Nursing Diagnosis: Disturbed Body Image (with Rationale)

Related Factors:

• 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

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Body Image                      
• Self-Esteem

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Body Image Enhancement
• Grief Work Facilitation
• Coping Enhancement                             

Ongoing Assessment

• 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

• 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, to work, and to other activities.

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.--Lay persons 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).

Nursing Diagnosis: Chronic Pain

Nursing Diagnosis: Chronic Pain
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Pain Control
* Quality of Life
* Family Coping

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

* Pain Management
* Medication Management
* Acupressure
* Heat/Cold Application
* Progressive Muscle Relaxation
* Transcutaneous Electrical Nerve Stimulation (TENS)
* Simple Massage

NANDA Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months

Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as cancer. With chronic nonmalignant pain the original tissue injury is not progressive or has been healed. Identifying an organic cause for this type of chronic pain is more difficult.

Chronic pain differs from acute pain in that it is harder for the patient to provide specific information about the location and the intensity of the pain. Over time it becomes more difficult for the patient to differentiate the exact location of the pain and clearly identify the intensity of the pain. The patient with chronic pain often does not present with behaviors and physiological changes associated with acute pain. Family members, friends, coworkers, employers, and health care providers question the legitimacy of the patient’s pain complaints because the patient may not look like someone in pain. The patient may be accused of using pain to gain attention or to avoid work and family responsibilities. With chronic pain, the patient’s level of suffering usually increases over time. Chronic pain can have a profound impact on the patient’s activities of daily living, mobility, activity tolerance, ability to work, role performance, financial status, mood, emotional status, spirituality, family interactions, and social interactions.

* Defining Characteristics: Weight changes
* Verbal or coded report or observed evidence of protective behavior, guarding behavior, facial mask, irritability, self-focusing, restlessness, depression
* Atrophy of involved muscle group
* Changes in sleep pattern
* Fatigue
* Fear of reinjury
* Reduced interaction with people
* Altered ability to continue previous activities
* Sympathetic mediated responses (e.g., temperature, cold, changes of body position, hypersensitivity)
* Anorexia

* Related Factors: Chronic physical or psychosocial disability

* Expected Outcomes Patient verbalizes acceptable level of pain relief and ability to engage in desired activities.

Ongoing Assessment

* Assess pain characteristics:
o Quality (e.g., sharp, burning)
o Severity (1 to 10 scale)
o Anatomical location
o Onset
o Duration (e.g., continuous, intermittent)
o Aggravating factors
o Relieving factors
Gathering information about the pain can provide information about the extent of the chronic pain.
* Assess for signs and symptoms associated with chronic pain such as fatigue, decreased appetite, weight loss, changes in body posture, sleep pattern disturbance, anxiety, irritability, restlessness, or depression. Patients with chronic pain may not exhibit the physiological changes and behaviors associated with acute pain. Pulse and blood pressure are usually within normal ranges. The guarding behavior of acute pain may become a persistent change in body posture for the patient with chronic pain. Coping with chronic pain can deplete the patient’s energy for other activities. The patient often looks tired with a drawn facial expression that lacks animation.
* Assess the patient’s perception of the effectiveness of methods used for pain relief in the past. Patients with chronic pain have a long history of using many pharmacological and nonpharmacological methods to control their pain.
* Evaluate gender, cultural, societal, and religious factors that may influence the patient’s pain experience and response to pain relief. Understanding the variables that affect the patient’s pain experience can be useful in developing a plan of care that is acceptable to the patient.
* Assess the patient’s expectations about pain relief. The patient with chronic pain may not expect complete absence of pain, but may be satisfied with decreasing the severity of the pain and increasing activity level.
* Assess the patient’s attitudes toward pharmacological and nonpharmacological methods of pain management. Patients may question the effectiveness of nonpharmacological interventions and see medications as the only treatment for pain.
* For patients taking opioid analgesics, assess for side effects, dependency, and tolerance. Drug dependence and tolerance to opioid analgesics is a concern in the long-term management of chronic pain.
* Assess the patient’s ability to accomplish activities of daily living (ADLs), instrumental activities of daily living (IADLs), and demands of daily living (DDLs). Fatigue, anxiety, and depression associated with chronic pain can limit the person’s ability to complete self-care activities and fulfill role responsibilities.

Therapeutic Interventions

* Encourage the patient to keep a pain diary to help in identifying aggravating and relieving factors of chronic pain. Knowledge about factors that influence the pain experience can guide the patient in making decisions about lifestyle modifications that promote more effective pain management.
* Acknowledge and convey acceptance of the patient’s pain experience. The patient may have had negative experiences in the past with attitudes of health care providers toward the patient’s pain experience. Conveying acceptance of the patient’s pain promotes a more cooperative nurse-patient relationship.
* Provide the patient and family with information about chronic pain and options available for pain management. Lack of knowledge about the characteristics of chronic pain and pain management strategies can add to the burden of pain in the patient’s life.
* Assist the patient in making decisions about selecting a particular pain management strategy. Guidance and support from the nurse can increase the patient’s willingness to choose new interventions to promote pain relief. The patient may begin to feel confident about the effectiveness of these interventions.
* Refer the patient to a physical therapist for evaluation. The physical therapist can help the patient with exercises to promote muscle strength and joint mobility, and therapies to promote relaxation of tense muscles. These interventions can contribute to effective pain management.

