Nursing Care Plan: Disturbed Personal Identity

The nursing diagnosis Disturbed Personal Identity is defined by NANDA as the inability to distinguish between self and nonself.

Disturbed Personal Identity Related To (Etiology)

  • Biochemical imbalance
  • Impaired neurologic development or dsyfunction
  • Failure to develop attachment behaviors resulting in fixation at autistic phase of development
  • Interrupted or uncompleted seperation/individuation process resulting in extreme seperation anxiety
As Evidenced By (Assessment Findings/Diagnostic Cues)
  • Seemingly unaware of or uninterested in others or their activities
  • Unable to identify parts of the body or bodily sensations (enuresis, encopresis)
  • Fails to imitate others or not able to stop imitating other’s actions or words (echolalia, echopraxis)
  • Fails to distinguish parent/caregiver as a whole person, instead relates to body parts (e.g., takes person’s hand and places it on doorknob)
  • Becomes distressed by bodily contract with others
  • Spends long periods of time in self-stimulating behaviors (self-touching,sucking,rocking)
  • Needs ritualistic behaviors and sameness to control anxiety
  • Has extreme distress reactions to changes in routines or the environment
  • Cannot tolerate being separated from parent/caregiver

Disturbed Personal Identity Nursing Care Plan Outcome Criteria

  • Demonstrate recognition of self-boundaries and being separate from others
Long-Term Goals
Child will:
  • Adjust to changes in activities and the environment within 9 months
Short-Term Goals
Child will:
  • Seek comfort and physical contact from others within 1 to 2 months
  • Relate to caregiver by name with eye contract and verbal requests within 6 months
  • Recognize body parts, body boundaries, and sexual identity within 6 months
  • Show an interest in the activities of others and tolerate their presence within 3 to 6 months
  • Spend more time in purposeful activities rather than rituals and self-stimulating activities in 2 to 6 months
  • Recognize body sensations (pain, hunger, fatigue, elimination needs)within 2 to 6 months
  • Express a full range of feelings within 4 to 6 months
  • Recognize the feelings and activities of others as separate within 6 months
  • Adjust to changes in activities and the environment within 5 to 9 months

Disturbed Personal Identity Nursing Interventions and Rationales

  1. Use one-on-one interaction to engage the client in a safe relationship with nurse/caregiver. R: A consistent caregiver provides for the development of trust needed for a sense of safety and security.
  2. Use names and descriptions of others to reinforce their separateness. R: Consistent reinforcement will help break into the client’s autistic world.
  3. Draw the client’s attention to the activities of others and events that are happening in the environment. R: Interrupts the client’s self-absorption and stimulates outside interests.
  4. Limit self-stimulating and ritualistic behaviors by providing alternative play activities or by providing comfort when stressed. R: Redirecting the client’s attention to favorite or new activities, or giving comfort, reduces anxiety.
  5. Foster self-concept development; reinforce identity; sexual identity, and body boundaries through drawing, stories, and play activities. R: Learning body parts and sexual identity is necessary and fun in play activities.
  6. Help client distinguish body sensations and how to meet bodily needs by picking up on cues and using ADLs to teach self-care. R: The lack of self-awareness contributes to problems with self-care, especially toileting.
  7. Provide play opportunities for the client that identify the feelings of others (stories, puppet play, peer interactions). R: Consistent feedback about the feelings of others helps with self-differentiation and the development of empathy.

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*Nursing Care Plan for Disturbed Personal Identity

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