Nursing Care Plan: Risk for fall related to amputation, body weakness, and old age.

Scientific Basis:

Falls are a major safety risk for adults, especially older adults. Evidence indicates that about 30% to 40% of older adults experience at least one serious fall per year. The consequences of these falls for the older adult represent a major health concern. Injuries sustained as a result of a fall include soft tissue injury, fractures (hip, spine, and wrist), and traumatic brain injury. Fall-related injuries are associated with prolonged hospitalizations for older adult. The quality of life for older adults is significantly changes following a fall-related injury. Death rate from fall-related injuries and their complications increases with the age of the patient.

Prevention of falls is an important dimension of the nursing care of patients in hospitals and long-term care settings. Implementation of policies and procedures designed to prevent falls is an essential part of nursing care in any health care setting. Fall prevention strategies need to promote patient dignity and functional independence by significantly limiting the use of physical restraints to maintain safety. Nurses also have a major role in educating patients, families, and caregivers about prevention of falls in the home.

(Gulanick, 2007)


Intervention and Rationale

I: Assess the client for factors known to increase fall risk such as: History of falls.
R: Evidence indicates that a person who has sustained one or more falls in the past year is more likely to fall again.

I: Mental status changes.
R: Confusion and impaired judgment increase the person’s risk for falls.

I: Age-related physical changes.
R: Normal changes associated with aging increase the person’s risk for falling. These changes include decreased visual capacity, impaired color perception, change in center of gravity, decreased muscle strength, decreased endurance, altered depth perception, and delayed response and reaction times.

I: Sensory deficit.
R: Impaired vision and hearing limit the person’s ability recognize hazards in the environment.

I: Disease-related symptoms.
R: Increased incidence of falls has been demonstrated in persons with symptoms such as orthostatic hypotension, dizziness, weakness, fatigue, and confusion.

I: Unsafe clothing.
R: Poor-fitting shoes, long robes, or long pants legs can limit a person’s ambulation and increase fall risk.

I: Assess the client’s environment for factors known to increase fall risk such as unfamiliar setting, inadequate lighting, wet surfaces, waxed floors, clutter, and objects on floor.
R: Clients who are not familiar with the placement of furniture and equipment in their room are more likely to experience a fall. Anything that blocks or limits a clear, straight path for ambulation can contribute to a person’s fall risk.

I: Ensure appropriate room lighting, especially at night.
R: Older adults with reduced visual capacity will benefit from adequate lighting, especially in an unfamiliar environment. Using a night light helps increase visibility if the client must get up at night.

I: Encourage the client to wear shoes or slippers with nonskid soles when ambulating.
R: Nonskid footwear provides sure footing for the client with diminished foot and toe lift when walking.

I: Provide the client with a chair that has a firm seat and arms on both sides.
R: This chair style is easier to get out of, especially when the client experiences weakness and impaired balance when transferring from bed to chair.

I: Encourage the client to participate in a program of regular exercise.
R: Evidence suggested that people who engage in regular exercise and activity will strengthen muscles, improve balance, and increase bone density. Increased physical conditioning reduces the risk of falls and limits injury that is sustained when a fall occurs.

I: Educate the client and family members about risk factors for fall in the home. Adaptation to increase safety.
R: About 40% of older adults living in the community sustain at least one fall per year. Falls are the leading cause of accidental death in the home setting.

I: Place bright, nonskid strips on the edge of stair treads. May install handrails on both sides of stairs from top to bottom if necessary.
R: Older adults have problems differentiating shades of the sane color and have diminished depth perception. These physiological changes make it difficult to see the edge of a stair tread that is a uniform color.

I: Ensure all rugs are securely fastened to the floors or removed.
R: Loose throw rugs increase the risk of slipping and falling.

I: Rearrange furniture to have a clear pathway between rooms. Keep traffic patterns free of clutter and electrical cords.
R: People with diminished strength are less able to negotiate around obstacles on their paths.

I: Increase lighting at the top and bottom of stairs. Use nightlight in bathrooms, bedrooms, and hallways.
R: Older adults have poor vision at night and in dimly lit areas.

