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Helping the person with an altered self-image
Helping the Person with an Altered Self-Image Hope Affect ion Rec og nit ion Meaningfu l life Susta ined relati on hip Alt era tion in self -image
Despair An ieties Lone line s Frustrat ions Change in relationsh ip Alteration in sell-image
Nursing Interventions A Balancing Factor
Whether a change in self-image is rejected or welcomed, warm encouragement is always essential. MARILYN HARRIS Almost everyone, regardless of age, has an idea of what social, physical, and economic conditions must prevail if life is to be "right." When one or more of these conditions changes, life can be perceived as "wrong," according to that person's standards. As a result of this change, the individual may fear not only an alteration in self and selfimage but also the disapproval of others, especially those close to
90 Geriatric Nursina March/April t986
him. How does an elderly individual deal with a specific alteration in self and self-image'? Imagine that you have a scale. On each side of the scale you place a change that may affect selfimage. On one side the potential changes in relationships, frustrations, loneliness, and anxieties add up to despair. On the other side the possibilities of sustained relationships, an interesting life-style, recognition, and affection add up to hope. Skillful nursing is one factor that can maintain a balance between the extremes of hope and Marilyn Harris, RN, MSN, a certified nurse administrator. is executive director, Visiting Nurse Association of Eastern Montgomery County, Inc., Abington, PA.
despair for the person with an altered self-image. Elderly individuals experience alterations in self-image for various reasons: an acute or chronic illness; a change in their social, economic, or physical environment; the normal aging process; death of a spouse or pet; even the temporary loss of such appliances as a hearing aid or eyeglasses. The nurse assesses the individual to identify the cause of the change and its effect before taking a specific action. The intervention for a person with an altered self-image is affected by several factors: Do the individual and family accept the altered image and attempt to set new goals or do they seem to deny the alteration'? How will the home set-
ting and family relationships help or hinder specific interventions'? Acceptance of Altered Self-Image During my years as a community health nurse I have interviewed many persons with chronic or acute illness to learn how they handled an alteration in their physical status and self-image. I have found that the individual who accepts a new self-image has decided there is still need for recognition, affection, and meaning in life, and has learned to cope with, or at least accept, the realities and anxieties that exist because of helplessness, insecurity, role change, and, sometimes, isolation from family and friends. Reaching this decision entails a reevaluation process that is, many times, spread over a long period. During this time the specific interventions a nurse can offer may vary considerably, but they always include support, encouragement, and direction. The medical diagnosis of a person whose self-image has been altered by illness may be multiple sclerosis, heart disease, fractured hip, arthritis, or any other disease process. Among other factors, the nursing care plan takes into consideration the patient's mobility status before the present condition, the past and present mental status of patient and caregiver, and the number of people in the home. Many times, the caregiver for the patient in the community is an elderly spouse who is in the samesometimes far worse-physical or mental condition as the patient. Arthur B, with whom I worked, was a man who accepted his altered self-image. His physical changes, caused by multiple sclerosis, were easily recognized. Over the years he experienced fatigue, tremors, staggering gait, and blurred vision. Strength left his arms and legs, a wheelchair replaced a cane and walker. Years later, the simplest tasks eluded him. He could no longer feed himself, pick up the telephone receiver, or adjust the television dials. Eventually, he had to rely on someone else even for the niceties of scratching an itch or
wiping his nose. During my visits, he described his experiences.
