident (CVA) also called Stroke is a condition in which the occurrence of neurological deficits caused by decreased blood flow to certain areas of the brain tissue.
Neurological deficits caused by ischemia caused necrotising cells in brain tissue in various areas of the brain.

In the U.S., stroke is the third leading cause of death after heart disease and cancer. This disease can be prevented or minimized by efforts: blood pressure under control, increase awareness of the necessary diet and avoid smoking.


Etiology of Stroke

The occurrence of stroke is caused by the presence of thrombi and emboli that cause the narrowing or occlusion of one of the perfect blood vessels that supply blood to the brain, also if there is bleeding (hemorrhagic). Stroke due to pressure on the walls of blood vessels and arteries spasm, rarely encountered.

1. Thrombosis:

Is the formation of blood clots in blood vessels that can lead to narrowing of the lumen of a blood vessel blockage even happen. Thrombosis is a major cause of cerebral infarction. Two-thirds of strokes are caused by thrombosis due to hypertension and diabetes mellitus both of which can lead to atherosclerosis.

Another factor that can be at risk of thrombosis is an oral contraceptive, coagulation disorders, polycithemia, arteritis, chronic hypoxia, and dehydration. Thrombosis occurs as a result of the formation of atheroma thus narrowing the lumen of blood vessels. Thrombus causing hypoperfusion, infarction and ischemia.

At first occurred paresis (decrease / reduction in force and limb movement), aphasia (language function disorder), paralysis, impaired consciousness, visual disturbances.

2. Embolism:

Blockage / cerebral artery occlusion by an embolus, which resulted in necrosis and edema in the area supplied by the blood vessel blockage.

Embolism is the second leading cause of stroke. Generally derived from the inner lining of the heart (endothelial) where plaque is formed which is then separated and flowed in the blood circulation. If embolism is walking / running on the smaller blood vessels then place it will clog embolism or vascular branching.
Embolism associated with disease / heart problems, namely atrial fibrillation, cardiac infarction, infective endocarditis, rheumatic heart disease, and atrial septal defect. Another cause is not often that air embolism, fat embolism due to fracture femor, amniotic fluid after delivery, and the presence of a tumor.

The attack is sudden. The patient is fully conscious, although patients also feel headache. Prognosis depends location of the blood vessel blockage.

3. Intracerebral hemorrhage:

Bleeding in the brain caused by the rupture of a blood vessel. Intracerebral hemorrhage is usually caused by the presence of hypertension. Another cause is a brain tumor, trauma, thrombolytic treatment, and aneurysm rupture.
Hypertension and atherosclerosis cause degenerative change in the artery walls, causing rupture and hemorrhage. Blood mass will suppress brain tissue. This pressure causes the brain tissue of urgency and decreased blood flow to the brain due to ischemia and infarction.

The area that is often experienced intracerebral hemorrhage putamen and the internal capsule (50%), thalamus, brain hemisper, and pons. Clients will experience a severe headache, nausea and vomiting, loss of ability to walk, dysphagia, eye movement disorders. Bleeding in the post is very dangerous because it is part of the basic life functions. Pons can lead to bleeding in hemiplegia, coma, hyperthermia, and subsequently died.

The prognosis is very bad intracerebral hemorrhage: 70% of patients died due to intracerebral hemorrhage.

4. Subarachnoid hemorrhage:

Caused by the aneurysm, vascular abnormalities, trauma, and hypertension. Aneurysms often occur in patients with atherosclerosis, trauma, hypertension, or vascular abnormalities that are usually congenital bleeding can also be caused by anticoagulant treatment, treatment trhrombolitik, and symphatomimetic.

Bleeding that occurs suppress arachnoid space and cause headache, dizziness, loss of consciousness, nausea, vomiting, fever, pain in the neck and back, paralysis, coma, and later died.


Prevention of Stroke

Primary prevention is to avoid the risk of public health education. Maintain body weight and cholesterol within normal limits, and avoid smoking or using oral contraceptives. Treatment / control diabetes, hypertension and heart disease.

Provide information to clients in connection with the illness with strokes. If already had a stroke, in this situation the goal is to prevent the occurrence of complications with respect to stroke and myocardial wider in the future. In the event of immobility will increase the risk of injury in connection with paralysis and aspiration of the airway. Further Prevention is monitoring the risk factors that can be identified.


Nursing Diagnosis for Stroke : Self-care deficit related to decrease in strength and endurance.

Goal:

Patients can help themselves according to their needs, and be able to express their needs.

Intervention:

1. Assess the capability and level of deficiency to perform day-to-day needs.
2. Maintain support, with a strong attitude.
3. Give positive feedback for any thing done or success.
4. Avoid doing something for patients to do their own patients, but provide assistance as needed

Rational:

1. Assist in anticipating / planning meeting individual needs.
2. Patients will require empathy, care giver to know that will help patients consistently.
3. Increase feelings of self meaning.
4. The patient may be very frightened and very dependent.

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Ineffective Individual Coping and Self-Care Deficit related to Hypopituitarism

Nursing Diagnosis and Interventions for Hypopituitarism

Signs and symptoms :

Anterior pituitary insufficiency (Panhypopituitarism) in general, will affect all of hormone that is normally secreted by the anterior pituitary gland. Therefore, the clinical manifestations of the combined effect of metabolic Panhypopituitarism is due to reduced secretion of each hormone hypophysis.

Clinical syndrome caused by Panhypopituitarism in children and adults differently. In children, somatic growth disturbances due to release growth hormone deficiency . Midget ( dwarfism ) is a consequence of the deficiency. When the child reaches puberty, it is a sign of secondary sksual and external genetalia tools fail to grow . Additionally often found slow intellectual development. The skin is usually pale in the absence of MSH.

In adults known as Simmonds disease characterized by general weakness, intolerance to cold, poor appetite, weight loss and hypotension, women who have the disease will be the cessation of Hait cycles or amenorrhea, later followed by breast trophy and external genetalia. While the men will show progresiof reduction in body hair and reed, beard, and reduced muscle growth, impotence and loss of libido. Also the skin will look pale due to the lack of MSH.

1. Ineffective Individual Coping related to the chronicity of the disease condition.

Goal: After nursing action was done to increase the level of individual coping.

Outcomes:

• Express feelings related to emotional state.
• Identify personal coping patterns and the consequences resulting behavior.
• Identifying personal strengths and to receive support through the nursing relationship.
• Make decisions and proceed with the appropriate action / change the provocative situation in the personal environment.

Intervention:
1. Assess the status of the existing individual coping.
R /: Improving the process of social interaction because the client has increased communicative.

2. Provide support if the individual speaking.
R /: Increasing confidence to others.

3. Helps individuals to suss out problems (problem solving).
R /: With less tension, fear will decrease and not isolate themselves from the environment.

4. Instruct individuals to perform technical relations, in the process of learning the techniques of stress management.
R /: The precision handling and healing process.

5. Collaboration with experts in the process of counseling psychology.
R / Client understand about the disease.


2. Self-Care Deficit related to reduced muscle strength.

Goal: After nursing actions clients can be active in self-care activities.

Outcomes:

• Identify the ability of self-care activities.
• Optimal hygiene after aid in the treatment given.
• Participate in physical / verbal activities, personal care / fulfillment of basic needs.

Intervention:
1. Assess factor of causation declining self-care deficit.
R / Inhibit causal factors can improve self-care.

2. Increase optimal participation.
R / optimal to maximize the participation of self-care.

3. Evaluation of the ability to participate in any activity of the treatment.
R / Can foster client confidence.

4. Give encouragement to express the feelings of lack of self-care.
R / can give the client a chance to perform self-care.

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