Mental Health

Mood Disorders in Children and Adolescents

Mood Disorders in Children and Adolescents

Mood Disorders In Children and Adolescents

Mood disorders are chronic, often debilitating illnesses that affect people of all ages.

Mental health problems ranging from depression to bipolar disorder are known as mood disorders, or affective disorders. In any of these disorders, a serious change in mood shapes the child’s emotional state. Unlike a normal bad mood a child feels occasionally, a mood disorder involves thoughts and feelings that are intense, difficult to manage, and persistent. A mood disorder is a real medical condition, not something a child will likely just “get over” on his own.

Today, clinicians and researchers believe that mood disorders in children remain one of the most under diagnosed health problems. Mood disorders that go undiagnosed can put children at risk for other conditions, like disruptive behavior and substance use disorders, that remain after the mood disorder is treated. Children and teens with a mood disorder don’t always show the same symptoms as adults. So it can be difficult for parents to recognize a problem in their child, especially since he or she may not easily express his or her thoughts or feelings.

The most common mood disorders in children and adolescents include:

  • Major depression. A depressed or irritable mood, lasting at least two weeks.
  • Persistent depressive disorder (dysthymia). A chronic, low-grade, depressed or irritable mood for at least 1 year.
  • Bipolar disorder. Periods of persistently elevated mood followed by periods of depressed or flat emotional response.
  • Disruptive mood dysregulation disorder. A persistent irritability and extreme inability to control behavior.
  • Premenstrual dysphoric disorder. This includes depressive symptoms, irritability, and tension before menstruation.
  • Mood disorder due to a general medical condition. Many medical illnesses, including cancer, injuries, and chronic medical illnesses, can trigger symptoms of depression.
  • Substance-induced mood disorder. Symptoms of depression due to drug use, the effects of a medication, or exposure to toxins.

Girls are at least twice as likely as boys to develop depression. Boys and girls are equally likely to develop bipolar disorder and obsessive-compulsive disorder.

Causes

The causes of mood disorders are not well understood. however the following can be attributed to;

  • Imbalances in brain chemicals.
  • Environmental factors, such as unexpected life events and/or chronic stress, can also contribute to a mood disorder.
  • Mood disorders often run in families, so there is a genetic component, too. Children who have relatives with depression are at increased risk for depression. In addition, a family history of bipolar disorder may predispose a child to have bipolar disorder or other mood disorder.
  • Sometimes, extreme stress or a life event can “turn on” a gene, causing the disorder to develop. This can happen especially with depression.

Signs and Symptoms

Children show symptoms differently, according to their age and biological makeup. Symptoms also vary according to the type of mood disorder. Overall signs of a mood disorder may include:

  • Sad, depressed, irritable, angry, or elevated mood that appears more intense than the child usually feels, lasts for a longer period of time, or occurs more frequently
  • Trouble with family, including difficult behavior
  • Lack of motivation or pleasure in previously enjoyed activities
  • Changes in sleep or eating patterns or weight
  • Frequent physical complaints, such as headaches, stomachaches, or fatigue
  • Loss of energy or fatigue
  • Difficulty achieving in school
  • Worthlessness, guilt, or low self-esteem
  • Severe recurrent temper outbursts
  • Increased energy or bursts of energy with racing thoughts or fast speech
  • Rebellious or high risk behavior
  • Running away or threats of running away from home
  • Difficulty with friends and peers
  • Expressions of suicidal thoughts, which should be evaluated immediately

Diagnosis

An accurate diagnosis of the mood disorder, as well as any other conditions, is a crucial first step in managing the disorder effectively. At the Hospital, a specialist performs a comprehensive evaluation. The evaluation may assess:  

  • child’s overall health and medical history
  • child’s symptoms
  • child’s behavior at home, at school, and with peers
  • Environmental factors that might be stressors in your child’s life
  • Input from teachers or guidance counselor about issues at school
  • child’s past experiences with specific medications or therapies
  • opinion or preference for treatment options

Treatment                    

Mood disorders can be treated with evidence-based treatments, especially with early recognition of the problem. Treatment can help manage the episode, reduce the severity of symptoms, and help to prevent future episodes. It can also enhance the child’s normal growth and development and improve his or her quality of life and relationships.

Individual therapy

  • identify  key problems in the child’s life and help the child learn how to manage these stressors.
  • Also use a variety of techniques to help the child manage the symptoms of the mood disorder, including
    • Cognitive-behavior. This approach involves changing problematic thoughts, feelings, and behaviors that your child may be experiencing.
    • Interpersonal therapy. This technique focuses on building social skills and helping children with difficult relationships in their lives.
  • Family therapy

Families play a vital supportive role in any mood disorder. Families, including parents or guardians, can learn methods to help their child manage mood and behavior problems. The specialist may also explore potential stressors in a child’s life and patterns of interaction within the family. A consultation with the child’s teachers or guidance counselor may also be advised.

  • Medications

A variety of medications are very effective in treating mood disorders by altering the brain chemicals involved.  Depending on the mood disorder and the child’s symptoms, medications may reduce the severity or frequency of symptoms, decrease problematic behaviors, improve functioning, and prevent future episodes.

  • Outlook

Many children who receive early and adequate treatment for their mood disorder may improve significantly and keep their condition managed with ongoing intervention or support . If the episodes recur, they can usually be managed with therapeutic support, including medications, therapy, and additional resources.

  • Follow-up Care

Depending on the child’s personalized treatment plan, the child and family may continue to meet with the specialist for a number of weeks or months. The focus of individual and family therapy may change over time, depending on the child’s age, progress, and needs. Medication needs may also change over time depending on a number of factors.

SPECIFIC MANAGEMENT OF MOOD DISORDERS.

  1. Assessment 🕵️‍♀️

    • Conduct thorough assessments to understand the child’s mood disorder, including emotional triggers and symptoms.

  2. Supportive Environment 🌈

    • Create a safe and nurturing environment to promote emotional well-being.

  3. Therapeutic Communication 🗣️

    • Utilize effective communication techniques to build trust and encourage expression of feelings.

  4. Medication Management 💊

    • Administer prescribed medications as directed, and monitor for any side effects or changes in mood.

  5. Psychotherapy 🧘‍♀️

    • Encourage participation in individual or group therapy sessions to address underlying issues.

  6. Education 📚

    • Provide education to both the child and their family about the mood disorder, coping strategies, and treatment options.

  7. Behavioral Interventions 🧩

    • Implement behavior modification techniques to manage disruptive behaviors and promote positive coping mechanisms.

  8. Emotion Regulation 🧘‍♂️

    • Teach the child emotional regulation skills, such as mindfulness and relaxation techniques.

  9. Family Involvement 👪

    • Engage the family in therapy and support, as their understanding and involvement are crucial.

  10. Safety Monitoring 🚸

    • Continuously monitor the child’s safety to prevent self-harm or harm to others, especially in severe cases.

BIPOLAR AFFECTIVE DISORDER click here

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Attention-deficit/hyperactivity disorder

Attention-Deficit/Hyperactivity Disorder

Attention-deficit hyperactivity disorder

Attention deficit hyperactivity disorder is the most commonly diagnosed mental disorder of children and teens and which can also continue to adulthood. Children with ADHD may be hyperactive and unable to control their impulses or they may have trouble paying attention

Attention deficit hyperactivity disorder (ADHD) is a brain disorder marked by an on-going pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning of development.

Inattention means a person wanders off task, lacks persistence, has difficulty sustaining focus and is disorganized and these problems are not due to defiance or lack of comprehension.

Hyperactivity means a person seems to move about constantly, including in situations in which it is not appropriate or excessively fidgets, taps, or talks.

Impulsivity means a person makes hasty actions that occur in the moment without first thinking about them and that may have high potential for harm or a desire for immediate rewards or inability to delay gratification. An impulsive person may be socially intrusive and excessively interrupt others to make important decisions without considering the long-term consequences.

This disorder is characterized by severe disruption of attention along with over activity more frequent and severe than is typical of children at a similar level of development. ADHD is thought to result from brain damage during birth. A child with ADHD cannot sit still or remain at one place for any length of time, is always on the go, fears no dangers, climbing and playing dangerously with house hold objects. The prevalence is much common in boys than girls

Aetiology

Biological influences

  • genetics; ADHD tends to run in families
  • biochemical theory; a deficit of dopamine and norepinephrine neurotransmitters has been attributed to cause over activity as seen in ADHD

Pre, Peri and postnatal factors

  • prenatal toxic exposure
  • prematurity
  • fetal distress
  • precipitated or prolonged labour
  • perinatal asphyxia
  • low Apgar scores
  • postnatal infections
  • CNS abnormalities resulting from trauma

Environmental influences

  • lead poisoning
  • food additives, colouring, preservatives and sugars

Psychosocial factors

  • prolonged emotional deprivation
  • stressful psychic events
  • disruption of family equilibrium

Risk factors

  • drug exposure in utero
  • birth complications
  • low birth weight
  • lead poisoning

Clinical features

  • sensitive to stimuli, easily upset by light, noises or environmental changes
  • more commonly active an sleeps little
  • short attention life span
  • failure to finish tasks
  • impulsivity
  • memory and thinking difficulties
  • specific learning disabilities

In school

  • answers only the first two questions and often blurts out answers before questions have been completed
  • unable to wait to be called on in school and may respond before everyone else
  • has difficulty awaiting in games or group situations
  • often loses things necessary for tasks or activities at school

Home

  • explosive or irritable
  • emotionally labile and easily set off to laughter or tears
  • unpredictable mood
  • impulsiveness and inability to delay gratification
  • often talks excessively
  • often engages in physically dangerous activities without considering possible consequences

Symptoms can also be grouped as follows;

Inattention symptoms

  • Overlook or miss details or make careless mistakes in schoolwork
  • Have problems sustaining attention in tasks or play including conversations, lectures or lengthy reading
  • Not seem to listen when spoken to directly
  • Not follow instructions and fail to finish school work or duties on work or start tasks but quickly lose focus and get easily side-tracked
  • Have problems organizing tasks and activities, such as what to do in sequence, keeping materials and belongings in order, having messy work and poor time management and failing to meet deadlines
  • Avoid or dislike tasks that require sustained mental effort, such as school work or homework.
  • Loose things necessary for tasks or activities such as school supplies, pencils, books, tools, eyeglasses, paperwork etc.
  • Be easily distracted by unrelated thoughts or stimuli
  • Be forgetful in daily activities like keeping appointments.

Hyperactivity-impulsivity symptoms

  • Leave seats in situations when staying seated is expected such as in classroom
  • Run or dash around or climb in situations where it is inappropriate or restless in teens
  • Be unable to play or engage in hobbies quietly
  • Be constantly in motion or ‘on the go’ or act if ‘driven by a motor’
  • Talking nonstop
  • Blurt out an answer before question has been completed, finish other peoples sentences or speak without waiting for a turn in conversation
  • Have trouble waiting for his or her turn
  • Interrupt or intrude on others, for example conversations, games or activities
  • Constant fidgeting
  • Acting without thinking
  • Little or no sense of danger

MANAGEMENT

Pharmacotherapy;

Medication do not offer permanent cure for ADH but may help someone with the condition to concentrate better, be less impulsive, fell calmer and learn to practice new skills. Drugs licensed for treatment of ADHD include;

  • Methylphenidate one tablet once a day
  • Lisdexamfetamine once capsule once a day
  • Dexamfetamine one tablet once or twice a day
  • Atomoxetine one capsule once or twice a day
  • Guanfacine one tablet once a day
  • tricyclic antidepressants
  • Antipsychotics
  • serotonin specific reuptake inhibitors

Psychological therapies

  • Psychotherapy especially behavioural therapy is very essential as it aims at a child changing their own behaviour. It might involve practical assistance such as help organizing tasks or completing schoolwork or working through emotionally difficult events
  • Cognitive behavioural therapy; here a therapist tries to change how a child thinks about the situation and in turn would change the behaviour
  • social skill training
  • family therapy

Nursing interventions

Children with ADHD need guidance and understanding from their parents, families, and teachers to reach their full potential and to succeed. For school age children, frustration, blame and anger may hinder recovery in other wards children need special help to overcome negative feeling and to develop new skills and attitudes.