tinuous frustration and anxiety. The goal of the nursing intervention for individuals who accept an I was a professional pianist but altered self-image is to help them over the years I lost my sense of identify and attain realistic goals. touch. I continued to play, but in- These people are receptive to innocreased practice only produced fa- vation and services that help them tigue, not perfection. I went from reach these goals. doctor to doctor until my funds Community agencies may prowere almost gone. I had known vide homemaker-home health someone with multiple sclerosis aides, meals on wheels, tel-e-care who had died and I couldn't accept (a daily phone call at a regular the idea. It was hard to realize that time), friendly visitors, and social I was washed up as a professional workers. Sometimes these services musician. My wife left me. I are available through one commucouldn't even sign my name. I got nity health agency. sicker and sicker in mind because I Rejection of Self-Image was losing everything. The individual who refuses to acMy first contact with Mr. B. was cept the altered image may come to provide physical nursing care, across as aggressive. This is the specifically for bowel and bladder person who may vehemently deproblems. During my visits he cline all help and suggestion, withtalked about his current physical draw completely, or determine to and past emotional helplessness. "do it alone or not at all." . Much of the groundwork that Some family members who rehelped him maintain the delicate fuse to accept the alteration intend balance between hope and despair to be helpful, but instead they overcompensate, thus making the pawas laid by his family. tient dependent. Or they may push the person beyond his capabilities. The familiar phrase is "you can do it" when, in reality, it may be imInterventions may vary possible for the person to accomplish the task set before him. but always include Sometimes, the family member support arid direction, avoids frank discussion of the existing problems. If so, the nurse listens for clues and counsels relatives as well as the patient. Intervention Through the use of community may not succeed if the family canresources he was helped to feel less not accept the alteration. dependent. The telephone company An elderly man's right lower exinstalled a special phone that he tremity was amputated and he was could answer with gross hand fitted with a prosthesis. Nursing inmovements or a dowel held be- tervention was hindered by his tween his teeth. He maintained his wife's inability to accept the ampusocial contacts and political activity tation from a cosmetic point of through phone calls . A slow but view. Her failure to offer support persistent letter writer, he used a and care at home between nursing dowel to depress keys on his electric visits slowed this man's recovery. typewriter. Another patient, Mary H., was Both Arthur B. and his family, being cared for by a community except for his wife, accepted his al- health nurse following hospitalizatered physical condition. They were tion. Ms. H. had ascites due to receptive to suggestion. Until his metastatic carcinoma and was setdeath, he remained a usually serene tled in a hospital bed. man who had the motivation, selfIn separate conversations, Mr. esteem, and security that enabled and Ms. H . each told the nurse that him to cope successfully with con- this was the first time in their mar-
Geriatric Nursing March/April 1986 91
ried life that they had slept in separate beds in their home. Both wished "things were like they used to be," but they had not discussed their feelings with each other. Both also referred with repugnance to Ms. H.'s distended abdomen. During a conversation with both of them, the nurse compared Ms. H.'s figure with her figure during the last months of her pregnancies. Subsequently, husband and wife seemed more accepting of her , altered appearance.
be required on interior doors for specific medical problems. Outlets for talents can be offered through local programs. Sometimes, the need to be recognized can be identified. Then special attention may ignite the spark to improve self-image. For example, nursing intervention involved Mr. R. in a public relations effort. Philip R., 89, received service from the visiting nurse association on a regular basis but usually refused to change from his pajamas to clothes.
Over time, listening to fears, putting problems into perspective, and discussing alternatives can enable patients to accept a changed image.
Listening and putting problems into perspective were successful interventions with this elderly couple. Both rejected the use of a hospital bed, so the double bed was reinstated. When Ms. H.'s condition deteriorated, the hospital bed was set up again. By that time both wife and husband were emotionally ready for the change. Homebound Status
The nurse asked permission to include his picture in a newspaper article that was being written about the association's services. This was all Mr. R. needed to spark an improved self-image. He sent his best suit and tie to the cleaners and had a friend help him dress hours before the photographer was due at the house. After the pictures were taken, Mr. R. called the office repeatedly to find out when his picture would 'appea r in the paper. After it was published, he wanted many copies for his relatives and friends. This short-lived special attention was very important to this man. He talked about it for months and he continued to wear daytime clothes rather than pajamas.
