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Hyperaldosteronism

Hyperaldosteronism

Hyperaldosteronism 

Hyperaldosteronism refers to excessive levels of aldosterone.

Aldosteronism refers to an abnormal excess of aldosterone, a hormone produced by the adrenal glands. Aldosterone plays a big role in regulating sodium and water balance in the body, thereby influencing blood pressure.

Aldosterone is a major mineralocorticoid hormone produced by the adrenal gland,  in the zona glomerulosa, which is the outermost layer of the adrenal cortex. Aldosterone plays an important role in the regulation of sodium and water in the body, thereby maintaining and having an effect on blood pressure.

It is a type under ALDOSTERONISM, so therefore, let’s start from the very beginning.

Types of Aldosteronism (1)

Types of Aldosteronism

Aldosteronism is broadly classified into two categories:

1. Primary Hyperaldosteronism (Conn’s Syndrome):

This condition is characterized by excessive aldosterone production due to a problem within the adrenal glands themselves. This leads to sodium retention, potassium loss, and ultimately, a combination of hypokalemia (low potassium) and hypertension.

a) Causes:

  • Adrenal Adenoma (Conn’s Syndrome): This is the most common cause of primary hyperaldosteronism, accounting for approximately 60% of cases. It involves a benign tumor in the adrenal gland, leading to overproduction of aldosterone.

b) Clinical Presentation:

  • Hypertension: This is the most common symptom, often resistant to traditional antihypertensive medications.
  • Hypokalemia (<3.5 mmol/L): This is a characteristic feature, often leading to muscle weakness, fatigue, and even cramps or tetany (involuntary muscle contractions).
  • Nocturia: Frequent urination at night due to increased fluid retention.
  • Metabolic Alkalosis: The excess aldosterone can cause an imbalance in the body’s pH, leading to metabolic alkalosis.
  • Other Symptoms: Headaches, polydipsia (excessive thirst), and muscle weakness.

c) Diagnosis:

  • Elevated Serum Aldosterone: Measurement of aldosterone levels in the blood is the primary diagnostic tool.
  • Low Plasma Renin Activity: As aldosterone secretion is independent of renin in this case, renin levels are typically low.
  • Salt Loading Test: This test involves a high-salt diet followed by measurement of aldosterone levels. In primary aldosteronism, aldosterone levels remain elevated despite salt loading.
  • Renin-Aldosterone Stimulation Test: This test involves stimulating the renin-angiotensin system and assessing the response of aldosterone levels.
  • Imaging Studies: CT scan and MRI can be used to visualize the adrenal glands and identify any tumors.

d) Treatment and Management:

Surgical Removal (Adrenalectomy): This is the definitive treatment for adrenal adenomas, aiming to remove the tumor and restore normal aldosterone levels.

Medical Management:

  • Aldosterone Antagonists: Spironolactone (100-400mg daily) and eplerenone are effective in blocking the action of aldosterone and correcting hypokalemia.
  • Calcium Channel Blockers: Nefidipine can be used to control hypertension.
  • Steroid Replacement (Post-Surgery): Following adrenalectomy, patients may require lifelong steroid replacement therapy to prevent adrenal insufficiency. This may include medications such as:
  1. Hydrocortisone (Cortef)
  2. Cortisone acetate (Cortate)
  3. Prednisone (Deltasone)
  4. Prednisolone (Prelone)
  5. Triamcinolone (Kenalog)
  6. Betamethasone (Celestone)
  7. Fludrocortisone (Florinef)
  • Fluid Management: Maintaining adequate fluid intake is important, especially following surgery.
  • Blood Sugar Monitoring: Regular monitoring of blood sugar is recommended due to potential effects on glucose metabolism.
2. Secondary Hyperaldosteronism:

This condition occurs when there is an increase in aldosterone production as a result of factors outside the adrenal glands. It is essentially a compensatory mechanism triggered by other conditions that lead to increased renin activity.

a) Common Causes:

  • Renovascular Hypertension: Narrowing of the renal arteries, leading to reduced blood flow to the kidneys and activating the renin-angiotensin-aldosterone system.
  • Heart Failure: The heart’s inability to effectively pump blood can lead to reduced blood flow to the kidneys, triggering renin release.
  • Cirrhosis: Liver disease can impair the synthesis of renin, causing a compensatory increase in aldosterone.
  • Nephrotic Syndrome: This condition involves protein loss in urine, which can activate the renin-angiotensin-aldosterone system.
  • Malnutrition: Prolonged malnutrition can lead to a decrease in circulating sodium, triggering the renin-angiotensin-aldosterone system.
  • Pregnancy: During pregnancy, there is a natural increase in aldosterone levels.

b) Treatment:

Treatment for secondary hyperaldosteronism focuses on addressing the underlying cause:

  • Angiotensin-Converting Enzyme (ACE) Inhibitors: Captopril, enalapril, etc., are effective in blocking the production of Angiotensin II, which in turn reduces aldosterone levels.
  • Angiotensin II Receptor Blockers (ARBs): Losartan, etc., block the action of Angiotensin II, lowering blood pressure and aldosterone levels.
  • Spironolactone: Can be used to directly block the action of aldosterone.

Complications of Aldosteronism:

High Blood Pressure Complications: Persistent hypertension can lead to:

  • Heart attack
  • Heart failure
  • Stroke
  • Kidney disease or failure

Hypokalemia (Low Blood Potassium): Can cause:

  • Arrhythmias (irregular heartbeats)
  • Muscle cramps
  • Weakness
  • Fatigue
  • Paralysis

Other Complications:

  • Metabolic alkalosis
  • Kidney stones
  • Bone loss
  • Diabetes

Nursing Care Plan: Hyperaldosteronism

Patient Data: A patient diagnosed with hyperaldosteronism presents with hypertension, muscle weakness, fatigue, polyuria, polydipsia, and hypokalemia. Lab results show elevated aldosterone levels, low potassium levels, and metabolic alkalosis.

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Nursing Interventions

Rationale

Evaluation

Patient presents with persistent hypertension, headache, blurred vision, and increased blood pressure readings.

Decreased Cardiac Output related to hypertension and electrolyte imbalance as evidenced by elevated BP (e.g., 160/100 mmHg), palpitations, and headache.

– Patient’s blood pressure will be maintained within normal limits. 

– Patient will verbalize understanding of hypertension management. 

– Patient will adhere to prescribed antihypertensive medications.

1. Monitor blood pressure, heart rate, and signs of hypertensive crisis. 

2. Administer prescribed antihypertensive medications (e.g., spironolactone, calcium channel blockers). 

3. Educate the patient on lifestyle modifications (low-sodium diet, weight control). 

4. Monitor for complications like left ventricular hypertrophy and heart failure. 

5. Prepare the patient for surgical adrenalectomy if indicated.

1. Prevents complications from sustained hypertension. 

2. Spironolactone blocks aldosterone effects and helps control BP. 

3. Lifestyle changes enhance BP control and prevent worsening of symptoms. 

4. Early detection prevents cardiac complications. 

5. Surgery may be necessary for aldosterone-secreting tumors (Conn’s syndrome).

– Patient maintains stable BP without complications. 

– Patient verbalizes adherence to lifestyle and medication regimen.

Patient has hypokalemia as evidenced by muscle weakness, fatigue, leg cramps, and ECG changes.

Impaired water- electrolyte Imbalance related to excessive aldosterone secretion as evidenced by serum potassium <3.5 mEq/L and muscle weakness.

– Patient’s potassium levels will return to normal (3.5–5.0 mEq/L). 

– Patient will demonstrate knowledge of potassium-rich dietary sources. 

– Patient will remain free from cardiac arrhythmias.

1. Monitor serum potassium levels and ECG for arrhythmias. 

2. Administer potassium supplements as prescribed. 

3. Encourage potassium-rich foods (bananas, oranges, spinach). 

4. Educate about the importance of medication adherence (spironolactone to conserve potassium). 

5. Monitor urinary output and renal function.

1. Hypokalemia can cause life-threatening arrhythmias. 

2. Corrects potassium deficit and prevents complications. 

3. Helps maintain normal potassium levels naturally. 

4. Spironolactone prevents potassium loss by blocking aldosterone. 

5. Ensures potassium is not lost excessively through urine.

– Patient maintains normal potassium levels. 

– No signs of arrhythmias or muscle weakness. 

– Patient adheres to dietary recommendations.

Patient reports excessive thirst (polydipsia) and frequent urination (polyuria).

Inadequate Fluid Volume related to excessive urinary loss due to aldosterone excess as evidenced by increased urine output and dehydration signs.

– Patient’s fluid balance will be maintained. 

– Patient will report decreased thirst and normal urine output. 

– Patient’s serum sodium and potassium levels will remain within normal limits.

1. Monitor intake and output, daily weights, and signs of dehydration. 

2. Encourage adequate fluid intake unless contraindicated. 

3. Administer IV fluids (e.g., isotonic saline) if severe dehydration occurs. 

4. Educate patient on fluid replacement strategies. 

5. Monitor serum sodium levels to prevent hypernatremia.

1. Early detection of dehydration prevents complications. 

2. Prevents dehydration-related symptoms. 

3. IV fluids help restore intravascular volume. 

4. Prevents excessive thirst and compensatory fluid loss. 

5. Prevents sodium imbalances that can worsen symptoms.

– Patient maintains normal hydration. 

– No signs of excessive thirst or dehydration. 

– Serum sodium remains stable.

Patient expresses anxiety about condition and potential need for surgery.

Excessive Anxiety related to uncertainty about disease and treatment as evidenced by patient verbalizing concerns about long-term health and surgery.

– Patient will verbalize reduced anxiety. 

– Patient will demonstrate understanding of the condition and treatment. 

– Patient will actively participate in care decisions.

1. Assess anxiety level and provide emotional support. 

2. Educate the patient on hyperaldosteronism, treatment options, and expected outcomes. 

3. Encourage expression of fears and concerns. 

4. Provide information on surgical adrenalectomy if indicated. 

5. Offer relaxation techniques (deep breathing, guided imagery).

1. Helps identify the patient’s emotional needs. 

2. Increases understanding and reduces fear of the unknown. 

3. Promotes coping and psychological well-being. 

4. Helps patient make informed treatment decisions. 

5. Helps reduce stress and its physiological effects.

– Patient verbalizes reduced anxiety. 

– Patient demonstrates understanding of condition. 

– Patient actively participates in treatment.

Patient reports difficulty engaging in daily activities due to muscle weakness and fatigue.

Activity Intolerance related to hypokalemia-induced muscle weakness as evidenced by patient reporting fatigue and inability to perform normal activities.

– Patient will report improved energy levels. 

– Patient will tolerate activities of daily living without excessive fatigue. 

– Patient will participate in gradual activity progression.

1. Assess muscle strength, fatigue levels, and ability to perform daily activities. 

2. Encourage rest periods between activities. 

3. Provide a potassium-rich diet and encourage adherence to medications. 

4. Assist with activities as needed but encourage independence. 

5. Monitor for muscle cramps, arrhythmias, and weakness progression.

1. Identifies severity of fatigue and weakness. 

2. Prevents overexertion and worsening of symptoms. 

3. Correcting potassium levels restores muscle function. 

4. Promotes independence while ensuring safety. 

5. Early detection prevents severe complications.

– Patient tolerates daily activities without excessive fatigue.

 – Muscle strength improves.

 – No signs of severe weakness or arrhythmias.

NANDA 2024-26

Considerations

  • Medications: Spironolactone (Aldactone) as first-line treatment; Eplerenone as an alternative.
  • Surgical Treatment: Adrenalectomy for patients with unilateral adrenal adenomas.
  • Dietary Modifications: Potassium-rich, low-sodium diet to counteract aldosterone effects.
  • Monitoring: BP, electrolytes, renal function, and cardiac status.

Hyperaldosteronism Read More »

status epilepticus

Status Epilepticus

STATUS EPILEPTICUS

Status epilepticus is a seizure lasting for more than 30 minutes or one another without restoration of consciousness in between the fits.

Status epilepticus is defined as a generalized convulsion lasting 30 minutes or longer, or
repeated tonic-clonic convulsions occurring over a 30-minute period without recovery of consciousness between each convulsion.

This is considered as a complication of grand mal epilepsy rather than a certain type of epilepsy. It is both a medical and psychiatric emergency. This condition is life threatening and getting treatment started fast is vital.

Diagnosis

  1. Observation of a fit i.e. >  Body temperatures increases
    >   There is increased heart rate.
    >   Brain metabolic demand increases.
  2. History of a fit
  3. Neurological examination to check the reflexes
  4. Electro encephalogram may reveal epileptiform activity
  5. CT scan to reveal brain function
  6. Skull X-ray may indicate evidence of lesions
  7. Additional laboratory tests; >  Do random blood and sugar levels
    >   Blood slide for malaria.
    >   Urinalysis  >  Renal and liver function.
    >   Electrolytes.
    >   Calcium and magnesium. 

Triggers of an epileptic fit

  • Fevers in childhood
  • Sleep; convulsions during sleep may occur soon after the child wakes up from bed
  • Daylong or overnight fast
  • Emotional arousal e.g fear, anger, excitement etc
  • Flickering lights
  • Intoxication with alcohol
  • Alcohol withdrawal
  • Fatigue and boredom
  • High altitude
  • Discontinuation of anti convulsions
  •  Dehydration
  •  Infections
  •  Look for associated injuries.

Treatment and management of a Status Epilepticus.

An epileptic seizure is usually sudden and time to prepare for it is not there. It can occur at any time in any place.

