For this nursing care plan and management guide learn how to provide care for patients with body image disturbance and low self-esteem. Get to know the nursing assessment, interventions, goals, and nursing diagnosis for impairment in tissue integrity.
Table of Contents
- What is body image?
- Signs and symptoms
- Goals and eoutcomes
- Nursing assessment
- Nursing interventions
What is body image?
Body image refers to an individual’s perception and feelings about their own body, influenced by internal factors such as age, gender, and physical condition, as well as external factors like social and environmental influences. Body image disturbance can occur when societal values prioritize physical appearance and fitness, leading to a distorted perception of one’s own body. This disturbance often manifests through appearance management behaviors aimed at improving perceived body flaws. It is an integral part of self-concept and can significantly impact overall well-being. Body image disturbance is associated with various forms of psychopathology, including depression, anxiety, disordered eating, body dysmorphia, and post-traumatic stress symptoms (Stasik-O’Brien & Schmidt, 2018).
A person begins forming their perceptions of the body’s attractiveness, health, acceptability, and functionality in early childhood. This body image continues throughout the lifespan and receives feedback from peers, family members, and coaches. For example, a woman may experience body image disturbance during pregnancy. Physical changes associated with aging may result in body image disturbance for the older adult. Personality traits such as perfectionism and self-criticism can also affect the development of a negative internalized image of the body.
Appropriate care for distorted body image is a significant step to recovery. Cognitive Behavioral Therapy, an approach where irrational thoughts are recognized, analyzed, and restructured to more rational self-talk, is frequently used in planning care to address body image disturbance.
Self-concept problems are an etiology when they precede a condition such as depression and play a central role in the condition. Etiologies for body image disturbance include but are not limited to:
- Loss of functioning or appearance (e.g. acne, scars, breast removal, amputation)
- Eating disorder
- Gender conflict
- Personality disorders
Signs and symptoms
Distortions of the body image are critical characteristics of eating disorders and body dysmorphic disorders. Several quantifiable measures are available for body image assessment in children, adolescents, and adults. Body image involves two independent modalities: an attitudinal component and a perceptual component (Hosseini & Padhy, 2022). Typical manifestations of a client with disturbed body image include the following characteristics:
- Reports about altered structure or function of a body part
- Verbal preoccupation with changed body part or function
- Intentional hiding of body part
- Refusal to discuss or acknowledge the change
- Focusing behavior on changed body part/function
- An actual change in structure or function
- Refusal to look at, touch, or care for altered body part
- Change in social behavior such as withdrawal, isolation, flamboyance
Goals and eoutcomes
The nursing goals and outcomes for disturbed body image focus on the client’s self-concept, or some aspect of it, and on how the client can improve it.
- The client will verbalize an understanding of body changes.
- The client will recognize and incorporate body image change into self-concept in an accurate manner without negating self-esteem.
- The client will be able to look at, touch, talk about, and care for actual or perceived altered body parts or functions.
- The client will verbalize acceptance of self in a situation.
- The client will verbalize relief of anxiety and adaptation to actual/altered body image.
- The client will seek information and actively pursue growth.
- The client will use adaptive devices/prostheses appropriately.
The nurse‘s assessment of the perceived alteration and importance placed by the client on the altered structure or function will be very important in planning care to address body image disturbance.
1. Assess the meaning of loss or change to the client, including future expectations and the impact of cultural or religious beliefs.
The extent of response is more related to the value or importance the client places in the part or function than the actual value or importance. This necessitates support to work through to optimal resolution. In a study of young women with breast cancer, body image concerns have been attributed to the loss of the breast from surgery, resulting in scarring and physical changes resulting from adjuvant treatment, all of which can have an impact on the overall quality of life and in particular, body image perceptions in younger women (Paterson et al., 2016).
2. Assess the perceived impact of change in ADLs, social participation, personal relationships, and occupational activities.
Alteration in body image can have an effect on the client’s ability to carry out daily roles and responsibilities. Impaired social interaction may occur when the client’s low self-esteem and external locus of control cause them to fear criticism or lack of acceptance from others.