  • Social skills training; this will help the child learn how to behave in social situations by learning how their behaviours affect others
  • Parenting skills training (behavioural parent management training) this teaches parents the skills to encourage and reward positive behaviours in their children. It helps parents learn how to use a system of rewards and consequences to change a child’s behaviour
  • Stress management techniques, these can benefit parents of children with ADHD by increasing their ability to deal with frustration so that they can respond calmly to their child’s behaviour
  • Support groups; these help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustration and successes to exchange information about recommended specialists and strategies and to talk with experts
  • Diet; sugar, food colourings and additives as well as caffeine should be excluded in the patients diet as they aggravate hyperactivity

Help the child with ADHD to stay organised and stay organised by;

  • Keeping a routine and a schedule. Keep the same routine every day from wake-up time to bedtime. Include times of homework, outdoor play and indoor activities. Write all changes on the schedule in advance as possible
  • Organizing everyday items; have a place for everything and keep everything in its place. This includes clothing, backpacks and toys
  • Using homework and notebook organizers. Stress to the child the importance of writing down assignments and bringing home necessary books
  • Being clear and consistent. Children with ADHD need consistent rules they can understand and follow
  • Giving praise or rewards when rules are followed. Children with ADHD often receive and expect criticism. Look for good behaviour and praise it.
  • Develop a trusting relationship with the child that conveys acceptance of the child separate from unacceptable behaviour
  • Ensure patient has a safe environment free from dangerous objects that can injure him due to random hyperactive movements
  • Keep the child in an environment that is free from distractions to help him comply on given tasks
  • Ensure child’s attention by calling his name and maintain an eye contact before giving instructions
  • Ask patient to repeat instructions before beginning the task
  • establish goals that allow the patient to complete part of the task, rewarding each step completion with a break for physical activity
  • Provide assistance on one-to-one basis beginning with simple concrete instructions
  • Gradually decrease the amount of assistance given to task performance while assuring patient that assistance is available if still needed
  • Offer recognition for successful attempts and positive reinforcement for attempts made
  • Provide quiet environment, self-contained classrooms an small group activities
  • Help the patient to learn how to take his turn, wait in line and follow rules
  • Provide information an materials related to the child’s disorder and effective parenting techniques
  • Explain and demonstrate positive parenting techniques to parents such as being vigilant in identifying the child’s behaviour and responding positively to that behaviour
  • Co-ordinate overall treatment plan with schools, child and family

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Standards of Care

Standards of Care

Standards of Care In Mental Health 

Standards of Care are a means for improving the quality care for mentally ill people.

They were enunciated by the American Nurses Association (ANA) in 1973.

Development of Code of Ethics

This is very important for a psychiatric nurse as she takes up independent roles in psychotherapy, behavior therapy, cognitive therapy, individual therapy, group therapy, maintains patient’s confidentiality, protects his rights and acts as patient’s advocate.

Legal Aspects in Psychiatric Nursing

The practice of psychiatric nursing is influenced by law, particularly initial concern for the rights of patients and the quality of care they receive.

  • The client’s right to refuse a particular treatment, protection from confinement, intentional torts, informed consent, confidentiality and Promotion of research in mental health nursing
  • The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.
  • Cost-effective nursing care. Studies need to be conducted to find out the viability in terms of cost involved in training a nurse and the quality of output in terms of nursing care rendered by her.
  • Focus of care. A psychiatric nurse has to focus care on certain target groups like the elderly, children, women, youth, mentally retarded and chronic mentally ill.
  • Record keeping are a few legal issues in which the nurse has to participate and gain quality knowledge.

STANDARDS OF MENTAL HEALTH NURSING

The purpose of Standards of Psychiatric and Mental Health Nursing practice is to fulfill the profession’s obligation to provide a means of improving the quality of care. The standards presented here are revision of the standards enunciated by the Division on Psychiatric and Mental Health Nursing Practice in 1973.

Professional Practice Standards

Standard I: Theory

The nurse applies appropriate theory that is scientifically sound as basis for decisions regarding nursing practice. Psychiatric and mental health nursing is characterized by the application of relevant theories to explain phenomena of concern to nurses and to provide a basis for intervention.

Standard II: Data Collection

The nurse continuously collects data that are comprehensive, accurate and systematic. Effective interviewing, behavioral observation, physical and mental health assessment enable the nurse to reach sound conclusions and plan appropriate interventions with the client.

Standard III: Diagnosis

The nurse utilizes nursing diagnosis and/or standard classification of mental disorders to express conclusions supported by recorded assessment data and current scientific premises.

Nursing logic basis for providing care rests on the recognition and identification of those actual or potential health problems that are within the scope of nursing practice.

Standard IV: Planning

The nurse develops a nursing care plan with specific goals and interventions delineating nursing actions unique to each client’s needs.

The nursing care plan is used to guide therapeutic intervention and effectively achieve the desired outcomes.

Standard V: Intervention

The nurse intervenes as guided by the nursing care plan to implement nursing actions that promote, maintain or restore physical and mental health, prevent illness and effect rehabilitation.

(a) Psychotherapeutic interventions

The nurse uses psychotherapeutic interventions to assist clients in regaining or improving their previous coping abilities and to prevent further disability.

(b) Health teaching

The nurse assists clients, families and groups to achieve satisfying and productive patterns of living through health teaching.

(c) Activities of daily living

The nurse uses the activities of daily living in a goal directed way to foster adequate self-care and physical and mental well-being of clients.

(d) Somatic therapies

The nurse uses knowledge of somatic therapies and applies related clinical skills in working with clients.

 (e) Therapeutic environment

The nurse provides structures and maintains a therapeutic environment in collaboration with the client and other health care providers.

Standard VI: Evaluation

The nurse evaluates client responses to nursing actions in order to revise the database, nursing diagnosis and nursing care plan.

Professional Performance Standards

Standard VII: Peer Review.

The nurse participates in peer review and other means of evaluation to assure quality of nursing care provided for clients.

Standard VIII: Interdisciplinary Collaboration

The nurse collaborates with other health care providers in assessing, planning, implementing and evaluating programs and other mental health activities.

Standard IX: Utilization of Community Health Systems

The nurse participates with other members of the community in assessing, planning, implementing and evaluating mental health services and community systems that include the promotion of the brand continuum of primary, secondary and tertiary prevention of mental illness.

Standard X: Research

The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.

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Law and Mental Illness

Law and Mental Illness

Law and Mental Illness

Law has relevance in nearly all aspects of nursing practice, but in no other area of nursing is the law more intimately involved than in psychiatric nursing.

This is because psychiatric clients may;

  • be placed on treatment against their own will
  • pose a risk to them selves
  • have been charged to have committed crime while legally insane
  • be un able or unwilling to consent to treatment
  • be incapable of fully understanding medical risks
  • require constant restraints for their safety or others
  • make threats to others
  • under go forensic evaluations that require nurses to testify in court

Forensic psychiatry

Forensic psychiatry is a branch of psychiatric nursing that deals with disorders of mind and their relationship with the legal principles.

 It is also concerned with the assessment, investigations, diagnosis and treatment of mental disorders among three broad categories of individuals i.e.;

  • individuals who have are alleged to have committed an offence and face prosecution
  • convicted prisoners who develop mental illness in the course of serving their sentence
  • individuals who have not committed an offence but are at risk because of their mental capacity

Under existing mental health legislation in Uganda, its not expected that the primary health care provider will provide this service. its however advised that a PHC provider knows something about prisoners’ mental health needs for the purpose of early and appropriate referrals to centres where a psychiatrist or other mental health professionals are available.

The basic forensic psychiatry includes;

  1. crime and psychiatric disorders
  2. criminal responsibility
  3. civil responsibility
  4. laws relating to psychiatric disorders
  5. admission procedures of patients in psychiatric hospital
  6. civil rights of mentally ill
  7. psychiatrists and court
Crime and psychiatric disorders

There is a close association between crime and psychiatric disorders like schizophrenia, affective disorders, epilepsy, drug dependency, personality disorders etc.

Mentally ill people may commit crime because;

  • they do not understand the implication of their behaviour
  • due to delusions and hallucinations
  • abnormal mental states like confusion or excitements
  • drug related violence

Instances when an individual facing prosecution may come to attention of a psychiatrist

  • when police notices signs of mental disorder in individual under their custody
  • when the judge observes signs of mental disorder
  • when relatives raise issue of mental disorder
  • when prisoner reports history of treatment for psychiatric disorder
  • when suspect pleads insane during court proceedings

Under any of the above, the magistrate may order assessment and observation of an individual to ascertain;

  • whether the individual is mentally disordered
  • the individual’s ability to stand trial if mentally disordered
  • whether the accused is criminally responsible for the offence he is charged with

Responsibilities of a psychiatrist in order to find answers for the above questions

  • hospitalize the accused for the purpose of observations and possible treatment or attend to matter as an out- patient case
  • take a full psychiatric history including history of previous episodes of illness and treatment
  • order an observation of patient by other nursing staff on dairy basis
  • conduct laboratory, psychological and social investigations
  • make a report to the magistrate who will then decide on the best course of action on the basis of a psychiatric report
Criminal responsibility

Criminal responsibility is a legal concept which refers to the extent to which an individual can be held liable for his or her offence.

According to section 84 of the Indian penal code act of 1860, “Nothing is an offence which is done by a person who, at a time of doing it, by reason of unsoundness of mind, is incapable of knowing the nature of act, or that he is doing what is either wrong or contrary to the law”.

 A clinical test of responsibility may be used to determine whether an individual is responsible for an offence or not.

Criteria for criminal responsibility

Criteria for Criminal Responsibility[CCR]

SCORE

1.      offence required careful planning

 

2.      offence was unrelated to symptoms of mental disorder

 

3.      identifiable motive for the crime was not a product of mental disorder

 

4.      mental capacity at a time of crime was unimpaired or did not impair rational judgement

 

5.      amnesia if present is incongruent with relevant key features of crime and mental state

 

 Score each item 1 for a Yes response and 0 for No response. The maximum score is 5. A score of 3 and more indicates that the individual is probably responsible for an alleged crime.

Other criteria used to determine criminal responsibility

  • M’Naghten’s rule

This states that the individual at a time of the crime did not know the nature and quality of the act and if he did know what he was doing, he did not comprehend it to be wrong.

  • The Irresistible impulse act

According to this rule, a person may have known an act was illegal but as a result of mental impairment lost control of their actions.

  • The Durham test or Product rule

This states that an accused is not criminally responsible if his unlawful act was the product of mental disease or abnormality

  • American law institute

This states that a person is not responsible for criminal conduct if at time of such conduct, as a result of mental disease or defect he lacks adequate capacity either to appreciate the criminality of his conduct or to conform his conduct to requirements of the law

Ability to Stand Trial

An individual will not be expected to have an ability to stand trial under the following circumstances;

  • mentally ill with active signs of mental disorder
  • lacks ability to understand court proceedings

in cases of the above, the psychiatrist may recommend that the individual receives relevant treatment for the mental disorder and after full recovery, the individual may then stand trial. However in cases of severe psychotic illness like schizophrenia, the case might be disposed.

Convicted prisoner

In case a prisoner who is serving sentence falls ill, he or she may be referred to a mental hospital under magistrates court Act for assessment, observation and treatment. Unfortunately, under existing laws, such an individual will not be excused from serving his prison sentence on ground of mental illness otherwise he will be released at the end of a prison sentence.

Civil responsibilities of mentally ill person

Management of property

In case the court ascertain that a person is of unsound mind and incapable of managing his property, a manager is appointed by court of law to take care of his property which may include selling or disposal of property to settle debts or expenses.