Aims of management

  1. Avoid injury to the patient
  2. To prevent complications

Emergency management (First Aid)

  • Stay calm and speak calmly if you are to give instructions or when reassuring bystanders
  • Remove the person from danger or vice versa if the patient is safe, don’t move them.
  • Note the time the seizure starts and continue checking if it does not stop in 5 minutes, call for an ambulance.
  • Loosen ties, necklaces or any cloth around the neck that may make it hard to breathe
  • Support the head with a soft flat material under like a folded jacket so as to protect it from injury during jerking
  • Clear space to and minimise any form of crowdness such that the patient receives fresh air.
  • As soon as the fit stops, Make the patient lie down in a lateral position so as to ensure he does not choke on his own saliva
  • Check that breathing is returning to normal if their breathing sounds difficult after the seizure has stopped call for an ambulance
  • Check gently to see that nothing is blocking their airway such as false teeth.
  • Stay with the patient until when the patient is fully awake
  • After recovery, reorient the patient and reassure incase he is embarrassed

The following should not be done

  1. Don’t put any hard object like spoon in the mouth this can injure teeth or jaw.
  2. Don’t hold his limbs tightly because that prevents contraction and relaxation of muscles
  3. Don’t give anything to eat or drink until he is fully alert
  4. Do not try to give mouth to mouth breaths, people usually start breath again on their own after a seizure

Emergency Management (In hospital)

  1. Give oxygen to support respiration
  2.  If hypoglycaemia is suspected, give a bolus of 50ml of 50% glucose IV
  3.  Consider giving parenteral thiamine if alcohol abuse is suspected
  4.  Give anticonvulsants such as diazepam IV, lorazepam IV, clonazepam, midazolam
  5.  Give diazepam 5 — 10mg IV start. You may repeat after 10 —20 minutes. Do not exceed 30mg in 8 hours. Refer immediately if no improvement. For children, give 0.05 —0.3 mg per doze over 2
    — 3 minutes. Do not exceed 10 mg. Refer if no improvement.
  6.  Stow intravenous injection of Phenytoin may be given if seizures recur or fail to respond to Diazepam 30 minutes after it began
  7.  Phenytoin by Intravenous infusion should be given at a dose of I 5mg/kg body weight at a rate not greater than 50mg! minute.
  8.  Monitoring of blood pressure and ECG is necessary and phenytoin should be diluted with sodium chloride (normal saline) at a ratio of 1 mg of phenytoin 1 ml of normal saline
  9.  Supportive care and prompt termination of electrical seizure
  10.  Care is individualized
  11.  Supportive care including ABC’s should be provided.
  12. Establish aetiology. This is a common neurological
    problem in the elderly, with an underlying etiology of stroke. Status epilepticus is associated with a high mortality.
  13. Identify and treat medical complications:

Monitoring

  1.  Regular neurological observations and measurements of
    pulse, blood pressure, temperature.
  2.  ECG, blood gases, clotting, blood count, drug levels.
  3.  EEG monitoring is necessary for refractory status. Consider
    the possibility of non-epileptic status.

Prognosis
Aetiology and conscious level predict outcome.
>   If the patient presents for the first time with status
epilepticus, the chance of a structural brain lesion is
greater than 50%.

Education of caretakers and persons with status epilepticus

The following should be taught to the patient and the community at large

  • Status epilepticus is an illness just like any other illness and on treatment a person gets better
  • People with status epilepticus should be encouraged to enjoy as much as possible
  • Isolating, stigmatizing and labelling an epileptic patient is very traumatizing to the patient, family and clan members so they should be avoided
  • Children with status epilepticus are encouraged to attend school
  • Teachers, school children and other school personnel should be educated about the illness so that they are enlightened
  • Adults with status epilepticus can marry and should be encouraged to do so
  • Persons with epilepsy should avoid dangerous activities such as driving, climbing height, operating heavy machines, swimming
  • People have to be taught that Status epilepticus is not contagious so patients should be treated fairly like other people
  • Epileptic seizures can effectively be controlled if drugs are taken as prescribed.

Status epilepticus becomes an emergency only when;

  • The person has never had a seizure before
  • The person has difficulty breathing or walking after the seizure
  • The seizure lasts longer than 5 minutes
  • The person has another seizure soon after the first one
  • The person is hurt during the seizure
  • The seizure happens in water
  • The person has a health condition like diabetes, heart disease or is pregnant

Prevention of Status epilepticus

  • Prevent head injury by wearing seat belts and bicycle helmets.
  • Seek medical help Immediately after suffering a first seizure.
  • Mothers should be encouraged to get good prenatal care to prevent brain damage to a developing fetus
  • Treatment of hypertension
  • Avoid excess alcohol abuse and alcohol intake
  • Treating high fevers in children
  • Treatment of any infections and proper nutrition including adequate vitamin intake

Complications of Status epilepticus

Status epilepticus complications

Specific Nursing Care for a patient with Status Epilepticus

  1. Assessment and Monitoring:

    • Regularly monitor the patient’s vital signs, including heart rate, blood pressure, and oxygen saturation.
    • Continuously observe and document the duration, frequency, and characteristics of seizures.
    • Assess the patient’s level of consciousness and neurological status.
    • Maintain a safe environment by ensuring there are no obstacles that could harm the patient during a seizure.

  2. Administering Medications:

    • Administer antiepileptic drugs (AEDs) as prescribed, which may include intravenous (IV) or intramuscular (IM) medications such as lorazepam or diazepam to stop seizures.
    • Ensure proper dosages and monitor for any adverse reactions.

  3. Airway and Breathing:

    • Position the patient on their side to prevent aspiration if vomiting occurs during or after a seizure.
    • Administer supplemental oxygen if the patient experiences respiratory distress.

  4. IV Access:

    • Establish and maintain IV access to administer medications and fluids.

  5. Monitoring Blood Glucose:

    • Check blood glucose levels to rule out hypoglycemia, which can trigger seizures.

  6. Seizure Documentation:

    • Maintain accurate records of seizure activity, including the start and stop times, characteristics, and any associated symptoms.

  7. Support and Reassurance:

    • Provide emotional support and reassurance to the patient and their family.
    • Explain the ongoing care and treatment plan.

  8. Preventing Injuries:

    • Pad side rails and protect the patient from self-inflicted injuries during seizures.
    • Utilize soft restraints if necessary for safety.

  9. Neurological Assessment:

    • Continuously assess the patient’s neurological status, including pupil size, response to stimuli, and motor function.

  10. Consultation and Referral:

    • Consult with a neurologist or epilepsy specialist for further evaluation and management.

Status Epilepticus Read More »

Catatonic stupor syndrome in schizophrenic patients

Catatonic stupor syndrome in schizophrenic patients

Catatonic schizophrenia is also the same as catatonic stupor syndrome. So before we start with catatonic stupor, lets begin by understanding Schizophrenia 

SCHIZOPHRENIA

Introduction

Schizophrenia is one of the most severe forms of mental illnesses
which tend to run a downward trend. It affects 1% of the general
population.The term schizophrenia was coined in 1908 by Swish
Psychiatrist EugenBleuler. The word was derived from the Greek
word Schizo which means split and Phren – mind.

Definition

Schizophrenia is functional psychosis characterized by disturbance in thinking, emotion, volition and perception.
Schizophrenia is one of the major mental illnesses
characterized by disorder of thinking, perception and mood, deterioration of interpersonal relationship
Causes of Schizophrenia

The actual cause of schizophrenia is unknown (idiopathic) but some factors are associated with it.

  1.  Genes
    Studies show that relatives of individuals with schizophrenia have a much higher probability of developing the disease than does the general population.
    Twin studies indicated that the rate of schizophrenia among
    monozygotic (identical) twins is four times that of dizygotic
    (fraternal) twins.
  2.  Personality
    People who are withdrawn and having no friends and live solitary lives and those who prefer being isolated than in group are most likely to suffer from schizophrenia.
  3. Biochemical influences
    The theory stets that schizophrenia may be caused by an excess of dopamine dependent neuronal activity in the brain.
  4. Anatomical abnormalities
    Structural brain abnormalities have been observed in individuals with schizophrenia. For example: Ventricular enlargement is the most consistent finding. It is associated with cognitive impairment:
  5.  Physiological influences
    >   Viral infections.
    >   Birth injuries
    >   Alcohol abuse
    >   Cerebral vascular accidents
    >   Myxedema
    >   Parkinsonism
    >   Head at adulthood
    >   Cerebral tumour
  6. Psychological influences.
    >   Poor parent child relationships.
    >   Dysfunctional family systems
  7. Environmental influences
    Greater numbers of individuals from the lower socioeconomic
    classes experience symptoms of Schizophrenia than do the higher socioeconomic class or group. This explains:
    >   Poor living conditions
    >   Poverty
    >   Congested houses
    >   Inadequate nutrition
    >   Absence of prenatal care
    >   Feeling of hopelessness for changing ones life style.
    8. Stressful events
    Stress may contribute to the severity of and course of the illness

Types of Schizophrenia
1. Acute Schizophrenia
2. Chronic Schizophrenia

Subtypes of schizophrenia
  1.  Simple Schizophrenia
    >  gradual onset
    >   odd behaviours
    >   wandering tendency
    >   self absorbed
    >   idle and aimless activity are present
    >   solitary (isolated)
    >   usually occurs at late 20s or early 30s
  2.  Hebephrenic Schizophrenia (disorganized schizophrenia)
    This type of schizophrenia is marked by incoherence flat, incongruous or sill affect.
    >   onset is at age of 15 to 25 years
    >   insidious onset
    >   extreme social impairment
    >   poor premorbid personality
    >   runs a chronic course
    >   behaviour is regressive and primitive
    >   contact with reality is often lost or poor
    >   mood is often inappropriate
    >   silly laughter
    >   giggling
    >   facial grimaces
    >   bizarre mannerisms
    >   neglected hygiene
    >   social impairment is extreme
  3.  Paranoid Schizophrenia
    Is type of schizophrenia characterized by the presence of delusions of persecution or grandeur.
    >  Auditory hallucinations
    >  Individual is often suspicious
    >  Hostile
    >  Often tense
    >  Argumentative
    >  Aggressive
    >  Onset is mainly at 20s or 30s
    >  Less regression in mental faculties
    >  Emotional and behaviour is seen than in other subtypes
    4. Catatonic Schizophrenia
    Catatonic schizophrenia is characterized by marked abnormalities in motor behaviour and may manifest in form of stupor or excitement

Catatonic Stupor

Catatonia is characterized by an inability to move normally. The symptoms of catatonia can include:  Mutism, Negativism,  Waxy flexibility,  Bizarre positions may be assumed,  Patient is aware of what is taking place around him or her staying still i.e. the patient adapts to a rather uncomfortable positions and maintains it for long hours condition called waxy flexibility, lack of speech, abnormal movements

Catatonic Stupor is the lack of critical mental function and a level of consciousness where a patient is almost entirely unresponsive and only responds to base stimuli such as pain. Its occurrence in depression is called Depressive stupor

Catatonic Excitement:  Is manifested by a state of extreme psychomotor agitation. Excitement, Restlessness, Purposeless movement, Incoherent speech

Catatonic excitement
Symptoms of catatonic schizophrenia may include:
  •  Stupor (a state close to unconsciousness)
  • Catalepsy (trance seizure with rigid body)
  • Waxy flexibility (limbs stay in the position another person puts them in)
  • Mutism (lack of verbal response)
  • Negativism (lack of response stimuli or instruction)
  • Posturing (holding a posture that fights gravity)
  • Mannerism (odd and exaggerated movements)
  • Stereotypy (repetitive movements for no reason)
  • Agitation (not influenced by eternal stimuli)
  • Grimacing (contorted facial movements)
  • Echolalia (meaningless repetition of another person’s word)
  • Echopraxia (meaningless repetition of another person’s movements)
  • The catatonic state may be punctuated by times of polar opposite behaviors. For example, someone with catatonia may experience brief episodes of:
    >   Unexplained excitability
    >   Defiance

Causes of Catatonic Behavior
  •  Brain abnormalities: These include unusual activity in the brain including irregularities in neurotransmitter systems involving dopamine, glutamate, and gamma-aminobutyric acid
    (GABA).
  • Psychiatric conditions: Catatonia or catatonic behavior is a serious psychiatric condition that has historically been associated with schizophrenia, but it can be present in a variety of psychiatric conditions, including schizoaffective disorder, bipolar disorder, and major depressive disorder.
  • Substances and other medications: Catatonic behavior may also result from drugs, alcohol, and certain medications.
  • Medical conditions: Some other medical conditions can cause catatonic behavior or behaviors that can be mistaken for catatonia. Dystonia, encephalopathy, HIV, and renal failure are
    conditions that can potentially cause catatonia.
    Catatonic symptoms like facial contortions, strange limb movements, or unusual body positions can lead to a misdiagnosis of tardive dyskinesia or other movement disorders. Similarly, Tourette’s syndrome may be confused for catatonia due to some of the vocalizations that can be part of the syndrome.


Risk factors for catatonic schizophrenia
>   Family history is a risk factor for this condition.
>  However, a person’s own lifestyle and behavior may also be related i.e. catatonic schizophrenic
episodes have been linked to substance misuse.
Diagnosis of catatonic schizophrenia
There are no labs or tests to diagnose catatonic symptoms in schizophrenia. Catatonic behavior can also occur in other conditions such as autism and mood disorders, so a doctor will evaluate symptoms to determine what is causing them.
> EEG (electroencephalogram)
> MRI scan
> CT scan
> physical examination
> psychiatric examination (performed by a psychiatrist)
Catatonic schizophrenia treatment
Medication
Typically, the first step in treating catatonic schizophrenia is medication.
> Lorazepam
> Alprazolam (Xanax)
> Diazepam (Valium)
> Clorazepate (Tranxene)
Psychotherapy
Sometimes psychotherapy is combined with medication to teach coping skills and how to deal with stressful situations.
This treatment also aims to help people who have mental health issues associated with catatonia learn how to collaborate with their Health providers to manage their condition better.
ECT
ECT, formerly known as electroshock therapy, is increasingly used to effectively treat catatonia in schizophrenia and other psychiatric conditions.

General Clinical features of Schizophrenia

  •  Neglected personal hygiene
  • Patient is withdrawn into world of his own
  • Pack of interest in the environment
  • Hallucinations are common
  • Illusions are also present
  • Lack of drive or will power
  • Delusions of persecutory
  • Passivity thoughts are also common
  • Disturbed thoughts for example insertion, broadcasting and
    withdrawal
  • Disturbed behaviour
  • Disturbed mood
  • Disturbed speech: echolalia, neologism, ward salad, Incoherency
  • Flexibilitas Cerea (is the capacity (as in catalepsy) to maintain the limbs or other bodily parts in whatever position they have been placed.)
  • Catalepsy
  • Echopraxia
  • Anergia- deficiency in energy
  • Anhedonia- inability to express or experience pleasure.
  • Regression
Positive symptoms of schizophrenia

Positive signs and symptoms of schizophrenia refers to mental disturbances in the patient’s perception of reality that do not exist objectively. Positive symptoms make treatment seem  more urgent, and they can often be effectively treated with antipsychotic drugs. They include:

  • Delusions: These firmly held erroneous beliefs due to distortions or exaggerations of reasoning and/or misinterpretations of perceptions or experiences. Delusions of being followed or
    watched are common, as are beliefs that comments, radio or TV programs, etc., are directing special messages directly to him/her.
  • Hallucinations: These are distortions or exaggerations of perception in any of the senses, although auditory hallucinations (“hearing voices” within, distinct from one’s own thoughts) are the most common, followed by visual hallucinations.
  • Disorganized speech/thinking, also described as “thought
    disorder” or “loosening of associations,” is a key aspect of
    schizophrenia. Disorganized thinking is usually assessed primarily
    based on the person’s speech such as loosely associated, or
    incoherent speech, neologisms
  • Grossly disorganized behavior which includes difficulty in goal-directed behavior (leading to difficulties in activities of daily living), unpredictable agitation or silliness, social disinhibition, or behaviors that are bizarre to onlookers. Their purposelessness
    distinguishes them from unusual behavior prompted by delusional beliefs.
  • Catatonic behaviors are characterized by a marked decrease in reaction to the immediate surrounding environment, sometimes
    taking the form of motionless and apparent unawareness, rigid or
    bizarre postures, or aimless excess motor activity.
  • Other symptoms sometimes present in schizophrenia but not
    often enough to be definitional alone include affect inappropriate
    to the situation or stimuli, unusual motor behavior (pacing, rocking), depersonalization, derealization, and somatic
    preoccupations.
Negative symptoms of schizophrenia are;

Negative symptoms are the main reason patients with schizophrenia cannot live independently, hold jobs, establish
personal relationships, and manage everyday social situations.
These symptoms are also the ones that trouble them most

  • Affective flattening is the reduction in the range and intensity of emotional expression, including facial expression, voice tone, eye
    contact, and body language.
  • Alogia, or poverty of speech, is the lessening of speech fluency and productivity, thought to reflect slowing or blocked thoughts,
    and often manifested as short, empty replies to questions.
  • Avolition(will power) is the reduction, difficulty, or inability to initiate and persist in goal-directed behavior; it is often mistaken for apparent disinterest. (examples of avolition include: no longer interested in going out and meeting with friends, no longer interested in activities that the person used to show enthusiasm for, no longer interested in much of anything, sitting in the house for many hours a day doing nothing.)
  • Anhedonia: absence of pleasure in social activities.
  • Social withdrawal: Patient becomes socially isolated, loses
    interests in friends.


Good prognosis of Schizophrenia
>  Acute and later onset
>  Obvious precipitating factor
>  Good premorbid personality
>  Affective symptoms are present
>  Married
>  Family history of mood disorder
>  Good support system
>  Positive symptoms are present


Poor prognosis
>  Insidious and younger onset
>  No precipitating factors
>  Poor premorbid social and work history
>  Withdrawn
>  Single, divorced or widowed
>  Family history of schizophrenia
>  Poor support system
>  Negative symptoms.

Schneider’s first-rank symptoms of schizophrenia

are symptoms which, if present, are strongly suggestive of schizophrenia. They include:

  •  Auditory hallucinations:
    >  hearing thoughts spoken aloud
    >  hearing voices referring to himself / herself, made
    in the third person
    >  auditory hallucinations in the form of a
    commentary
  • Thought withdrawal, insertion and interruption
  • Thought broadcasting
  • Somatic hallucinations
  • Delusional perception
  • Feelings or actions experienced as made or influenced by
    external agents
Nursing diagnoses of patient suffering from schizophrenic
illness.


1. Altered sensory-perception (auditory hallucination) related to
schizophrenia as evidenced by patient seen communicating to
people other people do not see, hearing voices.


2. Altered thought process (delusions) related to schizophrenia
as evidenced by patient believing that people are against him.


3. Impaired communication (neologisms) related to the disorder as evidenced by patient talking language which other people do not understand.

4. Impaired social interaction related to the disorder as
evidenced by patient becoming isolated and been suspicious
of the next of kin.

Management of Schizophrenia

 Nursing Management

  1.  Build positive nurse patient relationship which is difficult in
    schizophrenia
  2. Let patient and relatives know about the nature of the illness.
  3. Reality orientation is maintained through out the illness or period.
  4. Ensure that patient’s basic needs are met
  5. Minimize risks resulting from psychotic symptoms ie hallucinations and delusions.
  6. Employ reality orientation approaches
  7. Avoid highly expressed emotions.
  8. Avoid criticisms
  9. Do not argue with a patient in case of delusions. This may aggravate the condition

 

 Collaborative care

  •  Nurse identifies problems which need collective team
    interventions for example administering psychotic drugs in case the patient is aggressive.
  • Care to ensure that the patient gets the treatment.
  • Drugs should be prescribed and monitor side effects. They
    may poor drug compliance
  • Plan care for over coming side effects of the drugs.


 Psychological management

  •  Occupational therapy
    Care offered by specialists such as occupational therapist. Teach
    social skills in ADL(Activities of daily living e.g brushing his teeth, using places of inconvenience, e.t.c ). This is the hall mark of schizophrenia.
  •  Psychotherapy
    Reassurance and counseling about the disorder. This requires
    patience on the side of the nurse.
  •  Group therapy
    Has been effective especially with out patients. It is less
    productive with in-patients.
  •  Behaviour therapy
    Modification reduces the frequency of bizarre disturbing deviant
    behaviour.
  •  Family and involvement of other parties (family and supportive
    therapy),  Involve the family, religious leaders, organizations and friends in the care of the patient especially in giving support to such patients.


 Electroconvulsive therapy: can be prescribed incase drugs
have not worked.


 Medical management
The common drugs used are:

  •  Chlorpromazine both tablet and injection: 75mgs-1500mg
    daily in divided doses
  •  Haloperidol both tablets and injection: short and long acting
  •  Trifluoperazine: 5-30 mg
  •  Thioridazine: 100-300mg preferably in old age because it is less sedating.
  •  Artane 2-5mg orally PRN to treat the side effects.


 Rehabilitation and social therapy
Social skills training- patient be engaged in activities that make
him work with others and socialize.
Habit training for correcting deteriorated habits especially for
patients with hebephrenic schizophrenia.


 Advice on discharge

  •  Support be given to the patient and family
  •  Take treatment as prescribed
  •  Avoid stigma or labeling the patient.
  •  Advice to take drugs to treat side effects of drugs
  •  In case of any problem should always report to the hospital.
  •  Use skills to generate income and to avoid being idle.
  •  Link the patient other organizations for any support for
    example schizophrenia fellowship.

Effects of schizophrenia

When the signs and symptoms of schizophrenia are ignored or
improperly treated, the effects can be devastating both to the
individual with the disorder and those around him or her. Some
of the possible effects of schizophrenia are:

  1.  Relationship problems. Relationships suffer because people
    with schizophrenia often withdraw and isolate themselves.
    Paranoia can also cause a person with schizophrenia to be suspicious of friends and family.
  2.  Disruption to normal daily activities. Schizophrenia causes
    significant disruptions to daily functioning, both because of social difficulties and because everyday tasks become hard, if not impossible to do. A schizophrenic person’s delusions,
    hallucinations, and disorganized thoughts typically prevent
    him or her from doing normal things like bathing, eating, or
    running errands.
  3.  Alcohol and drug abuse. People with schizophrenia frequently develop problems with alcohol or drugs, which are often used in an attempt to self-medicate, or relieve symptoms. In
    addition, they may also be heavy smokers, a complicating
    situation as cigarette smoke can interfere with the
    effectiveness of medications prescribed for the disorder.
  4.  Increased suicide risk. People with schizophrenia have a high
    risk of attempting suicide. Any suicidal talk, threats, or gestures should be taken very seriously. People with
    schizophrenia are especially likely to commit suicide during
    psychotic episodes, during periods of depression, and in the first six months after they’ve started treatment.
  5.  Increased expenses to the family since they may need to take
    medication for the rest of their lives.
  6.  Stigmatization: The patient of family may be stigmatized.
  7.  Social embarrassment: family or community may feel ashamed because of abnormal behaviour of the patients.
  8.  Crimes committed: sometimes they commit crimes because of their poor thinking and judgment.

Catatonic stupor syndrome in schizophrenic patients Read More »

Panic attacks/disorders

Panic Attacks and Disorders

Panic attack is a sudden surge of overwhelming anxiety and fear. 
OR  A panic attack is a sudden episode of intense fear that triggers severe physical reactions when there is no apparent cause

Panic Disorder is the recurrent and unexpected panic attacks and long periods in constant fear of another attack.

Cause of panic attacks

The cause of panic attack is unknown (idiopathic) but the following are thought to trigger panic attacks

  • Chronic (ongoing) stress – this causes the body to produce
    higher than usual levels of stress chemicals such as adrenaline.
  •  Acute stress (such as experiencing a traumatic event) – can
    suddenly flood the body with large amounts of stress chemicals.
  •  Intense physical exercise – for some people, this may cause
    extreme reactions.
  •  Illness – may cause physical changes.
  •  A sudden change of environment – such as walking into an
    overcrowded, hot or stuffy environment.
  • Physical causes like sexual abuse e.g. rape in children
  •  Genetic- is more frequent among relatives of patients with condition
  •  Personality e.g. introverts
  •  Stimulants e.g. use of cocaine
  •  Biochemical —Disturbances in neurotransmitters especially nor-adrenaline, serotonin and GABA
  •  Psychological —as a result of intra-psychic conflicts as a conditioned response —maladaptive learning.
  •  Recent life events e.g. failing of examinations
  •  Hypoglycemia
  •  Medication withdraw
  •  Mitral valve prolapse
  •  Hyperthyroidism

Signs and Symptoms of Panic Attacks

The signs and symptoms of a panic attack develop abruptly and usually reach their peak within 10 minutes.
 Most panic attacks end within 20 to 30 minutes, and they rarely last more than an hour.
A full-blown panic attack includes a combination of the following
signs and symptoms:

  •  Heart palpitations
  •  Chest pain
  • Sweating
  •  Nausea and stomach upset
  •  Numbness
  • Anxious and irrational thinking
  • A strong feeling of dread, danger or foreboding
  • Fear of going mad, losing control or dying
  • Feeling lightheaded and dizzy
  • Tingling and chills, particularly in the arms and hands
  • Trembling or shaking, sweating
  • Hot flushes
  • Accelerated heart rate
  • A feeling of constriction in the chest
  • Breathing difficulties, including shortness of breath or
    hyperventilation
  • Tense muscles
  • Dry mouth
  • Feelings of unreality and detachment from the
    environment.
Panic attack symptoms

Management of a Panic Attack

Panic attacks is psychiatric emergency that need quick action and team work

Aims of management
(a)  Reducing the frequency and intensity of the panic attacks
(b) Reducing anticipatory anxiety and agoraphobic avoidance
(c) Treating co-occurring psychiatric disorders
(d) Achieving full symptomatic remission


Actual management

  1.  The management depends on the cause of the panic attacks.
  2. The patient’s symptomatic status should be monitored each session such as with the use of rating scales and patients can also self monitor by keeping a daily diary of panic symptoms
  3. For uncomplicated panic disorder and only should be admitted if there is evidence of dangerous behavior i.e. withdraw symptoms form drugs, suicidal or homicidal ideation as they may occur in context of acute anxiety, fear of anxiety or its consequences
  4. Assess the risk of suicide in patient with panic disorder
  5. Patient’s with chest pain, dyspnea, palpitations or near syncope should be placed on oxygen and in supine or fowlers position
  6. Monitor the patient with pulse oximetry, electrocardiography(ECG)
  7. Education of the patient that their symptoms are neither from a serious medical condition nor from a psychotic disorder but rather from a chemical imbalance of fight and flight response
  8. Require frequent re assurance and explanation
  9. Provision of social services intervention which may provide supportive discussion and explore resources for outpatient care
  10. Cognitive behaviour therapy helps patient to understand how automatic thoughts and false beliefs/distortions lead to exaggerated emotional responses such as anxiety and can be more effective if started earlier
  11.  Behavioral therapy involves sequentially greater exposure of the patient to anxiety provoking stimuli and over patient to anxiety provoking stimuli and overtime patient becomes desensitized
    to experience relaxation techniques also help to control patients levels of anxiety.
  12. Teach the patient respiratory training can help patient to control hyperventilation during panic and to control anxiety with controlled breathing
  13.  Inform the patient of potential adverse reaction of specific drugs as well as a realistic time for expecting results and the likely duration of treatment.


Psychotherapy

  1. Explain to the patient and relatives that the symptoms are not due to any physical disease but due to mild psychological problem which can be effectively treated.
  2. Reassure the patient that many people have similar problems, its short lived
  3. Be supportive to the patient and to the relatives
  4. It’s important to advise the patient to reduce on alcohol and smoking because caffeine, alcohol and
    nicotine are potentially anxiety producing agents.


