nursing care plan for hypochondriasis nursing care plan for hypochondriasis

RN, BSN, PHNClinical Nurse Instructor, Emergency Room Registered NurseCritical Care Transport NurseClinical Nurse Instructor for LVN and BSN students. 2008 Nov. 65(5):435-9. [QxMD MEDLINE Link]. Since both primary care and specialty physicians face specific chal-lenges with hypochondriasis patients, we specifi-cally focus on the presentation of hypochondriasis in the various practice settings. Medscape Education. This can also help establish rapport between the nurse and the patient. Somatic Symptom and Related Disorders. Key results of professionalism include better overall care, improved team communication, and a more positive work environment. Fallon BA, Liebowitz MR, Salman E, Schneier FR, Jusino C, Hollander E. Fluoxetine for hypochondriacal patients without major depression. Arch Intern Med. [QxMD MEDLINE Link]. Exercise helps to improve mood, reduce tension, and improve sleep in patients with associated depression, anxiety, or both. Nursing diagnoses handbook: An evidence-based guide to planning care. Search for underlying medical and psychiatric disorders potentially amenable to treatment. endstream endobj 159 0 obj<> endobj 161 0 obj[162 0 R] endobj 162 0 obj<>>> endobj 163 0 obj<> endobj 164 0 obj<> endobj 165 0 obj<> endobj 166 0 obj<> endobj 167 0 obj<> endobj 168 0 obj<> endobj 169 0 obj<> endobj 170 0 obj<> endobj 171 0 obj<> endobj 172 0 obj<> endobj 173 0 obj<> endobj 174 0 obj<> endobj 175 0 obj<> endobj 176 0 obj<> endobj 177 0 obj<> endobj 178 0 obj<> endobj 179 0 obj<> endobj 180 0 obj<> endobj 181 0 obj<> endobj 182 0 obj<> endobj 183 0 obj<> endobj 184 0 obj<> endobj 185 0 obj<> endobj 186 0 obj<>/Font<>/ProcSet[/PDF/Text]/ExtGState<>/Properties<>>> endobj 187 0 obj<> endobj 188 0 obj<>stream [QxMD MEDLINE Link]. Different healthcare organizations use different formats for the assessment phase. To establish baseline and ensure that there is no physical rationale for the patients complaint of pain. A randomized clinical trial of mindfulness-based cognitive therapy versus unrestricted services for health anxiety (hypochondriasis). Hypochondriacal patients' appraisal of health and physical risks. should answer: what, why, and how. Writing a care plan allows a team of nurses (as well as physicians, assistants, and other care providers) to access the same information, share opinions, and collaborate to provide the best possible care for the patient. [QxMD MEDLINE Link]. 158(5):783-7. ((TigerConnect, How to Develop a Nursing Care Plan for Your Hospital: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/)), Despite the overall general objective, nursing care plans written by students are not the same as those created by registered nurses in clinical settings. 0000003496 00000 n Check out our freebies and learn more at: https://nursing.com/?utm_medium=social&utm_source=youtube&utm_campaign=nursing%20mnemonicWelcome to the NURSING Fam. Vera., Nursing Care Plans (NCP): Ultimate Guide and Database, July 5, 2021: https://nurseslabs.com/nursing-care-plans/)), For example, in the interventions section, a student would write: vital signs recorded every four hours: blood pressure, heart rate, three- or five-lead electrocardiograms, functional oxygen saturation, respiratory rate, and skin temperature, while an experienced registered nurse might just write Q4 vital signs.. 2001 Jul. Hypochondriasis. [QxMD MEDLINE Link]. A Master of Science in Nursing, Whether youre an aspiring healthcare provider or a seasoned nurse practitioner, you may have considered pursuing a Master of Science in Nursing (MSN). Desired Outcome: The patient will be able to cope with her current condition by re-establishing normal ADLs. Symptoms and social adjustment in Jewish depressives. Bibliotherapy, using CBT principles, may also be useful. Psychother Psychosom. [QxMD MEDLINE Link]. (4):3:323-38. olde Hartman TC, Borghuis MS, Lucassen PL, van de Laar FA, Speckens AE, van Weel C. Medically unexplained symptoms, somatisation disorder and hypochondriasis: course and prognosis. Schweitzer PJ, Zafar U, Pavlicova M, Fallon BA. [QxMD MEDLINE Link]. Diagnostic and treatment interventions for hypochondriasis in the Kellner R, Abbott P, Pathak D, Winslow WW, Umland BE. !vsv[&$moYg\w*1;a. [QxMD MEDLINE Link]. Art. For example, one of the benefits of writing