Education/Continuity of Care

* Teach the patient and family about using nonpharmacological pain management strategies:
o Cold applications Cold reduces pain, inflammation, and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. This intervention requires no special equipment and can be cost effective. Cold applications should last about 20 to 30 min/hr.
o Heat applications Heat reduces pain through improved blood flow to the area and through reduction of pain reflexes. This is a cost-effective intervention that requires no special equipment. Heat applications should last no more than 20 min/hr. Special attention needs to be given to preventing burns with this intervention.
o Massage of the painful area Massage interrupts pain transmission, increases endorphin levels, and decreases tissue edema. This intervention may require another person to provide the massage. Many health insurance programs will not reimburse for the cost of therapeutic massage.
o Progressive relaxation, imagery, and music These centrally acting techniques for pain management work through reducing muscle tension and stress. The patient may feel an increased sense of control over his/her pain. Guided imagery can help the patient explore images about pain, pain relief, and healing. These techniques require practice to be effective.
o Distraction Distraction is a temporary pain management strategy that works by increasing the pain threshold. It should be used for a short duration, usually less than 2 hours at a time. Prolonged use can add to fatigue and increased pain when the distraction is no longer present.
o Acupressure Acupressure involves finger pressure applied to acupressure points on the body. Using the gate control theory, the technique works to interrupt pain transmission by "closing the gate." This approach requires training and practice.
o Transcutaneous Electrical Nerve Stimulation (TENS) TENS requires the application of 2 to 4 skin electrodes. Pain reduction occurs through a mild electrical current. The patient is able to regulate the intensity and frequency of the electrical stimulation.
Knowledge about how to implement nonpharmacological pain management strategies can help the patient and family gain maximum benefit from these interventions.
* Teach the patient and family about the use of pharmacological interventions for pain management:
o Nonsteroidal antiinflammatory agents (NSAIDs) These drugs are the first step in an analgesic ladder. They work in peripheral tissues by inhibiting the synthesis of prostaglandins that cause pain, inflammation, and edema. The advantages of these drugs are they can be taken orally and are not associated with dependency and addiction.
o Opioid analgesics These drugs act on the central nervous system to reduce pain by binding with opiate receptors throughout the body. The side effects associated with this group of drugs tend to be more significant that those with the NSAIDs. Nausea, vomiting, constipation, sedation, respiratory depression, tolerance, and dependency are of concern in patients using these drugs for chronic pain management.
o Anti-depressants These drugs may be useful adjuncts in a total program of pain management. In addition to their effects on the patient’s mood, the antidepressants may have analgesic properties apart from their antidepressant actions.
o Antianxiety agents These drugs may be useful adjuncts in a total program of pain management. In addition to their effects on the patient’s mood, the antidepressants may have analgesic properties apart from their antidepressant actions.
* Assist the patient and family in identifying lifestyle modifications that may contribute to effective pain management. Changes in work routines, household responsibilities, and the home physical environment may be needed to promote more effective pain management. Providing the patient and family with ongoing support and guidance will increase the success of these strategies.
* Refer the patient and family to community support groups and self-help groups for people coping with chronic pain. Adding to the patient’s network of social support can reduce the burden of suffering associated with chronic pain and provide additional resources.

NCP: pneumonia

Nursing Diagnosis:
Ineffective airway clearance related to decreased energy and fatigue resulting in decreased coughing and accumulation of secretions; tracheobronchial secretions related to inflammation resulting in increased mucus accumulation. Ineffective breathing pattern related to pain caused by positioning and coughing; decreased energy and fatigue caused by inflammatory process; decreased lung expansion caused by pain and fatigue resulting in hypoventilation.

Expected Outcomes: Adequate ventilation evidenced by respiratory rate, depth and ease within baseline limits.

Intervention and Rationale:
I. Assess for:

1. Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data baseline.
2. Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
3. Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.

II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease.

1. ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.

III. Administer:

1. Oxygen therapy via cannula - maintain optimal oxygen level.
2. Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough
3. Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.
4. Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.

IV. Perform or Provide:

1. Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and allows for full expansion of lungs.
2. Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and liquefies secretions.
3. Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.
4. Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes
5. Postural drainage and percussion PRN - mobilizes secretion.
6. Suction secretions if cough ineffective - removal if unable to bring up secretions.
7. Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.