Nursing diagonsis: situational low Self-Esteem related to Traumatic injury, situational crisis, forced crisis
Possibly evidenced by
Verbalization of forced 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
Actual change in structure and function
Lack of eye contact
Change in physical capacity to resume role
Confusion about self, purpose, or direction of life
Desired Outcomes/Evaluation Criteria—Client Will
Psychosocial Adjustment: Life Change
Verbalize acceptance of self in situation.
Recognize and incorporate changes into self-concept in accurate manner without negating self-esteem.
Develop realistic plans for adapting to role changes and new role.
Nursing intervention with rationale:
1. Acknowledge difficulty in determining degree of functional incapacity and chance of functional improvement.
Rationale: During acute phase of injury, long-term effects are unknown, which delays the client’s ability to integrate situation into self-concept.
2. Listen to client’s comments and responses to situation.
Rationale: Active listening provides clues to client’s view of self, role changes, needs, and level of acceptance.
3. Assess dynamics of client and SOs, including client’s role in family and cultural factors.
Rationale: Client’s previous role in family unit is disrupted or altered by injury. Role changes add difficulty in integrating selfconcept and level of independence.
4. Encourage SO to treat client as normally as possible, such as discussing home situations and family news.
Rationale: Involving client in family unit reduces feelings of social isolation, helplessness, and uselessness and provides opportunity for SO to contribute to client’s welfare.
5. Provide accurate information. Discuss concerns about prognosis and treatment honestly at client’s level of acceptance.
Rationale: Open discussion of treatment and prognosis may focus on current and immediate needs. Ongoing updates enable assimilation.
6. Discuss meaning of loss or change with client and SO. Assess interactions between client and SO.
Rationale: Actual change in body image may be different from that perceived by client. Distortions may be unconsciously reinforced by SO.
7. Accept client and show concern for individual as a person. Identify and build on client’s strengths; give positive reinforcement for progress noted.
Rationale: Genuine concern and regard for the client as an individual establishes therapeutic atmosphere for self-acceptance and encouragement.
8. Include client and SO in care, allowing client to make decisions and participate in self-care activities, as possible.
Rationale: Encouraging client participation in care decision making recognizes that client is still responsible for own life and provides some sense of control over situation. It sets the stage for future lifestyle, pattern, and interaction required in daily care. Note: Client may reject all help or may be completely dependent during this phase.
9. Be alert to sexually oriented jokes, flirting, or aggressive behavior. Elicit concerns, fears, and feelings about current situation and future expectations.
Rationale: Anxiety develops because of perceived loss and change in masculine or feminine self-image and role. Forced dependency is often devastating, especially in light of change in function and appearance.
10. Be aware of own feelings and reaction to client’s sexual anxiety.
Rationale: Personal reactions to client’s sexual anxiety may be as disruptive as the behavior itself, creating conflicts between client and staff, and can potentially eliminate client’s willingness to work through situation and participate in rehabilitation.