In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of self care in order to:

  • Assess client ability to manage care in home environment and plan care accordingly (e.g., equipment, community resources)
  • Consider client self care needs before developing or revising care plan
  • Assist primary caregivers working with the client to meet self-care goals

Dorothea Orem developed the Self Care Deficit Nursing Theory. According to this theory, there are three nursing systems that are used according to the patient's abilities to perform their own self care.

The wholly compensatory nursing system consists of complete care to the patient by the nurse because the patient is not able to perform any of their self care activities. Infants, neonates and patients in a coma are patients that need the wholly compensatory nursing system.

The partly compensatory nursing system consists of the provision of some care when the patient can perform some but not all of the needed self care activities. A patient who is acutely ill and able to only bathe their genital area and a young child who can brush their teeth but not bathe properly are examples of patients who need the care of the nurse using the partly compensatory nursing system. The nurse cares for the needs that the patient cannot do on their own.

Dorothea Orem's third nursing system is the supportive educative, also referred to as the developmental nursing system. The nurse only provides assistance and education to support the patient's self care abilities and activities.

Activities of daily living (ADLs) are separated into the basic activities of daily living and the instrumental activities of daily living.

Examples of basic activities of daily living include things like bathing, mobility, ambulation, toileting, personal care and hygiene, grooming, dressing, and eating.

The instrumental activities of daily living are more advanced than the basic activities of daily living. The instrumental activities of daily living include things like grocery shopping, housework, meal preparation, the communication with others using something like a telephone, and having transportation. The mnemonic to remember the instrumental activities of daily living is SHAFT which represents shopping, housekeeping, accounting and managing money, food purchasing and preparation, and the use of the telephone and needed transportation.

Assessing the Client's Ability to Manage Care in the Home Environment and Planning Care Accordingly

The patient's ability to perform self care can be assessed by the registered nurse by direct observation as the patient performs their self care activities, and, their ability to perform self care can also be assessed by using the services of a physical therapist, an occupational therapist and by using a standardized tool or test that measures the patient's abilities in terms of their basic and instrumental activities of daily living.

Some of the standardized tests to determine the patient's abilities to perform the basic and the instrumental activities are the Lawton Instrumental Activities of Daily Living Scale, the Bristol Activities of Daily Living Scale, the Cleveland Scale of the Activities of Daily Living, and the Katz Index of Independence in Activities of Daily Living.

The Lawton Instrumental Activities of Daily Living Scale is used to assess the client's ability to shop, prepare meals, run errands, manage their medications, managing their finances and bills, doing laundry and other activities like housekeeping and maintaining the household. Katz's Index of Independence in Activities of Daily Living assesses and measures the client's ability to perform such basic activities as bathing, feeding, toileting and level of continence or incontinence. The Bristol Activities of Daily Living Scale contains 20 items which are rated from number 1 to number 5. Some of the items on the Bristol Activities of Daily Living Scale include time orientation, eating, dressing, food preparation, space orientation, oral care and using transportation. The Cleveland Scale of Activities of Daily Living, developed by Patterson and Mack, is somewhat similar to the Bristol Activities of Daily Living Scale in that both are used to measure the functional abilities of the person with dementia in terms of their activities of daily living, but the Cleveland Scale is also used to assess these abilities among those with physical impairments.

Clients' abilities to perform self care and the activities of daily living can be impacted by a number of things including the patient's motivation, social support, physical and psychological status, their neurological status, their musculoskeletal abilities and deficits, their cognitive abilities, and their level of development.

The patient's neurological and musculoskeletal status can also be measured and determined using a standardized tests and tools like the Barthel Index and the Klein Bell Scale and the Assessment of Motor and Process Skills.

Range of motion, muscular strength, muscular tone, balance, coordination, gait, reflexes, and the patient's motor function can also be determined by nurses, physical and occupational therapists.

All efforts are made to support and assist patients with their activities of daily living in order for them to maintain their highest level of independence.

Nurses support clients with mobility problems, such as ambulation, transfers and positioning oneself, with interventions such as assisting with and teaching transfer techniques, encouraging range of motion exercises, and supporting the patient with any assistive devices they need for ambulation such as crutches or a cane.

Nurses also support and help patients with their personal care and hygiene self care needs as indicated. Some interventions can include setting the patient up and assisting them as needed and also by providing the patient with assistive devices and equipment such as a long shoe horn and adapted toothbrushes to facilitate the greatest possible level of independence. Bathing self care can be supported with assistance and the provision of devices such as a shower chair, grab bars in the bathroom, and long handled back brushes. Toileting can be supported with bowel and bladder training and assistive devices like a raised toilet seat.

Lastly, nurses refer clients to community resources, as indicated.

Considering the Client's Self Care Needs Before Developing or Revising the Care Plan

The client's level of self care and their functional abilities in relationship to the activities of daily living are an integral part of a complete assessment. When basic and/or instrumental self care needs are identified, the nurse plans care, or revises the plan of care, as based on these needs. Some of these needs may be simply met with some assistance by nurses or other health care providers and many may have to be completely met by another, including a nurse or a caregiver in the home.

Assisting the Primary Caregivers Working with the Client to Meet Self-Care Goals

After the nurse assesses the client and their self care needs, the registered nurse will assist and educate the client's primary caregivers so that they can assist the client with their self care activities or provide the client with their necessary care.

RELATED CONTENT:

SEE - Health Promotion & Maintenance Practice Test Questions