Extended body image in the ventilated patient

0266 612X/R9/0005

Extended

body image in the ventilated

OO3l/YIO.(Nl

patient

Sally Ann Smith

1

1

This paper explores the experience of altered body image in unexpected critical illness, with particular interest in the extended body image of ventilated patients. It examines from the patients perspective, the impact that ventilation within the intensive care environment, can have on an individuals body image. The concept is developed to explore nursing strategies aimed to support and promote a positive body image in ventilated patients. I

patient

INTRODUCTION ,Many

nurses

individuals

are aware

phantom

to these phenomena

loss of sensation,

Body

Cynthia

of central

her insight not ‘visualise

body

in relation

become

victims

have

sensations

when

(Leiderman,

Although pedantic

yet oblivious

veins

once

or imagine

to the bed’. body

to

re-sedated.

care nurse

the position

she

of her

that

time

intensive stantly

environment, outcomes fore

image,

nursing

the

Sally Ann Smith RGN DipN, Westminster Hospital, Dean Ryle Street, Horseferry Road, London, SW1 P 2AP (Requests for offprints to SAS) accepted

17 November

1988

perience

1980).

The

is a con-

personal

cannot

is complex

he

informa-

nature

of

which

at

body image, voice.

Because

and the patient

con-

as an ‘open system’ with the care it is difficult

to attribute

to any particular

strategies

Being

(Roberts,

and

the

boundaries

of this discussion

the individual

interacts

until

any other

of extended

therapy

altered may seem

one, because

way

disin iron

1979).

image

his body

of the unique

the experience

In some such stressin which

content

sequence of

reported

between

to assimilate

tion in a meaningful

ventilation

Manuscript

re-establishes

be unable

disEven

sleeping

body

it is an important

may

aware

distinction

and extended

to him

patient.

1958 in Ashworth,

this

body image individual

wears off. She was

as an intensive

extended

polio

the

be seen

for any ventilated

body

the

may

attached as a potentially

‘healthy’

and

autobiographical

people

of intubation

could

equipment emerges

orientated

speculative

as soon as sedation

ful situations

by

problem

From

mobility

permeable.

(1987)

that

conscious

Despite

in the critic-

is distorted

the ventilator

Smith’s

cannulation

is the

of self.

implies

their bodies starkly

and

become

perspective

account

Image’

tressing

lungs

Not dissimilar

feedback

function

boundaries

patient’s

side of

but less well recognised

of ‘Extended

iisan extension

a stroke

it is common

limb pain.

ally ill. Proprioceptive body

following

of the afIected

or that after amputation

to experience concept

that

lose perception

their body,

incorporates

into his body image,

which

successful

interventions.

underpin

the

Theretotality

of

care will be explored. on the receiving is an unpleasant so to mask

this

end of intubation

and

and

frightening

patients

are

ex-

heavily

sedated. In the acute stages of illness muscle relaxant drugs are given to conserve vital oxygen for cell metabolism. The individual is rendered 31

32

INTENSIVECARENURSING

immobile and his understanding of the environment fluctuates between unconsciousness and drowsy awareness. The culmination of these therapies intrudes into’ the established body image and its support strategies; perceptive ability is compromised by ventilator tubing which prevents the head from turning, so at best the visual field is restricted. More often muscle relaxants prevent spontaneous eye opening and relax the facial muscles so that the individual cannot express any emotion. This lack of feed-back can dissuade nurses, family and friends from providing the positive appraisals so badly needed to formulate a positive body image (Meisenhelder, 1985; Kunes Cannel, 1985). ‘Proprioception’ describes the conscious awareness of the body boundaries in space. Piagets developmental theory based on the study of children can be reapplied to critically ill people, suggesting that they regress to earlier developmental stages. An individual whose cognitive abilities are associated with the SensoriMotor stage may need to reidentify his body boundaries with touch (in much the same way as a child exploring his environment) before he can assimilate the meaning of language (Roberts, 1980). Therefore it cannot be assumed that the patient reaching his hand towards his endotracheal tube is intent on removing it. The nurse who supervises her patient exploring his environment through touch can protect his airway and still facilitate exploration of his environment. For the ventilated patient the biological significance attached to reliable lung function deteriorates as he loses his self confidence in breathing independently. Instead his confidence extends to the ventilator which is given a privileged position and becomes the focus of attention (Kleck, 1984; Carroll, 1986; Severino, 1980; Tourkow, 1974 in Platzer, 1986). Characteristic of Piaget’s Sensorimotor stage is ‘Object Consistency’ eliciting a response in the critically ill which may place ultimate importance in the ventilator remaining in the position it was first discovered. The nurse often adjusts the position of the ventilator to suit her own working needs. However the patient may view these seemingly innocent interventions as a threat or assault on his OWN body.

