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Congenital Toxoplasmosis

Congenital toxoplasmosis is a disease that occurs in fetuses or new-borns infected with Toxoplasma gondii, a protozoan parasite, which is transmitted from mother to fetus.

It can cause miscarriage or stillbirth.
It can also cause serious and progressive visual, hearing, motor, cognitive, and other problems in a child.
In healthy people it causes asymptomatic infection however in immunocomprised people and pregnant mothers it may cause serious infection
At birth there is no obvious damage but develops later in early childhood or adult hood.
The severity of the disease depends on the gestational age at transmission

Causes of Toxoplasmosis

Toxoplasmosis is caused by Toxoplasma gondii.

It which burrows in wild and domestic cats through which their infectious forms, oocysts, get excreted in their feces.

Mode of Transmission

There are different ways for a person to contract toxoplasmosis:

Vertical transmission.

Congenital transmission. A patient with toxoplasmosis can infect the unborn child. The patient may not present symptoms, but the unborn baby can have serious complications which can affect the nervous system and eyesight

Horizontal Transmission

Foodborne. Humans can contract toxoplasmosis by eating undercooked meat containing infective tissue forms of the parasite T. gondii. It can also be transferred to food and therefore to humans through contaminated utensils and cutting boards. Also, drinking unpasteurized goat’s milk can cause toxoplasmosis infection.
Zoonotic transmission. Zoonotic transmission refers to animal to human transfer of the infection. Cats play a major role in this type of transmission. Cats serve as hosts to T. gondii. They shed their oocysts through their feces, and these oocysts are microscopic and can be transferred to humans through accidental ingestion by not washing hands after cleaning the cat’s litter box, drinking water infected with oocysts, or not using gloves when gardening.
Rare means of transmission. In very rare occasions, toxoplasmosis can be transmitted through organ donation and transplant, as well as in blood transfusion.

LIFE CYCLE OF TOXOPLASMA GONDII

It is an ubiquitous obligate intracellular protozoa that infects animals and humans
It has intestinal and extra intestinal cycles in cats and only extra intestinal cycles in hosts.
It exists in 3 infective forms; Bradyzoites, Tachyzoites and Sporozoites

Bradyzoites: – slowly multiplying contained in tissue cysts usually localized to skeletal and cardiac muscles, Eyes and the brain. These live in their host cells for months to years.

Once ingested, gastric enzymes degrade the cyst wall liberating viable Bradyzoites

Tachyzoites: – rapidly dividing organisms found in the tissue in acute phases of the infection. They localize in neural and muscle tissues and develop into tissue cysts. They are responsible for tissue destruction. Multiplication continues till either the cyst formation or host cell destruction occurs. After cell death, the free Tachyzoites invade other cells and resume rapid multiplication

Sporozoites: – result from the parasite’s sexual cycle which takes place in the cat’s intestines. When eliminated by the cat these cysts first undergo sporulation to become infectious (2-3 days) therefore the risk of spread is minimized if cat litter is cleaned daily.

Pathogenesis for vertical transmission

Acute infection with Tachyzoites in blood during pregnancy increase the risk of transplacental infections
The Tachyzoites colonize in the placenta and cross the barrier to reach the fetus.
The frequency of transmission of the Tachyzoites to the fetus is related to the gestational age where the transmission rate is low in the first trimester and highest in the third trimester however the disease is more severe if the infection is acquired in early pregnancy.

Clinical Features

Premature birth — as many as half of infants with congenital toxoplasmosis are born prematurely
Abnormally low birth weight
Eye damage (Blurred vision, Photophobia, Epiphora)
Intrauterine growth restriction
Low-grade fever
Vomiting
Jaundice, yellowing of the skin and whites of the eyes
Diarrhea
Anemia
Hearing loss
Motor and developmental delays
Hydrocephalus
Difficulty feeding
Swollen lymph nodes (Lympadenopathy; painless, firm and confined to one chain)
Enlarged liver and spleen
Macrocephaly, an abnormally large head
Microcephaly, an abnormally small head
Rash (usually Maculopapular that spares hands and soles)
Bulging fontanelle
Abnormal muscle tone
Seizures
Motor and developmental delays
Hydrocephalus, a buildup of fluid in the skull
Intracranial calcifications, evidence of areas of damage to the brain caused by the parasites

Diagnosis of Toxoplasmosis

History taking
Physical examination

Investigations

Serologic testing – a blood test to measure the level of immunoglobulin G (IgG) can tell if a person has been infected. Immunoglobulin M (IgM) may also be tested if the time of infection needs to be determined. This is mostly appropriate to pregnant women as the time of infection is necessary to give the clinician a better understanding of the possible effects of toxoplasmosis to the unborn baby.
Culture – tissue sample like cerebrospinal fluid may be used to observe the parasite through culture. However, this method is not commonly done as the sample is not easily obtained.
Amniotic fluid testing – to check for the presence of the parasite’s DNA. This is particularly helpful in pregnant women with toxoplasmosis.
Brain biopsy – if the individual is not responding to treatment, a brain biopsy is performed to check for toxoplasmosis cysts.
LFT’s will be elevated(ALT, AST)
CBC: will show Eosinophilia.
RFT’s: elevated blood urea, creatinine.
Electrolytes: elaveted pottasium, calcium and sodium.

Imaging

ultrasound can be performed in pregnant women. It will not definitely diagnose toxoplasmosis, but it will give clinicians a visual of the baby’s brain for the presence of hydrocephalus. If the fetus is between 20 – 24 weeks of gestation, scan will show hepatosplenomegaly, intrahepatic calcification.
Magnetic Resonance Imaging (MRI) may also be performed to get images of the brain if nervous system involvement is suspected.
CT Scan will show intracranial calcifications, ventriculomegaly, hydrocephalus.

Treatment and Management

Usually managed as outpatient cases in patients who are immune competent or those without vial organ damage
Limitation of activity in patients with toxoplasmosis depends on the severity of the disease and organ system involved
Patient education on prevention methods, effects of T. gondii on the fetus to pregnant mothers.
Follow-up every 2 weeks till the patient is stable then monthly during the therapy. Perform CBC weekly for the first month then every 2 weeks perform LFTs and RFTs monthly.
Administer drugs such as
Pyrimethamine. This drug is typically used for malaria. It is a folic acid antagonist, and it prevents the body from absorbing folate.
Sulfadiazine. It is commonly prescribed together with pyrimethamine to treat toxoplasmosis.
Sulfadiazine is active against Tachyzoites however adjust doses it in renal insufficiency because it is only excreted by the kidneys, also avoids in G6PD because it causes haemolysis. It can be substituted with Clindamycin
Dose: 1-1.5g QID for 3-4 weeks or 100mg/kg/day in 2DD
Pyrimethamine when given in high doses may cause haemolytic anaemia therefore monitor closely
Dose: 50-75mg OD PO for 2-3weeks then 25-37.5mg OD PO for 4-5 weeks
Corticosteroids; esp. with elevated CSF protein and vision threatening Chorioretinitis administer Predinsolone 1mg/kg/day till they resolve
Trimethoprim Sulphamethoxazole: 40mg/kg/day in 2DD
Dapsone(in combination with Pyrimethamine): 100mg/kg/day PO for 1-3weeks
Clindamycin (in combination with Pyrimethamine for sulfadiazine sensitive patients):10-12mg/kg BD PO for 4 weeks
Folic acid: to prevent hematological effects associated with bone marrow suppression and also reduce effects of Pyrimethamine
Dose: 10mg 3times per week

Prevention

- This is particularly important to pregnant mothers and immunocompromised
- Avoid consuming raw or half cooked meat, unpasteurized milk or uncooked eggs
- Wash hands after touching raw meat, gardening or having contact with soil
- Avoid contact with cat feces
- Disinfect litter for 5 minutes with boiling water
- Cook food thoroughly
- Wash and peel all fruits and vegetables
- Wash hands frequently and any cutting boards used to prepare meat, fruits or vegetables
- Wear gloves when gardening or avoid gardening altogether to avoid contact with soil that may contain cat waste
- Avoid cleaning the litter box

Complications

Intrauterine growth restriction
Chorioretinitis (Blurred vision, Photophobia, Epiphora)
Cerebral calcifications
T. Encephalitis
Mental retardation
Seizures

Nursing Diagnosis for Toxoplasmosis

Hyperthermia related to parasitic infection secondary to toxoplasmosis, as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.
Deficient Knowledge related to new diagnosis of toxoplasmosis as evidenced by patient’s verbalization of “I want to know more about my condition, cause and treatment”

Congenital Toxoplasmosis Read More »

Assessment of the Mentally Ill

Mental Health Assessment

The psychiatric interview is the most important tool in psychiatry. It is the primary tool used to understand a patient’s problems, elicit signs and symptoms, uncover etiologies, and identify complications. This process is essential to making an accurate diagnosis, initiating treatment, and predicting outcomes.

A mental health assessment is a comprehensive evaluation of a person’s emotional, cognitive, and behavioral functioning. It’s a process used to diagnose mental health conditions, understand a person’s strengths and challenges, and develop a treatment plan.

Overview of the Assessment Process

The mental health assessment involves several key steps:

History Taking: Gathering information from the patient and, when possible, collateral sources (family, friends, or other close contacts).
Psychiatric Interview and Assessment: A comprehensive exploration of the patient’s mental state using structured interviews and observations.
Physical Examination: Evaluating physical health, which may influence or mimic psychiatric conditions.
Investigations: Requesting relevant investigations including biological tests (blood, urine, X-rays), psychological testing, social evaluations (home visits, environmental assessments), and any other assessments deemed necessary.

Conditions for an Effective Consultation

For the consultation to yield high-quality information, several environmental and practical factors must be met:

Factor	Details/Considerations
Adequate Time	Ensure that sufficient time is allocated so that the patient does not feel rushed.
Privacy	Conduct the interview in a private setting to encourage openness and honesty.
Tidy Environment	A neat and organized consultation room can positively influence the patient’s mood and level of comfort.
Minimized Interference	Avoid interruptions (e.g., answering phone calls) to maintain the focus of the consultation.
Professional Appearance	The appearance and grooming (e.g., well-kept nails, eyebrows, lips, and hair) of the health worker can affect the patient’s willingness to share personal details.

Establishing a Therapeutic Relationship

The quality of information gathered in a psychiatric interview greatly depends on the level of trust and confidentiality the patient perceives. A strong rapport encourages the patient to share personal and diagnostically important details. The following elements are essential to establishing an effective therapeutic relationship:

Respect: Treat the patient with respect regardless of appearance or socioeconomic status. This respect is often immediately sensed by the patient.
Compassion: Display genuine concern and empathy for the patient’s suffering and distress.
Genuineness and Non-Judgment: Approach the patient with a sincere, non-judgmental attitude. This helps build trust, making it easier for patients to open up about sensitive issues.
Cultural Sensitivity: Be aware of and respect cultural differences. For example, when taking a sexual history or discussing personal matters, consider cultural norms (such as attire or communication styles).
Flexibility with Accompaniment: If a patient prefers to have a relative or friend present, allow this unless confidentiality is required for certain parts of the discussion.

