NCLEX: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

The chief objective of this chapter is to highlight the most commonly observed behavioral and emotional problems and disorders in the mental health field. The emphasis is on (a) main points for assessment, (b) analysis of data based on underlying basic concepts and general principles drawn from a psychodynamic and interpersonal theoretical framework, and (c) nursing interventions based on the therapeutic use of self as the cornerstone of a helping process. Nursing actions are listed in priority whenever possible. Hence the nursing process framework is followed throughout. Note that nursing interventions are divided into planning and implementation (covering long-term and short-term goals and stressing priority of actions) and health teaching. Evaluation of results is listed separately, although this step of the nursing process is circular and relates back to “assessment” and “goals.”

The categorization of psychiatric-emotional disorders can be complex and controversial. For purposes of clarity and simplicity, an attempt has been made here to capsulize many theoretical principles and component skills of the helping process that these disorders have in common. That the term client is often used in place of patient reflects the interpersonal rather than medical model of psychiatric nursing. The diagnostic categorization of disorders (based on a synthesis of the North American Nursing Diagnosis Association [NANDA], Psychiatric Nursing Diagnosis [PND-I], and American Nurses Association [ANA] classification system for psychiatric nursing diagnoses) is included here to update the reader in current terminology in the mental health field.

The underlying organizational framework for this chapter is based on applicable categories of client needs and subneeds from the official NCLEX-RN® Test Plan.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: PSYCHOSOCIAL GROWTH AND DEVELOPMENT

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Major Theoretical Models

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span


  • Assumptions and key ideas:
    1. No human behavior is accidental; each psychic event is determined by preceding ones.
    2. Unconscious mental processes occur with great frequency and significance.
    3. Psychoanalysis is used to uncover childhood trauma, which may involve conflict and repressed feelings.
    4. Psychoanalytic methods are used: therapeutic alliance, transference, regression, dream association, catharsis.
  • Freud—shifted from classification of behavior to understanding and explaining in psychological terms and changing behavior under structured conditions.
    1. Structure of the mind: id, ego, superego; unconscious, preconscious, conscious.
    2. Stages of psychosexual development (Freud’s Stages of Psychosexual Development).
    3. Defense mechanisms.

II. PSYCHOSOCIAL DEVELOPMENT MODEL (Erikson, Maslow, Piaget, Duvall)

  • Erik Erikson—Eight Stages of Man (1963)
    1. Psychosocial development—interplay of biology with social factors, encompassing total life span, from birth to death, in progressive developmental tasks.
    2. Stages of life cycle—life consists of a series of developmental phases (Erikson’s Stages of the Life Cycle and Summary of Theories of Psychosocial Development Throughout the Life Cycle).
    a. Universal sequence of biological, social, psychological events.
    b. Each person experiences a series of normative conflicts and crises and thus needs to accomplish specific psychosocial tasks.
    c. Two opposing energies (positive and negative forces) coexist and must be synthesized.
    d. How each age-specific task is accomplished influences the developmental progress of the next phase and the ability to deal with life.
  • Abraham Maslow—Hierarchy of Needs (1962)
    1. Beliefs regarding emotional health based on a comprehensive, multidisciplinary approach to human problems, involving all aspects of functioning.
    a. Premise: mental illness cannot be understood without prior knowledge of mental health.
    b. Focus: positive aspects of human behavior (e.g., contentment, joy, happiness).

2. Hierarchy of needs—physiological, safety, love and belonging, self-esteem and self-recognition, self-actualization, aesthetic. As each stage is mastered, the next stage becomes dominant (Fig. 10.1).
3. Characteristics of optimal mental health—keep in mind that wellness is on a continuum with cultural variations.
a. Self-esteem: entails self-confidence and self-acceptance.
b. Self-knowledge: involves accurate self perception of strengths and limitations.
c. Satisfying interpersonal relationships: able to meet reciprocal emotional needs through collaboration rather than by exploitation or power struggles or  jealousy; able to make full commitments in close relationships.
d. Environmental mastery: can adapt, change, and solve problems effectively; can make decisions, choose from alternatives, and predict consequences. Actions are conscious, not impulsive.                                                                                                                                                           e. Stress management: can delay seeking gratification and relief; does not blame or dwell on past; assumes self-responsibility; either modifies own expectations, seeks substitutes, or withdraws from stressful situation when cannot reduce stress.

