Nursing diagnosis – DISTURBED PERSONAL IDENTITY

DISTURBED  PERSONAL  IDENTITY

DEFINITION

Inability to maintain an integrated and complete perception of self

DEFINING CHARACTERISTICS

• Disturbed body image

• Contradictory personal traits

• Fluctuating feelings about self

• Ineffective role performance

• Gender confusion

• Ineffective coping

• Unable to distinguish between

• Uncertainty about ideological

inner and outer stimuli

and cultural values

• Delusional description of self

• Uncertainty about goals

• Feelings of emptiness

• Disturbed relationships

• Feelings of strangeness

RELATED FACTORS

• Organic brain syndrome

• Situational crisis

• Dissociative identity disorder

• Dysfunctional family processes

• Psychiatric disorders

• Cultural discontinuity

• Low self-esteem

• Cult indoctrination

• Manic states

• Discrimination or prejudice

• Social role change

• Use of psychoactive drugs

• Stage of growth

• Ingestion of toxic chemicals

• States of development

• Inhalation of toxic chemicals

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Safety

• Sexual practices

• Mental status

• Cultural beliefs

• Self-care

• Relationships

EXPECTED OUTCOMES

The patient will

• Contract for safety.

• Identify internal versus external stimuli.

• Maintain adequate nutritional intake.

• Identify personal goals and realistic steps toward those goals.

• Compile a list of resources to call when needed.

• Remain free from substance abuse.

• Secure a safe place to live in.

SUGGESTED NOC OUTCOMES

Coping; Distorted Thought; Impulse self-Control; Self-Control;

Self-Esteem

INTERVENTIONS AND RATIONALES

Determine:  Assess for suicidal/homocidal ideation, self-induced cuts

or burns. Assess for self-induced vomiting or restricting of food.

Thorough mental status examination. Individuals struggling with

identified issues are at an increased safety risk.

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Monitor mental status daily to be able to intervene if necessary.
Monitor weight weekly to be able to detect changes that may

require further intervention.

Perform:  Contract with patient for safety. Schedule meetings with

patient to process feelings and experiences. Demonstrating care and

compassion for the patient allows him or her to feel safe and pro-

motes healing.

Inform:  Instruct patient to journal feelings and list coping strategies.

Journaling can help a patient maintain self-control and may increase

insight.

Attend:  Accept patient in his or her struggle. Reinforce taking

healthy risks and appropriate expression of feelings. Appropriate

expression of feelings enhances self-esteem and promotes resiliency.

Manage:  Refer patients to mental health services for medication and

symptom management. Disturbed personal identity may require

ongoing mental health care.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Environmental Management: Safety; Role

Enhancement; Self-Esteem Enhancement

Reference

Boyd, M. A. (2008). Psychiatric nursing. Philadelphia: Lippincott Williams &

Wilkins.

Nursing diagnosis – DISTURBED ENERGY FIELD

DISTURBED  ENERGY  FIELD

Disruption of the flow of energy surrounding a person’s being that

results in disharmony of body, mind, and/or spirit

DEFINING CHARACTERISTICS

Perceptions of changes in patterns of energy flow, such as changes in

• Hearing (tones, words).

• Perception of movement (wave spike, tingling, dense, flowing).

• Temperature.

• Sight (image, color).

RELATED FACTORS

Factors secondary to the slowing or blocking of energy flows may

be as follows:

• Maturational (age-related devel-

• Situational (anxiety, fear, griev-

opmental crisis and/or develop-
mental [mental] difficulties)

ing, and pain)
• Treatment-related (chemother-

• Pathophysiologic (illness,

apy, immobility, labor & deliv-

injury, and pregnancy)

ery, perioperative experience)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Emotional status

• Coping

• Sensation/perception

EXPECTED OUTCOMES

The patient will

• Feel increasingly relaxed by slower and deeper breathing, skin

flushing in treated area, audible sighing, or verbal reports of feel-
ing more relaxed.

• Visualize images that relax him.

• Report feeling less tension or pain.

• Use self-healing techniques such as meditation, guided imagery,

yoga, and prayer.

SUGGESTED NOC OUTCOMES

Comfort Level; Health Beliefs; Personal Health Status; Personal

Well-Being; Spiritual Health

INTERVENTIONS AND RATIONALES

Determine: Assess how much support patient desires. Evaluate the

presence of a disorder that is life threatening or requires surgery.

Monitor levels of pain and disorders that may affect the senses.