REDEFINING THE BODY BOUNDARIES In the acute stages of illness nursing strategies to promote normality are intent on helping the individual redefine his body boundaries and broadening his awareness of proprioception. A significant cause of extended body image is the sensory deprivation associated with immobility; therefore muscle relaxant drugs need to be used sparingly. The nurse advocates for their withdrawal as soon as oxygen saturation of the blood can be maintained at a satisfactory level. Passive limb exercises which place the limbs through their full range of motion will create the sensation of movement. Describing the area of the body being washed or repositioned will increase awareness of proprioception, as does the pressure from inflatable plastic splints used by Meekings (1981) to remind stroke patients of their weak limb. The individual who is recumbent but awake can be helped to gain a realistic perception of his body by reflecting his limbs, wounds and life support equipment in a mirror. Amongst the milieu of intensive care the use of touch is an innate nursing ability which can be developed to create therapeutic effects. The sensation of touch helps to re-establish body boundaries and its perceived intent can convey love, respect and value which fulfils the basic human need for self-esteem (Maslow, 1970). In a small study of institutionalised older adults Copstead (1980) found that those who experienced empathic touch possessed a greater self esteem than those rarely touched. A patient who can neither converse or see may become increasingly receptive to touch, making these findings especially relevant. To reap the benefits of touch however the patient needs to be familiarised with his care environment. Studies in the critical care setting propose that for touch to be therapeutic the crucial factor is whether its motivation revolves around physical procedures or striving to comfort (Weiss, 1986). Shortcomings in nursing practice within intensive care units were identified by Ashworth (1980j who observed that nurse-patient interactions were predominantly task orientated despite the nurse’s acknowledgement of the patient’s

INTENSIVE

emotional needs. Mills et al (1980) studied the effects of touch on coronary patients and concluded that if touch is interpreted as directing and controlling body function it can have detrimental effects causing coupled ectopic beats and tachycardias. This exemplifies the dynamic interaction between the biological and psychological systems and underlines the significance of an individual’s body perception. The patient’s unsophisticated perception of his body function may bear no resemblance to the nurse’s interpretation. It is often the practice in intensive care units to monitor cardiac functions by measuring central venous pressure and pulmonary capillary wedge pressure, and occasionally witness open heart surgery. The nurse builds up a multi-dimensional image of heart function which soon becomes second nature. In contrast Smith (1972) suggests that the heart is a crucial aspect of body image having emotional connotations with fear, love, pride and sadness. Most relevant to critical illness is the realistic belief that the patient only has one heart and its failure in any way means it is unrealiable, introducing the possibility of death. The need for intensive therapy including continuous and often invasive nursing procedures may reinforce the .changed body function. Purposeful nursing strategies unassociated with performing tasks can be initiated to minimise the impact of these fears. Holding the patients hand or stroking his arm is a simple non-intrusive way of showing empathy and concern. Cues can be found from observing the relatives behaviour to determine which body areas are socially acceptable to the patient to be touched. Weiss (1986) summarises that comfort orientated touch of short duration, light intensity and avoiding socially unacceptable areas will prevent arousal of the central nervous system into a stress response. Incorporating the relatives into this aspect of care will provide continuity with the patients real life and also fulfil their need to demonstrate care which Hampe (1975) found is felt acutely by relatives during the anticipatory grieving process.