  • Jean Piaget—Cognitive and Intellectual Development (1963)
    1. Assumptions—child development is steered by interaction of environmental and genetic influences; therefore, focus is on environmental and social forces (see  Summary of Theories of Psychosocial Development Throughout the Life Cycle for comparison with other theories).
    2. Key concepts:
    a. Assimilation: process of acquiring new knowledge, skills, and insights by using what the child already knows and has.
    b. Accommodation: adjusts to change by solving previously unsolvable problems because of newly assimilated knowledge.

c. Adaptation: coping process to handle environmental demands.
3. Age-specific developmental levels—sensorimotor, preconceptual, intuitive, concrete, formal operational thought (Piaget’s Age-Specific Development Levels).


Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span


Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span


  • E. M. Duvall—Family Development (1971)—
    developmental tasks are family oriented, presented
    in eight stages throughout the life cycle.
    1. Married couple:
    a. Establishing relationship.
    b. Defining mutual goals.
    c. Developing intimacy: issues of dependence independence- interdependence.
    d. Establishing mutually satisfying relationship.

e. Negotiating boundaries of couple with families.
f. Discussing issue of childbearing.

2. Childbearing years:
a. Working out authority, responsibility, and caregiver roles.
b. Having children and forming new unit.
c. Facilitating child’s trust.
d. Need for personal time and space while sharing with each other and child.

3. Preschool-age years:
a. Experiencing changes in energy.
b. Continuing development as couple, parents, family.
c. Establishing own family traditions without guilt related to breaks with tradition.


Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span


4. School-age years:
a. Establishing new roles in work.
b. Children’s school activities interfering with family activities.

5. Teenage years:
a. Parents continue to develop roles in community other than with children.
b. Children experience freedom while accepting responsibility for actions.
c. Struggle with parents in emancipation process.
d. Family value system is challenged.
e. Couple relationships may be strong or weak depending on responses to needs.

6. Families as launching centers:
a. Young adults launched with rites of passage.
b. Changes in couple’s relationship due to empty nest and increased leisure time.
c. Changes in relationship with children away from home.

7. Middle-aged parents: Dealing with issues of aging of own parents.

8. Aging family members:
a. Sense of accomplishment and desire to continue to live fully.
b. Coping with bereavement and living alone.

III. COMMUNITY MENTAL HEALTH MODEL (Gerald Kaplan)—levels of prevention

  • Primary prevention—lower the risk of mental illness and increase capacity to resist contributory influences by providing anticipatory guidance and maximizing strengths.
  • Secondary prevention—decrease disability by shortening its duration and reducing its severity through detection of early-warning signs and effective intervention following case-finding.
  • Crisis intervention.
  • Tertiary prevention—avoid permanent disorder through rehabilitation.

IV. BEHAVIORAL MODEL (Pavlov, Watson, Wolpe, Skinner)

  • Assumptions:
    1. Roots in neurophysiology (i.e., neurotransmitter functions versus effects).
    2. Stimulus-response learning can be conditioned through reinforcement.
    3. Behavior is what one does.
    4. Behavior is observable, describable, predictable, and controllable.
    5. Classification of mental disease is clinically useless, only provides legal labels.
  • Aim: change observable behavior. There is no underlying cause, no internal motive.

