ZAMBIA REGISTERED NURSING DIPLOMA

COURSE TITLE : MENTAL HEALTH AND PSYCHIATRIC NURSING

COURSE CODE: MHP 026

Reviewers:

VINCENT MHANGO

AMINU ABDULMAJEED

GEORGE CHIWELE

Introduction

Welcome to this very interesting course in general nursing which is offered as part of the general
nursing curriculum. The course focuses on the study of mental health and psychiatric nursing as
an aspect of general nursing and it is designed to provide you the opportunity of applying
the nursing sciences in the care of your patients in any given situation. This course will broaden
your knowledge and skills needed for meeting the ever changing needs of the clients/patients,
families and society. The total course will take 90 hours on theory and 135 hours practical
experience which embraces community psychiatry. It is a full course just like medicine and
medical nursing. Psychiatry is a branch of medicine which deals with the study and treatment of
mental diseases. It deals with the mind, emotions and behaviour of man precisely; the least
understood portion of the human being.

Psychiatric illness is characterized by a breakdown in the normal pattern of thought, emotion and
behaviour. Psychiatric symptoms, problems and illness of all kinds are very common throughout
life. Psychiatric nursing is a specialized branch of nursing in which the nurse utilizes
personal knowledge of psychiatric theory and the available environment to effect therapeutic
changes in the patients’ thoughts, feelings and behaviour. The nurse’s ability to effect these
changes varies according to the nurse’s experience and education. The therapeutic role of the
psychiatric nurse cannot be described only in terms of attitudes, feelings, relationship and

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understanding. What the nurse brings as a person to the treatment situation is directly related to
her therapeutic effectiveness.

Psychiatric nursing is concerned with the promotion of mental health, prevention of mental
disorder and the nursing care of patients who suffer from mental disorder. Thus, psychiatric
nursing is the process whereby the nurse assists persons, as individuals or in groups, in
developing a more positive self-concept, a more harmonious pattern of interpersonal
relationships and a more productive role in the society.

MAIN COURSE OBJECTIVE

Students will be equipped with knowledge and skills in mental health to enable them to
understand human behaviour and manage clients with mental health disorders.

COURSE OBJECTIVES

At the end of the course, you should be able to:

1. Describe normal human behavior

2. Describe abnormal human behavior

3. Describe common psychiatric condition

4. Apply psychiatric nursing principles in managing mentally ill patients

5. Explain how the family can be used as a primary resource in rehabilitating mental
patients

6. Identify resources within the community for rehabilitation of the mentally ill

7. Describe how available resources can be utilized in rehabilitation of the mentally ill

8. Apply communication skills in identifying clients at risk within the family and
community

COURSE CONTENT

This course has ten (10) unit titles.

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UNIT 1: Introduction to mental health and psychiatric nursing

In this unit you will look at the definitions of common terminologies used in mental health and
psychiatric nursing. You will also have a privilege to learn how mental health has evolved in
Zambia from the colonial days up to date. The unit will also introduce you to some of the mental
health laws and mental health policies in Zambia

UNIT 2: Psychiatric nursing skills

The unit will afford you an opportunity to learn about various psychiatric nursing skills. These
skills will enable you to effectively manage the mentally ill. They provide guidelines on how the
mentally ill can be managed.

UNIT 3: Classification and management of psychiatric disorders

In this unit, you will have a chance to look at the broad classifications of mental illness. I am
sure it will be of particular interest to you to learn that some mental disorders are
minor(neuroses) Where as others are major (psychoses). You will have a chance to learn how to
manage mental disorders

UNIT 4: Conditions not attributed to mental disorders that are a focus of attention and
treatment

This unit will certainly provide you with interesting information about certain conditions that are
generally considered to be mental disorders and yet they are not. These conditions are only of
particular interest to Psychiatric. Would you want to know why they are of particular interest to
Psychiatry?

UNIT 5: The abused child

This unit will afford you with an opportunity to learn how child abuse can significantly
contribute to disordered mental processes. You probably have abused a child knowingly or
unknowingly. What could be the impact of this abuse on the mental well being of a child? Lets
travel together through this unit and discover how the effects of child abuse

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UNIT 6: Psychosexual disorders

In this unit, you will learn that sexuality is a normal part of our being. The unit will also provide
you with information about what constitute normal and abnormal sex. Sexual issues are sensitive
topics, but you will discover how common sexual problems are as you look through this unit

UNIT 7: Management of clients with psychiatric emergencies

The unit will remind you that emergencies are not only limited to surgery, Medicine, IRH. Even
in psychiatry certain conditions require immediate intervention to avoid loss of life, injuries to
both the patients and psychiatric staff and damages to property

UNIT 8: Forensic psychiatry

In this unit, you will learn how certain psychiatric disorders can result in conflict with the law.
You probably have wondered what should happen to some one who has committed crime under
the influence of mental illness. This unit will provide you with insight into such issues

UNIT 9: Community psychiatry

This unit will provide you with information on why community psychiatric nursing is the
preferred way of attending to the mentally ill as opposed to institutional care. You will also learn
that Zambia is a signatory to the Alma ata convention which promotes community psychiatry as
an ideal way of looking after the mentally challenged

UNIT 10: Advocacy in psychiatry

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In this unit, you will learn how the mentally ill are stigmatized and how
generally the field of mental health has been neglected. The unit provides you
with information of how you can advocate for better services for the mentally
ill. It will equip you with skills of how you can lobby from people in influencial
position to improve care of the mentally ill.

CLINICAL EXPERIENCE
Your practical experience in mental health will last for four weeks and you are expected
to do it in the following areas:

1. Psychiatric wards
2. Community health centres
3. Drop in centres
4. Orphanages
5. Skills training centres
6. Geriatrics
7. Support groups

DEMONSTRATIONS
During your clinical experience the following demonstrations will be done:

 Admission
 Interview (Simulation)
 Psychosocial counseling skills
 Group therapy

ASSESSMENTS
Your work in this course will be assessed in the following two ways:

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 1. Tests and assignments will make up 40% of your continuos assessment
results.

Two written tests which will constitute 20% of your continuos assessment.

One group assignment which will constitute 10% of your continuous assessment.

One individual assignment in the form of a case study during your clinical placement
which will constitute 10% of you continuous assessment.

2. A written examination will take place at the end of the course. This exam is
worth 60% of the final mark.

LEARNING TIPS:

How long will it take?

It will probably take you a minimum 90 hours to work through this course. The time
should be spent on studying the Course and the readings, doing the activities and self
help questions and completing the assessment tasks. Note that units arnot same length.
Unit 3 is the longest and needs more hours to complete. You therefore need to plan and
pace how you will cover your work.

PRESCRIBED READING
There is a list of further reading at the end of this course. This includes books and
articles referred to in the Course in case you need to explore certain topics further. You
are encouraged to read as widely as possible to get different view points and
approaches.

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 UNIT 1: INTRODUCTION TO MENTAL HEALTH AND PSYCHIATRIC
NURSING
1, 0 INTRODUCTION
Mental illness has been with man since time immemorial. Over the years mental health
and psychiatry has gone a lot of changes. This has shifted from looking after psychiatric
patient from prisons to hospital. In order to fully appreciate mental health nursing,It will
be important to define key concepts used in psychiatry and mental health, look at the
history of psychiatric nursing in Zambia,learn about psychiatric nursinp principles and
the guidelines that governs the care of the mentally ill,

COURSE OBJECTIVE

Discuss mental health and psychiatric history, principles and laws in Zambia

UNIT OBJECTIVES

By the end of the unit, you should be able to:

1. Define common terminologies used t in mental health and psychiatric nursing:

2. Discuss the history of mental health and psychiatric nursing in Zambia.

3. Outline the principles of psychiatric nursing.
4. Explain mental health laws that apply in Zambia
5. Discuss the mental health policies in Zambia
6. Discuss the mental health association of Zambia.

