APPLICATION OF THE NURSING PROCESS
The underlying mechanism of somatization is consistent for clients with somatoform disorders of all types. This section discusses application of the nursing process for cli-ents with somatization; differences among the disorders are highlighted in the appropriate places.
The nurse must investigate physical health status thoroughly to ensure there is no underlying pathology requiring treatment. When a client has been diagnosed with a somatoform disorder, it is important not to dismiss all future complaints because at any time the client could develop a physical condition that would require medical attention.
Clients usually provide a lengthy and detailed account of previous physical problems, numerous diagnostic tests, and perhaps even a number of surgical procedures. It is likely that they have seen multiple health care providers over several years. Clients may express dismay or anger at the medical community with comments such as “They just can’t find out what’s wrong with me” or “They’re all incom-petent, and they’re trying to tell me I’m crazy!” The excep-tion may be clients with conversion disorder, who show little emotion when describing physical limitations or lack of a medical diagnosis (la belle indifférence).
Overall appearance usually is not remarkable. Often, cli-ents walk slowly or with an unusual gait because of the pain or disability caused by the symptoms. They may exhibit a facial expression of discomfort or physical dis-tress. In many cases, they brighten and look much better as the assessment interview begins because they have the nurse’s undivided attention. Clients with somatization dis-order usually describe their complaints in colorful, exag-gerated terms but often lack specific information.
Mood is often labile, shifting from seeming depressed and sad when describing physical problems to looking bright and excited when talking about how they had to go to the hospital in the middle of the night by ambulance. Emo-tions are often exaggerated, as are reports of physical symptoms. Clients describing a series of personal crises related to their physical health may appear pleased rather than distressed about these situations. Clients with con-version disorder display an unexpected lack of distress.
Clients who somatize do not experience disordered thought processes. The content of their thinking is pri-marily about often exaggerated physical concerns; for example, when they have a simple cold, they may be con-vinced it is pneumonia. They may even talk about dying and what music they want played at their funeral.
Clients are unlikely to be able to think about or to respond to questions about emotional feelings. They will answer questions about how they feel in terms of physical health or sensations. For example, the nurse may ask, “How did you feel about having to quit your job?” The cli-ent might respond, “Well, I thought I’d feel better with the extra rest, but my back pain was just as bad as ever.”
Clients with hypochondriasis focus on the fear of seri-ous illness rather than the existence of illness, as seen in clients with other somatoform disorders. However, they are just as preoccupied with physical concerns as other somatizing clients and are likewise very limited in their abilities to identify emotional feelings or interpersonal issues. Clients with hypochondriasis are preoccupied with bodily functions, ruminate about illness, are fascinated with medical information, and have unrealistic fears about potential infection and prescription medication.
Clients are alert and oriented. Intellectual functions are unimpaired.
Exaggerated responses to their physical health may affect clients’ judgment. They have little or no insight into their behavior. They are firmly convinced their problem is entirely physical and often believe that others don’t understand.
Clients focus only on the physical part of themselves. They are unlikely to think about personal characteristics or strengths and are uncomfortable when asked to do so. Cli-ents who somatize have low self-esteem and seem to deal with it by totally focusing on physical concerns. They lack confidence, have little success in work situations, and have difficulty managing daily life issues, which they relate solely to their physical status.
Clients are unlikely to be employed, although they may have a past work history. They often lose jobs because of excessive absenteeism or inability to perform work; clients may have quit working voluntarily because of poor physi-cal health. Consumed with seeking medical care, they have difficulty fulfilling family roles. It is likely that these cli-ents have few friends and spend little time in social activi-ties. They may decline to see friends or to go out socially for fear that they would become desperately ill away from home. Most socialization takes place with members of the health care community.
Clients may report a lack of family support and under-standing. Family members may tire of the ceaseless com-plaints and the client’s refusal to accept the absence of a medical diagnosis. The illnesses and physical conditions often interfere with planned family events such going on vacations or attending family gatherings. Home life is often chaotic and unpredictable.
In addition to the multitude of physical complaints, these clients often have legitimate needs in terms of their health practices. Clients who somatize often have sleep pattern disturbances, lack basic nutrition, and get no exercise. In addition, they may be taking multiple pre-scriptions for pain or other complaints. If a client has been using anxiolytics or medications for pain, the nurse must consider the possibility of withdrawal .