care plans is that it will allow you to develop professionalism, along with important values like accountability, respect, and integrity. Looper KJ, Kirmayer LJ. 0000003263 00000 n In general, the data you will collect here is both subjective (e.g., verbal statements) and objective (e.g., height and weight, intake/output). Talk with your doctor about medication options and the possible side effects and risks. McManus F, Surawy C, Muse K, Vazquez-Montes M, Williams JM. 0000002769 00000 n Having medical condition or is recovering from one, High risk of getting a condition due to strong family history, Financial issues due to frequent clinic visits. Illness anxiety disorder can affect all ages and genders. Media Inquiries: (760) 407-2301 Vera., Nursing Care Plans (NCP): Ultimate Guide and Database, July 5, 2021: The purpose of a nursing care plan is to document the patients needs and wants, as well as the nursing interventions (or implementations) planned to meet these needs. 0000003341 00000 n Your provider may diagnose illness anxiety disorder if you have health anxiety (or other illness anxiety disorder symptoms) for six months or longer even after tests show that youre not sick. ((Mariam Yazdi, 4 Steps to Writing a Nursing Care Plan, Nurse.org, March 23, 2018: : What does the patient suffer from? Be aware of emotional reactions toward the patient (ie, anger, hopelessness, helplessness) and seek frequent informal consultation when possible. This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. Is obsessive-compulsive disorder an anxiety disorder, and what, if any, are spectrum conditions? Pain is a subjective symptom; the treatment should involve the patients current feeling of pain. Treatment of hypochondriasis with clomipramine. 1981 Jun 4. 0000003808 00000 n [Full Text]. 54(5):331-43. Am J Psychiatry. Physicians' Desk Reference. van den Heuvel OA, Mataix-Cols D, Zwitser G, Cath DC, van der Werf YD, Groenewegen HJ, et al. 1993 Dec. 13(6):438-41. ((Chiung-Yu Shih et al, The association of sociodemographic factors and needs of haemodialysis patients according to Maslows hierarchy of needs, Journal of Clinical Nursing, July 30, 2018: https://pubmed.ncbi.nlm.nih.gov/29777561/)). Jones LR, Mabe PA 3rd, Riley WT. outlined in the care plan. The documentation format will vary according to. [QxMD MEDLINE Link]. 0000004354 00000 n It typically appears during early adulthood. Noyes R Jr, Stuart S, Langbehn DR, Happel RL, Longley SL, Yagla SJ. She is a clinical instructor for LVN and BSN students and a Emergency Room RN / Critical Care Transport Nurse. [QxMD MEDLINE Link]. It is helpful to assess what the patient has tried to correct their hearing loss, such as technological devices, surgery, or specialist care, so the nurse does not duplicate interventions. She found a passion in the ER and has stayed in this department for 30 years. Anxiety and Depression Association of America. David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic PsychiatryDisclosure: Nothing to disclose. Unnecessary tests and treatments should be prevented. J Psychosom Res. 0000002815 00000 n for: Medscape. in clinical settings. American Psychiatric Association. [QxMD MEDLINE Link]. People with illness anxiety disorder -- also called hypochondria or hypochondriasis -- have an unrealistic fear that they have a serious medical condition or fear that theyre at high risk of becoming ill. 485(3):148-50. [QxMD MEDLINE Link]. A nursing diagnosis is based on Maslows Hierarchy of Needs pyramid ((Saul McLeod, Maslows Hierarchy of Needs,, (which identifies and ranks human needs) and helps prioritize treatments. 70(3):810-27. Patients with illness anxiety disorder should be admitted to general medicine and surgery services based on the medical and surgical acuity, not solely to facilitate work-up. Magarinos M, Zafar U, Nissenson K, Blanco C. Epidemiology and treatment of hypochondriasis. [QxMD MEDLINE Link]. Genetic and biological factors. 1993 May. High level of anxiety about personal health. A) In somatic symptom disorder, clients consciously seek attention. 5 z`cF> 0 E6_ Its the highest level, 700 Windy Point DriveSan Marcos, CA 92069, 1 University BoulevardSt. Care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation, and evaluation. It helps reduce symptoms related to anxiety, depression, and. [QxMD MEDLINE Link]. 1992. Psychosomatics. Speckens AE, Spinhoven P, Sloekers PP, Bolk JH, van Hemert AM. 0000004042 00000 n Digital health records may help in the assessment process by populating some of this information automatically from previous records. [QxMD MEDLINE Link]. Advertising on our site helps support our mission. Hypochondriasis Hypochondriac (Nursing School Lesson) - YouTube After the diagnosis is the planning stage. Nursing Diagnosis: Ineffective Coping related to somatoform disorder as evidenced by restlessness, failure to do activities of daily living as normal, verbalization of distress. The Nurse's Guide to Writing a Care Plan | USAHS - University of St Somatoform Disorders Nursing Care Management - Nurseslabs To help the patient become relaxed and feel comfortable. 207-34. de Leon J, Bott A, Simpson GM. 0000114297 00000 n 0000003573 00000 n 2012 Oct. 80 (5):817-28. 0000296661 00000 n In the final step of a care plan, the health professional (who can be either a. or a nurse) will evaluate whether the desired outcome has been met. Anna began writing extra materials to help her BSN and LVN students with their studies and writing nursing care plans. 1989 May. There are several basic interventions that you need to implement during each shift: pain assessment, changing the resting position, listening, cluster care, preventing falls, and fluid consumption. [QxMD MEDLINE Link]. You will then adjust the care plan based on this information. Digital health records may help in the assessment process by populating some of this information automatically from previous records. Physician Assistant: Key Differences, The DNP Degree: Costs, Requirements, Benefits. Join NURSING.com to watch the full lesson now. Write down everything immediately so you dont forget the details. The student version is much longer, has a greater level of detail, and is exhaustively thorough. The challenges for clinicians include how to distinguish true somatic symptoms from those associated with fear or other psychiatric symptoms. Illness anxiety disorder may be associated with: Relationship or family problems because excessive worrying can frustrate others. 28(1-4):294-304. Barsky AJ. 2004. They interpret normal sensations, body functions and mild symptoms as a sign of a worst illness. Illness Anxiety Disorder (formerly Hypochondriasis), encoded search term (Illness Anxiety Disorder (formerly Hypochondriasis)) and Illness Anxiety Disorder (formerly Hypochondriasis), Pediatric Illness Anxiety Disorder (Formerly Hypochondriasis), Psychiatric Disorders Associated With Epilepsy, Fast Five Quiz: Generalized Anxiety Disorder. This is important both to maximize care efficiency and to provide documentation for healthcare providers. Individuals with hypochondriasis has fear that he or she has a serious disease (disease conviction) or will get a serious disease (disease phobia). [75], Cognitive and exposure therapy also seems promising for illness anxiety disorder. ((Nursco, Professionalism in Nursing 5 Tips for Nurses, July 13, 2018: https://www.nursco.com/professionalism-nursing-5-tips-nurses/)). People with hypochondriasis are very much worries of contracting a disease or sometimes very certain that they have a disease even though no medical tests support their belief. They should avoid substances that adversely affect mood, exacerbate anxiety symptoms, or reduce the quality of sleep (eg, caffeine, alcohol, nicotine). 0000003419 00000 n 2000 Aug. 2(4):117-121. Ulcerative Colitis Nursing Diagnosis & Care Plan | NurseTogether JAMA. Here, you will prepare SMART goals (more detail on this later) based on evidence-based practice (EBP) guidelines. Uneasiness with healthy body functions like. Their fears are very real to them. Behav Res Ther. The client will verbally express emotional feelings. Therapy. Assess the patient's developmental needs. Nursing Interventions for COPD: How Nurses Help Treat COPD [xU(%47(5[|)WrOU3O{{]mfAZ~'YrbvsKjW#U]Y|i0S~7tdU*+93>n;`W5Yngu6W=sr>_:_WYOrKdy#-I5R*hv7NY|^^Wy/Jxzxe6U7mYh0[{=SWtj\6IoO.U2D|a)~+dU~KV|\"R3}Io x>v' QPHI " PBiHE\21 Behav Res Ther. Successful treatment with pimozide of delusional parasitosis. Behavioral medicine approaches to somatoform disorders. [QxMD MEDLINE Link]. Provide comfort measures for the patient in terms of temperature of the room, positioning of the bed, provision of pillows. 