NURSING HISTORY AND ASSESSMENT
Jake is a 54-year-old client of the psychiatric outpatient department of the VA Medical Center. At age 42, Jake was diagnosed with colon cancer and underwent a colon resection. Since that time, he has had regular follow-up exams, with no recurrence of the cancer and no residual effects. He did not require follow-up chemotherapy or radiation therapy. For 10 years, Jake has had yearly physical and laboratory examinations. He regularly complains to his family physician of mild abdominal pain, sensations of “fullness,” “bowel rumblings,” and what he calls a “firm mass,” which he says he can sometimes feel in his lower left quadrant. The physician has performed x-rays of the entire gastrointestinal (GI) tract, an esophagoscopy, gastroscopy, and colonoscopy. All results were negative for organic pathology. Rather than being relieved, Jake appears resentful and disappointed that the physician has not been able to reveal a pathological problem. Jake’s job is in jeopardy because of excessive use of sick leave. The family physician has referred Jake for psychiatric evaluation. Jake was admitted as an outpatient with the diagnosis of Illness Anxiety Disorder. He has been assigned to Lisa, a psychiatric nurse practitioner.
In her assessment, Lisa learns that Jake has pretty much lived his adult life in isolation. He was never close to his parents, who worked and seldom had time for Jake or his sister. Jake told Lisa, “My parents really didn’t care about me. They were too busy taking care of the farm. Dad wanted me to take over the farm, but I was never interested. I liked working on cars, and went to vocational school to learn how to be a mechanic. I thought they would be proud of me, but they never cared. I think they only had kids so they would have some help on the farm. When I left home, they really didn’t care if they ever saw me again.” He has never been married nor had a really serious relationship. “Women don’t like me much. I spend most of my time alone. I guess I don’t really like people, and they don’t really like me.
NURSING DIAGNOSES AND OUTCOME
IDENTIFICATION
From the assessment data, the nurse develops the following nursing diagnoses for Jake:
1. Fear (of cancer recurrence) related to history of colon cancer evidenced by numerous complaints of the GI tract and insistence that something is wrong despite objective tests that rule out pathophysiology.
a. Short-Term Goal: Client will verbalize that fears associated with bodily sensations are irrational.
b. Long-Term Goal: Client interprets bodily sensations correctly.
2. Chronic low self-esteem related to unfulfilled childhood needs for nurturing and caring evidenced by transformation of internalized anger into physical complaints and hostility toward others.
a. Short-Term Goal: Within 2 weeks, client will verbalize aspects about self that he likes.
b. Long-Term Goal: By discharge from treatment, client will demonstrate acceptance of self as a person of worth, as evidenced by setting realistic goals, limiting physical complaints and hostility toward others, and verbalizing positive prospects for the future.
PLANNING AND IMPLEMENTATION
FEAR (OF CANCER RECURRENCE)
The following nursing interventions have been identified for Jake:
1. Monitor the physician’s ongoing assessments and laboratory reports to ensure that pathology is clearly ruled out.
2. Refer any new physical complaints to the physician.
3. Assess what function these physical complaints are fulfilling for Jake. Is it a way for him to get attention that he cannot get in any other way?
4. Show empathy for his feelings. Let him know that you understand how GI symptoms may bring about fears of the colon cancer.
5. Encourage Jake to talk about his fears of cancer recurrence. What feelings did he have when it was first diagnosed? How did he deal with those feelings? What are his fears at this time?
6. Have Jake keep a diary of the appearance of the symptoms.
In a separate diary, have Jake keep a record of situations that create stress for him. Compare these two records.
Correlate whether symptoms appear at times of increased anxiety.
7. Help Jake determine techniques that may be useful for him to implement when fear and anxiety are exacerbated (e.g., relaxation techniques; mental imagery; thought-stopping techniques; physical exercise).
8. Offer positive feedback when Jake responds to stressful situations with coping strategies other than physical complaints.
CHRONIC LOW SELF-ESTEEM
The following nursing interventions have been identified for Jake:
1. Convey acceptance and unconditional positive regard, and remain nonjudgmental at all times.
2. Encourage Jake to participate in decision-making regarding his care and in life situations.
3. Help Jake to recognize and focus on strengths and accomplishments. Minimize attention given to past (real or perceived) failures.
4. Encourage Jake to talk about feelings related to his unsatisfactory relationship with his parents.
5. Discuss things in his life that Jake would like to change.
Help him determine what can be changed and what changes are not realistic.
6. Encourage participation in group activities and in therapy groups that offer simple methods of achievement.
Give recognition and positive feedback for actual accomplishments.
7. Teach assertiveness techniques and effective communication techniques.
8. Offer positive feedback for appropriate social interactions with others. Role-play with Jake situations that he finds particularly stressful. Help him to understand that ruminations about himself and his health may cause others to reject him socially.
9. Help Jake to set realistic goals for his future.
EVALUATION
Some of the outcome criteria for Jake have been met, and some are ongoing. He has come to realize that the fears about his “symptoms” are not rational. He understands that the physician has performed adequate diagnostic procedures to rule out illness. He still has fears of cancer occurrence and discusses these fears with the nurse practitioner on a weekly basis. He has kept his symptoms and stressful situations diaries and has correlated the appearance of some of the symptoms to times of increased anxiety. He has started running and tries to use this as a strategy to keep the anxiety from escalating out of proportion and bringing on new physical symptoms. He continues to discuss feelings associated with his childhood, and the nurse has helped him see that he has had numerous accomplishments in his life, even though they were not recognized by his parents or others. He has joined a support group for depressed persons and states that he “has made a few friends.” He has made a long-term goal of joining a church with the hope of meeting new people. He is missing fewer workdays because of illness, and his job is no longer in jeopardy