Assess patient’s spiritual needs, including religious beliefs and affilia-

tion. Assessment of these areas will help to identify appropriate

interventions.

Perform: Implement measures to promote therapeutic healing. Place

your hands 4   to 6   above the patient’s body. Pass hands over the

entire skin surface to become intoned to the patient’s energy fields,

which is the flow of energy that surrounds the human being. Identify

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areas where there is energy disturbance considering cues such as

cold, heat, tingling, and electric sensation. This technique helps you

become attuned to patient’s energy field, the flow of energy that sur-

rounds a person’s being.

Administer medication as ordered to relieve pain.
Turn and reposition patient at least every 2 hr. Establish a turning

schedule for the dependent patient. Post schedule at bedside and

monitor frequency. Turning and repositioning prevent skin

breakdown, improve lung expansion, and prevent atelectasis.

Provide comfort measures such as bathing, massage, regulation of

environmental temperature, and mouth care, according to the

patient’s preferences. Comfort measures done for and with the

patient reduce anxiety and promote feelings of well-being.

Inform: Teach self-healing techniques to both the patient and family

(e.g., meditation, guided imagery, yoga, and prayer). Teach patient

how to incorporate the use of self-healing techniques in carrying out

usual daily activities. It will take repeated use of strategies to induce

a spirit of well-being.

Teach caregivers to assist patient with self-care activities in a way

that maximizes his or her comfort. Caregivers may need assistance

with techniques. Lack of skill can cause the patient unnecessary

pain.

Attend: Encourage patient’s cooperation as you continue with heal-

ing techniques, such as therapeutic touch. Listen for evidence of

effectiveness of treatment by patient’s statements about reduction in

tension or pain. One treatment rarely restores a full sense of well-

being.

Manage: Refer to mental health specialist or other community agen-

cies as needed. It is important for patient to have ongoing support.

Refer to a member of the clergy or a spiritual counselor, accord-

ing to the patient’s preference, to show respect for the patient’s

beliefs and provide spiritual care.

SUGGESTED NIC INTERVENTIONS

Therapeutic Touch; Discharge Planning; Anxiety Reduction; Pain

Management

Reference

Robb, W. J. (2006, April–June). Self-healing: A concept analysis. Nursing

Forum, 41(2), 60–77.

Nursing diagnosis – RISK FOR DISTURBED MATERNAL–FETAL Dyad

RISK  FOR  DISTURBED  MATERNAL–FETAL

DYAD

DEFINITION

At risk for disruption of the symbiotic maternal–fetal dyad as a

result of comorbid or pregnancy-related conditions

DEFINING CHARACTERISTICS

• Complications of pregnancy (e.g., premature rupture of

membranes, placenta previa or abruption, late prenatal care, multi-
ple gestation)

• Compromised O2 transport (e.g., anemia, cardiac disease, asthma,

hypertension, seizures, premature labor, hemorrhage)

• Impaired glucose metabolism (e.g., diabetes, steroid use)

• Physical abuse

• Substance abuse (e.g., tobacco, alcohol, drugs)

• Treatment-related side effects (e.g., medications, surgery,

chemotherapy)

RELATED FACTORS

• Mental health status

• Cultural background

• Psychosocial issues

• Fetal well-being

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Emotional

• Roles/relationships

EXPECTED OUTCOMES

The patient will

• Be compliant with recommendations for self-care activities to mini-

mize prenatal complications and optimize maternal–fetal health.

• Verbalize fears and uncertainty related to prenatal condition.

• Actively involve significant other/support systems with pregnancy

expectations and plan of care.

• Demonstrate the “maternal tasks of pregnancy” culminating in an

unconditional acceptance of the fetus before delivery.

SUGGESTED NOC OUTCOMES

Prenatal Health Behavior; Knowledge: Pregnancy; Role Performance;

Family Integrity

INTERVENTIONS AND RATIONALES

Determine: At each prenatal visit, assess physical condition,

psychosocial well-being, and cultural beliefs to be able to counsel

and/or refer as needed.

Perform: Encourage support/involvement of significant other(s) dur-

ing course of pregnancy to enhance maternal role adaptation.

Incorporate the cultural beliefs, rites, and rituals of the childbear-

ing family into the plan of care to foster feelings of normalcy with

pregnancy.

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Inform: Educate patient/significant other on role transition and

maternal tasks of pregnancy to provide anticipatory guidance on

expected psychosocial changes.

Teach trimester-specific risks/danger signs and emphasize

importance of self-monitoring to empower the patient and reduce

potential for adverse fetal effects.

Attend: Encourage patient to express disappointment/concerns

related to relationships, physical condition, and fetal well-being to

promote therapeutic communication.

Manage: Refer to community resources as needed (e.g., prenatal

classes, psychological counseling, pastoral care, social services) to

facilitate appropriate role adaptation.

SUGGESTED NIC INTERVENTIONS

Anticipatory Guidance; Childbirth Preparation; Coping

Enhancement; Role Enhancement

References

Olds, S., London, M., Ladewig, P., & Davidson, M. (2008). Maternal–

newborn nursing and women’s health care (8th ed.). Upper Saddle River,
NJ: Prentice-Hall Health.

Ward, S. L., & Hisley, S. M. (2009). Maternal–child nursing care: Optimizing

outcomes for mothers, children, and families. Philadelphia: F.A. Davis Com-
pany.

Nursig diagnosis – disturbed body image

Disturbed Body Image
DEFINITION
Confusion in mental picture of one’s physical self
DEFINING CHARACTERISTICS
• Physiologic changes, behavioral changes, usual patterns of coping
with stress
• Missing body part, not looking or touching a body part, negative
feelings about a body part
• Frequent or disparaging comments about aging and its physical
manifestations
• Personal rigidity or unwillingness to change
• Actual change in structure or function
• Change in social relationships
• Hiding or overexposing of a body part (intentional or
unintentional)
• Depersonalization of loss by using third person pronouns
• Unintentional or intentional overexposing of body part
RELATED FACTORS
• DISTURBED BODY IMAGE
• Biophysical
• Cognitive
• Cultural
• Illness
• Surgery
• Trauma
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Behavior
• Knowledge
• Sensory perception
EXPECTED OUTCOMES
The patient will
• Identify physical changes without making disparaging comments.
• Identify at least one positive aspect of aging.
• Use vision or hearing aids appropriately.
• Demonstrate increased flexibility and willingness to consider
lifestyles changes.
• Participate in at least one social activity regularly.
• Exercise and engage in other physical activity at level consistent
with desire, ability, and safety.
• Perform self-care activities to tolerance level.
SUGGESTED NOC OUTCOMES
Body Image; Grief Resolution; Self-Esteem
INTERVENTIONS AND RATIONALES
Determine: Monitor physiologic responses to increased activity level,
including respirations, heart rate and rhythm, and blood pressure.
Assess understanding of the current health problem and desire to
• Sexuality
• Values/beliefs
participate in treatment. Assessment information is helpful in determining
appropriate interventions.
Perform: Perform ADL measures that the patient is unable to
perform for self while promoting as much independence as possible.
Inform: Provide patient with information on appropriate self-care
activities (e.g., maintaining proper diet; bathing as needed; using
alcohol-free skin lotions to combat dryness; exercising appropriately
to maintain muscle mass, bone strength, and cardiorespiratory
health; avoiding fractures related to osteoporosis) to ensure that the
patient will be able to perform self-care measures.
Teach patient about isometric exercises to maintain or increase
muscle tone and joint mobility.
Teach caregivers to assist patient with self-care activities in a way
that maximizes patient’s potential. This enables caregivers to participate
in patient’s care while supporting patient’s independence.
Attend: Provide emotional support and encouragement to improve
patient’s self-concept and promote motivation to perform ADLs.
Assist patient to learn how to perform self-care activities. Begin
slowly and increase daily, as tolerated. Performing self-care activities
will assist patient to regain independence and enhance self-esteem.
Involve patient in planning and decision making. Having the ability
to participate will encourage greater compliance with the plan for
activity.
Focus on patient’s strengths and what the patient is able to do for
self.
Encourage patient to engage in social activities with people of all
age groups. Participation once a week will help relieve patient’s
sense of isolation.
Manage: Refer to case manager/social worker to ensure patient
receives long-term assistance with body image problem.
Refer patient to a support group. In the context of a group, the
patient may develop a more positive view of present situation.
Refer for corrective eyewear and hearing aids to address sensory
deficits.
SUGGESTED NIC INTERVENTIONS
Active Listening; Body Image Enhancement; Grief Work Facilitation;
Self-Esteem Enhancement
Reference
Barba, B. E., & Colemen, P. (2006, August). What are old people for? Journal
of Gerontological Nursing, 32(8), 7–8.