Some well elderly individuals experience alterations in self-image simply because they become homebound. They need assistance in getting out of the house, but that help is not available or not used. Being alone all day-whether this is the result of a spouse's death, relocation to the home of adult children who are employed, or simply Ambulatory WeD Individuals to timidity about leaving the house- affects self-image. Another category to whom the Nursing care, once again, is di- . nurse directs attention includes rected toward setting realistic goals people who are healthy and able to and identifying the resources nee- get about but who reject being old. essaryto reach these goals. Inter- The nurse encounters them in seventions may include the offer to nior centers, group teaching situaarrange for transportation, a tions, and in her own family or friendly visitor, tel-e-care, or notifi- neighborhood. Ms. A. and Ms. C. cation of the fire department that are typical examples: the person is homebound and would Alice A. lives with her daughter need immediate help in an emer- and was well until she turned 90. gency. Identification stickers may Following this birthday, she be-
91 Geriatric Nursing March/April 1986
came depressed, sulked, cried, and generally felt sorry for herself. Her daughter requested a nursing visit because her mother had been examined by the family doctor and no medical reason was found for her present condition. The nurse visited when Ms. A. was home alone. During the conversation, Ms. A. said she had suddenly realized that she was 90 years old and "too old to live." She expressed concerns about her welfare should something happen to her daughter. Over time, by listening to her fears and hopes and discussing alternatives with her, the nurse persuaded Ms . A. to reestablish previous living patterns. Since that episode Ms. H has celebrated her 94th birthday with no alteration in her self-image. Anna D. retired at 65 and seemed to be enjoying herself. She attended a senior center where the visiting nurse association provided nursing service. During a counseling session with the nurse, Ms. D. expressed concern about being recognized as "old." She had a limited income and could have used the senior citizen reduced rates, but she did not want the world to know her age and, therefore, refused to show her health insurance card for identification to qualify for reduced rates. Her question: "How can I enjoy the benefits without admitting to the req uirements?" Summary The nurse adapts the approach to each situation, establishes rapport with the individual and family, accepts them as persons, and helps them develop a realistic means to solve the current problem or alteration in status quo. The nurse tries to understand why the patient and family member behave as they do, tries to understand their anxieties, and allows each to express these emotions. These nursing interventions are essential regardless of the crisis or reason for change, be it a headache, cut finger, acute or chronic illness, or change in environment. GN
Despair An ieties Lone line s Frustrat ions Change in relationsh ip Alteration in sell-image
Nursing Interventions A Balancing Factor
Whether a change in self-image is rejected or welcomed, warm encouragement is always essential. MARILYN HARRIS Almost everyone, regardless of age, has an idea of what social, physical, and economic conditions must prevail if life is to be "right." When one or more of these conditions changes, life can be perceived as "wrong," according to that person's standards. As a result of this change, the individual may fear not only an alteration in self and selfimage but also the disapproval of others, especially those close to
90 Geriatric Nursina March/April t986
him. How does an elderly individual deal with a specific alteration in self and self-image'? Imagine that you have a scale. On each side of the scale you place a change that may affect selfimage. On one side the potential changes in relationships, frustrations, loneliness, and anxieties add up to despair. On the other side the possibilities of sustained relationships, an interesting life-style, recognition, and affection add up to hope. Skillful nursing is one factor that can maintain a balance between the extremes of hope and Marilyn Harris, RN, MSN, a certified nurse administrator. is executive director, Visiting Nurse Association of Eastern Montgomery County, Inc., Abington, PA.
