Nursing Care Plan Ineffective Breastfeeding Definition; Inability to maintain an integrated and complete perception of self,Nursing Care Plan
Defining Characteristics
- Disturbed body image
- Contradictory personal traits
- Fluctuating feelings about self
- Ineffective role performance
- Gender confusion
- Ineffective coping
- Unable to distinguish between
- Uncertainty about ideological inner and outer stimuli and cultural values
- Delusional description of self
- Uncertainty about goals
- Feelings of emptiness
- Disturbed relationships
- Feelings of strangeness
Related Factors
- Organic brain syndrome
- Situational crisis
- Dissociative identity disorder
- Dysfunctional family processes
- Psychiatric disorders
- Cultural discontinuity
- Low self-esteem
- Cult indoctrination
- Manic states
- Discrimination or prejudice
- Social role change
- Use of psychoactive drugs
- Stage of growth
- Ingestion of toxic chemicals
- States of development
- Inhalation of toxic chemicals
Assessment Focus
- Safety
- Sexual practices
- Mental status
- Cultural beliefs
- Self-care
- Relationships
Expected Outcomes
The Patient Will
- Contract for safety.
- Identify internal versus external stimuli
- Maintain adequate nutritional intake.
- Identify personal goals and realistic steps toward those goals.
- Compile a list of resources to call when needed.
- Remain free from substance abuse.
- Secure a safe place to live in.
Suggested Noc Outcomes
Coping; Distorted Thought; Impulse self-Control; Self-Control;Self-Esteem
Interventions And Rationales
Determine: Assess for suicidal/homocidal ideation, self-induced cuts or burns. Assess for self-induced vomiting or restricting of food Thorough mental status examination. Individuals struggling with identified issues are at an increased safety risk.179 Monitor mental status daily to be able to intervene if necessary.Monitor weight weekly to be able to detect changes that may require further intervention.Perform: Contract with patient for safety. Schedule meetings with patient to process feelings and experiences. Demonstrating care and compassion for the patient allows him or her to feel safe and pro-motes healing.Inform: Instruct patient to journal feelings and list coping strategies.Journaling can help a patient maintain self-control and may increase insight.Attend: Accept patient in his or her struggle. Reinforce taking healthy risks and appropriate expression of feelings. Appropriate expression of feelings enhances self-esteem and promotes resiliency.Manage: Refer patients to mental health services for medication and symptom management. Disturbed personal identity may require ongoing mental health care.
Suggested Nic Interventions
Coping Enhancement; Environmental Management: Safety; Role Enhancement; Self-Esteem Enhancement
Reference
Boyd, M. A. (2008). Psychiatric nursing. Philadelphia: Lippincott Williams & Wilkins.
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