Nursing Diagnosis: Disturbed Body Image Application of NANDA, NOC, NIC

Nursing Diagnosis: Disturbed Body Image
Gail B. Ladwig

NANDA Definition: Confusion in mental picture of one's physical self

Defining Characteristics: Nonverbal response to actual or perceived change in structure and/or function; verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function; verbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function; behaviors of avoidance, monitoring, or acknowledgment of one's body
Missing body part; actual change in structure or function; avoidance of looking at or touching body part; intentional or unintentional hiding or overexposure of body part; trauma to nonfunctioning part; change in social involvement; change in ability to estimate spatial relationship of body to environment
Change in lifestyle; fear of rejection or reaction by others; focus on past strength, function, or appearance; negative feelings about body; feelings of helplessness, hopelessness, or powerlessness; preoccupation with change or loss; emphasis on remaining strengths and heightened achievement; extension of body boundary to incorporate environmental objects; personalization of part or loss by name; depersonalization of part or loss by impersonal pronouns; refusal to verify actual change

Related Factors: Psychosocial, biophysical, cognitive/perceptual, cultural, spiritual, or developmental changes; illness; trauma or injury; surgery; illness treatment

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
·         Body Image
·         Child Development: 2 Years
·         Child Development: 3 Years
·         Child Development: 4 Years
·         Child Development: 5 Years
·         Child Development: Middle Childhood (6-11 Years)
·         Child Development: Adolescence (12-17 Years)
·         Distorted Thought Control
·         Grief Resolution
·         Psychosocial Adjustment: Life Change
·         Self-Esteem
Client Outcomes
·         States or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change
·         Calls body part or loss by appropriate name
·         Looks at and touches changed or missing body part
·         Cares for changed or nonfunctioning part without inflicting trauma
·         Returns to previous social involvement
·         Correctly estimates relationship of body to environment

