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Intracranial Hemorrhage

INTRACRANIAL HEMORRHAGE

An intracranial hemorrhage is a type of bleeding that occurs inside the skull (cranium).

Bleeding around or within the brain itself is known as a cerebral hemorrhage (or intracerebral hemorrhage).

Bleeding caused by a blood vessel in the brain that has leaked or ruptured is called a hemorrhagic stroke.

All bleeding within the skull is referred to as intracranial hemorrhage.

Causes of Intracranial Hemorrhage.

Head Trauma: Injury to the head from falls, car accidents, sports incidents, or seizures.
Hypertension: High blood pressure leading to damage in blood vessel walls, causing leakage or rupture.
Blood Clot: Blockage of a brain artery by a clot formed in the brain or traveling from another body part.
Cerebral Aneurysm: Rupture of a weak spot in a blood vessel wall, forming a balloon-like bulge that bursts.
Malformed Arteries or Veins: Leaking of improperly formed arteries or veins.
Bleeding Tumors: Hemorrhage from tumors causing bleeding.
Pregnancy-Related Conditions: Conditions linked to pregnancy or childbirth, including eclampsia, difficult delivery, and assisted delivery.
Coagulopathy or Anticoagulation Medicine: Blood clotting disorders, use of anticoagulants like warfarin or heparin, or bleeding disorders like hemophilia and thrombocytopenia.
Child Abuse Syndrome: Shaken baby syndrome as a result of child abuse.
Postsurgical Causes: Hemorrhage occurring after surgeries like craniotomy or shunting.

Pathophysiology:

The brain relies on a network of blood vessels to supply oxygen and nutrients. Intracranial hemorrhage disrupts this supply, preventing oxygen from reaching brain tissue. The pooled blood from the hemorrhage increases pressure on the brain, further limiting oxygen delivery.

During a hemorrhage or stroke, if oxygen deprivation persists for more than three or four minutes, brain cells begin to die. This results in damage to affected nerve cells and the related functions they control. The interruption of blood flow around or inside the brain is a critical factor leading to cellular damage and dysfunction.

Types of Intracranial Hemorrhage

Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Intra cerebral hemorrhage

Epidural Hematoma (Subgalea hemorrhage.

Subgaleal hemorrhage occurs when emissary veins between the skull and intracranial venous sinuses tear, leading to blood collection between the dura/apo-neurosis and periosteum of the skull.

High-pressure bleeding is a prominent feature. An epidural hematoma, may briefly lead to lose consciousness and then consciousness is regained latter.

Epidural hematoma is accumulation of blood between the Dura and the skull following fracture of the skull

Most commonly from rupture of middle meningeal artery.
The hematoma expands rapidly since accumulating blood is arterial in origin and causes compression of the Dura and flattening of underlying gyri
The patient develops progressive loss of consciousness if hematoma is not drained early.

Signs and symptoms

Swelling of the ears
Increasing head circumference as bleeding expands into this space. (hydrocephalus)
Hypovolemic shock,
Tachycardia,
Hypotension

Diagnosis

Subgaleal hemorrhage may present as a large, boggy fluid collection palpable on the head’s surface. Characteristic of a subgaleal hemorrhage is that it is not restricted by suture lines and may shift with movement. This is in contrast to the more common cephalohematoma, a superficial collection of blood restricted to the space between the periosteum and skull, which is contained along suture lines.
Neonates with subgaleal hemorrhage are at high risk for rapid decompensation; the subgaleal space can expand to collect a newborn’s entire intravascular blood volume if bleeding continues unrecognized.

Subdural hematoma (SDH)

A subdural hemorrhage occurs when bridging veins carrying blood through the dura mater to the arachnoid mater of the meninges are torn.

This causes bleeding, with blood collecting below the dura and brain.

Presence of blood on the surface of the brain beneath its outer covering.

SDH is a collection of blood below the inner layer of the dura mater but external to the arachnoid membrane.

Subdural hematoma is accumulation of blood between the Dura and subarachnoid.
Develops most often from rupture of veins which cross the surface convexities of the cerebral hemispheres.

Subdural hematoma may be acute or chronic.

Acute subdural hematoma; develops following trauma and consists of clotted blood, often in the front parietal region. There is no significant compression of gyri. Since the accumulated blood is of venous origin, symptoms appear slowly and may become chronic with passage of time if not fatal.
Chronic subdural hematoma; occurs often with brain atrophy. Chronic subdural hematoma is composed of liquid blood. Separating the hematoma from underlying brain is a membrane composed of granulation tissue.

Diagnosis

Because subdural bleeders are located within the skull, there is often no physical sign on the scalp that reflects injury. Instead, the presence of hemorrhage may initially be unrecognized. For most neonates, subdural hemorrhage remains asymptomatic and resolves without consequence.
Clinical problems can arise in case of large volume hemorrhage or if bleeding slowly continues over hours or even days, as in cases of bleeding disorders.
Symptomatic neonates often present 24–48 hours after birth with nonspecific signs such as apnea, respiratory distress, altered neurologic state, or seizures.

Subarachnoid hemorrhage

Subarachnoid hemorrhage occurs when the veins of the subarachnoid villi are torn, leading to a collection of blood in the subarachnoid space.

There’s bleeding between the brain and the thin tissues that cover the brain. These tissues are called meninges.

A sudden, sharp headache usually comes before a subarachnoid hemorrhage. Typical symptoms also include loss of consciousness and vomiting.

Hemorrhage into the subarachnoid space is most common, caused by;
rupture of an aneurysm, and rarely, rupture of a vascular malformation.
Of the three types of aneurysms affecting the larger intracranial arteries—berry, mycotic and fusiform, berry aneurysms are most important and most common.
Berry aneurysms are saccular in appearance with rounded or lobulated bulge arising at the bifurcation of intracranial arteries and varying in size from 2 mm to 2 cm or more.
They account for 95% of aneurysms which are liable to rupture.
Berry aneurysms are rare in childhood but increase in frequency in young adults and middle life.
They are, therefore, not congenital anomalies but develop over the years from developmental defect of the media of the arterial wall at the bifurcation of arteries forming thin-walled saccular bulges.
Although most berry aneurysms are sporadic in occurrence, there is an increased incidence of their presence in association with congenital polycystic kidney disease and coarctation of the aorta.
In more than 85% cases of subarachnoid hemorrhage, the cause is massive and sudden bleeding from a berry aneurysm on or near the circle of Willis.

The four most common sites are;

In relation to anterior communicating artery.
At the origin of the posterior communicating artery from the stem of the internal carotid artery.
At the first major bifurcation of the middle cerebral artery.
At the bifurcation of the internal carotid into the middle and anterior cerebral arteries

Intracerebral hemorrhage

An intracerebral brain hemorrhage (ICH) is bleeding in the brain caused by the rupture of a damaged blood vessel in the head.

As the amount of blood increases, the build-up of pressure can lead to brain damage, unconsciousness or even death.

Intra cerebral hemorrhage is when there’s bleeding inside the brain.

This is bleeding into the brain’s ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma or from hemorrhaging in stroke ( HTN). This is the most common type of ICH that occurs with a stroke. It’s not usually the result of injury.