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1,1Definition of commom terminologies used in mental health and psychiatric
nursing
 Psychiatry: a specialized or branch of medicine that deal in the
diagnosis and management of mental disorders.
 Agraphia: An inability to write occurring in general dysphasia also
called apraxia.
 Mental health: “Wright Taylor 1970” defines mental health as being
happy, efficient, lack of anxiety, maturity, able to adjust, practicing
autonomy and self-esteem is high.
 Health: A state of well being, but not merely the absence of infirmity
 Communication: Interaction between people and their environment
based on stimuli and responses.
 Language: This is a method by which thoughts and activities are
made available to conscious awareness. It can be vocal, written or
sign represented.
DISORDERS OF PERCEPTION
 Illusion: miss-interpretation of stimuli.
Hallucinations: presence of perception without stimuli.
DISORDERS OF THINKING:
 Flight of ideas: Too much ideas flowing together.
 Retardation of thought: No thinking in place such as seen in
depression.
 Circumstantial thinking: beating about the bush.
 Fragmented thinking: disjointed ideas.
 Delusion: false belief
 Obsession: Ideas coming into your mind frequently
DISORDERS OF ORIENTATION
 Disorientation: inability to recognize place, time, date, year and
person (all the spheres are forgotten).
DISORDERS OF SPEECH
 Incoherent speech: senseless speech.
 Echolalia: Repeating what the interviewer says.
 Neologism: Formation of own words.
 Word salads: mixing of words that only make sense to the owner.

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  Mutism: When someone can’t talk, as seen in severe depression.
DISODERS OF MOTOR ACTIVITY
 Stereotyped activity: copying what someone else is doing.
 Negativism: doing opposite of what you are taught.
 Compulsion: an act due to a repeated ideas coming into your mind.
 Waxy flexibility: maintaining of awkward posture.
DISORDERS OF MOOD OR AFFECT
 Euphoria/elation: excessive happiness.
 Depression: reduced affects.
 Incongruent affects: unexpected behavior or affect.
 Flat affect: un-aroused affect
 Ambivalence: Two conflicting ideas at the same time.
DISORDERS OF MEMORY
 Amnesia: forgetting things that happened.
 Anterograde amnesia: Amnesia of events that happened after the
accident or injury.
 Retrograde amnesia: Amnesia of events that happened before the
accident.
 Confabulation: creating own ideas to cover up what you have
forgotten.
 Erotomania: an individual normally un-married woman who believes
that she is loved by a person of high social status. She engages in
writing letters, sending gifts, telephoning or attempt visits.
 Grandiose delusion: an individual believe he/she possess a recognized
talent or in sight such as that of religious leader and seek for position
of power.
 Folie ᾰ duex: shared paranoid disorder which develops as a result of
close relationship with a person who already experience persecutory
delusion.

1.2 HISTORY OF MENTAL HEALTH AND PSYCHIATRY IN ZAMBIA

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Northern Rhodesia had no psychiatric hospital and most of the patients where
looked after in the general hospitals known as mental annex. These buildings were
very dirty and unfit for human habitation. The male patients were managed in
prisons while the female where treated in General hospitals like Kasama, Ndola,
Livingstone and Mansa.

Those who couldn’t recover from mental illness were sent to Southern Rhodesia in
Bulawayo at Ingutsheni hospital which had a bed capacity of 690 and yet it
accommodated 1, 391 patients resulting into congestion and poor psychiatric care.

Not until 1957 when Sir Steward Gobrown the then MP of Shiwangandu suggested
in parliament that psychiatric patients can best be nursed at home, here in Zambia
than at Ingutsheni. An inquiry was instituted and a bill was passed in parliament in
1957 with the following positive resolutions that:

a. Patients be looked after here in Zambia not in Bulawayo.

b. A psychiatric hospital be built at Chainama
c. Qualified human resources to be recruited from England, these should be
Roman Catholic Nuns and Brothers.

In 1962 three wards and student hostels were built together with the convent (A, B
and C wards).

Mental attendants were employed to assist in the care. After six months the
medical assistant training started, composed of 40 students out of which 10
qualified in 1965. The same year the hospital was extended by three modern blocks
for rehabilitation. (E, F and D wards). In 1967 psychiatric enrolled nursing started
and in 1968 Chainama East Forensic block was opened with 168 beds.

In 1970 children’s day centre was built by Jaycees and the bus was provided by the
Lion’s club for the disabled children.

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In 1989 enrolled psychiatric nursing was phased out. In September 1991 the first
intake of registered mental health nurses was commenced with 20 students.

It was a post basic programme with eighteen month duration. All 20 students
qualified and were sent in provincial annexes. Mrs. Ikafa and Hellen Blackburn
started the programme.

1.3 PRINCIPLE OF PSYCHIATRIC NURSING

 Allow client opportunity to set own pace in working with problems.

 Nursing interventions should centre on the client as a person, not on control
of symptoms. Symptoms are important, but not as important as the person
having them.
 Recognize your own feelings towards clients and deal with them.
 Go to the client who needs help the most.
 Do not allow a situation to develop or continue in which a client becomes
the focus of attention in a negative manner.
 If client’s behavior is bizarre, base your decision to intervene on whether the
client is endangering self or others.
 Ask for help-do not try to be a hero when dealing with a client who is out of
control.
 Avoid a highly competitive activity that is having one winner and a room
full of losers.
 Make frequent contact with clients- it lets them know they are worth your
time and effort.
 Remember to assess the physical needs of your client.
 Have patience, move at the client’s pace and ability.
 Suggesting, requesting, or asking works better than commanding.
 Therapeutic thinking is not thinking about or for, but with the client.
 Be honest so the client can rely on you.
 Make reality interesting enough that the client prefers it to his or her fantasy.
 Compliment, reassure and model appropriate behavior.
1.4 MENTAL HEALTH LAWS IN ZAMBIA

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Mental disorder in Zambia is defined by an act of parliament called the Mental disorders
Act Chapter 305 of the laws of Zambia. The law was enacted by the federal government
and contains terms that are deemed as derogatory to the mentally ill. Such terms refers
to the mentally ill as idiots, imbecile. Mental health activists are fighting for this law to be
repealed. The government has currently made tremendous progress in repealing this
outdated law.

According to this law, a mentally disordered or defective person means any person who,
in consequence of mental disorder or disease or permanent defect of reason of mind.
Congenital or acquired:

(a)        is incapable of managing himself or his affairs; or  

 

(b)        is a danger to himself or others; or  

 

(c)        is unable to conform to the ordinary usages of the society in which

 
he moves; or
 

(d)        requires supervision, treatment or control; or

   

(e)        (if a child) appears by reason of such defect to be incapable of

 
receiving proper benefit from the instruction in ordinary schools;

1.5 MENTAL HEALTH POLICIES IN ZAMBIA

The Government of Zambia has been trying to recognize the importance of mental health
in the country. In order to provide coordinated and well structured mental health services,
the government has offered policy direction as regarding care of the mentally ill. The care
is in different forms i.e. institutional care, community care as well as prevention aspects.

A complete document on mental health policies in Zambis is available and can be obtained
from Government printers. You are encouraged to access this document.

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 1.6 MENTAL HEALTH ASSOCIATION OF ZAMBIA

Mental Health Association of Zambia (MHAZ) is a non governmental organization that

looks into the welfare of the mentally challenged. The association collaborates with the
government to ensure that mental health services are well provided to the community at
large. MHAZ plays a key role in sensitizing the community on the prevention of mental
illnesses. It also highlights the challenges that the mentally ill go through. The association
has also been fighting stigma against the mentally ill.

Membership is open to all that are interested in mental health issues.

1.1

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 SUMMARY

Mental illness is commonly manifested by observable behaviour and its exceptionality to

individuals, its variation from time to time with even the same individual and its dependence
on a host of other factors that have made it easier to draw a distinct line between mental health
and mental illness. This means that no single characteristic or quality can be taken as evidence
of positive mental health but lack of any of these characteristics or traits is evidence of mental
illness. It is therefore easier to define mental health by use of mental illness observable actions
that are quite exceptional.

