Helping the Person withan Altered Self-Image

Hope

Despair

An ieties

Lone line s

Frustrat ions

Change in relationship

Alteration in sell -image

Affect ion

Rec ognit ion

Meaningful life

Susta ined relati on hip

Altera tion in self -image

Whether a change inself-image is rejectedor welcomed, warmencouragement isalways 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." Whenone or more of these conditionschanges, life can be perceived as"wrong," according to that person'sstandards. As a result of thischange, the individual may fear notonly an alteration in self and self­image but also the disapproval ofothers, especially those close to

90 Geriatric Nursina March/April t986

Nursing InterventionsA Balancing Factor

him. How does an elderly individu­al deal with a specific alteration inself and self-image'?

Imagine that you have a scale.On each side of the scale you placea change that may affect self­image. On one side the potentialchanges in relationships, frustra­tions, loneliness, and anxieties addup to despair. On the other side thepossibilities of sustained relation­ships, an interesting life-style, rec­ognition, and affection add up tohope. Skillful nursing is one factorthat can maintain a balance be­tween the extremes of hope and

Marilyn Harris, RN, MSN, a certifiednurse administrator. is executive director,Visiting Nurse Association of EasternMontgomery County, Inc., Abington, PA.

despair for the person with an al­tered self-image.

Elderly individuals experiencealterations in self-image for variousreasons: an acute or chronic illness;a change in their social, economic,or physical environment; the nor­mal aging process; death of aspouse or pet; even the temporaryloss of such appliances as a hearingaid or eyeglasses.

The nurse assesses the individualto identify the cause of the changeand its effect before taking a spe­cific action. The intervention for aperson with an altered self-image isaffected by several factors: Do theindividual and family accept the al­tered image and attempt to set newgoals or do they seem to deny thealteration'? How will the home set-

ting and family relationships helpor hinder specific interventions'?

Acceptance of Altered Self-Image

During my years as a communityhealth nurse I have interviewedmany persons with chronic or acuteillness to learn how they handled analteration in their physical statusand self-image. I have found thatthe individual who accepts a newself-image has decided there is stillneed for recognition, affection, andmeaning in life, and has learned tocope 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 areevaluation process that is, manytimes, spread over a long period.During this time the specific inter­ventions a nurse can offer may varyconsiderably, but they always in­clude support, encouragement, anddirection.

The medical diagnosis of a per­son whose self-image has been al­tered by illness may be multiplesclerosis, heart disease, fracturedhip, arthritis, or any other diseaseprocess. Among other factors, thenursing care plan takes into consid­eration the patient's mobility statusbefore the present condition, thepast and present mental status ofpatient and caregiver, and thenumber of people in the home.Many times, the caregiver for thepatient in the community is an el­derly spouse who is in the same­sometimes far worse-physical ormental condition as the patient.

Arthur B, with whom I worked,was a man who accepted his alteredself-image. His physical changes,caused by multiple sclerosis, wereeasily recognized. Over the yearshe experienced fatigue, tremors,staggering gait, and blurred vision.Strength left his arms and legs, awheelchair replaced a cane andwalker. Years later, the simplesttasks eluded him. He could no long­er feed himself, pick up the tele­phone receiver, or adjust the televi­sion dials. Eventually, he had torely on someone else even for theniceties of scratching an itch or

wiping his nose. During my visits,he described his experiences.

I was a professional pianist butover the years I lost my sense oftouch. I continued to play, but in­creased practice only produced fa­tigue, not perfection. I went fromdoctor to doctor until my fundswere almost gone. I had knownsomeone with multiple sclerosiswho had died and I couldn't acceptthe idea. It was hard to realize thatI was washed up as a professionalmusician. My wife left me. Icouldn't even sign my name. I gotsicker and sicker in mind because Iwas losing everything.

My first contact with Mr. B. wasto provide physical nursing care,specifically for bowel and bladderproblems. During my visits hetalked about his current physicaland past emotional helplessness.

. Much of the groundwork thathelped him maintain the delicatebalance between hope and despairwas laid by his family.

Interventions may varybut always includesupport arid direction,

Through the use of communityresources he was helped to feel lessdependent. The telephone companyinstalled a special phone that hecould answer with gross handmovements or a dowel held be­tween his teeth. He maintained hissocial contacts and political activitythrough phone calls . A slow butpersistent letter writer, he used adowel to depress keys on his electrictypewriter.

Both Arthur B. and his family,except for his wife, accepted his al­tered physical condition. They werereceptive to suggestion. Until hisdeath, he remained a usually sereneman who had the motivation, self­esteem, and security that enabledhim to cope successfully with con-

tinuous frustration and anxiety.The goal of the nursing interven­

tion for individuals who accept analtered self-image is to help themidentify and attain realistic goals.These people are receptive to inno­vation and services that help themreach these goals.

Community agencies may pro­vide homemaker-home healthaides, meals on wheels, tel-e-care(a daily phone call at a regulartime), friendly visitors, and socialworkers. Sometimes these servicesare available through one commu­nity health agency.

Rejection of Self-Image

The individual who refuses to ac­cept the altered image may comeacross as aggressive. This is theperson who may vehemently de­cline all help and suggestion, with­draw completely, or determine to"do it alone or not at all."

Some family members who re­fuse to accept the alteration intendto be helpful, but instead they over­compensate, thus making the pa­tient dependent. Or they may pushthe person beyond his capabilities.The familiar phrase is "you can doit" when, in reality, it may be im­possible for the person to accom­plish the task set before him.

Sometimes, the family memberavoids frank discussion of the exist­ing problems. If so, the nurse lis­tens for clues and counsels relativesas well as the patient. Interventionmay not succeed if the family can­not accept the alteration.

An elderly man's right lower ex­tremity was amputated and he wasfitted with a prosthesis. Nursing in­tervention was hindered by hiswife's inability to accept the ampu­tation from a cosmetic point ofview. Her failure to offer supportand care at home between nursingvisits slowed this man's recovery.

Another patient, Mary H., wasbeing cared for by a communityhealth nurse following hospitaliza­tion. Ms. H. had ascites due tometastatic carcinoma and was set­tled in a hospital bed.

In separate conversations, Mr.and Ms. H. each told the nurse thatthis was the first time in their mar-

Geriatric Nursing March/April 1986 91

Over time, listening to fears, putting problemsinto perspective, and discussing alternatives canenable patients to accept a changed image.

ried life that they had slept in sepa­rate beds in their home. Bothwished "things were like they usedto be," but they had not discussedtheir feelings with each other.

Both also referred with repug­nance to Ms. H.'s distended abdo­men. During a conversation withboth of them, the nurse comparedMs. H.'s figure with her figure dur­ing the last months of her pregnan­cies. Subsequently, husband andwife seemed more accepting of her ,altered appearance.

Listening and putting problemsinto perspective were successful in­terventions with this elderly couple.Both rejected the use of a hospitalbed, so the double bed was rein­stated. When Ms. H.'s conditiondeteriorated, the hospital bed wasset up again. By that time both wifeand husband were emotionallyready for the change.

Homebound Status

Some well elderly individuals ex­perience alterations in self-imagesimply because they become home­bound. They need assistance in get­ting out of the house, but that helpis not available or not used.

Being alone all day-whetherthis is the result of a spouse's death,relocation to the home of adult chil­dren who are employed, or simplyto timidity about leaving thehouse- affects self-image.

Nursing care, once again, is di- .rected toward setting realistic goalsand identifying the resources nee­essaryto reach these goals. Inter­ventions may include the offer toarrange for transportation, afriendly visitor, tel-e-care, or notifi­cation of the fire department thatthe person is homebound and wouldneed immediate help in an emer­gency. Identification stickers may

91 Geriatric Nursing March/April 1986

be required on interior doors forspecific medical problems. Outletsfor talents can be offered throughlocal programs.

Sometimes, the need to be recog­nized can be identified. Then spe­cial attention may ignite the sparkto improve self-image. For exam­ple, nursing intervention involvedMr. R. in a public relations effort.Philip R., 89, received service fromthe visiting nurse association on aregular basis but usually refused tochange from his pajamas to clothes.

The nurse asked permission to in­clude his picture in a newspaper ar­ticle that was being written aboutthe association's services.

This was all Mr. R. needed tospark an improved self-image. Hesent his best suit and tie to thecleaners and had a friend help himdress hours before the photograph­er was due at the house. After thepictures were taken, Mr. R. calledthe office repeatedly to find outwhen his picture would 'appea r inthe paper. After it was published,he wanted many copies for his rela­tives and friends. This short-livedspecial attention was very impor­tant to this man. He talked about itfor months and he continued towear daytime clothes rather thanpajamas.

Ambulatory WeD Individuals

Another category to whom thenurse directs attention includespeople who are healthy and able toget about but who reject being old.The nurse encounters them in se­nior centers, group teaching situa­tions, and in her own family orneighborhood. Ms. A. and Ms. C.are typical examples:

Alice A. lives with her daughterand was well until she turned 90.Following this birthday, she be-

came depressed, sulked, cried, andgenerally felt sorry for herself. Herdaughter requested a nursing visitbecause her mother had been ex­amined by the family doctor and nomedical reason was found for herpresent condition.

The nurse visited when Ms. A.was home alone. During the con­versation, Ms. A. said she had sud­denly realized that she was 90years old and "too old to live." Sheexpressed concerns about her wel­fare should something happen toher daughter.

Over time, by listening to herfears and hopes and discussing al­ternatives with her, the nurse per­suaded Ms . A. to reestablish pre­vious living patterns. Since thatepisode Ms. H has celebrated her94th birthday with no alteration inher self-image.

Anna D. retired at 65 andseemed to be enjoying herself. Sheattended a senior center where thevisiting nurse association providednursing service.

During a counseling session withthe nurse, Ms. D. expressed con­cern about being recognized as"old." She had a limited incomeand could have used the senior citi­zen reduced rates, but she did notwant the world to know her ageand, therefore, refused to show herhealth insurance card for identifi­cation to qualify for reduced rates.Her question: "How can I enjoy thebenefits without admitting to thereq uirements?"

Summary

The nurse adapts the approachto each situation, establishes rap­port with the individual and family,accepts them as persons, and helpsthem develop a realistic means tosolve the current problem or altera­tion in status quo. The nurse triesto understand why the patient andfamily member behave as they do,tries to understand their anxieties,and allows each to express theseemotions.

These nursing interventions areessential regardless of the crisis orreason for change, be it a headache,cut finger, acute or chronic illness,or change in environment. GN