I: May refer the family to community resources for assistance in making home safety modifications.
R: Many community service organizations provide financial assistance to help older adults make safety improvements in their homes as necessary.

Gulanick, 2007; Doenges, et al, 2002; Kruse, et al. 2003

Nursing Care Plan: Self-Care deficit related to depression, discouragement, loss of mobility, energy deficit, general debilitation and perceptual/cognitive impairment.

Scientific Basis:

The nurse may encounter the patient with a self-care deficit in the hospital or in the community. The deficit may be the result of transient limitations, such as those one might experience while recuperating from surgery, or the result of progressive deterioration that erodes the individual’s ability or willingness to perform the activities required to care for himself or herself. Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing at self-care because of a lack in material resources or a problem with arranging the environment to suit the patient’s physical limitations. The nurse coordinates services to maximize the independence of the patient and to ensure that the environment the patient lives in is safe and supportive of his or her special needs.

Alteration in physical ability may interfere with the individual’s performance of activities of daily living. Patients who are unable to participate on their own are dependent upon others to meet basic needs and are at risk for problems such as poor hygiene.

Self-care refers to those activities of an individual performs independently throughout the life to maintain personal well-being. Most adults care for themselves, whereas a person weakened by illness or disability require assistance with self-care activities.

Kozier, 2007; Gulanick, 2007; Neal, 2004



Intervention and Rationale

I: Determine current capabilities (0–4 scale) and barriers to participation in care.
R: Identifies need for/level of interventions required.

I: Assess ability to carry out ADL’s on regular basis. Determine the aspects of self care that are problematic to the client.
R: The client may only require assistance with some self-care measures.

I: Assess specific cause of each deficit (e.g., weakness, visual problems, cognitive impairment).
R: Different etiologic factors may require more specific interventions to enable self care.

I: Encouraging independence, but intervene when client cannot perform.
R: To decrease frustration.

I: Use consistent routines and allow adequate time for client to complete the tasks
R: This helps client organize and carry out self-care skills.

I: Provide positive reinforcement for all activities attempted; no partial achievements.
R: This provides the client with an external source of positive reinforcement.

I: Encouraged client to comb own hair. Suggested hairstyles that are low maintenance.
R: To enable the client to maintain autonomy for as long as possible.

I: Involve client in formulation of plan of care at level of ability.
R: Enhances sense of control and aids in cooperation and maintenance of independence.

I: Encourage self-care. Work with present abilities; do not pressure client beyond capabilities. Provide adequate time for client to complete tasks. Have expectation of improvement and assist as needed.
R: Doing for oneself enhances feeling of self-worth. Failure can produce discouragement and depression.

I: Provide and promote privacy, including during bathing/ showering.
R: Modesty may lead to reluctance to participate in care or perform activities in the presence of others.

I: Shampoo/style hair as needed. Provide/assist with manicure.
R: Aids in maintaining appearance. Shampooing may be required more/less frequently than bathing schedule.

I: Acquire clothing with modified fasteners as indicated.
R: Use of Velcro instead of buttons/shoelaces can facilitate process of dressing/undressing.

I: Encourage/assist with routine mouth/teeth care daily.
R: Reduces risk of gum disease/tooth loss; promotes proper fitting of dentures.

I: Provided supervision for each activity until client performed skill competently and is safe in independent care; evaluated regularly making sure that client is maintaining skill level and remains safe in environment.
R: The client’s ability to perform self-care measures may change often over time and will need to be assessed regularly.

Doenges, et al, 2008; Kruse, et al, 2003; Gulanick, 2007

Nursing Care Plan: Anxiety [mild]/Fear related to threat of death (perceived or actual) threat to, or change in health status (progressive/debilitating disease, terminal illness); interaction patterns, role function/status, environment (safety), and economic status.

Scientific Basis:

The emotional response of the patient during illness is of extreme importance. The mind-body-spirit connection is well established; it is known, for example, that when a physiological response occurs, there is a corresponding psychological response.

