The nurse determines that the client is physically incapable of maintaining personal hygiene. What is the most relevant nursing diagnosis for this client?
1. Disturbed body image
2. Impaired skin integrity
3. At risk for social isolation
4. Ineffective health maintenance
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4. Personal hygiene is a basic activity of daily living and most clients are capable of performing some of the tasks. A client unable to perform personal hygiene is very weak and has severe activity intolerance from an incapacitating condition such as end-stage chronic obstructive pulmonary disease or paralysis. Clients can become so helpless that they cannot lift their hands to wash their faces or dry the hands; thus, the clients are unable to perform other, more physically demanding activities related to maintaining health such as preparing meals, exercising, and seeing the provider.
1. Disturbed body image can be a suitable nursing diagnosis for the overall plan of care; it refers to a perception of a problem and not an actual physical condition.
2. The reader has insufficient data to determine whether impaired skin integrity is suitable.
3. If the client is incapable of personal hygiene, the nurse expects the client is unable to travel, thus isolating the client; however, this is not a physical problem.
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Which set of arterial blood gases would be consistent with the presence of this complication?
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