Sample of NCP Basic Human Needs: Personal Hygiene

ASSESSMENT

1. Client Identification

• Name:
• Address:
• Age:
• Gender:
• Level of education:

2. Health History

• Assess individual patterns of daily hygiene.
• Assess the factors that influence individual hygiene include:
• Culture: for example, the myth that being sick should not shower because it will aggravate the disease.
• Socio-economic status: to fulfill that adequate facilities and infrastructure.
• Religion: beliefs affect individuals within executing daily habits.
• The level of knowledge or the development of the individual to health.
• Health Status: will affect an individual's ability to perform self-care.
• Habit: the habit of using certain products in self-care.
• Physical disability:

3. Physical Assessment

• Hair: look dull? is there a loss?
• Scalp: dandruff, bald and signs of inflammation (redness, swelling)
• Eyes: observe signs of jaundice, pale conjunctiva, discharge on the eyelids, redness and itching of the eyelids.
• Nose: assess for sinusitis, nasal bleeding, signs of a cold that does not go away, the signs of allergy.
• Mouth: observe the presence of lesions, mouth sores, dry or chapped.
• Teeth: observe signs of tartar, caries, cracked teeth, incomplete and false teeth.
• Ear: observe the presence of cerumen, lesions, infections, changes in hearing.
• Skin: observe the texture, turgor and moisture and skin hygiene: Strie, wrinkled skin, lesions, pruritus.
• Hands and feet nails: nail observe cleanliness.
• Genetalia: observe cleanliness.

Etiology

1. Physical fatigue
2. Impairment of consciousness
3. Factors predisposing

• Developments: Family too protect and pamper clients.
• Biological: chronic disease.
• Ability reality down: Mental disorders.
• Social: less support and self-care skills training environment.

4. Factors precipitation

• Less / decreased motivation.
• Impairment in cognition or perceptual.
• Anxious.

5. Partial or total paralysis, secondary to (specify)
6. Coma
7. Visually impaired secondary to (specify)
8. Extremity malfunction
9. External equipment (casts, splints, advocates, IV)
10. Fatigue and post-operative pain
11. Pain


Signs and Symptoms

1. Subjective data

• Patients feels weak.
• Lazy to move.
• Feel powerless.

2. Objective data

• Filthy hair, unkempt.
• Bodies and clothes dirty and smelly.
• Mouth and teeth dirty with stink.
• Skin dull and dirty.
• Long nails and unkempt.
• Untidy appearance.

Psychologically: Lazy, no initiative, self Attractive, self-isolation, Feeling helpless, low self-esteem and feel humiliated.

Social: less interaction, less activity, not able to behave according to normal, eating irregular way, urinate and defecate in any place, brush your teeth and shower are not able to be independent.


Nursing Diagnosis

1. Self-Care Deficit: Bathing / hygiene (Less self care (bathing) is an impaired ability to perform activities of bathing / personal hygiene). relate to:

2. Self-Care Deficit: Wearing apparel / ornate.
Self-Care Deficit (wearing clothes) is an impaired ability to wear their own clothes and dress up activities.

3. Self-Care Deficit: Eat
Self-Care Deficit (eating) is an impaired ability to demonstrate the activity of eating.

4. Self-Care Deficit: toileting
Self-Care Deficit (toileting) is an impaired ability to perform or complete the toileting activity itself. (Nurjannah: 2004, 79).