Essential Must-Do’s for the Interview

Explain the Purpose: Clearly inform the patient about the reasons for the interview.
Reassurance: Provide reassurance regarding the need and benefits of the interview.

General Principles of the Psychiatric Interview

A successful interview involves active participation from both the clinician and the patient. Key principles include:

Active Observation: Notice behavioral cues such as gait, physical appearance, and facial expressions.
Two-Way Assessment: Recognize that the patient is also evaluating you. Show genuine attention, listen carefully, and engage with empathy.
Acceptance: Understand that every behavior has meaning. Avoid making premature assumptions and strive to fully comprehend the patient’s perspective.
Avoiding Arguments: Maintain assertiveness without engaging in confrontations. Focus on understanding rather than debating.
Emphasis on Feelings: Encourage the patient to express their emotions (for example, allow space for tears and exploration of emotionally charged topics).
Interpersonal Focus: Nurture a sense of connection and trust during the interaction.
Tolerance of Silence: Recognize that pauses can be valuable, allowing the patient time to reflect and respond.

Psychiatric History Components

A comprehensive psychiatric history is gathered from the patient and, when possible, from family members or close contacts. It includes the following sections:

1. Identifying Data

Name	Patient’s full name
Age	Chronological age
Tribe/Ethnicity	Cultural or ethnic background
Occupation	Employment status and type of work
Religion	Religious affiliation
Next of Kin	Primary contact or emergency contact
Marital Status	Current relationship status
Education	Highest level of education achieved

2. Referral System

Source of Referral	Who referred the patient (e.g., health worker, family member, police)
Reason for Referral	The main concerns or symptoms prompting the referral
Chief Complaints	Primary issues as reported by the patient, along with the duration of symptoms

3. History of Present Illness

Exploration of Problems	Detailed discussion of the current issues and emotional state.
Diagnostic Focus	Information should guide differential diagnoses, identify stressors, and note any complications.

4. Past Psychiatric and Medical History

Previous Illnesses	Past physical and emotional health issues
Investigations and Results	Relevant tests (including HIV tests) and their outcomes
Previous Diagnoses	Prior psychiatric diagnoses
Treatment History	Treatments received and their outcomes

5. Family History(Information to Gather)

Family Members	Note each member’s relationship with the patient
Current Health Conditions	Health status of family members
Dependency Issues	Whether any relative is dependent on the patient and how that affects the patient emotionally
Presence of Mental Illness	Any history of mental illness among nuclear or extended family

6. Personal and Developmental History

Early Development	Details about pregnancy, birth, and early childhood (up to 6 years, particularly important in children).
Childhood to Adolescence	School performance, peer group activities, and early social experiences.
Adolescence to Young Adulthood (up to 19 years)	Sexual history, personal interests, and identity formation.

7. Occupational and Marital History

Occupational History	Details
Nature of Work	Type of job and job description
Job Satisfaction and Issues	Level of satisfaction and any workplace challenges

Marital History	Details
Age at Marriage	The age when the patient got married
Spouse’s Occupation	Occupation and background of the spouse
Family Health	Health status of the spouse and children
Marital Relationship	Quality and dynamics of the marital relationship

8. Forensic History

Legal Encounters: Document any previous problems with the law or involvement in legal matters.

Mental Status Examination (MSE)

The Mental Status Examination (MSE) is the psychiatric equivalent of a physical examination in medical assessments. It provides a structured way to evaluate a patient’s mental health by systematically observing and documenting their psychological and cognitive functioning.

MSE observations begin the moment the clinician meets the patient and continue throughout the interaction until the patient leaves.

The MSE is a systematic appraisal of the patient’s appearance, behavior, mental functioning, and overall demeanor.

It is divided into several components:

The main elements of the MSE can be remembered with the mnemonic ASEPTIC:

A: Appearance and Behavior
S: Speech
E: Emotion (Mood and Affect)
P: Perception
T: Thought Content and Process
I: Insight and Judgment
C: Cognition

1. Appearance and Behavior

Observation	Examples/Observations	Sample Questions/Comments
Apparent Age	Compare stated age vs. observed appearance (Does the patient look younger or older than stated?)	“Can you confirm your age?” (This also helps compare self-report with observation.)
Dress	Clothing style and condition (casual, formal, disheveled, poorly maintained)	“How do you decide what to wear each day?” (Or simply note your observations.)
Grooming & Hygiene	Overall grooming, cleanliness, and personal care (well-groomed vs. disheveled; good vs. poor hygiene)	“Have you been taking care of yourself recently?” (Observation is usually key.)
Gait	The way a person walks (brisk, slow, intoxicated, ataxic, rigid, shuffling, staggering, uncoordinated)	“I’ve noticed a certain way you move—have you felt any changes in your energy or balance?”
Psychomotor Activity	Overall motor activity (normal, reduced, or excessive movements)	“Do you feel more or less energetic in your movements than usual?”
Abnormal Movements	Involuntary movements (grimaces, tics, tardive dyskinesias, foot tapping, ritualistic behaviors)	“Have you experienced any involuntary movements or twitches?”
Eye Contact	Level and quality of eye contact (good or poor)	“Do you feel comfortable maintaining eye contact during conversations?”
Attitude	Interpersonal stance (cooperative, belligerent, oppositional, submissive, etc.)	“How are you feeling about discussing your current situation today?”

2. Speech

Observation	Examples/Observations	Sample Questions/Comments
Speech Rate	Speed of speaking (rapid, pressured, or slowed)	“Do you feel you speak more quickly or more slowly than you normally do?”
Speech Rhythm	Flow of speech (hesitant, rambling, halting, stuttering, jerky, with long pauses)	“Do you ever feel that your thoughts are hard to get out in order?”
Tone of Voice	Quality of tone (appropriate or inappropriate for the context)	(Often observed; you may comment, “Your tone seems different today.”)
Volume	Loudness of speech (loud, soft, whispered, yelling, inaudible)	“Have you noticed any changes in how loudly or softly you speak?”
Clarity & Quantity	Articulation, pronunciation, and amount of speech (clear, accented, slurred; responds only when asked, overly repetitive, verbose)	“Do you think people understand you easily when you speak?”

3. Emotion (Mood and Affect)

Observation	Examples/Observations	Sample Questions/Comments
Mood	The patient’s subjective report of their emotional state (e.g., “good,” “depressed,” “anxious”)	“How have you been feeling emotionally lately?”
Affect	The observable expression of emotion (e.g., appears down, euphoric, blunted) and whether it matches the reported mood (congruent vs. incongruent)	“Does the way you feel inside match how you’re expressing yourself now?”
Range & Stability	Range: Broad versus restricted emotional expression; Stability: Fixed versus labile (rapid changes)	“Have you noticed any sudden changes in your mood during the day?”

4. Perception

Observation	Examples/Observations	Sample Questions/Comments
Hallucinations	Sensory experiences without external stimuli (auditory – hearing voices; visual – seeing things; olfactory – unusual smells)	“Have you experienced any sensations, like hearing voices or seeing things that others do not?”
Illusions	Misinterpretations of real sensory stimuli (e.g., mistaking a shadow for a person)	“Do you sometimes perceive things differently from others around you?”
Depersonalization/Derealization	Feelings of unreality regarding self (depersonalization) or surroundings (derealization)	“Do you ever feel as if you’re not real, or that the world around you isn’t real?”

5. Thought Content and Process

A. Thought Process

Observation	Examples/Observations	Sample Questions/Comments
Coherence & Organization	How well thoughts are connected (logical, coherent, relevant) versus disorganized (circumstantial, tangential, flight of ideas, loosening of associations)	“Do you find it easy to organize your thoughts when you speak?”
Specific Abnormalities	Instances of thought blocking (sudden stops), word salad (incoherent jumble), echolalia (repeating others’ words), or neologisms (making up new words)	“Have you noticed moments where your thoughts seem to just stop or jumble together?”

B. Thought Content

Observation	Examples/Observations	Sample Questions/Comments
Delusions	Fixed false beliefs (paranoid delusions: e.g., “people are watching you”; delusions of grandeur: e.g., “I have special powers”)	“Have you had any strong or unusual beliefs recently—such as feeling that people are out to get you or that you possess extraordinary abilities?”
Suicidal Ideation	Thoughts about life not being worth living or ending one’s life	“When things get overwhelming, have you ever felt that life isn’t worth living? Can you tell me more about those thoughts?”
Homicidal Ideation	Thoughts about hurting others	“Have you ever had thoughts about hurting someone else?”

6. Insight and Judgment

Observation	Examples/Observations	Sample Questions/Comments
Insight	Awareness of one’s own mental health (good insight: recognizes illness and need for treatment; partial: acknowledges a problem but is reluctant; poor: denies issues)	“What do you think is contributing to your current difficulties?”
Judgment	The ability to make sound decisions (good, fair, or impaired based on the patient’s reasoning and decision-making skills)	“Can you walk me through how you make decisions when faced with a difficult situation?”

7. Cognition

Observation	Examples/Observations	Sample Questions/Comments
Level of Consciousness	Overall alertness (alert, confused, lethargic, stuporous)	(Generally observed, but you might ask, “How aware do you feel right now?” if needed.)
Orientation	Awareness of person, place, and time (e.g., “What is your name? Where are you right now? What is the date today?”)	“Can you tell me your full name, your current location, and today’s date?”
Attention/Concentration	Ability to focus (good vs. poor concentration)	“Do you feel that you have any difficulty staying focused on tasks?”
Memory	Short-term memory (recalling recent events) and long-term memory (recalling distant events)	“What did you have for breakfast this morning?” (for short-term) and “Can you describe an important memory from your past?”
Intellectual Functioning	Overall cognitive abilities as inferred from speech and comprehension (below average, average, or above average)	“How do you solve everyday problems? Could you explain your thought process when faced with a challenge?”

Developing the Nursing Care Plan

Based on the findings from the interview, history, MSE, and physical examination, a nursing care plan is developed. This plan should include:

Assessment: Group findings into objective (observable) and subjective (reported) data.
Nursing Diagnosis: Identify the patient’s needs and formulate clear nursing diagnoses.
Goal Setting: Establish realistic, measurable goals for the patient’s treatment and recovery.
Planning and Implementation: Identify the methods, resources, and interventions required. Implement the care plan with a focus on holistic recovery.
Evaluation: Continuously assess and adjust the care plan based on the patient’s progress and feedback.

Assessment of the Mentally Ill Read More »

Mental Health

MENTAL HEALTH

Mental health is a state of balance between the individual and the surrounding world.

Mental health is a state of harmony between oneself and others.

Mental health is a co-existence between the realities of the self and that of other people and that of the environment.