Marriage

As per the Hindu marriage act 1995, marriage between any two individuals one of whom was of unsound mind at a time of marriage is considered null and void in the eyes of the law. Unsoundness of mind for a continuous period can be sighted as a ground for obtaining divorce. The other party can file divorce when unsoundness continues for a period of 2 years however divorce is granted with a precondition that one has to pay maintenance charges for the mentally ill.

Testamentary capacity

Testamentary capacity of the mental ability of a person is a precondition for making a valid will. The testator must be the major, free from coercion, understanding and displaying soundness of mind.

Right to vote

A person of unsound mind cannot contest for elections or exercise the privilege of voting.

Rights of psychiatric patients

  • Right to wear their own clothes
  • right to informed consent
  • right to habeas corpus
  • right to have individual storage space for their private use or right to privacy
  • right to keep and use their own personal possessions
  • right to spend some of their money for their own expenses
  • right to have reasonable access to all communication media like telephones
  • right to see visitors
  • right to treatment in the least restricted setting
  • right to hold civil service status or enter into legal contracts e.g marriage, personal last will etc
  • right to refuse treatment especially ECT
  • right to manage and dispose of property and execute wills

Aims of management in forensic work

  • diagnose to form a basis for treatment and recommendations to court
  • make report and submit to court
  • rehabilitate as part of management
  • promote acceptance of individual in his community
  • resettle individual back in community
  • promote after care following discharge from court and hospital

Legal responsibilities of a nurse

Psychiatric nurses are confronted on daily basis with the interface of legal issues as they attempt to balance the rights of the patient with the rights of the society. Nurses and other health care providers should never in any way violate the rights of the mentally ill.

Nurses should be aware of;

  • All the laws in the state in which they practice so as to protect herself from liability and patient from unnecessary detention and mistreat
  • patients’ rights
  • criminal and civil responsibilities of ill patients
  • legal documentation

In addition to knowing the above, the nurse should also;

  • protect patients’ rights
  • keep legal records safely
  • maintain confidentiality of patients information
  • take informed consent from patients of relatives for any procedure
  • explain based on the level of anxiety, span of attention and level of ability to decide

Nursing Malpractice

Malpractice involves failure of professionals to provide proper and competent care that is given by members of their profession, resulting in harm to the patient.

Common areas of liability in psychiatric service

  • patient committing suicide
  • misuse of psychoactive prescription drugs
  • failure to obtain consent
  • failure to report abuse
  • breach of confidentiality
  • failure to diagnose
  • inadequate monitoring of patients

Steps to avoid liability in Psychiatric nursing Services

  • reporting information to co-workers involved in patient care
  • clearly and accurately maintaining records
  • maintaining confidentiality of patients information
  • practice within the scope of state laws and nurse practice act
  • collaborate with colleagues to determine the best course of action
  • use established practice standards to guide decisions and action
  • always put patients’ rights and welfare first
  • develop effective interpersonal relationship with patients and family.
  • document all assessment data, treatment given, any interventions and evaluation of the patients response to care accurately and thoroughly.
To successfully argue a case of malpractice against a physician or psychiatric nurse;
The Patient must prove 3 conditions;
  1. There is an established standard of care.
  2. The physicians breached his/her responsibility to the plaintiff.
  3. The physicians breach of responsibility caused injury or damage to the plaintiff.

Compensatory damages are awarded to the patient and reimbursed medical expenses, lost salary or physical suffering.

Punitive damages are awarded to the patient only in order to punish the doctor or nurse for gross negligence or carelessness.

Mental Treatment Act

LEGAL DOCUMENTS AND ADMISSION OF CIVIL PATIENTS.

Civil patients are admitted under the mental treatment act which was passed in 1964 in parliament to replace the mental treatment ordnance which was passed in 1938.

REASONS FOR PASSING THE MENTAL TREATMENT ACT

  1. To safeguard the people with unsound mind from the public and vice vasa
  2. To authorize the mental hospitals to detain, treat, and discharge the mentally ill patients.

There are four orders under which civil patients are admitted in mental hospitals. These ;

  • Urgency order
  • Temporary detention order
  • Reception order
  • Voluntary order
URGENCY ORDER

This is provided by sec 7 of MTA. It is for quick removal of the mentally ill from the public to the mental hospital. It is signed by any of the following;

  • A medical practitioner who is licensed eg registered nurse, dr, pco etc
  • A police officer not below the level of the assistant inspector of police.
  • A gazzetted chief eg a RDC,

This order remains in place for a period of 10 days. If the patient has not improved, another urgency order is signed. It is not renewed. If not cancelled after 10 days the patient has the right to sue the hospital for illegal detention.

TEMPORARY DETENTION ORDER 
This is section 3 of MTA

This is the standard procedure for detaining the mentally ill patients in the mental hospital. The first and important thing is the information of the lunacy.

It can be made by any one at the ward, but in practice, it is made by the ward in charge.

This order remains in place for 14 days but can be renewed for another 14 days when it expires and cannot be renewed any further.

RECEPTION ORDER

This is section 5 of MTA

If the patient does not improve after renewing of the temporary detention order, a magistrate appoints 2 medical practitioners not related  to the patient to dig out patent’s information pertaining  his behavior and illness.

After the magistrate has received the medical reports, and is satisfied with the reports, he sign the order. This order remains in place for a period of 1 year. If the patient does not improve within one year, it can be renewed for another year, if still the patient has not improved, the order is renewed for 3 years, and will be renewed every 3 years.

Patients under this section are said to be satisfied and nor allowed to sign a will, vote, or stand as witness in court or marry.

VOLUNTARY ORDER 

This not under the MTA but is usually legally accepted.

Here the patient comes to the hospital by himself and is directed to the medical superintendent or director who examines the patient and confirms he is mentally sick or not.

The patient will promise to abide by hospital rules and regulations.

If this patient feels he wants to leave the ward, he informs the ward in charge with in 72 hrs who in turn informs the ward doctor that will also inform the medical director or superintendent.

DISCHARGE OF CIVIL PATIENTS 

Role of a nurse in discharge procedure
  • Identify the fitness of the patient and inform the ward doctor ( psychiatrist)
  • Provides feed back and information about patients discharge and seek patient’s opinion.
  • Make sure all the paper work and forms are ready, signed and copies sent to the records.
  • Ensure the patient hands over all the hospital property to the ward manager.
  • All necessary information especially regarding medications, follow up dates, should be made clear to the patient.
  • The nurse must bare in mind that the patient may be having mixed minds about staying in the hospital and going back to the community. And so must help the patient to coup.
  • Depending on circumstances, the patient’s community should be well prepared to receive and stay with the patient.
  • The nurse should at least escort the patient out of the ward or hospital compound.

Civil patients are discharged under the following sections in MTA

SEC 18; FOR RECOVERED PATIENTS

After the nurse has approved the fitness she informs the ward doctor who recommends the fitness and writes to the director reply and authorizes the doctor to discharge the patient on treatment. But in case the patient is on temporary detention or reception order, the magistrate if informed who then authorizes the discharge of the patient on treatment.

SEC 19; DISCHARGE OF A PATIENT UNDER THE CARE OF THE RELATIVES

If the relatives so wishes to take their patient, they should make a statement indicating that they are going to take care of the patient at home. If the patient becomes un manageable at home with in 28 days from the day of discharge, he/she can be re admitted using the previous order. But if 28 days have expired, then a new order is signed.

No drugs shall be provided unless they pay for it because it is a discharge against medical advice.

SEC 20; DISCHARGE FOR A PAYING PATIENT.

If the relatives think that they may not be able to pay the increasing costs of medical bills, they may request the medical suppretendant to discharge the patient. If the patient is still not yet well but relatives insists on discharge, the patient is discharged on a condition that if anything happens at home, the hospital will not be counted responsible. No medication is provided on discharge unless they pay for it.

SEC 21; DISCHARGE ON TRIAL LEAVE

The director of medical services authorizes the medical sup or ward Dr to discharge the patient an a trial leave for a specified period of time usually 28 days to return to the hospital for review. If the patient exceeds the 28 days given, then the patient if he /she is to be re admitted, afresh order must be signed.

SEC 22; DISCHARGE FOR ESCAPEE PATIENTS

If the patient escapes and does not return with in28days, the if brought back, he/she should not be re admitted unless a fresh order is signed. this section caters for for the safety of the hospital and management.

SEC 23; DISCHARGE OF A PERSON OF SOUND MIND;

If the person of a sound mind is detained against his will, the magistrate examines the person together with the psychiatrist and will direct the medical supretendant or ward doctor to immediately discharge the person.

SEC 36; TRANSFER OF PATIENTS

This section has 2 sub sections,

  1. Transfer of a patient from one hospital to another within the same country. If the patient or relatives or doctor deems it necessary to transfer the patient this section will allow the transfer.
  2. Transfer of a patient from one country to another. This section allows the transfer of a mental patient from one hospital to another hospital in a different country.
Sec 38; TRANSFER OF A FOREIGNER BACK TO THEIR OWN COUNTRY. 

This provides the mandate to transfer a foreign mental patient back to his/her own country of origin.

ADMISSION AND DISCHARGE OF A CRIMINAL MENTAL PATIENT.

These are forensic patients. They can be classified into 2.

  1. Remand patients
  2. Class A, B and C patient.

REMAND PATIENTS (panel code act 106)

These are accused persons charged with an offence but are suspected to be of un sound mind while undergoing court proceedings .

They are taken to the mental hospital by the magistrate for ;

  • Observations
  • Investigations
  • Medical report as requested by the magistrate
ADMISSION OF A REMAND PATIENT.

They are brought to the mental hospital on a warrant of commitment on remand signed by the judge or a magistrate. With affixed date or open date to re appear in court.

 

FIXED DATE REMAND.

This is when the date of the accused to appear in court is specified. When the date reaches, the patient is sent to court accompanied by the medical report stating whether the patient is capable or incapable of pleading. If capable then he is straight away sentenced but if incapable then he/she is brought back to the hospital as class B patient.

OPEN DATE REMAND.

This is when the date of next hearing is not indicated on the warrant of commitment and when a need arises the patient is collected on a production warrant signed by the magistrate.

CLASS A PATIENT.

These are prisoners who develop mental disorders while serving their sentences in prison

ADMISSION OF CLASS A PATIENTS
  1. They are transferred from prison to the mental hospital on the following orders.
  2. Temporally detention order or reception order
  3. Warrant of commitment indicating the offence committed
  4. Warrant slip on which the expiring of the sentence is indicated’
DISCHARGE OF CLASS A PATIENT.

If the patient recovers when the sentence has not yet expired, he/she is taken back to the prison to finish his sentence on a production warrant signed by the magistrate.

If the sentence expires when the patient is in the hospital he will be discharged directly home under sec 18 of the MTA.

If the sentence expires when the patient is in the hospital and has not shown any signs of improvement he/she is called off from the register and transferred to a civil hospital on civil orders.

CLASS B PATIENTS

These are patients admitted from the court having been incapable of making their own defense and follow the court proceedings due to insanity.

They are admitted on in a mental hospital for observations and treatment on the following orders.

  1. Warrant of detention of the accused person incapable of making a self defense signed by the minister of justice or attorney general.
  2. Warrant of detention of accused person incapable of making a self defense signed by the magistrate or judge pending the minister’s order.
DISCHARGE OF CLASS B PATIENT

When the patient is able to plead, a psychiatrist makes a certificate of mental fitness which is taken to the director of public prosecutions who will arrange for the hearing in court.

After pleading, if the accused is found guilty, he/she is sentenced directly. But if found not guilty, due to reasons of insanity he is sent back to the mental hospital as class C patient.

CLASS C PATIENTS.

They are admitted from the court after pleading not guilty due to reasons of insanity. They are admitted on the following orders.