3. Assess the result of body image disturbance in relation to the client’s developmental stage.
Adolescents and young adults may be individually 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. When children become aware of their body appearance, they attempt to manipulate their parents to receive admiration and approval. As children grow and socialize, they begin to compare themselves with other children, especially concerning appearance. 40 to 50% of school-aged children demonstrated dissatisfaction with some part of body size or shape. Body image in people aged 14 to 27 is greatly affected by their peers, and critical events such as teasing and rejection may lead to body image misperception (Hosseini & Padhy, 2022).
4. Evaluate the client’s behavior regarding the 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. Although by definition, the appearance defects are minimal or nonexistent, the client’s appearance can provide clues to the presence of body image disturbance. The client may pick on the skin or have noticeable skin lesions or scarring, or they may wear heavy or unusual makeup. The client may wear a hat all the time or cover their face with their hands or their hair. To cover the altered body part, the client may wear big or bulky clothes. The client may also engage in excessive hair plucking and even excessive plastic surgeries to make the altered or perceived changed body part more desirable in their eyes (Hosseini & Padhy, 2022).
5. Evaluate the client’s verbal remarks about the actual or perceived change in body part or function.
Negative statements about the affected body part may indicate a limited ability to integrate the change into the client’s self-concept. Social media often displays images that are idealized, edited, and posed as those in magazines and on billboards. Because of this, users are likely to encounter a stream of unrealistically attractive images of other people, which may induce social comparisons that result in feelings of body dissatisfaction (Saiphoo & Vahedi, 2019).
6. Assess the client’s feelings about their body size and shape or the attitudinal component.
Body dissatisfaction is the most frequently measured attitudinal component of body image. Commonly psychometric tools are used to evaluate body dissatisfaction. Figure rating scales have been the most commonly used tool. This type of scale typically includes a set of figures that vary in body size from being very underweight to very overweight. Participants are asked to choose a figure that represents their perceived actual body size, and also the figure that they would like to be. The discrepancy between an individual’s perceptual and ideal body image represents body dissatisfaction (Hosseini & Padhy, 2022).
7. Assess the client’s perceptual component or the accuracy with which an individual can judge the dimensions of their body.
Assessment of the perceptual component of body image has been more challenging than the attitudinal component. To date, several methods have been developed that are classified into two general groups. Depictive methods ask the participants to compare their own body to a visual or 2D image and include tasks such as distorting mirror, video distortion, and distorted photograph. Metric methods let the participants compare their own body to a physical length or a 1D standard, and include tasks such as the moving caliper, the image marking procedure, and the adjustable light beam apparatus (Hosseini & Padhy, 2022).
The following are the therapeutic nursing interventions for disturbed body image:
Establishing patient rapport
1. Acknowledge and accept the 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 the client before ready to deal with the situation. Denial may be prolonged and be an adaptive mechanism because the client is not ready to cope with personal problems. On the other hand, denial of the client’s feelings impedes the development of a trusting, therapeutic relationship.
2. Recognize the normalcy of response to the actual or perceived change in body structure or function and discuss it with the client.
Experiencing stages of grief over the loss of a body part or function is normal and typically involves a period of denial, the length of which varies among individuals. Women who had mastectomies felt the greatest loss among women diagnosed with breast cancer; they found it challenging to adapt to a missing breast and consequent asymmetry, feeling incomplete and seeing a “different person” when looking in the mirror (Buki et al., 2016).
3. Set limits on maladaptive behavior.
The client’s self-esteem will be damaged if the client is allowed to continue behaviors that are destructive or not helpful, and adaptation to the new image will be delayed. The process of accepting their new body image can be multifaceted and may take time a key difference between women who did and did not accept their body image was their ability to adapt and feel good about themselves in spite of their altered body image (Buki et al., 2016).
4. Maintain a nonjudgmental attitude while giving care, and help the client identify positive behaviors that will aid in recovery.
The client tends 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 disruptive and not helpful to recuperation but should realize that the behavior is usually directed toward the situation and not the caregiver. Alert the staff to monitor their own facial expressions and other nonverbal behaviors because they need to convey acceptance and not revulsion when the client’s appearance is affected.
