Health-care professionals are shifting from diseaseoriented to health-oriented systems of care. The potential for improving health is achieved through increasing the client's knowledge and encouraging active participation in self-care. The self-care philosophy recognizes the individual's right and ability to make choices about health and health care. The self-care movement has been tied to historical, social, and economic trends and will continue to be an important focus in our aging nation.
As the fastest growing segment of the American population, individuals over age 65 may require nursing assistance to manage self-care when experiencing fluctuations in health. Promoting health and self-care increases the probability that individuals will improve functional abilities, maintain independent lifestyles, and maintain control of their lives.1
Sullivan,2 Orem,3 and Carpenito4 incorporate the self-care movement into models for nursing. Sullivan2 described a model for nursing the elderly, with self-care approaches to health and health-care problems acting as the first line of defense for maintaining independence.
Orem3 views nursing's relationship to an individual as existing primarily to assist that person to maintain, restore, or increase the ability to provide selfcare. Self-care is learned behavior deliberately chosen to take care for self and maintain health and well-being. The term self-care deficit refers to a client's inability to take appropriate actions for self-care. Self-care deficit is determined by identifying actions required for self-care. Three broad categories of actions that may be required are universal, developmental , or healthdeviation self-care requisites (See Table 1).
After the demands for self-care actions are identified (therapeutic selfcare demands), the nurse assesses the individual's capacity to take the required actions.
The nurse assesses the client's ability to meet the specified set of actions by reviewing: 1) the demands for care in the universal, developmental, and health-deviation categories; 2) the currently used self-care actions; and 3) the therapeutic effectiveness of self-prescribed practices. If the client is unable to meet the demands of required selfcare, a deficit exists and nursing care is needed.
Certain factors influence the client's ability to provide self-care. Basic conditioning factors3 (eg, age, developmental level/event, health state, and available resources) and power components5 (eg, knowledge, motivation, and/or psychomotor skills) are essential for the successful implementation of self-care. Impairments of any of these factors may result in self-care deficits.
Self-care Deficit: A Mandate for Nursing
Self-care deficits occur when clients cannot meet the demands for health actions due to limitations in knowledge, motivation, psychomotor skills, or limitations arising within the basic conditioning factors. Orem's self-care deficit theory provides a useful framework in designing nursing systems. By applying the appropriate method of nursing assistance (acting or doing for, guiding, supporting, providing a developmental environment, and teaching), nurses collaborate with clients to meet therapeutic self-care demands and eliminate self-care deficits.
The definition of self-care deficit, according to Carpenito,4 is less broad than the framework of Orem's self-care deficit theory. The self-care deficit (similar to unmet needs of universal self-care requisites) is a decreased ability to feed, bathe, dress, or toilet oneself. Major signs and symptoms of self-care deficit are presented in Table 2. Focusing on a common language of function, rather than medical disability, enhances communication for all members of the health-care team, and promotes active involvement of the client in goal-setting, planning, and evaluation.6 Clients incurring impairment of cognitive or motor function are at risk for developing self-care deficits (See Table 3).
Mrs. M, aged 76 years, suffered a right middle cerebral vascular accident three months ago causing residual left shoulder, arm, and hand weakness, and sensory impairment. Following the stroke, Mrs. M had impaired balance, tending to lean to the left, but with gait retraining, walks safely with supervision. She required supervision around the clock, so she elected to move in with her daughter in a nearby community rather than into a nursing home. She continues to have difficulty sensing the position of her left arm, frequently allowing it to hang dependent, which then becomes cyanotic.
Immediately following hospital discharge, Mrs. M attempted to groom herself and dress in her favorite clothes. Gradually, she has come to dressing in a housecoat, sleeping in the same clothes she has worn for several days. The selfcare deficit related to her inability to dress herself reflects the impairment in neuromuscular function and cognitive perception. Inability to perceive the position of her left upper extremity, and the tendency to neglect her left arm and hand indicate uncompensated perceptual cognitive factors.
Despite a strong social support provided by her daughter, Mrs. M felt a sense of loss in terms of body function, personal independence, and worthfulness. Mrs. M could no longer drive and experienced little contact with her friends. Techniques for one handed dressing were practiced with Mrs. M while she was hospitalized, but were not reviewed with her daughter until the day of discharge. Mrs. M and her daughter have not been using .these dressing techniques at home.
