Nursing Diagnosis Objectives Nursing Interventions Rationale Evaluation
Short term goal: 1. Assess if how is the - It will provide important Client is able to groom
Self- Care Deficit client able to meet her information as to how and dress herself with
(Grooming and dressing) Client will be able to basic needs, who is she the client functions at minimal assistance or
maintain physical care residing with, presence home and indicate the with assistance as
Possible Etiologies: with less assistance of visual or hearing need for the degree of necessary.
(Related to) and on the level of her disabilities, and her assistance required by
ability, after 2 weeks of usual daily routine. the client. Client is participative in
Difficulty in completing intervention. activities like fixing and
tasks/ loss of previous 2. Observe and assess - Clients with cognitive feeding self at her own
capabilities Long term goal: for her appearance i.e. impairment often have level of ability,
appropriate dressing, some changes in reminiscing previous
Defining characteristics: Client will be able to disturbances in gait or appearance because of roles and capabilities,
(Evidenced by) participate in activities movement, presence of inability to assume and learning or
that would promote her injuries. previous role or relearning tasks
Subjective: level of functioning and functioning. (enhancing memory)
“Mama seems to forget learn and recall 3. Check her judgement, -These are indicators to needed for her to
herself nowadays. So, I previous capabilities, at orientation, memory and the proper functioning of accomplish her ADLs.
help her clean herself and the end of nurse- cognitive abilities. a person as client with
wear her clothes every patient social dementia usually would
day.” As verbalized by interaction. 4. Build rapport with require prompting to
daughter. client through a calm, complete tasks.
supportive approach in - Trust is the main key
Objective: interaction. point in establishing
- Inability to maintain relationship with the
her appearance unlike 5. Organize a client. It would prevent
before structured, routine the client from becoming
- Forgetfulness (time schedule of activities suspicious or delinquent
and place where she considering client’s from asking assistance.
abilities while - It would help client
- Inability to recall
previous tasks maximizing her resume her ADLs
- Presence of urinary independence. without overstimulation.
incontinence as 6. Reorient client
claimed by daughter frequently by putting her - This would help her
- Difficulty articulating name in bold big letters enhance her memory
needs in her door or by calling and it would create a
- Poor judgement when her by name always, comfortable environment
assessed putting a clock and for her.
some familiar pictures in
her room and even -This would ensure her
putting the schedule of safety and would help
activities for a given prevent harm/ injury
day. since client may be
7. Provide a safe, non- disoriented and
restrictive environment confused at times.
for the client through -This will help client
proper and adequate regain strength and
lighting, etc. energy and would
minimize mood changes
like irritability and some
8. Encourage enough agitation.
resting periods and - This will promote
adequate sleep. positive self- concept
and her ability to solve
9. Encourage client to or accomplish simple
engage in activities like tasks.
music therapy and
dancing; involve client in -By doing this, client will
simple decision making. be able to lessen
10. Assist client in her dependency and be able
ADLs but as much as to function with integrity.
possible let her regain
depending on her