5. Support verbalization of positive or negative feelings about the actual or perceived loss.
It is worthwhile to encourage the client to separate feelings about changes in body structure or function from feelings about self-worth. Expression of feelings can enhance the client’s coping strategies. Encourage the client to verbalize their fears and anxieties associated with identified stressful life situations. Verbalization of feelings with a trusted individual may help the client come to terms with unresolved issues.
6. Assist the client in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities.
The more noticeable the change in body structure or function, the more anxious the client may have about the response of others to the change. Opportunities for positive feedback and success in social situations may hasten adaptation. Involve the client in activities that reinforce a positive sense of self not based on appearance. When the client is able to develop self-satisfaction based on accomplishments and unconditional acceptance, the significance of the imagined defect or minor physical anomaly will diminish.
7. Exhibit positive caring in routine activities.
Positive remarks by the nurse may encourage the client to develop more positive responses to the changes in his or her body. Work with the client’s self-concept, avoiding moral judgments regarding the client’s efforts or progress. Positive reinforcement encourages the client to continue their efforts and strive for improvement. How others perceived them influences women’s perceptions and acceptance (Buki et al., 2016).
8. Be realistic and positive during treatments, in health teaching, and in setting goals within limitations.
This enhances trust and rapport between the client and the nurse. Provide information at the client’s level of acceptance and in small segments to allow easier assimilation. Discuss the client’s expectations and anticipated body changes, then assist the client in identifying realistic goals. Morbidly obese clients often set unrealistic goals for ideal body weight and appearance following bariatric surgery. Guidance is necessary to help them understand the limitations of the surgery.
9. Provide hope within the parameters of an individual situation; do not give false reassurance.
This promotes a positive attitude and provides an opportunity to set goals and plan for the future based on reality. Body image distress represents the negative effect experienced due to perceived body image in the present. Hope, however, is a cognitive construct regarding how the future is perceived. Alternatively, self-compassion is a cognitive construct that addresses present emotions and thoughts. This suggests that hope is unlikely to be a useful addition to existing body image interventions (Todorov et al., 2019).
Promoting self-esteem and positive coping
Self-esteem refers to an individual’s perception and feelings about themselves. Positive self-esteem arises when one feels confident and capable of handling challenges. However, a significant shift towards negative self-perception can lead to low self-esteem, which negatively impacts various aspects of life, including emotions, relationships, and resilience. It’s important to recognize that low self-esteem may be a temporary response to feeling helpless in a particular situation
1. Invite the patient to record past and current achievements: emotional, social, interpersonal, intellectual, vocational, and physical.
This approach is beneficial in presenting the patient with a more realistic view of his or her capabilities. Patients undergoing situational stress often lose sight of their past accomplishments in handling related circumstances.
2. Welcome statements the patient reveals about himself or herself.
The feeling of being unloved, unworthy, and incompetent is often expressed by patients with low self-esteem. The patient often presents himself or herself unable to manage the current situation.
3. Encourage the patient to express if he or she is able to associate these changes to a specific event in his or her life.
The patient may be knowledgeable of up-to-date situations that negatively change his or her self-concept.
4. Evaluate the degree to which the patient believes he or she is “in control” of his or her own behavior.
Patients may be taken into a vicious cycle of behaviors intended to cover the primary self-esteem dilemma. The acting-out fosters a sense of unworthiness and undermines efforts to esteem-building.
5. Assess the patient’s feelings of comfort and contentment with his or her own performance.
Patients with self-esteem issues may appear as though their actions are not in keeping with their own personal, moral, or ethical values; they may also deny these behaviors, project blame, and rationalize personal failure.
6. Assess for the presence of unfinished grief.
Ongoing grief may hinder the patient’s ability to move forward in life.
7. Evaluate recent variations in the patient’s behavior.
Patients may be able to compensate for low esteem through exceptional performance in work or areas of special interest while still having dilemmas with how he or she envisions self. Some patients may withdraw from engagement in work or family situations in an attempt to lessen the impact of the situation on self-esteem. Low self-esteem will not be fixed without weighing these issues into the care plan.
8. Evaluate the extent to which the patient feels loved and respected by others.
Lack of recognition of achievements or rejection by others may contribute to feelings of unworthiness. Care and support by others will be essential in developing the patient’s self-esteem.
9. Assess how competent patients feel about their ability to perform and carry out their own and others’ expectations.
The patient may have developed the ability to carry out personal responsibilities despite low self-esteem. This may be a positive indicator of the patient’s potential for successful improvement of self-esteem.
1. Act as a role model for the patient or significant others in healthy expression of feelings or concerns. Assume responsibility for own thoughts and actions by using “I think” language in conversations.
Patients may want an example of positive measures to display feelings. Self-awareness enables the nurse to show authentic behavior.
2. Present an environment favorable to the expression of feelings:
- 2.1. Spend time with the patient; set aside enough time so that the encounter is calm and deliberate. Having enough time for the patient conveys the nurse’s interest in and acceptance of the patient’s feelings. A trusting relationship is an important factor in building self-esteem.
- 2.2. Provide privacy. Private discussions need to take place in a setting where the patient is free to express feelings without being overheard.
- 2.3. Apply active listening and open-ended questions. These communication methods permit the patient to verbalize interests, concerns, worries, and thoughts without interruption. This technique will convey a sense of respect for the patient’s abilities and strengths in addition to recognizing problems and concerns.
3. Consider the “normal” impact of change on self-esteem. Reassure the patient that such modifications often occur in a variety of emotional or behavioral responses.
Disturbances in self-esteem are natural responses to important changes. Reconstitution of the patient’s self-esteem occurs as part of the patient’s adjustment to change.
4. Support the patient in his or her attempts to secure autonomy, reality, positive self-esteem, a sense of capability, and problem-solving.
The patient needs continuous positive feedback and support to manage behaviors to promote self-esteem. The patient will benefit from feedback that provides a realistic appraisal of his or her development and strengthens the effective change made by the patient.
5. Give anticipatory direction to reduce anxiety and fear if interference in self-esteem is an expected part of the process of adjustment to changes in health status.
The patient requires a view that places the change in self-esteem within the context of the normal recuperative process.
6. Educate the patient to join in activities anticipated to result in healthy self-esteem.
The patient needs to explore options to improve self-esteem by substituting negative behaviors with positive actions.
7. Present referral information about community resources, self-help groups, and professional counseling.
Professional and community sources of support provide the patient with more resources to sustain the work of rebuilding positive self-esteem.
8. Educate the patient about the harmful effects of negative self-talk.
Recognition of unfavorable thoughts can lift the patient to develop new techniques for coping. The patient must replace negative beliefs and ideas with positive thoughts about self.
Promoting social interaction
10. Give positive reinforcement of progress and encourage endeavors toward the attainment of rehabilitation goals.
Words of encouragement can support the development of positive coping behaviors. Acceptance, which was more prevalent among women in the long-term survivorship stage of breast cancer, was achieved when women experienced a feeling of worth similar to the one they had prior to the diagnosis. A woman needs psychological help to find herself again, to feel again that they are the same person, and that they are worth the same (Buki et al., 2016).
11. Encourage family interaction with each other and with the rehabilitation team.
A good conversation provides ongoing support for the client and family. According to a study, emotional support from their male partners, family, and friends normalized the woman’s experiences and reassured them they were loved despite the changes in their bodies. Women also received instrumental support from family members, which included one participant’s daughter driving her to the beauty salon to help manage her hair loss (Buki et al., 2016).
12. Provide a support group for caregivers. Give information about how caregivers can be helpful to the client.
Support groups promote the ventilation of feelings and allow for more helpful responses to the client. Caregivers may have health problems of their own that affect their ability to provide care for another. This is common among older couples. In order to be successful in caring for the client, the nurse must work with their family caregivers, take time at each visit to speak with them, and make sure to include them in the assessment, plan of care, and teaching.
13. Provide thorough teaching and complete aftercare instructions for the client.
Reinforcing teaching can help the client achieve self-care. Provide accurate information as requested and reinforce previously given information by nurses and other members of the healthcare team to ensure understanding of the instructions and correction f misperceptions. Recognition that a misperception exists is necessary before the client can accept reality and reduce the significance of the imagined defect.
14. Teach the client adaptive behavior (e.g., use of adaptive equipment, wigs, cosmetics, clothing that conceals the altered body part or enhances remaining part or function, use of deodorants).