V. COMPARISON OF MODELS: see Summary of Theories of Psychosocial Development Throughout the Life Cycle for comparison of four theories.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Body Image Development and Disturbances Throughout the Life Cycle

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

I. DEFINITION— “Mental picture of body’s appearance; an interrelated phenomenon which includes the surface, depth, internal and postural picture of the body, as well as the attitudes, emotions, and personality reactions of the individual in relation to his body as an object in space, apart from all others.”*


Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Body image is created by social interaction.
    1. Approval given for “normal” and “proper” appearance, gestures, posture, etc.
    2. Behavioral and physical deviations from normality not given approval.
    3. Body image formed by the person’s response to the approval and disapproval of others.
    4. Person’s values, attitudes, and feelings about self continually evolving and unconsciously integrated.
  • Self-image, identity, personality, sense of self, and body image are interdependent.
  • Behavior is determined by body image.


Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Image of self changes with changing posture (walking, sitting, gestures).
  • Mental picture of self may not correspond with the actual body; subject to continual but slow revision.
  • The degree to which people like themselves (good self-concept) is directly related to how well defined they perceive their body image to be.
    1.Vague, indefinite, or distorted body image correlates with the following personality traits:
    a. Sad, empty, hollow feelings.
    b. Mistrustful of others; poor peer relations.
    c. Low motivation.
    d. Shame, doubt, sense of inferiority, poor self-concept.
    e. Inability to tolerate stress.
    2. Integrated body image tends to correlate positively with the following personality traits:
    a. Happy, good self-concept.
    b. Good peer relations.
    c. Sense of initiative, industry, autonomy, identity.
    d. Able to complete tasks.
    e. Assertive.
    f. Academically competent; high achievement.
    g. Able to cope with stress.
  • Child’s concept of body image can indicate degree of ego strength and personality integration; vague, distorted self-concept may indicate schizophrenic processes.
  • Successful completion of various developmental phases determines body concept and degree of body boundary definiteness.
  • Physical changes of height, weight, and body build lead to changes in perception of body appearance and of how body is used.
  • Success in using one’s body (motor ability) influences the value one places on self (self-evaluation).
  • Secondary sex characteristics are significant aspects of body image (too much, too little, too early, too late, in the wrong place, may lead to disturbed body image). Sexual differences in body image are in part related to differences in anatomical structure and body function, as well as to contrasts in lifestyles and cultural roles.
  • Different cultures and families value bodily traits and bodily deviations differently.
  • Different body parts (e.g., hair, nose, face, stature, shoulders) have varying personal significance; therefore, there is variability in degree of threat, personality integrity, and coping behavior.
  • Attitudes concerning the self will influence and be influenced by person’s physical appearance and ability. Society has developed stereotyped ideas regarding outer body structure (body physique) and inner personalities (temperament). Current stereotypes are:
    1. Endomorph—talkative, sympathetic, good natured, trusting, dependent, lazy, fat.
    2. Mesomorph—adventuresome, self-reliant, strong, tall.
    3. Ectomorph—thin, tense and nervous, suspicious, stubborn, pessimistic, quiet.
  • Person with a firm ego boundary or body image is more likely to be independent, striving, goal oriented, influential. Under stress, may develop
    skin and muscle disease.
  • Person with poorly integrated body image and weak ego boundary is more likely to be passive, less goal oriented, less influential, more prone to external pressures. Under stress, may develop heart and GI diseases.
  • Any situation, illness, or injury that causes a change in body image is a crisis, and the person will go through the phases of crisis in an attempt to reintegrate the body image (Four Phases of Body Image Crisis).

