Self-Care Requisites and Functional & Structural Integrity

Maintenance of an Adequate Intake of food:

Data: There is no data at present to indicate any difficulty with his ability to obtain and ingest food. Data that would be required include present sources of nutrition, height/weight ratio, dietary habits, food preferences and state of dentition.

Analysis: Given the diagnosis of pulmonary edema and indication of electrolyte imbalance, it would be important to monitor dietary sources of fluid and electrolytes.

Maintenance of Adequate Intake of Water:

Data: x-ray reveals pulmonary edema; B/P= 180/100; Pulse = 120.  There is no data at present to indicate any difficulty with his ability to obtain and drink adequate amount of fluids.

Analysis:  His elevated arterial blood pressure and the fluid present in his lungs are indicative of existing fluid volume excess. Data from medical intervention will impact on the amount of fluid intake.

Elimination: Provision of care associated with elimination:

Data: B/P = 180/100; x-ray reveals pulmonary edema has had a cold for the past week

Analysis: Blood gas results demonstrate impaired gas exchange related to "lung problems" as analyzed previously. There is no data at present to indicate any problems with his renal function but it is anticipated that his urine output should be increased due to renal attempts to reduce increased arterial pressure. There is no data related to bowel function which must be obtained. Lack of dietary intake of sources of fibre could result in constipation. Any diaphoresis may also alter fluid and electrolyte balance.

Activity /Rest: Balance of activity and rest:

Data: marked shortness of breath agitated, confused and verbally abusive

Analysis:  Agitation is defined as excessive restlessness, increased mental and physical activity, especially the latter. Agitation therefore increases the need for oxygen due to skeletal muscle activity, increasing the oxygen deficit which already exists. The increasing hypoxemia will continue to influence the brain. The client's cognitive functions remain impaired and he will not likely respond to verbal or physical directions to rest. To implement teaching, further data will be required to ascertain daily activities of energy expenditure and knowledge required to maintain balance of activity and rest.

Solitude/Social Interaction: No pertinent data available. More data need to be collected regarding his family and friends in meeting this requisite.

Promotion of Normalcy: No data available at this time.

Self-care Requisite                                                                             Self-Care Demands (Actions)

Air: Maintenance of sufficient intake of air                             High Fowlers position; diaphragmatic breathing; pursed lip breathing; Chest physiotherapy qid; Suction prn; Diuretics as prescribed; Sedation as prescribed; O2 via NP @ 2 L/min.

Food: Maintenance of adequate intake of food        Weigh daily Monitor serum electrolytes  Diet as ordered/tolerated

Fluid: Maintenance of adequate intake of fluid        Monitor intake and output q shift            Oral Intake/IV solution as prescribed

Elimination: Provision of care associated with elimination      Bowel protocol as prescribed  Catheterize if ordered

Activity/Rest: Balance of activity and rest                               Use portable O2 with nasal prongs when mobilizing Take rest periods of 10 min./hr                            Plan activities to reduce exertion Use relaxation exercises

Solitude/Social Interaction:                      Assess satisfaction c social/activity schedule & its effect on personal development & responsibilities.

Prevention of Hazards:                            Use siderails Be aware of potential hazards of smoking near O2; Remove cigarettes Read pamphlets about smoking Change to low tar cigarette Adhere to limited access to smoking lounge

Promotion of Normalcy:                         Manage "lung problems" so that they fit into his own lifestyle within the limits of good health.

SELF-CARE DEFICITS:   -- Inability to maintain adequate air intake related to pulmonary edema and tachycardia.

-- Potential fatigue related to decreased oxygen level, breathing difficulty, agitation and possible arrythmias/electrolyte imbalances.

-- Anxiety related to difficulty breathing. -- Ptntal inadequate intake of oral food & fluid rltd to difficulty breathing, confusion, & agitation.

-- Potential injury related to confusion and agitation.        -- Potential electrolyte imbalance related to respiratory acidosis.

-- Potential weight gain/edema related to fluid retention.  -- Potential alterations in elimination patterns related to fluid retention.

-- Lack of compliance with therapeutic regimes related to possible lack of knowledge/ adaptation to retirement.

-- Lack of motivation related to smoking cessation.

Assessment Form: Basic Conditioning Factors Age, Gender, Developmental state, Physical, Cognitive, Psychosocial, Family system factors: Significant members, Family structure, Family dynamics, Family's perspective of  altered health state; Material & human resources; Sociocultural orientation, Education,  Religion, Language, Cultural perspective about altered health state, Patterns of living, Usual living conditions, Occupation, Usual daily activities & responsibilities at home & at work, Changes to usual patterns due to health state, Environmental factors, Health state & health care system factors, Previous experiences with altered health state, --“-- with h. care system, Perspective of other health care workers, Diagnostic findings,  Medical, Treatments prescribed, Medications prescribed, Allergies

Nursing Care Plan, Types of Nursing Systems: (n. diagnosis) *Unable to monitor vital signs and O2 saturation due to lack of knowledge, skill, & physical energy. →(method of helping) Doing→(n. actions)  Monitor vital signs/O2 sat.→(cl. actions) Co-operate with monitoring of vital signs → (evaluation) S-care deficit reduced         * Ineffective ability to use spirometer & practice deep breathing &coughing exercises qh due to lack of motivation→Teaching/Supporting → (n)Demonstrate deep breathing/coughing exercises and use of spirometer / Encourage → (cl)Do deep breathing/coughing /spirometer qh → Client needs to be reminded to do exercises / S-care deficit reduced; etc.

Self-care – actions we take to care for ourselves. (s.-c. actions)  Sc requisites – sc actions intended to meet some basic requirements in order to promote and maintain health. These requirements (s.c. requisites) are common to all humans: -- maint-ng adequate intake of air,

-- maint-ng adequate intake of food/water; -- providing care associated with elimination,  -- maint-ng balance between rest & activity, 

-- maint-ng balance between solitude & social interaction,  -- preventing hazards to life, functioning and well-being, -- promoting human functioning and development                            S.c. demands – s.c. actions that are required to meet known s.c. requisites (e.g. drink ↑ water)

Basic conditioning factors (bcf): age, gender, development state, family system factors, sociocultural orientation, patterns of living, material recourses, environmental factors, health state, health care system factors                S.c. agency: knowledge, skill, physical energy, motivation

S.c. deficit (same as nursing diagnosis) – lack of s.c. agency (knowledge, skill, physical energy, motivation) or bcf

Nursing system(wholly/partly compensatory, supportive-educative): Nurse actions (doing, teaching, guiding, supporting) + client actions

Nursing process: assessment, planning, implementation, evaluation

Stating s.c. deficit: -What does client need to do? (sc demand)               - Can client do it? (capacity of sc agency)

If not, why not? (lack of capabilities) → Write nursing diagnosis