NURSING CARE PLAN

PROBLEM: Spiritual Distress related to challenged belief and value system/ Separation from religious or cultural ties

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSI
S

Subjective The client will Dx: Dx: Fully Met if the

client will State
 Expresses Spiritual  State conflicts or  Observe client for self-  Verbalization of feelings conflicts or
concern with Distress disturbances esteem, self-worth, feelings of low self-esteem, low disturbances related
meaning of related to related to of futility, or hopelessness. self-worth, and to practice of belief
life/death and/or challenged practice of belief hopelessness may system, discuss
belief systems; belief and system indicate a spiritual need. beliefs about spiritual
 verbalizes inner value system/  Discuss beliefs issues, State feelings
conflict about Separation about spiritual  To effectively help a of trust in self, God,
beliefs; from issues client with spiritual
 Monitor support systems. Be or other belief
 verbalizes religious or  State feelings of needs, an understanding
aware of own belief systems systems, continue
concern about cultural ties trust in self, of one's own spiritual
and accept client's spiritual practices not
relationship with God, or other dimension is essential
spirituality. detrimental to health,
deity; belief systems (Highfield, Carson, discuss feelings
 Continue 1983). about death, Display
spiritual a mood appropriate
practices not  Older adults often
Objective for the situation
detrimental to identify spirituality as a
 displacement of health source of hope (Gaskins,
 Identify client's past sources
anger toward  Discuss feelings Forte, 1995).
of spirituality. Help client
religious about death explore his or her life and
representatives;  Display a mood identify those experiences
 unable to appropriate for that are noteworthy. Client
participate in the situation may want to read the Bible
usual religious or have it read to them.
practices;
 alteration in  Listening attentively and
 Ask how to be most helpful,
behavior/mood being physically present
then actively listen, reflect,
evidenced by can be spiritually
and seek clarification.
anger, crying, nourishing (Berggren-
withdrawal, Thomas, Griggs, 1995).
preoccupation, Obtain permission from
anxiety, hostility, the client to respond to
apathy; gallows spiritual needs from own
humor spiritual perspective
(inappropriate (Smucker, 1996).
humor in a grave
situation)
Tx:

Tx:  Listening attentively and

 Discuss personal definitions
of spiritual wellness with
client.
helping elderly clients
identify past coping
strategies is part of
helping with life review
and finding meaning in
life (Berggren-Thomas,
Griggs, 1995)

 It is worthwhile to
encourage the patient to
separate feelings about
 Support verbalization of
positive or negative feelings
about the actual or perceived
loss.
 Discuss the client's
perception of God in relation
to the illness.
 Offer to pray with client or
caregivers.
 Offer to read from the Bible
or other book chosen by
client
 Be physically present and
available to help client
determine religious and
spiritual choices.
 Provide quiet time for
meditation, prayer, and
relaxation.
 Help client develop and
accomplish short-term goals
and tasks.
 Listen to client's feelings
about death. Be
nonjudgmental and allow
time for grieving
changes in body structure
or function from feelings
about self-worth.
Expression of feelings
can enhance the patient’s
coping strategies.
 Different religion’s view
illness from different
perspectives.
 Prayer was described as
an important part of
spirituality by caregivers
(Kaye, Robinson, 1994).
 A religious ritual may
comfort the client.
 Physical presence can
decrease separation and
aloneness, which clients
often fear (Dossey et al,
1988). This study
showed an overwhelming
response that client's
faith and trust in nurses
produces a positive effect
on client and family.
Spiritual care
interventions promote a
sense of well-being
(Narayanasamy, Owens,
2001).
 Clients need time to be
alone during times of
health change.
 Accomplishing goals
increases self-esteem,
which may be related to
the client's spiritual well-
being.
 All grief work takes time
and is unique.
Acceptance of client
differences is essential to
open communication.
 Privacy shows respect for
and sensitivity to the
client
  Provide privacy for client to
pray with others or to be
read to by members of own
faith.

