Disturbed Body image

Teresa Howell, Gail Ladwig

NANDA
Definition

Confusion in mental picture of one's physical self

Defining Characteristics

EditVerbalization 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; nonverbal response to actual or perceived change in body structure and/or
function; behaviors of avoidance, monitoring, or acknowledgment of one's body

Objective

EditMissing body part; trauma to nonfunctioning part; not touching body part; hiding or
overexposing body part (intentional or unintentional); actual change in structure and/or function;
change in social involvement; change in ability to estimate spatial relationship of body to
environment; extension of body boundary to incorporate environmental objects; not looking at
body part

Subjective

EditRefusal to verify actual change, preoccupation with change or loss, personalization of part or
loss by name, depersonalization of part or loss by impersonal pronouns, extension of body
boundary to incorporate environmental objects

Related Factors (r/t)

EditPsychosocial, biophysical, cognitive/perceptual, cultural, spiritual, or developmental

changes; illness; trauma or injury; surgery; illness treatment

NOC
Outcomes (Nursing Outcomes Classification)
Suggested NOC Outcomes

EditBody Image
EditChild Development: 2 Years, 3 Years, 4 Years, Preschool, Middle Childhood,
Adolescence

EditDistorted Thought Self-Control

 EditGrief Resolution

EditPsychosocial Adjustment: Life Change

EditSelf-Esteem

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NOC Outcome with Indicators

Body Image as evidenced by the following indicators: Congruence between body reality, body
ideal, and body presentation/Satisfaction with body appearance/Adjustment to changes in
physical appearance (Rate each indicator of Body Image: 1 = never positive, 2 = rarely positive,
3 = sometimes positive, 4 = often positive, 5 = consistently positive [see Section I].)

Client Outcomes

Client Will (Specify Time Frame):

EditState or demonstrate acceptance of change or loss and an ability to adjust to

lifestyle change
EditCall body part or loss by appropriate name

EditLook at and touch changed or missing body part

EditCare for changed or nonfunctioning part without inflicting trauma

EditReturn to previous social involvement

EditCorrectly estimate relationship of body to environment

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NIC
Interventions (Nursing Interventions Classification)
Suggested NIC Intervention

EditBody Image Enhancement

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Example NIC ActivitiesBody Image Enhancement

Determine client's body image expectations based on developmental stage; assist the client to
identify activities that will enhance appearance

Nursing Interventions and Rationales

EditUse a tool such as the Body Image Instrument (BII) to identify clients who have
concerns about changes in body image. The five BII subscalesGeneral 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). EBN: Using a body image scale can help nurses to identify possible body image
disturbances and to plan individual nursing interventions (Souto & Garcia, 2002).
EditAssess for body dysmorphic disorder (BDD) and make appropriate referrals. The
severity of BDD varies. Some youth experience manageable distress about their
appearance and are able to function well, although not up to their potential. Psychiatric
treatment is often effective in decreasing BDD symptoms and the suffering they cause
(Phillips, 2003). EB: In delusional and nondelusional clients with body dysmorphic
disorder, fluoxetine hydrochloride was more effective than placebo (Rao, 2002).

EditObserve client's usual coping mechanisms during times of extreme stress and
reinforce their use in the current crisis. EBN: In this study of clients on hemodialysis,
more psychosocial stressors were associated with greater use of problem solving, social
support, and avoidance coping; avoidance coping was found to explain much of the
relationship between psychosocial stressors and depression (Welch & Austin, 2001).

EditExplore opportunities to assist the client to develop a realistic perception of his

or her body image. Actual body size may not be consistent with the client's perceived
body size. Inaccurate perception by the client can be unhealthy (Townsend, 2003).

EditAcknowledge denial, anger, or depression as normal feelings when adjusting to

changes in body and lifestyle. EB: The influence of emotion-focused coping (venting
emotions and mental disengagement) on distress following disfiguring injury was
associated with less body image disturbance (Fauerbach et al, 2002).

EditIdentify clients at risk for body image disturbance (e.g., body builders, cancer
survivors). EB: Male body builders are at risk for body image disturbance and the
associated psychological characteristics that have been commonly reported among
eating disorder clients. 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). EBN: The female perception of body
image contains passive assimilation of comments from others and acute observation of
the media and the environment (Chang et al, 2004).
 EditClients 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).

EditDo not ask clients to explore feelings unless they have indicated a need to do so.
EBN: Patients reported keeping their feelings to themselves as a frequently used coping
strategy (Zacharia et al, 1994).

EditExplore strengths and resources with client. Discuss possible changes in weight
and hair loss; select a wig before hair loss occurs. EBN: Nurses play an important role in
assisting the client to cope with alopecia and help clients move through a potentially
devastating experience to a renewed sense of well-being (Bachelor, 2001).

EditEncourage the client to purchase clothes that are attractive and that deemphasize
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).

EditAllow 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 exposurethe client
moves from a protected to an unprotected environment with the support of the nurse
(MacGinley, 1993).

EditEncourage the client to discuss interpersonal and social conflicts that may arise.
Changes in physical appearance and function associated with disease processes (and
sometimes treatment) need to be integrated into the interaction that occurs between
clients and lay caregivers (Price, 2000).

EditEncourage the client to make own decisions, participate in plan of care, and
accept both inadequacies and strengths. EBN: It has been found that support given to
women with breast cancer has a positive effect on their reactions to the illness and may
even prolong their survival (Lindrop & Cannon, 2001). EB: The results of this study of
clients with severe psoriasis indicate that the criterion for the management of psoriasis
should be the clients' own perception of the consequences of the disease (Wahl et al,
2002). EBN: Data from one study suggest that satisfaction with body image is disturbed
by surgery for breast cancer despite active participation in decisions regarding selection
of treatment. These outcomes suggest that women need assistance in adjusting to
alterations in body image from nurses (Newell, 1999).

