NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Disturbed After series of  Assess the perceived  Alteration in body Patient verbalize
body image nursing care the impact of change in image can have an understanding of
“Pwedeng wag na
related to patient will ADLs, social effect on the patient’s body changes and
lang kuhanan ng
growing mass understand and participation, personal ability to carry out daily acceptance of self
litrato ung braso ko.”
at left arm accept the body relationships, and roles and in situation.
changes that occupational activities. responsibilities.
happen to him
Objective:  Evaluate the patient’s  There is a broad range
without negating
behavior regarding the of behaviors associated
 Verbalization about self-esteem.
actual or perceived with body image
altered structure or changed body part or disturbance, ranging
function of a body function. from totally ignoring the
part. altered structure or
 Intentional hiding function to
of body part. preoccupation with it.

 Actual change in  Acceptance of these

structure or feelings as a normal
 Acknowledge and accept response to what has
function.
expression of feelings of occurred facilitates
 Mass size: frustration, dependency, resolution. It is not
diameter of arm (54 anger, grief, and hostility. helpful or possible to
cm); diameter of Note withdrawn behavior push patient before
forearm (60 cm); and use of denial. ready to deal with
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length of mass (24 situation. Denial may be
cm). prolonged and be an
adaptive mechanism
 Verbalization about
because patient is not
altered structure or
ready to cope with
function of a body
personal problems.
part.
 Experiencing stages of
grief over loss of a body
part or function is
normal and typically
involves a period of
denial, the length of
 Recognize the normalcy which varies among
of response to the actual individuals.
or perceived change in
body structure or function.  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
 Support verbalization of the patient’s coping
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positive or negative strategies.
feelings about the actual
 The more noticeable the
or perceived loss.
change in body structure
or function, the more
anxious the patient may
have about the response
of others to the change.
Opportunities for
positive feedback and
success in social
situations may hasten
adaptation.
 Assist the patient in  Positive remarks by the
incorporating actual nurse may encourage
changes into ADLs, social the patient develop
life, interpersonal more positive responses
relationships, and to the changes in his or
occupational activities. her body.
 Words of
encouragement can
support development of
positive coping
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behaviors.
 A good conversation
provides ongoing
 Exhibit positive caring in
support for patient and
routine activities.
family.
 Reinforcing teaching
can help patient achieve
self-care.
 This promotes positive
attitude and provides
 Give positive opportunity to set goals
reinforcement of progress and plan for future
and encourage endeavors based on reality.
toward attainment of
rehabilitation goals.
 Encourage family
interaction with each other

 Provide thorough teaching

and complete aftercare
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instructions for the patient.
 Provide hope within
parameters of individual
situation; do not give false
reassurance.