PROBLEM: Disturbed body image related to alteration in self-perception

ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSI
S

Subjective The client will Dx: Dx:  The patient will

demonstrate beginning use learned
 Verbalizes Disturbed adaptation to changes  Assess meaning of loss or  The extent of response is coping
negative body image in body functioning, change to patient and SO, more related to the value strategies to
feelings about related to lifestyle, roles, and including future expectations or importance the patient adjust to a new
bodily changes alteration in level of independence and impact of cultural or places in the part or reality
 Reports fear of self- as evidenced by: religious beliefs. function than the actual  The patient will
rejection by perception value or importance. This recognize self-
others  verbalization of necessitates support to sabotage and
 Talks about feelings of self- work through to optimal accept help
the affected worth resolution.  The patient will
body part  maintenance of identify
 Talks relationships with  Alteration in body image irrational beliefs
negatively significant others  Assess the perceived impact can have an effect on the and use new
about physical  active of change in ADLs, social patient’s ability to carry coping
change or participation in participation, personal out daily roles and strategies to
body part activities of daily relationships, and responsibilities. enhance
living occupational activities. perception about
 There is a broad range of body image.
 verbalization of a  Evaluate the patient’s behaviors associated with
Objective
beginning plan behavior regarding the actual body image disturbance,
 Refusal to talk for adapting or perceived changed body ranging from totally
about physical lifestyle to part or function. ignoring the altered
changes changes resulting structure or function to
 Hiding of from the injury or preoccupation with it.
affected body
disease and/or its
part
 Verbal treatment.
detachment  Negative statements about
from physical the affected body part
change  Evaluate the patient’s verbal may indicate limited
 Missing body remarks about the actual or ability to integrate the
part change into the patient’s
perceived change in body
 Does not look
part or function. self-concept.
at the body
part
 Does not touch Tx:
the body part  This is a form of coping
 Self-isolation strategy that starts the
 Refuses to healing process. Sharing
participate in Tx:
their feelings provides
teaching  Encourage the patient to
excellent insight into the
sessions to express feelings about body
become patient’s insecurities and
changes.
accustomed to helps the nurse in
the new individualizing care
situation.  Medications, such as
steroids, or treatments
such as chemotherapy can

 Explain the effects of
medications or treatment that
might be the cause of
alterations of the body.
 Set limits on maladaptive
behavior. Maintain
nonjudgmental attitude while
giving care, and help patient
identify positive behaviors
that will aid in recovery.
 Support verbalization of
positive or negative feelings
about the actual or perceived
loss.
 Exhibit positive caring in
Edx:
routine activities.
 Provide hope within
parameters of individual
situation; do not give false
reassurance.
alter appearance.
Discussing the
importance of the therapy
and educating about
possible body image
changes beforehand
might make it easier to
cope.
 Patient and SO tend 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
disrupting and not helpful
to recuperation but should
realize that the behavior is
usually directed toward
the situation and not the
caregiver.
 It is worthwhile to
encourage the patient to
separate feelings about
changes in body structure
or function from feelings
about self-worth.
Expression of feelings
can enhance the patient’s
coping strategies.
 Positive remarks by the
nurse may encourage the
patient develop more
positive responses to the
changes in his or her
body.
 This promotes positive
attitude and provides
opportunity to set goals
and plan for future based
on reality.
 Adaptive behaviors help
the patient compensate
for the actual changed
body structure and
function.
 The patient experiencing
a body image change
 needs new information to
support cognitive
Edx: appraisal of the change.

 Teach the patient adaptive  A good conversation

behavior (e.g., use of provides ongoing support
adaptive equipment, wigs, for patient and family.
cosmetics, clothing that
conceals the altered body part
or enhances remaining part or
function, use of deodorants).

 Discuss with patient about

the normalcy of body image
disturbance and the grief
process.

 Encourage family interaction

with each other and with
rehabilitation team.