Nursing care

  1.  The nurse dealing with anxiety disorder patient should be careful in not allowing the patient to become dependent on the nursing staff. Too much dependence will interfere with the therapeutic relationship.
  2. Patients comfort and safety are nursing priorities
  3. In case of tensed up patients, trembling, sweating, the nurse should approach in a calm and quite environment to handle such patients.
  4. The nurse should educate the patient to accept the reality
  5. Exposure therapy —encouragement to return or remain in places of anxiety


Drug treatment

  1.  Anxiolytics
  2. Educate the patient regarding the importance of long term management with selective serotonin reuptake inhibitors and the psychotherapeutic techniques
  3. Benzodiazepines: They can achieve long term control of panic disorder but they but they are reserved for patients with refractory panic disorder and they should not be used as monotherapy in panic disorder.
    > They act quickly but carry the liability of physiologic and psychological dependence can be used
    with SSRI. They use clonazepam coz it has a longer half life the alprazolam which was discouraged due to high abuse/dependence
    >  Lorazepam 1- 2 mg 4 hourly
    >  Diazepam 10- 20 mg i.v
    >  Clonazepam 0.5 — 2mg once daily
  4. Antidepressants e.g.:
    >  Amitriptyline 25mg nocte to 50mg once daily
    >  Imipramine 25mg nocte
  5.  Tricyclics SSRI’S —selective serotonin reuptake inhibitors e.g.
    >  Fluoxetine 10 mg stat and 60 mg maintenance
    >   Sertraline 50mg once daily, 200mg once daily maintenance.

Panic Attacks and Disorders Read More »

AGGRESSION AND VIOLENCE

Aggression and Violence

Aggression: It is harsh physical or verbal action intended to harm or injure another person.     OR     Aggression is verbal expression of readiness to cause an attack with threats.

Violence: is threat with physical attack that results into harm.   OR    Violence is showing marked physical force causing harm being inflicted on another person or
object.

Causes of aggression and violence

  1.  Mental illnesses: Patient experiencing hallucinations where a patient may hear voices telling him/her to fight or may see the health service provide as a lion and so she is fighting in self defence.
    >  The patient may also be experiencing delusions for example a patient may be having persecutory delusions whereby she is suspecting her and planning to do evil to the patient so she gets violent in self-defense.
  2. Forced admission of a patient with mental illness
  3.  Forced discharges of patients who prefer to stay in hospital than going back to the community (institutional neurosis)
  4.  Forced procedures such as Female Genital Mutilation.
  5.  Delusions and hallucinations especially auditory or visual
    types.
  6.  Pre or post ictal phase of epilepsy
  7.  Boredom and being idle on the ward
  8.  Monotonous routine activities on the ward
  9.  The ward environment may be boring or filthy
  10.  Provocation: by fellow patients, Staff , friends or relatives
  11.  Lack of communication between patient and staff
  12.  Staff may not be therapeutic to the patient. Poor nurse- patient relationship or patient being neglected by the health service provider. 
  13.  Learnt behaviour from friends or parents.
  14.  Inherited from the parents (genetic)
  15.  Violent and aggressive behaviour is associated with hormonal
    dysfunction for example Cushing’s disease. (hyperthyroidism)
  16.  Common in poor families due to lack essentials for life.
  17.  Frustration i.e. if one does not know what to do.
  18. Impulsive behaviour might be the cause if there is history of such behaviour
  19.  Medication might have been forced so the patient looks at relatives as enemies
  20.  Alcohol and drug misuse
  21. Stigmatization by community members or family members whereby the patient is called such names like, “wire”, “zolo” hence making the patient become violent
  22. Lack of financial support to the patient to return to hospital for review as prescribed by the psychiatrist or lack of review due to negligence of relatives.
  23.  Peer group influence for example living with people who have naturally aggressive behaviour (learnt behaviour)

Indicators of violence and aggression

  •  Restlessness moving up and down unable to sit still
  •  Tense facial expression and body language
  • Verbal or physical threats
  • Loud voice
  • Abusive language
  • Disturbed sleep
  • Tendencies to move with harmful objects
  • Shouting
  • Use of obscenities
  • Argumentative.
  • Threats of homicide or suicide
  • Panic attacks
  • Disturbed thought process
  • Suspiciousness
  • Angry mood often inappropriate to the situation
  • Crying without any clear reason
  •  Isolated or withdrawn
  • Temper tantrums (sudden outbursts and falling off)
  •  Scolding or annoying others
  • Negativism- Doing the opposite of what is expected
  •  Quietness- Not being able to say anything due to too much anger

Management of Aggression and Violence

This is psychiatric emergency
Aims of management
1. To safe guide the public or patient.
2. To treat and monitor the patient.

  1. Admission:  Patient should be admitted on acute ward and ensuring there are no harmful objects near the vicinity, Remain calm when dealing with this patient.

  2. Assessment: Common observations eg vitals, specific and general. Any physical illness, Patients mental status
    > Risk of violence and aggression or indicators.
    >  Assess for possible causes of violence and aggression. If any
    try to eliminate the cause.
  3. Establish a positive nurse-patient relationship.
  4.  In case the patient is hospitalized do not take her by surprise, explain all the procedures you are
    going to do assure the individual of his or her security
  5.  As a health worker should try to understand why he patient is aggressive before resorting to
    restraining methods
  6.  Show the aggressive patients that you are in control of the situation
  7.  Welcome the patient on the ward and address her by her name.
  8.  Move towards the patient with open hands
  9.  Talk to the patient and hear her response. Be firm and kind
  10.  Ensure that there is enough man power to help you in case the patient gets more violent
  11.  If the patient is chained, remove the chains and observe patient’s response
  12.  Ensure that there is no weapon or dangerous tool available before approaching the patient.
    Remove any dangerous objects such as knives by requesting the patient to place them on the
    table or floor.
  13. Distract the patient’s attention as the rest of the manpower is getting close to the patient to
    restrain her.
  14.  Make sure that in the process of restraining nobody is hurt. Also minimize damage to property.
  15.  The patient should be approached convincingly but if he/she is still resistant, should be put on the bed swiftly or on the floor where he must readily be immobilized.
  16.  Restraining the Patient, Firmly hold the joints and limbs in firm position so as to avoid fractures and dislocation or
    hurting/injuries.
  17.  Observe if the patient is still aggressive or violent. Ask if patient can promise not to repeat the behaviours
  18.  Administer sedatives or tranquilizers if available in injection form. i.e. diazepam 10mg to 20mg
    t.d.s
  19.  If still the same, put him/her in the side room (seclusion room) and indicate the duration of the
    seclusion.
  20.  Observe if still aggressive or violent, if yes repeat the sedation
  21.  Make plans to release the patient
  22.  Gradually tell the patient to avoid aggression and violence and avoid provoking situations
  23.  The nurse should talk to the patient to promise that he will not resort to violence if released back
    to his freedom.
  24.  The clinical team should discuss the future of the patient
Management after Discharge (while at home)
  •  Encourage family members to support the patient
  •  Community should be taught about the dangers of stigmatisation
  •  Relatives should be educated about the signs of aggression and violence so that early intervention can be made.
  •  Patient should be told to control emotions and be taught the skill of stress management
  •  Advise family members to always refer patient when he becomes violent or aggressive.

NURSING CARE

  • Avoid touching the patient when he becomes violent
  • Set or establish contract with the patient that he will not become violent
  •  Help the patient to establish the true cause of anger.
  •  If possible ignore initial derogatory remarks by the patient.
  •  Encourage the client to keep records of angry feelings that
    triggered him to become violent and how they were handled.
  •  Continuous observation of client for escalation of anger.
  •  Ensure sufficient staff are available.
  •  If becomes violent call for assistance and remove all other patients from the immediate environment

Physical Restraint

If not calmed down.

  •  Approach the client from in front with open hands to indicate
    no signs of harm.
  •  Call the patient by names when approaching him or her.
  •  Let patient express his feelings
  •  Ensure that patient and staff are not injured during the restraint. Do not sit on the patient. Ensure that patients are not involved in the restraint.
  •  Do not lift the patient when taking him to the side room. Let the patient walk to the seclusion room.
  •  Seclude the patient for specific period and indicate the reasons and goals of managing him in the side room.
  •  Continue observing if he has calmed down. If so remove him but if not continue to seclude with treatment.


Chemotherapy

  • Administer medication to calm the patient down. The drugs
    include: Tranquillizers for example chlorpromazine,
    haloperidol. Sedatives are also important for example
    diazepam intramuscularly.
  •  Document your care

Aggression and Violence Read More »

suicide , coronavirus, virus-4983590.jpg

Suicide and Suicidal Behaviour

Suicide

Suicide is the deliberate act of ending one’s life

Suicide refers to deliberate act of self harm that result into death.

Reasons for committing suicide
  • To solve problems like adultery for his/her spouse, poverty, stigma, discrimination,
  • To harm others incase of anger to parents decisions for children.
  • To end life in-case of terminal illnesses e.g. Newly diagnosed HIV, cancer
Conditions which predispose to suicide
  • Schizophrenia
  •  Hysteria
  •  Dementia: is an organic degenerative psychiatric disorder characterized by progressive deterioration of cognitive functions of an individual.
  •  PTSD
  •  Rape and defilement

Other risk factors include;

  • Depression with suicidal feelings
  • Family history of suicide attempts
  • Exposure to violence
  • Impulsivity [acting without thinking]
  • Aggressive or disruptive behaviour
  • Assess to fire arms and other harmful objects
  • Bullying and teasing at school
  • Feelings of hopeless or helpless
  • Acute loss or rejection
  • Death of a loved one
  • Loss of boyfriend of girlfriend
  • Humiliation by family members or friends
  • Trouble with the law
  • Failure at school
  • Alcohol and drug abuse
  • Sexual harassment
  • Chronic illness
  • Family disruption
  • Other mental disorders such as schizophrenia and PTSD

Methods of suicide

  •  Hanging
  •  Poisoning
  • Intentional accidents, gunshots, drowning
  •  Intentional rupturing of the main arteries e.g. radial artery
  •  Drug over dose
  • Self Starvation
Suicidal tendencies/ behavior

This is the act of an individual to harbor suicidal ideas, gestures or behavior.

Suicidal attempt

Is a psychiatric emergency characterized by trial to commit suicide but survives or fails.

MANAGEMENT OF SUICIDE ATTEMPT

Suicide attempt is a psychiatric emergency and therefore collaborative interventions should be implemented.

Aims of management:
(1). To prevent self harm.
(2). To restore the patient’s functional state.
(3). To restore patient’s self esteem.

  1. Establish a positive nurse patient relationship, that will help you in dealing with the patient i.e. attain the patient’s cooperation and trust.
     Immediately sign a caution card for such a patient for easy observation. The patient should be handed over and taken
    over physically using a caution card.
  2. Immediate admission of the patient to an isolated room while taking brief history and waiting for the doctor.
  3. Create a safe environment for the patient i.e. remove all potentially harmful objects from the patient’s vicinity e.g. sharp objects, belts, glass items, drug tray.
  4. Immediate assessment of the patient for; Vital observations, physical injuries of the patient and if they are life threatening we give urgent emergency treatment i.e. arresting of hemorrhage incase ruptured arteries, if cyanotic administration of prescribed oxygen, gastric lavage for ingested poison, immobilization incase of fractures.
  5. Also observe patient’s behavior’s like talking about ending his or her life (suicide).Handling dangerous objects, Refusing food,
    Accumulating drugs, Giving away property, Observe feeding since some starve themselves to death, and observe sleep pattern.
  6. Assess the patient’s mental status by interviewing the patient, attendants or family member to identify any underlying mental illnesses.
  7. Administration of prescribed drugs while re-assuring the patient if conscious
    >  Hydrocortisone 100mg to 200mg 3 times to 4 times incase of poisoning         > Chlorpromazine 100mg nocte incase psychosis induced suicidal attempt
    >   Amitriptyline 75mg nocte incase of depression induced attempted suicide
    >  Prophylactic antibiotics e.g. cloxacillin 500mg qid for 5 days incase of wounds.
  8. Chemotherapy 97% of patients with suicidal tendencies have depression hence give;
    > Antidepressants: e.g. Laroxyl 25mg-75mg ddd, Imipramine
    25mg-75mg ddd
    > Mood stabilizers e.g. Carbamazepine, Lithium carbonate,
    Sodium valproate
  9. The psychiatrist may order for therapeutic modalities to the patient e.g.
    >  ECT incase of severe depression, 2-3 shocks per week.
    >  Cognitive therapy incase of maladaptive feelings and behaviors
    > Psychotherapy e.g. group therapy, cognitive therapy, individual therapy, family therapy, Occupational therapy to divert the mind from the worries.

Nursing Concerns

  1.  Encourage the patient to express his feelings including anger.
  2.  Enhance self esteem of the patient by focusing on his strengths rather than his weaknesses.
  3. Rehabilitation to acquire skills to earn a living.
  4. Occupation of the patient in different activities like board games, football e.t.c to divert his mindset from suicidal thoughts
  5. Diet: provision of foods liked by the patient to stimulate his appetite
  6. Ensuring 24 hour around the clock close monitoring and observation of the patient
  7. Minimizing the number of nurses caring for this patient
  8.  Ensuring a good nurse patient relationship
  9.  Teaching the patient relaxation techniques incase of stress
  10.  Involvement of family members in the management of this patient i.e.
    >  Advising them to keep out reach items that the patient might use to harm herself
    >  Advise them to avoid being discriminative and be more of supportive to patient’s adaptation
    of suicide free life

Advice on Discharge.

  •  Patient should take treatment as prescribed.
  •  Patient should come back for review.
  •  Report any side effects to the nearest health center.
  •  Avoid psychosocial stresses others that may cause relapse.
  •  Avoid abuse of addictive drugs and alcohol.
  •  Family involvement in supporting the patient.
  •  Advise community and family members not to isolate the
    patient.
Prevention.
  1.  Patient should be properly managed in hospital i.e. show a
    good attitude to the patient while in hospital.
  2.  Early identification of problems that may cause mental health
    disorders.
  3.  Early and proper treatment of physical and psychological
    problems
  4.  Teach the community about factors that contribute to mental
    and physical illness.
  5.  People should learn to plan for their lives i.e. not someone to plan for them.
  6.  People should learn to be job creators but not job seekers.
  7.  Avoid harsh punishments to children.
  8.  People should learn to deal with difficult situations and
    effective copying mechanisms and stress management skills.
  9.  Counseling to people with social and physical health
    problems.
  10.  People should learn to share problems.
  11. Family should be helped to stay together.