CARE NURSING

33

WEANING FROM MECHANICAL VENTILATION The effect of extended body image is evident when weaning people from ventilators. Parsons (1964) has described the ‘sick role’ as passive and dependent so consequently there are difficulties when nurses become preoccupied with severing the patients’ connection with the machine. According to Seligman (1975) dependency produces fear, depression and loss of motivation to resume responsibility for physical functions; ‘learning that an outcome is independent of a response makes it more difficult to learn later that responses produce that outcome.’ Having been reassured by the presence of a ventilator the individual is frightened he will not be able to maintain his own respirations. From personal nursing experience Hanlon ( 1984) observes that although the nursing goal of weaning from ventilation may be achieved some individuals may remain overwhelmed by their helplessness and appear ‘suspended in a sort of no-man’s land’ unable to resume any self responsibility. Ventilated patients are highly dependent and it is easy for nurses to over-compensate for their disability. Carnes (1987) has compiled five introspective questions highlighting nursing actions which can foster unnecessary dependence: Are patients used to fulfil the nurses’ need to care? Are nurses performing care simply to save time when the patient could manage independently? Does nursing attention focus on the patients disability rather than what he can achieve? Is compliant behaviour praised by the nurse as it lets her care? Do nurses make decisions the patient is capable of making himself? Simple principles underpin the promotion of independence, even being given the opportunity to consent to a change in position constitutes a welcome independence to a ventilated patient. Attention can be focused on positive achievements. For instance, rather than focusing on the negative aspect of needing ventilation, attention can be transferred to the fact that the chest infection is resolving. However fears of weaning still need to be acknowledged. Reassurance that these are normal concerns and that the nurse is always near is

34

INTENSIVE

CARE NURSING

often all that is needed to help the patient cope. From repeated experiences of being ventilated for Status Asthmaticus, Cynthia Smith (1987) explains that when the effects of sedation were suddenly withdrawn it was such a shock to wake up to reality. In contrast the gradual withdrawal of sedation on previous occasions had made life so much easier. Practice demonstrates that mutual goal setting increases the patients confidence and autonomy to breathe alone (Hanlon, 1984; Carroll, 1986). For instance a patient with Guillain-Barre Syndrome has weak respiratory muscles following weeks of paralysing illness and ventilation. A contract can be negotiated between the nurse and the patient to alternate breathing spontaneously with ventilatory support on a specific time-frame basis.

ALTERED

BODY SENSATION

The ventilator is connected to the critically ill person via tubing and an endo-tracheal tube which is both internally invasive and violates the surrounding personal space. Patients who describe their memories of intensive care illustrate how these sensations can be misidentified. Kornfield (1969) reports the experiences of open heart surgery patients who felt the sensation of being ‘chained to their beds’. Ware and Chelgren (197 1) explain how a lady who was defibrillated for ventricular tachycardia and then ventilated in intensive care, felt she was about to slide down a chute and become ‘tinned like a sardine’, so she persistently clung to the bed rails for security. This behavioural pattern of ‘holding on’ to the bed rails is not an uncommon observation in nursing practice. Trying to extricate the patients hands from the rails may intensify their distress whereas offering nursing support may substitute the security offered by the bed rails. The disorganising effect of immobility combined with ventilation was first noticed when Poliomyelitis victims in iron lungs reported seeing ‘soldiers marching across the ceiling’ (Solomon et al, 1958). Experiments to explore the effects of immobility alone after just three hours bed rest in room fit volunteers experienced time, place and person (Downs,

found that even a single hospital disorientation of 1974). The indi-

vidual who appears confused when trying to get out of bed may really be trying to clarify his vivid sensory imagery. This attempt to establish ‘Sensoristasis’ is a human need defined by Schultz (1965) as ‘a drive state of cortical arousal which impels the organism (in a waking state) to strive to maintain an optimum level of sensory variwere ation’. In Downs’ study the participants often aware of their irrational thoughts and found this knowledge distressing. Therefore attempts to collude with these hallucinations will only increase patients’ stress. Reorientation should acknowledge the confusion and convey that these images are transient and will return to normal. The sensation of pain can demand all of the patient’s attention and distort his body image. This relationship between physical feelings and emotions is sometimes referred to as ‘dualism’ (McCaffrey, 1979). A ventilated patient with arterial disease is especially vulnerable to severe pain when the metabolic demands of a warm limb exceed the available oxygen supply (Hill, 1985). Distraction from self is a useful strategy to dissipate pain but difficult to employ in intensive care where there is a lack of pleasurable activities. Locsin’s ( 198 1) study found that music significantly reduced the physiological reactions to pain in female surgical patients who felt reassured and relaxed by its use. Hayward’s (1975) research suggests that relevant pre-operative information reduces the subsequent experience of pain, measurable by the amount of analgesia required. When applying this approach to a ventilated patient a difficulty arises when trying to assess his level of comprehension. Morphine derivatives are generally indicated and to avoid the ‘peak and trough’ effect they are delivered by continuous infusion (Wenger-Boyer, 1982). This requires the nurse to be especially vigilant to note changes in the patient as she relies on a machine to infuse the drug at the prescribed rate.

