IMPROVEMENT IN PATIENTS’ ABILITY TO CARE FOR ANXIETY AND IMPAIRED BODY IMAGE: A CASE REPORT OF ACCEPTANCE AND COMMITMENT THERAPY AND FAMILY PSYCHOEDUCATION

Heart failure and hypertension are non-communicable diseases that are responsible for 70% of deaths worldwide and cause anxiety and impaired body image. Nursing interventions (therapy in general) and acceptance and commitment therapy increase patients’ acceptance of the disease and commitment to alleviate anxiety and improve impaired body image. Meanwhile, family psychoeducation improves the family’s ability to care for the patient. This case report presents two patients with heart failure and hypertension. The two patients experienced a decrease in symptoms on the cognitive aspects (difficulty concentrating, focusing on self, and decline body changes), affective aspects (worry, shame, and despair), physiological aspects (sleep disorders and appetite), and behavioral aspects (daydreaming, decreased productivity, and social difficulties). Patients who find difficulty enjoying daily activities and increasing their ability and commitment to overcome anxiety and impaired body image should receive nursing intervention, acceptance and commitment therapy, and family psychoeducation as part of nursing services.


Introduction
Hypertension and heart failure are non-infectious diseases that cause 70% of deaths in the world (World Health Organization, 2017). The prevalence of hypertension is 25.8%, and it has become one of the 12 healthy family indicators as a minimum standard of health (Ministry of Health Republic of Indonesia, 2013Indonesia, , 2016.
Hypertension can cause physical disorders and mental health problems that affect the wellbeing and quality of life of patients (Hsu, Tsao, Chen, & Chou, 2014). About 59% of patients with hypertension develop anxiety and impaired body image (Fatimah, Maideen, Sidik, Rampal, & Mukhtar, 2014;Hsu et al., 2014). In 2015, the estimated number of people who experienced anxiety reached 264 million, which has increased by 14. 9% since 20059% since (WHO, 2017. The symptoms of anxiety and impaired body image are classified as physiological, behavioral, cognitive, and affective responses (Stuart, Keliat, & Pasaribu, 2016). Physiological responses include increased heart rate, hyperventilation, diaphoresis, insomnia, constipation, or diarrhea. Certain behaviors are performed repeatedly in a behavioral response. A cognitive response can be difficulty concentrating or thinking clearly about anything other than worry. Affective responses may include nervousness, anxiety, tension, and feelings of danger, panic, or fear (Legg, 2016).
Acceptance and commitment therapy (ACT) is a specialist nursing intervention that alleviates anxiety and improves impaired body image (Sharp, 2012). ACT focuses on changing the response of patients to stressors and not the unpleasant experience itself, with the eventual goal of the patient reconciling the problem and fostering a positive attitude to achieve life goals (Hayes, Strosahl, & Wilson, 2016).
Research has shown clinical improvement in anxiety disorders after ACT during an 8-month follow-up (Codd, Twohig, Crosby, & Enno, 2011). ACT can also improve the response to body image of patients with eating disorders (Masuda, Ng, Moore, Felix, & Drake, 2016), lowering dissatisfaction with body image and attitude maladaptation after a 1 month followup (Walloch, 2015).
Family involvement is important in patient recovery. The family plays an important role in the treatment process and provides moral support (Shields, Finley, & Chawla, 2012). Family psychoeducation is a nursing intervention allowing caregivers to provide appropriate care for patients and care for themselves (Caqueo-Urizar, Rus-Calafel, Urzua, Escudero, & Gutierrez-Maldonado, 2015). The existence of a caregiver accounted for 61.8% of hypertensive patient compliance (Yeni, Husna, & Dachriyanus, 2016). ACT combined with family psychoeducation increases acceptance and commitment and decreases anxiety and depression in patients with Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome (HIV/AIDS) (Silitonga, Keliat, & Wardani, 2013) The patients included in the study were those hospitalized in a public hospital ward and suffering from anxiety and impaired body image. Patients were selected using the following criteria: characteristics of the same disease (hypertension), experienced rehospitalization, and had an unpleasant experience. This study examined nurses specializing in ACT and family psychoeducation with the aim to decrease symptoms of anxiety and impaired body image and increase the patients' ability to overcome anxiety and impaired body image.
The nursing process used a modeling approach (Stuart) that describes stress adaptation to the whole disease, signs and symptoms, as well as the ability to form constructive coping strategies (Stuart et al., 2016).

