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 – INEFFECTIVE HEALTH MAINTENANCE

INEFFECTIVE  HEALTH  MAINTENANCE

DEFINITION

Inability to identify, manage, and/or seek out help to maintain health

DEFINING CHARACTERISTICS

· Demonstrated lack of adaptive behaviors (internal or external

environmental changes)

· Demonstrated lack of knowledge regarding basic health practices

· History of lack of health-seeking behaviors

· Reported or observed impairment of personal support systems

· Reported or observed inability to take responsibility for meeting

basic health practices in any or all functional pattern areas.

· Reported or observed lack of equipment or financial and other

resources

RELATED FACTORS

· Cognitive impairment

· Diminished gross motor skills

· Complicated grieving

· Inability to make appropriate

· Deficient communication skills

judgments

· Diminished fine motor skills

· Ineffective family coping

ASSESSMENT FOCUS                           (Refer  to  comprehensive  assessment  parameters.)

· Communication

· Knowledge

· Coping

· Risk management

· Healthcare system

· Values and beliefs

EXPECTED OUTCOMES

The patient will

· Maintain current health status.

· Sustain no harm or injury.

· Verbalize feelings and concerns.

· Explain health maintenance program.

· Identify available health resources.

SUGGESTED NOC OUTCOMES

Coping; Decision Making; Health Beliefs: Perceived Resources;

Health-Promoting Behavior; Social Support; Spiritual Health

INTERVENTIONS AND RATIONALES

Determine: Assess current health status; personal habits such as use

of tobacco, drugs, and alcohol; level of knowledge about disease

process; level of family and community assistance; coping

mechanisms and communication skills (verbal and written); and

degree of motivation to maintain health. Assessment factors will

assist the nurse in establishing interventions for this diagnosis.

Perform: Provide assistance with self-care, as needed. Encourage

increasing levels of independence. The patient should be as

independent in ADLs as possible.

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Administer medications as prescribed to ensure continuation of

therapy.

Adapt environment to that which is best suited to the particular

patient. Reorient the patient as needed. In the disoriented patient,

reorientation should take place frequently to keep the person as

close to knowing person, place, and time as possible.

Provide a consistent caretaker whenever possible to promote sta-

bility for the patient.

Plan a health maintenance program for patient and family members

addressing current disabilities. Provide patient and family with a writ-

ten copy. Giving instructions in writing will reinforce the various

aspects of the program and increase the possibility of compliance.

Inform: Fully describe all aspects of the patient’s care to the family

to elicit cooperation from them in continuing a plan.

Instruct family members how to carry out health maintenance

practices. Demonstrate skills such as bathing, feeding, and reality

orientation; then, have family members return demonstration under

supervision. Involving family members allows them the opportunity

to perform skills and solve problems with support and supervision.

Provide specific instructions on how to maintain a safe

environment for the patient to avoid falls and other types of

accidental injuries.

Teach relaxation techniques (e.g., guided imagery, progressive mus-

cle relaxation, and meditation) that can be done by the patient and

the family to enhance coping ability and restore psychological and

physical equilibrium by decreasing autonomic response to anxiety.

Attend: Encourage patient and family to verbalize feelings and con-

cerns related to health maintenance. This promotes better

understanding and greater ease in managing challenging situations.

Demonstrate willingness to repeat instruction and demonstrate

skills needed to care for the patients until they feel comfortable.

Manage: Refer to social and community resources, such a stroke sup-

port group, and Alzheimer’s family support group. This helps the family

gain support and receive factual information. It provides opportunity to

express feeling in a group where others are experiencing similar issues.

Making referrals is appropriate to mental health professional to

assist with prevention of burnout for the family.

SUGGESTED NIC INTERVENTIONS

Anticipatory Guidance; Coping Enhancement; Counseling; Discharge

Planning; Health Education; Health System Guidance; Physician

Support; Referral; Support System Enhancement

Reference

Cole, C. S., et al. (2006, April). Assessment and discharge planning for the

older hospitalized adults with delirium. Medsurg Nursing, 15(2), 71–76.