IV. ASSESSMENT: (Body Image Development and Disturbance Throughout the Life Cycle: Assessment).

V. ANALYSIS/NURSING DIAGNOSISbody image development disturbance may be related to:

  • Obvious loss of a major body part—amputation of an extremity; hair, teeth, eye, breast.
  • Surgical procedures in which the relationship of body parts is visibly disturbed—colostomy, ileostomy, gastrostomy, ureteroenterostomy.
  • Surgical procedures in which the loss of body parts is not visible to others—hysterectomy, lung, gallbladder, stomach.
  • Repair procedures (plastic surgery) that do not reconstruct body image as assumed—rhinoplasty, plastic surgery to correct large ears, breasts.
  • Changes in body size and proportion—obesity, emaciation, acromegaly, gigantism, pregnancy, pubertal changes (too early, too late, too big, too small, too tall, too short).
  • Other changes in external body surface—hirsutism in women, mammary glands in men.
  • Skin color changes—chronic dermatitis, Addison’s disease.
  • Skin texture changes—scars, thyroid disease, excoriative dermatitis, acne.
  • Crippling changes in bones, joints, muscles— arthritis, multiple sclerosis, Parkinson’s disease.
  • Failure of a body part to function—quadriplegia, paraplegia, stroke (brain attack).

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span


Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span


Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span


Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Distorted ideas of structure, function, and significance stemming from symbolism of disease seen in terms of life and death when heart or lungs are afflicted—heart attacks, asthmatic attacks, pneumonia.
  • Side effects of drug therapy—moon facies, hirsutism, striated skin, changes in body contours.
  • Violent attacks against the body—incest, rape, shooting, knifing, battering.
  • Mental, emotional disorders—schizophrenia with depersonalization, somatic delusions, and hallucinations about the body; anorexia nervosa, hypochondriasis; hysteria, malingering.
  • Diseases requiring isolation may convey attitude that body is undesirable, unacceptable— tuberculosis, AIDS, malodorous conditions (e.g., gangrene, cancer).
  • Women’s movement and sexual revolution—use of body for pleasure, not just procreation, sexual freedom, wide range of normality in sex practices, legalized abortion.
  • Medical technology—organ transplants, lifesaving but scar-producing burn treatment, alive but hopeless, alive but debilitated with chronic illnesses.


Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Protect from psychological threat related to impaired self-attitudes.
    1. Emphasize person’s normal aspects.
    2. Encourage self-performance.
  • Maintain warm, communicating relationship.
    1. Encourage awareness of positive responses from others.
    2. Encourage expression of feelings.
  • Increase reality perception.
    1. Provide reliable information about health status.
    2. Provide kinesthetic feedback to paralyzed part
    (e.g., “I am raising your leg.”).
    3. Provide perceptual feedback (e.g., touch,
    describe, look at scar).
    4. Support a realistic assessment of the situation.
    5. Explore with the client his or her strengths and
  • Help achieve positive feelings about self, about adequacy.
    1. Support strengths despite presence of handicaps.
    2. Assist client to look at self in totality rather than focus on limitations.
  • Health teaching:
    1. Teach client and family about expected changes in functioning.
    2. Explain importance of maintaining a positive self-attitude.
    3. Advise that negative responses from others be regarded with minimum significance.


Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Able to resume function in activities of daily living rather than prolonging illness.
  • Able to accept limits imposed by physical or mental conditions and not attempt unrealistic tasks.
  • Can shift focus from reminiscence about the healthy past to present and future.
  • Less verbalized discontent with present body; diminished display of self-displeasure, despair, weeping, and irritability.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Body Image Disturbance—Selected Examples

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

I. DEFINITION—a body image disturbance arises when a person is unable to accept the body as is and to adapt to it; a conflict develops between the body as it actually is and the body that is pictured mentally— that is, the ideal self.

II. ANALYSIS/NURSING DIAGNOSIS: body image disturbance may be related to:

  • Sensation of size change due to obesity, pregnancy, weight loss.
  • Feelings of being dirty—may be imaginary due to hallucinogenic drugs, psychoses.
  • Dual change of body structure and function due to trauma, amputation, stroke, etc.
  • Progressive deformities due to chronic illness, burns, arthritis.
  • Loss of body boundaries and depersonalization due to sensory deprivation, such as blindness, immobility, fatigue, stress, anesthesia. May also be due to psychoses or hallucinogenic drugs.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Body Image Disturbance Caused by Amputation

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Assessment:
    1. Loss of self-esteem; feelings of helplessness, worthlessness, shame, and guilt.
    2. Fear of abandonment may lead to appeals for sympathy by exhibiting helplessness and vulnerability.
    3. Feelings of castration (loss of self) and symbolic death; loss of wholeness.
    4. Existence of phantom pain (most clients).
    5. Passivity, lack of responsibility for use of disabled body parts.
  • Nursing care plan/implementation:
    1. Avoid stereotyping person as being less competent now than previously by not referring to client as the “amputee.”