Spontaneous intracerebral hemorrhage occurs mostly in patients of hypertension. Children with systemic diseases that manifest with HTN are at risk because they have micro aneurysms in very small cerebral arteries in the brain tissue.
Rupture of one of the numerous micro aneurysms is believed to be the cause of intracerebral hemorrhage
Not common to have recurrent intracerebral hemorrhages like is the case of subarachnoid hemorrhages
The common sites of hypertensive intracerebral hemorrhage are the region of the basal ganglia (particularly the putamen and the internal capsule), pons and the cerebellar cortex

Diagnosis

There are very few clinical symptoms of IcH. When present, signs may include an acute drop in hematocrit, new-onset hypotension, and lethargy.
However, these symptoms are often present in extremely low birth weight and prematures

Signs and Symptoms

A prominent warning sign is the sudden onset of neurological deficit. This is a problem with the brain’s functioning. The symptoms progress over minutes to hours and they include:

Headache accompanied by neck stiffness
Drowsiness
Difficulty speaking/crying
Nausea
Vomiting
Decreased consciousness
Seizure
Coma
Weakness in one part of the body
Elevated blood pressure
Cognitive dysfunction or memory loss
Sudden tingling, weakness, numbness, or paralysis of the face, arm or leg, particularly on one side of the body
Loss of balance or coordination in older children
Babies less than 12 months old may develop a swollen fontanel, or soft spot

Diagnosis

History taking
Computed temography (CT- scan) of head
MRI of head
CBC
Coagulation profile e.g. INR, PT
Physical examination e.g. glasgow coma scale (GCS):
- Eye Opening
- Verbal response
- Best motor response

GLASGOW COMA SCALE

Management

Admission in icu or surgical ward
Resuscitation (ABC); All patients with GCS < 8 should be intubated for airway protection
Surgical management

ICH is a medical emergency. Survival depends on getting treatment right away. It may be necessary to operate to relieve the pressure on the skull (craniotomy)

Craniotomy; to evacuate blood
Endovascular treatment; to occlude parent artery
Aneurysm coiling; obstruct aneurysm site with coil

MEDICAL MANAGEMENT

Steroids to Reduce Swelling: Steroids help reduce inflammation and swelling in the brain. Minimizing swelling is important to prevent further damage to delicate brain tissue.
Anticoagulants: Reduces clotting to prevent the formation of blood clots. Clots can exacerbate the existing hemorrhage and lead to complications like stroke.
Anti-Seizure Medications: Controls and prevents seizures. Seizures can further damage the brain and hinder the recovery process.
Medications to Counteract Anticoagulants: Reverses the effects of any blood thinners previously taken. Prevents excessive bleeding and facilitates clotting.
Blood Pressure Management: Maintain mean arterial pressure below 130 mm Hg. Helps control bleeding, but excessive hypotension should be avoided to ensure adequate blood flow to the brain.
Avoiding Hyperthermia: Prevents elevated body temperature. Elevated temperature can worsen brain damage; controlling it is essential for recovery.
Correction of Coagulopathy: Using interventions like fresh frozen plasma, vitamin K, or platelet transfusions. Correcting coagulation issues ensures proper blood clotting and reduces the risk of complications.
Anticonvulsant Initiation: Controls seizures. Seizures can cause additional harm to the brain and hinder recovery.
Transfer to Operating Room or ICU: Facilitates specialized care and monitoring. Swift transfer ensures prompt and appropriate management of the patient’s condition.
Consideration of Nonsurgical Management: For patients with minimal neurological deficits. Nonsurgical approaches may be appropriate in less severe cases, avoiding unnecessary interventions.
Dietary Measures: Initiating enteral feedings, possibly via nasogastric tube or percutaneous device. Ensures proper nutrition and supports the patient’s recovery.
Activity Management: Bed rest initially, followed by a progressive increase in activity. Balancing rest and activity promotes recovery without causing undue stress on the healing brain.

Nursing Concerns Intracranial Hemorrhage:

Risk for Increased Intracranial Pressure: Bleeding within the brain can lead to increased intracranial pressure, which can damage brain tissue.
Risk for Neurological Deficits: The hemorrhage can cause permanent neurological damage, such as paralysis, speech impairment, or cognitive decline.
Risk for Seizures: The hemorrhage can trigger seizures.
Risk for Complications of Immobility: The patient may be bedridden, increasing the risk of complications such as pneumonia, deep vein thrombosis, and pressure ulcers.
Risk for Anxiety and Fear: The patient and family may experience anxiety and fear about the diagnosis and prognosis.
Risk for Family Dysfunction: The patient’s illness can put a strain on family relationships.
Risk for Post-Traumatic Stress Disorder: The patient may experience PTSD after a traumatic brain injury.

Complications to Monitor:

Seizures: Can occur and require prompt management.
Paralysis: Possible impairment of motor functions.
Memory Loss: Cognitive deficits may arise.
Stroke: Hemorrhage can lead to a secondary stroke.
Permanent Brain Damage: A risk, especially if complications are not managed effectively.
Cerebral Coning: Herniation of brain tissue, a serious complication.
Depression: Emotional and psychological impact.
Bedsore: Potential complication due to immobility, requiring preventive measures.

Intracranial Hemorrhage Read More »

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.

Condition	Why it's similar	Key difference
Non-Hodgkin Lymphoma (NHL)	Also presents with painless lymphadenopathy and can have B symptoms.	Histopathology (lack of Reed-Sternberg cells, different cellular morphology, immunophenotype) is the definitive differentiator. NHL is a much more heterogeneous group.
Metastatic Carcinoma	Enlarged, firm lymph nodes, often in the cervical or supraclavicular regions.	Biopsy will reveal epithelial cells (carcinoma) rather than lymphoid cells, and immunohistochemistry will show different markers. Often, there's a known primary tumor.
Leukemias (especially CLL)	Can cause generalized lymphadenopathy.	Primarily involve the bone marrow and peripheral blood. Diagnosis involves blood counts, bone marrow biopsy, and flow cytometry.
Sarcomas	Can present as masses that may be mistaken for lymph nodes.	Originates from connective tissue, not lymphoid cells. Histopathology is distinct.
Castleman Disease	A rare lymphoproliferative disorder causing localized or generalized lymphadenopathy.	Histopathology shows characteristic features distinct from lymphoma (e.g., hypervascularity, onion-skinning of follicles).
Infectious Mononucleosis (EBV)	Widespread lymphadenopathy, fever, fatigue, splenomegaly.	Acute onset, often with sore throat. Diagnosis by serology and atypical lymphocytes on blood smear. Biopsy shows reactive hyperplasia.
Tuberculosis (TB) Lymphadenitis	Chronic, often painless, progressive lymph node enlargement (cervical).	Diagnosis by PCR for Mycobacterium tuberculosis, culture, and histopathology showing granulomatous inflammation with caseous necrosis.
HIV Lymphadenopathy	Chronic, painless, generalized lymphadenopathy.	Positive HIV test. Biopsy shows follicular hyperplasia.
Toxoplasmosis	Cervical lymphadenopathy, sometimes with fever and fatigue.	Diagnosis by serology. Biopsy shows characteristic reactive changes.
Cat Scratch Disease	Localized lymphadenopathy following cat scratch/bite.	History of cat exposure. Diagnosis by serology or PCR. Biopsy shows characteristic suppurative granulomas.
Bacterial Lymphadenitis	Enlarged, often painful lymph nodes, signs of acute infection.	Acute onset, pain, redness, warmth. Resolves with antibiotics.
Sarcoidosis	Bilateral hilar lymphadenopathy and peripheral lymphadenopathy.	Biopsy shows non-caseating granulomas. Elevated ACE levels.
SLE or Rheumatoid Arthritis	Generalized lymphadenopathy, systemic inflammation.	Presence of other systemic autoimmune features and positive autoantibody tests (ANA, RF).