Suicide and Suicidal Behaviour Read More »

research

Research

Introduction to research

Research is the systematic collection, analysis and interpretation of data to answer a certain question or solve a problem

Research is a term derived from the combination of two words: “re” and “search.” “Re” is a prefix meaning “again” or “anew,” and “search” is a verb signifying a close and careful examination, testing, probing, or trying. When combined, research becomes a noun describing a meticulous, systematic, and persistent study and investigation in a specific field of knowledge, carried out to establish facts or principles.

Research can also be defined as;

Research is an investigative process aimed at finding reliable solutions to problems through a systematic selection, collection, analysis, and interpretation of data related to the issue at hand.

 It encompasses all activities that enable us to discover new knowledge about the world around us. The process of research involves defining and redefining problems, formulating theories or suggested solutions, collecting, organizing, and evaluating data, making deductions and reaching conclusions, and rigorously testing those conclusions against the formulated hypothesis or theory.

Can also be defined as;

  • A search for knowledge.
  • A careful investigation or inquiry especially through search for new facts in any branch of knowledge.
  • A systematized effort to gain new knowledge.
  • It is an organized investigation of a problem.
  • It is a planned, systematic search for information for the purpose of increasing the total body of man’s knowledge.
  • A careful inquiry or examination, seeking facts or principles, a diligent investigation to ascertain something.
Purpose of research
  1. Finding answers to questions or solutions to problems.
  2. Discovering and interpreting new facts.
  3. Testing theories to revise accepted theories or laws in the light of new facts.
  4. Formulation of new theories.
  5. To test existing knowledge and theories.
  6. To determine the frequency and associations of events or phenomena.
  7. To provide a reliable guide or framework for decision-making.
  8. To predict, explain, and interpret behavior or occurrences.
  9. To expand the existing knowledge base and add to the collective understanding.
  10. To propose and implement solutions to problems and challenges.
  11. To achieve academic qualifications and enhance expertise.

CHARACTERISTICS OF RESEARCH

For research to be credible and valuable, it should possess the following characteristics:

  1. Clear purpose: The research must have a well-defined and specific objective.
  2. Transparent procedure: The methods and procedures used in the research should be described in sufficient detail to enable others to replicate the study.
  3. Objective design: The research design should be carefully planned to minimize bias and produce objective results.
  4. Honesty and truthfulness: Research findings should be reported with complete honesty and without distortion.
  5. Adequate data analysis: The data analysis should be appropriate and sufficient to reveal the significance of the findings.
  6. Validity and reliability: The data collected should be valid and reliable, ensuring the accuracy of the results.
  7. Generalizability: The research should be applicable and relevant beyond the specific study population.
  8. Limited and justifiable conclusions: Conclusions should be based solely on the data obtained from the research and should be well-supported.

Other characteristics include;

  • Directed towards the solution of a problem.
  • Emphasizes the generalizations of principles or theories
  • Demands accurate observations and description
  • Involves gathering new data from primary or first hand source or existing data for a new purpose.
  • Carefully designed
  • Requiring expertise
  • Striving to be objective and logical
  • Involves the quest for answers to unresolved problems
  • Involves patient and unharried activity
  • Carefully recorded and reported
  • Sometimes requiring courage

TYPES OF RESEARCH

  1. Applied research
  2. Basic research
  3. Correlational research
  4. Descriptive research
  5. Ethnographic research
  6. Experimental research
  7.  Exploratory research
  8.  Grounded theory research
  9.  Historical research
  10. Phenomenological research

APPLIED RESEARCH: Refers to the scientific study that solves practical problems. Applied research is used to find solutions to every day problems, cure illness and develop innovative technologies, rather than to acquire knowledge for the knowledge’s sake. E.g. improve agricultural crop production, Treat or cure specific diseases

BASIC REASEARCH:  It is driven by a scientist’s curiosity or interest in a scientific question. The main motivation is to expand man’s knowledge, not to create or invent something.
There is no obvious commercial value to the discoveries from results from basic research E.g. How did the universe begin ?, What is the specific genetic code of a fruit fly ?

CORRELATIONAL RESEARCH: Refers to the systematic investigation or statistical study of relationships among two or more variables without necessarily determining the cause and effect. It seeks to establish a relation/association/correlation between two or more variables. E.g. testing whether listening to music lowers blood pressure levels i.e. assign the groups to experimental and control

DESCRIPTIVE RESEARCH:  Refers to research that provides an accurate portrayal of characteristics of a particular individual, situation, or group. It is also known as statistical research, these studies are a means of discovering new meaning, describing what exists, determining the
the frequency with which something occurs, and categorizing information. E.g Finding the most frequent disease that affects
children of a given town.

ETHNOGRAPHIC RESEARCH:  Refers to an investigation of culture through an in-depth study of the members of the culture; It involves systematic collection, description, and analysis of data for development of theories of cultural behavior

EXPERIMENTAL RESEARCH:  

Refers to an objective, systematic, controlled investigation for the purpose of predicting and controlling phenomena and examining probability and causality among selected variables. E.g determining the efficacy of a particular drug in population

EXPLORATORY RESEARCH:  Is the type of research conducted for a problem that has not been clearly defined. Exploratory
research helps to determine the best research design, data collection method, and selection of subjects. The results of exploratory research are not usually useful for decision making by themselves, but they can provide significant insight into a given situation. It is not typically generalizable to the population
at large.

GROUNDED THEORY RESEARCH:  Is a research approach designed to discover what problems exist in a given social environment and
how persons involved handle them; It involves formulation, testing and reformulation of propositions until a theory is developed. Grounded theory is the research method operates almost in reverse fashion from
traditional research at first may appear to be in contradiction with to the scientific method.

HISTORICAL RESEARCH:  This is research involving analysis of events that occurred in remote or recent past. Historical research can show patterns that occurred in the past and over time which can help us to see where we came from and what kind of solutions we used in the past.

PHENOMENALOGICAL RESEARCH:  It is an inductive, descriptive research
approach developed from phenomenological philosophy; its aim is to describe an experience as it actually lived by the person. Phenomenology is concerned with the study of experience from the perspectives of the individuals.

 

Types of Research by Classification

Research can be classified into three main categories:

I. Classification by Purpose
  • Basic (Pure) research
  • Applied research
  • Action research
  • Evaluation research
Basic (Pure) Research
  • This is concerned with the production of results and findings which lead to the development of theory.
  • The primary motive is to expand one’s knowledge. This research is not involved in the creation and expansion of anything.
  • There are not any apparent commercial values to the discoveries that are associated with pure research.
Applied Research
  • This is conducted for the purpose of applying or testing theory and evaluating its usefulness in solving problems.
  • It is concerned with the usefulness of ideas or theories or practical situations.
  • The goal of the researcher is to bring about improvements and transformations within the human conditions.
  • In this research, it is the main duty of the researchers to investigate the ways that may bring about improvements and transformations, aiming at productivity and profitability.
Action Research
  • Advances the aims of basic and applied research to the point of utilization.
  • Concerned with the production of results for immediate application or utilization.
  • It improves practices and methods and generates technologies and innovations for application to specific technological situations.
  • Emphasis is here and now.
Evaluation Research
  • This involves the generation of results in research that help in decision making.
  • It looks at what was set to be done, what has been achieved, and thereafter makes a decision on what next steps need to be done.
II. Classification by Method
  • Historical research
  • Descriptive research
  • Analytical research
  • Correlational research
  • Experimental research
Historical Research
  • Historical research can show patterns that occurred in the past and over time, which can help us to see where we came from and what kinds of solutions we have used in the past.
  • Understanding this can add perspective on how we examine current events and educational practices.
Descriptive Research
  • Refers to research that provides an accurate portrayal of characteristics of a particular individual, situation, or group. Descriptive research, also known as statistical research.
  • These studies are a means of discovering new meaning, describing what exists, determining the frequency with which something occurs, and categorizing information.
  • In short, descriptive research deals with everything that can be counted and studied, which has an impact on the lives of the people it deals with. For example, finding the most frequent disease that affects the children of a town. The reader of the research will know what to do to prevent that disease thus, more people will live a healthy life.
Correlational Research
  • Refers to the systematic investigation or statistical study of relationships among two or more variables, without necessarily determining cause and effect.
  • Seeks to establish a relation/association/correlation between two or more variables that do not readily lend themselves to experimental manipulation.
  • For example, to test the hypothesis “Listening to music lowers blood pressure levels,” there are 2 ways of conducting research:
    1. Experimental – group samples and make one group listen to music and then compare the blood pressure levels.
    2. Survey – ask people how they feel? How often they listen? And then compare.
Analytical Research
  • Whereas as descriptive research attempts to determine, describe, or identify what is, analytical research attempts to establish why it is that way or how it came to be.
  • Analytical research looks at the association and the statistical significance of that occupancy.
Experimental Research
  • Is an objective, systematic, controlled investigation for the purpose of predicting and controlling phenomena and examining probability and causality among selected variables.
III. Classification based on the Approach
  • Qualitative research
  • Quantitative research
  • Mixed approach
Qualitative Research
  • Understanding of human behavior and the reasons that govern such behavior, involves analysis of data using words (e.g., from interviews), pictures (e.g., video), or objects (e.g., an artifact).
  • Qualitative research is research dealing with phenomena that are difficult or impossible to quantify mathematically, such as beliefs, meanings, attributes, and symbols.
  • Qualitative researchers aim to gather an in-depth understanding of human behavior and the reasons that govern such behavior.
  • The qualitative method investigates the why and how of decision making, not just what, where, when.
Quantitative Research
  • Involves analysis of numerical data and their relationship.
  • Quantitative research is generally made using scientific methods, which can include:
    • The generation of models, theories, and hypotheses.
    • The development of instruments and methods for measurement.
    • Experimental control and manipulation of variables.
    • Collection of empirical data.
    • Modeling and analysis of data.
    • Evaluation of results.
Mixed Method Approach
  • Qualitative + Quantitative.
  • Employs the use of numerical data and boosts them by the in-depth understanding of such occurrences.
REASONS FOR STUDYING RESEARCH
  1. Promote basic knowledge for infrastructure management including drug treatment, nursing or medical management of disease or health care.
  2. Development of new tools e.g drugs, vaccines, diagnostic tools etc.
  3. Informs public regarding research findings to emulate in health practice and lifestyles to maintain their health.
  4. Effective planning. It provides data for better management.
NEED FOR RESEARCH IN NURSING
  1. Molding the attitudes and intellectual competence and technical skills.
  2. Filling the gaps in the knowledge and practice
  3. Fostering a commitment accountability to clients
  4. Providing basis for professionalism
  5. Providing basis for professional accountability
  6. Identifying the role of nurse in changing society
  7. Discovering new measures for nursing practice
  8. Helping to take prompt decisions by the administration to relate problems
  9. Helping to improve standards in nursing education
  10. Refining existing theories and discovering new theories
Main benefits of research
  1. Development of a critical and scientific attitude
  2. Provides the chance to study a subject in depth
  3. Getting to know how to use library
  4. Learning to assess nursing/medical literature critically
  5. Development of special interest and skills
  6. Understanding the attitude of others whether in routine or research laboratories
  7. Academic awards.
Nurse’s responsibility in relation to research

All registered nurses should:

  • Read and interpret reports of research in their own nursing fields.
  • Identify areas of nursing where research is needed.
  • Collaborate intelligently with researchers.
  • Discuss with patients any research in which they are being asked to participate.

PRINCIPLES OF A GOOD RESEARCH

  • A clear statement of research aims, which defines the research question
  • Consenting all the respondents prior to research beginning
  • The methodology is appropriate to the research question
  • The research should be carried out in an unbiased fashion
  • The research should have appropriate and sufficient resources in terms of people, time, transport, money etc. allocated to it right from the start.
  • The people conducting the research should be trained in research and research methods
  • Those involved in designing, conducting, analyzing and supervising the research(supervisors) should have a full understanding of the subject area.
  • The researcher should have experience of working in the area
  • If applicable, the information generated from the research should inform the policy-making process.
  • All research should be ethical and not harmful in any way to the participants.

Research techniques

  1. Qualitative research
  2. Quantitative research

Qualitative research, refers to any research based on something that is impossible to accurately and precisely measure. For example, although you certainly can conduct a survey on job satisfaction and afterwards say that the percent of your respondents were very satisfied with their jobs, it is not possible to come up with an accurate, standard numerical scale to measure the level of job satisfaction precisely.

Quantitative research,  also called empirical research, refers to any research based on something that can be accurately and precisely measured. It deals with numbers i.e. data is presented in statistics like percentages like (heart rate, temperature, etc)

Differences between qualitative and quantitative research

research

Research Read More »

Concepts of Primary Health Care phc and cbhc

Concepts of Primary Health Care

Concepts of Primary Health Care – PHC

  1.  Essential Health Care: This is the care that meets the local needs of majority that enable individual to live a  socially and economically productive life.
  2.  Practically, scientifically sound methods and technology: The health care system should be able to solve the health problems in that community.
  3.  Accessibility Health Care: The services to promote health in the community should be easily reachable by individual / community.
  4.  Full community participation and involvement: The community should acquire responsibility for their own health and welfare in the community (in other words, the community members should not be left out) in any activities. When people are involved in organizing, planning, prioritizing, implementing, monitoring and evaluation, these services then will be socially acceptable and sustainable.
  5. Affordability of Health care: The cost of health care and its maintenance should be cheap and easily met by the community and country.
  6. Self-Reliance: The community should be independent, confident and trusting itself by doing from passive recipients to active partners with government/ Non –government and donors thus the community,
    government should be able to maintain (sustain) PHC activities without external interference.
  7. Self-determination: The community should be able to decide on its own and take action on matter concerning their own health and development.
  8. Integration: All sectors work together towards social economic development of the community with health as a nucleus in order to promote the health status of the people and refer where necessary.