Adaptive behaviors help the client compensate for the actual changed body structure and function. An examination of women’s experiences through the various survivorship stages revealed that body image acceptance was a gradual and ongoing “movement” representing a complex process for participants. In the acute stage, women anticipated how they would cope with the changes, and subsequently, in the reentry stage, they learned new ways to live with their altered bodies (Buki et al., 2016).
15. Support the client in identifying ways of coping that have been beneficial in the past.
These may help the client adjust to the current issue. Active coping, as well as emotional, informational, and instrumental support, are critical in shaping women’s perceptions of themselves. The acceptance process can also be associated with women’s way of coping. For example, women who thought of hair loss as temporary took greater control and reported greater acceptance of their new body images than participants who coped more passively (e.g. watching hair fall out) (Buki et al., 2016).
16. Refer the client and caregivers to support groups composed of individuals with similar alterations.
Lay people in similar situations offer a different type of support, which is perceived as helpful (e.g., United Ostomy Association, Y Me?, I Can Cope, Mended hearts). Participants in a study felt it was important to discuss experiences and exchange ideas with other survivors. Through these exchanges, some participants engaged in downward comparison and reported feeling luckier than others who have lost more critical body parts, such as legs and arms. Also, they started looking at their body from a functional perspective (Buki et al., 2016).
17. Refer to physical and occupational therapy, vocational counselor, psychiatric counseling, clinical specialist psychiatric nurse, social services, and psychologist, as needed.
These are helpful in identifying ways/devices to regain and maintain independence. The client may need further assistance to resolve persistent emotional problems. Professional support can help guide the client to change negative beliefs and behaviors, and build a positive relationship with their body (National Eating Disorders Collaboration, 2022).
18. Encourage the client to identify their strengths.
It is important to help the client identify past achievements and areas of strength. One way to do that is to point out areas of strength observed, such as emotional strengths, which might include the ability to express emotions or to “feel” for others. Other examples are the client’s relationship strengths which may include being sensitive to others’ needs and being a good listener, or spiritual strengths which may include faith in God and participation in church activities. Evaluate the client’s sense of humor, which can also be considered a strength, and also include the client’s special aptitudes, such as cooking, arts and crafts, sports, work, and education.
Initiating health teachings
19. Provide information on how to promote a positive body image.
Teach the client about topics for developing self-concept and self-esteem, such as accepting that healthy bodies come in a wide range of shapes and sizes. Fashion magazines and social media portray an ideal body that is unrealistic and unhealthy for most people, therefore, the client should avoid them if they make the client feel bad. Rather, the client should focus on activity and healthy eating instead of starving and depriving themselves to lose weight. Suggest that the client keep a list of things they like about their body and refer to it when feeling down. Then, provide the client with practice in accepting positive comments about their appearance and coach their responses as needed.
20. Promote role enhancement and satisfaction.
Sometimes the difficulty with self-concept centers on the inability to fulfill one’s usual or desired role. Help the client distinguish between ideal and actual role performance. Then discuss with them boundaries, expectations, and management defined by lifestyle and family networks. Facilitate communication between the client and family members regarding sharing of responsibilities to accommodate role changes of the ill person.
21. Educate the client about the role of evaluative conditioning in body image disturbance.
Self-disgust in particular may develop through evaluative conditioning, potentially deriving from specific childhood experiences such as bullying and abuse. Learning models also implicate evaluative conditioning in the development of the disgust response. Evaluative conditioning involves the pairing of a neutral and conditioned stimulus, changing the affective evaluation of, or attitude toward (e.g. good/bad, like/dislike), the conditioned stimulus due to its association with the unconditioned stimulus (Stasik-O’Brien & Schmidt, 2018).
22. Provide information about bullying prevention programs.
Both disgust and physical appearance concerns have been shown to be related to anti-fat prejudice. In particular, in both men and women, physical appearance concerns, including disturbed body images, were predictive of the dislike of overweight individuals. Participation in integrated prevention programs that target both bullying and prejudicial attitudes has been shown to decrease such attitudes and increased perceived knowledge of bullying (Stasik-O’Brien & Schmidt, 2018).