UNIT 1. REVIEW QUESTIONS

1. Define the following terminologies

a. Psychiatry

b. Confabulation

c. Grandiose delusion

d. d.Mental HealthEcholaria
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 ANSWERS

 Grandiose delusion: an individual believe he/she possess a

recognized talent or in sight such as that of religious leader and
seek for position of power.
 Echolalia: Repeating what the interviewer says.
 Mental health: “Wright Taylor 1970” defines mental health as being
happy, efficient, lack of anxiety, maturity, able to adjust, practicin
Confabulation: creating own ideas to cover up what you have
forgotten.
 Psychiatry: a specialized or branch of medicine that deal in the
diagnosis and management of mental disorders.

                

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 .

1.

2.

3.

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UNIT 2 PSYCHIATRIC NURSING SKILLS

2.0 INTRODUCTION

I welcome you to our second unit in which we will discuss the many different ways in
which you as a nurse is able to use psychiatric nursing skills to help people with mental
disorders recover. In our last unit 1, Introduction to mental health and psychiatric
nursing, we defined certain terms such as mental illness/disorder, psychiatry, mental
health to mention but a few. In this lesson I will be repeating some of these new terms,
and be sure to refer to unit one and the glossary at the end of this unit for any terms you
have difficulties understanding.

In this unit (2) on psychiatric nursing skills, we will cover the psychiatric nursing skills
that we need to use when caring for clients with psychiatric illness. Psychiatric nursing
skills are interventions a nurse uses to give care to a person with a mental disorder or
illness. These interventions are given to change the wrong thoughts and abnormal
behaviours that characterize people with mental illnesses.
A skill is an ability to do an activity or job well, especially because you have practiced it.
A nurse needs special skills in order to assist a patient with disorders of the mind and
abnormal behaviors. They are special because people with mental illness can be the
most challenging group of individuals to work with, as you shall discover when you
reach Unit three which deals with both minor and major mental disorders.

COURSE OBJECTIVE

Demonstrate an understanding of psychiatric nursing skills.

SPECIFIC OBJECTIVES

By the end of this unit you should be able to:

1. Apply communication skills

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 2. Demonstrate self awareness skills

3. Exhibit assertive behaviour

4. Apply counseling skills

5. Demonstrate interactive skills

6. Demonstrate observation skills

7. Apply stress management skills

8. Demonstrate behavioural modification skills

9. Utilize therapeutic nursing intervention skills

10. Conduct physical assessment of a psychiatric patient

11. Apply knowledge and skills of admitting a psychiatric patient

Activity
Using your own words, write down the meaning of the word “skill” in your notebook

Okay, so you have come up with your answer? Now you can compare it with the
definition below.

A skill is an ability to do an activity or job well, especially because you have

practiced it.
1.

If you have got the following two points give yourself two marks. Well done!

2.1 COMMUNICATION SKILLS

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From your lessons in psychology and fundamentals, what would you say
communication skills are? Start by doing the following activity.

Activity

Using your own words, write down the meaning of the term communication in your
notebook

Well done! I hope in your definition you mentioned that communication is the reciprocal
exchange of information, ideas, beliefs, feelings and attitudes between 2 people or
among groups of people. It is a skill that is practiced when making the different nursing
interventions in nursing practice.

Methods of communication

There are various methods used for communicating with clients in mental health. These
include:

- verbal

- non verbal

- written communication skills

Let us look at each method of communication in turn:

1. Verbal communication or the spoken word

Verbal communication occurs through words that are spoken or written. As a nurse you
need to be prepared to communicate effectively with patients that speak a different
language from your own. You may therefore also need to learn or adapt to your client’s
language because certain phrases or ways of expression are better done in the mother
tongue or local dialect.

As a nurse you start communicating with a patient with opening remarks that build
rapport and encourage clients to open up. Then when the patient opens up, as a nurse

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you need to listen. Don’t “interrogate patients’ or shower them with questions all at one
instant, thereby making them feel judged.

2. Non verbal communication or body language

These are messages received via facial expression, voice tone, pitch, physical postures
and gestures. Body language is always present during communication, without which
we cannot communicate. The body language of both the patient and ourselves as
nurses (the patient also sees our body language). For instance, if you are quick and
sharp as a nurse the patient may view such body language as rudeness and an “I don’t
care” attitude. On the other hand if you as a nurse is unhurried, smiles, warm and
friendly, it conveys acceptance and patients may turn to you for help, or disclose
personal feelings to you.

Tips For Understanding Non-Verbal Communication

Recognise that people communicate on many levels. Watch their facial expressions,
eye contact, posture, hand and feet movements, and their appearance. When
interviewing people, watch how they sit and wait. As you watch clients, take note of
negative gestures and personal space.

1. Negative Gestures
- Feet dragging: lethargic, don’t care
- Head down: timidity, shyness
- Shoulders Drooped: weariness, lethargy
- Shifty eyes: nervousness
- Hands in pockets: something to hide
- Weak handshake: meek, ineffectual
2. Personal space
- ‘proper’ space 2-4 feet
- Violation of personal space is seen as a threat and an aggressive gesture by
both the client and yourself as a nurse alike.

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The Importance of Listening to Clients

The first rule of a therapeutic relationship is to listen to the patient. It is the foundation
on which all other therapeutic skills (assertiveness, counseling, social, nurse patient
therapeutic relationship) are built. Real listening is difficult. It is an active, not a passive,
process. As nurses, we should suspend thinking of personal experiences and problems
and making personal judgements of the patient.

This can be demonstrated by behaviours which are summarized by the acronym known
as “SOLER”.

What does SOLER stand for?

Before you read on, do the following activity.

Activity
? In your notebook, write the acronymic SOLER. Then next to each letter indicate the
behavior that demonstrates that you are listening actively to a patient.

Now compare your answer with the following letters (SOLER). It stands for:

S – Sit squarely

O – Open posture

L – Lean forward

E – Eye contact

R – Relax as you listen

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Now that you know the meaning of SOLER, practice it with a fellow student. Imagine
yourself in a room with a client who is confiding his or her feelings to you. Place 2
chairs, and sit on one and adopt the SOLER behavior as the client talks to you.

We hope you now understand the meaning of communications, SOLER and the
methods used to pass on ideas from one person to another. In the next section we
shall look at another psychiatric nursing skill known as self awareness.

2,2 SELF AWARENESS SKILLS

To be able to relate effectively with clients that have mental illness you as a nurse must
know and understand yourself very well, that is, your weaknesses, strengths, biases,
attitudes and so on. When you know yourself well, you will avoid imposing your
personal values on patients. It will also keep you from being judgemental to patients
especially when they exhibit abnormal behaviours.

What Is Self-Awareness?

Self awareness involves looking inward to understand oneself and objectively (without
bias) examine one’s beliefs, values, attitudes, motivations, strengths and limitations.

This means that you must be able to examine your personal feelings, actions, and
reactions. However, no one ever completely knows their inner self, as shown in the
Johari window in Figure 2.1.

1 2

3 4

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Figure 2.1 The Johari Window

The Johari Window consists of four quadrants that represent the total self as follows:

 Quadrant 1 – Known to self and others. It includes the behaviours, feelings, and
thoughts known to the individual and others.

 Quadrant 2 – Known only to others. (It is an open secret!). It includes all the things
that others know but the individual does not know.

 Quadrant 3 – Known only to self. This quadrant includes the things about self that
only the individual knows.

 Quadrant 4 – Known neither to self nor to others.

The goal of increasing self awareness is to enlarge the area of quadrant 1 while
reducing the size of the other quadrants.

Why Is Self Awareness Important In Psychiatric Nursing

To ensure the most effective use of self, it is important to be aware of personal stress
that can interferes with your ability to communicate therapeutically with patients. If you
are tired, anxious, angry or apathetic, it will be very difficult to convey an interest in the
concerns and fears of the patient.

As a student nurse, what are your social biases? Remember that they can influence the
way you interact with patients.

The messages you communicate verbally & none verbally to patients can only be clear
when you as a nurse acknowledge your own feelings even when they are negative.

A good understanding and acceptance of yourself will allow you to acknowledge a

patient’s differences and uniqueness. By so doing, we will not be judgemental in our
dealings with patients.