Maturational factors are changes that occur with aging. Elderly often experience diminished vision and motor strength. Aging clients must meet not only the universal and developmental self-care requisites that other age groups experience, but must also cope with accumulating effects of chronic or degenerative processes and age-related constraints in performing those activities.7
An intact neuromuscular system is required for voluntary movement to perform self-care actions. Common results of right cerebral hemisphere dysfunction, impairment of spatial relationships and impulsiveness, frequently necessitates assistance from others for supervision, guidance, or teaching. Emotional factors, such as depression, limit the client's motivation for action. Limited knowledge and practice of dressing skills also contributed to Mrs. M's self-care deficit.
Assessment determines the extent to which the elderly client's resources, knowledge, motivation, and skills contribute to or hinder self-care. Careful consideration must be given to the element of time, as a hurried assessment will distort the actual degree of self-care deficit. A prolonged assessment might worsen performance due to fatigue or progressive weakness. Various diagnostic assessment tools are available to assist in a complete, organized assessment in an appropriate amount of time.
MAJOR DEFINING CHARACTERISTICS OF SELF-CARE DEFICIT
The inability to dress herself was the focus of assessment of Mrs. M's selfcare deficit, although her ability to feed, bathe, and toilet herself must also be assessed. Mrs. M and her daughter were observed during dressing. Assessment revealed that Mrs. M requested assistance nom her daughter in obtaining clothes from the dresser although Mrs. M had the ability. Mrs. M was able to transfer from the bed to a chair for dressing, maneuver underwear and slacks off and on, needing only standby assistance. She refused to attempt to slide her bra or housedress sleeve onto her left arm, waiting for her daughter to do this for her. She did not fasten any hooks or buttons. Mrs. M's daughter put her shoes and socks on for her, but Mrs. M was able to use a longhandled shoe horn for adjusting her shoes.
Grading self-care deficits on a scale (adapted from Jones8) aids the nurse in specifically communicating the presence and degree of self-care deficit and assists the nurse and client in tracking the outcomes of the intervention (See Table 4). The degree of assistance provided by another person may range from maximal assistance to stand-by assistance or supervision only. McCourt addressed this limitation,9 by defining Level 2 and Level 3 in subdivisions (See Table 4). Either scale may be used with each specific deficit (inability to feed, bathe, dress, or toilet oneself), or for an overall "total" self-care deficit score if the client is dependent in all of these activities.
In grading Mrs. M's self-care deficit in dressing, we see that she is able to perform some dressing using devices which assist and assistance from another person. Using the first grading scale, Mrs. M's deficit was at Level 3. Using the more specific second scale, the self-care deficit was Level 3.8, with her daughter performing 75% of the work.
The client's perception of current state of health is also an important aspect of self-care deficit that must be assessed. During collection of objective data, Mrs. M's perception of the deficit and meaning in her life was elicited. She reported not needing to dress since no one except her daughter saw her anyway. She also added, "I just don't have the energy to get dressed up. It's easier to let my daughter do it, since I take so long to dress."
When the initial assessment was completed, the nursing diagnosis of self-care deficit was confirmed. Goals were explored with the client, and the desired outcomes identified with Mrs. M are summarized (See Table 5.)
To allow. Mrs. M to finish breakfast in time to watch her favorite TV show, her daughter was providing assistance that prevented Mrs. M from performing her own self-care. The nurse discussed this with Mrs. M and her daughter. An assessment of self-care abilities showed that Mrs. M was capable of doing at least 50% of her own dressing, and it may be possible for her to do 75% of the dressing if modifications in clothing were made (wide-pant legs, front-hooking bra, velcro closures on blouses).
The nurse plans the intervention with the client to support and maintain current self-care abilities, while restoring or compensating for losses which contribute to self-care deficits. The plan may include collaboration with occupational and physical therapists for specific adaptive devices or tools.
Mrs. M's movement toward independence was guided by the mutually defined outcomes and weekly goals. On the 1st and 2nd day, Mrs. M was responsible for laying her blouse out in front of her, gathering up the left sleeve, grasping her left hand, and maneuvering the sleeve over her hand. On the 3rd day, the goal included maneuvering the sleeve to her forearm, and by the 4th day, sliding the sleeve up over her elbow. In this manner, her daughter would gradually reduce the amount of unnecessary assistance and promote the client's independence within safe limits.
Self-care deficits can be diminished or eliminated through the use of client re-education, self-monitoring, contracting, self-help groups, and reminiscence therapy. Re-education efforts focus on the knowledge and motivation to learn the psychomotor skills to maximize self-care in feeding, bathing, dressing, or toileting. Repetition of instructions and frequent feedback on performance occurs during frequent practice sessions. One-to-one teaching should be deficit specific, or psychomotor skill specific, tailored to the unique needs of the client.10
Contracting and self-monitoring can be combined with the teaching intervention. Self-monitoring is subjective appraisal of signs and symptoms of etiological factors which increase the self-care deficit eg, keeping a diary, journal, or chart of signs and symptoms, degree of self-care deficit, and application of the intervention. Records by clients are helpful in evaluating the intervention's effectiveness and to specifically identify areas for improving the intervention plan.