  1. Warrant of detention signed by the judge or magistrate pending minister’s order
  2. Minister’s order with a heading ORDER OF DETENTION of a person of un sound mind not found guilty due to reasons of insanity.
DISCHARGE OF CLASS C PATIENTS.

Depending on the ministers order the patient after recovery is discharged directly home unless otherwise ordered by the minister.

 

Law and Mental Illness Read More »

Mental Health Assessment

Assessment of the Mentally Ill

Mental Health Assessment

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

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

Overview of the Assessment Process

The mental health assessment involves several key steps:

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

Conditions for an Effective Consultation

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

Factor

Details/Considerations

Adequate Time

Ensure that sufficient time is allocated so that the patient does not feel rushed.

Privacy

Conduct the interview in a private setting to encourage openness and honesty.

Tidy Environment

A neat and organized consultation room can positively influence the patient’s mood and level of comfort.

Minimized Interference

Avoid interruptions (e.g., answering phone calls) to maintain the focus of the consultation.

Professional Appearance

The appearance and grooming (e.g., well-kept nails, eyebrows, lips, and hair) of the health worker can affect the patient’s willingness to share personal details.

Establishing a Therapeutic Relationship

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

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

Essential Must-Do’s for the Interview

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

General Principles of the Psychiatric Interview

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

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

Psychiatric History Components

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

1. Identifying Data

Name

Patient’s full name

Age

Chronological age

Tribe/Ethnicity

Cultural or ethnic background

Occupation

Employment status and type of work

Religion

Religious affiliation

Next of Kin

Primary contact or emergency contact

Marital Status

Current relationship status

Education

Highest level of education achieved

2. Referral System

Source of Referral

Who referred the patient (e.g., health worker, family member, police)

Reason for Referral

The main concerns or symptoms prompting the referral

Chief Complaints

Primary issues as reported by the patient, along with the duration of symptoms

3. History of Present Illness

Exploration of Problems

Detailed discussion of the current issues and emotional state.

Diagnostic Focus

Information should guide differential diagnoses, identify stressors, and note any complications.

4. Past Psychiatric and Medical History

Previous Illnesses

Past physical and emotional health issues

Investigations and Results

Relevant tests (including HIV tests) and their outcomes

Previous Diagnoses

Prior psychiatric diagnoses

Treatment History

Treatments received and their outcomes

5. Family History(Information to Gather)

Family Members

Note each member’s relationship with the patient

Current Health Conditions

Health status of family members

Dependency Issues

Whether any relative is dependent on the patient and how that affects the patient emotionally

Presence of Mental Illness

Any history of mental illness among nuclear or extended family

6. Personal and Developmental History

Early Development

Details about pregnancy, birth, and early childhood (up to 6 years, particularly important in children).

Childhood to Adolescence

School performance, peer group activities, and early social experiences.

Adolescence to Young Adulthood (up to 19 years)

Sexual history, personal interests, and identity formation.

7. Occupational and Marital History

Occupational History

Details

Nature of Work

Type of job and job description

Job Satisfaction and Issues

Level of satisfaction and any workplace challenges

Marital History

Details

Age at Marriage

The age when the patient got married

Spouse’s Occupation

Occupation and background of the spouse

Family Health

Health status of the spouse and children

Marital Relationship

Quality and dynamics of the marital relationship

8. Forensic History

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

Mental Status Examination (MSE)

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

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

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

It is divided into several components:

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

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

Observation

Examples/Observations

Sample Questions/Comments

Apparent Age

Compare stated age vs. observed appearance (Does the patient look younger or older than stated?)

“Can you confirm your age?” (This also helps compare self-report with observation.)

Dress

Clothing style and condition (casual, formal, disheveled, poorly maintained)

“How do you decide what to wear each day?” (Or simply note your observations.)

Grooming & Hygiene

Overall grooming, cleanliness, and personal care (well-groomed vs. disheveled; good vs. poor hygiene)

“Have you been taking care of yourself recently?” (Observation is usually key.)

Gait

The way a person walks (brisk, slow, intoxicated, ataxic, rigid, shuffling, staggering, uncoordinated)

“I’ve noticed a certain way you move—have you felt any changes in your energy or balance?”

Psychomotor Activity

Overall motor activity (normal, reduced, or excessive movements)

“Do you feel more or less energetic in your movements than usual?”

Abnormal Movements

Involuntary movements (grimaces, tics, tardive dyskinesias, foot tapping, ritualistic behaviors)

“Have you experienced any involuntary movements or twitches?”

Eye Contact

Level and quality of eye contact (good or poor)

“Do you feel comfortable maintaining eye contact during conversations?”

Attitude

Interpersonal stance (cooperative, belligerent, oppositional, submissive, etc.)

“How are you feeling about discussing your current situation today?”

2. Speech

Observation

Examples/Observations

Sample Questions/Comments

Speech Rate

Speed of speaking (rapid, pressured, or slowed)

“Do you feel you speak more quickly or more slowly than you normally do?”

Speech Rhythm

Flow of speech (hesitant, rambling, halting, stuttering, jerky, with long pauses)

“Do you ever feel that your thoughts are hard to get out in order?”

Tone of Voice

Quality of tone (appropriate or inappropriate for the context)

(Often observed; you may comment, “Your tone seems different today.”)

Volume

Loudness of speech (loud, soft, whispered, yelling, inaudible)

“Have you noticed any changes in how loudly or softly you speak?”

Clarity & Quantity

Articulation, pronunciation, and amount of speech (clear, accented, slurred; responds only when asked, overly repetitive, verbose)

“Do you think people understand you easily when you speak?”

3. Emotion (Mood and Affect)

Observation

Examples/Observations

Sample Questions/Comments

Mood

The patient’s subjective report of their emotional state (e.g., “good,” “depressed,” “anxious”)

“How have you been feeling emotionally lately?”

Affect

The observable expression of emotion (e.g., appears down, euphoric, blunted) and whether it matches the reported mood (congruent vs. incongruent)

“Does the way you feel inside match how you’re expressing yourself now?”

Range & Stability

Range: Broad versus restricted emotional expression; Stability: Fixed versus labile (rapid changes)

“Have you noticed any sudden changes in your mood during the day?”

4. Perception

Observation

Examples/Observations

Sample Questions/Comments

Hallucinations

Sensory experiences without external stimuli (auditory – hearing voices; visual – seeing things; olfactory – unusual smells)

“Have you experienced any sensations, like hearing voices or seeing things that others do not?”

Illusions

Misinterpretations of real sensory stimuli (e.g., mistaking a shadow for a person)

“Do you sometimes perceive things differently from others around you?”

Depersonalization/Derealization

Feelings of unreality regarding self (depersonalization) or surroundings (derealization)

“Do you ever feel as if you’re not real, or that the world around you isn’t real?”

5. Thought Content and Process

A. Thought Process

Observation

Examples/Observations

Sample Questions/Comments

Coherence & Organization

How well thoughts are connected (logical, coherent, relevant) versus disorganized (circumstantial, tangential, flight of ideas, loosening of associations)

“Do you find it easy to organize your thoughts when you speak?”

Specific Abnormalities

Instances of thought blocking (sudden stops), word salad (incoherent jumble), echolalia (repeating others’ words), or neologisms (making up new words)

“Have you noticed moments where your thoughts seem to just stop or jumble together?”

B. Thought Content

Observation

Examples/Observations

Sample Questions/Comments

Delusions

Fixed false beliefs (paranoid delusions: e.g., “people are watching you”; delusions of grandeur: e.g., “I have special powers”)

“Have you had any strong or unusual beliefs recently—such as feeling that people are out to get you or that you possess extraordinary abilities?”

Suicidal Ideation

Thoughts about life not being worth living or ending one’s life

“When things get overwhelming, have you ever felt that life isn’t worth living? Can you tell me more about those thoughts?”

Homicidal Ideation

Thoughts about hurting others

“Have you ever had thoughts about hurting someone else?”

6. Insight and Judgment

Observation

Examples/Observations

Sample Questions/Comments

Insight

Awareness of one’s own mental health (good insight: recognizes illness and need for treatment; partial: acknowledges a problem but is reluctant; poor: denies issues)

“What do you think is contributing to your current difficulties?”

Judgment

The ability to make sound decisions (good, fair, or impaired based on the patient’s reasoning and decision-making skills)

“Can you walk me through how you make decisions when faced with a difficult situation?”

7. Cognition

Observation

Examples/Observations

Sample Questions/Comments

Level of Consciousness

Overall alertness (alert, confused, lethargic, stuporous)

(Generally observed, but you might ask, “How aware do you feel right now?” if needed.)

Orientation

Awareness of person, place, and time (e.g., “What is your name? Where are you right now? What is the date today?”)

“Can you tell me your full name, your current location, and today’s date?”

Attention/Concentration

Ability to focus (good vs. poor concentration)

“Do you feel that you have any difficulty staying focused on tasks?”

Memory

Short-term memory (recalling recent events) and long-term memory (recalling distant events)

“What did you have for breakfast this morning?” (for short-term) and “Can you describe an important memory from your past?”

Intellectual Functioning

Overall cognitive abilities as inferred from speech and comprehension (below average, average, or above average)

“How do you solve everyday problems? Could you explain your thought process when faced with a challenge?”

Developing the Nursing Care Plan

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

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

Assessment of the Mentally Ill Read More »

mental health

Mental Health

MENTAL HEALTH

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

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

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

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

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

Concepts of Mental Health

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

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

 

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

 

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

 

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

 

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

Stress and Mental Health

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

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

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

Stressor:  is a source of stress.

Stress can produce adaptive and maladaptive responses.

Responses to Stress

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

Determinants of response to stress

Responses are influenced by internal and external resources.

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

 

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

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

  1. Causes:
    • Bewitching
    • Spirits from ancestors
    • Failure to perform cultural rituals.
    • Lack of respect from the elders
    • Over reading books
  2. Treatment:
  • Prayer
  • Performing cultural rituals
  • Visiting traditional healers
  • Left to roam about
  • Chased away from homes
  • Home and property are destroyed

Other beliefs include:

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

 How does the belief affect health care delivery

  1. Delayed treatment
  2. Refusal to accept modern medicine
  3. The disorder becomes chronic
  4. Frequent relapses

Characteristics of a mentally healthy person 

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

MENTAL ILLNESS 

Mental illness is the maladjustment in living.

The inability to cope with stress and environment.

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

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

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

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

Common signs and symptoms of mental illness  

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

 PROBLEMS ASSOCIATED WITH MENTAL DISODERS 

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

ETIOLOGY OF MENTAL ILLNESS

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

Predisposing factors

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

These are 

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

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

These are 

  • Physical stress
  • Psychosocial stress.
Perpetuating factors

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

Thus etiological factors of mental illness can be 

  • Biological factors 
  • Psychological factors 
  • Social factors 
Biological factors 

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

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

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

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

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

Psychological factors 

  • It’s observed that some specific personality types are more prone to develop certain psychological disorders. For example those who are unsocial and reserved (schizoid) are vulnerable to schizophrenia when they face adverse situations and psychosocial stresses.
  • Psychological factors like ,strained interpersonal relationships at home, place of work ,school or college, bereavement ,loss of prestige, loss of job etc
  • childhood insecurities due to parents with pathological personalities ,faulty attitude of parents (over-strictness, over-leniency), abnormal parent child relationship (over-protection, rejection, unhealthy comparisons) deprivation of child’s essential psychological and social needs etc 
  • Social and recreational deprivations resulting in boredom, isolation and alienationation.
  • Marriage problems like ,forced bachelorhood ,disharmony due to physical ,emotional, social, educational or financial incapability , childlessness or having too many children etc 
  • Sexual difficulties arising out improper sex education, unhealthy attitudes towards sexual functions, guilt feelings about masturbation, pre and extra –marital sexual relations, worries about sexual perversions.
  • Stress, frustration, climatic conditions and seasonal variations, seasonal variations and seasonal differences are sometimes noted in the occurrence of mental diseases.
Social factors 
  • Poverty, unemployment, injustice, insecurity, migration, urbanization.
  • Gambling, alcoholism, prostitution ,broken home ,divorce ,very big family ,religion .traditions political up heals and other social crises .