We hope you now understand the importance of self awareness. When your self
awareness is high, you do not let your personal biases to get in the way of nursing care

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to our patients. Next, we shall learn how you can use assertiveness skills to help
patients with mental conditions.

2.3 ASSERTIVENESS SKILLS

What is assertiveness?

Assertiveness means communicating directly with another person to express yourself. It

means:

- Saying no to unreasonable requests

- Being able to state complaints without being aggressive

- Expressing appreciation as appropriate

Training Patients to Be Assertive

Lack of assertiveness is common in psychiatric patients because of their mental

illnesses. Patients who lack assertiveness skills easily get frustrated when dealing with
other people. This can cause them to have aggressive behaviours. Such patients are
easily taken advantage of when they lack assertiveness. To enable a patient develop
assertive behaviours, nurses can carry out assertiveness training. This is done in
groups so that the patient learns to relate to other people within the group in an
assertive way, before generalizing the behavior to another setting.

Methods of Training Patients to Be Assertive

Patients can learn assertiveness by participating in groups. Patients watch the staff
demonstrate specific skills in a role play, (such as, saying please when asking for
something; thank you when they are given something, or seeking redress when treated
unfairly, without insults or violence).

They then engage in a role play and demonstrate the skills they have learnt. Staff can
then provide feedback to the patients on the appropriateness and effectiveness of their
responses in the role play. They can also assign homework to the patients to help them

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generalize these skills outside the group. As the patient learns new and more effective
assertiveness skills, their aggressive behavior diminishes.

HOMEWORK TASK

Practice assertive behaviours with your peers. Say no to unreasonable requests, state
your complaints without being aggressive and express appreciation as appropriate).

2.4 COUNSELLING SKILLS

What is counseling?

Counseling is a method of relieving distress undertaken by means of a dialogue

between 2 people. The aim is to help the client find their own solutions to problems,
while being supported and being guided by appropriate advice.

Nurses who care for clients with mental problems must be ready at all times to take on
the role of a counselor. A counselor must have certain qualities if clients are to confide
in him or her. Let us look at that next.

Qualities of a Counselor

The most important qualities in a counselor are being genuine, accepting, and
empathic. What do these mean?

 Being genuine means that a counselor cares for the client and behave toward the
client as they really feel. It is similar to congruence.
 Being accepting means that counselor should appreciate clients for who they are,
despite the things that they may have done. Counselor does not have to agree with
clients, but they must accept them. It is the same as unconditional positive regard.
 Being empathic means that the counselor understands the client’s feelings and
experiences and conveys this understanding back to the client. Empathetic
understanding can be demonstrated through reflection of feelings, and clarification.

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ROLE PLAY (GROUP WORK) As a group, go through the following paragraph on
empathy and then practice the following dialogue that demonstrates how a
counselor shows empathy to a client.

To show empathy, a counselor restates what the client has said and seeks clarification
of the client’s feelings. The counselor may use such phrases as “What I hear you saying
is…” and “You’re feeling like…” The counselor seeks mainly to reflect the client’s
statements back to the client accurately, and does not try to analyze, judge, or lead the
direction of discussion. For example:

Client: I always felt my husband loved me. I just don’t understand why this happened.
Counselor: You feel surprised by the fact that he left you, because you thought he
loved you. It comes as a real surprise.
Client: M-hm. I guess I haven’t really accepted that he could do this to me. A big part of
me still loves him.
Counselor: You seem to still be hurting from what he did. The love you have for him is
so strong.

Basic Counseling Skills

There are 8 basic skills of counseling that a nurse needs to learn. These skills are used
by the nurse when counseling and are necessary for forming a working relationship with
the patient.

The skills are:

 Attending
 Listening
 Clarifying
 Reflecting
 Paraphrasing

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 Asking questions / probing
 Summarizing
 Challenging

Let us consider each skill at a time.

Attending

Patients in distress are acutely aware of the attention/inattention of the attending nurse,
and are sensitive to both verbal/non-verbal cues. . A nurse or counselor must show
through their body position and facial expression that they are paying attention—for
example, by directly facing the client and making good eye contact. Attending involves
‘SOLER’ behaviours which we discussed earlier in this unit.

Listening

Listening includes hearing what the patient has to say, gathering and processing
information, and observation of non-verbal cues. It requires more than a physical
relationship, but should involve personal contact during consultation. Active listening
demonstrates empathy—letting clients know that they are being fully listened to and
understood.

Clarifying

Clarifying is an attempt to understand a client’s statements. Asking clients to give

examples to clarify what they mean can help you understand better. Other strategies
used to clarify something the client has said include summarizing, at the beginning,
during and at the end of a session.

Reflecting

Reflecting involves the nurse acting as a sounding board for the patient by reflecting
back what she or he is saying or feeling. The nurse does this by repeating the client’s
verbal and non verbal message. Reflection conveys back to the speaker their thoughts
and feelings.

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Paraphrasing

The nurse determines the basic message in a patient’s statement, and then rephrases
it, or restates the sentence in similar words used by the patient. It gives an opportunity
to test your understanding of what is being communicated.

Asking questions / Probing

Probing is a counselor’s use of a question or statement to direct the client’s attention

inward to explore his/her situation in more depth. A probing question, sometimes called
an “open-ended question”, requires more than a one word (yes, no) answer from the
client. When phrased as a statement, the probe contains a strong element of direction
by the counselor; e.g. “Tell me more about your relationship with your parents,” or
“Suppose we explore a little bit more your ideas about what an alcoholic is.”

Summarizing

To summarize is to select the key points or basic meanings from the client’s verbal
content and feelings and tie them together. This should not include the assumption of
the counselor. Summarizing then, is a review of the main points already discussed in
the session to ensure continuity in a focused direction.

Challenging

The counselor invites the client to examine thoughts and observable behaviour that is
self defeating and change such thoughts and behaviour for the better.e.g. She / he
might ask this question to challenge a belief: “What is your evidence for this belief?” or
challenge clients to explore behavioural consequences.

2,5 SOCIAL SKILLS

What Are Social Skills?

It is the knowledge and skills people need to have to live in the community. Examples
of social skills include:

 Holding conversations

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 Establishing and maintaining friendships
 Dating
 Managing medications
 Grooming
 Numerous other activities that are a part of leading a happy, successful life

How to Conduct Social Skills Training

In social skills training we teach the patient a structured (step by step) way of examining
and modifying their own thoughts and behavior. The clinician or nurses teaching
involvement is reduced as the patient becomes more skillful at managing difficult
situations.

Like assertive training, social skills training is conducted in a group setting so that
clients can learn to interact with both the staff training them and other clients within the
same group. From this group they develop confidence to generalize behavior learned to
other settings such as home when they get discharged or shops when they go
shopping.
? Do you remember assertiveness training? Well, social skills training is conducted in a
similar manner. In fact assertiveness is a social behavior.
Why Is Social Skills Training Important?

Social skills training is important for the following reasons:

- People with abnormal behaviours, do not interact with others because their social
skills are poor.

- Other people may avoid people with mental disorders because of their self
absorption, pessimism or elation.

- When someone has had mental illness for a long time, they tend to loose their social
skills.

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Clients with mental illness loose their social skills due to chronic or long illnesses or
admissions. As nurses we have to train them so that they can regain the lost social
skills, to avoid social isolation and stigmatization.

2.6 OBSERVATIONS IN MENTAL HEALTH

Observations are an integral part of nursing as a whole, as you can recall from your
lessons in Fundamentals of Nursing. In mental health, Observations are cardinal to the
safety of all, and when carried out correctly, they ensure a safe environment for clients
and staff alike. This is because many patients lack insight into their illness and may
pose a danger to themselves and others when measures are not put in place to watch
them carefully.

What does the word “Observe” mean?

To observe is to watch carefully the way something happens or the way someone does
something. To notice or see something. Patients with mental disorders can be
unpredictable, for example, violent, risk to self and others, suicidal, homicidal, arsonists,
destructive to property.