Contracting entails explicitly identifying the desired behavior in measurable terms which are acceptable to both the client and nurse. Steckel" focuses on health and self-care, and the development of contracts using the nursing process. Desired behavior is broken down into smaller manageable steps, each of which builds toward the desired behavior. Rewards or reinforcement are decided by the client for performance of specific behaviors. The contract is reevaluated on dates determined at the beginning of the contract. Progress is evaluated by records or diaries kept by the client, and achievement of shortand long-term goals. Contracting reinforces the client's role as active participant, and helps heahh-care professionals focus the client's view of reality.
ETIOLOGIES OF SELF-CARE DEFICIT
The most appropriate intervention for Mrs. M's self-care deficit in dressing was a teaching approach coupled with contracting. Mrs. M and her daughter observed techniques for aiding dressing for right arm hemiparesis. Written directions with diagrams illustrating dressing step-by-step were given to them. Her daughter returned a demonstration on this step-by- step approach. She was also shown how to replace buttons with Velcro® closures, encouraged to find loosely fitted, wide-legged slacks, and given a booklet on making clothing alterations.
Daily goals were outlined by Mrs. M, with the understanding that if she had difficulty achieving a goal, she could remain at that goal for an additional day, but would need to practice that skill not only with morning dressing but one time in the afternoon. A checklist was provided describing a step-by-step approach to record Mrs. M's progress, and to indicate which steps required 50% or 75% of assistance from her daughter.
Mrs. M decided to reward herself by videotaping the TV program she would miss while dressing. Since this TV program was already a part of her daily schedule, she was encouraged to choose another reward- one she might not otherwise receive. She suggested a 15-minute visit with the nurse in one week, and a hair appointment in two weeks. Mrs. M and her daughter would plan to play a game of cards each day that Mrs. M undertook a new goal.
Other interventions are also appropriate for self-care deficit. These include self-help groups and reminiscence therapy. Self-help groups are comprised of individuals who gather together to satisfy a common need or find mutual assistance to overcome a common handicap. Self-help groups are based on the idea that a person can best be helped by another person experiencing similar events. Providing information, emotional support, and role models are important aspects of self-help groups.12
GRADING SCALE FOR CLASSIFYING LEVEL OF SELF-CARE DEFICIT
OUTCOME CRITERIA FOR RESOLUTION OF SELF-CARE DEFICIT
Reminiscence therapy, eg, sharing life experiences, may occur during selfhelp group or individual meetings.13 In an experimental study to test individual reminiscence therapy as an intervention to reduce depression in aged clients, Hibel14 also found an increase in selfcare activities and the desire to socialize.
Reassessment using a scale for selfcare deficits objectively measures where improvement has been achieved and where further improvement is needed. Evaluation of the plan reveals ineffective interventions and together, the nurse and client use the evaluation data to set new goals or design a new plan. It is the plan, not the client, that has failed when a goal is not met. The specific indicator of achievement for Mrs. M was participation in dressing, doing 50% of the dressing by the end of one month, using adapted clothing. Her functional level improved from level 3.8 to 3.4 on the McCourt Index of Functional Ability.
Client satisfaction with the present degree of self-care is also a measure of the effectiveness of the intervention. Mrs. M enjoyed selecting her favorite clothes to wear, and looked forward to the opportunities to visit with the nurse and to have a special time set aside with her daughter. She reported feeling better about herself and began to make plans to visit old friends in her hometown.
The nursing process has been used to illustrate active client participation in a problem-solving process for self-care deficit. Through a collaborative process, the nurse can communicate an understanding of the self-care deficit, and elicit the client's perspective of the self-care deficit and its meaning to daily living. Building upon this collaborative relationship, availability of resources, knowledge, motivation, and psychomotor skills can be enhanced in a way that the self-care skills are comfortably adapted to the client's lifestyle.
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MAJOR DEFINING CHARACTERISTICS OF SELF-CARE DEFICIT
ETIOLOGIES OF SELF-CARE DEFICIT
GRADING SCALE FOR CLASSIFYING LEVEL OF SELF-CARE DEFICIT
OUTCOME CRITERIA FOR RESOLUTION OF SELF-CARE DEFICIT