HEALTH; it is a state of well being of an individual, socially, physically, mentally, not merely the absence of a disease or infirmity. (WHO)

PSYCHIATRY; is a branch of medicine which deals with assessment, diagnosis and treatment of mental disorders.

Concepts of Mental Health

There are many concepts of mental health and each person or society sees mental health in different perspective.

Medical Concept: According to Medical concept one is considered to be mentally healthy if he or she is described to be free from pain, gross pathology and disability.

Cultural Concept: of mental health described it as the capacity to be competent in performance of social roles within a wide range of behaviours.

Statistical Concept: of mental health is described as the behaviours distributed within a normal curve with deviant behaviours occurring at both extremities. Statistics indicate that:

Legal Concept: of insanity is described as the inability to distinguish right from wrong and to conformbehaviour to law. Codes to define mental health is been developed by the states.

Process Concept: of mental health is the ability to effectively integrate biological, psychological and social system as life events are met at progressive stages of growth and development.

Stress and Mental Health

Stress: Is a stimulus or demand that generates disruption in homeostasis or produces a reaction.

Stress: Is a state of disequilibrium that occurs when there is a disharmony between demands occurring within an individual’s internal and external environment and his or her ability to cope with those demands.

Stressor: a demand from within an individual’s internal and external environment that elicits a physiological and or psychological response.

Stressor: is a source of stress.

Stress can produce adaptive and maladaptive responses.

Responses to Stress

Neurobiological responses: Stimulation of the autonomic nervous system prepares the person for “fight and flight” Physical manifestations of stress include: increased heart beat, increased respiration rate, increased visual acuity.
Behavioural responses: Behavioural responses are determined by client’s coping mechanism/skills. These responses include: Anger, Uncooperativeness, Perceptual disturbances, Sensory disturbances

Determinants of response to stress

Responses are influenced by internal and external resources.

Internal resources include:

Personality traits: determine ones appraisal of events, tolerance, to stress,self esteem and ability to form meaningful relationships. Coping patterns
Biological response to stress are determined by ones cognitive processes, genetic predisposition, developmental stage and biochemical processes that influence the appraisal of the event. Ones stress may be uneventful to another. When an event is appraised as threatening the usual response are anxiety, fear, worry, agitation/restlessness or denial. Neuro-endocrine is mobilized to maintain biological stability (homeostasis)

External resources: close relationship with others that foster support, protection and self reliance during stressful periods. The quality of the relationships influences susceptibility to maladaptive responses and buffers people against distress.

Other factors include ; number of stressors and severity of the stressor.

Causes:
- Bewitching
- Spirits from ancestors
- Failure to perform cultural rituals.
- Lack of respect from the elders
- Over reading books
Treatment:

Prayer
Performing cultural rituals
Visiting traditional healers
Left to roam about
Chased away from homes
Home and property are destroyed

Other beliefs include:

A normal person will never be abnormal.
Mentally sick should be treated in asylums
Mental illness is incurable
There is no treatment for mental illness
Mental patient admitted in mental hospital is dangerous.
Mental illness is not related to physical illness.
Mental illness is something to be ashamed of.

How does the belief affect health care delivery

Delayed treatment
Refusal to accept modern medicine
The disorder becomes chronic
Frequent relapses

Characteristics of a mentally healthy person

He has the ability to make adjustments
He has a sense of personal worth ,feels worthwhile and important
He solves his problems largely by his own effort and makes his own decisions
He has a sense of personal security and feels secure in a group ,shows understanding of other people’s problems and motives
He has a sense of responsibility
He can give and accept love
He lives in a world of reality rather than fantasy
He shows emotional maturity in his behavior and develops a capacity to tolerate frustration and disappointment in his daily life
He has developed a philosophy of life that gives meaning and purpose to his daily activities
He has a variety of interests and generally lives in a well balanced life of work, rest and recreation.
Adequate contact with reality
Control of thoughts and imaginations
Efficiency in work and play
Social acceptance
Positive self concept
A healthy emotional life

MENTAL ILLNESS

Mental illness is the maladjustment in living.

The inability to cope with stress and environment.

It produces a disharmony in the person’s ability to meet human needs comfortably or effectively and function with culture

Mentally ill person loses his ability to respond according to the expectations he has for himself and the demands that society has for him

In general an individual may be considered to be mentally ill if

The personal behavior is causing distress to self and others
The person’s behavior is causing disturbance in his day-to-day activities, job and interpersonal relationships

Common signs and symptoms of mental illness

Disturbances in motor behavior; motor retardation, stupor, stereotype, negativism, ambitendency, waxy flexibility, echopraxia, restlessness, agitation and excitement
Disorders of thought ,language and communication; pressure of speech ,poverty of speech ,flight of ideas ,circumstantially ,loosening of association ,tangentially ,incoherence ,perseveration ,neologism ,clang associations ,thought block ,thought insertion ,thought broadcasting echo-Lilia ,delusions ,obsessions and phobias
Disorders of perception: illusions, Hallucinations: depersonalization, derealization.
Disorders of emotions: blunt affect, labile affect, elated mood, euphoria, ecstasy, dysphonic mood, depression, anhedonia.
Disturbances of consciousness; clouding of consciousness, delirium and coma.
Disturbances in attention; distractibility, selective inattention
Disturbance in orientation; disorientation of time, place or person.
Disturbance of memory; amnesia, confabulation
Impairment judgment
Disturbance in biological function e.g. Persistence deviations in temperature, pulse and respiration, nausea, vomiting, headache, loss of appetite or increased appetite, loss of weight, pain, fatigue, weight gain, insomnia or hypersonic and sexual dysfunction.

PROBLEMS ASSOCIATED WITH MENTAL DISODERS

Self –care limitations or impaired functioning related to mental illness.
Significant deficits in biological ,emotional and cognitive functioning
Disability ,life-process changes
Emotional problems such as anxiety ,anger, sadness, loneliness and grief
Physical symptoms that occur along with altered psychological functioning
Alteration in thinking ,perceiving ,communicating and decision making
Difficulties in relating with others
Behavior may be dangerous to self or others
Adverse effects on the well-being of the individual ,family and community
Financial ,marital ,family ,academic and occupational problems

ETIOLOGY OF MENTAL ILLNESS

Many factors are responsible for the causation of mental illness. These factors may predispose an individual to mental illness, precipitate or perpetuate the mental illness

Predisposing factors

These factors determine an individual’s susceptibility mental illness. They interact with precipitating factors resulting in mental illness

These are

Genetic make up
Physical damage to the central nervous system
Adverse psychological influence

Precipitating factors

These are factors that occur shortly before the onset of a disorder and appear to have induced it

These are

Physical stress
Psychosocial stress.

Perpetuating factors

These factors are responsible for aggravating or prolonging the disease already existing in an individual. psychological stress is an example

Thus etiological factors of mental illness can be

Biological factors
Psychological factors
Social factors

Biological factors

Heredity .what one inherits is not the illness or its symptom, but a predisposing to the illness which is determined by genes that we inherit directly. Studies have shown three –fours of mental defectives and one third of psychotic individuals owe their condition mainly to unfavorable heredity.

Biochemical factors; biochemical abnormalities in the brain are considered to be the cause of some psychological disorders. Disturbances in neuro-transmitters in the brain is found to play an important role in etiology of certain psychiatric disorders

Brain damage : Any damage to the structure and functioning of the brain may be due to one of the following causes.

Infection e.g. neuro syphilis, encephalitis ,HIV infection
Injury ;loss of brain tissue due to head injury
Intoxication; damage to the brain tissue due to toxins such as alcohol ,barbiturate ,lead etc
Vascular ;poor blood supply ,bleeding ,(intra-cranial hemorrhage)
Alteration in brain function; changes in blood chemistry that interfere with the brain functioning such as disturbance in blood glucose levels, hypoxia, anoxia and fluid and electrolyte imbalance.
Tumors; brain tumors
Vitamin deficiency and malnutrition ,in particular deficiency of vitamin B complex
Degenerative diseases; dementia
Endocrine disturbances ;hypothyroidism ,thyrotoxicosis etc
Physical defects and physical illness; acute physical illness as well as chronic illnesses with all their handicapping conditions may result in loss of mental capacities.

Physiological changes

It has been observed that mental disorders are more likely to occur at certain critical periods of life namely-puberty, menstruation, pregnancy, delivery, puerperium and climacteric.. These periods are marked not only by also by psychological issues that diminish the adaptive capacity of the individual. Thus the individual becomes more susceptible to mental illness during this period

Psychological factors

It’s observed that some specific personality types are more prone to develop certain psychological disorders. For example those who are unsocial and reserved (schizoid) are vulnerable to schizophrenia when they face adverse situations and psychosocial stresses.

Psychological factors like ,strained interpersonal relationships at home, place of work ,school or college, bereavement ,loss of prestige, loss of job etc

childhood insecurities due to parents with pathological personalities ,faulty attitude of parents (over-strictness, over-leniency), abnormal parent child relationship (over-protection, rejection, unhealthy comparisons) deprivation of child’s essential psychological and social needs etc

Social and recreational deprivations resulting in boredom, isolation and alienationation.

Marriage problems like ,forced bachelorhood ,disharmony due to physical ,emotional, social, educational or financial incapability , childlessness or having too many children etc

Sexual difficulties arising out improper sex education, unhealthy attitudes towards sexual functions, guilt feelings about masturbation, pre and extra –marital sexual relations, worries about sexual perversions.

Stress, frustration, climatic conditions and seasonal variations, seasonal variations and seasonal differences are sometimes noted in the occurrence of mental diseases.

Social factors

Poverty, unemployment, injustice, insecurity, migration, urbanization.

Gambling, alcoholism, prostitution ,broken home ,divorce ,very big family ,religion .traditions political up heals and other social crises .

CLASSIFICATION OF MENTAL ILLENESS

It’s important to classify mental illness because it serves as a guide to Diagnosis and prognosis (outcome)

In psychiatry classification is based on clinical description of disease.

General classification

Neurosis

It means a group of mental disorder which have a combination of symptoms in which there’s is no evidence of organic brain disorder .People who suffer from those conditions don’t lose touch with the external reality ,the behavior may be affected but remains within socially acceptable limits.

In neuroses, there are no hallucinations and delusions.

Patients may have insight and seek help.

Examples of neurosis are:

Anxiety

Disorders occur in various combination of psychological and physical or symptons. Anxiety is vague feeling, worry and tension characterized by excessive fear and apprehension.

Obsessive

Compulsive disorder [OCD] recurred, persistent thought, impulses or images that the pt regards as upgrade, while recognizing them as physical and dissociative problems

Phobic – fear

Panic – Extreme of fear.

PTSD [post – Traumatic stress Disorders]

This is a group of mental symptoms that usually follow a traumatizing experience like war, floods, and epidemics like Ebola, rape, defilement, and accident.

The condition is characterized by severe anxiety persistent disturbing and reoccurring thought or night mares of the experience.

Conversion and dissociation disorder

(Hysteria) present as physical problem present as psychological.