As a nurse, you should therefore use all your senses to observe the patient by using
your ears, touch, taste, smell & instincts. Observations are therefore carried out
continuosly around the clock by nurses on duty because a nurse is the only staff who is
with the patient on a 24hour continuous basis.

Why are Observations Important in Psychiatric Nursing?

Observations are important for the following reasons:

- Physical condition of patient is affected by mental disorder

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- People with mental disorder are not able to tell you what is wrong with them
physically

- Observations include general condition, mental state examination, appearance, vital

signs, fluid balance, sleep patterns, nutritional status, side effects of psycho tropics,
look out for absconding etc

When nursing patients, we should always record all our observations using the correct
charts, sheets and case notes.

Importance of Recordkeeping

Record keeping is very important for the following reasons:

- When your observations are in writing they will facilitate treatment and
interventions by other professionals (psychiatrists, psychologists, sociologists,
courts of law) that may not be present with the patient on a 24 hour basis.

- It may protect you in courts of law.

- It helps you to report abnormal findings to psychiatrist.

NURSES’ NOTES

The nurses’ notes of observations of their patients are a large part of their value as long
as they are accurate and complete records of their findings are kept. Nursing notes are
already in use in many psychiatric hospitals and provide information of great value
without in any way interfering with the nurses’ other duties.

The following are the purposes of such notes:

1. To give the psychiatrist information about the 24hour behavior of the patient.

2. To indicate the patient’s relationships with other significant people.

3. To pass on useful information to other nurses.

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 4. To serve as part of the official record of the patientt, nurses’ notes may be of
great importance in planning current treatment, in subsequent research and may
in some circumstances be a significant legal document.

5. To assist the trainee nurse by stimulating her interest in the particular problem
under consideration and to provoke her/his additional reading.

6. To provide psychiatrists and senior nursing staff with a basis for teaching, the
notes may be used in group discussions to help trainees to evaluate situations in
an objective way and to analyze the factors which affect the nurse pt relationship.

The following 10 principles should be observed in the preparation of nursing

notes

1. Care must be taken to convey the precise meaning intended; description of

behavior and conversation must be accurate.

2. Statements should be as objective as possible.

3. Notes should be brief – the quality not the quantity is important

4. Information should be concrete – generalizations are usually valueless

5. Simple descriptive English should always be used in preference to technical

terms.

6. Direct quotation can be most valuable, especially in reporting delusions and

hallucinations

7. The form of the notes should be flexible, depending on the type of pt being
studied. Depending on hospital policy, some places use the SOAPIER format to
write nurses’ notes.

8. Notes should be written at least once a week, with special incidents being
described as they occur.

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 9. Notes must be dated and signed, they are valueless if they lack a proper time
sequence and if the writer cannot be identified

10. Any relevant material produced by the patient himself should be included – for
example, writings, sketches, and paintings.

Things to note in the patient when writing a progress report

Activities of daily living such as the sleeping pattern, resting, eating habits/ appetite,
interaction among fellow pts and members of staff, personal hygiene, speech, mood,
participation in ward activities, such as sweeping, bedmaking, washing plates, insight of
the illness, hallucinations or delusions, weight, vital signs, elimination and toilet habits,
hobbies.

Observations are necessary when caring for clients with mental illness because may
not always tell you what is troubling them. It is always important to keep a record of
your observations in patients’ charts and notes.

2.7 STRESS MANAGEMENT SKILLS

You will recall from your Psychology in Nursing that Stress Management skills are
means and ways of dealing with, or solving problems that we daily encounter in
everyday living. In mental health we are going to use the stress management skills
that we learnt in Psychology to train patients with mental health problems so that they
can be able to cope up with stress thereby preventing relapse.

What is Stress?

Stress may be viewed as an individual’s reaction to any change that requires an

adjustment or response.

What is Stress management?

Stress management involves the use of coping strategies, ways or methods that protect
the individual from harm in response to stressful situations or stressors.

Importance of Stress Management for People with Mental Disorders

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To prevent people with vulnerability to mental illness falling sick, they can be taught how
to manage the stress. Stress is a precipitating factor in a person with an already existing
vulnerability (such as, genetic inheritance, early childhood traumatic experiences).

Coping Strategies

There are a various coping strategies that we can teach our patients to help them
manage stress. These include:

- Awareness of stressors– Become aware of stressors, then omit, avoid, or accept

them.

- Relaxation – Through physical exercises, breathing exercises and muscle

relaxation.

- Meditation.

- Seeking support and talking to others if anxiety is too much.

- Problem solving technique of counseling can be used, during which catharsis

(ventilation of feelings) is allowed to take place.

- Good social support networks that are able to offer material, informational and
emotional support.

- Prayer

- Music

- Pets

- Good nutrition

- Balance your life. Avoid too much of one thing.

2.8 BEHAVIOR MODIFICATION SKILLS

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Behavior modification is to change behavior. If you remember at the beginning of this
unit we discussed that people with mental health problems have disordered thinking that
leads to abnormal behaviours. These abnormal behaviours can be changed into good
or acceptable behavior using behavior modification skills.

As a nurse, you have to make interventions to change behavior during the

implementation phase of the nursing process. Behavior modification skills utilize the
principles of classical and operant conditioning, and social learning which you have
already covered in Psychology in Nursing. Kindly read up these topics so that you can
easily follow and understand this lesson.

What is behavior modification?

Behavior modification is a practice that treats behavioural problems. It is based on

operant, classical conditioning and social learning.

It is based on the premise that all behaviours are learned and can therefore also be
unlearned. In this approach, bad behaviours are unlearned while good behaviours are
learned using the principles of classical and operant conditioning and social learning.

DIFFERENT WAYS OF CHANGING ABNORMAL BEHAVIOR

Classical conditioning

- Many of our feelings e.g. violent emotions, are probably conditioned responses to
a face, or voice that we associate with previous childhood bad experiences, such
as being scolded, beaten, or mistreatment.

- Since such emotional responses (fear, anger, poor self esteem) are learned,
perhaps they can be unlearned.

- This change (to unlearn) of disturbing emotional responses by classical

conditioning is called behaviour modification.

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- For example patients with aggressive behaviour can be trained in anger
management skills which include assertiveness that we earlier looked at,
relaxation and deep breathing technique, all which are behavioural methods.

- In operant conditioning, if a response to a stimulus produces positive

consequences for the individual it will tend to be repeated, while if it is followed
by negative consequences it will tend not to be repeated. For instance patients
who manipulate others by for instance by making fun of them should not have
such behaviour reinforced.

This means that the bad behaviour should be ignored and good things that they
like should be withdrawn from them. For instance, when it is time to go out for a
social outing, explain to them that they cannot go out because they are
unpleasant to other people. They will only be able to go out when they stop
treating other people unkindly.

- Positive reinforcement – Adding a rewarding stimulus as a consequence of a

behaviour, thus increasing the probability that it will occur again. When patients
display good behaviour like being helpful, being good to others, they can be
positively reinforced by giving them something they like in the form of food,
makeup, a social outing and so on.

- Extinction – When positive reinforcement for a particular response (behaviour)

is withdrawn, the behaviour usually stops. This means that when you ignore and
do not laugh at a patient’s unkind jokes that targets vulnerable patients, the
unkind jesting will soon stop.

- Social learning / observation (e.g. assertive skills & social skills) Is a strategy
used to form new behaviour patterns, increase existing skills, or reduce
avoidance behaviour (such as phobias and panic attacks (systemic
desensitisation) The behaviour to be learned is broken down into a series of
separate stages that are ranked in order of difficulty or distress, with the first
stage being the least anxiety provoking.

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 - The person then acquires the new behaviour by observing a person modelling
the behaviour in a controlled environment. The person then imitates the model’s
behaviour.

- Social learning or modelling can be displayed by nurses as they interact with

patients in the ward environment. As a nurse you can model behaviours like
greeting, politeness to say ‘thank you’ and ‘please’. You can also model
grooming, holding conversation, maintaining personal space and good table
manners, through involving themselves in the activities of daily leaving in the unit.
The nurse is a role model for clients. They watch and imitate your behaviour. So
remember your self awareness skills while in the unit with your patients.

