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Disturbed Body Image — Anorexia & Bulimia Nervosa Nursing Care Plans

Nurseslabs — Sat, 05 May 2012 10:25:55 +0000

NURSING DIAGNOSIS: Body image, disturbed/Self-Esteem, chronic low

May be related to

Morbid fear of obesity; perceived loss of control in some aspect of life
Personal vulnerability; unmet dependency needs
Dysfunctional family system
Continual negative evaluation of self

Possibly evidenced by

Distorted body image (views self as fat even in the presence of normal body weight or severe emaciation)
Expresses little concern, uses denial as a defense mechanism, and feels powerless to prevent/make changes
Expressions of shame/guilt
Overly conforming, dependent on others’ opinions

Desired Outcomes

Establish a more realistic body image.
Acknowledge self as an individual.
Accept responsibility for own actions.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Have patient draw picture of self.	Provides opportunity to discuss patient’s perception of self/body image and realities of individual situation.
Involve in personal development program, preferably in a group setting. Provide information about proper application of makeup and grooming.	Learning about methods to enhance personal appearance may be helpful to long-range sense of self-esteem/image. Feedback from others can promote feelings of self-worth.
Suggest disposing of “thin” clothes as weight gain occurs. Recommend consultation with an image consultant.	Provides incentive to at least maintain and not lose weight. Removes visual reminder of thinner self. Positive image enhances sense of self-esteem.
Assist patient to confront changes associated with puberty/sexual fears. Provide sex education as necessary.	Major physical/psychological changes in adolescence can contribute to development of eating disorders. Feelings of powerlessness and loss of control of feelings (in particular sexual sensations) lead to an unconscious desire to desexualize self. Patient often believes that these fears can be overcome by taking control of bodily appearance/development/function.
Establish a therapeutic nurse/patient relationship.	Within a helping relationship, patient can begin to trust and try out new thinking and behaviors.
Promote self-concept without moral judgment	Patient sees self as weak-willed, even though part of person may feel sense of power and control (e.g., dieting/weight loss).
States rules clearly regarding weighing schedule, remaining in sight during medication and eating times, and consequences of not following the rules. Without undue comment, be consistent in carrying out rules.	Consistency is important in establishing trust. As part of the behavior modification program, patient knows risks involved in not following established rules (e.g., decrease in privileges). Failure to follow rules is viewed as patient’s choice and accepted by staff in matter-of-fact manner so as not to provide reinforcement for the undesirable behavior.
Respond (confront) with reality when patient makes unrealistic statements such as “I’m gaining weight, so there’s nothing really wrong with me.”	Patient may be denying the psychological aspects of own situation and is often expressing a sense of inadequacy and depression.
Be aware of own reaction to patient’s behavior. Avoid arguing.	Feelings of disgust, hostility, and infuriation are not uncommon when caring for these patients. Prognosis often remains poor even with a gain in weight because other problems may remain. Many patients continue to see themselves as fat, and there is also a high incidence of affective disorders, social phobias, obsessive-compulsive symptoms, drug abuse, and psychosexual dysfunction. Nurse needs to deal with own response/feeling so they do not interfere with care of patient.
Assist patient to assume control in areas other than dieting/weight loss, e.g., management of own daily activities, work/leisure choices.	Feelings of personal ineffectiveness, low self-esteem, and perfectionism are often part of the problem. Patient feels helpless to change and requires assistance to problem-solve methods of control in life situations.
Help patient formulate goals for self (not related to eating) and create a manageable plan to reach those goals, one at a time, progressing from simple to more complex.	Patient needs to recognize ability to control other areas in life and may need to learn problem-solving skills to achieve this control. Setting realistic goals fosters success.
Note patient’s withdrawal from and/or discomfort in social settings.	May indicate feelings of isolation and fear of rejection/judgment by others. Avoidance of social situations and contact with others can compound feelings of worthlessness.
Encourage patient to take charge of own life in a more healthful way by making own decisions and accepting self as she or he is at this moment (including inadequacies and strengths).	Patient often does not know what she or he may want for self. Parents (mother) often make decisions for patient. Patient may also believe she or he has to be the best in everything and holds self responsible for being perfect.
Let patient know that is acceptable to be different from family, particularly mother.	Developing a sense of identity separate from family and maintaining sense of control in other ways besides dieting and weight loss is a desirable goal of therapy/program.
Use cognitive-behavioral or interpersonal psychotherapy approach, rather than interpretive therapy.	Although both therapies have similar results, cognitive-behavioral seems to work more quickly. Interaction between persons is more helpful for patient to discover feelings/impulses/needs from within own self. Patient has not learned this internal control as a child and may not be able to interpret or attach meaning to behavior.
Encourage patient to express anger and acknowledge when it is verbalized.	Important to know that anger is part of self and as such is acceptable. Expressing anger may need to be taught to patient because anger is generally considered unacceptable in the family, and therefore patient does not express it.
Assist patient to learn strategies other than eating for dealing with feelings. Have patient keep a diary of feelings, particularly when thinking about food.	Feelings are the underlying issue, and patient often uses food instead of dealing with feelings appropriately. Patient needs to learn to recognize feelings and how to express them clearly.
Assess feelings of helplessness/hopelessness.	Lack of control is a common/underlying problem for this patient and may be accompanied by more serious emotional disorders. Note: Fifty-four percent of patients with anorexia have a history of major affective disorder, and 33% have a history of minor affective disorder.
Be alert to suicidal ideation/behavior.	Intense anxiety/panic about weight gain, depression, hopeless feelings may lead to suicidal attempts, particularly if patient is impulsive.
Involve in group therapy.	Provides an opportunity to talk about feelings and try out new behaviors.
Refer to occupational/recreational therapy.	Can develop interest and skills to fill time that has been occupied by obsession with eating. Involvement in recreational activities encourages social interactions with others and promotes fun and relaxation.