Psychosis:

This is a severe form of mental disorder that is characterized by loss of touch with reality.

A person who has lost touch with reality has abnormal thoughts or beliefs (delusions) and abnormal sensory experience (hallucinations)

She or he may also have disorganized speech and behavior.

Psychoses are divided into function and organic psychosis.

ORGANIC PYSCHOSIS.

Results from identifiable cause e.g malaria, HIV/AIDS, gonorrhea, syphilis, head injury.

Organic mental disorder can be acute or chronic.

Acute organic disorder (delirium)

In this condition there’s fluctuation level of consciousness or clouding of consciousness, hallucinations and loss of memory.

Chronic organic disorder (dementia)

There is no impairment of consciousness but there’s a gross impairment of memory which is due to drainage.

FUNCTIONAL PSYCHOSIS.

Don’t result from early identifiable cause.

No structure damage in brain cell e.g. schizophrenia which is one of the worst form of chronic illness characterized by loss of touch with reality, social withdraw, disturbed thinking, altered perception and behavior.

Affective disorder.

It’s characterized by mood changes i.e. mania and depression.

Depression

Is one of the most mental disorders in the community characterized by persistent low mood, reduced activity and persistent physical complaints.

Mania

Is one of the major mental disorders characterized by excessive happiness increased activity and pressure of speech.

Note: The classification of mental disorders into psychosis and neurosis of an old way of classifying mental disorders though still being used by many clinicians.

Difference between neurosis and psychosis

Neurosis	Psychosis.
A minor form of M.I	Severe form of M.I
no loss of contact with reality	Loss of contact with reality
No abnormal thoughts and beliefs	Abnormal thoughts and beliefs
No abnormal sensory experience and illusion	Abnormal sensory experience and illusion
Have sight	No sight
Doesn’t require hospitalization	Hospitalization is mandatory
Continue to function socially at work	Does not act normally in society and can easily hurt himself or others
The patient frequently talks about his symptoms (has sight)	Patient denies that there’s nothing wrong with him/her.

NEWLY ADOPTED TWO MAIN CLASSIFICATIONS

Diagnostic and Statistical Manual for Classification of Mental disorders (DSM) – American.
International Classification of Disorders (ICD) – WHO.

ICD-10

More general categories.
Generally single axis.

But uses broad aetiology. Uses term neurotic.

DSM-IV-TR

Larger no. of discrete categories. Uses a multi-axial system. Uses term psychotic.

The inclusion of the axes reflect the assumption that most disorders are caused by the interaction of:

Biological
Sociological
Psychological factors.
The patient is assessed more broadly giving a more global in depth picture.

Conditions include

Disorders usually first diagnosed in infancy, childhood or adolescence
Delirium, Dementia & amnestic, & other cognitive disorders
Mental disorders due to a general medical condition
Substance related disorders
Schizophrenia & other psychotic disorders
Mood disorders
Anxiety disorders
. Somatoform disorders
10.Factitious disorders
Dissociative disorders
Sexual & Gender identity disorders
Eating disorders
Sleep disorders
Impulse control disorders not elsewhere classified
Adjustment disorders
Personality disorders
Other conditions that may be a focus of clinical attention

THE FIVE AXES OF THE DSM-IV-TR.

Axis I Clinical syndromes. (All mental disorders & criteria for rating them except personality disorders/mental retardation, also abuse/neglect)
Axis II Personality disorders, Mental retardation. (Life long deeply ingrained, inflexible & maladaptive)
Axis III General medical condition. (Any medical condition that could affect the patients mental state.)
Axis IV Psychosocial & environmental problems. (Stressful events that have occurred within theprevious year)
Axis V global assessment functioning. (How well the patient performed during the previous year)

GENERAL SYMPTOMATOLOGY OF MENTAL DISORDERS

Symptoms of mental disorders are exaggerated of normal patterns of behavior in everyday life. These exaggerations occur in mood, beliefs, perception, awareness and memory.

Most people who suffer from mental disorders may present with unexplained persistent headaches, vague, but general health, change in pattern of general gainful economic activity.

Signs and symptoms of mental disorders

The signs and symptoms of mental disorders are going to be described according to the area of the brain they affect and or the behavior cause and these are;

Appearance

One can identify mental disorders from a person’s appearance. A person with mental disorders may have poor grooming and hygiene .these will include dirty clothing, hair, and nails.

Behavior

This refers to how a person reacts to present situation e.g. mentally ill person may be withdrawn, hostile, uncommunicative, guarded etc

Disorders of movement

These symptoms include the way the patients move their limbs and body .symptoms include:

Slow in movement and speech (psychomotor retardation)
One cannot sustain purposeful movement (restlessness)
Imitating other people’s behavior
Pacing up and down in one spot
Involuntary movement of the muscles like uncontrolled shaking (tremors and ties )
Bizarre posturing (involuntarily taking on abnormal posture for a long time), also called mannerisms, for example a person prolonged facial expressions, standing in one position for a long time.

Speech

Is the way we put together statements, when we are talking, their meaning and appropriateness, tone and rate. Symptoms of mental disorders in relation to speech are:-

The speed –speaking too fast (extremely rapid )or too slow (can be slurred ,not clear )
Volume of speech, the volume may be low or whispered or inappropriately loud and difficult to understand as in mania.
Absent speech or muteness as may occur in depression
The appropriateness of speech –where it may be relevant to a particular situation.
Echolalia –echoing or repeating everything that the health provider or another people around the patient say.
Slow with speech (taking too long to answer) as in depression.
Pressured and forceful speech (talking too much or too fast without giving the health work the chance to ask more )
Word salad –saying words that do not connect to make an intelligible sentence.
Neologism –the patient makes up words of which the meaning is only understood to him /her.

Mood and effect

Mood is the state of one’s sustained feelings or emotions which often influence individuals’ behavior and their perception of the world as described as sadness or happiness.

A person’s emotions or feelings need to be appropriate to the situation that they are in .in mental disorders the mood may be elated ‘extreme happiness’ or depression ‘extreme sadness’

Affect refers to the health provider’s assessment of the appropriateness of emotions of the health provider. This maybe normal, elated, depressed, labile ‘alternating between extremes’, inappropriate, blurred or flat ‘total or nearly absent emotional expression’

Perception

Perception is the process through which we become aware of our environment through the five senses of touch, taste, hearing, smell and sight. Some mental disorders affect the way can occur in any of these five senses.

Perceptions include; Illusions and hallucinations

An illusion refers to the misinterpretation of a sensory stimulus e.g. mistaking a rope for a snake in broad day light. Illusions occur in normal people and should be associated with other symptoms to detect mental disorder.

Hallucinations; refers to a perception without sensory stimulus .symptoms may present in all sensory modalities as follows

Auditory hallucinations –hearing voices or sounds which other people cannot hear. this is the most common type of hallucination
Visual hallucinations; seeing things which other people cannot see.
Tactile hallucination-feeling something on the skin without existing stimulus, such as feeling insects crawling on the body.
Olfactory hallucinations; smelling things which other people cannot smell
Gustatory; hallucinations-a sense of taste which other people cannot taste.

Thinking

This is the ability to process information in one’s mind .the processing of information includes stream, content and form.

Symptoms associated with thinking include;

Stream of thoughts
Form of thoughts
Content of thought

Stream of thought refers to the mount and speed of things one reports that they are thinking about .the symptoms are ;

Pressure of thought-thoughts are rapid ,abundant and varied .the patient will feel over whelmed by these thoughts

Flight of ideas; too many varied ideas that don’t connect.

Poverty of thoughts :the patient will report feelings un able to sustain thinking i.e. very few thoughts

Thought block-this is when the mind is suddenly empty and the individual loses truck of his / her own thoughts. The patient may report that the thoughts are being stolen from him

Form of thought;

this refers to the logical order of the flow of ideas or how ideas are connected and related to each other .the symptoms of thought are

Perseveration. Persistent repetition of the some words or ideas irrespective of the nature of question or conversation

An abstract thought is the ability to interpret complex information according to expected ability.

Content of thought. This refers to what the patient is thinking about.

The disorders of thought content include delusions, phobias and obsessions

Delusions; these are personal beliefs that cannot be changed by rational arguments or evidence and they are not shared by people with same social, culture or religious background and experiences.

Types of delusions include

Grandiose delusions; the patient believes s/he is somebody great /important ,knowledgeable or powerful contrary to the social cultural ,religious background and experiences
Delusion of guilty and worthlessness; the patient believes s/he is not worth to live even though there’s nothing to justify this belief.
Delusions of jealousy –the patient believes that spouse/partner is being unfaithful even when there is no evidence to suggest so.
Delusion of persecution: the patient believes they’re being deliberately wronged, conspired or harmed by another person or agency even when there’s no evidence to suggest so.
Religious delusions; the individual believes he or she has a special link with God that is out keeping with people of the same religious belief.
Delusions of control, influence or phenomenon , these are three types ;belief that the person performs activities as a result of an extreme force .

This includes

Thought insertion; the patient will report that his ideas are not his own and have been inserted into his mind by another person or force.
Thought withdrawal; the patient states that his ideas, thoughts are being taken away by another person for use.
Thought broadcasting; this is where the patient feels that his ideas are being broadcasted live by other people on radio, television or newspaper.
Phobia; these are excess fears e.g. fear of a cat.
Obsessions –excessive ,preoccupation with an idea e.g. excessive orderliness, cleanliness etc

AWARENESS AND MEMORY

This includes the level of consciousness, orientation, attention, concentration, memory, intellect and abstract thoughts.

Level of consciousness: consciousness refers to the state of alertness of a person. Disturbance of consciousness usually fluctuate from mild (lethargy or drowsiness) to severe impairment of consciousness (coma).

Progress symptoms of consciousness include:

Clouding of consciousness or lack of clear mindedness in perception and attitude.
Delirium or being bewildered, confused, restless and disoriented.
State of sustained motionlessness despite being aware of what’s going on around them.
Coma or unconsciousness and the patient cannot be aroused

Orientation: this refers to a state in which an individual is aware of his current place in time .the person can tell what the day it is, where he is and correctly identifies the people around him.
Attention and concentration: attention refers to the ability of an individual to focus his mind on a task at hand, while concentration refers to the ability to sustain this focus. Concentration can be assessed by asking the individual to name the month of the year. The individual is expected to give correct answers in a maximum of two and half to three minutes .a person with poor attention and concentration may fail to learn new information and will therefore have poor registration and short term memory.

Depersonalization and derealization

Depersonalization: this is when the patient says his body has changed, looks different or looks unreal. Depersonalization is a change of awareness of the self, and is sometimes described as being unable to feel emotion
Derealsation; is a sense of being detached from ones environment. This is when the patient states that everything in his surrounding looks changed, strange and feels distanced from the world .this may occur in anxiety, stress, fatigue, affective disorder and hyperventilation.

Memory

Refers to the a ability to recall present and past events and general knowledge .Symptoms manifest in the form of forgetfulness and inability to remember important things .symptoms related to memory can be immediate ,short and long term.

