Alterations in Self-Concept

1. Assessment:
   1. Self-derisive; self-diminution; and criticism.
   2. Denies own pleasure due to need to punish self; doomed to failure.
   3. Disturbed interpersonal relationships (cruel, demeaning, exploitive of others; passive-dependent).
   4. Exaggerated self-worth or rejects personal capabilities.
   5. Feels guilty, worries (nightmares, phobias, obsessions).
   6. Sets unrealistic goals.
   7. Withdraws from reality with intense self-rejection (delusional, suspicious, jealous).
   8. Views life as either-or, worst-or-best, wrong or right.
   9. Postpones decisions due to ambivalence (procrastination).
   10. Physical complaints .
   11. Self-destructive (substance abuse or other destructiveness).
   
   
2. Analysis/nursing diagnosis: Altered self-concept may be related to:
   1. Low self-esteem that is related to parental rejection, unrealistic parental expectations, repeated failures.
   2. Altered personal identity (negative): self-rejection and self-hate related to unrealistic self-ideals.
   3. Identity confusion related to role conflict, role overload, and role ambiguity.
   4. Feelings of helplessness, hopelessness, worthlessness, fear, vulnerability, inadequacy related to extreme dependency on others and lack of personal responsibility.
   5. Disturbed body image.
   6. Depersonalization.
   7. Physiological factors that produce self-concept distortions (e.g., fatigue, oxygen and sensory deprivation, toxic drugs, isolation, biochemical imbalance).
   
   
3. Nursing care plan/implementation:
   1. Long-term goal: Facilitate client’s self-actualization by helping him or her to grow, develop, and realize potential while compensating for impairments.
   2. Short-term goals:
      1. Expand client’s self-awareness:
         1. Establish open, trusting relationship to reduce fear of interpersonal relationships.
            1. Offer unconditional acceptance.
            2. Nonjudgmental response.
            3. Listen and encourage discussion of thoughts, feelings.
            4. Convey that client is valued as a person, is responsible for self and able to help self.
         2. Strengthen client’s capacity for reality testing, self-control, and ego integration.
            1. Identify ego strengths.
            2. Confirm identity.
            3. Reduce panic level of anxiety.
            4. Use undemanding approach.
            5. Accept and clarify communication.
            6. Prevent isolation.
            7. Establish simple routine.
            8. Set limits on inappropriate behavior.
            9. Orient to reality.
            10. Activities: gradual increase; provide positive experiences.
            11. Encourage self-care; assist in grooming.
         3. Maximize participation in decision making related to self.
            1. Gradually increase participation in own care.
            2. Convey expectation of ultimate self-responsibility.
      2. Encourage client’s self-exploration.
         1. Accept client’s feelings and assist self-acceptance of emotions, beliefs, behaviors, and thoughts.
         2. Help clarify self-concept and relationship to others.
            1. Elicit client’s perception of own strengths and weaknesses.
            2. Ask client to describe: ideal self, how client believes he or she relates to other people and events.
         3. Nurse needs to be aware of own feelings as a model of behavior and to limit countertransference.
            1. Accept own positive and negative feelings.
            2. Share own perception of client’s feelings.
         4. Respond with empathy, not sympathy, with the belief that client is subject to own control.
            1. Monitor sympathy and self-pity by client.
            2. Reaffirm that client is not helpless or powerless but is responsible for own choice of maladaptive or adaptive coping responses.
            3. Discuss: alternatives, areas of ego strength, available coping resources.
            4. Use family and group-support system for self-exploration of client’s conflicts and maladaptive coping responses.
      3. Assist client in self-evaluation.
         1. Help to clearly define problem.
            1. Identify relevant stressors.
            2. Mutually identify: faulty beliefs, misperceptions, distortions, unrealistic goals, areas of strength.
         2. Explore use of adaptive and maladaptive coping responses and their positive and negative consequences:
      4. Assist client to formulate a realistic action plan.
         1. Identify alternative solutions to client’s inconsistent perceptions by helping him or her to change:
            1. Own beliefs, ideals, to bring closer to reality.
            2. Environment, to make consistent with beliefs.
         2. Identify alternative solutions to client’s self-concept not consistent with his or her behavior by helping him or her to change:
            1. Own behavior to conform to self-concept.
            2. Underlying beliefs.
            3. Self-ideal.
         3. Help client set and clearly define goals with expected concrete changes. Use role rehearsal, role modeling, and role playing to see practical, reality-based, emotional consequences of each goal.
      5. Assist client to become committed to decision to take necessary action to replace maladaptive coping responses and maintain adaptive responses.
         1. Provide opportunity for success and give assistance (vocational, financial, and social support).
         2. Provide positive reinforcement; strengths, skills, healthy aspects of client’s personality.
         3. Allow enough time for change.
      6. Health teaching: how to focus on strengths rather than limitations; how to apply reality oriented approach.
      
      
4. Evaluation/outcome criteria
   1. Client able to discuss perception of self and accept aspects of own personality.
   2. Client assumes increased responsibility for own behavior.
   3. Client able to transfer new perceptions into possible solutions, alternative behavior.