A common reaction to stress is anxiety, a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationship.

An actual or perceived threat to life, health, self-esteem, or role cause anxiety. Fear is the response to known factors. Questions arise as to whether the individual will survive of be able to continue previous life-style. Individuals feel anxious whenever they are threatened, whether the threat is perceived or actual. High levels of anxiety however, can be overwhelm the person and impair the ability to think and function. As the severity of the anxiety increases, the person is less able to function; thereby it threatens his health status and condition.

DeLaune and Ladner, 2002; Berman, et al, 2008


Intervention and Rationale

I: Note palpitations, elevated pulse/respiratory rate.
R: Changes in vital signs may suggest the degree of anxiety patient is experiencing or reflect the impact of physiological factors, e.g., endocrine imbalances, medications.

I: Acknowledge fear/anxieties. Validate observations with patient, e.g., “You seem to be afraid.”
R: Feelings are real, and it is helpful to bring them out in the open so they can be discussed and dealt with.

I: Assess degree/reality of threat to client and level of anxiety (e.g., mild, moderate, severe) by observing behavior such as clenched hands, wide eyes, startle response, furrowed brow, clinging to family/staff, or physical/verbal lashing out.
R: Individual responses can vary according to cultural beliefs/traditions and culturally learned patterns. Distorted perceptions of the situation may magnify feelings.

I: Note narrowed focus of attention (e.g., client concentrates on one thing at a time).
R: Narrowed focus usually reflects extreme fear/panic.

I: Observe speech content, vocabulary, and communication patterns, e.g., rapid/slow, pressured speech; words commonly used, repetition, use of humor/laughter, swearing.
R: Provides clues about such factors as the level of anxiety, ability to comprehend what is currently happening, cognition difficulties, and possible language differences.

I: Assess severity of pain when present. Delay gathering of information if pain is severe.
R: Severe pain and anxiety leave little energy for thinking and other activities.

I: Orient to environment and new experiences or people as needed.
R: Orientation and awareness of the surroundings promotes comforts and may decrease anxiety.

I: Identify client’s/SO’s perception(s) of the situation
R: Regardless of the reality of the situation, perception affects how each individual deals with the illness/stress.

I: Acknowledge reality of the situation as client sees it, without challenging the belief.
R: Client may need to deny reality until ready to deal with it. It is not helpful to force client to face facts.

I: Evaluate coping/defense mechanisms being used to deal with the perceived or real threat.
R: May be dealing well with the situation at the moment; e.g., denial and regression may be helpful coping mechanisms for a time. However, continued use of such mechanisms diverts energy client needs for healing, and problems need to be dealt with at some point in time.

I: Review coping mechanisms used in the past, e.g., problem-solving skills, recognizing/asking for help.
R: Provides opportunity to build on resources client/SO may have used successfully.

I: Assist client to use the energy of anxiety for coping with the situation when possible.
R: Moderate anxiety heightens awareness and can help motivate client to focus on dealing with problems.

I: Maintain frequent contact with client/SO. Be available for listening and talking as needed.
R: Establishes rapport, promotes expression of feelings, and helps client and SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.

I: Acknowledge feelings as expressed (e.g., use of Active-
Listening, reflection). If actions are unacceptable, take necessary steps to control/deal with behavior. (Refer to ND: Violence, risk for.)
R: Often acknowledging feelings enables client to deal more appropriately with situation. May need chemical/physical control for brief periods.

I: Identify ways in which client can get help when needed, including telephone numbers of contact persons.
R: Provides assurance that staff/resources are available for assistance/support.

I: Stay with or arrange to have someone stay with client as indicated.
R: Continuous support may help client regain internal locus of control and reduce anxiety/fear to a manageable level.

I: Provide accurate information as appropriate and when requested by client/SO. Answer questions freely and honestly and in language that is understandable by all. Repeat information as necessary; correct misconceptions.
R: Complex and/or anxiety-provoking information can be given in manageable amounts over an extended period. As opportunities arise and facts are given, individuals will accept what they are ready for. Note: Words/phrases may have different meanings for each individual; therefore, clarification is necessary to ensure understanding.