 

CLASSIFICATION OF MENTAL ILLENESS

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

In psychiatry classification is based on clinical description of disease.

General classification

Neurosis

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

In neuroses, there are no hallucinations and delusions.

Patients may have insight and seek help.

Examples of neurosis are:

Anxiety

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

Obsessive

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

Phobic   – fear

Panic –     Extreme of fear.

PTSD [post – Traumatic stress Disorders]

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

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

Conversion and dissociation disorder

(Hysteria) present as physical problem present as psychological.

Psychosis: 

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

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

She or he may also have disorganized speech and behavior.

Psychoses are divided into function and organic psychosis.

 

ORGANIC PYSCHOSIS.

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

Organic mental disorder can be acute or chronic.

Acute organic disorder (delirium)

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

Chronic organic disorder (dementia)

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

FUNCTIONAL PSYCHOSIS.

Don’t result from early identifiable cause.

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

Affective disorder.

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

Depression

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

Mania

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

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

Difference between neurosis and psychosis

Neurosis

Psychosis.

A minor form of M.I

Severe form of M.I

no loss of contact with reality

Loss of contact with reality

No abnormal thoughts and beliefs

Abnormal thoughts and beliefs

No abnormal sensory experience and illusion

Abnormal sensory experience and illusion

Have sight

No sight

Doesn’t require hospitalization

Hospitalization is mandatory

Continue to function socially at work

Does not act normally in society and can easily hurt himself or others

The patient frequently talks about his symptoms (has sight)

Patient denies that there’s nothing wrong with him/her.

NEWLY ADOPTED TWO MAIN CLASSIFICATIONS

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

ICD-10

  • More general categories.
  • Generally single axis.

But uses broad aetiology. Uses term neurotic.

DSM-IV-TR

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

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

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

Conditions include

  1. Disorders usually first diagnosed in infancy, childhood or adolescence
  2. Delirium, Dementia & amnestic, & other cognitive disorders
  3. Mental disorders due to a general medical condition
  4. Substance related disorders
  5. Schizophrenia & other psychotic disorders
  6. Mood disorders
  7. Anxiety disorders 
  8. . Somatoform disorders
  9. 10.Factitious disorders
  10. Dissociative disorders
  11. Sexual & Gender identity disorders
  12. Eating disorders
  13. Sleep disorders
  14. Impulse control disorders not elsewhere classified
  15. Adjustment disorders
  16. Personality disorders
  17. Other conditions that may be a focus of clinical attention 

THE FIVE AXES OF THE DSM-IV-TR.

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

GENERAL SYMPTOMATOLOGY OF MENTAL DISORDERS

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

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

Signs and symptoms of mental disorders

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

Appearance 

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

Behavior 

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

Disorders of movement 

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

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

Speech

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

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

Mood and effect 

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

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

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

Perception 

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

Perceptions include; Illusions and hallucinations

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

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

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

Thinking 

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

Symptoms associated with thinking include;

  • Stream of thoughts
  • Form of thoughts
  • Content of thought 

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

  • Pressure of thought-thoughts are rapid ,abundant and varied .the patient will feel over whelmed by these thoughts 
  • Flight of ideas; too many varied ideas that don’t connect.
  • Poverty of thoughts :the patient will report feelings un able to sustain thinking i.e. very few thoughts
  • Thought block-this is when the mind is suddenly empty and the individual loses truck of his / her own thoughts. The patient may report that the thoughts are being stolen from him 

Form of thought; 

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

  • Perseveration. Persistent repetition of the some words or ideas irrespective of the nature of question or conversation  
  • An abstract thought is the ability to interpret complex information according to expected ability.

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

The disorders of thought content include delusions, phobias and obsessions

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

Types of delusions include 

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

This includes 

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

AWARENESS AND MEMORY 

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

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

Progress symptoms of consciousness include:

  • Clouding of consciousness or lack of clear mindedness in perception and attitude.
  • Delirium or being bewildered, confused, restless and disoriented.
  • State of sustained motionlessness despite being aware of what’s going on around them.
  • Coma or unconsciousness and the patient cannot be aroused  
  • Orientation: this refers to a state in which an individual is aware of his current place in time .the person can tell what the day it is, where he is and correctly identifies the people around him.
  • Attention and concentration: attention refers to the ability of an individual to focus his mind on a task at hand, while concentration refers to the ability to sustain this focus. Concentration can be assessed by asking the individual to name the month of the year. The individual is expected to give correct answers in a maximum of two and half to three minutes .a person with poor attention and concentration may fail to learn new information and will therefore have poor registration and short term memory.

 

Depersonalization and derealization

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

Memory

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

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

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

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

Relationship; is the way we interact with others.

Symptoms related with relationships include 

  • Social withdrawal: Not wanting or desiring to participate in social activities.
  • Isolation keeping to one’s self ,even when in a social environment 
  • Poor interpersonal relations: Gets into fights or quarrels very easily with other people.

Appetite and weight :

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

Sleep disorders 

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

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

Mental Health Read More »

Eating Disorders in Children and Adolescents

Eating Disorders in Children and Adolescents

EATING DISORDERS

Eating disorders are conditions characterized by an extreme disturbance in eating related behaviour.

OR

Eating disorders are moderate to severe illnesses that are characterized by disturbances in thinking and behaviour around food, eating and body weight or shape.

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association,
2013) outlines six types of disordered eating patterns but four types are commonly diagnosed:

  1.  Anorexia Nervosa (AN)
  2. Bulimia Nervosa (BN)
  3. Binge Eating Disorder (BED)
  4. Avoidant Restrictive Food Intake Disorder (ARFID)

The rest of the two types are;

5. Other Specified Feeding or Eating Disorders (OSFED)
OSFED is also a moderate to severe illness and may include eating disorders of clinical significance that do not meet the criteria for AN or BN. OSFED and USFED may be as severe as AN or BN.
6. Unspecified Feeding or Eating Disorders (USFED)
USFED applies to where behaviours cause significant distress or impairment of functioning, but do
not meet the full criteria of any of the other feeding or eating disorder criteria.

ANOREXIA NERVOSA

Anorexia nervosa (AN) is a severe eating disorder characterized by a distorted body image that leads to restricted eating, over exercise and other behaviors that prevents a person from gaining weight or
maintaining a healthy weight.

OR

Anorexia Nervosa is defined as self-induced starvation resulting from fear of gaining weight rather than from true loss of appetite.

Person with anorexia nervosa continues to feel hunger but persists in denying himself or her self food. 

eating disorders anorexia nervosa

Children and teens with anorexia have a distorted body image. People with anorexia view themselves as heavy, even when they are dangerously skinny. They are obsessed with being thin and refuse to maintain even a minimally normal weight.

Signs and Symptoms of Anorexia Nervosa
  • Refusal to maintain a minimum normal body weight.
  • Is intensely afraid of gaining weight.
  • Significant disturbance in the perception of the shape or size of his or her body.(distorted image)
  • Dieting even when one is thin or emaciated
  • The individual maintains a body weight that is below a minimally normal level for age and weight.
  • They exclude from their diet what they perceive to be highly caloric foods. ie they restrict diet.
  • Purging i.e. self-induced vomiting or misuse of laxatives, diuretics.
  • There is excessive exercise to reduce weight.
  • Reduced total food intake
  • Intense fear of becoming fat or obese.
  • Strange eating habits, very picky.
  • Infrequent menstruation or Amenorrhea due to reduced estrogen and loss of weight
  • Oligomenorrhoea or failure to reach menarche.
  • Loss of sexual interest
  • Anxiety, depression, perfectionism(hold themselves to impossibly high standards)
Possible complications of Anorexia Nervosa

Anorexia nervosa is fatal in about 10% of cases. Most common death from anorexia nervosa is due to, cardiac arrest, electrolyte imbalance and suicide.

  • Heart muscle damage that can occur as a result of malnutrition or repeated vomiting may be life threatening. 
  • Arrhythmias (a fast, slow, or irregular heartbeat)
  • Hypotension (low blood pressure)
  • Electrolyte imbalance.
  • Anaemia (low RBC’s) and Leukopenia(low WBC’s)
  • GIT disturbances.
  • Dehydration
  • Refeeding Syndrome,
    Refeeding Syndrome “is potentially a fatal condition defined by severe electrolyte and fluid shifts as a result of a rapid reintroduction of nutrition after a period of inadequate nutritional intake
Management or Treating Anorexia Nervosa

Refer to General Management,

  • The major aim of treatment is to bring the young person back to normal weight and eating habits.
  • Hospitalization, sometimes for weeks, may be necessary. In cases of extreme or life-threatening malnutrition, tube or intravenous feeding may be required.

Nursing care

  • Short term management is focused on ensuring weight gain and correcting nutritional deficiencies. maintaining normal weight and preventing relapses
  • provide a balanced diet of at least 3000 calories in 24 hours
  • a nurse should always supervise the patient during meals
  • patient should be under complete bed rest initially under nurses observation so as to achieve a weight gain goal of 0.5 to 1kg per week
  • control vomiting by making the bathroom inaccessible 2 hours after food
  • in extreme cases when the patient refuses to comply with treatment and eating, gavage feeding may need to be instituted
  • weight should be checked regularly and plotted on a weight chart
  • maintain a strict intake and output chart
  • monitor skin status and oral mucous membrane for signs of dehydration
  • encourage patient to verbalise feelings of fear and anxiety related to the achievement
  • encourage family to participate in education regarding patients disorder
  • avoid discussions that focus on food and weight

Long-term treatment addressing psychological issues include:

  • antidepressant medication
  • Neuroleptics
  • appetite stimulants
  • behavioral therapy
  • individual therapy
  • cognitive behavioural therapy
  • family therapy
  • psychotherapy
  • support groups

BULIMIA NERVOSA

Bulimia nervosa, or bulimia, is a type of eating disorder in which a person engages in episodes of bingeing—during which he or she eats a large amount of food—and then purges, or tries to get rid of the extra calories.

OR

Bulimia nervosa is a syndrome of episodes of binge eating followed by self-induced vomiting or purge behaviour accompanied by an excessive pre occupation with weight and body shape.

Young people with bulimia try to prevent weight gain by inducing vomiting or using laxatives, diet pills, diuretics, or enemas. After purging the food, they feel relieved. Binge eating is often done in private. Because most people with bulimia are of average weight or even slightly overweight, it may not be readily apparent to others that something is wrong.

The condition often begins in the late teens or early adulthood and is diagnosed mostly in women. People with bulimia may have other mental health issues, including depression, anxiety, drug or alcohol abuse, and self-injurious behaviors.

Doctors make a diagnosis of bulimia after a person has two or more episodes per week for at least three months. People with bulimia usually fluctuate within a normal weight range, although they may be overweight, too. As many as one out of every 25 females will have bulimia in their lifetime.

Binge is eating in a discrete period of time an amount of food that is definitely larger than most individuals would eat under similar circumstances.

eating disorder bulimia nervosa
Signs and Symptoms of Bulimia Nervosa
  • The individual is typically ashamed of his or her eating problem.
  • Persistent heart burn and sore throat.
  • Abdominal and epigastric pain.
  • They tend to conceal their symptoms, It occurs in secrecy
  • Food is consumed rapidly
  • Binge eating continues until the individual is uncomfortable or even painfully full.
  • The binge eating is usually triggered by low mood, interpersonal stressors, intense hunger
    following dietary restraint.
  • Loss of self control, Difficult in resisting binge eating or difficult in stopping it.
  • Employs compensatory technique for example induce vomiting after binge eating.
  • They place emphasis on body shape and weight in their self evaluation.
  • Have fear in losing weight.
  • May be overweight or underweight
  • Low self esteem
  • Increased frequency of anxiety for example fear of social situation
  • Fluid and electrolyte imbalance due to purging
  • Menstrual irregularity or amenorrhea may occur
  • Rectal prolapse
  • Increased dental caries
  • Scarring of knuckles from using fingers to induce vomiting.

