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INEFFECTIVE BREATHING PATTERN Nursing Care Plan

Stuart, 23 years old, diagnosed with pneumonia 3 months ago. Because of having not enough money for hospitalization. His state got worse day...

DISTURBED BODY IMAGE Nursing Care Plan

My sibling, Ivan, turned 14 last month and became so much conscious about his appearance. One day my mom called me that Ivan doesn't want to go to school because of his acne. It spreads all over his face and for him it is very unpleasant that his classmates will just laugh and bully him if he would go to school. With all the means of encourage of my mother and father for Ivan to go back to school, Ivan insisted that he should stay at home as long as his acne gone. Below is a sample of disturbed body image nursing care plan of Ivan who had tremendous amount of acne and felt embarrassed about it.


ASSESSMENT

Subjective:
"How could I go to school in this situation, my classmates would probably laugh at me," as verbalized by the patient.
Objectives:
I observed from the patient that he had acne in facial structure, his face was sad and no eye contact when I was taking to him/her. He/she only used non-verbal response to communication and he
 skipped meals. Vital signs was taken and noted as follows: Body temperature is 36.6 degrees Celcius, blood pressure is 110/80 mmHg, respiratory rate is 16 cycles per minut, and pulse rate of 72 beats per minute.

DIAGNOSIS

Disturbed body image related to change in facial structure secondary to negative eye contact and using only non-verbal communication.

PLANNING

After 8 hours of nursing intervention, the patient will able to verbalize acceptance to body changes and incorporate body image change into self-concept.

INTERVENTION

- Establishment rapport with Ivan because this will increase the nurse-patient relationship. Note his withdrawn behavior and use of his denial. Discuss pathophysiology present and situation affecting the patient. For example, when alteration of the body image is related to neurological deficit such as cerebrovascular accident, refer to unilateral neglect.

- Assess Ivan's, the patient, mental and physical influence of illness or conflict on his emotional state such as disease of the endocrine system or use of thyroid therapy. Recognize Ivan's behavior indicative of over concern with his body and its processes. Have him describe himself, noting what is positive and what is negative. Be aware of how Ivan believes others see himself.

- Discuss meaning of loss or change in the patient. A small loss may have a bid impact such as the use of a urinary catheter or enema for incontinence. A change in function such as immobility in elderly may be more difficult for some to deal with than a change in appearance. Permanent facial scaring of child may be difficult for parents to accept. Note signs of grieving or indicators of severe or prolonged depression to evaluate need for counseling and medication.

- Listen to Ivan's comments and responses to his situation. Different situations are upsetting to different people, depending on his coping skills and past experiences. Note his use of addictive substances or alcohol because it may reflect dysfunctional coping.

- Alert staff to monitor own facial expressions and other non-verbal behaviors because they need to convey acceptance and not revulsion when Ivan's appearance is affected. Encourage Ivan's family members to treat him normally and not as invalid. Help Ivan to select and use clothing and make up to minimize face changes and enhance his appearance. Provide him information at his level of acceptance and in small pieces to allow easier assimilation. Clarify his misconception. Reinforce explanations given by other health team members. Offer positive reinforcement for efforts made such as wearing make up.

EVALUATION

After 8 hours of nursing intervention, the patient had verbalized acceptance to body changes and intervention body image change into self-concept.

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