I: Avoid empty reassurances, with statements of “everything will be all right.” Instead, provide specific information: e.g., “Your heart rate is regular, your pain is being easily controlled, and that is what we want”
R: It is not possible for the nurse to know how the specific situation will be resolved, and false reassurances may be interpreted as lack of understanding or honesty, further isolating client. Sharing observations used in assessing condition/prognosis provides opportunity for client/SO to feel reassured.

I: Note expressions of concern/anger about treatment or staff.
R: Anxiety about self and outcome may be masked by comments or angry outbursts directed at therapy/caregivers.

I: Ask client/SO to identify what he or she can/cannot do about what is happening.
R: Assists in identifying areas in which control can be exercised and those in which control is not possible.

I: Provide as much order and predictability as possible in scheduling care/activities, visitors.
R: Helps client anticipate and prepare for difficult treatments/movements, as well as look forward to pleasant occurrences.

I: Instruct in ways to use positive self-talk, e.g., “I can manage this pain for now”
R: Internal dialogue is often negative. When this is shared out loud, client becomes aware and can be directed in the use of positive self-talk, which can help reduce anxiety.

I: Encourage client to develop regular exercise/activity program.
R: Helpful in reducing level of anxiety; has been shown to raise endorphin levels to enhance sense of well-being.

I: Encourage/instruct in guided imagery/relaxation techniques; e.g., imaging a pleasant place, use of music/tapes, deep-breathing, meditation, and mindfulness.
R: Promotes release of endorphins and aids in developing internal locus of control, reducing anxiety. May enhance coping skills, allowing body to go about its work of healing. Note: Mindfulness is a method of being in the here and now, concentrating on what is happening in the moment.

I: Provide touch, Therapeutic Touch, massage, and other adjunctive therapies as indicated.
R: Aids in meeting basic human need, decreasing sense of isolation, and assisting client to feel less anxious. Note: Therapeutic Touch requires the nurse to have specific knowledge and experience to use the hands to correct energy field disturbances by redirecting human energies to help or heal.

I: Use simple language and brief statements when instructing about self care measure, diagnostic or surgical procedures.
R: When experiencing moderate to severe anxiety, the patient may be unable to comprehend anything more than simple, clear, and brief instructions.

I: Refer to social service or other appropriate agency for assistance. Have case manage and social worker discuss modifications of medical aid if client is eligible for these resources.
R: Often client is not aware of the resources available providing current information about individual courage/ limitations and other possible sources of support will assist with adjustment to situation.

Gulanick, 2007; Doenges, et al, 2006; Kruse, et al, 2003

Nursing Care Plan: Caregiver role strain related to illness severity, unpredictability of illness course, knowledge deficit, and increasing clients care needs.

Scientific Basis:

The focus of this care plan is on the supportive care rendered by family, significant others, or caregivers responsible for meeting the physical and/or emotional needs of the patient. With limited access to health care for many people, most disease are diagnosed and managed in the outpatient setting.

Today’s health care environment places high expectations on the designated caregiver, whether a family member or someone to hire. For many older patients, the only caregiver is a fragile spouse overwhelmed by his or her own health problems. Even in cultures where care of the ill is the anticipated responsibility of family members, the complexities of today’s medical regimens, the chronicity of some of disease processes, and the burdens of the caregiver’s own family or environmental milieu provide and overwhelming challenge.

Caregivers have special needs for knowledge and skills in managing the required activities, access to affordable community resources, and recognition that the care they are providing is important and appreciated. People undergoing the role strain are frustrated because they feel inadequate or unsuited to a role.

Gulanick, 2007; Taylor, et al, 2005; Gulanick, 2007


Intervention and Rationale

I: Establish relationship with the caregiver and care recipient.
R: This facilitates assessment and intervention.

I: Assess caregiver-care recipient relationship.
R: Dysfunctional relationship can result in ineffective, fragmented care or even to neglect or abuse.