Condition & Assessment	Interventions
Neutropenia (Low WBCs/Risk of Infection) Assessment: Monitor ANC, temperature (q4h), signs of infection (chills, redness, swelling, sore throat).	Implement strict hand hygiene. Administer colony-stimulating factors (filgrastim). Education: Avoid crowds, sick contacts, raw foods. Maintain aseptic technique for invasive procedures. Avoid rectal temps/enemas. Encourage oral hygiene with soft toothbrush.
Thrombocytopenia (Low Platelets/Risk of Bleeding) Assessment: Monitor platelets, observe for bleeding (petechiae, purpura, epistaxis, hematuria, melena). Neuro status.	Administer platelet transfusions. Avoid aspirin/NSAIDs. Bleeding precautions: soft toothbrush, electric razor, avoid IM injections. Education: Avoid falls, contact sports, vigorous nose blowing.
Anemia (Low RBCs/Fatigue) Assessment: Monitor Hb/Hct, fatigue, pallor, dyspnea, tachycardia.	Administer packed RBC transfusions. Encourage rest periods; assist with ADLs. Educate on energy conservation.

Condition & Assessment	Interventions
Nausea and Vomiting Assessment: Frequency, severity, triggers.	Administer antiemetics proactively. Offer small, frequent, bland meals. Encourage clear liquids, ginger ale, crackers. Relaxation techniques.
Mucositis/Stomatitis (Oral Sores) Assessment: Inspect mucosa daily for redness/lesions. Assess pain.	Frequent oral care with soft brush, non-irritating mouthwash. Administer pain meds (topical/systemic). Avoid acidic, spicy, hot foods. Offer soft, moist foods.
Diarrhea/Constipation Assessment: Bowel habits, consistency.	Diarrhea: Antidiarrheals, low-fiber diet, hydration. Constipation: Laxatives/stool softeners, fluids, fiber (if not neutropenic), ambulation.

Condition & Assessment	Interventions
Fatigue Assessment: Severity, impact on ADLs.	Encourage balanced rest/activity. Prioritize activities. Energy conservation strategies. Light exercise if tolerated.
Peripheral Neuropathy Assessment: Numbness, tingling, burning, weakness.	Safety education (fall prevention, water temp). Administer neuropathic pain meds. Assistive devices.
Skin Reactions (Radiation) Assessment: Redness, dryness, itching, peeling.	Gentle skin care: mild soap, pat dry, no rubbing. Non-perfumed lotions recommended by oncologist. Avoid tight clothing. Protect from sun.
Alopecia Assessment: Discuss expectations/emotional impact.	Info on wigs, scarves, hats. Emphasize hair growth resumes after treatment.

Complication & Assessment	Interventions
Tumor Lysis Syndrome (TLS) Assessment: Electrolytes (K+, Phos, Ca), Uric acid, cardiac arrhythmias, muscle cramps, decreased urine output.	Vigorous hydration. Allopurinol or rasburicase. Monitor cardiac rhythm.
Superior Vena Cava (SVC) Syndrome Assessment: Facial/neck edema, dyspnea, distended neck veins.	Elevate head of bed. Avoid tight clothing/restraints. Corticosteroids/diuretics. Emergency radiation/chemo.
Infections (Opportunistic) Assessment: Assess for fungal/viral infections.	Prophylactic antibiotics/antivirals/antifungals. Strict infection control.

Modality	Procedure / Use	Findings in Lymphedema
1. Lymphoscintigraphy (Radionuclide Lymphangioscintigraphy)	Gold Standard (Functional Assessment). Radioactive tracer injected into web space of toes/fingers. Images taken over time to visualize vessels/nodes and tracer transport.	Delayed or absent lymphatic uptake, visualization of collateral channels, dermal backflow (tracer remaining in skin), absence of lymph node visualization.
2. Indocyanine Green (ICG) Lymphography	Fluorescent dye (ICG) injected intradermally and illuminated with near-infrared light. Visualizes superficial vessels.	Shows "dermal backflow," abnormal patterns ("splashes," "stardust"), and areas of obstruction. Useful for surgical planning.
3. Magnetic Resonance Lymphangiography (MRL)	Uses MRI (with/without contrast) to visualize deeper lymphatic vessels and nodes.	Identifies vessel abnormalities, lymph node status, and differentiates lymphedema from other conditions.
4. Ultrasonography (Ultrasound)	Primarily used to rule out DVT or cysts, and assess tissue thickness.	Increased subcutaneous tissue thickness, "honeycomb" patterns (dilated channels), thickening of dermis.
5. CT Scan & MRI	Assess tumor involvement, quantify limb volume, differentiate from lipedema.	Show characteristic patterns of subcutaneous edema and thickening.

Anatomy and Physiology of the Lymphatic System

Anatomy and Physiology of Lymphatic System

The lymphatic system is part of the circulatory system which begins with very small close ended vessels called lymphatic capillaries which is in contact with the surrounding tissues and interstitial fluid. The lymphatic system is almost a parallel system to the blood circulatory system.

It consists of:

Lymph
Lymph vessel
Lymph nodes
Diffuse lymphoid tissue
Bone marrow

Lymph

Lymph is a clear, watery fluid that circulates throughout the lymphatic system. It is essentially an ultrafiltrate of blood plasma that has left the capillaries and entered the interstitial spaces, eventually being collected by the lymphatic vessels. Understanding its origin and contents is key to grasping its physiological roles.

I. Definition of Lymph

A clear, yellowish or whitish fluid that flows through the lymphatic vessels.
It is derived from interstitial fluid (tissue fluid) that surrounds the cells, which in turn is formed from blood plasma that filters out of blood capillaries.
It is identical to interstitial fluid in its composition.

II. Composition of Lymph

The composition of lymph is very similar to blood plasma, but with some key differences, primarily a lower concentration of large proteins.

Water: The primary component, providing the solvent for all other substances.
Electrolytes: Ions such as sodium (Na+), potassium (K+), chloride (Cl-), bicarbonate (HCO3-), etc., are present in similar concentrations to plasma.
Nutrients: Glucose, amino acids, fatty acids, and vitamins, which have filtered out of the blood capillaries and are essential for cellular metabolism.
Metabolic Waste Products: Urea, creatinine, and other cellular waste products.
Proteins:
- Lower concentration than plasma: While most large plasma proteins are too big to easily exit blood capillaries, some do leak out into the interstitial fluid. Lymph serves to return these leaked proteins to the bloodstream.
- Plasma proteins: Albumin, globulins (including antibodies), and clotting factors are present in smaller amounts.
Cells:
- Lymphocytes: These are the most abundant cells in lymph, especially after it has passed through lymph nodes. Lymphocytes are crucial for immune responses.
- Macrophages: Phagocytic cells that engulf foreign particles, cellular debris, and pathogens.
- Other immune cells: Neutrophils may be present, particularly during infection.
- Erythrocytes (Red Blood Cells): Generally absent in lymph unless there is trauma or pathology.
Fats (Chylomicrons): After a fatty meal, specialized lymphatic vessels in the small intestine (lacteals) absorb dietary fats, which are then transported as chylomicrons in the lymph (giving it a milky appearance, especially after a meal).
Bacteria, Viruses, Cellular Debris, Damaged Tissues: These are also transported within the lymph to the lymph nodes for filtration and immune processing.
Antibodies: Carried by lymphocytes and dissolved in the fluid component, providing immune protection.