Disturbed Body Image — Anorexia & Bulimia Nervosa Nursing Care Plans Original source at: Nurseslabs

Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plans

Nurseslabs — Tue, 01 May 2012 15:37:24 +0000

NURSING DIAGNOSIS: Self-Esteem/Body Image disturbed

May be related to

Biophysical changes/altered physical appearance
Uncertainty of prognosis, changes in role function
Personal vulnerability
Self-destructive behavior (alcohol-induced disease)

Possibly evidenced by

Verbalization of change/restriction in lifestyle
Fear of rejection or reaction by others
Negative feelings about body/abilities
Feelings of helplessness, hopelessness, or powerlessness

Desired Outcomes

Verbalize understanding of changes and acceptance of self in the present situation.
Identify feelings and methods for coping with negative perception of self.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Discuss situation/encourage verbalization of fears and concerns. Explain relationship between nature of disease and symptoms.	Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related to alcohol (70%) or other drug use.
Support and encourage patient; provide care with a positive, friendly attitude.	Caregivers sometimes allow judgmental feelings to affect the care of patient and need to make every effort to help patient feel valued as a person.
Encourage family/SO to verbalize feelings, visit freely/participate in care.	Family members may feel guilty about patient’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to patient. Participation in care helps them feel useful and promotes trust between staff, patient, and SO.
Assist patient/SO to cope with change in appearance; suggest clothing that does not emphasize altered appearance, e.g., use of red, blue, or black clothing.	Patient may present unattractive appearance as a result of jaundice, ascites, ecchymotic areas. Providing support can enhance self-esteem and promote patient sense of control.
Refer to support services, e.g., counselors, psychiatric resources, social service, clergy, and/or alcohol treatment program.	Increased vulnerability/concerns associated with this illness may require services of additional professional resources.

Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plans Original source at: Nurseslabs

Disturbed Body Image — Burns Nursing Care Plans

Nurseslabs — Sat, 31 Mar 2012 12:30:29 +0000

Nursing Diagnosis: Body Image disturbed/Role Performance, ineffective

May be related to

Situational crisis: traumatic event, dependent patient role; disfigurement, pain

Possibly evidenced by

Negative feelings about body/self, fear of rejection/reaction by others
Focus on past appearance, abilities; preoccupation with change/loss
Change in physical capacity to resume role; change in social involvement

Desired Outcomes

Incorporate changes into self-concept without negating self-esteem.
Verbalize acceptance of self in situation.
Talk with family/SO about situation, changes that have occurred.
Develop realistic goals/plans for the future.

Nursing Interventions	Rationale
Assess meaning of loss/change to patient/SO, including future expectations and impact of cultural/religious beliefs.	Traumatic episode results in sudden, unanticipated changes, creating feelings of grief over actual/perceived losses. This necessitates support to work through to optimal resolution.
Acknowledge and accept expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial.	Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push patient before ready to deal with situation. Denial may be prolonged and be an adaptive mechanism because patient is not ready to cope with personal problems.
Set limits on maladaptive behavior (e.g., manipulative/ aggressive). Maintain nonjudgmental attitude while giving care, and help patient identify positive behaviors that will aid in recovery.	Patient and SO tend to deal with this crisis in the same way in which they have dealt with problems in the past. Staff may find it difficult and frustrating to handle behavior that is disrupting/not helpful to recuperation but should realize that the behavior is usually directed toward the situation and not the caregiver.
Be realistic and positive during treatments, in health teaching, and in setting goals within limitations.	Enhances trust and rapport between patient and nurse.
Encourage patient/SO to view wounds and assist with care as appropriate.	Promotes acceptance of reality of injury and of change in body and image of self as different.
Provide hope within parameters of individual situation; do not give false reassurance.	Promotes positive attitude and provides opportunity to set goals and plan for future based on reality.
Assist patient to identify extent of actual change in appearance/body function.	Helps begin process of looking to the future and how life will be different.
Give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals.	Words of encouragement can support development of positive coping behaviors.
Show slides or pictures of burn care/other patient outcomes, being selective in what is shown as appropriate to the individual situation. Encourage discussion of feelings about what patient has seen.	Allows patient/SO to be realistic in expectations. Also assists in demonstration of importance of/necessity for certain devices and procedures.
Encourage family interaction with each other and with rehabilitation team.	Maintains/opens lines of communication and provides ongoing support for patient and family.
Provide support group for SO. Give information about how SO can be helpful to patient.	Promotes ventilation of feelings and allows for more helpful responses to patient.
Role-play social situations of concern to patient.	Prepares patient/SO for reactions of others and anticipates ways to deal with them.
Refer to physical/occupational therapy, vocational counselor, and psychiatric counseling, e.g., clinical specialist psychiatric nurse, social services, psychologist, as needed.	Helpful in identifying ways/devices to regain and maintain independence. Patient may need further assistance to resolve persistent emotional problems (e.g., posttrauma response).

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Disturbed Body Image — Burns Nursing Care Plans Original source at: Nurseslabs

Disturbed Body Image — Anorexia Nervosa Nursing Care Plan

Nurseslabs — Thu, 09 Feb 2012 12:03:50 +0000

Common Related Factors

Difficulty coping with development and maturation
Inability to achieve unreasonable personal goals
Alexithymia (channeling uncomfortable feelings into behaviors such as self-starvation)

Defining Characteristics

Distorted views of one’s body weight and shape for age
Negative feelings about self and body
Self-loathing (impulsive or obsessive)
Intense fear of gaining or not being able to lose weight

Common Expected Outcomes

Patient identifies positive thoughts and feelings regarding body and self.
Patient identifies a direct means of coping with problems.