0000295470 00000 n 58(3):41-2. Geriatrics. Disorders of hysterical conversion. They also enable. B) In somatic symptom disorder, clients are not consciously aware that needs are being met through physical complaints. 16(1):9-22. Increased physical activity. Coming to a Cleveland Clinic location?Hillcrest Cancer Center check-in changesCole Eye entrance closingVisitation, mask requirements and COVID-19 information, Notice of Intelligent Business Solutions data eventLearn more. 1999 Sep-Oct. 40(5):387-95. [QxMD MEDLINE Link]. Financial problems due to excessive health care visits and medical bills. 54(5):200-1. Key results of professionalism include better overall care, improved team communication, and a more positive work environment. 1991 May-Jun. 62(1):55-8. 30(3):301-6. Illness anxiety disorder (hypochondria) is extremely rare. A nursing diagnosis is based on Maslows Hierarchy of Needs pyramid ((Saul McLeod, Maslows Hierarchy of Needs, Simply Psychology, Dec. 29, 2020: https://www.simplypsychology.org/maslow.html)) (which identifies and ranks human needs) and helps prioritize treatments. 1996 Jan. 40(1):95-104. Hypochondriacal beliefs and attitudes in family practice and psychiatric patients. Psychother Psychosom. 19(4):327-39. Illness Anxiety Disorder (Hypochondria, Hypochondriasis) - Cleveland Clinic They may misinterpret typical body functions as signs of illness. If clinically recommended by the psychosomatic medicine consultant, psychotropic medication interventions can be started. When illness anxiety disorder is suspected in a medical or surgical inpatient, a psychosomatic medicine consultation should be performed to elucidate the diagnosis and address psychiatric comorbidity. Anna Curran. This is a form of counseling which is helpful in changing the thought process and behavior of the client. Weck F, Neng JM, Schwind J, Hfling V. Exposure therapy changes dysfunctional evaluations of somatic symptoms in patients with hypochondriasis (health anxiety). Healthcare providers now use the term illness anxiety disorder. trailer Cogn Behav Ther. [QxMD MEDLINE Link]. Fallon BA, Petkova E, Skritskaya N, et al. [78]. Weck F, Neng JM. The major nursing care plan goals for patients with somatoform disorders are: The client will identify the relationship between stress and physical symptoms. [QxMD MEDLINE Link]. Somatic Symptom Disorder and Illness Anxiety Disorder. 6(2):168-75. As in the outpatient care model, patients should not be exposed to high-risk invasive procedures. Allow the patient to express his/her feelings and thoughts about pain, such as its intensity, as well as what he/she believes to trigger it, intensify it, and relieve it. , you will also develop them over time and with practical experience. You may be more prone to illness anxiety disorder if you have a family history of: People with illness anxiety disorder have ongoing but unrealistic fear about being seriously ill. Ford CV, Long KD. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMjkwOTU1LXRyZWF0bWVudA==. If theres any identified medical condition, then treatment will be prescribed accordingly. [QxMD MEDLINE Link]. 2007. Her written works are combined learning from theoretical to actual nursing background and ongoing research. Last reviewed by a Cleveland Clinic medical professional on 02/02/2021. b) His symptoms subside with appropriate medical treatment. Your provider may make a diagnosis or they may refer you to a behavioral health specialist, such as a psychologist or psychiatrist. Int J Psychiatry Med. The exact cause of somatoform disorder remains unknown. Thinks that normal physical sensations are signs of a severe disease, Thinks that symptoms are serious even if medical exam says otherwise, Fears that medical assessment and treatment is inadequate, Fears that physical activity can cause physical damage, Frequent clinic visits do not reduce concerns rather make them worse, Medical treatments do not usually work and sensitivity to medication side effects, More severe symptoms than those expected of an illness. As an Amazon Associate I earn from qualifying purchases. Augustine, FL 32086, Douglas Entrance North Tower 800 S. Douglas Road, Suite 149Coral Gables, FL 33134, 901 W Walnut Hill Lane, Suite 210AIrving, Texas 75038, General Inquiries: (800) 241-1027 Acta Psychiatr Scand. No. 1999 Dec. 30(4):251-8. Psychol Med. Why do they risk suffering from this? Somatization: a borderland between medicine and psychiatry. Acta Derm Venereol. Group psychotherapy of somatizing patients. Arch Gen Psychiatry. Basic management principles include the following: Establish a firm therapeutic alliance with the patient Educate the patient regarding the manifestations of hypochondriasis Offer consistent. Earn your advanced nursing degree while keeping your work and life in balance. Nursing Diagnosis: Disturbed Thought Process related to aging asevidenced by disorientation to person, place, and time. A SMART goals template can help in this process: Unless your care plan is communicated effectively to all relevant stakeholders, it will only be a plan. Numerous other strategies appear to benefit patients with illness anxiety disorder orhypochondriasis (see the image below). 1977. Due to the enigmatic nature of various physical symptoms, occasionally patients with illness anxiety disorder are admitted to the general medical-surgical hospital for an extensive work-up. 11(3):156-65. Adler G. The physician and the hypochondriacal patient. It can be easily described as the conversion of emotional state into physical symptoms or somatization. 1-13. Thats why its important that you choose the right program for your needsone that will help you develop communication and critical thinking skills, as well as professionalism, to be ready for the day-to-day nursing life. Nursing Care Plans, 10th Edition - 9780323711180 - Elsevier Your provider can diagnose and treat illness anxiety disorder. Gottlieb GL. 2001 May. This can affect the affected persons occupational and social functioning, as well as activities of daily living. 1990 Sep. 76(281):991-6. Group therapy for somatization disorders in primary care: maintenance of treatment goals of short cognitive-behavioural treatment one-and-a-half-year follow-up. Also discuss setting reasonable limits on tests, evaluations and specialist referrals. a) No physiologic cause has been found for his symptoms. Psychotherapy. Cognitive behavioral therapy helps to identify beliefs and expectations with health and symptoms. BMC Psychiatry. A symptom of somatoform disorder can indicate a particular condition like cancer. They also enable effective communication in a nursing team. J Clin Psychopharmacol. 310-318. 0000004998 00000 n 1982. 0000212525 00000 n ((M. Writing skills are crucially important for nursesyoull need to be as accurate and current as possible in your descriptions. However, it is believed that the following risk factors contribute to how a person responds to symptoms and how they are perceived: The symptoms experienced that a person with somatoform disorder is often more severe than usual. A care plan ensures collaboration among nurses, patients, and other healthcare providers. Wooley SC, Blackwell B, Winget C. A learning theory model of chronic illness behavior: theory, treatment, and research. Nursing Care Plans Related to Ulcerative Colitis Diarrhea. December 2008. Personality disorders in hypochondriasis: prevalence and comparison with two anxiety disorders. When is hypochondriasis not hypochondriasis? She received her RN license in 1997. ((TigerConnect, How to Develop a Nursing Care Plan for Your Hospital: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/)), Finally, you will need to update your care plans often with the latest information. You might consider seeing a provider if you or others notice signs of illness anxiety disorder. Kellner R. Prognosis of treated hypochondriasis. Well also outline best practices to keep in mind and provide you with a nursing care plan sample that you can download and print. Greeven A, van Balkom AJ, Visser S, et al. A clinical study. Hollifield M, Tuttle L, Paine S, Kellner R. Hypochondriasis and somatization related to personality and attitudes toward self. Step 3: Plan Patient Goals and Desired Outcomes. [QxMD MEDLINE Link]. Memory processes and hypochondriacal tendencies. Hiller W, Leibbrand R, Rief W, Fichter MM. Family therapy can be included in the therapy regimen to assess family relationship and establish family support. Treatment of underlying conditions. Treatment goals focus on improving quality of life by minimizing symptoms. Because the intensive search for illness cannot be found, they tend to get frustrated and angry. 1996 Jan. 34(1):23-31. Medications. [QxMD MEDLINE Link]. Nursing care plans: Diagnoses, interventions, & outcomes. . 