NURSING DIAGNOSIS: Self-concept disturbance*

related to:
  1. changes in appearance (e.g. periocular edema and ecchymosis, skull indentation, loss of scalp hair);
  2. dependence on others to meet basic needs
  3. anticipated changes in lifestyle and roles associated with changes that occur as a result of cerebral tissue damage (e.g. impaired motor and sensory function, altered thought processes).

*This diagnostic label includes the nursing diagnoses of body image disturbance, self-esteem disturbance, and altered role performance.

Desired Outcome
The client will demonstrate beginning adaptation to changes in appearance, physical and cognitive functioning, lifestyle, and roles as evidenced by:
  1. verbalization of feelings of self-worth
  2. maintenance of relationships with significant others
  3. active participation in activities of daily living
  4. verbalization of a beginning plan for adapting lifestyle to changes resulting from the underlying disease process and/or residual effects of the surgery.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for signs and symptoms of a self-concept disturbance (e.g. verbalization of negative feelings about self, withdrawal from significant others, lack of participation in activities of daily living, lack of plan for adapting to necessary changes in lifestyle).
  2. Be aware that client may recognize and grieve for the losses experienced. Provide support during the grieving process.
  3. Discuss with client improvements in appearance and neurological function that can realistically be expected.
  4. If periocular edema and ecchymosis are present:
    1. reinforce that they are temporary (edema usually begins to subside 48-72 hours after surgery and ecchymosis usually disappears in 10-14 days)
    2. instruct client in and assist with measures to reduce swelling (e.g. cold compresses to affected area, lying on unoperative side unless contraindicated, keeping head of bed elevated 30° unless contraindicated).
  5. Implement measures to reduce client's embarrassment about partial or total loss of hair and misshapen skull if bone flap was not replaced (e.g. provide client with a surgical cap, turban, hat, or scarf; assist client to obtain a wig or hairpiece to wear after the incision has healed). Reinforce the fact that the hair will grow back and encourage client to discuss with physician the possibility of a cranioplasty in the future to restore the original shape of the skull.
  6. Discuss techniques the client can utilize to adapt to altered thought processes if present:
    1. encourage client to make lists and jot down messages and to refer to these rather than relying on memory
    2. instruct the client to place self in a calm environment when making decisions
    3. encourage client to validate decisions, clarify information, and seek assistance to problem solve if indicated
    4. encourage client to schedule adequate rest periods and reduce stressors in order to decrease irritability.
  7. Support behaviors suggesting positive adaptation to changes that have occurred (e.g. scanning environment or wearing eyepatch if visual disturbances are present, utilizing alternative methods of communicating if speech is impaired, utilizing assistive devices to perform self-care activities).
  8. Encourage significant others to allow client to do what he/she is able so that independence can be re-established and/or self-esteem redeveloped.
  9. Assist client's and significant others' adjustment by listening, facilitating communication, and providing information.
  10. Assist client and significant others to have similar expectations and understanding of future lifestyle and to identify ways that personal and family goals can be adjusted rather than abandoned.
  11. Encourage client to continue involvement in social activities and to pursue usual roles and interests. If previous roles, interests, and hobbies cannot be pursued, encourage development of new ones.
  12. Provide information about and encourage utilization of community agencies and support groups (e.g. brain injury support groups; vocational rehabilitation; American Cancer Society; family, individual, and/or financial counseling) if appropriate.
  13. Consult appropriate health care provider (e.g. psychiatric nurse clinician, physician) about psychological counseling if client desires or seems unwilling or unable to adapt to changes resulting from the disease and/or the surgery.