By Debra Wood, RN, contributor
April 28, 2014 - Is there more to a patient’s story than just the physical symptoms that you see?
At its core, nursing provides a holistic approach to care, addressing patients’ psychological as well as physical concerns to deliver comprehensive care and improve outcomes.
Rebecca Lehto, PhD, RN, OCN, said nurses may need to dig deeper to discover if something is bothering the patient and could impact the care plan.
“It’s essential we consider all of the important aspects of functioning, which include emotional and cognitive pieces,” said Rebecca Lehto, PhD, RN, OCN, assistant professor at Michigan State University College of Nursing in East Lansing. “Patients often won’t be able to focus on their illness or what they need to do to feel better if they are emotionally distraught.”
Florence Nightingale understood the psychological component of healing, said Elda G. Ramirez, PhD, RN, FNP-C, FAANP, associate professor of nursing at The University of Texas Health Sciences Center at Houston School of Nursing.
Margaret Silver, RN, MEd, NP, a psychiatric nurse practitioner and director of the RN-to-BSN undergraduate ASCEND program at Adelphi University, College of Nursing and Public Health in Garden City, N.Y., added that nurses are taught to look at the whole patient.
“If you don’t look at the whole [person], you are in trouble,” Silver said.
Students at Adelphi study human behavior and incorporate those theories into their care planning. They also learn therapeutic communication techniques to talk with people who are in pain, anxious or depressed.
“It’s tough, because the nurses today are expected to do a lot,” Silver said. However, it’s imperative.
The connection between physical and mental health
Margaret Silver, RN, MEd, NP, said nurses are taught therapeutic communication to help patients cope with their conditions.
Science supports a mind–body connection.
“We’ve identified, in multiple types of research and theoretical frameworks, the patient who is affected in a psychological way because they can no longer function as a husband, wife or child,” Ramirez said. “Their illness limits them.”
Illnesses and accidents can present temporary or permanent changes to body image and quality of life. All of a sudden the patient and family are dealing with something unexpected.
“The psychological part is so hard, because denial is the No 1. coping mechanism humans have when it comes to illness,” Ramirez said.
Depression commonly occurs with certain diagnoses, such as stroke or multiple sclerosis, conditions that often result in long-term disability. A cancer diagnosis often causes patients to worry. Additionally, depression is associated with fatigue, and anxiety will dampen the appetite. When anxious, “it may be more difficult for them to adhere to the prescribed regimen,” Lehto said.
Patients in acute pain have difficulty learning, they need relief from the pain before patient teaching can occur, said Joan McTigue, MS, PA-C, a physician assistant in the division of rheumatology at the University of Florida College of Medicine in Gainesville and board member for the Gout and Uric Acid Education Society.
Patients under stress or grieving may present with physical complaints, such as gastrointestinal complaints or a panic attacks, Ramirez added.
Looking beyond the physical
Nurses should ask patients about how they are feeling, not just physically, but emotionally, Lehto said. Conversations may take place while changing a dressing or performing some other task.
Often nurses can tell when something is bothering a patient. He may avoid eye contact or make a comment that signals an emotional need. Lehto suggested nurses spend a few minutes to dig a little deeper into the person’s concerns and actively listen.
Ramirez advised nurses to remain nonjudgmental and check their biases at the door. Holding someone’s hand may help, as might sitting and taking the time to listen and connect. She suggested the nurse ask patients if there is anything else they want to talk about and give them time to respond. Offer the opportunity for conversation.
Sitting down and making eye contact is important for establishing therapeutic relationships, Silver added.
Karissa Smith, RN, BSN, has learned to develop therapeutic rapport remotely as a telehealth nurse educator at the MS One-to-One Program, a disease management program for patients on Aubagio, sponsored by Genzyme. She begins with a thorough assessment and may suggest stress management techniques and discuss mental as well physical health concerns with the patient’s physician or other provider.
“We try to help them stay in the positive,” Smith said.
Elda G. Ramirez, PhD, RN, FNP-C, FAANP, said a focus on the whole person is what makes nursing different from other professions.
Demonstrating genuine caring can go a long way. Nurses may be able to offer resources to help the patient deal with his or her concerns. The nurse can add the psychological or coping issues to the patient’s care plan. A referral to social work or other members of the health care team may be warranted. The provider may order a psychiatric consult.
In the outpatient setting, the nurse might be able to suggest resources, but it’s up to the patient to follow through. Patients may resist counseling due to the stigma associated with it, Ramirez said.
Although in the past primary care providers hesitated to diagnose a patient with a psychiatric condition, such as depression or anxiety, Lehto and Silver agreed that is becoming less of a problem, as the mind–body connection becomes more accepted and evidence suggests illness affects the psyche.
“A lot of physicians only look at the medical piece,” Silver said. “NPs are much more holistic.”
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