Management or Treating Bulimia Nervosa

Refer to General Management,

Treatment aims to break the binge-and-purge cycle. Treatments may include the following:

Nursing care

  • engage patient in therapeutic alliance to obtain commitment to treatment
  • establish contract with the patient that specifies amount and type of food she must eat at each meal
  • set a time limit for each meal
  • identify patients elimination patterns
  • encourage the patient to recognize and verbalize her feelings about her eating behavior
  • explain the risks of laxative, emetic and diuretic abuse
  • assess and monitor patients suicide potential

Other treatment modalities

  • antidepressants medication
  • behavior modification
  • individual, family, or group therapy
  • nutritional counseling
  • self help groups
Complications of Bulimia Nervosa
  • Stomach acids from chronic vomiting can cause,
  • damage to tooth enamel,
  • inflammation of the esophagus,
  • swelling of the salivary glands in the cheeks,
  • low potassium which can lead to abnormal heart rhythms.

BINGE EATING DISORDER

Binge eating is similar to bulimia.

Binge eating refers to  chronic, out-of-control eating of large amounts of food in a short time, even to the point of discomfort without  purging the food through vomiting or other means.

People with binge eating disorder eat unusually large amounts of food often and in secret but do not attempt to get rid of calories once the food is consumed. People with the condition may be embarrassed or feel guilty about binge eating, but they feel such a compulsion that they cannot stop.

These people can be of average weight, overweight, or obese. They may also have other mental health disorders, such as depression. Many binge eaters have trouble coping with anger, sadness, boredom, worry, and stress.

Binge eating disorder often has no physical symptoms, but it has psychological symptoms that may or may not be apparent to others, such as depression, anxiety, or shame or guilt over the amount of food eaten. Frequent dieting without weight loss is another symptom.

The excess weight caused by binge eating puts the child at risk of these health problems:

Treatments include the following: Refer to General Management,

  • behavioral therapy
  • medications, including antidepressants
  • psychotherapy

AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER

Avoidant/restrictive food intake disorder, is an eating disorder where a person is unable to or refuses to eat certain foods based on texture, color, taste, temperature, or aroma.

The condition can lead to weight loss, inadequate growth, nutritional deficiencies, and impaired psychosocial functioning, such as an inability to eat with others. Unlike anorexia nervosa, there are not weight or shape concerns or intentional efforts to lose weight.

For instance, a child may consume only a very narrow range of foods and refuse even those foods if they appear new or different. This type of eating disorder commonly develops in childhood and can affect adults as well.

Assessment/Screening for an Eating Disorder

  1. The SCOFF Test: 

Early detection in patients with unexplained weight loss improves prognosis and may be aided by use of the SCOFF questionnaire, developed by John Morgan at Leeds Partnerships NHS Foundation
Trust.

This questionnaire uses five simple screening questions and has been validated in specialist and primary care settings. It has a sensitivity of 100% and specificity of 90% for anorexia nervosa. A score of 2 or more positive answers should raise your index of suspicion of a case, highlighting the need for a comprehensive assessment for an eating disorder and
consultation with an eating disorder expert or mental health clinician. 

scoff test eating disorder

2.  SUSS (Sit up – Squat – Stand Test) for muscle strength

1. Sit-up: patient lies down flat on the floor and sits up without, if possible, using their hands

2. Squat–Stand: patient squats down and rises without, if possible, using their hands.

Scoring (for Sit-up and Squat-Stand tests separately)

ParameterScore
Unable0
Able only when using hands to help1
Able with noticeable difficulty2
Able with no difficulty3

A Sit up – Squat – Stand(SUSS) score ≤ 2 indicates a RED FLAG.

Anorexia Nervosa (AN) has the HIGHEST MORTALITY rate of ALL mental health illnesses
Patients with AN are at risk of sudden death if the have the RED FLAGS below.

RED FLAGS

  • SUSS score less or equal to 2
  • Postural drop
  • Bradycardia
  • Hypothermia
  • Electrolyte abnormalities
Nurses Role during assessment
  • Nurses in the hospital or primary care setting are in a crucial position to screen for and detect eating disorders, hence the importance for nurses to have an awareness of the indicators for eating disorder assessment.
  • supporting psychological based therapies, psycho-education regarding
    effects of the eating disorder,
  • assessment of risk,
  • promoting recovery and hope,
  • involving famil and caretakers,
  • observing for co-morbidities.

GENERAL MANAGEMENT OF EATING DISORDERS

Aims

  •  To restore the patient’s nutritional status.
  • To prevent complications.


General management

  1.  Develop a trusting relationship with the patient.
  2. Convey positive regard to the patient
  3. Stay with the patient especially at the time of meals and 1 hour after meals.
  4. Avoid arguing or bargaining with the patient who is resistant to treatment.
  5. State matters of facts which behaviours are unacceptable.
  6. Encourage the patient to verbalize feelings regarding role within the family and issues related to dependence.
  7. Help the patient to recognize ways to gain control over these problems in life.
  8. Help the patient to develop a realistic perception of body image and relationship with food.
  9. Promote feelings of control within the environment through participation and dependent
    decision making.
  10. Weigh patient daily. Always use the same weighing scale to avoid errors.
  11. Keep strict record of observations especially fluid input and output.
  12. Assess skin; motility and tugor regularly.
  13. Assess moistness and color of the skin and oral mucus membranes.


Behaviour modification

  •  Develop care plan together with the client
  • Encourage the client to sign a contract is necessary
  • Staff and client can agree on a system of reward.
  • Individual therapy such as psychotherapy may be important. This is particularly helpful when there is underlying psychological problems contributing to the maladaptive behaviour.
  • Family therapy:
    > Counsel the family members. This includes educating the family about the disorder, assessing the family perception or attitudes.
    > Support given to the family
  • Refer if necessary
  • Chemotherapy: there are no specific drugs indicated for the treatment of the condition. Drugs
    such as flouxetine, chlorpromazine, and lithium carbonate have been used.

Nursing Diagnoses

  •  Imbalanced nutrition less than body requirement related to refusal to eat or self induced vomiting as evidenced by loss of weight.
  • Ineffective denial related to fear of losing or retarded ego development as evidenced by inability to admit the impact of maladaptive eating behaviours on life pattern.
  • Disturbed body image related to false perception of increased body weight evidenced by patient’s verbalization of that she has global over weight.

Eating Disorders in Children and Adolescents Read More »

pharmacolgy and mental nursing quiz

Pharmacology & Mental health Quiz

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Self study questions for nurses and midwives

Self Study Question For Nurses and Midwives

PREPARATORY QUESTIONS FOR END OF SEMESTER EXAMINATIONS

SURGERY

1a) define the term epistaxis

b) What are the causes of epistaxis?

c) Write down the management of a patient presenting with epistaxis

2a) define a sty

b) What are the causes of a sty?

c) Outline the signs and symptoms of a sty

3 An adult has been admitted to a surgical ward with difficulty in breathing, he requires urgent tracheostomy.

a) List the indications of tracheostomy

b) Describe the post-operative management of this patient till discharge

c) Outline the complications that are likely to occur

d) Formulate five actual nursing diagnoses and four potential diagnoses from this patient with tracheostomy

4. Mrs Akello 38years old has presented with nasal polyps and she is to undergo polypectomy

a) List the causes of nasal polyps

b) Outline the signs and symptoms of nasal polyps

c) Give the specific pre and post-operative management of this patient

d) List four complications of nasal polyps

5. a) Define tonsillitis

b) List 6 symptoms and signs of a patient with tonsillitis

c) Give the specific post-operative management for a patient who has undergone tonsillectomy

6. Mrs Nabukeera was admitted on a surgical with a diagnosis of adenitis .She is to undergo adenoidectomy

a) Define adenitis

b) List the signs and symptoms of adenitis

c) Describe the specific post-operative management you would give to her till discharge

7. a) Define burns

b) What are the causes of burns?

c) How can burns be classified

d )Mr. KK has sustained burns on the neck and chest

>calculate the percentage of the area burnt

>what specific management do you give to Mr. KK in the first 72hrs of admission

>give five actual nursing diagnoses Mr KK will have due to the burns

8a) Define the term electrolyte imbalance

b) Give the causes of electrolyte imbalance

c) List the signs and symptoms of electrolyte imbalance

d) Mention the types of electrolyte imbalance in the body

e) How can you manage patient with electrolyte imbalance

9a) Define the term gangrene

b) What are the causes of gangrene?

c) Write down the types of gangrene

d) Mention the signs and symptoms of different types of gangrene

e) Describe the specific management which is given to this patient with gas gangrene

10a) Define the term shock

b) Write down the types/classification of shock

c) State the clinical features of shock

d) Write down all possible complications of shock

e) How can a health worker prevent surgical shock?

11a) Outline the classifications of wounds

b) Give the factors that delay wound healing

c) State five complications of wounds

d) What advice do you give to a patient about wound care at home who is due for discharge?

e) Explain the process of wound healing

12a) Define the term a fracture

b) Mention the different types of fracture

c) Describe the management of a closed fracture of a femur

d) List any 6 complications of a fracture

13a) Define the term inflammation

b) List the signs and symptoms of inflammation

c) Describe the process of inflammation

d) Explain the specific management of a 12yr old patient with inflammation on the lower limb

13A 28year old male was admitted on a surgical ward with a diagnosis of tetanus

a) List five cardinal signs and symptoms this patient would present with

b) Explain the specific nursing management you would give to this from admission to discharge

c) Formulate four actual and two potential nursing diagnoses from this patient’s condition

14a) Define the term immunity

b)Classify immunity

c) Explain the factors that affect an individual’s immune system

15a) Define hemorrhage

b) Explain the different types of hemorrhage

c) Explain the mechanism of hemostasis

d) Outline the specific management of a patient with severe bleeding on the left lower leg

16a)What is blood transfusion?

b) Describe five complications that may occur due to blood transfusion

c) What would cause failure of of a blood drip to run during blood transfusion

d) Explain the nurse’s responsibility before , during, and after blood transfusion

17a) Define a cataract

b) outline the cardinal signs of a cataract

c)Describe the management of Mr Moses a 40yr old presented to your OPD department with a cataract using a nursing process

d)list the likely complications of a cataract

MENTAL HEALTH

18. Define the following terms

a)suicide

b) Suicidal ideation

c) Attempted suicide

d) par suicide

e) paradoxical suicide

19a) outline the common psychiatric conditions associated with suicidal ideation

b) Explain the common factors contributing to suicide in the community

c) Mention the impact of suicide to the family and the community

d) Describe the management of a patient who intends to commit suicide

e) Explain the assessment you would carry out on a patient with suicidal ideation

20a) Define PTSD

b) Outline four signs and symptoms of a patient with PTSD

c) Manage an 11yr old girl who presented with PTSD after rape

21a) Define the term delirium tremens

b) Identify the causes of delirium tremens

C) How can you manage the patient with delirium tremens?

d) Formulate 5 potential nursing diagnoses for a patient with delirium tremens

22. Madam EKEB a 26yr old is very aggressive on the ward that she cares away fellow patients

a) Differentiate between aggression and violence

b) What management do you give to madam EKEB who presents with severe aggression on the ward?

23a) what is a psychiatric emergency?

b) List 10 common psychiatric emergencies

c) Which admission procedure would you follow when admitting a patient presenting with any of the psychiatric emergencies

23a) Explain standards of care in psychiatry

b) Who is a class B criminal lunatic?

c) Mention all the orders used to admit mentally ill patient

d) Write down and explain all the sections used in discharging a mentally ill patient

e) Outline the rights of a mentally ill patient

24. A 30yr old patient has presented in a psychiatric ward with status epilepticus

a) Define status epilepticus

b) Manage the patient who presents with status epilepticus on a ward

c) Formulate four potential and 2actual nursing diagnoses for a patient with status epilepticus

25aDefine mental retardation

b) Classify mental retardation

c) Explain 8 causes of mental retardation

d) What advice do you give to a family with a mentally retarded child?

