• Home
  • About Me
  • Nurse Convo
  • What My Nurse Needs To Know About
  • Book Review

NurseConvo

~ Read and Reflect

NurseConvo

Tag Archives: nurse

Understanding Conversion Disorder to better inform your patient sensitively

08 Saturday Jul 2017

Posted by Annette Horton in Clinical Care, Nurse Convo

≈ Comments Off on Understanding Conversion Disorder to better inform your patient sensitively

Tags

Conversion Disorder, FNSD, informing, nurse, sensativity, stigma

Conversion Disorder has had a name recently with the update of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) – Functional Neurological Symptom Disorder (FNSD).

The prevalence of FNSD is estimated to have a 1-3% occurrence rate in general population. In neurological outpatient clinics, the incident is thought to be as high as 25-30%.

“medically unexplained, neurological symptoms that are believed to develop
unintentionally in reaction to psychological and environmental factors
such as trauma or daily stressors.”

In previous years FNSD aetiology was believed to be anxiety/stress related. Sigmund Freud a 19th Century Austrian neurologist and founder of psychoanalysis theorised that anxiety is “converted” into physical symptoms.

More recent work in this area now suggests it has many interrelated and complex variables with or without an anxiolytic or stressful preceding event which makes treatment less than simple or a “one size fits all” scenario.

Diagnosing FNSD

Diagnosis of FNSD is considered clinically when all diagnostic testing is not compatible with presenting signs and symptoms. Misdiagnosis does occur although is less likely today due to significant advancements in diagnostics and research.

The DSM-5 diagnostic criteria for FNSD (conversion disorder) are as follows:

• One or more symptoms of altered voluntary motor or sensory function.
• Clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions.
• The symptom or deficit is not better explained by another medical or mental disorder.
• The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

PNSD is more prevalent in women than men, rarely found in children or the elderly and has an increased rate in people aged the mid to late 30s. Patient populations considered more at risk are those with a personality disorder or dissociative identity disorder.

Hoover’s sign is a test available to clinicians when assessing limb weakness which with a positive result “simply suggests that the majority of the weakness you are observing is not due to disease”.

  Breaking the news

”The doctor just told me my stroke is all in my head”.
”I can’t move my bloody arm”.
“I’m not making it up”.
“I’m not crazy”.

A diagnosis of FNSD can elicit strong emotional reactions from the patient and family if not handled sensitively. Mental health illness still has a stigma very much attached. Commonly families and staff don’t know what to say or how to care for the patient which can isolate the patient more with feelings of stigmatisation.

Use of a standardised non-judgmental script and having confidence in responding to emotive and challenging questions “you don’t believe me?” is necessary for the diagnosis disclosure.

The information provided is just as important as the delivery in explaining the diagnosis to your patient. While the initial conversation is not necessarily a nurses role, the ongoing reinforcement and provision of information related to the diagnosis certainly are.

Communicating that PNSD is a significant health condition requiring a whole of team effort for the condition to improve and symptoms resolve and as per below:
• the emphasis that symptoms are genuine and potentially reversible;
• explanation of the positive nature of the diagnosis (i.e., not a diagnosis of exclusion);
• simple advice about distraction techniques, self-help techniques and sources of information;
• referral on to appropriate physiotherapy and psychological services; and
• offering an outpatient review

Treatment options available

  • The treatment plan found to be most effective is one with a motor learning program and a behavioural approach which is individualised within a multidisciplinary team environment.
  • Person-centred goal setting with the patient/family is recommended.
  • Behavior-oriented treatment strategies include unlearning maladaptive responses to eliminate example for the patients’ belief the limb is paralysed by informing them 1. that all tests indicate the muscles and nerves are functioning normally 2. the brain is communicating with the nerves and muscles, and 3. this apparently lost ability is recoverable.
  • Pharmacological treatment includes prescribing of antidepressants and anxiolytics if indicated.

Clinical Take Home Message

• FNSD is a significant health condition requiring a multidisciplinary treatment plan based on a motor learning and behavioural approach.
• FNSD has many interrelated and complex variables with or without an anxiolytic or stressful preceding event.
• Motor learning program with a behavioural approach which is individualised within a multidisciplinary team environment is most effective.
• Sensitivity is required when disclosing diagnosis and with ongoing communication due to stigma and spoken or unspoken sense of not being believed.
• Treatment options available include individualised motor learning and behavioural approach programs, anti-depressants, anxiolytics, education, and suggestive therapy.

Reference:
Carson A, Lehn A, Ludwig L, Stone J, 2016 Explaining functional disorders
in the neurology clinic: a photo story Pract Neurol;16:56–61. 
http://dx.doi.org/10.1136/ practneurol-2015-001241

Boeckle M, Liegl F, Jank R, Pieh C 2016 Neural correlates of conversion 
disorder: overview and meta-analysis of neuroimaging studies on motor
conversion disorder BMC Psychiatry,16:195 DOI 10.1186/s12888-016-0890-x

Share this:

  • Tweet
  • Email
  • Print

Like this:

Like Loading...

My Pain Is What I Say It Is Nurse

16 Thursday Apr 2015

Posted by Annette Horton in Nurse Convo

≈ 1 Comment

Tags

chamberlain, dingo, Lindy, nurse, pain

You put down what your doing and head into a Room 23A to answer the buzzer. Patty (patty the patient) is recovering from a fractured left ankle, ribs and right humerus post MVA. Patty wheeled past you in her wheelchair just 5 minutes ago with some friends in tow.

“I need my pain meds nurse.Its 8/10 and driving me crazy”. A friend jokes “I thought you said you weren’t going to be driving anywhere anytime soon”. Patty and her friends continue to joke and muck around as you leave the room.

Seriously you ask yourself how can someone be in soooooo much pain but show very little sign of being in pain. We are all unique and respond to situations including pain in our own way. Not appearing to respond as one would normally expect can at times influence how others judge or perceive the situation.

“I am in pain you just don’t know it cause I smile through the rain and refuse to show it

image“The dingo took my baby” is a prime example of this. Some Australians judged Lindy Chamberlain negatively and with suspicion purely based on how she responded to the situation and appeared in the media. Her response was not considered normal by many at the time. Lindy was viewed with suspicion and labelled by many.

Pain is by its very nature subjective. Yes when pain is severe there are physical changes i.e. vital signs which are an objective measure. Irrespective of our thoughts of how much pain Patty is experiencing in this instance it is all about the patient. What the patient says the pain is what the nurse needs to treat.

Analgesia is one strategy to minimise pain however there are other alternatives that can by considered in collaboration with or as stand alone treatments. Resting, positioning, activity, stretching, thermal (ice or heat) and diversion such as listening to music and meditation are non pharmacological strategies for pain management.

Educating patients regards pain is also an important aspect of a nurses role in pain management. Not understanding why they have or still have pain increases anxiety. Anxiety exacerbates or heightens the pain. Having a good understanding of why the pain exists and knowing the plan for relieving that pain can reduce some of that anxiety.

Working with Patty in developing a plan of care around her pain management assists in giving her a much needed feeling of control over her pain. Patty is the expert when it comes to what has worked best for her in the past which must be respected in developing the plan.

Increasing medication is not always the answer. With each new medication or increase in dose the risk increases for drug interactions and unwelcome side effects. Getting the right management plan in place though is always the answer.

Share this:

  • Tweet
  • Email
  • Print

Like this:

Like Loading...

Follow Blog via Email

Enter your email address to follow this blog and receive notifications of new posts by email.

Join 128 other subscribers

Nurse Convo

Nurse Convo

Powered by WordPress.com.

 

Loading Comments...
 

    %d bloggers like this: