Nursing Interventions ^*denotes collaborative interventions

Rationale

^*Do a thorough initial assessment, including physical problems, complaints, history of diseases, treatment, surgeries, and hospitalizations. Obtaining the client’s prior medical record(s) or interviewing family members or significant others may be helpful. Do not assume there is not a physiologic basis for the client’s symptoms.

An adequate database is necessary to rule out pathophysiology. The client may be a poor historian. The client may have been seen in the treatment setting in the past (without evidence of pathophysiology), but may have developed a physiologic illness since that time.

Ask for the client’s perceptions about physical problems, but do not argue or put the client on the defensive.

Arguing will damage your trust relationship. The client’s symptoms are real to the client.

Ask the client to identify expectations of treatment, himself or herself, and the staff. Try to involve the client in identifying problems, goals, and actions to work toward goals.

If the client is involved and invests energy in his or her care, the chances for positive outcomes increase.

Develop and implement a nursing care plan regarding the client’s physical health as soon as possible. Be matter-offact in your approach and treatment. Do not overemphasize physical problems or give undue attention to physical symptoms.

Optimal physical health facilitates achievement of emotional health. You must consider the client’s physical care, but not as the primary focus. Remember that the client’s problems are real to the client and not hypochondriacal or imaginary.

Talk with the client directly regarding a correlation between emotions, stress, and physical symptoms.

The client’s chance for health is enhanced if the interrelatedness of physical and emotional health is recognized.

Assess the client’s activities and interactions with others in the treatment setting and with visitors with regard to stress, support, dependency, and expressing feelings.

Stress-related factors are important in the dynamics of somatization disorder.

Talk with the client about your observations and ask for the client’s perceptions regarding stress, sources of satisfaction and dissatisfaction, relationships, work, and so forth.

You are focusing on emotional issues. The client may have spent minimal time considering those aspects of health.

Give the client positive feedback for focusing on emotional and interpersonal issues rather than on physical symptoms.

Positive feedback increases the likelihood that the client will continue to express feelings and deal with interpersonal issues.

Without always connecting the client’s physical problems with emotions, encourage the client to express feelings, by writing, in individual conversations, and in groups (start small and progress to larger).

It is less threatening for the client to begin expressing feelings to one person and work his or her way up to talking with more people about emotional issues.

Encourage the client to express feelings directly in relationships and stressful situations—especially feelings that are uncomfortable for the client. Role-play situations and give support for expressing feelings during and after role-playing. See “Key Considerations in Mental Health Nursing: Nurse-Client Interactions.”

Role-playing allows the client to try out new behaviors in a nonthreatening situation.

Especially support the client for expressing feelings spontaneously or independently (e.g., writing, art work, or verbal expression).

True client change is best evidenced by spontaneous behavior.

^*Teach the client and his or her family or significant others about physical symptoms, stress, and stress management skills.

The client may have little or no knowledge of stress or of stress management techniques.

Gradually attempt to identify with the client the connections between anxiety or stress and the exacerbation of physical symptoms.

Acknowledging the interrelatedness of physical health and emotional health will help the client recognize this and make changes in the future.

Encourage the client to identify his or her own strengths; making a written list may be helpful.

It may be difficult for the client to see his or her own strengths, but this can promote an increased sense of self-worth.

Teach the client about the problem-solving process: identify a problem, identify and evaluate possible solutions, choose and implement a solution, and evaluate its success.

The client may never have learned a logical, step-by-step approach to dealing with problems.

^*Talk with the client and significant others about secondary gains. Identify the needs the client is attempting to meet (e.g., need for attention, means of dealing with perceived excess responsibilities). Help the client plan to meet these needs in more direct ways.

Significant others may be unaware of how they reward the client for physical symptoms. Their participation in treatment is essential so the client can give up the sick role and deal with emotional problems.

^*Conferences with only the client’s family or significant others may help increase their insight. For example, they unknowingly may be giving the client the message that emotional problems are a sign of weakness and that only physical illness is acceptable.

Unless significant others make changes in their relationships with the client, chances for positive client changes are diminished.

^*Encourage the client to continue to identify stresses and attempt to deal with them directly. Encourage the client to continue therapy on an outpatient basis or refer to a chronic pain clinic if indicated.

Long-term change depends on how the client continues to progress after treatment.

^*Encourage the client to develop an outside support system to continue to talk about feelings (e.g., significant others, support group, or group therapy).

The client needs to continue to express feelings to avoid returning to coping through physical symptoms.

^*Teach the client and his or her family or significant others about treatment and medications for the client’s physical symptoms, if any.

Clients need to have clear instructions regarding self-care and the safe use of medications if they require continued treatment.

Encourage the client to enhance his or her physical health (e.g., with regular exercise, good nutrition).

General physical wellness will facilitate management or control of illness.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Assess the client’s activities and interactions with others with regard to stress, support, dependency, and expression of emotions.

Stress-related factors are important in the dynamics of somatization disorder.

Ask for the client’s perceptions about physical problems, but do not argue or put the client on the defensive.

Arguing will damage your trust relationship.

Talk with the client about your observations and ask for the client’s perceptions regarding stress, sources of satisfaction and dissatisfaction, relationships, work, and so forth.

You are focusing on emotional issues. The client may have spent minimal time considering these aspects of health.

Talk with the client directly regarding a correlation between emotions, stress, and physical symptoms.

The client’s chance for health is enhanced if the interrelatedness of physical and emotional health is recognized.

Give the client positive feedback for focusing on emotional and interpersonal issues rather than on physical symptoms.

Positive feedback increases the likelihood that the client will continue to express feelings and deal with interpersonal issues.