I: Assess family communication pattern.
R: open communication in the family creates a positive environment, whereas concealing feelings creates problems for caregiver and care recipient.

I: Assess family resources and support systems.
R: Family and social support is related positively to coping effectiveness. Some cultures are more accepting of this responsibility. However, factors such as blended family unit aging, geographical distances between family members, and limited financial resources may hamper coping effectiveness.

I: Assess the caregiver’s appraisal of the care giving situation, level of understanding, and willingness to assume caregiver role.
R: Individual responses to potentially stressful situations are mediated by an appraisal of the personal meaning of the situation. For some, care giving is viewed as a “duty”; for others it may be an act of love.

I: Assess for neglect and abuse of the care recipient and take necessary steps to prevent injury to the care recipient and strain on the caregiver.
R: Safe and appropriate care are priority nursing concerns. The nurse must remain a client advocate.

I: Assess the caregiver’s health.
R: Even though strongly motivated to perform the role of caregiver, the person, may have physical impairments or cognitive impairments that affect the quality of the care giving activities.

I: Encourage the caregiver to identify available family and friends who can assist with care giving.
R: Successful care giving should not be the sole responsibility of one person. In some situations there may be no readily members hesitate to notify other family members or significant others because of unresolved conflicts in the past.

I: Encourage involvement of the other family members to relieve pressure on the primary caregiver.
R: Caring for a family member can be a mutually rewarding and satisfying family experience.

I: Suggest that the caregiver use available community resources.
R: This provides opportunity for multiple competent providers and services on a temporary or more extended period.
I: Encourage the caregiver to set aside time for self. This could be simple as a relaxing bath, time to read a book/newspaper, or going out with friends.
R: Having own time helps conserve physical and emotional energy.

I: Teach the care giver stress-reducing techniques.
R: It is important that the caregiver has the opportunity to relax and reenergize emotionally throughout the day.

I: Encourage the caregiver in support group participation.
R: Groups that come together for mutual support can be quite beneficial in providing education and anticipatory guidance. A group can meet in the home, social setting, by telephone.

I: Acknowledge the caregiver’s role and its values.
R: Caregivers have identified how important it is to feel appreciated for their efforts.

I: Encourage the care recipient to thank the caregiver for care given.
R: Feeling appreciated decreases feelings of strain.

I: Provide time for the caregiver to discuss problems, concerns, and feelings. Ask the caregiver how he or she is managing.
R: As a caregiver, the nurse is in an excellent position to provide emotional support and provide guidance throughout this challenging period.

I: Provide information on the disease process and management strategies.
R: Accurate information increases understanding of the care recipient’s condition and behavior. Caregivers may have an unrealistic picture of the extent of care required at the present time.

Gulanick, 2007; Doenges, et al, 2002; Kruse, et al, 2003

Nursing Care Plan: Coping, ineffective/Decisional Conflict related to situational crises/personal vulnerability; multiple life changes/maturational crises, age/developmental stage, inadequate level of confidence in ability to cope, perception of control; high degree of threat; support no vacations/inadequate relaxation, impaired adaptive behaviors and problem-solving skills, severe pain/overwhelming threat to self unclear personal values/beliefs; perceived threat to value system; lack of experience/interference with decision making and lack of information.

Scientific Basis:

For most persons, everyday life includes shares of stressors and demands, ranging from family, work, and professional role responsibilities to major life events such as divorce, illness, and the death of loved ones. How one responds to such stressors depends in part on the person’s coping resources. Such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources.

Socio-cultural and religious factors may influence how people view and handle their problems. Some cultures may prefer privacy and avoid sharing their fear in public, even to health care providers. As resources become limited and problems become more acute, this strategy may prove ineffective. Vulnerable populations such as patients, those in adverse socioeconomic situations, those with complex medical problems such as those who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic stressors. Such problems can occur in any setting (e.g., during hospitalization for an acute event, in the home or rehabilitation environment as a result of chronic illness, or in response to another threat or loss).