NOC Outcome

Body Image

NIC Interventions

Self-Awareness Enhancement
Body Image Enhancement

Ongoing Assessment

Explore the patient’s understanding of his or her physical body, especially as it relates to maturation. Assess to what degree the patient’s negative body image and negative self-concept are related to overwhelming anxiety. Patients with anorexia have a distorted body image.
Assess to what degree culture, religion, race, and gender influence the patient’s negative views of self. Cultural and social norms about body size and shape may influence the patient’s thinking and feelings about his or her body image.
Determine the family or patient’s perceptions regarding psychological and physical changes brought about by anorexia. These data need to be compared to the patient’s thinking prior to the onset of anorexia.
Obtain the patient’s assessment of personal strengths and weaknesses. Patients learn they have the ability to handle day-to-day stress.
Assess the patient’s ability to identify “here and now” emotional states and precipitating events that trigger negative behaviors. The patient may not be aware of the relationship between feelings and eating behaviors.

Interventions

Encourage reexamination of positive and negative self-perceptions. The patient needs to develop a realistic understanding of his or her body image.
Encourage the patient to identify the differences between “real people” and celebrities. Patients often use media reports of celebrities as a guide for their eating behaviors.
Encourage recognition, expression, and acceptance of unpleasant feelings. Patients with anorexia have a need for control in multiple areas of their lives. Mastery over food may have become a method for reducing tensions.
Help the patient develop a realistic, acceptable perception of body image and food. Patients must understand the complex health problems associated with anorexia.
Refer the patient to individual counseling and a support group for eating disorders. Multiple approaches are needed to achieve long-term changes in behavior. Groups that come together for mutual support and guidance can provide long-term assistance.

Disturbed Body Image — Anorexia Nervosa Nursing Care Plan Original source at: Nurseslabs

2 Anorexia Nervosa Nursing Care Plans

Nurseslabs — Wed, 08 Feb 2012 12:20:29 +0000

Anorexia nervosa is an eating disorder that causes people to obsess about their weight and the food they eat. People with anorexia nervosa attempt to maintain a weight that’s far below normal for their age and height. To prevent weight gain or to continue losing weight, people with anorexia nervosa may starve themselves or exercise excessively.

Anorexia nervosa is a disease that affects all organ systems, principally the cardiovascular and endocrine systems. However, complications can also involve other systems, including the GI, renal, reproductive, neurologic, orofacial, dermatologic, and hematologic symptoms.

A typical case of anorexia nervosa involves a young person (teenager or young adult) who is mildly overweight or of normal weight and who begins a diet and exercise plan to lose weight. As she loses weight and receives initial positive reinforcement for this behavior (eg, compliments by peers on her appearance), the reward is high and causes an inability to stop this behavior once an ideal weight is achieved.

Nursing Diagnoses:

1. Imbalanced Nutrition: Less Than Body Requirements

Common Related Factors	Defining Characteristics
Severe fear of obesity

Severely distorted self-concept, self-esteem, and/or body image

Absence of physical conditions that would explain weight loss or prevent weight gainBody weight 15% to 29% or more below ideal weight for height

Self-restricted calorie intake despite hunger

Obsession with food, calories, weight, and control issuesCommon Expected Outcomes

Patient stops losing weight.

Patient begins to gain weight.