despair for the person with an altered self-image. Elderly individuals experience alterations in self-image for various reasons: an acute or chronic illness; a change in their social, economic, or physical environment; the normal aging process; death of a spouse or pet; even the temporary loss of such appliances as a hearing aid or eyeglasses. The nurse assesses the individual to identify the cause of the change and its effect before taking a specific action. The intervention for a person with an altered self-image is affected by several factors: Do the individual and family accept the altered image and attempt to set new goals or do they seem to deny the alteration'? How will the home set-
ting and family relationships help or hinder specific interventions'? Acceptance of Altered Self-Image During my years as a community health nurse I have interviewed many persons with chronic or acute illness to learn how they handled an alteration in their physical status and self-image. I have found that the individual who accepts a new self-image has decided there is still need for recognition, affection, and meaning in life, and has learned to cope with, or at least accept, the realities and anxieties that exist because of helplessness, insecurity, role change, and, sometimes, isolation from family and friends. Reaching this decision entails a reevaluation process that is, many times, spread over a long period. During this time the specific interventions a nurse can offer may vary considerably, but they always include support, encouragement, and direction. The medical diagnosis of a person whose self-image has been altered by illness may be multiple sclerosis, heart disease, fractured hip, arthritis, or any other disease process. Among other factors, the nursing care plan takes into consideration the patient's mobility status before the present condition, the past and present mental status of patient and caregiver, and the number of people in the home. Many times, the caregiver for the patient in the community is an elderly spouse who is in the samesometimes far worse-physical or mental condition as the patient. Arthur B, with whom I worked, was a man who accepted his altered self-image. His physical changes, caused by multiple sclerosis, were easily recognized. Over the years he experienced fatigue, tremors, staggering gait, and blurred vision. Strength left his arms and legs, a wheelchair replaced a cane and walker. Years later, the simplest tasks eluded him. He could no longer feed himself, pick up the telephone receiver, or adjust the television dials. Eventually, he had to rely on someone else even for the niceties of scratching an itch or
wiping his nose. During my visits, he described his experiences.
tinuous frustration and anxiety. The goal of the nursing intervention for individuals who accept an I was a professional pianist but altered self-image is to help them over the years I lost my sense of identify and attain realistic goals. touch. I continued to play, but in- These people are receptive to innocreased practice only produced fa- vation and services that help them tigue, not perfection. I went from reach these goals. doctor to doctor until my funds Community agencies may prowere almost gone. I had known vide homemaker-home health someone with multiple sclerosis aides, meals on wheels, tel-e-care who had died and I couldn't accept (a daily phone call at a regular the idea. It was hard to realize that time), friendly visitors, and social I was washed up as a professional workers. Sometimes these services musician. My wife left me. I are available through one commucouldn't even sign my name. I got nity health agency. sicker and sicker in mind because I Rejection of Self-Image was losing everything. The individual who refuses to acMy first contact with Mr. B. was cept the altered image may come to provide physical nursing care, across as aggressive. This is the specifically for bowel and bladder person who may vehemently deproblems. During my visits he cline all help and suggestion, withtalked about his current physical draw completely, or determine to and past emotional helplessness. "do it alone or not at all." . Much of the groundwork that Some family members who rehelped him maintain the delicate fuse to accept the alteration intend balance between hope and despair to be helpful, but instead they overcompensate, thus making the pawas laid by his family. tient dependent. Or they may push the person beyond his capabilities. The familiar phrase is "you can do it" when, in reality, it may be imInterventions may vary possible for the person to accomplish the task set before him. but always include Sometimes, the family member support arid direction, avoids frank discussion of the existing problems. If so, the nurse listens for clues and counsels relatives as well as the patient. Intervention Through the use of community may not succeed if the family canresources he was helped to feel less not accept the alteration. dependent. The telephone company An elderly man's right lower exinstalled a special phone that he tremity was amputated and he was could answer with gross hand fitted with a prosthesis. Nursing inmovements or a dowel held be- tervention was hindered by his tween his teeth. He maintained his wife's inability to accept the ampusocial contacts and political activity tation from a cosmetic point of through phone calls . A slow but view. Her failure to offer support persistent letter writer, he used a and care at home between nursing dowel to depress keys on his electric visits slowed this man's recovery. typewriter. Another patient, Mary H., was Both Arthur B. and his family, being cared for by a community except for his wife, accepted his al- health nurse following hospitalizatered physical condition. They were tion. Ms. H. had ascites due to receptive to suggestion. Until his metastatic carcinoma and was setdeath, he remained a usually serene tled in a hospital bed. man who had the motivation, selfIn separate conversations, Mr. esteem, and security that enabled and Ms. H . each told the nurse that him to cope successfully with con- this was the first time in their mar-
Geriatric Nursing March/April 1986 91
ried life that they had slept in separate beds in their home. Both wished "things were like they used to be," but they had not discussed their feelings with each other. Both also referred with repugnance to Ms. H.'s distended abdomen. During a conversation with both of them, the nurse compared Ms. H.'s figure with her figure during the last months of her pregnancies. Subsequently, husband and wife seemed more accepting of her , altered appearance.
