Nursing Diagnosis: Bathing/hygiene Self-care deficit Application of NANDA, NOC, NIC

Nursing Diagnosis: Bathing/hygiene Self-care deficit
Linda S. Williams

NANDA Definition: Impaired ability to perform or complete bathing/hygiene activities for oneself

Defining Characteristics: Inability to: wash body or body parts; obtain or get to water source; regulate temperature or flow of bath water; get bath supplies; dry body; get in and out of bathroom

Impaired physical mobility-functional level classification:
0   Completely independent
1   Requires use of equipment or device
2   Requires help from another person for assistance, supervision, or teaching
3   Requires help from another person and equipment or device
4   Dependent—does not participate in activity

Related Factors: Decreased or lack of motivation; weakness and tiredness; severe anxiety; inability to perceive body part or spatial relationship; perceptual or cognitive impairment; pain; neuromuscular impairment; musculoskeletal impairment; environmental barriers

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Self-Care: Activities of Daily Living (ADLs)
·         Self-Care: Bathing
·         Self-Care: Hygiene
Client Outcomes
·         Remains free of body odor and maintains intact skin
·         States satisfaction with ability to use adaptive devices to bathe
·         Bathes with assistance of caregiver as needed without anxiety
·         Explains and uses methods to bathe safely and with minimal difficulty
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Bathing
·         Self-Care Assistance: Bathing/Hygiene
Nursing Interventions and Rationales
·         Assess client's ability to bathe self through direct observation (in usual bathing setting only) and from client/caregiver report, noting specific deficits and their causes. Use of observation of function and report of function provide complementary assessment data for goal and intervention planning (Reuben et al, 1992).
·         If in a typical bathing setting for the client, assess via direct observation using physical performance tests for ADLs. Observation of bathing performed in an atypical bathing setting may result in false data for which use of a physical performance test compensates to provide more accurate ability data (Guralnik, 1994).
·         Ask client for input on bathing habits and cultural bathing preferences. Creating opportunities for guiding personal care honors long-standing routines, increases control, prevents learned helplessness, and preserves self-esteem (Miller, 1997). Cultural preferences are respected (Freeman, 1997).
·         Develop a bathing care plan based on client's own history of bathing practices that addresses skin needs, self-care needs, client response to bathing and equipment needs. Bathing is a healing rite and should not be routinely scheduled with a task focus. It should be a comforting experience for the client that enhances health. (Rader, Hoeffer, McKenzie, 1996).
·         Individualize bathing by identifying function of bath (e.g., odor or urine removal), frequency required to achieve function, and best bathing form (e.g., towel bathing, tub, or shower) to meet client preferences, preserve client dignity, make bathing a soothing experience, and reduce client aggression. Individualized bathing produces a more positive bathing experience and preserves client dignity. Client aggression is increased with shower (especially) and tub bathing. Towel bathing increases privacy and eliminates need to move client to central bathing area; therefore it is a more soothing experience than either showering or tub bathing (Rader, Hoeffer, McKenzie 1996; Hoeffer et al, 1997; Miller, 1997).
·         Request referrals for occupational and physical therapy. Collaboration and correlation of activities with interdisciplinary team members increases the client's mastery of self-care tasks (Schemm, Gitlin, 1998).
·         Plan activities to prevent fatigue during bathing and seat client with feet supported. Energy conservation increases activity tolerance and promotes self-care.
·         Provide medication for pain 45 minutes before bathing if needed. Pain relief promotes participation in self-care.
·         Consider environmental and human factors that may limit bathing ability, such as bending to get into tub, reaching required for bathing items, grasping force needed for faucets, and lifting of self. Adapt environment by placing items within easy reach, lowering faucets, and using a handheld shower. Environmental factors affect task performance. Function can be improved based on engineering principles that adapt environmental factors to the meet the client's capabilities (Rogers et al, 1998).
·         Use any necessary adaptive bathing equipment (e.g., long-handled brushes, soap-on-a-rope, washcloth mitt, wall bars, tub bench, shower chair, commode chair without pan in shower). Adaptive devices extend the client's reach, increase speed and safety, and decrease exertion.
·         Provide privacy: have only one caregiver providing bathing assistance, encourage a traffic-free bathing area, and post privacy signs. The client perceives less privacy if more than one caregiver participates or if bathing takes place in a central bathing area in a high-traffic location that allows staff to enter freely during care (Miller, 1994).
·         Keep client warmly covered. Clients, especially elderly clients, who are prone to hypothermia may experience evaporative cooling during and after bathing, which produces an unpleasant cold sensation (Miller, 1994).
