VOL: 97, ISSUE: 48, PAGE NO: 57
Stephen Hopkins, Dip.Nurs.Studies (Mental Health), is a staff nurse, West Middlesex University Hospital, Isleworth, London
Addressing the psychological needs of patients who have chronic or acute wounds presents a daily challenge to clinicians, but the subject is poorly addressed in the literature. It is possible that professionals find it difficult to articulate and describe the strategies employed to help patients cope with wounds (Anon, 1995), yet 12% of people who make a full physical recovery following a critical injury still suffer psychological adjustment difficulties more than one year later, and up to 58% are unable to return to previous work levels (Grossman,1995).
Physical and emotional wounds
Faugier (1988) suggests that wounding, particularly long-term damage to the integrity of the body, will inevitably leave emotional as well as physical scars. However, such emotional scars are often difficult to detect.
People’s minds can be harder to treat than their bodies. The human psyche has the capacity to rationalise, ignore or deny the unpleasant if it conflicts with self-perception. A patient may not be willing to admit the degree to which they are affected by an injury, yet there is little doubt that living with a wound has a huge impact on a person’s psyche, particularly if it also affects their ability to perform everyday tasks.
Nurses can help patients come to terms with a physical injury through warmth, empathy, acceptance and by helping them to face reality without resorting to destructive defence mechanisms (Faugier, 1988). Magnan (1996) suggests that defence mechanisms related to wounds may find expression in suppression, avoidance and withdrawal.
Grieving may also form part of an individual’s response to a wound (Magnan, 1996) in instances where the person is trying to come to terms with loss of bodily function or altered body image.
The need for endurance
Wound healing can test a patient to the limit of his or her endurance (Dewar, 1995). Physical suffering, grieving for a lost limb, having to endure hospitalisation and ongoing treatment when healing may be non-existent or slow are some of the issues that an individual with a wound may have to cope with. Inappropriate responses of family members and strangers is another factor that some people will encounter (Dewar, 1995). Reactions to deformities, particularly when they are on the face, can be very damaging and lead to ‘social death’ for the sufferer (Magnan, 1996). A capacity to endure is therefore called for.
Range of emotional responses
Emotional responses to a wound can be wide-ranging and include fear about the future, frustration with the lack of progress in healing, a sense of loneliness and frustration at a loss of physical capacity (Dewar, 1995). A number of emotions have been identified that are directly linked with a traumatic wound - for example, anxiety, isolation and a lowering of self-esteem by being made the object of care (Lenehan, 1986). Overall, the individual can feel vulnerable and a nuisance to others, and in time this can lead to a sense of worthlessness and possibly depression.
Coping mechanisms can help prolong the capacity to endure (Dewar, 1995). Social support networks, diverse interests and religious faith all help to counteract a patient’s sense of injury, loss, frustration and pain caused by a wound. Individuals should also be empowered to participate in their care through being informed, for example, about appropriate wound dressings and treatments. This can help to alleviate or reduce a sense of powerlessness (Gibson, 1991). Above all, patients will appreciate a carer who endeavours genuinely to understand how they may be feeling and to show compassion in all aspects of care. All this helps to relieve the frustration and pain and prolongs the capacity of the human spirit to endure (Dewar, 1995).
Pain is a significant factor in wound management. Patients need to be encouraged to ask for remedies for the alleviation of pain and may need to be informed about appropriate treatments.
Pain can result in agitation and irritability. At its worst it may be so overwhelming that it will cause psychological changes resulting in increased anxiety, for example (Caunt, 1992). Pain will compound the stresses already affecting the patient with a wound.
Some patients may feel guilt and that they are somehow responsible for causing their wound, which may or may not be the case. Nurses should help address these issues by encouraging them to share thoughts that they might feel are irrational, thereby helping them to achieve a greater sense of perspective or objectivity about their situation (Lenehan, 1986). Patients’ doubts and fears should be treated with respect. By encouraging them to view their situation less harshly or with less self-condemnation patients can be helped to rebuild their self-esteem (Lenehan, 1986). Where possible nurses should try to build up hope based on an honest assessment of the patient’s situation and prognosis.
