Nursing diagnosis: disturbed body image related to situational crisis—traumatic event, dependent client role; disfigurement, pain
Possibly evidenced by
Negative feelings about body and self, fear of rejection or reaction by others
Focus on past appearance, abilities; preoccupation with change/loss
Change in physical capacity to resume role, change in social involvement
Desired Outcomes/Evaluation Criteria—Client Will
Incorporate changes into self-concept without negating self-esteem.
Verbalize acceptance of self in situation.
Talk with family/SO about situation and changes that have occurred.
Develop realistic goals and plans for the future.
Nursing intervention with rationale:
1. Assess meaning of loss or change to client and SO, including future expectations and impact of cultural and religious beliefs.
Rationale: Traumatic episode results in sudden, unanticipated changes, creating feelings of grief over actual or perceived losses. This necessitates support to work through to optimal resolution.
2. Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial.
Rationale: Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push client before he or she is ready to deal with the situation. Denial may be prolonged and be an adaptive mechanism because client is not ready to cope with personal problems.
3. Set limits on maladaptive behavior (e.g., manipulative or aggressive). Maintain nonjudgmental attitude while giving care, and help client identify positive behaviors that will aid in recovery.
Rationale: Client and SO tend to deal with this crisis in the same way in which they have dealt with problems in the past. Staff may find it difficult and frustrating to handle behavior that is disrupting and not helpful to recuperation but should realize that the behavior is usually directed toward the situation and not the care provider.
4. Be realistic and positive during treatments, in health teaching, and in setting goals within limitations.
Rationale: Enhances trust and rapport between client and nurse.
5. Encourage client and SO to view wounds and assist with care, as appropriate.
Rationale: Promotes acceptance of reality of injury and of change in body and image of self as different.
6. Provide hope within parameters of individual situation; do not give false reassurance.
Rationale: Promotes positive attitude and provides opportunity to set goals and plan for future based on reality.
7. Assist client to identify extent of actual change in appearance/ body function.
Rationale: Helps begin process of looking to the future and how life will be different.
8. Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals.
Rationale: Words of encouragement can support development of positive coping behaviors.
9. Show slides or pictures of burn care or other client outcomes, being selective in what is shown as appropriate to the individual situation. Encourage discussion of feelings about what client has seen.
Rationale: Allows client and SO to be realistic in expectations. Also assists in demonstration of importance of, and necessity for, certain devices and procedures.
10. Refer to physical or occupational therapy, vocational counselor, and psychiatric counseling, for example, a psychiatric clinical nurse specialist, social services, or a psychologist, as needed.
Rationale: Helpful in identifying ways and devices to regain and maintain independence. Client may need further assistance to resolve persistent emotional problems—especially posttrauma response.