26. ADHD is one of the common psychiatric conditions in children

a) Outline 6 signs and symptoms of ADHD

b) Manage an 11yr old boy with ADHD

c) What specific advice do you give to a family with a child having ADHD?

27a) Define autism

b) Explain the common features of autism

c) Describe the management of the above condition

28. Depression is one of the common psychiatric conditions

a) Define depression

b) Outline the specific management of a patient with severe depression on a psychiatric ward

c) Make 4 priority nursing diagnoses for a patient with severe depression

COMMUNITY HEALTH

29. a) Define PHC

b) Mention the principles of PHC

c) Outline components /elements of PHC

d) What strategies are used to achieve PHC activities in a given community?

30a) What is community assessment?

b) Explain how you would identify any health problems in a given community

c) Outline 9 important information you would find out in a given home during assessment

31a) Define a home visit

b) Explain how you apply a nursing process during a home visit

c) Outline the merits and demerits of a home visit

32a) Define vital statistics in health

b) Explain the importance of vital statistics in health

c) Outline 6 key vital statistics used to determine the health status of a community or country

33a) Explain the relationship between PHC and CBHC

b) Explain the role of a community nurse/midwife in implementation and achievement of any 4 of the PHC principles

c) Outline the advantages of PHC over other specialized medical services

34a) Define community mobilization

b) Describe how you would mobilize a community towards implementation of a health education program

35a) Define school health

b) Explain the importance of a school health program

c) Explain the role of a nurse in the provision of a school health program

d) Outline the components of school health services

36a) Explain the role of a community in PHC services

b) Give 8 advantages of community participation in PHC services

c) Explain the obstacles to effective community participation in PHC programs

37a) Define community diagnosis

b) Discuss why community diagnosis is important

c) Explain the steps in conducting community diagnosis

38Health promotion are actions related to lifestyles and choices that maintain/enhance population health

a) Outline any 5 health promotion interventions you would implement in a given a community

b) Explain 5major steps in community mobilization

39. Describe the different levels of disease prevention

40. Appropriate technology is one of the elements of PHC

a) How is appropriate technology expressed in implementation of PHC services?

b) Explain the advantages and disadvantages of appropriate technology as an element

41. a) Define the term epidemics

b) Explain the factors that contribute to the causes of epidemics

c) What is the role of a nurse in the management of an epidemic in the community?

42a) Define community health and community based health care

b) State the characteristics of CBHC

c) Describe how you would enter a village in Mityana to implement a community health activity

TROPICAL MEDICINE

43a) Define schistomiasis

b) Explain the different types of schistosomiasis

c )Give the clinical manifestations of schistosoma mansoni

d) Describe the lifecycle of schistosomiasis haematobium using a well labelled diagram

e) Outline the preventive measures of all types of schistosomiasis

44The current disease burden in Uganda is attributed to communicable diseases

a) Describe the modes of transmission of communicable diseases in general

b) Describe the methods/approaches used to prevent and control communicable diseases in the community

c) Explain the types of water diseases and their examples

45a) Define diarrhoea

b) Outline the causes of diarrhoea in Uganda

c) Discuss the drugs used in the management of diarrhoea in children

d) Formulate 5 priority nursing diagnoses of this patient

46a) Define measles

b) Outline the signs and symptoms of measles basing on the stages

c) Describe the management of a12yr old child presenting with measles from admission to discharge

d) List the likely complications of measles

47. Malaria is one of the communicable diseases affecting most communities of Uganda

a) Classify malaria

b) Outline the cardinal signs of complicated malaria

c) Describe the lifecycle of malaria in both man and the mosquito with the aid of diagrams

d) How can different communities prevent the spread of malaria?

e) Make 5 actual and 3 potential diagnoses of malaria

48a) Describe the life cycle of ackylostomiasis with the aid of diagrams

b) Explain the preventive measures of hook worm infestation

c) List the likely complications of neglected worms

49a) Ebola is one of the hemorrhagic fevers devastating some communities and countries due to known and unknown reasons

a) Define hemorrhagic fevers

b) List the different hemorrhagic fevers

c) Outline the different causes and predisposing factors to hemorrhagic fevers

d) Describe the management of Mr. X presented to your hospital suspected to be an Ebola patient

50a) Define rabies

b) Describe the management of rabbis both at home and in the hospital

c) Explain the complications of rabies

51a) Define bacilliary dysentery

b) State the differences between bacilliary dysentery and amoebic dysentery

c) Describe the specific management of a 3yr old child with bacilliary dysentery from admission to discharge

52a) Define typhoid fever

b) Explain the cardinal signs and symptoms of typhoid fever

c) Describe the important information you would give to the community concerning prevention of typhoid fever

53a) Define trachoma

b) Outline the signs and symptoms of trachoma

c) Explain the management of 23yr female presenting with trachoma

d) List the complication

54. Samuel a 30yr old peasant has been presented to the OPD with all the features of tetanus

a) Outline the clinical features of tetanus

b) Describe the management from admission to discharge

c) List the complications of tetanus

MIDWIFERY 1 AND 2 AND OBSTETRIC ANATOMY

55. List the 5 medications used in antenatal and discuss them under

a) Dose

b) Indication

c) Side effects

56a) Outline the obstetrical causes of anemia in pregnancy

b) List the five causes of hemolytic anemia

c) Describe the management of Mrs. mucosal who presents at 36weeks with severe anemia

57a) Define a cervix

b) With the aid of a diagram, describe the structure of the cervix

c) Outline the 6 functions of the cervix

58a) Define the term good antenatal care

b) Give the indications of referring a mother to a doctor during this period

c) How would you manage a mother who comes with lower back pain in antenatal at 32weeks?

59a) Define normal puerperium

b) Describe the management of a mother who has had normal delivery up to discharge

c) List the complication that may occur during this period

60a) Outline the symptoms of pregnancy

61a) Explain the characteristics of normal uterine action during first stage of Labour

b) What is the management of a gravid 3 para 2 mother at term who presents to hospital with history of precipitate Labour on the previous pregnancies?

62a) Describe a vagina

b) What information is got on vaginal examination during labor?

c) Mention four contractions of vaginal examination giving reasons for each

d) List the complications of vaginal examination

63a) Define intrauterine fetal death

b) Outline the causes of IUFD

c) How is the diagnosis of IUFD made?

d) What is the management of IUFD in the hospital?

64a) Describe the pelvic floor

b) Outline injuries that can occur to the pelvic floor during Labour

c) Explain how the knowledge of fetal skull can help you as a midwife prevent perineal tears

65a) Describe the fetal skull

b) How is fetal wellbeing monitored during pregnancy?

C) List the indications of ultrasound scan in late pregnancy

66a) Describe a non-pregnant uterus

b) Describe the changes that take place in this organ during pueperium

c) List the likely complication in the first stage of labor

67a) what is the effect of DM on pregnancy?

68a) how does pregnancy affect DM?

b) How would you care for a diabetic mother who has had a caesarean section in the first 48hours of the operation

69a) Describe the umbilical cord

b) Describe the different abnormalities of the cord

70. Malaria is of the conditions contributing affecting pregnancy and contributing factor to increased maternal mortality and morbidity

a) Explain why pregnant women are more susceptible to malaria

b)Describe the a primigravida who presents to your maternity center at 34 weeks with severe malaria

c) Outline the likely complications of malaria on pregnancy

71. Essential hypertension is one of the hypertensive disorders experienced by pregnant women

a) Define essential hypertension

b) Classify hypertensive disorders in pregnancy

c) Describe the management of Mrs Nangobi a G4P2+1 presenting in antenatal clinic at 32weeks with a diagnosis of essential hypertension

d) How does hypertension affect pregnancy?

72a) outline the signs and symptoms of first stage of Labour

b) Describe the management of a young primigravida in first stage of Labour

c) List the complications likely to occur during this stage of Labour

73a) Define hyperemesis gravidarum

b) Outline the causes of hyperemesis gravidarum

c) Describe the management of G2P1+0 presenting to your maternity center with hyperemesis gravidarum at 28 weeks of gestation

d) Explain the likely complications of this condition

74a) what is preeclampsia

b) Outline the signs and symptoms of preeclampsia

c) What are the predisposing factors of this condition?

d) Outline the nursing of a mother with severe preeclampsia

e) List the complication of severe preeclampsia

75a) Describe the placenta at term

b)Explain the functions of the placenta

c) Outline the abnormalities that may be found on the placenta

76a) With the aid of a diagram, describe the structure of the female breast

b) Explain the physiology of lactation

c) Explain the factors that promote successful lactation

77a) Define labor

b) Explain the physiology of the first stage of Labour

c) Describe the management of a mother in the second stage of Labour admitted in the hospital

78a) Outline the changes in the cervix during the first stage of labor

b) What information is found on the partograph?

c) A G2P1+0 mother came to a health center in normal labor , what may make you refer?

79. Most women find it helpful to get further information and support in their own homes.

a) Give 5 advantages of following up post-partum mothers

b) Explain postpartum maternal assessment you would carry out during domiciliary care

c) List the problems that you would identify during domiciliary care

80a) Describe 6 factors that influence the length of second stage of labor

b) Explain 3 phases used in conducting 2nd stage of labor

c) Give immediate assessment of the baby after 2nd stage of labor

81a) Mention factors that aid in involution of the uterus

b) Explain how you assess and document uterine involution immediately after delivery to 10days postpartum

c) Give five complications of sub involution of the uterus

82a) Explain the antenatal appointment schedules

b) Give 6 barriers to adherence to goal oriented antenatal visits

c) Identify 5 complications a pregnant woman is likely to get if no antenatal is attended

83a) Describe the structure of the ovary

b) List the functions of the ovary

c) Describe the menstrual cycle

MEDICINE I AND 111

84. Mr. KIBULA known hypertensive has been brought to hospital with suggestive features of hypertensive crisis.

a) Mention 8 clinical features of hypertension

b) List 4 causes of HTN and predisposing factors

c) Explain the specific Nursing Care you will give to Mr. KIBULA from the time of admission to discharge.

85. Write short notes on the following (definition, causes, signs and symptoms and complications).

a) Hydrocele

b) Hodgkin’s disease

c) Ankylosing spondylitis

86 a) Define Paget’s disease/Osteitus, deformans?

b) Explain the pathophysiology and etiology of Paget’s disease

c) Describe the specific nursing care you would give to Mr. Muwonge with Paget’s disease

87. Hepatitis B morbidity and mortality is much higher today than before.

a) What are the factors, contributing to the high prevalence of hepatitis B in the communities

b) How does a patient with hep.B present?

c) Give five priority nursing diagnoses for a patient with Hep B infection.

d) Describe the specific nursing management you would give to a patient with hep B.

e) Mention the complications of hep B.

f) Suggest ways how we can prevent hep B infection in the community

88. Define myocardial infarction. List the clinical features of myocardial infarction.

Explain the specific Nursing care given to a patient with myocardial infarction within the first 24Hrs of admission.

89. An adult male patient has presented to OPD with features of pulmonary tuberculosis

a) Outline five cardinal signs and symptoms of pulmonary tuberculosis.

b) List five specific investigations that can be done to confirm pulmonary tuberculosis.

c) Explain the specific nursing care given to this patient from the time of admission until discharge.

90. Mrs. A, a female patient has been admitted on a medical ward with suspected bronchial pneumonia,

a) Outline the clinical features of bronchial pneumonia

b) Describe the specific nursing management you would give to Mrs. X with in the first 72HRS of admission.

c) Explain five likely complications Mrs. X is likely to get following this condition.