23. Reinforce information about cognitive behavioral therapy.
Cognitive behavioral therapy (CBT) is the most commonly used and most empirically supported intervention to improve body image. CBT aims to target core cognitive and behavioral processes that contribute to negative body image, and helps individuals to modify their dysfunctional thoughts, feelings, and behaviors related to their body image (Hosseini & Padhy, 2022).
24. Schedule activities that enhance physical fitness.
Fitness training interventions comprise aerobic or anaerobic exercises for enhancing physical capacities such as muscular strength, and also for encouraging individuals to focus more on functionality and less on appearance (Hosseini & Padhy, 2022).
25. Encourage the client to lessen social media usage time and provide media literacy.
Media literacy interventions aim to teach individuals to critically evaluate the appearance ideals that are conveyed to them by the media. This includes discussing beauty ideals or engaging in media literacy training (Hosseini & Padhy, 2022).
26. Utilize validated tools in evaluating parental feeding practices, as appropriate.
Parents also play an essential role in the development of body image, body dissatisfaction, and eating problems. Several measures of parental feeding practices have been developed, validated, and widely used, such as the Pre-schooler Feeding Questionnaire and Child Feeding Questionnaire. These measures evaluate how parents feed their children and how their feeding practice influence the children’s weight and eating behavior (Hosseini & Padhy, 2022).
27. Inform the client about the benefits of psychoeducation.
Psychoeducation aims to educate individuals about body image concepts, negative body image, and its causes and consequences. Psychoeducation is often useful along with other interventions, such as fitness training interventions or self-esteem enhancement. Examples of the techniques include discussions of the causes, consequences, and behavioral expression of negative body image, and the concept of body image (Hosseini & Padhy, 2022).
28. Administer serotonin reuptake inhibitors (SSRIs) as indicated.
Current clinical guidelines indicate that CBT plus SSRIs are the first-line treatments for body dysmorphic disorder (BDD). Appropriate pharmacotherapy improves core BDD symptoms, suicidality, and psychosocial functioning in a majority of clients. The doses of SSRI necessary to treat BDD are often higher than doses needed to address other common psychiatric disorders, and clients should remain on medication for relatively long periods (Hosseini & Padhy, 2022).
Here are some resources you can use to further your study about disturbed body image or body image distortion:
- Buki, L. P., Reich, M., & Lehardy, E. N. (2016, August). “Our organs have a purpose”: body image acceptance in Latina breast cancer survivors. Psycho-Oncology, 25(11).
- Hosseini, S. A., & Padhy, R. K. (2022, September 5). Body Image Distortion – StatPearls. NCBI.
- Holzer LA, Sevelda F, Fraberger G, Bluder O, Kickinger W, Holzer G. Body image and self-esteem in lower-limb amputees. PLoS One. 2014 Mar 24;9(3):e92943. doi: 10.1371/journal.pone.0092943. PMID: 24663958; PMCID: PMC3963966.
- National Eating Disorders Collaboration. (2022). Body Image. National Eating Disorders Collaboration.
- Paterson, C., Lengacher, C. A., Donovan, K. A., Kip, K. E., & Tofthagen, C. S. (2016). Body Image in Younger Breast Cancer Survivors: A Systematic Review. Cancer Nursing, 39(1). 10.1097/NCC.0000000000000251
- Saiphoo, A. N., & Vahedi, Z. (2019). A meta-analytic review of the relationship between social media use and body image disturbance. Computers in Human Behavior.
- Stasik-O’Brien, S. M., & Schmidt, J. (2018). The role of disgust in body image disturbance: Incremental predictive power of self-disgust. Body Image, 27.
- Todorov, N., Sherman, K. A., Kilby, C. J., & Breast Cancer Network Australia. (2019, August). Self-compassion and hope in the context of body image disturbance and distress in breast cancer survivors. Psycho-Oncology, 28(10), 2025-2032.
- Townsend, M. C. (2014). Psychiatric Mental Health Nursing: Concepts of Care in Evidence-based Practice. F.A. Davis Company.
- Wilkinson, J. M., & Treas, L. S. (2014). Basic Nursing: Concepts, Skills, & Reasoning. F.A. Davis Company.