III. Formation of Lymph

Lymph formation is a direct consequence of fluid exchange between blood capillaries and the interstitial spaces:

Filtration at Capillary Ends: Due to the relatively high hydrostatic pressure within blood capillaries, a significant amount of fluid, along with dissolved substances (but not large proteins or blood cells), is forced out of the capillaries and into the interstitial spaces, becoming interstitial fluid.
Absorption at Venule Ends: Most of this interstitial fluid (about 85-90%) is reabsorbed back into the capillaries at the venule end, where hydrostatic pressure is lower and osmotic pressure is higher.
Lymphatic Drainage: However, about 10-15% of the interstitial fluid, along with any leaked plasma proteins and cellular debris, remains in the interstitial spaces. This fluid is collected by the blind-ended lymphatic capillaries, at which point it is officially called lymph. The unique structure of lymphatic capillaries allows large molecules to enter easily.
Volume: Approximately 2-4 liters of lymph are formed and returned to the bloodstream each day. This represents about 1-3% of the body's total weight.

IV. Functions of Lymph

The composition of lymph directly supports its critical functions within the body:

Fluid Balance:
- Return of Excess Interstitial Fluid: Lymph collects excess fluid from the interstitial spaces and returns it to the bloodstream. This prevents edema (swelling) and maintains fluid homeostasis. Without this function, interstitial fluid would accumulate rapidly, leading to death within approximately 24 hours.
- Transport of Proteins: It returns plasma proteins that have leaked out of blood capillaries into the interstitial fluid back to the circulation. This is crucial because if these proteins remained in the interstitial fluid, they would increase its osmotic pressure, drawing more fluid out of the capillaries and causing persistent edema.
Immune Surveillance and Defense:
- Transport of Pathogens to Lymph Nodes: Lymph effectively "sweeps up" bacteria, viruses, cellular debris, and foreign particles from tissues and transports them to regional lymph nodes.
- Antigen Presentation: Within the lymph nodes, these pathogens and antigens are presented to lymphocytes (T and B cells) and macrophages, initiating specific immune responses.
- Distribution of Immune Cells: Lymph circulates lymphocytes and antibodies throughout the body, providing a means for immune cells to patrol tissues and quickly respond to infections.
Fat Absorption and Transport:
- Transport of Dietary Lipids: In the small intestine, specialized lymphatic capillaries called lacteals absorb dietary fats (in the form of chylomicrons), cholesterol, and fat-soluble vitamins (A, D, E, K).
- Bypassing Liver (Initially): This lymphatic pathway allows these absorbed fats to bypass initial processing by the liver and enter the systemic circulation directly via the thoracic duct.

Lymph Vessels (Lymphatics) and Lymph Capillaries

The lymphatic system begins with tiny, blind-ended capillaries that merge to form progressively larger vessels, eventually returning lymph to the bloodstream. These vessels have unique structural features that facilitate the collection and transport of lymph.

I. Lymph Capillaries

Structure:
- Blind-ended: Unlike blood capillaries which form a continuous loop, lymphatic capillaries originate as blind-ended tubules in the interstitial spaces. This "closed" end is crucial for initiating lymph flow.
- Single Layer of Endothelial Cells: They are composed of a single layer of flattened endothelial cells, similar to blood capillaries.
- No Basement Membrane: A key distinguishing feature is the absence or incomplete presence of a continuous basement membrane beneath the endothelial cells. This lack of structural support makes them more permeable.
- Overlapping Endothelial Cells (Mini-Valves): The endothelial cells significantly overlap each other. These overlaps are loosely attached and form one-way flap-like mini-valves. When interstitial fluid pressure is high, these flaps open inwards, allowing fluid, proteins, bacteria, and larger particles to enter the capillary. When pressure inside the capillary is high, the flaps close, preventing lymph from leaking back into the interstitial space.
- Anchoring Filaments: Fine collagen filaments (anchoring filaments) extend from the endothelial cells into the surrounding connective tissue. These filaments anchor the capillaries to the tissue, ensuring that when tissue fluid volume increases, the capillaries are pulled open, preventing collapse and facilitating fluid entry.
Permeability:
- Lymph capillaries are much more permeable than blood capillaries. This high permeability allows them to absorb not only excess interstitial fluid but also large molecules like plasma proteins (which have leaked out of blood capillaries), cell debris, bacteria, and even whole cancer cells. This ability to absorb large particles is vital for their immune and fluid balance functions.
Distribution:
- Lymph capillaries are extensive networks found almost everywhere blood capillaries are present. They permeate nearly all body tissues, forming dense plexuses within the interstitial spaces.
- Exceptions: They are generally not found in certain areas, including:
  - Brain and Spinal Cord: The central nervous system has its own fluid drainage system (cerebrospinal fluid).
  - Bone Marrow: While lymphoid tissue is in bone marrow, it doesn't have lymphatic capillaries in the same way.
  - Avascular tissues: Like cartilage, epidermis of the skin, and the cornea of the eye.
  - Spleen: The spleen is a lymphoid organ, not a site of fluid collection from the interstitium via capillaries.

II. Lymph Vessels (Lymphatics)

Lymph capillaries merge to form progressively larger collecting vessels, which are collectively known as lymphatics. These vessels share structural similarities with veins but also have distinct features.

Structure:
- Similar to Veins, but Thinner Walls: Lymphatic vessels are structurally similar to veins, possessing three tunics (intima, media, externa), but their walls are generally much thinner and more delicate.
- More Valves: A distinguishing feature of lymphatic vessels is the presence of an even greater number of valves than in veins. These numerous one-way valves are crucial for preventing the backflow of lymph and ensuring its unidirectional flow towards the heart. The presence of these valves gives the lymphatic vessels a characteristic beaded or segmented appearance.
- Lymphangions: The segment of a lymphatic vessel between two consecutive valves is called a lymphangion. These lymphangions have smooth muscle in their walls, which contract rhythmically to propel lymph forward.
- Afferent and Efferent Vessels: Lymphatic vessels entering a lymph node are called afferent lymphatic vessels, while those leaving a lymph node are efferent lymphatic vessels.
Types of Lymphatic Vessels (in increasing size):
- Lymphatic Capillaries: The starting point, blind-ended, highly permeable.
- Collecting Lymphatic Vessels: Formed by the union of capillaries, these often travel alongside arteries and veins, having numerous valves.
- Lymphatic Trunks: Formed by the convergence of collecting vessels. There are typically five major lymphatic trunks:
  - Lumbar trunks: Drain lymph from the lower limbs, pelvic organs, and anterior abdominal wall.
  - Bronchomediastinal trunks: Drain lymph from the thoracic viscera and chest wall.
  - Subclavian trunks: Drain lymph from the upper limbs.
  - Jugular trunks: Drain lymph from the head and neck.
  - Intestinal trunk (unpaired): Drains lymph from the digestive organs.

Lymphatic Ducts:

The two largest lymphatic vessels in the body, which ultimately return lymph to the venous circulation.

Thoracic Duct (Left Lymphatic Duct):
- Origin: Begins in the abdomen as a dilated sac called the cisterna chyli (located anterior to the L1 and L2 vertebrae). The cisterna chyli receives lymph from the lumbar trunks and the intestinal trunk, meaning it drains the lower limbs, pelvic and abdominal organs.
- Course: Ascends through the thoracic cavity, collecting lymph from the left broncho-mediastinal trunk, left subclavian trunk, and left jugular trunk.
- Drainage Area: Drains lymph from the entire lower half of the body (both legs, pelvis, abdomen), the left side of the thorax, the left upper limb, and the left side of the head and neck.
- Termination: Empties into the venous system at the junction of the left internal jugular vein and the left subclavian vein in the root of the neck.
Right Lymphatic Duct:
- Origin: A much shorter vessel (about 1-2 cm long).
- Drainage Area: Drains lymph from the right upper limb, the right side of the thorax, and the right side of the head and neck (from the right jugular, right subclavian, and right broncho-mediastinal trunks).
- Termination: Empties into the venous system at the junction of the right internal jugular vein and the right subclavian vein in the root of the neck.