If the client denies experiencing stress or certain feelings, the discussion may need to be less direct. For example, point out apparent stresses or feelings and ask the client for feedback about them.

Directly confronting the client’s denial can make the denial stronger if the client is not ready to deal with issues.

Without always connecting the client’s physical problems with emotions, encourage the client to express feelings, by writing, in individual conversations, and in groups (start with small and progress to larger groups).

It is less threatening for the client to begin expressing feelings in writing or to one person and work his or her way up to talking with more people about emotional issues.

^*Teach the client and family or significant others about the physical symptoms, stress, and stress management skills.

The client may have little or no knowledge of stress or stress management techniques.

Gradually attempt to identify with the client the connections between anxiety or stress and the exacerbation of physical symptoms.

Acknowledging the interrelatedness of physical health and emotional health provides a basis for the client’s future lifestyle changes.

^*Encourage the client to continue to identify stresses and attempt to deal with them directly. Encourage the client to continue therapy, if indicated.

Long-term change depends on how the client continues to progress after treatment.

^*Encourage the client to develop an outside support system to continue to talk about feelings after discharge (e.g., significant others, a support group, or group therapy).

The client needs to continue to express feelings to avoid returning to coping through physical symptoms.

Nursing Interventions ^*denotes collaborative interventions

Rationale

Observe the client’s ability to perform activities of daily living, ambulate independently, and so on. Intervene if the client is risking injury to himself or herself, but minimize attention given to the client’s limitation and your supervision.

Often clients with histrionic types of behavior will not experience physical injuries.

^*Obtain the client’s thorough history on admission and request records from prior hospitalizations, if possible. Contact the family or significant others if necessary to complete the history.

A complete database is essential to the validity of the diagnosis.

Observe and document the client’s behavior, especially in relation to the symptom, including precipitating events, the environment (such as the presence of others), and changes in the severity of the symptom(s).

Observational data will provide clues to the client’s perception of stress and the relationship of the conversion symptom to that stress.

Assess the client’s food and fluid intake, elimination, and amount of rest as unobtrusively as possible.

You must be aware of the client’s physical status, without giving excessive attention to it.

Assist or prepare the client as necessary for any tests to rule out a physical (organic) basis of the symptom.

Organic pathology must be ruled out.

Approach the client with the attitude that you expect improvement in the physical symptom.

Communicating your expectation may help the client expect to improve. Hospitalization may relieve the conflict by removing the client from his or her usual environment.

Initially, avoid making demands on the client that are similar to the client’s prehospitalization conflict or situation.

Such demands could intensify the client’s conflict, resulting in exacerbation of the symptom.

Initially, if the conflict is related to a particular person in the client’s life, visits from that person may need to be restricted or prevented.

Temporary limitations of visits may help alleviate the client’s stress.

As the physical symptom improves, gradually allow stressful situations or increase visits, as tolerated; monitor the client’s response.

The client can begin to tolerate increased stresses as his or her skills develop, but too much stress may exacerbate the symptom.

^*Any intervention regarding the client’s physical state (e.g., poor food or fluid intake) must be planned and consistently implemented by the treatment team.

A consistent team approach decreases opportunities for manipulation.

Provide nursing care in a matter-of-fact manner.

A matter-of-fact approach minimizes secondary gain and can help separate emotional issues from physical symptoms.

Talk with the client about his or her life, usual environment, work, significant others, and so forth.

General, leading questions or open discussion is a nonthreatening approach to discover the nature of the conflict.

Focus interactions on the client’s feelings, home or work situation, and relationships.

Your consistent attention to emotional issues will help the client shift attention to these issues.

Encourage the client to express feelings directly, verbally, or in writing. Support the client’s efforts to express feelings.

Direct expression of feelings can relieve tension and conflict, diminishing the need for physical symptoms.

Explore with the client his or her personal relationships and related feelings.

Conversion reaction symptoms often are related to interpersonal conflicts or situations.

^*Teach the client and the family or significant others about conversion reaction, stress, stress management, interpersonal dynamics, and conflict resolution strategies.

The client and the family or significant others may have little or no knowledge of these areas. Increasing their knowledge can promote understanding, motivation for change, and support for the client.

Praise the client when he or she is able to identify the physical symptom as a method used to cope with conflict.

Positive feedback can reinforce the client’s insight.

Explore alternative methods of expressing feelings related to the identified conflict.

The client has the opportunity to practice unfamiliar behavior with you in a nonthreatening environment.

Provide opportunities for the client to succeed at activities, tasks, and interactions. Give positive feedback and point out the client’s demonstrated strengths and abilities.

Activities within the client’s abilities will provide opportunities for success. Positive feedback provides reinforcement for the client’s growth and can enhance self-esteem.

Help the client set goals for his or her behavior; give positive feedback when the client achieves these goals.

Setting and achieving goals can foster the client’s sense of control and self-esteem and teaches goal-setting skills.

Teach the client about the problem-solving process: identify the problem, examine alternatives, weigh the pros and cons of each alternative, select and implement an approach, and evaluate its success. Encourage him or her to use it to examine the conflict.

The client may have few or no problem-solving skills or knowledge of the problem-solving process.

Encourage the client to identify strategies to deal with the conflict and evaluate their effectiveness.

The client must actively explore new strategies because they are unfamiliar.

Give the client positive feedback for expressing feelings about the conflict and trying conflict resolution strategies.

Positive feedback can increase desired behavior.

^*Refer the client and the family or significant others for continuing therapy if appropriate.

The client may need long-term therapy to deal with feelings, conflict, or relationships.

^*Encourage the client to increase his or her support system outside the hospital. See Care Plan 2: Discharge Planning.

Extended support in the community strengthens the client’s ability to cope more effectively.