·         Allow client to participate as able in bathing. Smile and provide praise for accomplishments in a relaxed manner. The client's expenditure of energy provides the caregiver the opportunity to convey respect for a well-done task, which increases the client's self-esteem. Smiling and being relaxed are associated with a calm, functional client response (Maxfield et al, 1996).
·         Inspect skin condition during bathing. Observation of skin allows detection of skin problems.
·         Use or encourage caregiver to use an unhurried, caring touch. The basic human need of touch offers reassurance and comfort.
·         If client is bathing alone, place assistance call light within reach. A readily available signaling device promotes safety and provides reassurance for the client.
·         Provide same type of bathrobe and bathing articles, such as scented dusting powder and bath oil, that client used previously. Use of sensory channels to stimulate memory may help foster understanding of bathing and self-care (Danner et al, 1993).
·         Assess for grieving resulting from loss of function. Grief resulting from loss of function can inhibit relearning of self-care.
·         Arrange bathing environment to promote sensory comfort: reduce noise of voices and water and decrease glare from tiles, white walls, and artificial lights. Noise discomfort can result from high-echo tiled walls, loud voices, and running water. Glare can cause visual discomfort, especially in clients with visual changes or cataracts (Miller, 1994).
·         When bathing a cognitively impaired client, have all bathing items ready for client's needs before bathing begins. Injury often occurs when cognitively impaired client is left alone to obtain forgotten items (Sloane et al, 1995).
·         Bathe elderly clients before bedtime to improve sleep. An evening bath helps elderly clients sleep better (Kanda, Tochihara, Ohnaka, 1999).
·         Bathe cognitively impaired clients before bedtime. Bathing a cognitively impaired client in the evening helps improve symptoms of dementia (Deguchi et al, 1999).
·         Limit bathing to once or twice a week; provide a partial bath at other times. Frequent bathing promotes skin dryness. Reducing frequency of bathing decreases aggressive behavior in cognitively impaired clients (Hoeffer et al, 1997).
·         Allow client or caregiver adequate time to complete the bathing activity. Significant aging increases the time required to complete a task; therefore elderly individuals with a self-care deficit require more time to complete a task.
·         Avoid soap or use only mild soap on genital and axillary areas; rinse well. Soap can alter skin pH and thus skin defenses, and it may increase skin dryness that results from decreased oil and perspiration production in the elderly (Skewes, 1997).
·         Use tepid water: test water temperature before use with a thermometer. Hot water promotes skin dryness and may burn a client with decreased sensation.
·         Use a gentle touch when bathing; avoid vigorous scrubbing motions. Aging skin is thinner, more fragile, and less able to withstand mechanical friction than younger skin.
·         Add hydrating bath oils to tub bath water 15 minutes after client immerses in water. Client's skin is coated with oil rather than being hydrated if bath oil is placed in water before client's skin is moistened with water (Skewes, 1997).
Home Care Interventions
·         Based on functional assessment and rehabilitation capacity, refer for home health aide services to assist with bathing and hygiene. Support by home health aides preserves the energy of the client and provides respite for caregivers.
·         Cue cognitively impaired clients in steps of hygiene. Cognitively impaired clients can successfully participate in many activities with cueing, and participation in self-care can enhance their self-esteem.
·         Respect the preference of terminally ill clients to refuse or limit hygiene care. Maintaining hygiene, even with assistance, may require excessive energy demands from terminally ill clients. Pain on touch or movement may be intractable and not resolved by medication.
·         If a terminally ill client requests hygiene care, make an extra effort to meet request and provide care when client and family will most benefit (e.g., before visitors, at bedtime, in the early morning). When desired, improved hygiene greatly boosts the morale of terminally ill clients.
·         Maintain temperature of home at a comfortable level when providing hygiene care to terminally ill clients. Terminally ill clients may have difficulty with thermoregulation, which will add to the energy demand or decrease comfort during hygiene care.
Client/Family Teaching
·         Teach client and family how to use adaptive devices for bathing, and teach bathing techniques that promote safety (e.g., getting into tub before filling it with water, emptying water before getting out, using an antislip mat, wall-grab bars, tub bench). Adaptive devices can provide independence, safety, and speed (Schemm, Gitlin, 1998).
·         Teach client and family an individualized bathing routine that includes a schedule, privacy, skin inspection, soap or lubricant, and chill prevention. Teaching methods to meet client's needs increases the client's satisfaction with the bathing experience.

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