Patient recognizes eating disorder.NOC Outcomes

Nutritional Status: Food and Fluid Intake; Weight Control

NIC Interventions

Eating Disorders Management; Weight Gain Assistance; Nutritional Therapy

Ongoing Assessment

Actions/Interventions	Rationale
Record the patient’s weight and height on intake. Weigh regularly, maintaining standard conditions (i.e., same scale, same time of day, patient wearing similar clothes).	This ensures accurate record of weight changes.
Weigh the patient in a matter-of-fact manner without discussion.	This reduces risk of acting-out behaviors. Weight gain is only one aspect of the total therapeutic program; other critical factors include nutritional adequacy, behaviors related to eating, appropriate use of exercise, and development of a healthy body image.
Obtain weight history, including initial motivation for weight loss or food restrictions.	Clinical anorexia can follow ordinary weight loss dieting.
Conduct a nutritional assessment:	It is critical that the health care provider openly discuss and have an understanding of the complex food and weight-related behaviors of the patient so that appropriate supports can be integrated into the treatment plan.
Assess the patient’s beliefs and fears about food and weight gain	Excessive focus on food and weight can be a maladaptive method of coping with stress.
Knowledge about nutrition and sources of information	This information provides the basis for an individualized teaching plan about maintaining adequate nutritional intake.
Behaviors used to reduce calorie intake (dieting), to increase energy output (exercising), and generally to lose weight (vomiting, purging, and laxative abuse)	This provides data on patient thinking and thought distortions.
Assess cardiovascular, metabolic, renal, gastric, hematological, and endocrine system functioning.	Assessment provides data on the severity of malnutrition.
Monitor intake (i.e., daily food plans that track eating trends along with emotional states and triggering events). Record intake and output for the hospitalized patient.	These data help determine the patient’s actual caloric intake and eating behaviors.

Therapeutic Interventions

Actions/Interventions	Rationale
Prescribe appropriate nutrition and total calories per day to relieve acute starvation.	A gradual refeeding prescription ensures steady weight gain and reduces risk of medical complications.
Supervise all activities immediately before and after meals; maintain supervision consistency.	This decreases opportunity to engage in compensatory activities to reduce calorie intake.
Provide food and meals without comment.	This helps separate emotional behaviors from eating behaviors.
Set limits on all exercise but allow daily activity.	Preventing all forms of exercise may induce severe anxiety.
Assure the patient that treatment is not designed to produce obesity.	Patients have an overwhelming fear of weight gain and obesity.
Acknowledge any anger, sadness, or feeling of loss that the patient may have toward treatment.	This helps provide external emotional controls that have not yet been internalized by the patient.
Provide supplemental feedings and nutrition as indicated.	Nutritional supplements may be necessary if the patient is malnourished. Tube or parenteral feedings may be necessary if the patient is unable to allow herself or himself oral feedings.

2. Disturbed Body Image

Common Related Factors	Defining Characteristics
Difficulty coping with development and maturation

Inability to achieve unreasonable personal goals

Alexithymia (channeling uncomfortable feelings into behaviors such as self-starvation)Distorted views of one’s body weight and shape for age

Negative feelings about self and body

Self-loathing (impulsive or obsessive)

Intense fear of gaining or not being able to lose weightCommon Expected Outcomes

Patient identifies positive thoughts and feelings regarding body and self.

Patient identifies a direct means of coping with problems.NOC Outcome

Body Image

NIC Interventions

Self-Awareness Enhancement; Body Image Enhancement

Ongoing Assessment

Actions/Interventions	Rationale
Explore the patient’s understanding of his or her physical body, especially as it relates to maturation. Assess to what degree the patient’s negative body image and negative self-concept are related to overwhelming anxiety.	Patients with anorexia have a distorted body image.
Assess to what degree culture, religion, race, and gender influence the patient’s negative views of self.	Cultural and social norms about body size and shape may influence the patient’s thinking and feelings about his or her body image.
Determine the family or patient’s perceptions regarding psychological and physical changes brought about by anorexia.	These data need to be compared to the patient’s thinking prior to the onset of anorexia.
Obtain the patient’s assessment of personal strengths and weaknesses.	Patients learn they have the ability to handle day-to-day stress.
Assess the patient’s ability to identify “here and now” emotional states and precipitating events that trigger negative behaviors.	The patient may not be aware of the relationship between feelings and eating behaviors.

Therapeutic Interventions

Actions/Interventions	Rationale
Encourage reexamination of positive and negative self-perceptions.	The patient needs to develop a realistic understanding of his or her body image.
Encourage the patient to identify the differences between “real people” and celebrities.	Patients often use media reports of celebrities as a guide for their eating behaviors.
Encourage recognition, expression, and acceptance of unpleasant feelings.	Patients with anorexia have a need for control in multiple areas of their lives. Mastery over food may have become a method for reducing tensions.
Help the patient develop a realistic, acceptable perception of body image and food.	Patients must understand the complex health problems associated with anorexia.
Refer the patient to individual counseling and a support group for eating disorders.	Multiple approaches are needed to achieve long-term changes in behavior. Groups that come together for mutual support and guidance can provide long-term assistance.