INTRODUCTION TO PRIMARY HEALTH CARE

Historical Background of PHC

  • In 1976, Haldan T Mahlar of Denmark (who was by then the WHO Director General) proposed the goal of “health for all by the year 2000”. This was during the World health Organization assembly.
  •  The international conference on primary health care took place at Alma-Ata was the capital of the soviet republic of Kazakhstan located in the Asiatic region of the Soviet Union (Russia). The conference was attended by 300 delegates from 134 governments and 67 international organizations from all over the world.
  •  The 3rd world health assembly that took place in Geneva in 1979 endorsed the conference as declaration i.e. the declaration of Alma-Ata (WHO 1978). This declaration highlighted a minimum set of activities
    considered essential if there were to be implemented. These set of activities were later the components of PHC.
  •  Primary health care was endorsed by all countries attending a world conference in Alma-Ata,  USSR (Russia) as an approach to reach the goal of HFA/2000 (WHO, UNICEF 1978).

Definition According to World Health Organization WHO :

WHO defines PHC as essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individual and families in the community through their full participation and at the cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

Primary Health Care is different in each community depending upon:

  • Needs of the residents;
  • Availability of health care providers;
  •  The communities geographic location; 
  •  Proximity to other health care services in the area.
Levels of PHC
Primary health care
  •  The “first” level of contact between the individual and the health system.
  •  Essential health care (PHC) is provided.
  •  A majority of prevailing health problems can be satisfactorily managed.
  •  They are closest to the people.
  •  Provided by the primary health centers.
  • This is the care provided by nurses, clinical officers, and village health teams.
  • These include(Uganda) Health centers up to HC3, Private clinics, Community church based medical centers.
Secondary health care
  •  More complex problems are dealt with.
  •  Comprises curative services
  •  Provided by the district hospitals
  •  The 1st referral level
  • At this level, physicians and health care team carry out assessment and also treat health problems, and at this level, minor surgeries can be carried out.
  • These include Health Centre 4’s, KCCA Hospitals and district based hospitals.
Tertiary health care
  •  Offers super-specialist care
  •  Provided by regional/central level institution.
  •  Provide training programs
  • At this level, is where specialists are responsible for giving care and where major surgeries are performed.
  • These include Regional Referral Hospitals, All regional and national hospitals acting as Teaching and Training Hospitals, National Referral Hospitals, Specialist medical centers.

Concepts of Primary Health Care – PHC

  1.  Essential Health Care: This is the care that meets the local needs of majority that enable individual to live a  socially and economically productive life.
  2.  Practically, scientifically sound methods and technology: The health care system should be able to solve the health problems in that community.
  3.  Accessibility Health Care: The services to promote health in the community should be easily reachable by individual / community.
  4.  Full community participation and involvement: The community should acquire responsibility for their own health and welfare in the community (in other words, the community members should not be left out) in any activities. When people are involved in organizing, planning, prioritizing, implementing, monitoring and evaluation, these services then will be socially acceptable and sustainable.
  5. Affordability of Health care: The cost of health care and its maintenance should be cheap and easily met by the community and country.
  6. Self-Reliance: The community should be independent, confident and trusting itself by doing from passive recipients to active partners with government/ Non –government and donors thus the community,
    government should be able to maintain (sustain) PHC activities without external interference.
  7. Self-determination: The community should be able to decide on its own and take action on matter concerning their own health and development.
  8. Integration: All sectors work together towards social economic development of the community with health as a nucleus in order to promote the health status of the people and refer where necessary.

Principles of Primary Health Care

There are 6 basic principles identified in the primary health care approach.

  1.  Equitable distribution.
  2.  Man power development
  3.  Community participation.
  4.  Appropriate technology.
  5.  Multi-Sectoral approach.
  6.  Self-reliance.

1. Equitable distribution: This means that health services must be shared equally by all people irrespective of their social, economic, cultural and religious differences. All the people- the rich or poor, the urban or rural must have access to health services. So this principle is to address the imbalance currently in health care by distributing the health care budget to rural areas other than concentrating the budget only in cities.
2. Manpower development: Primary health care aims at mobilizing the human potential of the entire country by making use of available resources. This ensures that there is availability of adequate number of appropriate health personnel required to devise and implement plan and action. The strategies required
would be re-orientation of the existing health workers development of new categories of workers in health, motivation and training of all manpower to serve the community.
3. Community participation: This is a process by which individuals, families and communities assume responsibility in promoting their own health and welfare. To promote the development of the community and community’s self-reliance, residents themselves need to participate in decisions about their health in
the community. Community members and health workers/providers need to work together in partnership to seek solutions to the complex problems facing communities today.
4. Appropriate technology: Is technology that is sound scientifically, flexible and adaptable to the community’s local needs, acceptable to those who use it and to it is used to (served), and it can be maintained by the community people themselves in keeping with the principle of self-reliance, using the resources the community has and can afford. Refers to health care that is relevant to people’s health needs and concerns as well as being acceptable to them. It includes issues of costs and affordability of services within the context of existing resources i.e. the number and type of health professionals’ equipment, and their pattern of distribution throughout the community. Appropriate technology means a technology which requires low capital investment, conserves natural resources, is managed by its users and is in harmony with the environment.
5. Multisectoral approach: Health and family welfare programs cannot stand on their own in an isolated manner. It is recognized that the health of a community cannot be improved within just the health sector; other sectors are equally important in promoting the community’s health and self-reliance, These sectors
include, agriculture, animal husbandry, education, housing, public works, communication, water, environment, rural development, cooperatives, industries etc. These sectors need to work together in a multi-sectoral partnership to coordinate their goals, plans and activities to ensure that they contribute to
the health of the community and to avoid conflicting or duplicity efforts.
6. Self-reliance: this principle self-reliance applies at the three client level of individual family and community.
PHC practitioners play a major role in helping people achieve self-reliance in relation to their health care through community participation and involvement. This means the individuals, families and or communities are encouraged to change the attitude of being passive recipients to active partners with or without government or donor support.

Pillars of Primary Health Care

  1.  Community participation; this is very important for PHC programs to be socially acceptable and sustainable. Community participation is a process whereby the individuals and families assume  responsibility for their own health and that of their community. The community can participate by providing resources e.g. finances and raw material like bricks, sand, stones etc.
  2.  Intersectoral/multi-sectoral partnership: there is no sector which works in isolation but the activity one sector has influence on the other e.g. agriculture, water and sanitation, finance etc.
  3. Equity – all the people irrespective of color, tribe, race, nationality in every country should have access to essential health care.
  4.  Appropriate Technology: This is the technology which is scientifically sound, adaptable to local needs, culturally acceptable and financially feasible
  5. Political and social support; political leaders must be committed in policy formation, resource mobilization and allocation and mobilization of the community to support PHC programs.
    Positive Effects of political will:
    >  Policy making
    >  Monitoring and evaluation of PHC activities.
    >  Ensure adequate budgetary allocation
    >  Mobilization that is made from up (top) to bottom
    > Ensuring priority plans at different levels to reflect PHC characteristics, elements and pillars
    >  Active involvement and participation
    >  Setting aside a day for observing PHC e.g. PHC Day.
    Negative Effects of political will:
    >  Embezzlement of funds
    >  Civil wars
    >  Self centeredness
    >  Delay of service delivery due to top – bottom approach.
    >  Conflict ideas.
    >  Need to get high salaries by the political leaders

Elements or Components of PHC

  1.  Education concerning prevailing health problems including the methods of preventing or controlling them. (Health education). This was a broad component and each country was supposed to make strategies for its implementation. For example in Uganda; STI/HIV/AIDS, Malaria, Tuberculosis and epidemics have a priority in the health education department – MOB.
  2. Promotion of safe food supply and proper nutrition: this involves the process of improving food production, processing, storage, marketing, preparation and consumption with the ultimate goal of improving the nutritional status as well as economy of the community. Education is necessary especially on cultural beliefs and practices on nutrition for proper nutrition.
  3.  Provision of adequate safe water supply and proper sanitation.
    >  The quality of water sources and their availability in the communities.
    >  Sanitation involves control of those factors in total human environment that has a bearing to the health e.g. housing for proper sanitation, more emphasis is put on;
    >   Latrine coverage.
    >   Refuse disposal,
    >   Sewage management
  4.  Provision of maternal child health and family planning: These are health services rendered to mothers and children through ante-natal, maternity, post natal, family planning clinic; with the aim of improving the life of the mother and child. Most of the donor funding in form of conditional grants is targeted to this component so that the services are subsidized in terms of costs.
  5.  Provision of immunization against major infectious diseases: This gets a lion’s share on the donor funding than other components. WHO/UNICEF & CDC have been spearheading immunization worldwide. In Uganda 8 diseases are immunized i.e. poliomyelitis, tuberculosis, measles, diphtheria, whooping cough (pertussis), tetanus, hemophilic influenza type B and hepatitis B under EPI. Other vaccines like pneumococcal and Rotavirus are proposed to be included in EPI. The Human Papilloma Virus (HPV) against Cervical Cancer is also being introduced.
  6.  Prevention and control of locally endemic diseases: Special programs have been established to eradicate these endemic diseases e.g.
    >  Malaria- malaria control program.
    >  Leprosy and Tuberculosis- TB/Leprosy control program.
    >  Onchocerciasis.
    >  Schistosomiasis.
    >  Guinea worm.
  7.  Appropriate treatment of common diseases and minor injuries: this involves; Establishing of primary health centers i.e. HC II, III and IV with qualified health professionals. Establishment of home based care
    through community health workers(CHW) who should be trained to treat and for refer to the next level of service delivery.
  8.  Provision of essential drugs: The aim is to supply the community with the most needed drugs that meet the community’s needs. This also depends on the level of the health facilities or health service delivery.
    NB: These 8 elements of PHC were the first and original under the declaration of Alma-Ata conference. 

In case of Uganda, more components have been added
These include;

9.   Dental health and oral care
>  Oral hygiene education.
>  Prevention of oral and dental diseases.
>  Treatment of dental diseases.
10.  Mental health (community mental health): This is directed to care and rehabilitate the mentally sick in their community and prevention of mental illness.
11.  Rehabilitative health services (physically and mentally handicapped): Those services are provided by the community based rehabilitation programs to help PLW/PLWDs to live an independent life, earning and feel important and acceptable to the community.
12. STI/HIV/AIDS prevention and care. Efforts are geared to prevention and control of STI/HIV infection and treatment and care of the sick.
13.  Eye care (primary comprehensive eye care)
>   To prevent eye related problems in the community through health education.
>   Treatment and referral of patients with eye related problems in the community.

Concepts of Primary Health Care Read More »

Anaemia

Anaemia in Pregnancy

ANAEMIA IN PREGNANCY

Anaemia during pregnancy refers to a condition where the red blood cell count or haemoglobin  level in the mother’s blood is lower than normal. Anaemia in pregnancy is defined as haemoglobin (Hb) concentration is less than 11 g/dl.

Anaemia means a reduction in oxygen carrying capacity or in quantity of red blood cells. Red blood cells carry oxygen throughout the body, and low levels can lead to oxygen deprivation for both the mother and developing fetus.

This may be due to:

  • A reduction in the number of red blood cells.
  • A low concentration haemoglobin .
  • A combination of both
Classification or degree of anaemia (1)

Classifications/Degrees of Anaemia

  • Mild anaemia: haemoglobin  levels between 9.0 and 10.9 g/dL.
  • Moderate anaemia: haemoglobin  levels between 7.8 and 9.0 g/dL.
  • Severe anaemia: haemoglobin  levels below 7.0 g/dL.
  • Very Severe anaemia: haemoglobin  levels below 4.0 g/dL.
Causes of anaemia in Pregnancy

Causes of anaemia in Pregnancy

1. Social and Economic Factors:

  • Ignorance about utilizing food: Lack of knowledge about nutritious food sources and dietary practices, especially for iron-rich foods.
  • Poverty: Inability to afford a balanced diet rich in protein, iron, and other essential nutrients.
  • Unstable country / Insecurity: Conflict, displacement, and lack of access to healthcare resources can contribute to malnutrition and anaemia.
  • Beliefs and Cultural Superstitions: Certain cultural beliefs or practices might restrict the consumption of essential foods like chicken, eggs, or other iron-rich sources.

2. Obstetrical Causes:

  • Frequent childbearing: Closely spaced pregnancies can deplete iron stores, making anaemia more likely.
  • Repeated Hemodilution: The blood volume expands significantly during pregnancy to accommodate the needs of the growing fetus. This expansion can dilute the existing red blood cells, leading to lower haemoglobin  levels even if the body is producing enough red blood cells.
  • Multiple Pregnancy: The fetus requires iron for growth and development. The mother also needs extra iron to support the increased blood volume and oxygen delivery. This increased demand can deplete iron stores, leading to iron-deficiency anaemia.
  • Hyperemesis Gravidarum: Severe morning sickness can lead to poor absorption of nutrients, including vitamin B12, which is crucial for red blood cell production.
  • Abortions, Ruptured Ectopic Pregnancies, Postpartum Hemorrhage (PPH), Antepartum Hemorrhage (APH), and Heavy Periods: These conditions can lead to blood loss and iron deficiency.

3. Medical Causes:

  • Frequent Attacks of Malaria: Malaria infection destroys red blood cells, contributing to anaemia.
  • Hookworm Infestation: Hookworms can cause blood loss from the intestines, leading to iron deficiency anaemia.
  • Infections: Infections like septicemia (blood poisoning) and tuberculosis (TB) can impair red blood cell production.
  • Sickle Cell anaemia: A genetic blood disorder characterized by abnormal red blood cells, leading to chronic anaemia.
  • Drugs: Certain medications like chloramphenicol can interfere with red blood cell production and contribute to anaemia.