III. Overall Distribution

The lymphatic system is a vast, one-way network of vessels that transports lymph from peripheral tissues back to the cardiovascular system. It essentially runs parallel to the venous system, collecting fluid that cannot be reabsorbed by blood capillaries and filtering it before returning it to the blood.

Lymph Circulation

Lymph circulation is a one-way street, beginning in the peripheral tissues and ending back in the bloodstream. This accessory route is vital for maintaining fluid balance, transporting absorbed nutrients, and facilitating immune responses.

I. Path of Lymph Circulation

Interstitial Fluid: Fluid (plasma minus large proteins) filters out of blood capillaries into the interstitial spaces, becoming interstitial fluid. This fluid surrounds tissue cells.
Lymphatic Capillaries: The blind-ended, highly permeable lymphatic capillaries collect excess interstitial fluid, leaked proteins, cellular debris, and pathogens from the interstitial spaces. Once inside these capillaries, the fluid is called lymph.
Collecting Lymphatic Vessels: Lymphatic capillaries merge to form larger collecting vessels. These vessels have numerous one-way valves, giving them a beaded appearance, and often travel alongside blood vessels.
Lymph Nodes: Lymphatic vessels typically pass through one or more (often 8-10) lymph nodes. Lymph flows into a node via afferent lymphatic vessels, is filtered as it passes through the node, and then exits via efferent lymphatic vessels. This filtration process allows immune cells within the node to monitor the lymph for foreign substances.
Lymphatic Trunks: Efferent vessels eventually converge to form larger lymphatic trunks. There are several major trunks throughout the body (e.g., lumbar, intestinal, broncho-mediastinal, subclavian, jugular).
Lymphatic Ducts: The lymphatic trunks drain into one of two large lymphatic ducts:
- Thoracic Duct:
  - Receives lymph from the cisterna chyli (which collects lymph from the lumbar trunks and intestinal trunk).
  - Also receives lymph from the left jugular, left subclavian, and left broncho-mediastinal trunks.
  - Drains: The entire lower body, left upper limb, left side of the thorax, and left side of the head and neck.
  - Terminates: Empties into the venous circulation at the junction of the left internal jugular vein and the left subclavian vein.
- Right Lymphatic Duct:
  - Receives lymph from the right jugular, right subclavian, and right broncho-mediastinal trunks.
  - Drains: The right upper limb, right side of the thorax, and right side of the head and neck.
  - Terminates: Empties into the venous circulation at the junction of the right internal jugular vein and the right subclavian vein.
Subclavian Veins: Once lymph enters the subclavian veins, it mixes with blood plasma and becomes part of the general venous circulation, eventually returning to the heart.

II. Factors Aiding Lymph Flow (The Lymphatic Pump)

Unlike the cardiovascular system, which has the heart as a central pump, the lymphatic system relies on extrinsic and intrinsic mechanisms to propel lymph against gravity and low pressure. These mechanisms collectively form what is sometimes called the "lymphatic pump."

Skeletal Muscle Pump:
- Mechanism: Contraction and relaxation of skeletal muscles surrounding lymphatic vessels compress the vessels. This compression pushes lymph forward through the one-way valves.
- Importance: This is a major driving force, especially in the limbs. Increased physical activity (exercise) significantly enhances lymph flow by increasing muscle contractions. Conversely, prolonged inactivity leads to sluggish lymph flow.
Respiratory Pump (Pressure Changes during Breathing):
- Mechanism: During inhalation, the diaphragm descends, increasing intra-abdominal pressure and decreasing intrathoracic pressure. This pressure gradient compresses abdominal lymphatic vessels (including the cisterna chyli) and draws lymph into the thoracic duct, which is in the lower-pressure thoracic cavity. During exhalation, the reverse occurs, helping to maintain flow.
Rhythmic Contraction of Smooth Muscle in Lymphatic Vessels (Intrinsic Lymphatic Pump):
- Mechanism: The walls of larger lymphatic vessels (collecting vessels, trunks, ducts) contain smooth muscle cells, particularly in the segments between valves (lymphangions). These smooth muscles undergo slow, rhythmic, spontaneous contractions.
- Importance: This intrinsic peristaltic-like action helps to actively propel lymph forward, especially when other external pumps are less active.
Pulsations of Adjacent Arteries:
- Mechanism: Lymphatic vessels often run in close proximity to arteries. The pulsations (throbbing) of these arteries, due to each heartbeat, can compress the lymphatic vessels and gently massage lymph along.
One-Way Valves:
- Mechanism: These numerous valves are crucial structural components within lymphatic vessels that ensure unidirectional flow. They prevent lymph from flowing backward due to gravity or pressure fluctuations.
Compression of Tissues by External Objects:
- Mechanism: External compression, such as massage, compression garments, or simply leaning on an object, can also temporarily increase pressure on lymphatic vessels and aid lymph flow.
Hydrostatic Pressure in Interstitial Fluid:
- Mechanism: The initial entry of interstitial fluid into lymphatic capillaries is driven by a pressure gradient. When interstitial fluid pressure is higher than the pressure inside the lymphatic capillary, the mini-valves open, allowing fluid to enter.

III. Significance of Lymph Circulation

Essential for Life: The continuous return of fluid and proteins from the interstitial spaces to the blood prevents fatal edema and hypovolemia (low blood volume).
Immune System Function: It allows immune cells and antigens to be circulated and processed in lymph nodes, initiating vital immune responses.
Nutrient Transport: Especially important for the absorption and transport of dietary fats.

Lymph Nodes

Lymph nodes are small, encapsulated organs that are strategically distributed throughout the body along the lymphatic vessels. They serve as primary sites for immune surveillance.

I. Structure of a Lymph Node

Lymph nodes are typically oval or bean-shaped, ranging in size from 1 mm to 25 mm (about 1 inch) in diameter.

Capsule:
- Each lymph node is enclosed by a dense fibrous capsule made of connective tissue.
- Trabeculae: Extensions of the capsule, called trabeculae, extend inwards into the interior of the node, dividing it into compartments and providing structural support.
Cortex and Medulla:
- Cortex (Outer Region): The outer part of the lymph node. It contains:
  - Lymphoid Follicles (Nodules): Spherical clusters of lymphocytes.
  - Primary Follicles: Densely packed with small, inactive B lymphocytes.
  - Secondary Follicles: Develop in response to an antigen. They have a lighter-staining central area called a germinal center, which contains rapidly proliferating B cells, plasma cells (antibody-producing cells), and follicular dendritic cells.
  - Paracortex (Deep Cortex): The region between the follicles and the medulla. This area is rich in T lymphocytes and high endothelial venules (HEVs), through which lymphocytes can enter the node from the bloodstream. Dendritic cells, which present antigens to T cells, are also abundant here.
- Medulla (Inner Region): The central part of the lymph node. It consists of:
  - Medullary Cords: Branching cords of lymphatic tissue that extend inward from the cortex. They contain B lymphocytes, plasma cells, and macrophages.
  - Medullary Sinuses: Large lymphatic capillaries that separate the medullary cords. Lymph flows through these sinuses.
Lymphatic Sinuses (Channels for Lymph Flow):
- These are a network of irregular channels lined by reticular cells and macrophages, forming a labyrinth through which lymph percolates.
- Subcapsular Sinus (Marginal Sinus): Located immediately beneath the capsule, where afferent lymphatic vessels first empty.
- Cortical Sinuses (Trabecular Sinuses): Extend from the subcapsular sinus, along the trabeculae.
- Medullary Sinuses: Located in the medulla.
- Flow Path: Lymph enters the subcapsular sinus, flows through cortical and medullary sinuses, and eventually collects in the efferent lymphatic vessels.
Blood Supply:
- Lymph nodes receive arterial blood and drain venous blood. High Endothelial Venules (HEVs) in the paracortex are particularly important, allowing lymphocytes to enter the node directly from the blood circulation.
Afferent and Efferent Lymphatic Vessels:
- Afferent Lymphatic Vessels: Several (typically 4-5) afferent vessels pierce the convex surface of the capsule, bringing lymph into the node. These vessels have valves that direct lymph inward.
- Efferent Lymphatic Vessels: Fewer (typically 1-2) efferent vessels emerge from the hilum (the indented region) of the lymph node, carrying filtered lymph out of the node. These also have valves to prevent backflow.

