| Phase | Assessment | Nursing Care Plan/Implementation |
|---|
| Acute shock | Anxiety, numbness, helplessness. | - Provide sustained support, be available to listen, express interest and concern.
- Allow time for silence and privacy.
|
| Denial | Retreats from reality; fantasy about the wholeness and capability of the body; euphoria; rationalization; refusal to participate in self-care. | - Accept denial without reinforcing it. Avoid arguing and overloading with reality. Gradually raise questions, reply with doubt to convey unrealistic ideas.
- Follow client’s suggestions for personal-care routine to help increase feelings of adequacy and to decrease helplessness.
|
| Acknowledgment of reality | Grief over loss of valued body part, function, or role; depression, apathy; agitation, bitterness; physical symptoms (insomnia, anorexia, nausea, crying) serve as outlet for feeling; redefinition of body structure and function, with implications for change in lifestyle; acceptance of and cooperation with realistic goals for care and treatment; preoccupation with body functions. | - Expect and accept displacement onto nurse of anger, resentment, projection of client’s inadequacy.
- Examine own behavior to see if client’s remarks are justified.
- Simply listen if this is the only way the client can handle feelings at this time.
- Offer sustained, nonjudgmental listening without being defensive or taking remarks personally.
- Help dispel anger by encouraging its ventilation.
- Encourage self-care activities.
- Support family members as they cope with changes in client’s health or body image, role changes, treatment plans.
|
| Resolution and adaptation | Perceives crisis in new light; increased mastery leads to increased self-worth; can look at, feel, and ask questions regarding altered body part; tests others’ reactions to changed body; repetitive talk on painful topic of changed self; concentration on normal functions in order to increase sense of control. | - Teaching and counseling by same nurse in warm, supportive relationship.
- Assess level of knowledge; begin at that level.
- Consider motivational state.
- Provide gradual, nontechnical medical information and specific facts.
- Repeat instructions frequently, patiently, consistently.
- Support sense of mastery in self-care; draw on inner resources.
- Do not discourage dependence while gradually encouraging independence.
- Focus on necessary adaptations of lifestyle due to realistic limitations.
- Provide follow-up care via referral to community resources after client is discharged.
|
From © Lagerquist, S: Nursing Examination Review, ed 4. Addison-Wesley, Redwood City, CA.