Sources: (1) (2) (3)

2 Anorexia Nervosa Nursing Care Plans Original source at: Nurseslabs

4 Dermatitis Nursing Care Plans

Nurseslabs — Tue, 24 Jan 2012 17:32:48 +0000

Dermatitis is a general term that describes an inflammation of the skin. There are different types of dermatitis, including seborrheic dermatitis and atopic dermatitis (eczema). Although the disorder can have many causes and occur in many forms, it usually involves swollen, reddened and itchy skin.

Dermatitis is a common condition that usually isn’t life-threatening or contagious. But, it can make you feel uncomfortable and self-conscious. A combination of self-care steps and medications can help you treat dermatitis.

1. Impaired Skin Integrity - Dermatitis Nursing Care Plans

Common Related Factor	Defining Characteristics
Contact with irritants or allergens	Inflammation Dry, flaky skin Erosions, excoriations, fissures Pruritus, pain, blisters
Common Expected Outcome Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin.	NOC OutcomesKnowledge: Treatment Regimen; Tissue Integrity: Skin and Mucous MembranesNIC Interventions Skin Care: Topical Treatments; Skin Surveillance; Teaching: Procedure/Treatment

Ongoing Assessment

Actions/Interventions	Rationale
Assess skin, noting color, moisture, texture, temperature; note erythema, edema, tenderness.	Specific types of dermatitis may have characteristic patterns of skin changes and lesions.
Assess the skin systematically. Look for areas of irritant and allergic contact.	Flexural areas (elbows, neck, posterior knees) are common areas affected in atopic dermatitis.
Assess skin for lesions. Note presence of excoriations, erosions, fissures, or thickening.	Open skin lesions increase the patient’s risk for infection. Thickening occurs in response to chronic scratching (lichenification).
Identify aggravating factors. Inquire about recent changes in use of products such as soaps, laundry products, cosmetics, wool or synthetic fibers, cleaning solvents, and so forth.	Patients may develop dermatitis in response to changes in their environment. Extremes of temperature, emotional stress, and fatigue may contribute to dermatitis.
Identify signs of itching and scratching.	The patient who scratches the skin to relieve intense itching may cause open skin lesions with an increased risk for infection. Characteristic patterns associated with scratching include reddened papules that run together and become confluent, widespread erythema, and scaling or lichenification
Identify any scarring that may have occurred.	Long-term scarring may result in body image disturbances.

Therapeutic Actions

Actions/Interventions	Rationale
Encourage the patient to adopt skin care routines to decrease skin irritation:	One of the first steps in the management of dermatitis is promoting healthy skin and healing of skin lesions.
Bathe or shower using lukewarm water and mild soap or nonsoap cleansers.	Long bathing or showering in hot water causes drying of the skin and can aggravate itching through vasodilation.
After bathing, allow the skin to air dry or gently pat the skin dry. Avoid rubbing or brisk drying.	Rubbing the skin with a towel can irritate the skin and exacerbate the itch-scratch cycle.
Apply topical lubricants immediately after bathing.	Lubrication with fragrance-free creams or ointments serves as a barrier to prevent further drying of the skin through evaporation. Moisturizing is the cornerstone of treatment. Over-the-counter moisturizing lotions include Eucerin, Lubriderm, and Nivea. Lotions are lighter and less emollient than creams. If more moisturizing is required than a lotion can provide, a cream is recommended. These include Keri cream, Cetaphil cream, Eucerin cream, and Neutrogena Norwegian formula. Ointments are the most emollient. Vaseline Pyre Petroleum Jelly or Aquaphor Natural Healing Ointment may be beneficial.
Apply topical steroid creams or ointments.	These drugs reduce inflammation and promote healing of the skin. The patient may begin using over-the-counter hydrocortisone preparations. If these are not effective, the physician may include prescription corticosteroids for topical use. Usual application is twice daily, thinly and sparingly. Do not use with an occlusive dressing, because this potentiates the action and systemic absorption of the steroid. Usual duration of use of topical steroids is up to 14 days in adults.
Apply topical immunomodulators (TIMs): Tacrolimus (Protopic) Pimecrolimus (Elidel)	Tacrolimus (Protopic) has recently been approved for the treatment of atopic dermatitis. TIMs alter the reactivity of cell-surface immunological responsiveness to relieve redness and itching. In 2005, the Food and Drug Administration advised a potential cancer risk with long-term use of pimecrolimus and tacrolimus based on animal studies.
Prepare the patient for phototherapy or photochemotherapy.	This treatment modality uses ultraviolet A or B light waves to promote healing of the skin. The addition of psoralen, which increases the skin’s sensitivity to light, may benefit patients who do not respond to phototherapy alone.
Encourage the patient to avoid aggravating factors.	Some change in lifestyle may be indicated to reduce triggers.