91. Mr. Lusoke, a 62 yrs. old male is presented at the OPD with features of congestive cardiac failure

a) Outline the signs and symptoms of congestive cardiac failure.

b) Mention the causes of congestive cardiac failure.

c) Describe the specific nursing care / management you will give to Mr. Lusoke from time of admission to discharge.

92. Outline the signs and symptoms of Parkinson’s disease.

b) Mention the causes and predisposing factors to Parkinson’s disease.

c) Describe the specific Nursing management given to a patient with Parkinson’s disease.

93. Mr. Okello a 28yrs old male presents at OPD with clinical features of urinary tract infection and was admitted.

a) List 5 causes and 6 signs and symptoms of urinary tract infection.

b) Describe the specific nursing care you would give to Mr.Okello within the first 48 hours of admission.

c) Give the measures that can be taken to prevent urinary tract infections.

94 Define Addison’s disease?

b) Outline the causes and risk factions that leads to Addison’s disease.

c) Using the Nursing process, describe the management of a patient with Addison’s disease.

PEDIATRICS 1 AND 11

95. Define the term Apgar score

a) Outline 10 characteristics of a normal new born baby

b) Describe the care given to the normal new born baby within 72 hours after delivery of the head.

96. Differentiate between SAM and MAM

b) Explain the causes of malnutrition in children under 5 years.

c) Explain the importance of breastfeeding in babies’ up to 2years of age.

97. Define the term congenital abnormalities

a) Classify the congenital abnormalities of the heart

b) Explain ways of preventing congenital abnormalities.

98. Mention the factors that predispose to neonatal infections in new born babies.

b) List 8 clinical features of a child with neonatal tetanus.

c) Describe the specific management of a 3 month old child with tetanus.

99. Outline the factors that predispose to birth injuries

Differentiate between a caput succedaneum and a cephalo hematoma.

c) Describe the specific management you would give to a new born baby who presents with a caput succedaneum.

100. Brandon a five weeks old neonate is admitted on ward with a history of fast breathing, chest in drawing and stridor.

b) Explain the specific nursing care you would offer to Brandon in a hospital within the first eight hours of admission.

101. A five year old child has been bought to OPD in a painful sickle cell crisis.

a) Outline 5 possible causes of sick cell crisis.

b. List 4 diagnostic signs and symptoms of sick cell disease in children.

c) Explain the specific management of this child from admission to discharge.

102. A 4 months old baby has been admitted on a pediatric ward and diagnosed with pneumonia.

a) Outline the clinical presentation of this child.

b) Explain the specific management given to the child with in the first 72 hours.

103. Define the following terms.

1) Fracture

ii)Osteopenia of prematurity

osteogenesis imperfecta

Osteomyelitis

b) Mention 5 signs and symptom of osteomyelitis in children.

c) Describe the nursing management of 3 years old child with osteomyelitis.

104. A 8 month old child has been diagnosed with nephrotic syndrome.

a) List 6 signs and symptoms of nephrotic syndrome in children.

b) Describe the specific nursing management you world give to this child within the first 72 hours of admission on a pediatric ward.

c) Outline five complications of nephrotic syndrome.

105. What are the advantages of breast feeding?

Compare human milk and cow’s milk

Outline problems that are faced by mothers during breastfeeding.

106. List five congenital abnormalities of the G’T and 5 musculoskeletal system

Outline the causes of congenital abnormalities.

How do you cause a mother who has delivered a baby with spinal bifida?

107. List the factors that promote good nutrition in the under-five.

List five pieces of advice you would give to a prime para with a two year old baby suffering from protein calorie malnutrition.

List five problems of birth injuries in Uganda.

Outline the roles of a nurse in prevention of birth injuries in Uganda.

PHARMACOLOGY 1 AND 111

108. Define rational drug use

Outline the medical classification of drugs giving examples of each

Mention the legal classes of drugs with examples of each.

109. Define infertility.

State the common cause of infertility in women

c) State the indications, side effects and contraindications of clomiphene and Bromocriptine.

110. Describe the mechanism of action of non-opioid analgesics.

b) Write briefly about the handling of the class of drugs in a hospital

c) Define the following:-

Chemotherapy

Anti tussive

111. Mention 4 Four sources of drugs

b) Write down all routes which can be used for drug administration giving advantages and disadvantages of each.

c) Write down the factors that affects drugs absorption.

d) What factors affect drug dosage and action?

112. State the clinical uses of oxytocin and mention 6 adverse side effects of the drug.

b) Outline 5(five) contraindications of oxytocin

c) Describe 10 (ten) Nursing considerations while administering oxytocin.

113. Define Narcotic drugs and state the types of narcotics.

b) List down 7 nursing considerations before during and after administrating narcotics on ward.

c) What are the legal implications of Narcotics according to the Uganda narcotic drugs and psychotropic substance control ACT?

114. Define immunity and explain the two major types of immunity.

State the specific side effects, indication and the dosage following drugs:-

  1. Anti D (RHO) Immunoglobulin
  2. B) Rabies vaccine
  3. Pneumococcal Vaccine.

115. Describe the physiology of erection in males

b) State the causes of erectile dysfunction

b) Mention the class, indication, Dosage and side effects of the following drugs.

i) Sildenafil.

ii) Tadalafil

iii) Finesteride.

GYNAECOLOGY

  1. a) Outline signs of breast cancer.

b) Explain post operative care after mastectomy.

c) List possible complications of mastectomy.

  1. . a) Draw a diagram showing possible sites of vaginal fistula.

b) Outline the 5 major causes of vaginal fistula.

c) Explain specific nursing care of a woman after VVF repair.

118. a) Define the different types of Abortion.

b) Outline causes of missed Abortion.

c) Explain different methods used in the management of missed abortion.

d) Outline the 5 elements of PAC.

  1. a) Define ectopic pregnancy.

b) Outline signs and symptoms of tubal pregnancy.

c) A mother presents to the medical facility with a tubal pregnancy, describe her management till discharge.

119. a) List the disorders of menstruation.

b) Explain the advice and treatment given to a 17 year old girl with dysmenorrhea.

120 a) Define Hydatidiform mole.

b) Outline signs and symptoms of hydatidiform mole.

c) Describe the methods of managing the above condition and list complications that may follow.

121. Describe pelvic inflammatory disease.

b) What are the predisposing factors of this condition?

c) Describe management of PID in the hospital.

  1. a) What is infertility?

b) Outline causes of infertility.

c) Explain the different methods that can be used to manage infertility.

  1. a) Draw a diagram of a uterus indicating sites of fibroids.

b) Differentiate between benign and malignant tumor.

c) Give the management of the mother after myomectomy within the first 48 hours.

d) What specific advice would you give this mother on discharge.

REPRODUCTIVE HEALTH

  1. a) Define STDs?

b) Explain ten preventive measures against sexually transmitted infections.

c) Describe the syndromic management of STDs.

  1. a) List 7 components of reproductive health.

b) Outline the advantages and disadvantages of intergrating reproductive health.

c) Outline 10 factors that affect women’s reproductive health.

  1. a) Define sexual abuse?

b) Explain factors that expose adolescent girls to sexual abuse or vulnerability.

c) Outline 5 clinical features of sexual abuse in an adolescent.

  1. a) Define i) Post Abortion Care

ii) Comprehensive abortion care.

b) Explain the Rational for PAC.

  1. a) Who is an adolescent?

b) Describe Tanner’s stage of development in an adolescent.

c) List common health problems faced by adolescents.

  1. a) What is safe motherhood?

b) Outline the 3 delays that can increase maternal mortality.

c) What is your role as a midwife in reduction of maternal mortality in your community?

  1. Describe syndromic approach of managing STIs.
  2. a) Define domestic violence.

b) What are the factors that make you suspect that one is a victim of domestic violence?

c) How would you prevent domestic violence?

  1. Describe manual vacuum aspiration.

FOUNDATIONS OF NURSING.

  1. a) Define wounds.

b) Give 5 types of wounds.

c) Outline the factors that delay wound healing.

d) Give the specific management for a patient with specific wound.

e) What specific advice do you give to a patient with a wound prior to discharge.

f) Describe the process of wound healing.

  1. a) Outline the indications for oxygen administration.

b) Give the rules to follow before, during and after administration of oxygen.

c) Define blood transfusion.

d) Outline the indications of blood transfusion.

e) Outline the appropriate care of the patient before, during and after blood transfusion.

f) Give the complications of blood transfusion.

  1. a) Define drug administration.

b) Outline the different routes of drug administration.

c) Mention the principles of drug administration including the dos and don’ts in drug administration.

  1. a) Define infection prevention and control.

b) Define nosocomial infection.

c) Outline the steps taken to prevent infections of the wound.

d) What are the advantages of oral route drug administration over the parental route.

  1. a) Outline the indications of Tracheostomy.

b) Give the specific pre and post operative nursing care for the patient with tracheostomy.

c) Mention the complications of tracheostomy.

d) Formulate 4 actual nursing diagnoses for a patient with colostomy.

  1. a) Define lumber puncture.

b) Outline the indications of lumber puncture.

c) Explain the specific nursing care given to the patient prior to after the procedure of lumber puncture.

d) List the complications of lumber puncture.

  1. a) Define abdominal paracentesis.

b) Outline the indications of paracentesis.

c) Give the specific care given to the patient before and after abdominal paracentesis.

d) Mention the complications of abdominal paracentesis.

  1. a) Define tractions.

b) Explain the different types of tractions.

c) Outline the specific nursing care given to a patient with tractions.

d) Formulate 5 actual nursing diagnoses for a patient with tractions.

e) Outline the likely complications of the patient on traction.

  1. a) Outline the indications of underwater seal drainage.

b) Give the specific nursing care for a patient on underwater seal drainage.

c) Formulate four nursing diagnoses for a patient on underwater seal drainage.

d) List the complications of underwater seal drainage.

  1. a) Outline 6 indications of gastric lavage.

b) Define colostomy.

c) Formulate 4 actual nursing diagnoses and 4 potential nursing diagnoses for a patient with colostomy.

d) Give the specific nursing care to the patient with colostomy.

  1. a) List the indications of Glasgow coma scale.

b) Describe the Glasgow coma scale.

ANATOMY AND PHYSIOLOGY II

  1. a) With illustration, describe the formation of flow of CSF.

b) List the functions of CSF.

c) Describe the meninges covering the brain and spinal cord.

  1. a) Describe the position and gross structure of the parathyroid glands. Outline the functions of parathyroid hormone and calcitonin.

b) Explain the disorders of the thyroid gland.

  1. a) Describe the structure of a nephron.

b) Explain the processes involved in the formation of urine.

c) Describe how body water and electrolyte balance is maintained.

  1. a) Describe the structure of the ear.

b) Explain the physiology of hearing.

c) Explain the functions of the accessory organs of the eye.

  1. a) Explain the role of lymphatic vessels in the spread of infections and malignant disease.
  2. a) Describe the location of the pharynx and relate it’s structure to it’s function.

b) List the functions of the trachea in respiration.

c) Explain the main mechanisms by which respiration is controlled.

d) Describe the common inflammatory and infectious disorders of the upper respiratory tract.

  1. a) Define a neuron.

b) Outline the 12 cranial nerves of the nervous system.

c) Describe the transmission of an impulse across a synapse.

PALLIATIVE CARE NURSING

150 a) Define palliative care

b) Explain the principles of palliative care

c) Give the challenges faced in implementing in palliative care services in Uganda

151.a) Define pain according to WHO

b) Explain different types of pain in palliative care

c) Describe the principles of pain management in palliative care

d) Describe the steps of breaking bad news

152.a) Explain 6 roles of palliative care in Uganda

b) Outline 6 symptoms commonly experienced by terminary ill patients

153.a) What is grief?

b) Explain 5 stages of grief experienced by palliative care patients

c) Explain the HOPE approach to spiritual pain management

d) Outline the spiritual problems experienced by palliative care patients

Self Study Question For Nurses and Midwives 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 »

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