2.9 THERAPEUTIC NURSING INTERVENTIONS

You may remember that we defined the terms ‘therapeutic’ and ‘interventions’ in one of
our earlier lessons.

? What did we say the terms ‘therapeutic’ and ‘interventions’ are?

Therapeutic nursing interventions are actions that nurses take to help, treat or deliver
nursing care to clients so that they may recover or get well. Giving nursing care or
therapeutic nurse interventions to clients with abnormal behaviors and disordered
thought patterns is more effective when clients’ trust has been built up within a nurse
patient therapeutic relationship. In fact, the psychiatric nursing skills are nursing
interventions and therefore delivered within a nurse patient therapeutic relationship.

THE NURSE PATIENT THERAPEUTIC RELATIONSHIP

The nurse patient therapeutic relationship can be defined as an interaction between two
people (usually a caregiver and a care receiver) in which input from both parties
contributes to a climate of healing, growth promotion, and illness prevention.

THE IMPORTANCE OF A NURSE PATIENT THERAPEUTIC RELATIONSHIP

The nurse-client relationship is the foundation upon which psychiatric nursing is

established. This means all nursing interventions are most effective within a nurse

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patient relationship. It is a relationship in which both participants learn from one another
(Peplau 1991). Like other areas of nursing practice, psychiatric mental health nursing
works within nursing models (Hildegard Peplau, Dorothea Orem) utilizing nursing care
plans, and seeks to care for the whole person.

The emphasis of mental health nursing is on the development of a therapeutic

relationship (healing or beneficial to patient) or alliance. In practice this means the nurse
seeks to engage with the client in a positive collaborative manner that empowers them
to draw on their inner resources in addition to other treatment they may be receiving.

A therapeutic or “helping” relationship is established through use of basic counseling

skills as seen earlier during our lesson on counseling skills.

Activity

In your GROUP list the basic counseling skills. Write them in your note books
and discuss each one of them.

ADVANTAGES OF A NURSE PATIENT RELATIONSHIP

- Through establishment of a nurse-pt relationship, clients learn to transfer their

relationship with the nurse to relationships with significant others because the
nurse acts as a role model.

- Therapeutic relationships are goal oriented. The nurse and client decide together
what the goal of the relationship will be.

- The goal of a therapeutic relationship may be based on a problem solving model.

- Therapeutic use of self is whereby the nurse uses her personal qualities to
establish the relation and to give care to the patient. To use oneself in a

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 therapeutic way one needs to have a great deal of self awareness skills. Eg.
Don’t use the patient to direct your feelings for someone in your life.

- The relationship is the means by which the nursing process is implemented.

Through the relationship problems are identified and resolution is sought.

PHASES OF A NURSE PATIENT RELATIONSHIP

The relationship is divided into 4 phases:

1. Pre interaction

The nurse and patient first meet during this phase.

The nurse’s primary concern is to find out why the patient sought help, & together
with patient formulate objectives on what should be achieved in the relationship

- Tasks:

- Establish a climate of trust, understanding, acceptance, and open

communication.

- Formulate a contract with the patient

2. Orientation (Introduction)

- Elements of a Nurse-Patient Contract:

- Names of individuals

- Roles of nurse and patient

- Responsibilities of nurse and patient

- Expectations of nurse and patients

- Purpose of the relationship

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 - Meeting location and time

- Conditions for termination

- Confidentiality

3. Working

- Most of the therapeutic work is carried out in this phase.

- Problems (reasons patient sought for help) are dealt with using problem solving
approach.

- Actual behavioural change is the focus of this phase.

- The psychiatric nursing skills are used to bring about this behavioural change.

4. Termination

- Prepare the patient for termination by decreasing visits, incorporating others into
meetings, or changing location of meetings.

- Clarify reason for such changes so pt does not interpret it as rejection by the
nurse.

- Mutually explore feelings of rejection, loss sadness and anger etc.

- Review progress of therapy and attainment of goals.

Therapeutic Nursing Interventions are composed of nursing care directed towards the
patient with the aim of helping him or her recover. Such interventions are best made
within the nurse patient relationship utilizing the nursing process.

2.10 PHYSICAL ASSESSMENT OF A PSYCHIATRIC PATIENT

A physical assessment is an examination that is conducted the first time a patient

comes to the health facility with a complaint. It may also be conducted upon

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admission. Psychiatric patients may not tell you what physical problems they are
having, so you have to be very observant and skillful in the way that you conduct your
examination.

You can also refer to your Procedure and Evaluation manuals for a step by step
procedure of physical assessment of a psychiatric patient. It starts with history taking, is
followed by vital signs, and then a physical examination. A variety of techniques and
medical equipment is used when performing a physical assessment. Examination may
either be head to toe or may be system by system. After the physical examination,
laboratory, x-ray and other investigations may be carried out and will depend on findings
of the physical examination and any complaints from the patient.

Timing of physical assessment – ideally carried out as part of the admission procedure.
If there is a delay in examining due to an unstable mental state reasons of delay should
be recorded clearly. A physical assessment contains 2 kinds of information: Subjective
and objective. A patients’ feedback is subjective information. A nurse’s observation is
considered objective information.

When conducting a physical examination it is advisable to have a chaperone in

attendance, to guard against accusations of sexual harassment when examining a
member of the opposite sex. Also guards against risk of violence by patients who may
be aggressive.

PURPOSE OF PHYSICAL EXAMINATION IN PSYCHIATRIC PATIENTS.

- To identify physical illnesses that may have been overlooked and then refer the
patient to appropriate specialists.

- To assess impact of mental illness on the physical wellbeing of the patient such
as nutritional status and symptoms of dehydration in conditions like major
depression, anorexia nervosa and mania.

- To identify side effects of neuroleptic (drugs used to treat mental illness) drugs.

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 - To assess for signs of neglect and ill treatment such as disheveled hair, unkempt
appearance; injuries due to unrecommended methods of restraint that lead to
skin abrasions on the wrists and ankles and swellings on the body due to being
beaten.

BENEFITS OF PHYSICAL EXAMINATION IN PSYCHIATRIC PATIENTS

1. Physical disease is more prevalent in people with mental disorder than in the
general population. It is important for psychiatrists to maintain skills in physical
examination to ensure that physical illnesses are diagnosed and treated
appropriately. Annual death rates from all causes among psychiatric patients are
2-4 times higher than in the general population with higher rates of physical
disorder across the entire range of mental disorder.

2. Patients who are mentally disturbed may be unable to give a clear account of
their symptoms, even in the presence of a life threatening disorder. Studies have
also shown that in many cases, physical diseases will not be diagnosed and
treated when a patient is admitted to a psychiatric unit.

3. An important aspect of psychiatric evaluation is differentiating organic disease

from ‘functional’ psychiatric disorders.

4. A competent assessment of patientt’s physical health also helps to tailor drug

use and reduce the risk of side effects.

5. Physical assessment gives a clear baseline for comparison, should a patient’s

physical state change, thus informing the clinician of the severity of the effect of a
drug and of the need for action.

Remember that when you are examining a patient with mental illness you should not
be alone with him or her in the room for safety reasons. In addition, psychiatric
patients may not tell you what physical problems they are having, so you have to be
very observant and skillful in the way that you conduct your examination.

SELF TEST

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Encircle the correct answer

Benefits of physical examination in psychiatric patients

1. Physical disease is more prevalent in people with mental disorder than in

the general population. TRUE / FALSE

2. Patients who are mentally disturbed are able to give a clear account of
their symptoms, even in the presence of a life threatening disorder. TRUE /
FALSE

3. An important aspect of psychiatric evaluation is differentiating organic

disease from ‘functional’ psychiatric disorders. TRUE / FALSE

4. A competent assessment of patient’s physical health does not help tailor drug
use and reduce the risk of side effects. TRUE /FALSE

ANSWERS TO SELF TEST

1. True

2. False

3. True

4. False

2.11 ADMISSION OF PSYCHIATRIC PATIENTS

In psychiatry, patients are admitted for care when they become a danger to
themselves and others. There are three types of admission that govern admission to a
psychiatric or other medical facility. It is to be remembered that whilst admitting a
patient to protect the general public, care must be taken to avoid infringing upon the
patient’s rights as a person and as a patient with a mental disorder.