REALITY The

ORIENTATION

sensory environment

of intensive

care can

also be implicated in producing an extended body image. The well recognised state of delirium occurring three to 5 days after exposure to

INTENSIVE

this setting

is known

(Kornfield,

1969;

as ‘Intensive Kleck,

people with respiratory underpinned by metabolic which

mechanical

attempts

However

night

and the vulnerable body the

(1977) Diffusion’

the

patient

In

people

and

appreciation

and

and

feel-

Investigating that

care

conversation

most

where physical

associating

of nursing phrases

away’ and

‘packed

person-

the drug

cabinet

smith,

the

drowsy

which

tensive

care

Academia invasive,

and affords

body function

with

which

found

for nurses

within

sight of the patient.

jargonised

language

reasonably

be expected

how by in-

confusing, the

Clearly out

mis-

clinicians-(Phippen,

the patient

or

will promote can proand

be a

as lack of con-

these same qualities

seem

weak

to the nurses

1986).

to remind

Photographs

those delivering

‘personality’

gases pro-

knowledge

of

often incomways

must

of earshot

The use ofsimple the

to understand and recognition

patient

THE PATIENTS MECHANISMS feeling

care of

lying in the bed.

with

be yet

noncan

loss of body from

a serious

also protect found

body

evidence

and

heart

(1985)

his body. image

of denial

feeling

of being

ment.

Throughout

himself

open

Post-operatively feeling

moments

To

depersonalisation by referring name

sur-

describes

the

by the care

environregarding

clinicans

referred

not directly

things

and

alleviate

the nurse to the

and

of major

discussions

but

encouraging

cancer Kelly’s

to

affecting

he experienced

of saying later’.

lung

care

and

of the (1975)

Michael

account

‘engulfed’

interesting

constiit may

Zigler

in stroke,

intensive

he felt nurses

something

and

patients.

necessitating

Whilst

from the reality

autobiographical

gery

is the

the individual

disturbance

by Levine

disease

boundaries when

the individual A study

the ‘pecuhearing

these

them

feelings

can personalise

patient

using

open

of care

his preferred

visiting

for friends

and relatives. Sleep positive

will con-

rapid

of him as

optimism

Sweeny (1982) successfully of reality orientation when

COPING

of ‘depersonalisation’

situation.

liar

an individual. Nordhurft and employed methods

and

him.

patient.

and becomes

of blood

intimate

which

vey the nurses’ respect

visualise

illustrate

control

to converse

that by the

understood

is unavailable,

to the owner.

in fre-

a visit

subordinate analysis

right keys to

might

be

the nurse

clinician

prehensible

patient

even

found

she speculates

descriptions

for instance

the

she them

when

and

may

make

tuting

patterns

stat!’ were

is commonly nurses

informative

lost,

discussions

in jail! These

language

vides

were

providworn

of identity Just

and

are not seen as ideal qualities

feels disconnected

Developing

further

an incident

field,

photographs

to the patient,

may

Associated

staff was the

and explore

‘get me lignocaine

the ensuing

himself

from

of in-

observed

cells we need

use. Describing

from

(1979)

disturbing.’

communication

such

quent

and

visual

aid if normally

relatives.

his

a clock

the patients

to him factors

Noble

environment.

to acknowledge

sense

trol and immobility of body image

for

to the patient,

Placing

Family

to anxious

the unconscious

predisposing

to test its validity

reality.

that

within

care

the window

the individuals

it is conceivable

‘emanating

conspicuous

her study

lock

the

mote

near

are eligible

herself

the patients

the bed

links with

intensive

introduce

or hearing

will also serve

to refer

psychosis

placing

these

by his name

within

comfort

ally. tensive

calendar

and

interaction.

as an

alarms

will be assumed

him

in the

environment

the surrounding

all conversations

in the

ing spectacles

of ‘Body

of his

egocentric

of self. Therefore

earshot

the

its impact

concept

application

place

day and

to this theme,

for the elderly,

addressing

all serve to per-

the

as central

loses

becoming

between

caring

The nurse should

therapy

within

exploring

describes

limits extension

aspects

is invaded,

psychosis.