Altered body image
Body image has been described as the totality of how one feels and thinks about one’s body and its appearance or as the composite of thoughts, values and feelings that one has for one’s physical and personal self at any given time (Magnan, 1996). An altered body image can result in a variety of emotional responses, including grief, depression, low self-esteem, sexual problems and guilt (Magnan, 1996).
Morse (1995) emphasises the need to make a patient feel comfortable. It is usually when the body is in some state of illness or pain that it forces itself into a person’s consciousness. When a person is suffering - for example, with a wound - it is possible that they will feel betrayed by their body. Ultimately, however, if the wound becomes permanent or semi-permanent, people tend to become resigned to their altered state (Morse, 1995; Magnan, 1996). Nurses can take a number of steps to help people come to terms with such changes:
- Listen, encourage talking, communicate acceptance and provide a caring and supportive presence;
- Provide information that will help to reduce the patient’s uncertainty about the situation;
- Develop an awareness of the effect of one’s own body language as a means of helping patient to come to terms with their physical scars;
- Recognise that the patient may feel depressed and endeavour to show compassion by making appropriate referrals for treatment or counselling;
- Encourage relaxation techniques, such as controlled breathing, and therapeutic techniques, such as guided imagery.
Depression, which can lead to depressive illness, is a possible consequence of enduring a wound or injury. Even after a wound has healed it may take people several years before they perceive themselves to be recovered (Welch,1995).
Depression can be avoided with good psychosocial support. Braulin et al (1982) identify the need to address support for the family to aid the long-term recovery of the patient. Identifying coping mechanisms is a key factor, but these need to be assessed and adapted in each case (Welch,1995).
Depression may be rooted in denial or anger about a patient’s circumstances and often leads to introverted behaviour. A long period of hospitalisation, uncertain prognosis and severe functional loss are strong contributors to acute depression (Welch, 1995). Predictably, there is less denial, depression and anger when the recovery period is short and uninterrupted with a return to full functioning.
Once again the family is identified as having a significant impact on recovery and long-term adaptation (Welch, 1995). Hence a patient who is enduring a serious wound or injury needs a psychosocial assessment, including an investigation into his or her psychosocial history. This would establish how the individual’s mental state has been affected by their family life and upbringing and can be used as a basis for developing care.
Adjusting to the new reality
Patients may need assistance to adjust to the new reality of their situation caused by a wound or injury. This may be achieved through some form of transitional process (Neil and Barrell, 1998). Selder’s (1994) transition theory describes the patient’s experience as going through a phase of disrupted reality when their wound does not heal, followed by a period of uncertainty complicated by factors of denial, anxiety, pain, immobility and altered body image. This may or may not lead to a restructuring of reality, but the health care professional can assist in bringing this about, initially through assessing the situation accurately and then by providing appropriate information, interventions and referrals (Neil and Barrell, 1998).
Price (1998) demonstrates a need to understand the patient’s perspective in assessing the effects of living with chronic wounds and also describes various tools that can be used to achieve this. Clearly designed goals need to be set in the care of patients with chronic wounds and injuries (Davis, 1995). Helping a patient to preserve self-esteem is crucial to survival and to a successful rehabilitation (Morse et al, 1995). Domestic rehabilitation has been identified as important to functional recovery and to quality of life (Gelling, 1998) and there are steps that nurses can take to promote this (Box 1).
In order that friends and family can offer the best support to the injured individual it is important that they are also supported (Grossman, 1995). The impact of the trauma on the family can be almost as great as for patients themselves (Braulin et al, 1982). They have to adjust to their loved one’s altered situation, which may or may not be permanent. They will require support from health care professionals and an intelligible explanation as to what has happened as well as a prognosis for healing. They will need to be prepared for the patient’s possible psychological reactions.
There are many ways in which a person with a wound can be affected psychologically. Anticipation and observation for possible reactions in patients and their friends and family is important. Psychological aspects of wound care must be acknowledged if care is to be holistic and the speed and completeness of recovery are to be optimised.