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PROBLEM: Body Image Disturbance

NURSING DIAGNOSIS: Body image disturbance related to obvious skin rash, patches in the mouth, lesions in oral cavity, palm of hands secondary to syphilis
TAXONOMY: Self perception self concept pattern
CAUSE ANALYSIS: Since organism multiply locally and disseminate systemic through bloodstream and lymphatics results with diffusion of plasmacytic infiltrate and
endothelial proliferation cause to body image disturbance. (Medical Surgical Nursing 6th ed. by Black, Pathologic Basic of disease 5th ed. by Robbins
CUES OBJECTIVES INTERVENTION RATIONALE EXPECTED OUTCOME
STO: INDEPENDENT: STO:
After 2-3 days in giving >Acknowledge and accept expression >Acceptance of this feeling as a normal After 2-3 days of giving nursing
nursing intervention, the of feelings of frustration, grief, hostility. response to what has occurred facilitates interventions the patient was able
patient will be able to Note withdrawn behavior and use of resolution. It is not helpful of possible to verbalized acceptance of self in
verbalize acceptance of denial. push patient ready to deal with situation. situation relief anxiety and
self in situation, relief of Denial maybe prolonged and be an adaptation to altered body image
anxiety and adaptation to adaptive mechanism because patient is and was able verbalized
altered body image and will not ready to cope with personal problems. understanding of body changes.
be able to verbalize >Be realistic and positive during > Enhance trust and rapport between
understanding of body treatments in health teaching and patient and nurse.
changes. setting goals within limitations.
> Provide hope within parameters of > Promotes positive attitude and provides LTO:
individual situation, do not give false opportunity to set goals and plan for After 10 days the patient was
reassurance. future based on reality. able to recognized and
OBJECTIVES LTO: > Give positive reinforcement of > Words of encouragement can support incorporated body image into self-
>skin rash After 10 days of giving progress and encourage endeavors development of positive coping concept in accurate manner
>lesions either nursing intervention, the toward attainment of rehabilitation behaviors. without negating self-esteem and
in oral cavity, patient will be able to goals. was able to acknowledge self as
soles of the recognize and incorporate > Encourage family interaction with >maintain open lines of communication an individual who has responsibility
feet body image change into each other and with rehabilitation and provides on ongoing support for for self.
>patches in self concept in accurate team. patient and family.
the mouth manner without negating >Provide support group for So. Give > Promotes ventilation of feelings and
>actual self esteem, and will be information about how so can be allow for more helpful responses to
change of the able to acknowledge self as helpful to patient. patient.
skin an individual who has > Role play social situation of concern > Prepares patient for reactions of others
responsibility to self. to patient. and anticipates ways to deal with them.
>Encourage patient to look at/ touch > To begin to incorporate changes in
affected body part. body image.

References: NCP 6th edition by: Doenges


Nurses Pocket Guide 7th edition by: Doenges