What is psychiatric admission?

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It is when a patient is accepted to stay in hospital for inpatient services.

TYPES OF ADMISSION

There are several types of admissions: Voluntary, emergency, involuntary or

compulsory, medical board and court adjudication.

Voluntary Admission

This is where a patient is willing to be admitted and knows that he/she has a problem,
and the medical officer in charge of the mental hospital sees that the patient really
needs admission. The Mental Health Services Bill, (2006) states that:

- “Patients aged 18 years and above must be encouraged to opt for voluntary
admission into a psychiatric institution, facility or ward.
- Patient with mental health problems may seek help from any health institution
including primary health care clinics, as first contact before being transferred to a
psychiatric facility.
- If any patient is admitted to a psychiatric facility as a voluntary patient, the person
in-charge of the hospital or ward must notify the patient’s parents, guardians or
relatives as soon as possible. In the absence of the relatives, community leaders
from the same locality must be notified.
- Where a patient is already admitted to a mental health facility as a voluntary
patient but wishes to discharge himself contrary to the considered opinion of the
person in-charge, the patient may be held at the institution or ward as an
involuntary admission upon recommendation of the attending mental health
practitioner.

- A mental health practitioner should physically and mentally examine any

voluntary patient within 24 hours of admission to a mental health facility.”

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Emergency admission

A family member, friend, community health worker or any responsible citizen may
request orally or in writing that health institution admits a suspected mentally disordered
person as an emergency admission under the following conditions:

- If a person in a community begins to act in a manner inconsistent with

the norms of society because of suspected mental illness;

- If a person in the community is believed to be mentally ill and because

of mental illness lacks proper care in terms of food, clothing and shelter
or is neglected or cruelly treated.

- If any person believed to be suffering from mental disorder is

dangerous to himself, others and property.

Involuntary or Compulsory Admission

This is where the patient is not willing to be admitted and does not accept treatment, or
is unable to give consent for treatment, but he or she has a problem, illness or he is a
potential abscondee. A detention order will permit a compulsory emergency admission
under the leglislation or law in place. According to human rights you are not supposed
to force the patient to be admitted or to force the patient to take medication, hence you
get detention orders, a form that is signed by the magistrate, which will allow medical
personnel to enforce an admission and administer medication. Without detention orders
you can be sued, Detention orders are obtained from the police station or magistrates
court.

The Mental Health Services Bill, (2006) stipulates that:

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- “Involuntary admissions to be are initiated by a family member, a friend or
a community health worker who takes a person suspected of suffering
from mental illness to the nearest health centre where such a person is
examined by an approved health worker who then certifies in writing that
the person required to be detained suffers from a mental illness.

- An approved health worker, if satisfied that a person is mentally

disordered and is dangerous to himself and others, shall refer such a
person to a psychiatric facility or ward within five days of such certification,
where the person so certified to be suffering from a mental illness shall be
admitted.

- Upon receipt of the patient the person in-charge of the said psychiatric
facility shall ensure that the patient is examined physically and mentally.

- The patient must not be admitted to or detained in a psychiatric institution

unless the person in-charge of the psychiatric institution is of the opinion
that no other care of a less restrictive kind is appropriate and reasonably
available to the patient.

- Where it is not possible for a family member, friend or social worker to

convey a person suspected of suffering from mental disorder to a
psychiatric institution a family member, friend or social worker may seek
the assistance of the nearest health centre or police station which
wherever possible shall provide transport with which to convey a
suspected mental patient to the psychiatric institution. The in-charge of
the health facility or police station must provide transport within 24 hours.

- A person in-charge of the health centre or police station should provide

transport for conveyance of a patient to a specialist psychiatric institution.

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 - The in-charge of the health centre or police station may enter premises of
the mentally disordered person if need be in order to facilitate conveyance
of the patient to the health centre.

- Where the patient is of the opinion that his admission or continued

detention is unjustified he may appeal to a mental health review board for
review of his detention. The review must be carried out within fourteen
(14) days of the receipt of the application.

- Any patient involuntarily admitted shall not be detained for more than
fourteen (14) days without review by a mental health practitioner.”

Request for compulsory admission may be made by any family member or relative who
are above 18 years. Other people like friends, employers etc who have good knowledge
of the person and have been with the individual for at least 15 days may request for
compulsory admission.

Medical Practitioners may also certify a patient for admission for as long as they have
identified reasonable grounds for compulsory treatment after a medical examination.
Police officers, judges, local or traditional rulers in whose jurisdiction the individual
resides are also empowered to request for compulsory admission. In other words it’s an
admission where by the patient is not willing to be admitted but he’s a danger to himself,
society as well as to property.

Admission under medical board

This is when the employers writes a letter to the hospital requesting the medical officers
who in turn consult the psychiatrist where applicable, to examine the patient thoroughly
and come up with a report to say whether that person can continue working or be retired
on medical grounds.
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Admission by Court Adjudication

The client is admitted into a psychiatric forensic unit by the court’s decision, whilst
his/her case is being reviewed by the courts of law. In the psychiatric hospital courts
request for assessments, treatment and psychiatrists are required to submit periodical
reports to the courts.

In these reports the following examinations should be included: Previous psychiatric

history, past medical, surgical, obstetric, early childhood and adolescent developmental
history, social histories, alcohol and drug history, family history of any mental history or
any offences in the family, marital status, educational and employment record,
prognosis of disorder and outcome if treated.

The important issues on which opinion may be required in the psychiatric report are:

i. Mental state at time of interview and of the alleged offence. – it must be

established whether the person was mentally ill at the time of the offence.

ii. Competence to attend court and make a defence.

iii. Criminal responsibility – does the patientt understand the difference between
pleading guilty and not guilty. Does the patient understand the nature of the
charge.

THE ADMISSION PROCEDURE

The admission procedure consists of history taking, mental state examination, physical
examination, investigations and a diagnosis is arrived at. The clinician or psychiatrist
will come up with a psychiatric diagnosis after which the patient is commenced on

48
appropriate medication to stabilize him or her and reduce symptoms. You as a nurse
have to conduct your own assessment which should include demographic details,
chief complaint, various histories and mental state examination.

As you learned in the last psychiatric nursing skill of physical examination, you conduct
a systemic examination and obtain the vital signs. In addition, you will ensure
recommended investigations are carried out and prescribed treatments given. The
information derived from the above assessment is used to identify needs and
problems of the patient thereby coming up with a nursing diagnosis. At the same time
you also identify strengths of the patient. You will work with the patient assisting him or
her to solve problems noted by utilizing the strengths, or resources that you have
identified to solve his or her problems.

The actual admission procedure involves receiving the patient into an inpatient
psychiatric or medical ward in which there are restrictions that will prevent him or her
absconding if he or she has come on an involuntary or emergency basis. For
indications, principles and actual procedure refer to your Procedure Manual, Learning
Guide and Evaluation Manuals for admission of a psychiatric patient.

SELF TEST

Complete the following sentences:

Voluntary admission is the entry of a patient into a psychiatric

hospital……………………….

Emergency admission is ………………………………….of a patient into hospital due to a

sudden health crisis.

Involuntary admission is the entry and detention of a patient within an

institution……………………………...

ANSWERS TO SELF TEST

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 A. With his/her agreement.

B. Unexpected and sudden entry.

C. Without his consent.

THE DISCHARGE OF A PSYCHIATRIC PATIENT

We have discussed how a psychiatric patient is admitted. It therefore goes without

saying that when a patient is admitted, a day will come when upon his recovery, he will
get discharged. A process to prepare the patient for discharge begins as soon as the
patient is admitted to hospital. This process is known as discharge planning.

50
DISCHARGE OF A PSYCHIATRIC PATIENT FROM HOSPITAL

The leaving of the hospital by a patient is officially termed DISCHARGE, and involves a
corresponding discharge note.