2. Foster independence; encourage self-care by assessing what client can do for himself or herself.
3. Help person set realistic short-term and long-term goals by exploring with the client his or her strengths and resources.
4. Health teaching:
a. Encourage family members to work through their feelings, to accept person as he or she presents self.
b. Teach how to set realistic goals and limitations.
c. Explain what phantom pain is; that it is a normal experience.
d. Explain role and function of prosthetic devices, where and how to obtain them, and how to find assistance in their use.

  • Evaluation/outcome criteria:
    1. Can acknowledge the loss and move through three stages of mourning (shock and disbelief, developing awareness, and resolution).
    2. Can discuss fears and concerns about loss of body part, its meaning, the problem of compensating for the loss, and reaction of persons (repulsion, rejection, and sympathy).

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Body Image Disturbance in Brain Attack (Stroke)

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Assessment:
    1. Feelings of shame (personal, private, self judgment of failure) due to loss of bowel and bladder control, speech function.
    2. Body image boundaries disrupted; contact with environment is hindered by inability to ambulate or manipulate environment physically; may result in personality deterioration due to diminished number of sensory experiences. Loses orientation to body sphere; feels confused, trapped in own body.
  • Nursing care plan/implementation:
    1. Reduce frustration and infantilism due to communication problems by:
    a. Rewarding all speech efforts.
    b. Listening and observing for all nonverbal cues.
    c. Restating verbalizations to see if correct meaning is understood.
    d. Speaking slowly, using two- to three-word sentences.
    2. Assist reintegration of body parts and function; help regain awareness of paralyzed side by:
    a. Tactile stimulation.
    b. Verbal reminders of existence of affected parts.

c. Direct visual contact via mirrors and grooming.
d. Use of safety features (e.g., Posey belt).
3. Health teaching: control of bowel and bladder function; how to prevent problems of immobility.

  • Evaluation/outcome criteria: dignity is maintained while relearning to control elimination.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Body Image Disturbance in Myocardial Infarction

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Emotional problems (e.g., anxiety, depression, sleep disturbance, fear of another myocardial infarction [MI]) during convalescence can seriously hamper rehabilitation.
The adaptation and convalescence are influenced by the multiple symbolic meanings of the heart, for example:

1. Seat of emotions (love, pride, fear, sadness).
2. Center of the body (one-of-a-kind organ).
3. Life itself (can no longer rely on the heart; failure of the heart means failure of life).

  • Assessment:
    1. Attitude—overly cautious and restrictive; may result in boredom, weakness, insomnia, exaggerated dependency.
    2. Acceptance of illness—use of denial may result in noncompliance.
    3. Behavior—self-destructive.
    4. Family conflicts—related to activity, diet.
    5. Effects of MI on:
    a. Changes in lifestyle—eating, smoking, drinking; activities, employment, sex.
    b. Family members—may be anxious, overprotective.
    c. Role in family—role reversal may result in loss of incentive for work.
    d. Dependence-independence—issues related to family conflicts (especially restrictive attitudes about desirable activity and dietary regimen).
    e. Job—social pressure to “slow down” may result in loss of job, reassignment, forced early retirement, “has-been” social status.


  • Nursing care plan/implementation:
    1. Prevent “cardiac cripple” by shaping person’s and family’s attitude toward damaged organ.
    a. Instill optimism.
    b. Encourage productive living rather than inactivity.
    2. Set up a physical and mental activity program with client and mate.
    3. Provide anticipatory guidance regarding expected weakness, fear, uncertainty.
    4. Health teaching: nature of coronary disease, interpretation of medical regimen, effect on sexual behavior.