Intellect; refers to the ability to receive, process, interpret and use information and other forms of experience for survival and adaptation in life. It is also the ability to learn and retain new information .for example, ask the patient what they would do if they found a child playing with a a razor blade.

Insight: refers to the individual’s awareness of his or her situation and illness. There are varying degrees of insight .lack of insight generally means that it will be difficult to encourage the individual to accept treatment

Others Symptoms of mental disorder may also present with problems in relationships, appetite and sleep disturbances

Relationship; is the way we interact with others.

Symptoms related with relationships include

Social withdrawal: Not wanting or desiring to participate in social activities.

Isolation keeping to one’s self ,even when in a social environment

Poor interpersonal relations: Gets into fights or quarrels very easily with other people.

Appetite and weight :

Appetite and weight disorders tend to go together .one who has an increased appetite will gain weight whereas on with a decreased appetite will lose weight .one may refuse one may refuse to eat, hind the food and is excessively worried about their weight and body image.

Sleep disorders

Patients with mental disorder may present with sleep problems .The examples of these include;

Altered pattern of sleep i.e. awake all night, dozing all day.
Failure to fall asleep in the early hours of the night
Failure to sleep in late in late hours i.e. from 3 am to dawn .i.e. early morning awakening that occurs in depression.
Interrupted sleep associated with horrifying dreams or with florid dreams.
Quality of sleep; some people may sleep the whole night through but wake up not feeling refreshed

Mental Health Read More »

Normal Midwifery Questions and answers

Normal Midwifery

Abdominal examination; do systematically from the head to toes to find out the lie, presentation, position, level of descent, nature of contractions and fetal heart moulding if any.

1. Hygiene given; bath and a clean gown provided.
2. Records: All the information about the mother is charted on the record sheet.
3. Position: Mother is allowed to adopt any comfortable position especially sitting up position.
4. Ambulation: In early 1^st SOL mother is allowed to move about where the midwife can observe her.
5. Nutrition: Mother is allowed to eat alight diet like porridge, but later in established 1^st SOL she is given hot sweetened tea.
6. Care of the bladder: Mother is encouraged to empty the bladder after every 2hours and urine should be tested for any abnormality.
7. Rest and sleep: assist the mother by dimming off lights and control noise and visitors.
8. Prevention of infections: Ensure aseptic techniques and proper hygiene of the ward to prevent infections.
9. Bowel actions: Mother is encouraged to empty the bowel, move frequently and clean the bed pan if offered.

Write short notes on the following

1. Causes of pain in labour.
2. Factors that affect pain perception during
3. Observation done during fourth stage of Labour indicating importance of each.
4. List indications of ultra sound scan during

SOLUTIONS

LABOUR

Is the physiological process by which the fetus, placenta and membranes are expelled through the birth canal by the help of the mother‘s effort after 28 weeks of gestation and there are four stages of labour that is to say; first, second, third and fourth stage and there are two types of labour and that is normal and abnormal labour.

PAIN

Is a sensory /emotional experience of what the patient feels and there are two types of pain; somatic and visceral pain.

CAUSES OF PAIN

There are two major causes of pain;

Hormonal factors
Mechanical factors

Hormonal factors

These include;

Oxytocin stimulation. This increases the strength, intensity, duration and frequency of the contractions leading to pain.
Progesterone withdrawal. The reduced levels of progesterone lead to an increase in estrogen levels which stimulates the muscles of the deciduae muscles of the uterus to produce prostaglandin which stimulates the smooth muscles of the uterus to contract.

Mechanical factors

These include;

Strength and frequency of Braxton hick‘s contractions occurring in late pregnancy which leads to over stretching of the uterus which irritates the uterine muscles to contract leading to pain.
Pressure of the presenting part on the sacra-nerves and lumbar nerves which has pain receptor.
Pressure of the presenting part on the cervix. The presenting part exerts pressure on the cervix muscles hence leading to pain.
Displacement of the pelvic floor muscles. The advancing presenting part distends the vagina and displaces the pelvic floor muscles which are over stretched and the nerves are compressed leading to pain.

PART (B)

PERCEPTION.

Is the process of becoming aware of the environment through the five senses.

Factors that affect pain perception during labour

These factors are emotional experience involving physical and psychological mechanism and can be contributed by the mother, fetus, health workers and structural environment.

Mother

Maternal medical; conditions like pre-eclampsia and eclampsia, cardiac conditions which can affect pain perception.
Compromised immunity due to chronic conditions like HIV and cancer which can affect pain perception.
Size of the pelvis. Any pelvic deviation from normal leading to cephalous pelvic disproportion which can affect pain perception.
Age. Young prime gravidae below 18years their pelvic bones are not fully developed and the mother above 35years their pelvic bones are contracted and this hinders normal progress of labour and affects pain.
Parity. Prime gravidae‘s their muscles are still intact and sensitive to pain which leads to strong contractions. The multipara mothers their muscles are laced which leads to uterine itial.
Past obstetrical history like caesarian section which increases the risks of uterine rapture and affects normal labour
Social economic factors for example lack of support which can affect pain perception.
Cultural factors like use of native drugs can affect pain perception.
Past experience can also affect pain perception
Level of education, occupation, religion can also affect pain perception.

Fetus

Fetal abnormalities like hydrocephalous, macrosomic babies can lead to cephalopelvic disproportion hence affecting pain.
Lie, position and presenting pain can affect pain perception during labour
Size of the fetus that is to say big babies which cannot pass through the pelvis hence affecting pain perception
Gestation age. In past maturity the sutures and the fontanels are closing and molding can hot take place hence affecting pain perception.

Health workers

Poor screening of mothers during antenatal Poor management during labour
Poor attitude towards the mother

Structural environment

Hospital setting where there is no privacy for mothers, all stages of labour in one room which can affect pain perception.
Lack of recreation in labour rooms like newspapers, television to occupy the mothers.

PART (C)

Forth stage of labour

Is the 1-2 hours following third stage of labour. Observations done during the fourth stage of labour

To the mother

Per vagina

Perineum to inspect for perineal tears, episiotomy and other injuries Bleeding to rule out anemia and post partner hemorrhage

Per abdominal

Fundal height estimation to rule out the retained products of conception State of the uterus whether it has contracted

Bladder encourages the mother to pass urine to prevent PPH

Vital observations like blood pressure, temperature, pulse, and respiration for consciousness of the mother to rule out pre –eclampsia and eclampsia, dehydration and
Breast examination – to rule out abnormalities of the nipple which can hinder breast feeding like inverted nipples.
Observe the bowel action if the bowel movements are present and able to pass out stool
Observe the legs for varicose veins

To the baby

Assessment of the baby after five minutes for example APGAR scoring the baby General examination of the baby to rule out abnormalities
Observation of the cord for bleeding and well ligatured
Bowel for passage of meconium to rule out anal impaction
Observe if the baby is breast feeding for the presence of the sucking reflex.

PART (D)

Ultra- sound scan

Is a tool used in pregnancy and obstetrics generally for diagnosis. The system uses waves of sound that create images by bounding off and td safe to the developing fetus.

Methods

Trans abdominal
Trans vaginal

INDICATIONS

To determine the gestation age
To detect the sex of the baby
To detect the fetal abnormalities
To know the site of the placenta
To determine the maturity where the dates are not accurate
To rule out intra- uterine fetal death
To rule out intra- fetal growth retardation
To confirm pregnancy
To asses amniotic fluid amount an order to rule out polyhydrominous and oligohydrominous
To determine the causes of bleeding in pregnancy

For detection of multiple pregnancies
To determine the size of the baby
For diagnostic purposes
Improves the woman‘s pregnancy experience

For pelvic assessment.

- Vital observations. Vital observations like blood pressure is taken to rule out conditions like pre-eclampsia that will necessitate referral.

- Physical examination. This is done to exclude conditions like anaemia, jundice, dehydration, oedema, malnutrition.
- External pelvic assessment. This is done especially from 36 weeks of gestation those mothers who have not delivered vaginally and prime gravidas by considering gait, stature, height and weight.

- Blood tests. Blood test like complete blood count(CBC),blood grouping and rhesus factor, venereal disease research laboratory test(VDRL),Random blood sugar (RBS),Routine counseling and testing(RCT) to rule out conditions like anaemia, rhesus incompatibility, syphilis, diabetes, HIV &Aids respectively that will necessitate referral.
- Urine test. Urinalysis is done at every visit to exclude the presence of glucose, protein and ketones in the urine which indicates conditions like diabetes, hypertensive disorders, urinary tract infection and unmet fetal demand respectively which necessitate referral.

- Breast examination. It is done to exclude conditions like breast abscess ,breast cancer and any abnormality of the breast that will necessitate referral.

Abdominal examination

On inspection. Observe the size and shape of the abdomen and previous scars that indicates condition like polyhydrominous and oligohydrominous and fresh previous scars that will necessitate referral.

On palpation. It is done to ascertain any abnormality like; Height of fundus not corresponding with gestational weeks, oblique and transverse lie, breech presentation at term especially prime gravidas and absence of fetal movement that will necessitate referral.

Auscultation. This is to exclude abnormal fetal heart tone, regularity, rhythm and absence of fetal heart that will necessitate referral.

Define a partograph.
What information is recorded on the partograph?
List the observations/ nursing care that can be done for a woman in first stage of labour but cannot be plotted on the partograph.

SOLUTIONS

A partograph is a tool used to monitor the progress of labour, condition of the fetus and the mother.

Is the chart used to record all information and observations of a woman in labour/its a partogram before plotting and becomes a partograph after plotting.

A PARTOGRAPH IS STARTED

- When a woman is in active phase of labour that is 4cm or more of cervical opening.

- When the pregnancy of at least 30 completed weeks.

- When the presenting part is cephalic or breech.

- When there is no complication that needs immediate action.

THE INFORMATION RECORDED ON A PARTOGRAPH.

The following information is recorded on a partograph;

Mothers demographic data.
Fetal conditions
Labour progress.
Maternal condition.
Outcome of labour.

MOTHERS DEMOGRAPHIC DATA

This is the first information entered on a partograph, this is essential as it helps a midwife to easily identify the mother she is following to know the weeks of Amenorrhoea and any risk factor etc. It includes name of the health facility, in patient‘s number, name, and data of admission on the partograph, time of admission of the partograph, LNMP, EDD, WOA risk factors and time of rapture of membranes.

FETAL CONDITION.

This part of the graph is used to monitor and assess fetal condition.

It consists of the following; fetal heart, membranes, liquor, molding and caporal.

Fetal heart; Listening to and recording feta heart is safe and reliable away of knowing that the fetus is well. It‘s recorded after every 30 minutes when a mother is active phase of labour .The normal range is between 120b/m to 160b/m.

Membranes; Liquor can assist in assessing the fetal condition.

- If membranes are intact record 1 on the partograph.

- If ruptured record R.

Liquor; The following are recorded about the color of liquor when membranes have ruptured;

If membranes rapture and liquor is clear: C
If membranes rupture and liquor is blood stained: B
If membranes rupture and liquor is Meconium stained: M
If membranes rupture and; liquor is absent: A
If membranes rupture and liquor is brown: B

Moulding; This indicates how well the cervix will accommodate the fetal head.

- Bones separatable, sutures can be felt easily. O
- Bones are flit fast touching each other. +
- Bones are overlapping but can be easily separated with pressure from your fingers ++
- Bones are overlapping but can not be separated easily with pressure from your fingers +++
- In ++ and +++ refer a mother if in a maternity centre or lower health facility in a hospital inform a Doctor.

The labour progress.

Cervical dilation;

First stage of labour is divided into two; latent phase and active phase;-

1. Latent phase; This is a slow period of cervical dilation 0.3cm with gradual shortening of the cervix. It should not exceed 8hours.

1. Active phase; This is the faster period of cervical dilation from 4-10cm.

The cervix dilates at a rate of at least 1cm/hr.

Cervical dilation is plotted with letter X and vaginal examination is done every 4 hours from 4cm to 6cm.Then from 7cm after 3 hours, 8cm after 2hours, 9cm hourly.

If the progress of labour is satisfactory plotting of cervical dilation will remain on the left of the alertline. It should not cross the right of the action line. If cervical dilation is going towards or is on action line the mother is referred from the health centre, in the hospital and Dr is informed.

Desent of the head;

For labour to progress well, dilation of the cervix should be accompanied by desent of the head. For desent to occur at an expected rate the head should be well flexed. This is assessed abdominally.

Desent is plotted with O on the partograph.

Uterine contractions;

Good uterine contractions are necessary for progress of labour; normally contractions become more frequent and last longer as labour progresses and contraction are observed after every 30mins for frequency, strength and duration.

Maternal conditions;

All observations for a mother‘s condition are recorded at the bottom of the partograph e.g. temperature 4hours, pulse ½ hourly. B.P 2hourly, urine output 2hourly.

Drug, rehydration fluids, Oxytocin, if labour is augmented and analysis of proteins, sugar and acetones are cleared.

Out comes of labour;

This information is entered in a partograph after the mother has delivered e.g. Date of delivery, type of delivery, duration of 1^st SOL and 2^nd SOL, post delivery vitals, time of delivery of the placenta and membranes Oxytocin given, amount of blood loss, state of the

perineum whether intact has sustained a tear or episiotomy was made immediate post, partum care and treatment.

Only the baby;

Involves weight, sex, time of delivery, APGAR score, treatment given at birth, any physical abnormality and immediate care.

Observation / Nursing care;

Observation while the mother is coming; the gait whether normal stature, short indicates risk mothers.

General examination from head to toe to examine Anaemia, jaundice and oedema.

Abdominal examination; do systematically from the head to toes to find out the lie, presentation, position, level of descent, nature of contractions and fetal heart moulding if any.

1. Hygiene given; bath and a clean gown provided.
2. Records: All the information about the mother is charted on the record sheet.
3. Position: Mother is allowed to adopt any comfortable position especially sitting up position.
4. Ambulation: In early 1^st SOL mother is allowed to move about where the midwife can observe her.
5. Nutrition: Mother is allowed to eat alight diet like porridge, but later in established 1^st SOL she is given hot sweetened tea.
6. Care of the bladder: Mother is encouraged to empty the bladder after every 2hours and urine should be tested for any abnormality.
7. Rest and sleep: assist the mother by dimming off lights and control noise and visitors.
8. Prevention of infections: Ensure aseptic techniques and proper hygiene of the ward to prevent infections.
9. Bowel actions: Mother is encouraged to empty the bowel, move frequently and clean the bed pan if offered.

Write short notes on the following

1. Causes of pain in labour.
2. Factors that affect pain perception during
3. Observation done during fourth stage of Labour indicating importance of each.
4. List indications of ultra sound scan during

SOLUTIONS

LABOUR

PAIN

Is a sensory /emotional experience of what the patient feels and there are two types of pain; somatic and visceral pain.

CAUSES OF PAIN

There are two major causes of pain;

Hormonal factors
Mechanical factors

Hormonal factors

These include;

Oxytocin stimulation. This increases the strength, intensity, duration and frequency of the contractions leading to pain.
Progesterone withdrawal. The reduced levels of progesterone lead to an increase in estrogen levels which stimulates the muscles of the deciduae muscles of the uterus to produce prostaglandin which stimulates the smooth muscles of the uterus to contract.

Mechanical factors

These include;

Strength and frequency of Braxton hick‘s contractions occurring in late pregnancy which leads to over stretching of the uterus which irritates the uterine muscles to contract leading to pain.
Pressure of the presenting part on the sacra-nerves and lumbar nerves which has pain receptor.
Pressure of the presenting part on the cervix. The presenting part exerts pressure on the cervix muscles hence leading to pain.
Displacement of the pelvic floor muscles. The advancing presenting part distends the vagina and displaces the pelvic floor muscles which are over stretched and the nerves are compressed leading to pain.

PART (B)

PERCEPTION.

Is the process of becoming aware of the environment through the five senses.

Factors that affect pain perception during labour

These factors are emotional experience involving physical and psychological mechanism and can be contributed by the mother, fetus, health workers and structural environment.

Mother

Maternal medical; conditions like pre-eclampsia and eclampsia, cardiac conditions which can affect pain perception.
Compromised immunity due to chronic conditions like HIV and cancer which can affect pain perception.
Size of the pelvis. Any pelvic deviation from normal leading to cephalous pelvic disproportion which can affect pain perception.
Age. Young prime gravidae below 18years their pelvic bones are not fully developed and the mother above 35years their pelvic bones are contracted and this hinders normal progress of labour and affects pain.
Parity. Prime gravidae‘s their muscles are still intact and sensitive to pain which leads to strong contractions. The multipara mothers their muscles are laced which leads to uterine itial.
Past obstetrical history like caesarian section which increases the risks of uterine rapture and affects normal labour
Social economic factors for example lack of support which can affect pain perception.
Cultural factors like use of native drugs can affect pain perception.
Past experience can also affect pain perception
Level of education, occupation, religion can also affect pain perception.

Fetus

Fetal abnormalities like hydrocephalous, macrosomic babies can lead to cephalopelvic disproportion hence affecting pain.
Lie, position and presenting pain can affect pain perception during labour
Size of the fetus that is to say big babies which cannot pass through the pelvis hence affecting pain perception
Gestation age. In past maturity the sutures and the fontanels are closing and molding can hot take place hence affecting pain perception.

Health workers

Poor screening of mothers during antenatal Poor management during labour
Poor attitude towards the mother

Structural environment

Hospital setting where there is no privacy for mothers, all stages of labour in one room which can affect pain perception.
Lack of recreation in labour rooms like newspapers, television to occupy the mothers.

PART (C)

Forth stage of labour

Is the 1-2 hours following third stage of labour. Observations done during the fourth stage of labour

To the mother

Per vagina

Perineum to inspect for perineal tears, episiotomy and other injuries Bleeding to rule out anemia and post partner hemorrhage

Per abdominal

Fundal height estimation to rule out the retained products of conception State of the uterus whether it has contracted

Bladder encourages the mother to pass urine to prevent PPH

Vital observations like blood pressure, temperature, pulse, and respiration for consciousness of the mother to rule out pre –eclampsia and eclampsia, dehydration and
Breast examination – to rule out abnormalities of the nipple which can hinder breast feeding like inverted nipples.
Observe the bowel action if the bowel movements are present and able to pass out stool
Observe the legs for varicose veins

To the baby

Assessment of the baby after five minutes for example APGAR scoring the baby General examination of the baby to rule out abnormalities
Observation of the cord for bleeding and well ligatured
Bowel for passage of meconium to rule out anal impaction
Observe if the baby is breast feeding for the presence of the sucking reflex.

PART (D)

Ultra- sound scan

Is a tool used in pregnancy and obstetrics generally for diagnosis. The system uses waves of sound that create images by bounding off and td safe to the developing fetus.

Methods

Trans abdominal
Trans vaginal

INDICATIONS

To determine the gestation age
To detect the sex of the baby
To detect the fetal abnormalities
To know the site of the placenta
To determine the maturity where the dates are not accurate
To rule out intra- uterine fetal death
To rule out intra- fetal growth retardation
To confirm pregnancy
To asses amniotic fluid amount an order to rule out polyhydrominous and oligohydrominous
To determine the causes of bleeding in pregnancy

For detection of multiple pregnancies
To determine the size of the baby
For diagnostic purposes
Improves the woman‘s pregnancy experience

For pelvic assessment.

- Plasma volume increase by 30% this results into hydraemia.
- Increased blood flow to the uterus to aid placental circulation by 10-15% or about 750mls per minute, kidneys for excretion of extra waste product of metabolism.

Identification of abnormalities that necessitate referral.

- History taking. A comprehensive history is taken on medical, surgical, past and present obstetrical, social and family history that may complicate or be complicated by pregnancy, labour and pueperium like diabetes, hypertension, epilepsy, sickle cell disease and accident involving the spine, pelvis and the lower limbs that will necessitate referral.

- Vital observations. Vital observations like blood pressure is taken to rule out conditions like pre-eclampsia that will necessitate referral.

- Physical examination. This is done to exclude conditions like anaemia, jundice, dehydration, oedema, malnutrition.
- External pelvic assessment. This is done especially from 36 weeks of gestation those mothers who have not delivered vaginally and prime gravidas by considering gait, stature, height and weight.

- Blood tests. Blood test like complete blood count(CBC),blood grouping and rhesus factor, venereal disease research laboratory test(VDRL),Random blood sugar (RBS),Routine counseling and testing(RCT) to rule out conditions like anaemia, rhesus incompatibility, syphilis, diabetes, HIV &Aids respectively that will necessitate referral.
- Urine test. Urinalysis is done at every visit to exclude the presence of glucose, protein and ketones in the urine which indicates conditions like diabetes, hypertensive disorders, urinary tract infection and unmet fetal demand respectively which necessitate referral.

- Breast examination. It is done to exclude conditions like breast abscess ,breast cancer and any abnormality of the breast that will necessitate referral.

Abdominal examination

Auscultation. This is to exclude abnormal fetal heart tone, regularity, rhythm and absence of fetal heart that will necessitate referral.

DISEASE OF LYMPH VESSELS

Lymphoedema/lymphatic dysfunction

Lymphoedema refers to swelling in the tissues due to obstruction of lymph drainage

Lymphedema is also defined as the interstitial collection of protein-rich fluid due to disruption of lymphatic flow.

When lymph vessel is obstructed, lymph accumulates in the distal parts leading to low grade inflammation and lymph vessels

Lymphatic dysfunction means that lymphatic system is not working well

Physiologic basis of lymphedema — Lymphedema occurs when the lymphatic load exceeds the transport capacity of the lymphatic system, which causes filtered fluid to accumulate in the interstitium. As opposed to generalized edematous states, the rate of capillary filtration is normal in patients with lymphedema

Causes of lymphoedema

Causes of Lymphoedema can be:

Primary: is due to a congenital and or inherited condition associated with pathologic development of the lymphatic vessels.
Secondary: This occurs as the result of other conditions or treatments

Congenital lymphatic obstruction (Milroy’s disease): failure for the lymph vessel especial in lower limb to develop. This is also called hereditary or primary lymphoedema
Surgical removal of lymph vessel and lymph nodes due to cancer to prevent secondary tumors and further disease spread i.e. removal of axillary nodes during mastectomy may lead to lymphoedema of the affected arm
Tumours can compress lymph vessel blocking lymph flow and tissue drainage
Filariasis: It is a disease caused by tissue dwelling nematode, transmitted by mosquito bite
Malignant metastasis of lymph node and lymph vessel

Signs and symptoms of lymphoedema

Typical signs and symptoms of lymphedema include:

The onset of lymphedema is usually insidious. Affected patients may initially experience aching pain at the affected area and a sense of heaviness or fullness of the limb. Over time, the skin becomes dry and firm with less pitting and is fibrous to palpation.
Two-thirds of cases of lymphedema are unilateral, although the laterality depends on the precipitating event. For example, an axillary node dissection will increase the risk of lymphedema in the ipsilateral arm while a pelvic node dissection increases the risk of bilateral lower extremity edema.
At onset, swelling in the affected limb is typically characterized as “soft” and “pitting”. Pitting is variable in patients with lymphedema and reflects movement of the excess interstitial water in response to pressure. It is generally absent with progressive lymphedema, reflecting the evolution of fibrosis and adipose tissue deposition.
For patients who had previously undergone a lymph node dissection and radiation, lymphedema is typically characterized by slowly progressive ipsilateral swelling of an arm following axillary node dissection or a leg following inguinal node dissection. The swelling may first be apparent only in the proximal portion of the limb, or it can affect only a portion of the distal limb including the digits.
Among patients with breast cancer, there may also be swelling over the ipsilateral breast and/or upper chest wall. Other manifestations include a feeling of heaviness, tightness, aching or discomfort in the limb, and restricted range of motion.
Skin changes — With worsening lymphedema, dermal thickening becomes clinically apparent, which is manifested by cutaneous fibrosis. The overlying skin of the affected limb also becomes hyperkeratotic, which can lead to verrucous and vesicular skin lesions.
Discomfort — A feeling of heaviness, tightness, aching or discomfort in the affected limb commonly accompanies swelling.
Restricted range of motion — With later stages of lymphedema, patients may develop restricted range of motion in the affected limb as a result of the increased weight, which may limit their ability to perform activities of daily living (ADLs).

Summary of Clinical Features

Swelling in arms and legs
Tissues of the neck and head may be affected also.
Reduced mobility due to swelling
Heaviness of the affected area
Skin changes i.e discoloration
Blister formation
Leaking of fluid from the skin
Infections
Poor vision, ear pain and nasal congestion in case of head and neck lymphoedema
Difficult in swallowing
Difficulty in breathing and talking
Salivating
Lymphangitis and cellulitis occur as complications which presents as streaky red patch on area affected, fever, chills and itching

Diagnosis and Investigation of lymphoedema

History: Components of history that should be addressed include:

Age of onset
Area(s) of involvement
Associated symptoms (e.g., pain)
Medications — While none is directly associated with an increased risk of lymphedema, some are associated with edematous states (e.g., NSAIDs agents) or are contraindicated in the treatment of lymphedema (e.g., diuretics)
Progression of symptoms
Past medical history, including of medical conditions associated with lymphedema, any prior travel, infections, surgery or prior RT
Family history

2. Physical Examination.

The physical exam should evaluate the vascular system, skin, and soft tissue, and palpation of the lymph nodes.

If primary lymphedema is suspected, evaluation should include documentation of any physical signs or congenital anomalies associated with an inherited condition. Examples include:

Short stature (Turner Syndrome)
Port wine stains or hemangiomas (Klippel-Trenaunay-Weber Syndrome)
Shield chest (Turner Syndrome, Noonan Syndrome)
A positive Stemmer sign is indicative of lymphedema. It is characterized by the examiner’s inability to lift the skin of the affected limb compared to the contralateral limb. It is also described as difficulty lifting the skin of the dorsum of the fingers or toes of the affected limb. A positive Stemmer sign can be found in any stage of lymphedema. While it is possible to have a false negative Stemmer sign, a false positive sign is rare.
Opto electronic volume try — Volume can be assessed utilizing an infrared, optoelectronic measurements. This technique utilizes infrared beams to scan the limb and calculate a volume.
Circumferential measurements — Circumferential measurements on the affected and contralateral arm are a simple and inexpensive method to estimate edema. Measurements can be taken at any point in the arm or leg, or circumferentially around the head, neck, or trunk, as long as the clinician is utilizing anatomic landmarks to reproduce the measurements. Measurements in the arm are made at four points in both the affected and contralateral arm:
Metacarpal-phalangeal joints
Wrists
Ten centimeters distal to the lateral epicondyles
Fifteen centimeters proximal to the lateral epicondyles
Water displacement detects changes in volume of less than 1 percent. For patients with limb lymphedema, volume difference of 200 mL or more between the affected and opposite limbs is typically considered as a cutoff point to define lymphedema.
Bioimpedance spectroscopy — Bioimpedance spectroscopy (BIS) is a reliable and accurate tool to determine volume. Using electrical current, resistance measurements are used to compare the composition of fluid compartments.

4. Imaging

Computed tomography (CT) scan can demonstrate accumulation of fluid within soft tissue with good sensitivity
MRI has also been used in the evaluation of lymphedema.
Lymphoscintigraphy — Lymphoscintigraphy is a technique used to image the flow of fluid from the skin to the lymph nodes, particularly in the extremities.
X-ray of lymphatic system by introducing a dye between toes or in the groin
Genetic testing — For patients diagnosed with primary lymphedema or suspected of lymphedema tarda, referral to a medical geneticist or genetic counselling service is suggested for evaluation of the family history and recommendations for further work-up.
Blood smear to isolate filarial worms

Stages of Lymphedema.

Staging — Lymphedema is staged using the criteria of the International Society of Lymphology. It involves two criteria to diagnose and classify lymphedema: the “softness” or “firmness” of the limb (reflecting fibrotic soft tissue changes) and the outcome after elevation:

Stage 0 — Stage 0 lymphedema is a subclinical or latent condition where swelling is not evident despite impaired lymphatic transport. Most patients are asymptomatic, but some report a feeling of heaviness in the limb. Stage 0 may exist for months or years before the onset of overt lymphedema occurs (stage I to III).
Stage I – There is accumulation of fluid that subsides with 24-hour limb elevation. The appearance is that of soft edema that may pit, with no evidence of dermal fibrosis. This is sometimes called reversible edema.
Stage II – Stage II lymphedema does not resolve with 24-hour limb elevation alone. This reflects the evolution of dermal fibrosis. As the fibrosis progresses, the limb may no longer pit on examination. This is sometimes called spontaneously irreversible lymphedema.
Stage III – Stage III lymphedema is characterized by lymphostatic elephantiasis. On exam, pitting is absent, and the skin reveals trophic skin changes such as fat deposits, acanthosis, and warty overgrowths.

Classification of lymphedema

Several classification systems are used, including the American Physical Therapy Association (APTA) & National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE). Of these, we prefer the APTA classification system. Both schemas are described below.

APTA uses girth as an anthropometric measurement to classify lymphedema. The maximum girth difference between the affected and unaffected limb is used to determine the class of lymphedema. See ‘Circumferential measurements‘ below):

Mild lymphedema — maximum girth difference <3 cm
Moderate lymphedema — 3 to 5 cm difference
Severe lymphedema — difference >5 cm

National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) — categorizes lymphedema based upon exam findings & the presence of functional impairment:

Grade 1 — Trace thickening or faint discoloration
Grade 2 — Marked discoloration; leathery skin texture; papillary formation; limiting instrumental activities of daily living (ADL)
Grade 3 — Severe symptoms limiting self care ADL

Management of lymphoedema

Compression of the affected limb to promote lymph drainage
Wrapping the affected limb in elastic bandage to maintain continuous pressure on swollen limb to reduce the size and improve mobility
Use of compression garments (special designed socks), stockings, or sleeves that have a comfortable fit over the swollen limb (manual lymphatic drainage/lymphatic drainage massage)
Exercise can help fluid move from the vessels and reduce on swelling such as knee bending, wrist rotation, swimming, walking, etc for 20 to 30 minutes daily
Routine skin care
Liposuction in advanced stages of lymphedema when other options fail
Anti biotic are prescribed prevent spread of infections
Treat secondary fever with analgesics
Ensure good diet to improve immunity
Lymphatic venous anastomosis
Massaging
Elevation
Apply pressure on the affected areas
Complete decongestive therapy
Surgery due to obstruction

Lymphangitis

Lymphangitis refers to inflammation of lymph vessels due bacterial infection.

Microbes in the lymph, draining the area infected, spread along the walls of lymph vessel. This may be stopped in the first lymph node or continue involving whole lymph drainage network to even blood.

Potential pathogens include

bacteria,
mycobacteria,
viruses,
Fungi
parasites.

Lymphangitis commonly develops after cutaneous inoculation of microorganisms into the lymphatic vessels through a skin wound or as a complication of a distal infection.

Pathophysiology of Lymphangitis

The major function of the lymphatic system is to resorb fluid and protein from tissues and extravascular spaces. The absence of a basement membrane beneath lymphatic endothelial cells affords the lymphatic channels a unique permeability, allowing resorption of proteins that are too large to be resorbed by venules.
Lymphatic channels are situated in the deep dermis and subdermal tissues parallel to the veins and have a series of valves to ensure one way flow. Lymph drains via afferent lymphatics to regional lymph nodes and then by efferent lymphatics to the cisterna chyli and the thoracic duct into the subclavian vein and venous circulation.
Lymphangitis develops after cutaneous inoculation of microorganisms that invade the lymphatic vessels and spread toward the regional lymph nodes. Organisms may invade lymphatic vessels directly through a skin wound or an abrasion or as a complication of a distal infection.

Pathophysiology of Edema

Circulation of lymph is a complex process. All body tissues are bathed in interstitial fluid and when in excess, it accumulates leading to oedema.

Therefore edema occur due to;

Excessive production of interstitial fluid as in increased capillary permeability due to inflammation, colloid osmotic pressure in hypoproteinemia, high venous pressure in thrombosis
Inadequate removal/ transport of interstitial fluid by lymphatic system lead to accumulation of interstitial fluids a condition called lymphoedema

Normally 2-4 liters of interstitial fluids is filtered per day and is returned to vascular circulation. Fluid flux across capillary depend on hydrostatic and oncotic pressure (positive in arterial end and negative in the venular end)

Causes

Extremity oedema is due to right sided heart failure, constrictive pericarditis, renal diseases, liver cirrhosis and hypoproteinemia
Acute or chronic obstruction in the venous system
Abnormalities in lymphatic system
Allergic disorders

Clinical Manifestation of Lymphangitis

Characterized by erythematous streaks with pain and rapid spread, or by nodular swellings along the course of the lymphatic vessels.

