Saturday, June 19, 2010

Nursing Diagnosis Disturbed Body Image

NANDA Nursing diagnosis Definition Confusion in mental picture of one's physical self Defining Characteristics: Nonverbal response to actual or perceived change in structure and/or function; verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function; verbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function; behaviours of avoidance, monitoring, or acknowledgment of one's body

Missing body part; actual change in structure or function; avoidance of looking at or touching body part; intentional or unintentional hiding or overexposure of body part; trauma to non-functioning part; change in social involvement; change in ability to estimate spatial relationship of body to environment

Change in lifestyle; fear of rejection or reaction by others; focus on past strength, function, or appearance; negative feelings about body; feelings of helplessness, hopelessness, or powerlessness; preoccupation with change or loss; emphasis on remaining strengths and heightened achievement; extension of body boundary to incorporate environmental objects; personalization of part or loss by name; depersonalization of part or loss by impersonal pronouns; refusal to verify actual change

Related Factors: Psychosocial, biophysical, cognitive/perceptual, cultural, spiritual, or developmental changes; illness; trauma or injury; surgery; illness treatment

NOC Outcomes (Nursing Outcomes Classification)
• Body Image
• Child Development: 2 Years
• Child Development: 3 Years
• Child Development: 4 Years
• Child Development: 5 Years
• Child Development: Middle Childhood (6-11 Years)
• Child Development: Adolescence (12-17 Years)
• Distorted Thought Control
• Grief Resolution
• Psychosocial Adjustment: Life Change
• Self-Esteem

Client Outcomes
  • States or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change
  • Calls body part or loss by appropriate name
  • Looks at and touches changed or missing body part
  • Cares for changed or nonfunctioning part without inflicting trauma
  • Returns to previous social involvement
  • Correctly estimates relationship of body to environment

NIC Interventions (Nursing Interventions Classification)
  • Use a tool such as the Body Image Instrument (BII) to identify clients who have concerns about changes in body image.
  • Observe client's usual coping mechanisms during times of extreme stress and reinforce their use in the current crisis
  • Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle.
  • Identify clients at risk for body image disturbance (e.g. body builders, cancer survivors).
  • Clients should not be rushed into sharing their feelings.
  • Do not ask clients to explore feelings unless they have indicated a need to do so.
  • Explore strengths and resources with client. Discuss possible changes in weight and hair loss; select a wig before hair loss occurs.
  • Encourage client to purchase clothes that are attractive and that de-emphasize their disability.
  • Allow client and others gradual exposure to the body change.
  • Encourage client to discuss interpersonal and social conflicts that may arise.
  • Encourage client to make own decisions, participate in plan of care, and accept both inadequacies and strengths.
  • Help client accept help from others; provide a list of appropriate community resources.
  • Help client describe self-ideal, identify self-criticisms, and be accepting of self.
  • Encourage client to write a narrative description of their changes.
  • Avoid looks of distaste when caring for clients who have had disfiguring surgery or injuries. Provide privacy; care should be completed without unnecessary exposure.
  • Encourage client to continue same personal care routine that was followed before the change in body image.
  • Focus on remaining abilities. Have client make a list of strengths.

Home health Care Interventions
  • Assess client's stage of grieving or acceptance of body change upon return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate.
  • Assess family/caregiver level of acceptance of client's body changes.
  • Be accepting of changes in all interactions with client and family/caregivers.
  • Help client to see new or changing roles in family.
  • Refer to medical social services for level of acceptance and possible financial impact of changes.
  • Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty.
  • Teach family and client complications of medical condition and when to contact physician.
  • Refer to occupational therapy if necessary to evaluate home setting for safety and adaptive equipment and to assist client with return to normal activities.
  • If appropriate, provide home health aide support to help the client and family through ADL transition.
  • Refer to physical therapy if necessary to build range-of-joint-motion (ROJM) flexibility and strength, prevent contractures.
  • Assess for and promote good nutrition and sleep patterns. Adapt nutrition to specific physiological situations.

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