  • Evaluation/outcome criteria:
    1. Adheres to medical regimen.
    2. Modifies lifestyle without becoming overly dependent on others.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Body Image and Obesity

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Definition: body weight exceeding 20% above the norm for person’s age, sex, and height constitutes obesity. Body mass index (BMI) is also used. Although a faulty adaptation, obesity may serve as a protection against more severe illness; it represents an effort to function better, be powerful, stay well, or be less sick. The problem may not be difficulty in losing weight; reducing may not be the appropriate cure.


  • Assessment—characteristics:
    1. Age—one out of three persons under 30 years of age is more than 10% overweight.
    2. Increase risks for stroke, MI, diabetes.
    3. Feelings: self-hate, self-derogation, failure, helplessness; tendency to avoid clothes shopping and mirror reflections.
    4. Viewed by others as ugly, repulsive, lacking in will power, weak, unwilling to change, neurotic.
    5. Discrepancy between actual body size (real self) and person’s concept of it (ideal self).
    6. Pattern of successful weight loss followed quickly and repetitively by failure; that is, weight gain.
    7. Eating in response to outer environment (e.g., food odor, time of day, food availability, degree of stress, anger); not inner environment (hunger, increased gastric motility).
    8. Experiences less pleasure in physical activity; less active than others.
    9. All people who are obese are not the same.
    a. In newborns and infants who are obese, there is an increased number of adipocytes via hyperplastic process.
    b. In adults who are obese, there may be increased body fat deposits, resulting in increased size of adipocytes via hypertrophic process.
    c.When an infant who is obese becomes an adult who is obese, the result may be an increased number of cells available for fat storage.
    10. Loss of control of own body or eating behavior.


  • Analysis/nursing diagnosis: defensive coping related to eating disorder. Contributing factors:
    1. Genetic.
    2. Thermodynamic.
    3. Endocrine.
    4. Neuroregulatory.
    5. Biochemical factors in metabolism.

6. Ethnic and family practices.
7. Psychological:
a. Compensation for feelings of helplessness and inadequacy.
b. Maternal over protection; overfed and force-fed, especially infants who are formula-fed.
c. Food offered and used to relieve anxiety, frustration, anger, and rage can lead to difficulty in differentiating between hunger and other needs.
d. As a child, food offered instead of love.
8. Social:
a. Food easily available.
b. Use of motorized transportation and labor-saving devices.
c. Refined carbohydrates.
d. Social aspects of eating.
e. Restaurant meals high in salt, sugar, trans-fats, and larger portions.


  • Nursing care plan/implementation:
    1. Encourage prevention of lifelong body image problems.
    a. Support breastfeeding, where infant determines quantity consumed, not mother; work through her feelings against breastfeeding (fear of intimacy, dependence, feelings of repulsion, concern about confinement, and inability to produce enough milk).
    b. Help mothers to not overfeed the infant if formula-fed: suggest water between feedings; do not start solids until 6 months old or 14 pounds; do not enrich the prescribed formula.
    c. Help mothers differentiate between hunger and other infant cries; help mothers to try out different responses to the expressed needs other than offering food.
    2. Use case findings of infants who are obese, as well as young children, and adolescents.
    3. Assess current eating patterns.
    4. Identify need to eat, and relate need to preceding events, hopes, fears, or feelings.
    5. Employ behavior modification techniques.
    6. Encourage outside interests not related to food or eating.
    7. Alleviate guilt, reduce stigma of being obese.
    8. Health teaching:
    a. Promote awareness of certain stressful periods that can produce maladaptive responses such as obesity (e.g., puberty, post-nuptial, postpartum, menopause).
    b. Assist in drawing up a meal plan for slow, steady weight loss.
    c. Advise eating five small meals a day and increase exercises.
  • Evaluation/outcome criteria: goal for desired weight is reached; weight-control plan is continued.













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