Nursing diagnosis: ineffective Role Performance related to changes in ability to perform usual tasks; increased energy expenditure, impaired mobility
Possibly evidenced by
Change in structure or function of affected parts
Negative self-talk, focus on past strength and function, appearance
Change in lifestyle, physical ability to resume roles; loss of employment, dependence on significant other (SO) for assistance
Change in social involvement; sense of isolation
Feelings of helplessness, hopelessness
Desired Outcomes/Evaluation Criteria—Client Will
Psychosocial Adjustment: Life Change
Verbalize increased confidence in ability to deal with illness, changes in lifestyle, and possible limitations.
Formulate realistic goals and plans for future.
Nursing intervention with rationale:
1. Encourage verbalization about concerns of disease process and future expectations.
Rationale: Provides opportunity to identify fears or misconceptions and deal with them directly.
2. Discuss meaning of loss or change to client and SO. Ascertain how client views self in usual lifestyle functioning, including sexual aspects.
Rationale: Identifying how illness affects perception of self and interactions with others will determine need for further intervention or counseling.
3. Discuss client’s perception of how SO perceives limitations.
Rationale: Verbal and nonverbal cues from SO may have a major impact on how client views self.
4. Acknowledge and accept feelings of grief, hostility, and dependency.
Rationale: Constant pain is wearing, and feelings of anger and hostility are common. Acceptance provides feedback that feelings are normal.
5. Note withdrawn behavior, use of denial, or overconcern with body and changes.
Rationale: May suggest emotional exhaustion or maladaptive coping methods, requiring more in-depth intervention and psychological support.
6. Set limits on maladaptive behavior. Assist client to identify positive behaviors that will aid in coping.
Rationale: Helps client maintain self-control, enhancing self-esteem.
7. Involve client in planning care and scheduling activities.
Rationale: Enhances feelings of competency and self-worth and encourages independence and participation in therapy.
8. Assist with grooming needs, as necessary.
Rationale: Maintaining appearance enhances self-image.
9. Give positive reinforcement for accomplishments.
Rationale: Allows client to feel good about self. Reinforces positive behavior. Enhances confidence.
10. Refer to psychiatric counseling, such as psychiatric clinical nurse specialist, psychiatrist/psychologist, and social worker.
Rationale: Client/SO may require ongoing support to deal with long-term debilitating process.