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
Nursing Interventions and Rationales
·         Use a tool such as the Body Image Instrument (BII) to identify clients who have concerns about changes in body image The five BII subscales-General Appearance, Body Competence, Others' Reaction to Appearance, Value of Appearance, and Body Parts-exhibited moderate to high internal reliability and concurrent validity (Kopel et al, 1998).
·         Observe client's usual coping mechanisms during times of extreme stress and reinforce their use in the current crisis. Clients are in shock during acute phase, and their own value system must be considered. Clients deal better with change over time (Price, 1992).
·         Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle. Changes in body image cause anxiety. People in this situation use a variety of unconscious coping mechanisms to deal with their altered body image (ABI). Defense mechanisms are normal, unless they are used so much that they interfere with rather than improve self-esteem (MacGinley, 1993).
·         Identify clients at risk for body image disturbance (e.g., body builders, cancer survivors). The results of one study suggest that male body builders are at risk for body image disturbance and the associated psychological characteristics that have been commonly reported among eating disorder patients. These psychological characteristics also appear to predict steroid use in this group of males. Steroid users reported an elevated drive to put on muscle mass in the form of bulk (Blouin, Goldfield, 1995).
·         Clients should not be rushed into sharing their feelings. Feelings associated with complicated and emotionally powerful issues involving an altered body image take time to work through and express (Johnson, 1994).
·         Do not ask clients to explore feelings unless they have indicated a need to do so. Patients reported keeping their feelings to themselves as a frequently used coping strategy (Zacharias, Gilig, Foxall, 1994).
·         Explore strengths and resources with client. Discuss possible changes in weight and hair loss; select a wig before hair loss occurs. Emphasizing strengths promotes a positive self-image. Planning for an event such as hair loss helps to decrease the anxiety associated with a sudden change in appearance.
·         Encourage client to purchase clothes that are attractive and that de-emphasize their disability. Individuals with osteoporosis are not usually disabled but may perceive themselves as unattractive and experience social isolation as a result of ill-fitting clothes that accentuate the physical changes (Sedlak, Doheny, 2000).
·         Allow client and others gradual exposure to the body change. Begin by having the client touch the affected area; then use a mirror to look at it. Go to a hospital shop with a nurse or support person and discuss feelings associated with the reaction of others to the body change. Part of the rehabilitation process is graded exposure-the client moves from a protected to an unprotected environment with the support of the nurse (MacGinley, 1993).
·         Encourage client to discuss interpersonal and social conflicts that may arise. A good perception of body image is best achieved within a supportive social framework. Clients with an active social support network are likely to make better progress (Price, 1990). Changes in physical appearance and function associated with disease processes (and sometimes treatment) need to be integrated into the interaction that occurs between patients and lay caregivers (Price, 2000).
·         Encourage client to make own decisions, participate in plan of care, and accept both inadequacies and strengths. It is important for clients to be involved in their own care. If they have received information about their altered body image, treatment, and rehabilitation, they will be able to make their own choices. Consequently they will be more likely to come to terms with and adapt to their ABI (Price, 1986). Healthy adaptation to body image exists when the person is able to maximize ability despite disability (Samonds, Cammermeyer, 1989).
·         Help client accept help from others; provide a list of appropriate community resources (e.g., Reach to Recovery, Ostomy Association). Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning (Payne, 1993).
·         Help client describe self-ideal, identify self-criticisms, and be accepting of self. The perception of self-image involves knowing the self and what is important and valued. Disability causes individuals to live as changed human beings whether they are willing to or not (Pohl, Winland-Brown, 1992).
·         Encourage client to write a narrative description of their changes. An analysis based on the grounded theory method revealed that one's experience of coping or adjustment to a disability is represented as narratives about himself or herself. Each person with TBI reconstructed certain self-narratives when coping with their changed self-images and daily lives (Nochi, 2000).
·         Avoid looks of distaste when caring for clients who have had disfiguring surgery or injuries. Provide privacy; care should be completed without unnecessary exposure. Nurses must be aware of their nonverbal behavior; clients often become acutely aware of nurses' feelings as a result of the nurses' facial expressions, tone of voice, touch, or other behaviors (MacGinley, 1993).
·         Encourage client to continue same personal care routine that was followed before the change in body image. It is preferable that this care be completed in the bathroom and not in bed. This routine gives the client privacy and also prevents the client from settling into an "invalid" role. Research has shown that women who resume familiar routines and habits heal better and suffer less depression than those who settle into the role of patient (Johnson, 1994).
·         Focus on remaining abilities. Have client make a list of strengths. Results from unstructured interviews with women aged 61 to 92 regarding their perceptions and feelings about their aging bodies suggest that women exhibit the internalization of ageist beauty norms, even as they assert that health is more important to them than physical attractiveness and comment on the "naturalness" of the aging process (Hurd, 2000). Motivation and self-worth are increased in the elderly by highlighting their capabilities. Even a severely disabled client is usually capable of accomplishing some tasks. Normal changes in body image occur as a result of the aging process (MacGinley, 1993).
·         Assess for the influence of cultural beliefs, norms, and values on the client's body image. The client's body image may be based on cultural perceptions, as well as influences from the larger social context (Leininger, 1996).
·         Validate the client's feelings with regard to the impact of health status on disturbances in body image. Validation lets the client know that the nurse has heard and understands what was said and promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1991).
·         Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnicity. Body image disturbances are pervasive across western cultures and appear to increase in other cultures with acculturation to western ideals.
Home Care Interventions
·         Assess client's stage of grieving or acceptance of body change upon return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate.
·         Assess family/caregiver level of acceptance of client's body changes.
·         Be accepting of changes in all interactions with client and family/caregivers. Acceptance promotes trust.
·         Help client to see new or changing roles in family. Point out ways in which the community can help support client and family strengths.
·         Refer to medical social services for level of acceptance and possible financial impact of changes. Clients and caregivers may see the nurse's visit as being solely involved with physiological issues such as dressing, especially under managed care systems. Social worker visits can support the client or caregivers with dedicated time and can help the nurse be supportive and adapt interventions to promote acceptance. The nurse or social worker can introduce or reinforce use of community resources.
·         Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty looking at or touching changed body part. The quicker the involvement in self-care, the greater the chances for permanent acceptance and positive self-esteem.
·         Teach family and client complications of medical condition and when to contact physician.
·         Refer to occupational therapy if necessary to evaluate home setting for safety and adaptive equipment and to assist client with return to normal activities. The quicker the reinvolvement in daily living activities and self-care, the greater the chances for permanent acceptance and positive self-esteem.
·         If appropriate, provide home health aide support to help the client and family through ADL transition.
·         Refer to physical therapy if necessary to build range-of-joint-motion (ROJM) flexibility and strength, prevent contractures, assist with transfer/ambulation safety, or obtain use of a prosthetic device in the home setting.
·         Assess for and promote good nutrition and sleep patterns. Adapt nutrition to specific physiological situations (e.g., client with ostomy). Good nutrition and sleep patterns promote faster healing and better coping.
·         Assist family with obtaining needed supplies. Cost of ostomy supplies and adaptive equipment can be an added stressor for the client. Community resources can assist.

Client/Family Teaching
·         Teach appropriate care of surgical site (e.g., mastectomy site, amputation site, ostomy site). Patient teaching by ET nurses may alleviate problems associated with altered body image in relation to the presence of an ostomy (Tomaselli, Jenks, Morin, 1991).
·         Inform client of available community support groups; offer to make initial phone call. Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning (Payne, 1993).
·         Refer client to counseling for help adjusting to body change. Counseling is important for a client who is trying to create a new body ideal or work through a grief process (Price, 1990).
·         Provide printed material and didactic information for significant others. Some significant others prefer to receive didactic material rather than vent their feelings as a way of showing support (Northouse, Peters-Golden, 1993).
·         Encourage significant others to offer support. Social support from significant others enhances both emotional and physical health (Badger, 1990).
·         Direct social support as follows: instruct regarding practical care (bandaging), encourage appraisal support (listening), encourage self-esteem support (favorable comparisons between client's and other's appearance), and encourage sense of belonging (assist with socializing). The preceding are four categories of support recognized in the body-image care model. Clients with an active social support network are likely to make better progress than those without support (Price, 1990).
·         Refer to an interdisciplinary team clients with ostomies who are having difficulty with personal acceptance, personal and social body-image disruption, sexual concerns, reduced self-care skills, and the management of surgical complications Many clinical studies have found patients with ostomies to be a group facing multiple adjustment demands. One of these demands is coping with a significant change in body image. At the Medical College of Wisconsin, a team approach has been initiated; the ET nurse, the psychologist, and the surgeon deal with body image concerns together. The multidisciplinary approach has been demonstrated to be successful in facilitating adaptation to an altered body image (Walsh et al, 1995).

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