II. Location and Distribution

Lymph nodes are found throughout the body, often clustered in strategic locations where they can effectively filter lymph from large regions. They are typically arranged in deep and superficial groups. Key large groups include:

Cervical Lymph Nodes:
- Location: In the neck, both superficial (along the sternocleidomastoid muscle) and deep (around the internal jugular vein).
- Drainage: Head and neck.
- Clinical Significance: Often swell during throat infections, colds, and ear infections.
Axillary Lymph Nodes:
- Location: In the armpits (axilla).
- Drainage: Upper limbs, pectoral region, and the mammary glands.
- Clinical Significance: Crucial in the staging of breast cancer, as cancer cells often metastasize via lymphatic drainage to these nodes.
Inguinal Lymph Nodes:
- Location: In the groin region.
- Drainage: Lower limbs, external genitalia, and superficial abdominal wall.
- Clinical Significance: May swell with infections or cancers of the lower extremities or pelvic area.
Popliteal Lymph Nodes:
- Location: Behind the knee.
- Drainage: Superficial leg and foot.
Thoracic Lymph Nodes:
- Location: Within the mediastinum and around the hila of the lungs (hilar nodes), along the aorta (aortic nodes), and sternum (sternal nodes).
- Drainage: Thoracic organs (lungs, heart, esophagus, mediastinum).
- Clinical Significance: Involved in lung infections (e.g., tuberculosis) and lung cancer.
Abdominal and Pelvic Lymph Nodes:
- Location: Along the aorta (e.g., para-aortic nodes), iliac vessels, and within the mesentery of the intestines (e.g., mesenteric nodes).
- Drainage: Abdominal and pelvic organs (e.g., gastrointestinal tract, kidneys, reproductive organs).
- Clinical Significance: Involved in cancers of the digestive system and urogenital system.
Cisterna Chyli: While not a true lymph node, this is a dilated sac that collects lymph from the lumbar and intestinal trunks, located in front of L1 & L2 vertebrae.

III. Functions of Lymph Nodes

Lymph nodes perform two primary, interconnected functions:

Filtration of Lymph:
- Mechanism: As lymph slowly flows through the intricate network of sinuses within the node, macrophages and reticular cells lining these sinuses phagocytose (engulf) debris, foreign particles, bacteria, viruses, dead cells, and cancer cells.
- Importance: This cleansing action prevents harmful substances from reaching the bloodstream, effectively "purifying" the lymph before it is returned to the circulation. Lymph typically passes through around 8-10 nodes before returning to the blood, ensuring thorough filtration.
Immune Surveillance and Activation:
- Antigen Presentation: Lymph nodes are packed with lymphocytes (T cells and B cells) and antigen-presenting cells (APCs) like dendritic cells and macrophages. When pathogens or their antigens are carried into the node via lymph, APCs capture and present these antigens to lymphocytes.
- Lymphocyte Proliferation: This antigen presentation triggers the activation and rapid proliferation (clonal expansion) of specific T and B lymphocytes that recognize the antigen.
- Antibody Production: Activated B cells transform into plasma cells, which produce and secrete large quantities of antibodies into the lymph and eventually into the blood, targeting the invading pathogens.
- Cell-Mediated Immunity: Activated T cells differentiate into various effector T cells (e.g., cytotoxic T cells that directly kill infected cells) and memory T cells.
- Importance: Lymph nodes are the key sites where adaptive immune responses are initiated and amplified, leading to the eradication of infections and the development of immunological memory.

Lymphoid Tissues (e.g., tonsils, Peyer's patches)

Lymphoid tissue is a specialized connective tissue containing large numbers of lymphocytes and macrophages, forming the structural and functional basis of the immune system. It can be categorized into primary lymphoid organs (where lymphocytes mature) and secondary lymphoid organs/tissues (where lymphocytes become activated). For this objective, we'll focus on the more "diffuse" or "aggregated" lymphoid tissues.

I. Diffuse Lymphoid Tissue

This refers to collections of lymphocytes and macrophages that are loosely scattered within the connective tissue of mucous membranes, particularly those lining the gastrointestinal, respiratory, urinary, and reproductive tracts. It is the most common form of lymphoid tissue and lacks a distinct capsule. Its primary role is to protect these open passages from invading pathogens.

II. Aggregated Lymphoid Follicles (Nodules) - MALT

When lymphoid tissue is organized into dense, spherical clusters, it forms lymphoid follicles or nodules. These are typically unencapsulated. Many of these are part of Mucosa-Associated Lymphoid Tissue (MALT), which collectively guards the body's mucous membranes.

Tonsils:
- Description: Ring-like arrangements of lymphoid tissue located in the pharynx (throat) region, forming a protective circle at the entrance to the digestive and respiratory tracts. They are covered by epithelium that invaginates to form blind-ended crypts, which trap bacteria and particulate matter, allowing immune cells to destroy them.
- Types:
  - Palatine Tonsils: Located at the posterior end of the oral cavity (the "tonsils" commonly removed). They are the largest and most often infected.
  - Lingual Tonsil: Located at the base of the tongue.
  - Pharyngeal Tonsil (Adenoids): Located on the posterior wall of the nasopharynx. When enlarged, they can obstruct breathing and are often referred to as "adenoids."
- Significance: Act as the first line of defense against inhaled and ingested pathogens, initiating immune responses locally.
Aggregated Lymphoid Follicles (Peyer's Patches):
- Description: Large, oval or elongated clusters of lymphoid follicles found in the wall of the distal part of the small intestine (ileum). They are strategically positioned to monitor the bacterial flora of the gut and prevent the growth of pathogenic bacteria.
- Significance: Crucial for immune surveillance in the intestine. They contain B cells that can differentiate into IgA-producing plasma cells, which secrete IgA antibodies into the gut lumen to neutralize pathogens. They also contain specialized M (microfold) cells that sample antigens from the gut lumen and present them to underlying immune cells.
Appendix (Vermiform Appendix):
- Description: A small, finger-like projection extending from the large intestine (cecum). Its wall contains a high concentration of lymphoid follicles.
- Significance: Thought to be a lymphoid organ that plays a role in gut immunity, possibly serving as a "safe house" for beneficial gut bacteria or a site for immune cell maturation. Its exact functions are still being fully elucidated, but its lymphoid tissue indicates an immune role.

