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NCLEX & CGFNS Practice Questions
Disturbed Body Image
  • Actual
  • Risk for (Potential)

Related To: [Check those that apply]

  • 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

As evidenced by: [Check those that apply]

  • 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 behaviour 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 behaviour (withdrawal, isolation, flamboyance)
  • Compensatory use of concealing clothing or other devices

Patient’s Diagnosis: –
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Objective/Expected Outcome;The patient will:

  • demonstrates enhanced body image and self-esteem.
  • Others

Note: you need to indicate time frame/target as objective must be measurable.

Nursing Interventions Scientific Rationale
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.
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 are particularly important.
Note patient's behaviour regarding actual or perceived changed body part or function. There is a broad range of normal behaviours associated with body image disturbance, ranging from totally ignoring the altered structure or function to preoccupation with it.
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 is 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, work, and other activities.
Help patient identify ways of coping that have been useful in the past. Asking patients to remember other body image issues (i.e., 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 comprised of individuals with similar alterations. Lay persons in similar situations offer a different type of support, which is perceived as helpful.

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