Image

drug

and claustrophobic

space

Tinnin

in

noise and interrup-

the lack of differentiation

petuate

and

such as repetitive

tions,

ing when

Confusion

failure is commonly imbalance and anoxia

ventilation

to address.

care setting

Care Psychosis’

1984).

35

CARE NURSING

is a natural

restorative

body

particularly

image,

eye movement and

self

which esteem

strategy the

is thought (Farrimond,

for a stage

of

to promote 1984).

Despite the unconscious or sedated persons apparent relaxed appearance he may still experience sensory stimulation. The recticular activat-

36

INTENSIVE

CARE NURSING

ing system in the brain selectively filters stimuli, determining which will progress to arouse the cerebral cortex. Research tentatively suggests that the absence of ascending sensory stimulation to the reticular activating system produces relaxation and sleep (O’Brien and Alexander, 1985). Therefore for both conscious and unconscious patients the nurse can facilitate the person’s innate coping mechanisms by producing an environment which is conducive to sleep. Hilton (1976) examined the quantity and quality of patients’ sleep in intensive care. She concluded that nursing interruptions which were frequent and often avoidable were the main cause of sleep deprivation. Strategies to induce night time sleep include turning suction and oxygen off when not in use to reduce noise and if possible physical interventions should be withheld for 90 to 120 minutes to allow the patient to obtain a full sleep cycle (McGonigal, 1986). Because of the continuous nature of treatment adequate rest needs to be provided during the day. This demands a diplomatic nursing approach enlisting the co-operation of visiting clinicians. If everyone involved in the patient’s care attended one ward round repeated disturbances would be avoided and the patient allowed to rest.

SUMMARY

AND

CONCLUSION

In contrast to their physically relaxed appearance ventilated patients may not be emotionally detached from their environment. This review leads the reader to deduce that extended body image is an acute emotional experience occurring far more frequently than is generally realised. The attributes of an ‘adult’ image such as autonomy and control are lost reducing the patient to a dependent ‘child-like’ state. Altered sensations make the body boundaries become permeable and the patients self perception diffuses into the environment to assume the ventilator as an extension of self. Much of the evidence to support this discussion is grounded in autobiographical material and is necessarily speculative, but its value emerges in sensitising the reader to the human perspective. Clinical management of a ventilated

patient in intensive care may well overshadow the individuals emotional experiences and it is contended that the essence of intensive care nursing is to interact therapeutically to alleviate the psychosis characteristic of extended body image. The importance of the personal nurse-patient relationship in reducing emotional disturbance appears to be supported by Lasarus and Hagens (1968). This small study was conducted by a psychiatrist who counselled patients prior to surgery and encouraged the nurse to provide a supportive, reality-orientated, sleep-inducive recovery environment. Only 14% of these patients as opposed to 33”/0 in the control group developed psychosis. In unexpected critical illness it is impossible to counsel people prior to the event so the practice of these principles may not produce such an effective outcome. However the results become increasingly significant because the nurse not the researcher manipulates the situation in the care setting. Application of research-based communication strategies to critical illness is in its infancy. Noble ( 1979) and Ashworth (1980) have identified shortcomings in nursing interactiom within intensive care, but the quality of desirable communication has yet to be clarified. Roberts (1980) provides an alternative approach using Piaget’s developmental theory as an explanatory framework for the emotional needs of the critically ill, presenting the hypothesis that they regress to earlier developmental stages. The implications for nursing practice would be tremendous if this idea was validated and would generate research questions to identify the critically ill persons behaviour at each developmental stage, together with the therapeutic level of information required. The visually compromised patient who is unable to express his needs places an onus on the nurse to compensate for these disabilities, and a strong emphasis falls on the skills of non-verbal communication. This review exemplifies the need for a deeper knowledge of psychology than is currently provided by the English National Board’s Intensive Care Course. This need is clearly demonstrated by the diverse nature and emotional connotations of touch which can be therapeutic or detrimental (Weiss, 1986). At