III. Other Locations of Lymphoid Tissue

Bone Marrow: Not just a site for hematopoiesis (blood cell formation), but also a primary lymphoid organ where B lymphocytes mature and where all lymphocytes originate.
Spleen: The largest lymphoid organ, it contains vast amounts of lymphoid tissue (white pulp) for filtering blood and initiating immune responses.
Thymus Gland: A primary lymphoid organ where T lymphocytes mature and are "educated."
Liver and Lungs: While not considered primary lymphoid organs, they contain significant populations of immune cells (e.g., Kupffer cells in the liver, alveolar macrophages in the lungs) and diffuse lymphoid tissue that contribute to local immunity.

IV. General Significance of Lymphoid Tissue

Pathogen Surveillance: They constantly monitor for pathogens entering through various portals of entry (e.g., respiratory, digestive).
Immune Response Initiation: They provide sites where lymphocytes can encounter antigens, proliferate, and differentiate into effector cells (e.g., plasma cells, cytotoxic T cells) to combat infections.
Immunological Memory: They contribute to the development of immunological memory, allowing for a faster and stronger response upon subsequent exposure to the same pathogen.

The Spleen

The spleen is a soft, blood-rich organ that is unique among lymphoid organs because it filters blood, not lymph. Its complex internal structure allows it to perform diverse immunological and hematological functions.

I. Anatomy and Location

Location:
- The spleen is located in the upper left quadrant of the abdominal cavity, nestled inferior to the diaphragm, posterior to the stomach, and superior to the left kidney.
- It is typically between the 9th and 11th ribs. Its posterior surface is related to the diaphragm, and its medial surface to the stomach, left kidney, and tail of the pancreas.
- It is intraperitoneal, meaning it is almost entirely surrounded by peritoneum.
Size and Shape:
- Typically about 12 cm (5 inches) long, 7 cm (3 inches) wide, and 3-4 cm (1.5 inches) thick. It weighs about 150-200 grams in adults.
- It is oval-shaped, dark red-purple, and has a soft, friable (easily torn) consistency.
Capsule and Trabeculae:
- The spleen is enclosed by a thin, but relatively tough, fibrous capsule made of dense irregular connective tissue. This capsule also contains some smooth muscle cells, which can contract to help expel blood.
- Trabeculae extend inward from the capsule, dividing the spleen into compartments and providing structural support. They also carry blood vessels into the splenic pulp.
Hilum:
- The medial surface of the spleen has an indentation called the hilum, where the splenic artery (bringing blood to the spleen) and splenic vein (draining blood from the spleen) enter and exit, respectively. Lymphatic vessels and nerves also pass through the hilum.
Splenic Pulp:
- The internal substance of the spleen is called the splenic pulp, which is highly vascularized and consists of two main components:
  - White Pulp:
    - Description: Consists of spherical clusters of lymphoid tissue, primarily lymphocytes (T and B cells) surrounding central arteries. It appears as "white" spots on a gross section.
    - Composition:
      - Periarteriolar Lymphoid Sheath (PALS): Concentric rings of T lymphocytes surrounding a central arteriole.
      - Splenic Follicles: Nodules of B lymphocytes, often with germinal centers, located within the PALS.
    - Function: Involved in immune responses. It is the site where immunological reactions to blood-borne antigens occur.
  - Red Pulp:
    - Description: Surrounds the white pulp and makes up the bulk of the spleen. It is rich in blood, giving it a deep red color.
    - Composition:
      - Splenic Cords (Cords of Billroth): Networks of reticular connective tissue containing macrophages, lymphocytes, plasma cells, and red blood cells.
      - Splenic Sinuses (Sinusoids): Wide, leaky capillaries that separate the splenic cords. These sinusoids have a discontinuous basement membrane, allowing blood cells to easily move between the cords and sinuses.
    - Function: Primarily involved in filtering blood, removing old/damaged red blood cells and platelets, and storing blood.

II. Key Functions of the Spleen

Blood Filtration and Cleansing (Hematological Functions):
- Removal of Old/Damaged Red Blood Cells: As red blood cells age (typically after 120 days), they become less flexible and are unable to navigate the narrow splenic sinusoids and cords. Macrophages in the red pulp recognize and phagocytose these senescent or damaged red blood cells, breaking down hemoglobin and recycling iron. This is often called the "graveyard of red blood cells."
- Removal of Platelets: Similarly, old or damaged platelets are removed from circulation by macrophages in the spleen.
- Removal of Other Blood-borne Debris: Phagocytic cells in the spleen also remove cellular debris, microorganisms, and other particulate matter from the blood.
Immune Surveillance and Response (Immunological Functions):
- Immune Response to Blood-borne Pathogens: The white pulp of the spleen is analogous to a very large lymph node, but it filters blood instead of lymph. It provides a site for lymphocytes (T and B cells) and antigen-presenting cells to encounter blood-borne antigens (e.g., bacteria, viruses) and initiate specific immune responses.
- Antigen Presentation: Dendritic cells and macrophages in the white pulp present antigens to lymphocytes, leading to their activation.
- Lymphocyte Proliferation: Activated B and T cells proliferate in the white pulp, generating an army of immune cells.
- Antibody Production: Plasma cells generated in the spleen produce antibodies that are released into the bloodstream to target pathogens.
Blood Storage:
- Red Blood Cells and Platelets: The red pulp acts as a reservoir for blood. In some animals, the spleen can contract to release a significant volume of blood into circulation during hemorrhage or increased activity (though this function is less pronounced in humans). It also stores a considerable amount of platelets (up to 30-40% of the body's total platelet count).
- Monocytes: The spleen serves as a large reservoir for monocytes, which can be rapidly deployed to sites of tissue injury or infection.
Hematopoiesis (Fetal Life):
- Fetal Blood Cell Production: During fetal development, the spleen is an important site of hematopoiesis (blood cell formation).
- Adult Life (Pathological Conditions): In adults, the spleen generally does not produce red or white blood cells under normal conditions. However, in certain pathological conditions (e.g., severe anemia, myelofibrosis), it can resume its hematopoietic function (extramedullary hematopoiesis).

III. Clinical Significance

Splenomegaly: Enlargement of the spleen, often indicative of an underlying condition such as infection (e.g., mononucleosis), liver disease, or certain blood cancers.
Splenectomy: Surgical removal of the spleen. While individuals can live without a spleen, they become more susceptible to certain bacterial infections (particularly encapsulated bacteria like Streptococcus pneumoniae, Haemophilus influenzae type B, and Neisseria meningitidis) because the spleen is crucial for filtering these bacteria from the blood and initiating an early immune response.

Bone Marrow in the Lymphatic and Immune Systems

Bone marrow is a primary lymphoid organ, alongside the thymus, meaning it is where lymphocytes originate and mature. It is a highly vascular, soft, spongy tissue found in the medullary cavities of bones.

I. Anatomy and Location

Location:
- Found within the spongy (cancellous) bone and medullary cavities of long bones.
- In adults, red bone marrow (the active, hematopoietic type) is primarily found in the flat bones (sternum, ribs, vertebrae, pelvic bones, skull) and the epiphyses (ends) of long bones (femur, humerus).
- Yellow bone marrow (composed mostly of fat cells) replaces red marrow in the shafts of long bones during adolescence, though it can convert back to red marrow if needed (e.g., severe hemorrhage).
Composition:
- The primary cellular components are hematopoietic stem cells (HSCs), which are multipotent cells capable of differentiating into all types of blood cells, including immune cells.
- It also contains stromal cells (fibroblasts, adipocytes, endothelial cells, macrophages) that create the microenvironment (bone marrow niche) necessary for hematopoiesis and lymphocyte development.