1991 Nov. 52(11):457-60. Nursing Care Plans - Apps on Google Play Based on the diagnosis, youll set goals (Step 3) to resolve the patients problems through nursing implementations (Step 4). Acta Psychiatr Scand. Creating Nursing Care Plans: The Definitive Guide - Simple Nursing Somatoform Disorder NCLEX Review and Nursing Care Plans. diagnosis care plan format includes a definition/explanation of the diagnosis, related factors, defining characteristics, expected outcomes, related NOC Outcomes and NIC Interventions, ongoing assessment, and therapeutic interventions.Disorders care plan format covers synonyms for the disorder (for ease in cross referencing), a definition, However, there may or may not be any medical explanation to the symptoms they are undergoing. Mental: Ch 21 Somatic Symptom Disorders Flashcards | Quizlet 0000004276 00000 n Phillips KA. Please complete our contact form. [QxMD MEDLINE Link]. ((TigerConnect, How to Develop a Nursing Care Plan for Your Hospital: https://tigerconnect.com/blog/how-to-develop-a-nursing-care-plan-for-your-hospital/)), Care plans also need to be easy to share with the relevant stakeholderspatients, doctors, other members of the nursing team, insurance companies, etc. This guide will help you understand the fundamentals of nursing care plans and how to create them, step by step. Tyrer P, Cooper S, Tyrer H, et al. Ball RA, Clare AW. Tuition Reduction Available for Select Programs When You Start this Summer! It leads to persistent contraction and malabsorption of the colon, producing frequent bowel movements. Heres what a care plan written by a student looks like: Note that student care plans often have an additional columnrationalewhere students note the scientific explanation for the implementations they chose. Somatoform disorder, also known as Somatic Symptom Disorder (SSD), is a mental health condition characterized by having significant physical symptoms brought about by psychological or emotional distress. On the other hand, nurses often assume some basic concepts and note some of the steps in the care plan only mentally. 0000106761 00000 n Resource utilization of patients with hypochondriacal health anxiety and somatization. The implementation stage consists of performing the nursing interventions outlined in the care plan. Avoid seeking advice from multiple doctors or emergency . Adult outcomes of pediatric recurrent abdominal pain: do they just grow out of it?. Br J Psychiatry. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Vera., Nursing Care Plans (NCP): Ultimate Guide and Database, July 5, 2021: : heart rate 100 bpm, dyspnea, restlessness, guarding behavior., : impaired gas exchange RT collection of mucus in airway., : patient must maintain optimal gas exchange., : assess respiration; encourage breathing and position changes., : respiration will indicate the level of lung involvement, as the patient will adjust their breathing to facilitate gas exchange; these will improve ventilation and allow for chest expansion., : the patient maintained good gas exchange, normal respiratory rate., Wrapping Up: Writing an Effective Nursing Care Plan, For example, one of the benefits of writing care plans is that it will allow you to develop. Typically, physicians feel angry, hopeless, and/or helpless because their assessments and interventions are not effective and efforts at reassuring the patient are usually met with resistance and even escalation of physical symptoms. Body dysmorphic disorder. An increase in heart rate is the body's first response to compensate for reduced cardiac output (CO). 1986 Sep 15. Symptoms of illness anxiety disorder include: To diagnose illness anxiety disorder, healthcare providers refer to the criteria listed in the American Psychiatric Associations (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), 5th edition. St. Louis, MO: Elsevier. This can improve social interactions and can have an effect on mood as well. CMAJ. As a nurse, you will either follow doctors orders for nursing interventions or develop them yourself using evidence-based practice guidelines. As a nurse, you will either follow doctors orders for nursing interventions or develop them yourself using evidence-based practice guidelines. Subjects handled: Psychiatric, Obstetric, Pediatric and Fundamentals of Nursing.