Case Illustrations
This paper describes the cases of two patients with anxiety and impaired body image due to hypertension (the general state of each patient is illustrated in Table 1). The patients received nursing intervention as usual, and specialist nurses used ACT intervention and family psychoeducation for the caregivers to measure signs and symptoms.
Symptoms of cognitive, affective, physiological, behavioral, and social aspects; anxiety; and impaired body image were assessed. The patients' ability to address anxiety, impaired body image, reception, capability and commitment, and family abilities was examined using instruments from Stuart models that have not yet been tested for validity and reliability.
Nursing interventions included usual and specialist nursing interventions. General nursing interventions for anxiety include 1) teaching the patient how to relax and take a deep breath, 2) management of anxiety with distractions, 3) positive thinking, and 4) management of anxiety with a spiritual technique. The nursing interventions for impaired body image included 1) identifying the healthy parts of the body, 2) identifying the affected parts of the body, 3) training the healthy and injured body parts, and 4) a positive affirmation for body parts.
Normal nursing interventions are given concurrently with specialist nursing interventions. ACT can be performed two to three times per meeting. ACT consists of 4 sections: section 1, reviewing the unpleasant experience; section 2, discussing the patients' response to an unpleasant experience; section 3, identifying together the impact of the response of an unpleasant experience and accepting the incident; and section 4, identifying the patients' values and how to commit and adapt the therapy to achieve the patients' objectives based on a shared value. All sections can be conducted simultaneously in the first meeting. The objectives of ACT are as follows: 1) to help patients accept an unpleasant experience, including illness; 2) to help patients identify the value and purpose of their life; and 3) to help patients identify ways to achieve their goals, including undergoing treatment, and commit to them.
Family psychoeducation is provided together with family education in as many as six sections or in three or five meetings. Section 1, identification of the health problems faced when caring for family members; section 2, taking care of the patients' health problems; section 3, stress management in the family; section 4, management of the burden on families; section 5, utilizing support systems; and section 6, evaluation of the benefits of family psychoeducation. Family psychoeducation is in accordance with the following functions of the family: 1) recognize family health problems; 2) decide to care for sick members; 3) care for family members; 4) create a therapeutic environment for sick members; and 5) use a health facility to care for sick members.
The assessment and implementation of patients included evaluating the signs and symptoms of    Table 2.
Patient 1 showed decreased signs and symptoms after the nursing intervention, especially after the second and third interventions. However, at the end of the intervention, the patient showed signs and symptoms of cognitive decline in learning ability. The patient experienced difficulty in absorbing the information because of her age. The signs and symptoms of affective aspects were a feeling of sadness when the patient remembered her son had died, despite being able to accept that her daughter had died. For behavioral lifestyle changes, the patient must follow dietary rules and not eat high-glucose foods, which can increase blood pressure.
The ability of families also increased after nursing actions, and acceptance, capability, and commitment emerged after the third meeting. The patient accepted the pain of heartburn, accepted that her son had died, and received all forms of medical therapy. The caregiver treated her by adjusting her diet for hypertension and diabetes, and motivated the patient to seek treatment.
The signs and symptoms for patient 2 did not appear again after the nursing intervention. At the end of the meeting, the family's ability also increased. Acceptance of the disease occurred after the second meeting when he accepted his head pain condition. He was able to focus not only on his sick body but also on the healthy parts of his body and commit to the rules for treatment given after the third meeting.
Graphic 1 shows the signs and symptoms, the patients' ability, and the ability of the families after nursing.

Discussion
Unpleasant experiences before and during hospitalization were factors in anxiety and impaired body image reported by the patients. All patients revealed that the rehospitalization was the most unpleasant thing. The level of rehospitalization on cardiovascular disease was about 30% within a period of 30-90 days (Gheorghiade, Vaduganathan, Fonarow, & Bonow, 2013). Rehospitalization causes the patients to experience rejection and boredom in the face of their illness.
The first focus of the intervention is to decrease the signs and symptoms of patients in the form of cognitive, affective, and behavioral aspects after the administration of ACT therapy. Data obtained at the end of therapy showed that the patients had decreased signs and symptoms of anxiety and impaired body image. However, patients with signs and symptoms of cognitive and  The second focus is to increase the patients' acceptance of the pain they are experiencing and commitment to treatments for anxiety and impaired body image. Data showed that ACT and family psychoeducation improved the abilities of patients and families. Patients showed increased acceptance and value in their life, the family, and a social sphere with a motivation and commitment to healing. According to Grumet and Fitzpatrick (2016), values can improve motivation and compliance to engage in treatment.

Implementation of Nursing Measures
Meeting (Day) Nursing Implementation Σ S Σ PC Σ CA 3 Family: a. Evaluation of family issues in caring for the patient b. Validation of the ability to know the problem and make the decision to care for the patient, treat hypertension, anxiety, impaired body image, stress and load management, create a therapeutic environment, and use health facilities for treating the patient. c. Identify a support system: brother, wife, and health care affordability. d. Evaluating the benefits of family psychoeducation. Work values also contribute to the creation of meaning and purpose that can positively improve the quality of life.
Family psychoeducation therapy provides families with care assistance to patients in accordance with the Orem model of nursing systems. According to Sulistiowati, Keliat, and Wardani (2014), cognitive and psychomotor ability increased significantly in families after family psychoeducation. Family psychoeducation can also increase family psychosocial support for patients with physical health problems (Rahayu, Hamid, & Sabri, 2011). It improves the patients' acceptance of the disease conditions and motivation to comply with a given therapeutic program.

Conclusions
This case report shows a decrease in symptoms of patients with anxiety and impaired body image in cognitive, affective, physiological, behavioral, and social aspects. The patients' ability to accept pain and commit to treatment for anxiety and impaired body image increased after ACT. The ability of the family to care for patients and to motivate patients and cope with the burden of caring also increased after family psychoeducation. This case report recommends the provision of nursing actions, specialist nurses, ACT, and family psychoeducation as part of nursing services.