II. Key Roles in the Lymphatic and Immune Systems

Bone marrow performs two fundamental and indispensable roles:

Site of Hematopoiesis (Origin of All Immune Cells):
- All Lymphocytes and Other Leukocytes Originate Here: Hematopoietic stem cells (HSCs) in the red bone marrow are the progenitors for all blood cells, including:
  - Lymphoid Stem Cells: These differentiate into B lymphocytes, T lymphocytes (though T cells leave the bone marrow to mature in the thymus), and Natural Killer (NK) cells.
  - Myeloid Stem Cells: These differentiate into all other white blood cells (leukocytes) that are crucial for innate immunity (Neutrophils, Eosinophils, Basophils, Monocytes) and Erythrocytes/Platelets.
- Continuous Production: The bone marrow continuously produces billions of new blood cells daily, ensuring a constant supply of immune cells to maintain the body's defense.
Site of B Lymphocyte Maturation:
- Primary Lymphoid Organ for B Cells: Unlike T cells, B lymphocytes undergo their entire maturation process (from lymphoid stem cell to immunocompetent, naive B cell) within the bone marrow.
- Development and Selection: During this process, B cells acquire their unique B cell receptors (BCRs) and undergo rigorous selection to ensure that they are functional and, crucially, self-tolerant (i.e., do not react against the body's own tissues).
- Release of Naive B Cells: Once mature, naive (antigen-inexperienced) B cells are released from the bone marrow into the bloodstream and lymphatic circulation, ready to encounter antigens in secondary lymphoid organs (like lymph nodes or the spleen).
Site of Long-Lived Plasma Cells and Memory B Cells:
- After an immune response, activated B cells can differentiate into long-lived plasma cells and memory B cells. A significant proportion of these long-lived cells migrate back to the bone marrow, where they reside for years or even decades.
- Long-Lived Plasma Cells: Continuously produce antibodies, providing long-term humoral immunity.
- Memory B Cells: Provide a rapid and robust secondary immune response upon re-exposure to the same antigen. The bone marrow acts as a crucial niche for the survival of these essential memory cells.

III. Clinical Significance

Bone Marrow Transplants: Used to treat various hematological disorders and cancers (e.g., leukemia, lymphoma) by replacing diseased or damaged bone marrow with healthy hematopoietic stem cells.
Immune Deficiencies: Dysfunction of the bone marrow can lead to severe immune deficiencies due to a lack of mature lymphocytes and other immune cells.
Autoimmune Diseases: Problems with B cell selection in the bone marrow can contribute to autoimmune diseases where B cells produce antibodies against self-antigens.

The Thymus Gland

The thymus is a primary lymphoid organ because it is the site of T-cell maturation and education. It is particularly active during childhood and adolescence, undergoing a process of involution (shrinkage) after puberty.

I. Structure and Location

Location:
- Located in the superior mediastinum, posterior to the sternum and anterior to the great vessels of the heart and the trachea.
- It partially overlies the superior part of the heart and its great vessels.
Size and Development:
- It is relatively large in infants and children, continuing to grow until puberty.
- After puberty, it begins to atrophy (shrink), a process called involution, where much of its lymphoid tissue is replaced by adipose (fat) tissue. While it becomes smaller, it remains functionally active throughout life, albeit at a reduced capacity.
Gross Anatomy:
- Typically bilobed (two lobes), connected by an isthmus.
- Enclosed by a fibrous capsule.
- The capsule sends trabeculae (septa) into the interior, dividing the lobes into numerous smaller compartments called lobules.
Microscopic Anatomy (within each lobule): Each lobule has two distinct regions:
- Cortex (Outer Region):
  - Composition: Densely packed with rapidly dividing T lymphocytes (thymocytes), macrophages, and specialized epithelial cells called thymic epithelial cells (TECs).
  - Function: This is the primary site for the initial stages of T-cell maturation and the first round of T-cell selection (positive selection).
- Medulla (Inner Region):
  - Composition: Less densely packed with thymocytes. It contains more mature T cells, dendritic cells, macrophages, and characteristic structures called thymic (Hassall's) corpuscles.
  - Thymic Corpuscles: Concentric layers of flattened, keratinized epithelial cells. Their exact function is not fully understood, but they may be involved in the final stages of T-cell maturation and the production of specific cytokines.
  - Function: This is where the crucial second round of T-cell selection (negative selection) occurs, and where mature, naive T cells exit the thymus.

II. Key Functions of the Thymus Gland

The thymus's primary function is the education and maturation of T lymphocytes (T cells). This process ensures that T cells are both functional and self-tolerant.

Site of T Lymphocyte Maturation:
- "Boot Camp" for T Cells: T cell precursors (pro-thymocytes) originate in the bone marrow and migrate to the thymus. Here, they are called thymocytes.
- Acquisition of T Cell Receptors (TCRs): Within the thymus, thymocytes undergo gene rearrangement to develop unique T cell receptors (TCRs) on their surface, which allow them to recognize specific antigens presented by other cells.
- Immunocompetence: The process by which T cells become able to recognize and bind to antigens presented by MHC (Major Histocompatibility Complex) molecules.
T-Cell Selection (Thymic Education):
- This is a highly rigorous and critical process, often described as "survival of the fittest," ensuring that the body's T-cell repertoire is effective but not harmful. Over 95% of thymocytes die during this process.
- Positive Selection (in Cortex):
  - Purpose: Ensures that T cells are capable of recognizing self-MHC molecules (MHC restriction).
  - Process: Thymocytes must successfully bind to MHC molecules presented by cortical thymic epithelial cells. T cells that bind too weakly or not at all undergo apoptosis (programmed cell death). This ensures the T cell will be able to interact with antigen-presenting cells later.
- Negative Selection (in Medulla):
  - Purpose: Ensures that T cells do not react too strongly against self-antigens presented by self-MHC molecules (self-tolerance). This prevents autoimmune reactions.
  - Process: Thymocytes that bind too strongly to self-peptide-MHC complexes presented by medullary thymic epithelial cells or dendritic cells undergo apoptosis. This eliminates potentially autoreactive T cells.
  - AIRE (Autoimmune Regulator) Gene: Medullary TECs express the AIRE gene, which allows them to present a wide array of "self" proteins from other parts of the body, thus educating T cells about self-antigens they might encounter elsewhere.
Hormone Production:
- Thymic epithelial cells produce several hormones, such as thymosin, thymopoietin, and thymulin, which are essential for the maturation and differentiation of T cells within the thymus.
Release of Naive T Cells:
- Only about 2-5% of the original thymocytes successfully pass both positive and negative selection. These "survivors" are mature, immunocompetent, and self-tolerant naive T cells.
- These mature T cells exit the thymus and populate secondary lymphoid organs (like lymph nodes and spleen), ready to encounter their specific antigens and participate in immune responses.

III. Clinical Significance

DiGeorge Syndrome: A congenital disorder where the thymus fails to develop, leading to a severe deficiency of T cells and profound immunodeficiency, making individuals highly susceptible to infections.
Thymoma: A tumor of the thymic epithelial cells. It can sometimes be associated with autoimmune diseases like myasthenia gravis.
Involution: While it shrinks, the thymus remains functionally important throughout life, continually supplying T cells, though at a reduced rate. Loss of thymic function early in life (e.g., due to disease or surgical removal) can significantly compromise the immune system.

Anatomy and Physiology of the Lymphatic System Read More »

INTRACRANIAL HEMORRHAGE

Causes of Intracranial Hemorrhage.

Pathophysiology:

Types of Intracranial Hemorrhage

Epidural Hematoma (Subgalea hemorrhage.

Subdural hematoma (SDH)

Subarachnoid hemorrhage

Intracerebral hemorrhage

Management

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