Acute lymphangitis – occur in skin abrasion with infection at a distal site, such as interdigital dermatophyte infection or cellulitis of the lower leg. This may be accompanied by lymphangitis with red, tender streaks extending proximally with involvement of regional lymph nodes (lymphadenitis). Fever may also be present as a systemic symptoms.
In individuals with normal immunity the cause is Streptococcus pyogenes; can also occur in Staphylococcus aureus infection. In immunocompromised patients, gram-negative organisms are important causes of lymphangitis following lower limb cellulitis.
Pasteurella multocida from dog and other animal bites can result in localized infection with concomitant lymphangitis. It occurs in up to 30 percent of Erysipelothrix infections, a zoonosis occurring in persons in contact with fish and some animals. Cutaneous anthrax can present with extensive edema, regional lymphadenopathy, and lymphangitis.
Lymphangitis associated Rickettsiosis has been described with the causative organism R. sibirica mongolotimonae and in African tick bite fever due to R. africae. The presence of an inoculation eschar suggests tick-transmitted infection.
Nodular lymphangitis
- Nodular lymphangitis (also known as sporotrichoid lymphangitis, sporotrichoid spread, or lymphocutaneous syndrome) presents as painful or painless nodular subcutaneous swellings along the course of the lymphatic channels.
- Sporotrichosis has been described in the setting of gardening trauma or injury due to a thorn or wood splinter. It can have an incubation period of up to three months and presents in a cutaneous or a lymphocutaneous form accompanied by lymphangitis; painless ulcers may also be observed. Lesions on the upper limbs are the most common presentation
- lesions may ulcerate with accompanying regional lymphadenopathy. The incubation period between exposure and the onset of nodular lymphangitis can be prolonged and the presentation may be indolent with few or no systemic symptoms.
- Causes of nodular lymphangitis include: Sporothrix schenckii, Nocardia (most often N. brasiliensis), M. marinum, leishmaniasis, tularemia, and systemic mycoses:
- M. marinum has been described to cause “fish tank granuloma,” an entity that can occur following a hand injury while cleaning a fish tank. It has an incubation period of up to eight weeks. Infection due to rapidly growing mycobacteria can also occur in the setting of thorn or splinter injury. Other mycobacterial causes of lymphangitis include M. kansasii, M. chelonae, and M. fortuitum.
- Nocardia infections may present with cutaneous, subcutaneous, or lymphocutaneous manifestations following traumatic injury. Although this may mimic the appearance and clinical course of acute staphylococcal or streptococcal infection, the clinical course is usually much more indolent.
- Cutaneous leishmaniasis can present with subcutaneous nodules with lymphangitis or lymphadenitis up to 24 weeks following exposure. This presentation is more frequent with New World leishmaniasis caused by L. braziliensis or L. mexicana than with Old World Leishmaniasis due to L. major or L. tropica.
- Nodular lymphangitis is a rare manifestation of Francisella tularensis and Burkholderia pseudomallei infection. The initial skin lesion of F tularensis infection may be a papule or an ulcer or contain an eschar. The systemic mycoses, including coccidioidomycosis, blastomycosis, and histoplasmosis, can present with nodular lymphangitis.
- Filarial lymphangitis — The presence of the parasite within the lymphatic channels causes inflammation and subsequent dilatation, thickening, tortuosity of the lymphatic channels with valvular incompetence. Often occurs in a retrograde progression with distal or peripheral spread away from the regional lymph nodes where the adult parasite resides. It can also occur as a result of inflammation due to dying parasites.
- Wuchereria bancrofti, B. malayi, and B. timori are the causes of lymphangitis due to lymphatic filariasis.

Diagnosis of Lymphangitis.

Clinical features, & laboratory analysis of clinical specimens.

Microbiological investigations

Swab, aspirate, and biopsy of the primary site, nodule, or distal ulcer for histology and microscopy (including gram, fungal and acid fast staining), as well as culture (including bacterial, fungal, and mycobacterial cultures).
Serology (e.g., F. tularensis, Histoplasma)
Blood film (e.g., filaria)
Imaging —Lymphangiography (using dye injection into the lymphatics) and lymphoscintigraphy (using intradermal technetium injection at distal site of affected limb) have been used to evaluate for lymphedema and lymphatic obstruction . This may be useful if surgical management of lymphedema is a consideration.

Treatment of Lymphangitis

Some cases of nodular lymphangitis require surgical debridement. In the setting of lymphedema with significant lymphatic obstruction, surgical intervention may also be appropriate. Pending diagnostic evaluation, empiric antibiotic therapy with activity against skin flora may be initiated.

DISEASES OF LYMPH NODES

Lymphadenitis/adenitis

Lymphadenitis refers to inflammation of lymph nodes due bacterial infection spreading from infected lymph vessels.

The lymph nodes become enlarged, tender, congested with blood and chemotaxins.

If the phagocytes and antibody production is overwhelmed abscess may form with in the node Neighboring tissues may become involved and infected materials may be transported to other nodes and blood

Lymphadenititis may be acute or chronic. In children cervical lymph nodes are more affected

Causes of acute lymphadenititis

Measles Typhoid
Cat-scratch fever Wound
Skin infections

Causes of chronic lymphadenititis

TB
Syphilis
Unresolved acute infections

Signs and symptoms of lymphadenitis

Tenderness of the affected nodes
Redness of the skin around the affected nodes
Fever in severe cases

Lymphadenopathy

This refers to enlargement of lymph nodes.

Causes of Lymphadenopathy

It may be local or generalized

Causes of generalized lymphadenopathy include;

Infection like TB, HIV, syphilis
Acute and chronic lymphoid leukemia
Lymphoma like Hodgkin’s and Non-Hodgkin’s lymphoma
Sarcoidosis

Causes of localized lymphadenopathy include

Localized infection ie scalp infection leads to cervical lymph nodes enlargement,
infection of the upper extremity lead to axillary lymph nodes enlargement, infection of the lower limbs lead to inguinal lymph nodes enlargement and infection of the throat or tonsils lead to mandibular lymph node enlargement
Carcinoma that spread to lymphatics lead to regional lymphadenopathy i.e. stomach cancer lead to supraclavicular lymphadenopathy, breast cancer lead to axillary lymphadenopathy.

DISEASES OF THE SPLEEN

Splenomegaly/ hypersplenism

Splenomegaly refers to enlargement of the spleen more than its normal size (12x 7 cm).

The enlarged spleen may be non palpable but it is detectable on scan. It becomes palpable only when enlarged more than two and half times its normal size.

The spleen may be infected by blood-borne microbes or local spread of infection Enlargement of the spleen is associated with problems which include;

Premature destruction of red blood cells
Sequestration of red cells, white cells and platelets (pancytopenia)
Valunabirity to traumatic rapture
Hyperplasia of bone marrow follows as a compensatory response

Causes of splenomegaly

Bacterial infection like endocarditic, tuberculosis, septicemia, brucellosis, syphilis and typhoid
Viral infection like hepatitis and AIDS
Protozoa infection like malaria, leishmaniasis and trypanosomiasis
Fungal like histoplasmosis
Inflammatory disorders like SLE, rheumatoid arthritis and sarcoidosis
Congestion due to portal hypertension, hepatic vein thrombosis, chronic CCF and pericardial effusion
Hemolytic disorders like sickle cell anemia and spherocytosis
Infiltrative diseases of the spleen like leukemia and lymphomas
Iron deficiency anemia and megaloblastic anemia
Idiopathic

Signs and symptoms of splenomegaly

Palpable spleen Fever
Jaundice
Other signs of underlying disease

Management of splenomegaly

Investigations helps in identifying the cause such as blood smear, CBC, radiological imaging and culture and biopsy.
Treat the cause accordingly
In severe persistent spleenism, splenectomy may be performed

Hyposplenism

This refers to lack or impairment of spleen function.

It is due to Trauma
Surgical removal of the spleen
Autoplenectomy as in sickle cell due to ischemic atrophy (microvascular occlusion) Splenic atrophy in celiac disease

Signs of hypoplenism

Recurrent bacterial infection such as streptococci, E-coli, Haemophilus influenza and Neisseria meningitides
Severe septicaemia Intravascular coagulation Multiorgan failure
Red cell abnomalities

DISEASE OF LYMPH VESSELS Read More »

Congenital Toxoplasmosis

Causes of Toxoplasmosis

LIFE CYCLE OF TOXOPLASMA GONDII

Clinical Features

Diagnosis of Toxoplasmosis

Treatment and Management

Prevention

Complications

Nursing Diagnosis for Toxoplasmosis

Mental Health Assessment

Overview of the Assessment Process

Conditions for an Effective Consultation

Establishing a Therapeutic Relationship

Essential Must-Do’s for the Interview

General Principles of the Psychiatric Interview

Psychiatric History Components

Mental Status Examination (MSE)

1. Appearance and Behavior

2. Speech

3. Emotion (Mood and Affect)

4. Perception

5. Thought Content and Process

A. Thought Process

B. Thought Content

6. Insight and Judgment

7. Cognition

Developing the Nursing Care Plan

MENTAL HEALTH

Concepts of Mental Health

Stress and Mental Health

Responses to Stress

Determinants of response to stress

Characteristics of a mentally healthy person

MENTAL ILLNESS

Common signs and symptoms of mental illness

ETIOLOGY OF MENTAL ILLNESS

Predisposing factors

Precipitating factors

Perpetuating factors

Biological factors

Physiological changes

Social factors

CLASSIFICATION OF MENTAL ILLENESS

General classification

Neurosis

Psychosis:

ORGANIC PYSCHOSIS.

FUNCTIONAL PSYCHOSIS.

Difference between neurosis and psychosis

NEWLY ADOPTED TWO MAIN CLASSIFICATIONS

GENERAL SYMPTOMATOLOGY OF MENTAL DISORDERS

Signs and symptoms of mental disorders

Normal Midwifery

Module Unit CN-111: Anatomy and Physiology (I)

Learning Outcomes for this Unit:

Topic: Structures and functions of various body systems - Blood

Blood

Composition of Blood

Plasma

Plasma proteins

Albumins

Globulins

Clotting factors

Electrolytes

Nutrients

Waste products

Hormones

Gases

Cellular Contents of Blood

Red Blood Cells

Life span and function of erythrocytes

Haemoglobin

Control of Erythropoiesis

Revision Questions for Blood and its Composition:

References (from Curriculum for CN-1102):

Hodgkin’s disease

LYMPHOMAS

Classification of lymphomas

Hodgkin’s Lymphoma