NANDA define ineffective individual coping as an “inability to form a valid appraisal of the stressors, inadequate choices of practical responses, and/or inability to use available resources. Stimuli likely to cause ineffective coping in illness, pain and incapacitation, lack of sleep, stressful hospital environment and treatment procedures, loss of control over what’s happening to self, loss of hope, lack of meaningful contact with loved ones, uncertain future.

Conditions and stimuli to cause ineffective coping are perception on a harmful stimulus or cues that a harmful stimulus is imminent, perception that the harmful stimulus threatens the individual’s goals or values and perception that the patient’s resources aren’t equally to coping with the threat.

The period of impact begins immediately after injury and is characterized by shock, disbelief and feelings of being overwhelmed. The client and family members may be aware of what is happening but may be coping to the situation poorly.

Black and Hawks, 2004; Gulanick, 2007; Doenges, et al, 2002; Holloway, 2004


Intervention and Rationale

I: Review pathophysiology affecting client and extent of feelings of hopelessness/helplessness/loss of control over life, level of anxiety; perception of situation.
R: Indicators of degree of disequilibrium and need for intervention to prevent or resolve the crisis. Studies suggest that up to 85% of all physically ill people are depressed to some degree. Impairment of normal functioning for more than 2 wk, especially in presence of chronic condition, may reflect depression, requiring further evaluation.

I: Establish therapeutic nurse-client relationship.
R: Client may feel freer in the context of this relationship to verbalize feelings of helplessness/powerlessness and to discuss changes that may be necessary in client’s life.

I: Note expressions of indecision, dependence on others, and inability to manage own ADLs.
R: May indicate need to lean on others for a time. Early recognition and intervention can help client regain equilibrium.

I: Assess presence of positive coping skills/inner strengths, e.g., use of relaxation techniques, willingness to express feelings, use of support systems.
R: When the individual has coping skills that have been successful in the past, they may be used in the current situation to relieve tension and preserve the individual’s sense of control. However, limitations of condition may impact choices available to client; e.g., playing musical instrument to relieve stress may not be possible for individual with tremors or hemiparesis, but listening to tapes/CDs may provide some degree of comfort.

I: Encourage client to talk about what is happening at this time and what has occurred to precipitate feelings of helplessness and anxiety.
R: Provides clues to assist client to develop coping and regain equilibrium.

I: Evaluate ability to understand events. Correct misperceptions, provide factual information.
R: Assists in identification and correction of perception of reality and enables problem solving to begin.

I: Provide quiet, non stimulating environment. Determine what client needs, and provide if possible. Give simple, factual information about what client can expect and repeat as necessary.
R: Decreases anxiety and provides control for client during crisis situation.

I: Allow client to be dependent in the beginning, with gradual resumption of independence in ADLs, self-care, and other activities. Make opportunities for client to make simple decisions about care/other activities when possible, accepting choice not to do so.
R: Promotes feelings of security (client will know nurse will provide safety). As control is regained, client has the opportunity to develop adaptive coping/problem solving skills.

I: Accept verbal expressions of anger, setting limits on maladaptive behavior.
R: Verbalizing angry feelings is an important process for resolution of grief and loss. However, preventing destructive actions (such as striking out at others) preserves client’s self-esteem.

I: Discuss feelings of self-blame/projection of blame on others.
R: Although these mechanisms may be protective at the moment of crisis, they eventually are counterproductive and intensify feelings of helplessness and hopelessness.

I: Note expressions of inability to find meaning in life/reason for living, feelings of futility or alienation from God.
R: Crisis situation may evoke questioning of spiritual beliefs, affecting ability to cope with current situation and plan for the future.

I: Promote safe and hopeful environment, as needed. Identify positive aspects of this experience and assist client to view it as a learning opportunity.
R: May be helpful while client regains inner control. The ability to learn from the current situation can provide skills for moving forward.

I: Provide support for client to problem-solve solutions for current situation. Provide information and reinforce reality as client begins to ask questions; look at what is happening.
R: Helping client/SO to brainstorm possible solutions (giving consideration to the pros and cons of each) promotes feelings of self-control/esteem.