EditHelp 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).

EditHelp 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 regardless of whether they
are willing to do so (Pohl & Winland-Brown, 1992).

EditEncourage the client to write a narrative description of their changes. EB: One's
experience of coping or adjustment to a disability is represented as narratives about
himself or herself. Each person with traumatic brain injury (TBI) reconstructed certain
self-narratives when coping with their changed self-images and daily lives (Nochi, 2000).

EditAvoid 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).

EditEncourage the 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. EBN: 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 client (Johnson, 1994).

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Geriatric

EditFocus on remaining abilities. Have client make a list of strengths. EB: Results
from unstructured interviews with women aged 61 to 92 years 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).

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Multicultural

EditAssess for the influence of cultural beliefs, norms, and values on the client's body
image. EBN: The client's body image may be based on cultural perceptions, as well as
influences from the larger social context. Use of pan-ethnic status such as Asian or
 Hispanic may obscure important ethnic group differences (Cochran, 1998; Doswell &
Erlen, 1998; Leininger & McFarland, 2002; Yates, Edman, & Aruguete, 2004).
EditValidate the client's feelings with regard to the impact of health status on
disturbances in body image. EBN: Validation is a therapeutic communication technique
that lets the client know that the nurse has heard and understands what was said and
promotes the nurse-client relationship (Heineken, 1998).

EditAcknowledge that body image disturbances can affect all individuals regardless
of culture, race, or ethnicity. EBN: Body image disturbances are pervasive across
western cultures and appear to increase in other cultures with acculturation to western
ideals (Thomas & Ricciardelli, 2000; Hebl, King, & Lin J 2004). EB: Non-Caucasian
girls were found to report higher internalization of the thin ideal than their Caucasian
peers (Hermes & Keele, 2003).

EditAssess for the presence of conflicting cultural demands. EBN: Poor peer
socialization and family rigidity were found to be related to the preoccupation with body
size and slimness in a young female Mexican-American population (Kuba & Harris,
2001).

EditAssess for the presence of depressive symptoms. EBN: Recent studies have
shown that body image attitudes were significantly related to depressive symptoms in a
study of diverse postpartum women (Walker, Timmerman, King, & Sterling, 2002).

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Home Care

EditAbove interventions may be adapted for home care use.

EditAssess client's stage of grieving or acceptance of body change on return to home
setting. Include the future role of sexuality in the psychological assessment of acceptance
as appropriate. Body change or loss of a body part raises multiple issues relating to self-
concept, as well as continuing functional ability and dealing with responses of others.

EditAssess family/caregiver level of acceptance of client's body changes. Negative

feedback from family/caregiver can influence client's reactions and ability to adjust to
body changes negatively.

EditRecognize that older women may continue their younger preoccupation with
weight and recurrent dieting, despite being at normal weight. Assess source of low weight
or weight loss with this in mind. EB: Reports suggest that elderly women continue to be
preoccupied with being thin. Increased awareness of eating habits and weight
preoccupation in elderly women has been recommended (Fallaz et al, 1999).
 EditBe accepting of body changes in all interactions with client and
family/caregivers. Acceptance promotes trust and assures client that others can be
accepting of him or her.

EditHelp client to see new or changing roles in family. Point out ways in which the
community can help support client and family strengths.

EditRefer to medical social services to address level of acceptance and possible

financial impact of changes. Social worker visits can support the client or caregivers with
dedicated time and can work with the nurse to be supportive and adapt interventions to
promote acceptance. The nurse or social worker can introduce or reinforce use of
community resources.

EditTeach 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 are the chances for permanent
acceptance and positive self-esteem.

EditTeach family and client complications of medical condition and when to contact
physician.

EditRefer 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 activies of daily living (ADLs) and self-care, the greater are the chances
for permanent acceptance and positive self-esteem.

EditIf appropriate, provide home health aide support to help the client and family
through ADL transition.

EditRefer to physical therapy if necessary to build range-of-motion, flexibility, and

strength; prevent contractures; assist with transfer or ambulation safety; or obtain use of a
prosthetic device in the home setting.

EditAssess 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.

EditAssist family with obtaining needed supplies. Cost of ostomy supplies and
adaptive equipment can be an added stressor for the client. Community resources can
assist.

EditBe alert to the differential body image found in clients with schizophrenia that
may contribute to the need for assisted living and avoidance of competitive situations.
EB: Five body image factors differentiated individuals with schizophrenia from those
 without: dullness in movement, powerlessness, unusually strong digestive function,
lifelessness, and fragility (Koide, Iizuka, & Fujihara et al, 2002). Refer to care plan for
Powerlessness.

EditRefer for psychiatric home health care services for client reassurance and
implementation of a therapeutic regimen. Psychiatric home care nurses can address issues
relating to client's distorted body image. Behavioral interventions in the home can assist
client to participate more effectively in treatment plan (Patusky et al, 1996).

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Client/Family Teaching

EditTeach appropriate care of surgical site (e.g., mastectomy site, amputation site,
ostomy site). Patient teaching by enterostomal therapist (ET) nurses may alleviate
problems associated with altered body image in relation to the presence of an ostomy
(Tomaselli et al, 1991).
EditInform 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).

EditRefer the 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).

EditProvide 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).

EditEncourage significant others to offer support. Social support from significant

others enhances both emotional and physical health (Badger, 1990).

EditDirect social support as follows: instruct regarding practical care (bandaging);

encourage appraisal support (listening); encourage self-esteem support (favorable
comparisons between client's and others' 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).

EditRefer an interdisciplinary team to 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. EB: Many
clinical studies have found clients 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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