Nursing Diagnosis: Application to Clinical Practice
11th Edition

Disturbed Self-Concept*
DEFINITION
Disturbed Self-Concept: State in which a person experiences or is at risk of experiencing a negative state of change about the way he feels, thinks, or views himself. It may include a change in body image, self-esteem, or personal identity (Boyd, 2004).
DEFINING CHARACTERISTICS
Because a disturbed self-concept may include a change in any one or a combination of its three component parts (body image, self-esteem, personal identity), and because the nature of the change causing the alteration can be so varied, there is no typical response to this diagnosis. Reactions may include the following:
  • Refusal to touch or look at a body part
  • Refusal to look into a mirror
  • Unwillingness to discuss a limitation, deformity, or disfigurement
  • Inappropriate attempts or refusal to direct own treatment
  • Denial of the existence of a deformity or disfigurement
  • Increasing dependence on others
  • Signs of grieving: weeping, despair, anger
  • Self-destructive behavior (alcohol, drug abuse)
  • Displaying hostility toward the healthy
  • Showing change in ability to estimate relation of body to environment
RELATED FACTORS
A disturbed self-concept can occur as a response to a variety of health problems, situations, and conflicts. Some common sources follow.
Pathophysiologic
Related to change in appearance, lifestyle, role, response of others secondary to:
  • Chronic disease
  • Pain
  • Severe trauma
  • Loss of body functions
  • Loss of body parts
Situational (Personal, Environmental)
Related to feelings of abandonment or failure secondary to:
Divorce, separation from or death of a significant other
Loss of job or ability to work
Related to immobility or loss of function
Related to unsatisfactory relationships (parental, spousal)
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Related to sexual preferences (homosexual, lesbian, bisexual, abstinent)
Related to teenage pregnancy
Related to gender differences in parental child rearing
Related to experiences of parental violence
Related to change in usual patterns of responsibilities
Maturational
Middle Aged
Loss of role and responsibilities
Older Adult
Loss of role and responsibilities
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Focus Assessment Criteria
Disturbed Self-Concept is manifested in a variety of ways. A person may respond with an alteration in another life process (see Spiritual Distress, Fear, Ineffective Coping). The nurse should be aware of this and use the assessment data to ascertain the dimensions affected.
It may be difficult for the nurse to identify the cues and make the inferences necessary to diagnose a self-concept disturbance. Each person reacts differently to loss, pain, disability, and disfigurement. Therefore, the nurse should determine a person’s usual reactions to problems and feelings about himself or herself before attempting to diagnose a change.
Subjective Data
Assess for Defining Characteristics
Self views
“Describe yourself.”
“What do you like most/least about yourself?”
“What do you/others want to change about you?”
“What do you enjoy?”
“Has being ill affected how you see yourself?”
Identity
“What personal achievements have given you satisfaction?”
“What are your future plans?”
Role responsibilities
“What do you do for a living? Job responsibilities? Home responsibilities?”
“Are these satisfying?”
If the person has had a role change, how has it affected lifestyle and relationships?
Somatic problems
“Do you feel fearful, anxious, or nervous?”
“Ever feel like you are falling apart? Dizziness? Aches and pains? Shortness of breath? Palpitations? Urinary frequency? Nausea/vomiting? Sleep problems? Fatigue? Loss of sexual interest?”
Affect and mood
“How do you feel now?”
“How would you describe your usual mood?”
“What things make you happy/upset?”
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Body image
“What do you like most/least about your body?”
“What limitations do you think will result?”
“How do you feel about this illness/disability?”
“Has it changed the way you feel about yourself or the way others respond to you?”
Children may be able to draw self-portraits.
Assess for Related Factors
Stress management
“How do you manage stress?”
“To whom do you go for help with a problem?”
Support system
“Any problems in current relationships?”
“How does your family feel about your illness?” “Do they understand?”
“Does your family regularly discuss problems?”
“What other supports do you have? Spiritual? Social?”
Objective Data
Assess for Defining Characteristics
General appearance
Facial expression
Body posture/language (eye contact, head and shoulder flexion, gait/stride)
Thought processes/content
Orientation
Suspicious
Homicidal/suicidal ideation
Rambling
Sexual preoccupation
Delusions (grandeur, persecution, reference, influence, or bodily sensations)
Difficulty concentrating
Slowed thought processes
Poor memory or may even be missing large portions of personal history
Impaired judgment
Anxiety
Behavior
School problems (truancy, low/drop in grades)
Problems on job (lateness, decreased productivity, accident-prone, burnout symptoms)
Social withdrawal
Sexual behavior (increase, decrease, promiscuity)
Communication patterns
With significant others
  • Relates well
  • Hostile
  • Dependent
  • Demanding
Nutritional status
Appetite
Eating patterns
Weight (gain/loss)
Rest–sleep pattern
Recent change
For more information on Focus Assessment Criteria, visit http://connection.lww.com.