I: Provide for gradual implementation and continuation of necessary behavior and lifestyle changes. Reinforce positive adaptation/new coping behaviors.
R: Reduces anxiety of sudden change and allows for developing new and creative solutions.

I: Refer to other resources as necessary (e.g., clergy, psychiatric clinical nurse specialist/psychiatrist, family/marital therapist, addiction support groups).
R: Additional assistance may be needed to help client resolve problems/make decisions.

Doenges, et al, 2002; Gulanick, 2007; Kruse, et al, 2003

Nursing Care Plan: Disturbed body image related to change in body structure and function.

Scientific Basis:

The image of physical self, or body image, is how a person perceives the size appearance, an functioning of the body and its parts. Body image has both cognitive and affective aspects. The cognitive is the knowledge of the material body; the affective includes the sensations of the body, such as pain, pleasure, fatigue, and physical movement. Body image is the sum of these attitudes, conscious and unconscious, that a person has toward his or her body. The individual who has a body image disturbance may hide or not look at or touch a body part that is significantly changes in structure by illness or trauma. Some individuals may also express feelings of helplessness, hopelessness, powerlessness, and vulnerability, and may exhibit self-destructive behavior such as over- or under eating or suicide attempts.

The attitude is dynamic and is altered through interaction with other persons and situations, and is influenced by age and developmental level. As an important part of one’s self-concept, body image disturbance can have a profound impact on how individuals view their overall selves. In cultures where one’s appearance is important, variations from the norm can result in body image disturbance. The importance that an individual places on a body part or function may be more important in determining the degree of disturbance that the actual alteration in structure or function.

Gulanick, 2007; Bearman, et at, 2008; Taylor, et al, 2005



Intervention and Rationale

I: Assess perception of change in structure or function of the body part.
R: The extent of the response is more related to the value or importance the client places on the part or function than the actual value or importance. Even when an alteration improves the overall health of the individual, the alteration may result in a body image disturbance.

I: Assess perceived impact of change on activities of daily living (ADLs), social behavior, personal relationships, and occupational activities.
R: Changes in body image can have an impact on the person’s ability to carry out daily roles and responsibilities.

I: Assess impact of body image disturbance in relation to the client’s developmental stage.
R: In every developmental stage, they see their body image differently.

I: Note the client’s behavior regarding the actual or perceived change body part or function.
R: There is a broad range of behaviors associated with body image disturbance, ranging from totally ignoring the altered structure or function to preoccupation with it.

I: Note the frequency of the client’s self-critical remarks.
R: Negative statements about the affected body part indicate limited ability to integrate the change into the client’s self-concept.

I: Acknowledge normalcy of emotional response to actual change in body structure or function.
R: Stages of grief over loss of a body part or function is normal and typically involves a period of denial, the length of which varies between individuals.

I: Help the client identify actual changes.
R: clients may perceive changes that are not present or real, or they place an unrealistic value on a body structure or function.

I: Support and encourage client; provide care with a positive, friendly attitude.
R: Caregivers sometimes allow judgmental feelings to affect the care of client and need to make every effort to help patient feel valued as a person.

I: Encourage verbalization of positive or negative feelings about the actual or perceived change.
R: It is worthwhile to encourage the client to separate feelings about changes in body structure and/or function from feelings about self-worth. Expression of feelings can enhance the person’s coping strategies.

I: Assist the client in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities.
R: Opportunities for positive feedback and success in social situations may hasten adaptation.

I: Demonstrate positive caring in routine activities.
R: Professional caregivers represent a microcosm of society, and their actions and behaviors are scrutinized as the client plans to return to home, work, and other activities.

I: Teach the client about the normalcy of body image disturbance and the grief process.
R: The person experiencing a body image changes needs new information to support cognitive appraisal of the change.

I: Teach the client adaptive behavior (e.g., wearing shoes)
R: This compensates for the actual changed body structure and function.

I: Encourage family/SO to verbalize feelings, visit freely/participate in care.
R: Family members may feel guilty about client’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to client. Participation in care helps them feel useful and promotes trust between staff, client, and SO.