be required on interior doors for specific medical problems. Outlets for talents can be offered through local programs. Sometimes, the need to be recognized can be identified. Then special attention may ignite the spark to improve self-image. For example, nursing intervention involved Mr. R. in a public relations effort. Philip R., 89, received service from the visiting nurse association on a regular basis but usually refused to change from his pajamas to clothes.
Over time, listening to fears, putting problems into perspective, and discussing alternatives can enable patients to accept a changed image.
Listening and putting problems into perspective were successful interventions with this elderly couple. Both rejected the use of a hospital bed, so the double bed was reinstated. When Ms. H.'s condition deteriorated, the hospital bed was set up again. By that time both wife and husband were emotionally ready for the change. Homebound Status
The nurse asked permission to include his picture in a newspaper article that was being written about the association's services. This was all Mr. R. needed to spark an improved self-image. He sent his best suit and tie to the cleaners and had a friend help him dress hours before the photographer was due at the house. After the pictures were taken, Mr. R. called the office repeatedly to find out when his picture would 'appea r in the paper. After it was published, he wanted many copies for his relatives and friends. This short-lived special attention was very important to this man. He talked about it for months and he continued to wear daytime clothes rather than pajamas.
Some well elderly individuals experience alterations in self-image simply because they become homebound. They need assistance in getting out of the house, but that help is not available or not used. Being alone all day-whether this is the result of a spouse's death, relocation to the home of adult children who are employed, or simply Ambulatory WeD Individuals to timidity about leaving the house- affects self-image. Another category to whom the Nursing care, once again, is di- . nurse directs attention includes rected toward setting realistic goals people who are healthy and able to and identifying the resources nee- get about but who reject being old. essaryto reach these goals. Inter- The nurse encounters them in seventions may include the offer to nior centers, group teaching situaarrange for transportation, a tions, and in her own family or friendly visitor, tel-e-care, or notifi- neighborhood. Ms. A. and Ms. C. cation of the fire department that are typical examples: the person is homebound and would Alice A. lives with her daughter need immediate help in an emer- and was well until she turned 90. gency. Identification stickers may Following this birthday, she be-
91 Geriatric Nursing March/April 1986
came depressed, sulked, cried, and generally felt sorry for herself. Her daughter requested a nursing visit because her mother had been examined by the family doctor and no medical reason was found for her present condition. The nurse visited when Ms. A. was home alone. During the conversation, Ms. A. said she had suddenly realized that she was 90 years old and "too old to live." She expressed concerns about her welfare should something happen to her daughter. Over time, by listening to her fears and hopes and discussing alternatives with her, the nurse persuaded Ms . A. to reestablish previous living patterns. Since that episode Ms. H has celebrated her 94th birthday with no alteration in her self-image. Anna D. retired at 65 and seemed to be enjoying herself. She attended a senior center where the visiting nurse association provided nursing service. During a counseling session with the nurse, Ms. D. expressed concern about being recognized as "old." She had a limited income and could have used the senior citizen reduced rates, but she did not want the world to know her age and, therefore, refused to show her health insurance card for identification to qualify for reduced rates. Her question: "How can I enjoy the benefits without admitting to the req uirements?" Summary The nurse adapts the approach to each situation, establishes rapport with the individual and family, accepts them as persons, and helps them develop a realistic means to solve the current problem or alteration in status quo. The nurse tries to understand why the patient and family member behave as they do, tries to understand their anxieties, and allows each to express these emotions. These nursing interventions are essential regardless of the crisis or reason for change, be it a headache, cut finger, acute or chronic illness, or change in environment. GN