Goal
The person will demonstrate healthy adaptation and coping skills.
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Indicators
  • Appraise self and situations realistically without distortions.
  • Verbalize and demonstrate increased positive feelings.
General Interventions
Nursing interventions for the various problems that might be associated with a diagnosis of Disturbed Self-Concept are very similar.
Contact the Client Frequently and Treat Him or Her with Warm, Positive Regard
Encourage the Client to Express Feelings and Thoughts About the Following
  • Condition
  • Effects on lifestyle
  • Progress
  • Support system
  • Prognosis
  • Treatment
Provide Reliable Information and Clarify Any Misconceptions
Explain the Process of Reimaging (Refer to Key Concepts—Loss of Body Parts or Functions)
Explain that reimaging oneself after a loss of appearance or function is distinct and unique.
Advise that the process takes at least 1 year.
Assist client to examine societal homophobia and its results, so it is not internalized. Link him or her to appropriate groups and organizations.
Provide maternal education and a sound supportive system, which includes alternatives for care of the infant when delivered.
Provide education and refer to support groups that promote empowerment and change of focus to assist in evaluating and raising quality of life.
Help Client to Identify Positive Attributes and Possible New Opportunities
Assist with Hygiene and Grooming, as Needed
Encourage Visitors
Help Client Identify Strategies to Increase Independence and to Maintain Role Responsibilities
Prioritizing activities
Using mobility aids and assistive devices, as needed
Discuss with Client’s Support System the Importance of Communicating the Client’s Value and Importance to Them
Assess for Signs and Symptoms. Use the Focus Assessment Criteria to Isolate Signs and Symptoms. Refer to the Defining Characteristics of Disturbed Self-Esteem, Disturbed Body Image, and Ineffective Role Performance. After Confirmation, Use Interventions Under the Diagnosis
Initiate Health Teaching, as Indicated
Teach person what community resources are available, if needed (eg, mental health centers, self-help groups such as Reach for Recovery, Make Today Count).
Refer to specific health teaching issues under Disturbed Body Image, Disturbed Self-Esteem (Chronic and Situational).
Encourage Professional Counseling for Victims of Abuse, Violence, Cultism, or Unresolved Grief
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Rationales
  • Frequent contact by the caregiver indicates acceptance and may facilitate trust. The client may be hesitant to approach the staff because of negative self-concept.
  • Encouraging the client to share feelings can provide a safe outlet for fears and frustrations and can increase self-awareness.
  • Misconceptions can increase anxiety and damage self-concept needlessly.
  • The client may tend to focus only on the change in self-image and not on the positive characteristics that contribute to the whole concept of self. The nurse must reinforce these positive aspects and encourage the client to reincorporate them into the new self-concept.
  • Participation in self-care and planning can aid positive coping.
  • Frequent visits by support people can help the client feel that he or she is still a worthwhile, acceptable person, which should promote a positive self-concept.
  • A strong component of self-concept is the ability to perform functions expected of one’s role, thus decreasing dependency and reducing the need for others’ involvement.
  • Communication of the client’s values enhances self-esteem and promotes adjustment.
  • Optimism enhances social relationships and enables a person to make more effective use of social supports to maintain self-esteem. Supportive friends and family can bolster self-esteem by reinforcing a sense of personal control through suggestions and resources and a sense of confidence (Morse, 1997).
  • Addressing spiritual issues within the counseling process involves an accurate assessment of spiritual functioning and relevant interventions used with discretion and respect for client beliefs.
  • Nurses must receive adequate education and keep their knowledge updated. Nurses should receive regular clinical supervision and support to ensure that they can provide therapeutic care for patients with self-concept disturbances.
Rationales
  • It is more helpful to be specific and descriptive when praising a child rather than describing behavior as “good” or “bad”.
  • Allowing the child to describe the experience supports that he or she is unique.
  • The nurse can provide information that helps the child make sense of the situation by linking the present or future experience to past experience.
  • Positive self-talk denotes optimism to the child.
  • Allowing the child choices and productive play can enhance self-concept.
  • Skill building and positive social relationships increase a child’s sense of value and worth (Wong, 2003).
Footnote
*These diagnoses are not currently on the NANDA list but have been included for clarity or usefulness.