Other Factors

  • Dietary Deficiencies: Inadequate intake of iron, folate, and vitamin B12 are common contributing factors to anaemia.
  • Underlying Medical Conditions: Conditions like celiac disease, chronic kidney disease, or certain types of cancer can impair the body’s ability to produce red blood cells.
  • Previous anaemia: Women with a history of anaemia before pregnancy are more likely to experience it again.

Types of Anaemia

  1. Physiological anaemia.
  2. Nutritional anaemia.
  3. Aplastic anaemia.
  4. Haemorrhagic anaemia.
  5. Haemolytic anaemia.
  6. Pernicious anaemia.

1.  Physiological Anaemia: A temporary, physiological decrease in haemoglobin levels, often during pregnancy. This type of anaemia is considered “normal” during pregnancy and is primarily due to hemodilution. As the blood volume increases by 25-30% during pregnancy to accommodate the growing fetus, the concentration of red blood cells (and haemoglobin) appears to decrease, leading to a diluted blood picture.

  • Hemodilution: During pregnancy, blood volume increases significantly, diluting the haemoglobin concentration. This is a normal adaptation to support the growing fetus and placenta.
  • Increased Iron Demand: The growing fetus requires a substantial amount of iron for development, potentially leading to a temporary iron deficiency.
  • Physiological anaemia is usually mild and resolves itself after childbirth. 

2. Nutritional Anaemia: Anaemia caused by dietary deficiencies of essential nutrients required for RBC production. Nutritional anaemia can present as;

  • Iron Deficiency Anaemia: The most common type, caused by insufficient iron intake or absorption. Iron is essential for haemoglobin synthesis. Inadequate iron leads to smaller, paler RBCs (hypochromic microcytic anaemia). The increased fetal demand for iron, especially from the 28th week onwards, exacerbates this issue. Excessive morning sickness can also contribute by reducing iron absorption.
  • Folate Deficiency Anaemia (Megaloblastic Anaemia): A lack of folate (vitamin B9) disrupts DNA synthesis, leading to the formation of large, immature RBCs (megaloblasts). These cells are less effective at carrying oxygen.
  • Vitamin B12 Deficiency Anaemia (Pernicious Anaemia): A deficiency in vitamin B12, important for DNA synthesis and maturation of RBCs, results in megaloblastic anaemia. A lack of protein can also contribute to this type.
  • Vitamin C Deficiency: Vitamin C is important for iron absorption. Its deficiency can worsen iron deficiency anaemia.
  • Impact: Nutritional anaemia is preventable and treatable with dietary modifications and supplementation.

3. Aplastic Anaemia: A rare and serious condition characterized by the suppression of bone marrow activity, resulting in reduced production of all blood cell types, including RBCs. The most common cause being Bone Marrow Failure, The bone marrow, responsible for blood cell production, becomes unable to generate enough RBCs. This can be caused by various factors, including:

  • Drug-induced: Prolonged use of certain medications like chloramphenicol can suppress bone marrow function.
  • Radiation Exposure: Exposure to ionizing radiation can suppress bone marrow function, since they can damage bone marrow cells.
  • Diseases: Conditions like leukemia, cancer, and autoimmune diseases can affect bone marrow activity.
  • Toxins: Exposure to toxic chemicals can damage bone marrow cells.
  • Aplastic anaemia can be life-threatening. It requires immediate medical attention and may necessitate bone marrow transplantation or other intensive treatments.

4. Hemorrhagic anaemia: Anaemia resulting from excessive blood loss, leading to a reduction in circulating RBCs. This type results from excessive blood loss, which can occur due to a variety of reasons:

  • Frequent Childbearing: Closely spaced pregnancies can deplete iron stores and increase the risk of blood loss during delivery.
  • Worm Infestations: Hookworm infestation can lead to chronic blood loss from the intestines.
  • Abortions, PPH, and APH: These conditions can lead to significant blood loss.
  • Ruptured Ectopic Pregnancy: A ruptured ectopic pregnancy can cause internal bleeding.
  • Trauma and Accidents: Trauma or accidents can cause severe blood loss.
  • Gastrointestinal Bleeding: Conditions like ulcers, gastritis, and esophageal varices can cause internal bleeding.
  • Acute Blood Loss: Sudden and significant blood loss, often due to trauma, surgery, or internal bleeding, causes a rapid decrease in RBCs.
  • Chronic Blood Loss: Persistent, slow blood loss, often from gastrointestinal bleeding or heavy menstrual periods, gradually depletes the body’s iron stores and reduces RBC production.
  • Hemorrhagic anaemia can be severe, particularly in cases of acute blood loss. Treatment focuses on stopping the bleeding and replacing lost blood.

5. Hemolytic anaemia: Anaemia caused by the premature destruction of RBCs (hemolysis), leading to a shortage of healthy RBCs in circulation. This may be due to,

Intrinsic Defects: Hemolysis can be caused by abnormalities within the RBCs themselves, such as:

  • Sickle Cell Disease: This genetic disorder leads to the production of abnormal red blood cells that are easily destroyed. An inherited disorder where RBCs adopt a sickle shape, making them fragile and prone to destruction.
  • Thalassemia: Genetic disorders that impair haemoglobin production, leading to weakened RBCs.

Extrinsic Factors: Factors outside the RBC can also trigger hemolysis:

  • Infections: Infections like septicemia, pyelonephritis, and bacterial streptococcal infections can destroy red blood cells.
  • Diseases: Malaria is a common cause of hemolytic anaemia due to its destruction of red blood cells.
  • Mismatched Blood Transfusion: Receiving mismatched blood can lead to an immune reaction that destroys red blood cells.
  • Immune Reactions: Antibodies against RBCs, often due to blood transfusions or autoimmune disorders, can cause hemolysis.
  • Drugs: Certain medications like primaquine can cause hemolytic anaemia.

6. Pernicious anaemia: A specific type of megaloblastic anaemia caused by a deficiency in vitamin B12, usually due to a lack of intrinsic factor, a protein produced in the stomach that helps the body absorb vitamin B12. Pernicious anaemia is less common during childbearing years, but can occur due to:

  • Autoimmune Destruction of Parietal Cells: In most cases, pernicious anaemia is caused by an autoimmune attack on the parietal cells in the stomach, leading to a deficiency of intrinsic factor.
  • Diseases of the Stomach: Conditions like stomach cancer can interfere with intrinsic factor production.
  • Hyperemesis Gravidarum: Severe morning sickness can lead to vitamin B12 deficiency due to poor absorption.
  • Gastrectomy or Gastric Bypass Surgery: These procedures can reduce intrinsic factor production, impairing vitamin B12 absorption.
  • Other Causes: Conditions like Crohn’s disease and celiac disease can also interfere with vitamin B12 absorption.
Anaemia in pregnancy

Signs and Symptoms of Anaemia in Pregnancy

Anaemia’s signs and symptoms can vary depending on the severity and underlying cause. 

On History Taking

  • General Body Weakness: This is usually the most common symptom, resulting from the body’s reduced oxygen-carrying capacity.
  • Dizziness and Faintness: Reduced blood flow to the brain can cause lightheadedness and a feeling of faintness.
  • Palpitations: The heart may beat faster to compensate for the reduced oxygen supply.
  • Loss of Appetite (Anorexia): A decrease in appetite can be associated with anaemia.
  • Headaches: Headaches can be caused by reduced oxygen to the brain.
  • Breathlessness: The lungs may work harder to deliver oxygen to the body’s tissues.
  • Shortness of Breath: Increased effort for the heart to pump oxygenated blood.
  • History of Heavy Bleeding: A history of significant blood loss, such as from trauma, surgery, or gastrointestinal bleeding, can be a contributing factor.

On Examination

  • Pale Mucous Membranes and Conjunctiva: This refers to the paleness of the gums, lips, tongue, soles of the feet, and palms of the hands, which are visible indicators of reduced haemoglobin.
  • Distention of the Jugular Veins: This can be seen in severe cases of anaemia due to a decrease in blood volume.
  • Edema (Swelling): Swelling of the ankles, feet, or even generalized edema can occur in severe cases.
  • Enlarged Spleen and Liver: Palpation of the abdomen might reveal an enlarged spleen and liver, indicating an increase in red blood cell destruction or storage.
  • Jaundice: Yellowing of the skin and whites of the eyes can occur in some types of anaemia, particularly those related to red blood cell breakdown.
  • Cold Hands and Feet: Poor blood flow can lead to cold extremities.

Laboratory Tests

  • Haemoglobin Level: The most crucial test for anaemia, measuring the amount of haemoglobin in the blood. Levels below 12.5 g/dL are generally considered anaemic.
  • Increased Susceptibility to Infections: A weakened immune system makes pregnant women more prone to infections.

Diagnosis

Anaemia diagnosis relies on a combination of factors:

  • History: A detailed history of the patient’s symptoms, diet, medical history, medications, and potential exposures helps narrow down the possible causes.
  • Physical Examination: Careful assessment for physical signs like pallor, edema, and enlarged organs provides further clues.
  • Laboratory Investigations:
  • Haemoglobin Estimation: Confirming a low haemoglobin level.
  • Packed Cell Volume (PCV): Measures the percentage of red blood cells in the blood.
  • Blood Film: Examining the shape, size, and maturity of red blood cells, identifying specific features like:
  • Microcytosis and Hypochromia: Small, pale red blood cells (iron deficiency)
  • Megaloblastic Cells: Large, immature red blood cells (vitamin B12 and folate deficiency)
  • Sickle Cells: Abnormal, crescent-shaped red blood cells (sickle cell anaemia)
  • Target Cells: Red blood cells with a bullseye appearance (thalassemia)
  • Reticulocytes: Immature red blood cells (indicating red blood cell production)
  • Blood Sugar (BS) for Malarial Parasites: To rule out malaria, a common cause of anaemia in certain regions.
  • Sickling Test: To confirm the presence of sickle cells in cases of suspected sickle cell disease.
  • Coombs Test: To detect antibodies against red blood cells, suggesting autoimmune hemolytic anaemia.
  • Bone Marrow Examination: To assess the bone marrow’s ability to produce red blood cells and identify any abnormalities.
  • Urinalysis: To check for protein, indicating kidney damage, and to examine for red blood cells or other abnormalities.
  • Stool Examination: To identify intestinal parasites like hookworms, which can cause anaemia.
  • Haemoglobin Electrophoresis: To confirm sickle cell disease.

Iron Requirements During Pregnancy

  • Increase in Maternal Haemoglobin (400-500 mg): The mother’s blood volume expands significantly during pregnancy, requiring an increased production of red blood cells, which in turn need iron to carry oxygen.
  • The Fetus and Placenta (300-400 mg): The growing fetus requires iron for its own red blood cell production and development. The placenta also needs iron for its own functioning and to support fetal growth.
  • Replacement of Daily Loss (250 mg): Iron is lost daily through urine, stool, and skin. This loss needs to be replenished to maintain adequate iron stores.
  • Replacement of Blood Lost at Delivery (200 mg): Labour and delivery can involve significant blood loss, requiring iron replenishment afterwards.

Total Iron Needs: These factors contribute to a total iron requirement of approximately 1,500 mg during pregnancy.

Other Essential Nutrients:

  • Elemental Iron: Recommended daily intake is 30 mg to 60 mg for pregnant women.
  • Folic Acid: Recommended daily intake is 400 µg (0.4 mg) to prevent neural tube defects in the fetus.

Effects of anaemia on pregnancy and labour

Effects on Pregnancy:

General Body Fatigue: Anaemia leads to decreased oxygen carrying capacity, causing widespread fatigue, breathlessness, palpitations, and headaches.

Placental Insufficiency: Reduced oxygen delivery to the placenta can lead to:

  • Intra-Uterine Fetal Death (IUFD): The fetus may not receive enough oxygen to survive.
  • Small for Dates (SFD): The fetus may not grow at the expected rate due to insufficient nutrient and oxygen supply.
  • Neonatal Death: anaemia can increase the risk of death in the newborn.
  • Abortion and Premature Labour: Anaemia can increase the risk of both.

Increased Risk of Complications:

  • Postpartum Haemorrhage: Anaemia can impair blood clotting, making mothers more susceptible to excessive bleeding after delivery.
  • Heart Failure: The heart works harder to compensate for lower oxygen levels, increasing the risk of heart failure.
  • Venous Thrombosis: Anaemia can increase blood viscosity, leading to blood clots in the veins.
  • Infections: A weakened immune system due to anaemia makes mothers more vulnerable to infections.
  • Poor Lactation: Anaemia can impact milk production and quality.
Effects on Labour:
  • Stress of Labour: Anaemic women may struggle to tolerate the stress of labour, and even minor blood loss can be life-threatening.
  • Fetal and Maternal Distress: Low oxygen levels can lead to fetal and maternal distress, potentially necessitating an instrumental delivery (e.g., forceps or vacuum extraction).
  • Increased Risk of Complications: Anaemia can increase the risk of complications during labor, including postpartum haemorrhage, infection, and prolonged labor.

Management of anaemia in Pregnancy

Management of anaemia in pregnancy depends on the severity of the anaemia, stage of gestation, and underlying cause.

Early Pregnancy with Mild or Moderate anaemia in a Maternity Center and Hospital:

Outpatient Management:

  • Put the mother in bed.
  • Take a history from the mother concerning diet, lifestyle, and surroundings to determine the cause of anaemia.
  • Conduct a general examination to assess the degree of anaemia using a Tallquist book.
  • The midwife can treat mild and moderate anaemia in early pregnancy.
  • Manage the condition according to the underlying cause.
  • Refer the mother to the hospital for further investigations if haemoglobin is found to be below 60%.

Active Treatment for haemoglobin  of 60% and Above:

  • Administer three doses of Fansidar 960 mg tablets where malaria is common.
  • Administer Mebendazole 200 mg twice daily for three days for hookworm.
  • Provide iron therapy with ferrous sulfate (200 mg twice daily) and folic acid (5 mg once daily). Review after 2 months.

Note: In the maternity centre, refer moderate anaemia in late pregnancy to the hospital.