4 Dermatitis Nursing Care Plans Original source at: Nurseslabs

14 Mastectomy Nursing Care Plans

Nurseslabs — Tue, 24 Jan 2012 17:32:47 +0000

Mastectomy is the surgical removal of the breast which is usually a surgical management for patients with breast cancer. This is done to prevent the metastasize of the cancer cells. Breast cancer is the most common malignancy experienced by women. Breast cancer is the uncontrolled growth of breast cells.

The nursing goal for a patient who underwent mastectomy can be: pain management, counseling due to disturbed body image, and preventing infection due to surgical incision.

This post contains 14 nursing care plans for patients who underwent mastectomy.

1. Risk for Injury - Mastectomy Nursing Care Plans

Areas involving the neck are considered to be the most vascularized parts of a person’s body. We all know that the most common complication of a surgery is excessive bleeding or hemorrhage, this was brought about by excessive blood loss intra or post operatively.

NDx: Risk for Injury related to change in center of gravity secondary to extensive removal of chest tissue

Assessment

Objectives

Nursing Interventions

Rationale

Desired Outcomes

S: ØO:The patient may manifest:

edema
muscle weakness
altered mobility
sensory and perceptual disturbances due to anesthesia
Apprehension, restlessness
thirst; cold , moist, pale skin
increase in pulse rate, respiration rate
drop in temperature
decrease in urinary output

Short term:After 3-4 hours of nurse-patient interaction, the patient will verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations.

Long Term:

After 3-4 days of nurse-patient interaction, the patient will demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Establish pt. Rapport
Monitor vital signs frequently.
Access mood, coping abilities and personality styles
Identify interventions and safety devices
Encourage participation in self-help programs, such as assertiveness training, positive self image
Provide bibliotherapyand written resources
Assist client during periods of ambulation
Walk client’s unaffected side
Instruct the client to keep the shoulders level and the muscle relaxed when walking

To gain trust and cooperation of the pt.
VS could indicate possible bleeding
That may result in carelessness and increased risk-taking without consequences.
To promte safe physical environment and individual safety
To enhance self-esteem and sense of self-worth
For later review and self-pced learning
The nurse supports the client when or if client loose balance
The lient is more likely to drift toward the side of the body that is heavier
Clients tend to accommodate for the change in the center of gravity by leaning to the side

Short term:The patient shall verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situations.

