Self-care Checklist

Ambulation:

• Independent with steady gait ___________
• Uses cane ___________ walker ___________ wheelchair ___________
• Needs staff to accompany when walking ___________ assist sitting/getting up ___________ assist in/out of bed ___________ assist up/down stairs ___________

Effective techniques for assistance

• Resists using necessary equipment/assistance: Yes ___________ No ___________
• If yes, nursing approach: ___________

Feeding:

• Independent ___________
• Adequate nutritional intake ___________
• Difficulty swallowing ___________
• Needs staff to locate dining area ___________
• Provide assistance prompts ___________
• Feed patient ___________

Effective techniques for assistance

• Requires special feeding routine: Yes ___________ No ___________
• Requires special food/supplements: Yes ___________ No ___________
• If yes, describe: ___________

Fluid intake:

• Independent ___________
• Adequate amount ___________
• Needs staff to monitor daily amount of fluid intake ___________
• Provide prompts to drink ___________ hold cup while drinking ___________ drink with straw ___________

Effective techniques for assistance ___________

Toileting:

• Independent: Yes ___________ No ___________
• If no, words/behaviors patient uses to express need to toilet: ___________
• Diarrhea ___________
• Constipation ___________
• Frequency ___________
• Uses bedpan ___________ urinal ___________ commode ___________ adult diapers ___________
• Needs assessment of frequency/circumstances of urination ___________ defecation ___________
• Needs staff to take to toilet at scheduled times (every hour ___________ before going to bed ___________)

Effective technique to encourage patient to use toilet ___________

Bathing/Hygiene:

• Independent: ___________
• Areas of skin breakdown ___________
• Areas of paralysis ___________
• Needs staff to provide assistance and prompts ___________
• Wash certain body areas (list) ___________
• Full bath ___________
• Mouth care ___________

Effective means for assistance ___________

Dressing/Grooming:

• Independent ___________
• Hearing aid ___________
• Glasses ___________
• Needs staff to provide assistance and prompts ___________
• Change clothes ___________
• Provide grooming (for example, comb hair)
• If yes, specify steps that require assistance or if total care is needed: ___________

Effective techniques for assistance ___________