Nursing diagnoses commonly used when working with clients who somatize include the following:
· Ineffective Coping
· Ineffective Denial
· Impaired Social Interaction
· Disturbed Sleep Pattern
Clients with conversion disorder may be at risk for disuse syndrome from having pseudoneurologic paralysis symptoms. In other words, if clients do not use a limb for a long time, the muscles may weaken or atrophy from lack of use.
Treatment outcomes for clients with a somatoform disor-der may include the following:
· The client will identify the relationship between stress and physical symptoms.
· The client will verbally express emotional feelings.
· The client will follow an established daily routine.
· The client will demonstrate alternative ways to deal with stress, anxiety, and other feelings.
The client will demonstrate healthier behaviors regard-ing rest, activity, and nutritional intake.
The nurse must help the client learn how to establish a daily routine that includes improved health behaviors. Adequate nutritional intake, improved sleep patterns, and a realistic balance of activity and rest are all areas with which the client may need assistance. The nurse should expect resistance, including protests from the client that she or he does not feel well enough to do these things. The challenge for the nurse is to validate the client’s feelings while encouraging her or him to participate in activities.
Nurse: “Let’s take a walk outside for some fresh air.” (encouraging collaboration)
Client: “I wish I could, but I feel so terrible, I just can’t do it.”
Nurse: “I know this is difficult, but some exer-cise is essential. It will be a short walk.” (validation; encourag-ing collaboration)
The nurse can use a similar approach to gain client participation in eating more nutritious foods, getting up and dressed at a certain time every morning, and setting a regular bedtime. The nurse also can explain that inactivity and poor eating habits perpetuate discomfort and that often it is necessary to engage in behaviors even when one doesn’t feel like it.
Client: “I just can’t eat anything. I have no appetite.”
Nurse: “I know you don’t feel well, but it is important to begin eating.” (validation; encour-aging collaboration)
Client: “I promise I’ll eat just as soon as I’m hungry.”
Nurse: “Actually, if you begin to eat a few bites, you’ll begin to feel better, and your appetite may improve.” (encouraging collaboration)
The nurse should not strip clients of their somatizing defenses until adequate assessment data are collected and other coping mechanisms are learned. The nurse should not attempt to confront clients about somatic symptoms or attempt to tell them that these symptoms are not “real.” They are very real to clients, who actually experience the symptoms and associated distress.
Teaching about the relationship between stress and physi-cal symptoms is a useful way to help clients begin to see the mind–body relationship. Clients may keep a detailed journal of their physical symptoms. The nurse might ask them to describe the situation at the time such as whether they were alone or with others, whether any disagreements were occurring, and so forth. The journal may help clients to see when physical symptoms seemed worse or better and what other factors may have affected that perception.
Limiting the time that clients can focus on physical complaints alone may be necessary. Encouraging them to focus on emotional feelings is important, although this can be difficult for clients. The nurse should provide attention and positive feedback for efforts to identify and discuss feelings.
It may help for the nurse to explain to the family about primary and secondary gains. For example, if the family can provide attention to clients when they are feeling better or fulfilling responsibilities, clients are more likely to continue doing so. If family members have lavished attention on clients when they have physical complaints, the nurse can encourage the relatives to stop reinforcing the sick role.
Two categories of coping strategies are important for cli-ents to learn and to practice: emotion-focused coping strategies, which help clients relax and reduce feelings of stress, and problem-focused coping strategies, which help to resolve or change a client’s behavior or situation or manage life stressors. Emotion-focused strategies include progressive relaxation, deep breathing, guided imagery, and distractions such as music or other activities. Many approaches to stress relief are available for clients to try. The nurse should help clients to learn and practice these techniques, emphasizing that their effectiveness usually improves with routine use. Clients must not expect such techniques to eliminate their pain or physical symptoms; rather, the focus is helping them to manage or diminish the intensity of the symptoms.
Problem-focused coping strategies include learning problem-solving methods, applying the process to identi-fied problems, and role-playing interactions with others. For example, a client may complain that no one comes to visit or that she has no friends. The nurse can help the client to plan social contact with others, can role-play what to talk about (other than the client’s complaints), and can improve the client’s confidence in making relationships. The nurse also can help clients to identify stressful life situations and plan strategies to deal with them. For example, if a client finds it difficult to accomplish daily household tasks, the nurse can help him to plan a schedule with difficult tasks followed by something the client may enjoy.
Somatoform disorders are chronic or recurrent, so changes are likely to occur slowly. If treatment is effective, the client should make fewer visits to physicians as a result of physical complaints, use less medication and more positive coping techniques, and increase functional abilities. Improved fam-ily and social relationships are also a positive outcome that may follow improvements in the client’s coping abilities.