Long Term:

The patient shall demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

14 Mastectomy Nursing Care Plans Original source at: Nurseslabs

Disturbed Body Image — Nursing Diagnosis

Nurseslabs — Mon, 03 Oct 2011 18:02:35 +0000

Nursing Diagnosis:

Disturbed Body Image

Definition of Disturbed Body Image

Confusion in mental picture of one’s physical self
Body image is the attitude a person has about the actual or perceived structure or function of all or part of his or her body. This attitude is dynamic and is altered through interaction with other persons and situations and influenced by age and developmental level. As an important part of one’s self-concept, body image disturbance can have profound impact on how individuals view their overall selves.
Throughout the life span, body image changes as a matter of development, growth, maturation, changes related to childbearing and pregnancy, changes that occur as a result of aging, and changes that occur or are imposed as a result of injury or illness.
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 than the actual alteration in the structure or function. Therefore the loss of a limb may result in a greater body image disturbance for an athlete than for a computer programmer. The loss of a breast to a fashion model or a hysterectomy in a nulliparous woman may cause serious body image disturbances even though the overall health of the individual has been improved. Removal of skin lesions, altered elimination resulting from bowel or bladder surgery, and head and neck resections are other examples that can lead to body image disturbance.
• The nurse’s assessment of the perceived alteration and importance placed by the patient on the altered structure or function will be very important in planning care to address body image disturbance.

Defining Characteristics of Disturbed Body Image

Verbalization about altered structure or function of a body part
Verbal preoccupation with changed body part or function
Naming changed body part or function
Refusal to discuss or acknowledge change
Focusing behavior on changed body part and/or function
Actual change in structure or function
Refusal to look at, touch, or care for altered body part
Change in social behavior (e.g., withdrawal, isolation, flamboyance)
Compensatory use of concealing clothing or other devices

Related Factors of Disturbed Body Image

Situational changes (e.g., pregnancy, temporary presence of a visible drain or tube, dressing, attached equipment)
Permanent alterations in structure and/or function (e.g., mutilating surgery, removal of body part [internal or external])
Malodorous lesions
Change in voice quality
Expected Outcomes Patient
Demonstrates enhanced body image and self-esteem as evidenced by ability to look at, touch, talk about, and care for actual or perceived altered body part or function.

Ongoing Assessment Disturbed Body Image

Assess perception of change in structure or function of body part (also proposed change). The extent of the response is more related to the value or importance the patient places on the part or function than the actual value or importance. Even when an alteration improves the overall health of the individual (e.g., an ileostomy for an individual with precancerous colon polyps), the alteration results in a body image disturbance.
Assess perceived impact of change on activities of daily living (ADLs), social behavior, personal relationships, and occupational activities.
Assess impact of body image disturbance in relation to patient’s developmental stage. Adolescents and young adults may be particularly affected by changes in the structure or function of their bodies at a time when developmental changes are normally rapid, and at a time when developing social and intimate relationships is particularly important.
Note patient’s behavior regarding actual or perceived changed body part or function. 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.
Note frequency of self-critical remarks.

Therapeutic Interventions Disturbed Body Image

Acknowledge normalcy of emotional response to actual or perceived change in body structure or function. Stages of grief over loss of a body part or function are normal, and typically involves a period of denial, the length of which varies from individual to individual.
Help patient identify actual changes. Patients may perceive changes that are not present or real, or they may be placing unrealistic value on a body structure or function.
Encourage verbalization of positive or negative feelings about actual or perceived change. It is worthwhile to encourage the patient to separate feelings about changes in body structure and/or function from feelings about self-worth.
Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities. Opportunities for positive feedback and success in social situations may hasten adaptation.
Demonstrate positive caring in routine activities. Professional caregivers represent a microcosm of society, and their actions and behaviors are scrutinized as the patient plans to return to home, to work, and to other activities.

Disturbed Body Image Education/Continuity of Care

Teach patient about the normalcy of body image disturbance and the grief process.
Teach patient adaptive behavior (e.g., use of adaptive equipment, wigs, cosmetics, clothing that conceals altered body part or enhances remaining part or function, use of deodorants). This compensates for actual changed body structure and function.
Help patient identify ways of coping that have been useful in the past. Asking patients to remember other body image issues (e.g., getting glasses, wearing orthodontics, being pregnant, having a leg cast) and how they were managed may help patient adjust to the current issue.
Refer patient and caregivers to support groups composed of individuals with similar alterations.

Disturbed Body Image — Nursing Diagnosis Original source at: Nurseslabs