Nursing Dx

Taxonomy II: Self-Perception—Class 3 Body Image (00118)
[Diagnostic Division: Ego Integrity]
Submitted 1973; Revised 1998 (by small group work 1996)
Definition: Confusion [and/or dissatisfaction] in mental picture of one’s physical self

Related Factors
Biophysical illness; trauma or injury; surgery; [mutilation, pregnancy]; illness treatment [change caused by biochemical agents (drugs), dependence on machine]
Psychosocial
Cultural or spiritual
Cognitive/perceptual; developmental changes
[Significance of body part or functioning with regard to age, sex, developmental level, or basic human needs]
[Maturational changes]


Defining Characteristics
SUBJECTIVE
Verbalization of feelings/perceptions that reflect an altered view of one’s body in appearance, structure, or function; change in life style
Fear of rejection or of reaction by others
Focus on past strength, function, or appearance
Negative feelings about body (e.g., feelings of helplessness, hopelessness, or powerlessness); [depersonalization/grandiosity]
Preoccupation with change or loss
Refusal to verify actual change
Emphasis on remaining strengths, heightened achievement
Personalization of part or loss by name
Depersonalization of part or loss by impersonal pronouns
OBJECTIVE
Missing body part
Actual change in structure and/or function
Nonverbal response to actual or perceived change in structure and/or function; behaviors of avoidance, monitoring, or acknowledgment of one’s body
Not looking at/not touching body part
Trauma to nonfunctioning part
Change in ability to estimate spatial relationship of body to environment
Extension of body boundary to incorporate environmental objects
Hiding or overexposing body part (intentional or unintentional)
Change in social involvement
[Aggression; low frustration tolerance level]

Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize acceptance of self in situation (e.g., chronic progressive disease, amputee, decreased independence, weight as is, effects of therapeutic regimen).
• Verbalize relief of anxiety and adaptation to actual/altered body image.
• Verbalize understanding of body changes.
• Recognize and incorporate body image change into selfconcept in accurate manner without negating self-esteem.
• Seek information and actively pursue growth.
• Acknowledge self as an individual who has responsibility for self.
• Use adaptive devices/prosthesis appropriately.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Discuss pathophysiology present and/or situation affecting the individual and refer to additional NDs as appropriate. For example, when alteration in body image is related to neurological deficit (e.g., cerebrovascular accident—CVA), refer to ND unilateral Neglect; in the presence of severe, ongoing pain, refer to chronic Pain; or in loss of sexual desire/ability, refer to Sexual Dysfunction.
• Determine whether condition is permanent/no hope for resolution. (May be associated with other NDs, such as Self-Esteem [specify] or risk for impaired parent/infant/child Attachment, when child is affected.)
• Assess mental/physical influence of illness/condition on the client’s emotional state (e.g., diseases of the endocrine system, use of steroid therapy, and so on).
• Evaluate level of client’s knowledge of and anxiety related to situation. Observe emotional changes.
• Recognize behavior indicative of overconcern with body and its processes.
• Have client describe self, noting what is positive and what is negative. Be aware of how client believes others see self.
• Discuss meaning of loss/change to client. A small (seemingly trivial) loss may have a big impact (such as the use of a urinary catheter or enema for continence). A change in function (such as immobility) may be more difficult for some to deal with than a change in appearance. Permanent facial scarring of child may be difficult for parents to accept.
• Use developmentally appropriate communication techniques for determining exact expression of body image in child (e.g., puppet play or constructive dialogue for toddler). Developmental capacity must guide interaction to gain accurate information.
• Note signs of grieving/indicators of severe or prolonged depression to evaluate need for counseling and/or medications.
• Determine ethnic background and cultural/religious perceptions and considerations.
• Identify social aspects of illness/disease (e.g., sexually transmitted diseases, sterility, chronic conditions).
• Observe interaction of client with SO(s). Distortions in body image may be unconsciously reinforced by family members, and/or secondary gain issues may interfere with progress.
NURSING PRIORITY NO. 2. To determine coping abilities and skills:
• Assess client’s current level of adaptation and progress.
• Listen to client’s comments and responses to the situation. Different situations are upsetting to different people, depending on individual coping skills and past experiences.
• Note withdrawn behavior and the use of denial. May be normal response to situation or may be indicative of mental illness (e.g., schizophrenia). (Refer to ND ineffective Denial.)
• Note use of addictive substances/alcohol; may reflect dysfunctional coping.
• Identify previously used coping strategies and effectiveness.
• Determine individual/family/community resources.
NURSING PRIORITY NO. 3. To assist client and SO(s) to deal with/accept issues of self-concept related to body image:
• Establish therapeutic nurse-client relationship conveying an attitude of caring and developing a sense of trust.
• Visit client frequently and acknowledge the individual as someone who is worthwhile. Provides opportunities for listening to concerns and questions.
• Assist in correcting underlying problems to promote optimal healing/adaptation.
• Provide assistance with self-care needs/measures as necessary while promoting individual abilities/independence.
• Work with client’s self-concept without moral judgments regarding client’s efforts or progress (e.g., “You should be progressing faster; you’re weak/lazy/not trying hard enough”).
• Discuss concerns about fear of mutilation, prognosis, rejection when client facing surgery or potentially poor outcome of procedure/illness, to address realities and provide emotional support.
• Acknowledge and accept feelings of dependency, grief, and hostility.
• Encourage verbalization of and role-play anticipated conflicts to enhance handling of potential situations.
• Encourage client and SO(s) to communicate feelings to each other.
• Assume all individuals are sensitive to changes in appearance but avoid stereotyping.
• Alert staff to monitor own facial expressions and other nonverbal behaviors because they need to convey acceptance and not revulsion when the client’s appearance is affected.
• Encourage family members to treat client normally and not as an invalid.
• Encourage client to look at/touch affected body part to begin to incorporate changes into body image.
• Allow client to use denial without participating (e.g., client may at first refuse to look at a colostomy; the nurse says “I am going to change your colostomy now” and proceeds with the task). Provides individual time to adapt to situation.
• Set limits on maladaptive behavior, and assist client to identify positive behaviors to aid in recovery.
• Provide accurate information as desired/requested. Reinforce previously given information.
• Discuss the availability of prosthetics, reconstructive surgery, and physical/occupational therapy or other referrals as dictated by individual situation.
• Help client to select and use clothing/makeup to minimize body changes and enhance appearance.
• Discuss reasons for infectious isolation and procedures when used and make time to sit down and talk/listen to client while in the room to decrease sense of isolation/loneliness.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Begin counseling/other therapies (e.g., biofeedback/relaxation) as soon as possible to provide early/ongoing sources of support.
• Provide information at client’s level of acceptance and in small pieces to allow easier assimilation. Clarify misconceptions. Reinforce explanations given by other health team members.
• Include client in decision-making process and problemsolving activities.
• Assist client to incorporate therapeutic regimen into activities of daily living (ADLs) (e.g., including specific exercises, housework activities). Promotes continuation of program.
• Identify/plan for alterations to home and work environment/ activities to accommodate individual needs and support independence.
• Assist client in learning strategies for dealing with feelings/ venting emotions.
• Offer positive reinforcement for efforts made (e.g., wearing makeup, using prosthetic device).
• Refer to appropriate support groups.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Observations, presence of maladaptive behaviors, emotional changes, stage of grieving, level of independence.
• Physical wounds, dressings; use of life-support–type machine (e.g., ventilator, dialysis machine).
• Meaning of loss/change to client.
• Support systems available (e.g., SOs, friends, groups).
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications of plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions.
• Specific referrals made (e.g., rehabilitation center, community resources).