In the Hospital:

  • Admit the mother to the antenatal ward.
  • Take a history about diet, environment, and hygiene.
  • Monitor observations: temperature, pulse, respirations, and blood pressure.
  • Treat any underlying cause accordingly.
  • Provide routine nursing care.
  • Ensure proper hygiene.
  • Provide a high-protein diet.

Severe anaemia in Early and Late Pregnancy:

In a Maternity Center:

  • Refer to the hospital.

In the Hospital:

  • Admit the mother and take a history.
  • Conduct observations and investigations.
  • Resuscitate immediately with:
  • Blood transfusion or parenteral iron dextran (Inferon) infusion if blood is unavailable. Note: Total dose of Inferon is given slowly, only in severe anaemia close to delivery. After delivery, transfuse with packed cells under Lasix.
  • Administer diuretics, e.g., Lasix 120 mg IV.
  • Nurse the patient with severe anaemia propped up in bed and provide comprehensive care.
  • Pay special attention to mouth care, as stomatitis and glossitis are common in anaemia patients.
  • Provide a high-protein diet with green vegetables and fresh fruit.
  • Maintain a strict fluid balance chart and observe for signs of impending cardiac failure, such as increasing pulse and respirations. Report breathlessness, especially if the patient has tuberculosis. 
  • Note: IV Inferon: 5 ampoules of 250 mg each in 100 ml of dextrose 5% or normal saline 500 ml.

Management During Labor:

1st Stage:

  • Comfortable Positioning: Ensure the mother is in a comfortable position on the bed.
  • Light Analgesia: Consider light pain relief measures as needed.
  • Oxygenation: Administer oxygen to increase maternal blood oxygenation and prevent fetal hypoxia.
  • Strict Asepsis: Maintain strict sterile practices to minimize infection risk.

2nd Stage:

  • Usually No Specific Issues: This stage typically proceeds without major issues related to anaemia.
  • Methergin or Oxytocin Administration: Administer 0.2 mg of Methergin or 20 units of oxytocin in 500 ml of Ringer’s Lactate intravenously, followed by 10 units intramuscularly, to prevent postpartum haemorrhage.

3rd Stage:

  • Good management of the 3rd stage of labour to prevent much blood loss.
  • Intensive Observation: Closely monitor for postpartum haemorrhage and other complications.
  • Blood Replacement: Replace any significant blood loss with fresh packed red blood cells.
  • Avoid Overloading: Be cautious not to exceed the amount of blood loss replaced to avoid fluid overload.

Puerperium (Postpartum Period):

  • Bed Rest: Encourage bed rest to allow for recovery.
  • Infection Monitoring and Treatment: Monitor for signs of infection and treat promptly.
  • Continuation of Iron Therapy: Continue iron supplementation until haemoglobin levels return to normal.
  • Dietary Guidance: Continue to promote a healthy, iron-rich diet.
  • Counselling: Provide education and support to the mother and family regarding baby care and household chores.

Prevention of anaemia:

  • Good Antenatal Care: Detect and treat anaemia and malaria early.
  • Health Education: Teach about diet, personal hygiene, and environmental sanitation, including proper use of latrines.
  • Malaria Protection: Take preventive measures against malaria.
  • Blood Loss Reduction: Manage all stages of labour to reduce blood loss in the third stage.
  • Protein Replacement: Provide extra protein during lactation.
  • Folic Acid Supplementation: Administer as needed.
  • Routine Blood Examinations: Monitor haemoglobin levels regularly.
  • Avoidance of Frequent Childbirths: Spacing pregnancies adequately allows the body time to recover iron stores.
  • Dietary Advice: Encourage a diet rich in iron-rich foods like red meat, fish, beans, lentils, and leafy green vegetables.
  • Supplementary Iron Therapy: Prescribe iron supplements as needed, based on individual needs and blood tests.
  • Treatment of Underlying Illnesses: Address any underlying medical conditions that may contribute to anaemia, such as infections, parasitic infestations, or chronic diseases. Early diagnosis and treatment are crucial.

Advice to the Mother:

  • Tell the mother to report immediately when they become pregnant in order to receive appropriate prophylactic treatment of  iron therapy.
  • Explain the cause of anaemia, its dangers, and how to prevent it.
  • Advise rest to avoid overworking.
  • Discuss diet and types of food.
  • Encourage taking any prescribed treatment regularly.
  • Stress the importance of preventing mosquito bites to avoid malaria.
  • Advise on family planning to avoid frequent childbearing.
  • Recommend delivery in the hospital.

Complications of Anaemia in Pregnancy

Maternal Complications

Fetal Complications

Increased risk of PPH

Premature birth

Increased risk of infection

Low birth weight

Increased risk of heart failure

Fetal growth restriction

Fatigue and weakness

Stillbirth

Shortness of breath

Cerebral palsy

Increased risk of preeclampsia

Congenital anomalies

Increased risk of delayed wound healing

Cognitive impairment

Increased risk of death

Delayed development

Anaemia in Pregnancy Read More »

Domiciliary care

Domiciliary Care

Domiciliary care is an obstetric care given to a mother in her home during pregnancy, labour and puerperium

Types of Domiciliary Care

  1.  Type one domiciliary midwifery care “continuity:; In this type the woman is cared for in her home all through during antenatal period delivery and postnatal care. The woman will only visit a health unit or hospital only when there is a problem that requires specialized care or more gadgets to be used. This care is known as continuity of care or fragmented care. In this case one midwife provides all the care to the woman.
  2.  Type two, community, integrated or centralized care; In this care service is integrated (mixed) in a way that part of the care may be given at home and some in the health setting like a hospital. Usually antenatal or delivery may be offered in the hospital and puerperium period managed at home. This is the type of care that student midwives and nurses offer as part of their midwifery part two and is compulsory for them.
  3.  Employee or independent practitioner in domiciliary; This is a type of care in which a midwife practices as a private midwife in the community but not necessarily on one woman. The midwife may have a maternity Centre for all or part of the care or she may combine it with one to one community midwifery care. This is the commonest type of domiciliary care in Uganda.

Forms of Domiciliary Care
Characteristics of patterns of domiciliary care depend on a number of factors and these can be:

  • Decision of the midwife
  • Decision of the woman / family
  •  Location and nature of community
  •  Availability of basic requirements for domiciliary care

Objectives of Domiciliary Care.

  1.  Domiciliary midwifery care  to take midwifery near to the community thus increasing accessibility to services

  2.  To encourage full participation and involvement of male partners and family members in the birth process so as to get their full support

  3.  To reduce on maternal / infant morbidity and mortality as the midwife has less workload and concentrates on one woman.

  4.  To reduce on hospital/health facility over crowding

  5.  To promote midwife-mother relationship and mutual understanding between the woman and the midwife.

Domiciliary Care given by midwives
  1.  Care before conception
    >   Health education to young girls on good nutrition and hygiene
    >   Teaching young girls about life skills
    >    Immunization of young girls with tetanus toxoid
    >    Counselling adolescents on reproductive health and other social issues
  2.  Care during pregnancy
    >   Immunization
    >   Antenatal check ups
    >   Treatment of minor problems.    >   Health education on problems in pregnancy
  3. Care during labour
    >   Care of mother in Labour
    >   Use of partograph to monitor labour
    >   Delivering of the baby
    >   Infection prevention
  4. Care after delivery
    >   Immunization
    >   Care of mother and baby
    >   Postnatal exercises
    >   Family planning

Advantages of Domiciliary Services.

  • Domiciliary services promotes midwife – mother relationships and thus minimizing fears and phobias of childbirth
  • It promotes continuity of care and close supervision of the mother thus – contributing to the reduction of maternal / infant morbidity and mortality
  •  Increases access to health services as the woman is found in her home instead of herself looking for the services
  •  Domiciliary is cost effective to a certain level as only relevant care will be given to individual women and at the same time the woman will continue her responsibilities especially supervision of the home
  •  It gives peace of mind to the mother, husband children and other house members because the woman remains at home
  •  It promotes woman centered care including choice control over services rendered and also encourages continuity of care.
  •  It promotes privacy and security and respect the mother with less interference and exposure
  • Promotes good communication and openness. Only relevant information is given to the mother and her family. As the midwife knows the woman personally, she understands better their concerns, lives, and challenges and assists them accordingly.
  •  Promotes autonomy to the midwife and there is job satisfaction
  •  It promotes creativity, problem solving skills and maturity in service with good experience.

Brief History of Domiciliary Care

 Throughout the ages, women have depended upon a skilled person, usually another
woman to be with them during child birth
 In United Kingdom, the midwives skills are increasingly valued and midwives are being urged to expand their role even further in the field of public health.

  • In Uganda in 1960’s(May 1968), this is when the midwife would look after the mother in the home environment.  Midwives would do antenatal care, deliver mothers in their own homes and continue to give post natal care in the mother’s home.
     >    This would also give opportunity for the midwife to give health education to the other family members.
    >     In the 1970s when the political system in Uganda changed, leading to a lot of insecurity, the midwives stopped delivering mothers at home  and instead delivered mothers in hospitals and maternity units. Then the midwives continued to nurse the mothers and their babies at the mother’s home.
     > These services have continued today and are being practiced by Private Midwives and the student midwives who are undertaking Registered Midwifery Course of Diploma in Midwifery Course.
Types/ Groups of mothers Needing Domiciliary care
  • Group 1: Women with less risk of getting complications
    Women who have ever delivered one baby but have not exceeded five – that is gravid two to four.
    This group of women if they did not experience any major complication in pregnancy labour and puerperium, can be care for in the community throughout, pregnancy labour and puerperium
  • Group 2: These are the women who are suspected of developing a complication, though they may not develop them at all. For examples: primigravida – pregnant for the first time,
    Grandmultipara – has delivered more than four times, short women- less than 152cm high, women with previous complications that are likely to occur again e.g. cord prolapsed.
    This group of women may be cared for only for antenatal or delivery and puerperium depending on other factors as detected on history and assessment.
  • Group 3: These are the high Risk Mothers, women who come with obvious complications, or are highly suspected of developing various complications. Examples: Multiple pregnancy – those with medical conditions like cardiac diseases, diabetes mellitus, sickle cell disease.

Common Drugs used in Domiciliary 

  •  Ergometrine
  •  Ferrous sulphate
  •  Folic acid
  •  Panadol
  •  Chloroquine

How Domiciliary is carried out.

  •  Booking

A mother who has to be booked must be with the following
>  Must be normal with no risk factors like CPD,
>  Grandemultparity, multiple pregnancy

  •  Home delivery

The following must be put in consideration
(a).   Well ventilated home without without overcrowding
(b).   Clean house, good hygiene in and around the house
(c).   The house should have more than 4 bedrooms, toilets
and kitchen
(d).   The floor must be cemented
(e).   There must be tap water
(f).   There must be easy means of boiling water

  •  Enough equipment especially for the mother and baby(bathing)
  •  Husband and wife should be willing for the care
  •  The distance from the home to hospital should be less than 2 miles.

QUALITIES OF A MIDWIFE

In normal circumstances the midwife should be a qualified senior student midwife with enough knowledge
(a)  She must create a friendly relationship between her, the mother and family
(b)   She must remember that she does not belong to the family and is only a guest so she must adopt her behavior in relation to the family routine
(c)   No commands or orders should be given but advices, the midwife should be flexible
(d)   She should show interest in the family
(e)   Avoid embarrassing the mother in the family

(f)   She has to apply her professional code of conduct and stay in the home only as a midwife
(g)   Quick and correct judgment has to be applied in providing the best care expected


DOMICILIARY BAGS

The midwife must be equipped with the following

  •  Sphyginomanometer
  •  Stethoscope
  •  Urine testing strips
  •  Clinical thermometer
  •  Spirit for baby’s cord
  •  Swabs in the gallipot and cord ligatures
  •  Receivers, dissecting forceps, artery forceps, scissors
  •  Antiseptic lotion
  •  Plastic apron and tape measure
  •  Drugs like Panadol, and iron tablets

 

Care

Here in Uganda a mother is delivered in the hospital then cared for in her home for seven day including the 1st days in the hospital
ANTENATAL CARE
Normally a mother is booked on her 1st visit at 12wks.It should be during this time when the midwife inspect the home of the mother until the mother is delivered in the hospital and cared for the first 2 days and  then 5 days at home
PUEPERIUM
During puerperium the midwife continues to visit the mother daily at her home. If there is any indication of complication arising of the mother requires extra supervision and support additional visits will be made
The midwife observes the mother’s general condition both mentally and physically, ask her how she is feeling. Inquire about the baby particularly feeding, sleeping, passage of urine and stool.
If the mother appears stressed, depressed, or anxious about the baby or any other problem. The midwife should sit, listens and responds. The time spent listening and discussing problems with the mother invariably of great value to her wellbeing
The midwife inquires whether the mother is sleeping and eating well passing urine without difficult or discomfort and has had a bowel action.
She take the mothers vitals and carries out a full postnatal examination of the breast, abdomen to palpate the uterus, vulva to inspect lochia and perineum.
Any abnormality detected should be discussed with the mother and appropriate advice is given. Postnatal exercises are taught on the first day after delivery and the mother is encouraged to practice them dairy throughout puerperium
On the first postnatal visit the midwife usually assists the mother to bath there after the mother should have a bath on her own should be twice or more daily, mother should be advised to change her pads frequently.

Adequate rest and sleep are essential and though ambulating is good but the mother should rest and sleep at appropriate time each day.
The mid wife performs a daily examination on the baby and shows the mother how to bath and dress the baby and attend to the cord.
> She observes its general condition,  examine him from head to toe observing the skin, eyes, mouth and cord for any signs of infection or any abnormality.
> Stool should be observed and the passage of urine.
> Baby should be observed whether breastfeeding well
> At the last visit, the mid wife advises the mother when to go back to postnatal clinic and the baby to health clinic.
> Health educate and demonstrates to the mother the postnatal exercises.

Domiciliary Care Read More »

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