INTENSIVE CARE NURSING

present the course contains a strong physiological bias justified by the need to prioritise physical stability and safety. Course nurses need to attain practical skills and are not supernumerary so inevitably service needs take precedence over education if there is a conflict. If nurses believe in a humanistic approach they cannot hide behind the pragmatic view which stereotypes ventilated patients or persistently excuses lack of attention to the individual’s emotional needs on the grounds of physical priorities. It is unrealistic to expect achievement of optimum nursing levels in the present staffing crisis, so nurses must examine their practice. The allocation of nursing resources to unnecessary management of technology which diverts their skills from the personality lying in bed must be questioned. Support must be provided for junior colleagues who may become overwhelmed with managing the ventilator and drug infusions, to the detriment of the patients emotional integrity. In conclusion an insight has been gained into the experience of extended body image in ventilated patients, which provides the nurse with an empathic basis for delivery of care. The challenge to the intensive care nurse to develop this concept is wide open.

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37

Kelly M P 1985 Loss of Grief Reactions as Responses to Surgery. Journal ofAdvanced Nursing lO(6): 517-525 Kleck H G 1984 ICU Syndrome: Onset, Manifestations, Treatment Stressors and Prevention. Critical Care Quarterly 6(4): 21-28 Kornfield D S 1969 Psychiatric View of the Intensive Care Unit. British Medical Journal, 1 pp 108-109 Lazarus H R, Hagens J H 1968 Prevention of Psychosis following Open Heart Surgery. American Journal of Psychiatry 124(g): 76-81 Levine J, Zigler E 1979 Denial and Self Image in Stroke, Lung Cancer and Heart Disease Patients. Journal of Consulting and Clinical Psychology 43(6j: 75 l-757 Locsin R 1981 The Effect of Music on the Pain of Selective post-operative patients. Journal ofAdvanced Nursing 6(l): 19-25 Maslow AH 1970 Motivation and Personality 2nd Ed, Harper Row Publishers, London McCaffery M 1979 Nursing Management of the Patient with Pain 2nd Ed, Lippincott, Philadelphia McGonigal K S 1986 The Importance ofSleep and the Sensory Environment to Critically Ill Patients. Intensive Care Nursing 2(2): 73-83 Meekings H 1981 More than a Helping Hand. Nursing Mirror 153(13): 20 Meisenhelder J B 1985 Self-Esteem: a closer look at clinical interventions. International Journal of Nursing Studies 22(2): 127--135 Melia K M 1977 The Intensive Care Unit-Stress Situation. Nursing Times - Occasional Paper 73 (5): 17-20 Mills M E et al 1976 Effect of Pulse Palpation on Cardiac Arrhythmia in Coronary Care Patients. Nursing Research 25(5): 378 Noble M A 1979 Communication in the ICU: Therapeutic or Disturbing. Nursing Outlook 27(3): 195- 198 Nordhurft V L, Sweeny N IM 1982 Reality Orientation Therapy for the institutionalised Elderly. Journal of Gerontological Nursing 8 (7) : 40 1 Norris J, Kunes-Connel M 1985 Self Esteem Disturbance. Nursing Clinics of North America pp 745-761 O’Brien D, Alexander S 1985 High Dependency Nursing Care. Churchill Livingstone, London Phippen M L 1987 Patient Shame. AORN Journal 4611): 88-94 Platzer H 1987 Body Image (Part 2) Helping Patients rope with Changes-a problem for Nurses. Intensive Care Nursing 3(3): 125 Roberts S L 1980 Piagets Theory reapplied to the Critically Ill. Advances in Nursing Science 2(2): 61-78 Roy C 1970 Adaption: A Conceptual Framework for Nursing Practice. Nursing Outlook 18(3): 42-45 Schultz D 1965) Sensory Restriction: Effects on Behaviour. Academic Press, New York p 30 Smith C A 1972 Body Image Changes after Myocardial Infarction. Nursing Clinics ofNorth America 7(4): 663-668 Smith C 1987 In Need of Intensive Care -A Personal Perspective. Intensive Care Nursing 2(3): 116-122 Solomon P, Leiderman P H, Mendelson J H, Wexler D 1958 Sensory deprivation: clinical aspects. Archives of Internal Medicine 101(Z): 389-396 as cited in Ashworth (1979) Stockwell F 1972 The Unpopular Patient. Royal College of Nursing, London

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