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 Celsius, blood
pressure is 110/80 mmHg, respiratory rate is 16 cycles per minute, 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withdrawn behavior and use of his denial.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 him.
- 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 makeup.
EVALUATION
After 8 hours of nursing
intervention, the patient had verbalized acceptance to body changes and
intervention body image change into self-concept.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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