I: Help the client identify ways of coping that have been useful in the past.
R: Asking client to remember other body image issues and how they were managed may help the client adjust to current issue.

I: May refer the client and caregivers to support groups composed of individuals with similar alterations.
R: Lay persons in similar situations offer a different type of support, which is perceived as helpful.

Doenges, et al, 2008; Gulanick, 2007; Kruse, et al, 2003

Nursing Care Plan: Family Coping: readiness for enhanced related to knowledge deficit regarding illness prognosis, inaccurate, incomplete, or conflicting information and inadequate coping method.

Scientific Basis:

Family coping mechanisms are the behaviors families use to deal with stress or changes imposed from either within or without. Coping mechanisms can be viewed as an active method of problem solving developed to meet life’s challenges. Families may use coping patterns rather consistently over time or may challenge their coping strategies when new demands are made on the family. The success of a family largely depends on how well it copes with the stresses it experiences. Nurses working together with families realize the importance of assessing coping mechanisms as a way of determining how families relate to stress.

The stress that affects an ill person affects the person’s family members or significant others. When family is viewed as a system, the behavior of the individual’s behavior in turn affects the family. Stressors for the family include changes in the family structure and roles, anger and feelings of helplessness and guilt, loss of control over normal routines, and concern for future financial stability.

The family is disrupted as members abandon their usual activities and focus their energy on restoring family equilibrium. Roles and responsibilities previously assumed by the ill person are delegated to other family members, or those functions may remain undone for duration of the illness. The family’s ability to deal with the stress of illness depends on the members’ coping skills.

Berman, et al, 2008; Taylor, et al, 2005


Intervention and Rationale

I: Provide opportunities for family to talk with client and/or caregiver(s).
R: Reduces anxiety and allows expression of what has been learned and how they are managing, as well as opportunity to make plans for the future and share support.

I: Assess normal coping patterns in the family, including strengths, limitations, and resources.
R: Successful adjustment is influenced by previous coping success. Families with a history of unsuccessful coping may need additional resources.

I: Listen to family’s expressions of hope, planning, effect on relationships/life, change of values.
R: Provides clues to avenues to explore for assistance with growth.

I: Provide opportunities for and instruction in how SOs can care for client. Discuss ways in which they can support client in meeting own needs.
R: Enhances feelings of control and involvement in situation in which SOs cannot do many things. Also provides opportunity to learn how to be most helpful when client is discharged from care.

I: Determine ability of family members to provide necessary care.
R: Safe and appropriate care are priority nursing concerns. The nurse may have to intervene with suggestions for additional resources, as appropriate.

I: Provide a role model with which family may identify.
R: Having a positive example can help with adoption of new behaviors to promote growth.

I: Discuss importance of open communication. Role-play effective communication skills of Active-Listening, “messages,” and problem solving.
R: Helps individuals to express needs and wants in ways that will develop family cohesiveness. Promotes solutions in which everyone wins.

I: Encourage family to learn new and effective ways of dealing with feelings.
R: Effective recognition and expression of feelings clarify situation for involved individuals.

I: Encourage seeking help appropriately. Give information about available persons and agencies.
R: Permission to seek help as needed allows them to choose to take advantage of available assistance/resources.

I: Assist family to support the client in meeting own needs within ability and/or constraints of the illness or condition.
R: Provides a way to allow family member to take an active role in the care of the client.

I: Recognize the primary caregiver’s need for relief from continuing care responsibility. Assess the role of the client in the family structure.
R: The role of family members varies among culture.

I: Evaluate resources or support systems available to the family.
R: In some situations there may be no readily available resources; however, often family members hesitate to notify other family members or significant others because of unresolved conflicts in the past.

I: May refer to specific support group(s) as indicated.
R: Provides opportunities for sharing experiences; provides mutual support and practical problem solving; and can aid in decreasing alienation and helplessness.

Doenges, et al, 2008; Gulanick, 2007; Kruse, et al, 2003