Nurse's Pocket Guide

disturbed personal IDENTITY
• Note withdrawn/automatic behavior, regression to earlier
developmental stage, general behavioral disorganization, or
display of self-mutilation behaviors in adolescent or adult;
delayed development, preference for solitary play, display of
self-stimulation in child.
• Determine presence of hallucinations/delusions, distortions
of reality.
NURSING PRIORITY NO.2.To assist client to manage/deal with threat:
• Make time to listen to client, encouraging appropriate expression
of feelings, including anger and hostility.
• Provide calm environment. Helps client to remain calm and
able to discuss important issues related to the identity crisis.
• Use crisis-intervention principles to restore equilibrium
when possible.
• Discuss client’s commitment to an identity. Those who have
made a strong commitment to an identity tend to be more
comfortable with self and happier than those who have not.
• Assist client to develop strategies to cope with threat to identity.
Helps reduce anxiety and promotes self-awareness and
self-esteem.
• Engage client in activities to help in identifying self as an individual
(e.g., use of mirror for visual feedback, tactile stimulation).
• Provide for simple decisions, concrete tasks, calming activities.
• Allow client to deal with situation in small steps. May be
unable to cope with larger picture when in stress overload.
• Encourage client to develop/participate in an individualized
exercise program (walking is an excellent beginning).
• Provide concrete assistance, as needed (e.g., help with ADLs,
providing food).
• Take advantage of opportunities to promote growth. Realize that
client will have difficulty learning while in a dissociative state.
• Maintain reality orientation without confronting client’s irrational
beliefs. Client may become defensive, blocking opportunity
to look at other possibilities.
• Use humor judiciously, when appropriate.
• Discuss options for dealing with issues of sexual gender (e.g.,
therapy/gender-change surgery when client is a transsexual).
• Refer to NDs disturbed Body Image; Self-Esteem [specify];
Spiritual Distress.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/
Discharge Considerations):
• Provide accurate information about threat to and potential
consequences for individual. Helps client to make positive
decisions for future.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
432 Cultural Collaborative Community/Home Care