DISCHARGE PLANNING

Discharge Planning begins as soon as the patient enters hospital. It is most effective
when the patient and his or her family are active in the discharge planning process. In
addition to the family or friends, a variety of hospital staff (also known as the multi-
disciplinary team - MDT) can be involved in the discharge planning process. Discharge
planning involves working through phases:

Introduction or admission phase

Introduction or admission phase in which the admitting nurse and multi disciplinary team
holds a meeting with the client and relatives on admission in which they together begin
to plan for the patient’s eventual discharge upon recovery.

In this meeting clients and relatives are given Information Education Communication
(IEC) on the condition of the patient, signs and symptoms, treatment, hospital stay,
visiting of patient whilst in hospital, preparation of home environment and family
resources for discharge, and prognosis of illness. In addition, relatives are involved in
the goal formation of the patient so that upon discharge they will continue care, in line
with goals.

Working (treatment phase)

After the patient has stabilized the nurse meets with relatives and the rest of the MDT
(mental health nurse, psychologist, psychiatrist, clinical officer, community health
nurse / team to review / evaluate patient’s progress, ascertain his/her suitability for
discharge, and to further prepare patient for discharge. At this time the community

51
mental health team may be called upon to make a home visit to assess the home
environment for any psychosocial stressors before a patient goes there.

Termination phase
Termination phase (this is when the patient goes into the community): this is a transition
( passing from mental hospital to the community) in which the patient is discharged and
given a review date for continuity of care. If the patient is in need of other services such
as a physician, surgeon, counseling services, rehabilitation services etc, he/she is
discharged via those services.

Advantages of discharge planning

1. Discharge planning reduces relapses or hospitalization by identifying clients who

are at risk for experiencing problems when discharged, so that they can be referred to
appropriate places or people who can be of good help to prevent relapses and
admissions.

2. To help patients re-socialize or reintegrate in to community:

- those with chronic enduring psychiatric illness,

- those with special education needs, or

- elderly living alone,

- homeless etc.

PREPARATION FOR DISCHARGE

1. Assess the readiness of patient to leave the treatment setting.

2. Assess the level of functioning with regard to activities of daily living.

52
3. Financial resources – Ask the family about financial resources and that they
should identify anticipated problems associated with discharge as soon as possible after
admission from hospital. Let them suggest possible solutions for their problems.

4. Conduct home visit for home exploration prior to client’s discharge.

5. Provide client and family with verbal and written information about available
medical, social, vocational and support resources in the community (services)

ACTUAL DISCHARGE PROCEDURE

For the actual practical discharge procedure you can refer to your procedure and
Evaluation manuals.

Throughout hospitalization, and indeed, upon discharge, Information, Education and

Communication (IEC) are given to the patient, relatives and significant others on the
following:

PATIENT’S CONDITION

- The client’s symptoms. Train relatives on how to handle and respond to the
patient when he/she becomes violent

- Educate family on emotionally supporting client (importance of preventing High

Expressed Emotion)

- Importance of compliance to medication – it can take as long as 6 months for

antipsychotic drugs to be excreted from the system during which time a patient
might think they no longer need the drug. However, once the drug has all been
excreted, the patient will relapse.

- Prevention of relapse (how to recognize early signs of relapse)

MEDICATION

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 - Clear information about medication (dosage, frequency, route – if i/m which place
and days it will be administered from), who will keep medication, who will
assist/support/ensure pt takes medication.

- Duration of drugs

- Side effects of drugs

- Review dates that should be open appointments

- Nutrition, that some foods cannot interact with certain drugs i.e. alcohol, or
patient has to eat something before taking drugs.

- Give the patient medication that will be taken at home and the discharge slip.

When a patient’s behavior and thoughts become normal, they are ready to go home.
Various measures are undertaken to successfully prepare the patient for discharge.
The community, that’s the patient’s neighbourhood, workplace and church must
undergo sensitization for successful integration of the patient upon discharge.

We have finally come to the end of UNIT 2. I hope you thoroughly enjoyed our time
together and understood the psychiatric nursing skills that we covered. You will be
able to put these skills into practice when you come to our next unit which is UNIT 3. It
consists of Mental Disorders. So you will practice the psychiatric nursing skills you
have just learned.

SELF TEST

Fill in the blanks:-

Discharge planning involves working through phases:

54
 1. Introduction (thus admission phase) the admitting nurse and multi disciplinary
team holds a meeting with the client and relatives in which
………………………………….for the patient’s eventual discharge upon recovery.
2. Working (treatment phase): At this time the community mental health team may
be called upon …………………………………………………………………….before
a patient goes there.
3. Termination phase (this is when the patient goes into the community) this is a
transition (that is, passing from mental hospital to the community)
……………………………………………..

ANSWERS TO SELF TEST

1. They together begin to plan

2. To make a home visit to assess the home environment.

3. In which the patient is discharged.

SUMMARY

We have together discussed the nursing skills used to care for patients with mental
disorders. Mental disorders consist of abnormal behaviours and wrong, negative or
abnormal thinking patterns. Psychiatric nursing skills covered in this unit are directed
towards putting a stop to these abnormal behaviours and wrong thinking patterns.

We also saw that these psychiatric nursing skills are delivered to the patient within the
framework or context of the nursing process to ensure systematic individualized
nursing care. In addition, it was highlighted to you that in order for any nursing
interventions to be successful the nurse has to create rapport and engage the patient
in a therapeutic relationship. The reason is simply that patients will only cooperate with
nursing interventions when they have learned to trust their care giver, in this case the
nurse.

55
Our next UNIT three (3) will be on the different mental illnesses that affect patients.
Remember that psychiatric nursing skills that you have just completed are for the
purpose of implementing nursing care targeted at ending or minimizing abnormal
behaviours of these same mental disorders.

GLOSSARY

Jurisdiction – The authority to enforce laws or pronounce legal judgements.

Mental Health Review Board - means an autonomous body appointed to inquire into a
specific matter relating to the rights of mental patients.

SELF TEST QUESTIONS

ENCIRCLE LETTER THAT CORRESPONDS WITH CORRECT ANSWER

The psychiatric assessment consists of the following:

a. The mental state examination, history taking and psychiatric interview.

b. The psychiatric interview, investigations, physical examination.

c. The mental state examination, investigations, and physical examination.

d. History taking, the psychiatric interview and investigations.

Which of the following is a priority assessment for the patient with major depression?

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 a. Nutritional status
b. Fluid and electrolyte balance
c. Suicidal ideation
d. Mood and affect

MATCH THE FOLLOWING PSYCHIATRIC NURSING SKILLS WITH THEIR

CORRESPONDING DEFINITION BY WRITING THE NUMBER OF THE CORRECT
SKILL ON THE DOTTED LINE.

1.Communication skills …….teach patient step by step way of

changing bad behavior and learn good
manners.

2.Self awareness skills …….. to watch carefully the way something

happens or the way someone does something.

3.Assertiveness training skills ……..Inspect oneself inwardily

4.Counseling skills ………Help patients change abnormal

behaviour

5.Self awareness skills ……….Train patients to express themselves in

an appropriate way

6.Social training skills ………Train patients not to be

aggressive

7.Observation skills ………..Solve a problem successfully

8.Stress management skills …………The reciprocal exchange of

information, ideas and feelings

57
9.Behavior modification skills ………….Acting to bring about a desired
treatment outcome.

10.Therapeutic intervention skills ………. The leaving of the hospital by a patient

which involves a corresponding discharge
note.

11.Physical assessment of psychiatric patient….. actions nurses take to help, treat

or deliver nursing care to clients so that they
may recover or get well.

12.Admission of psychiatric patients ……….. an examination that is conducted the

first time a patient comes to the health facility
with a complaint. It may also be conducted
upon admission.

13.Discharge of psychiatric patients ………….When a patient makes up his mind

and leaves minus psychiatric consent.

UNIT 3 TITLE: CLASSIFICATION AND MANAGEMENT OF PSYCHIATRIC

DISORDERS

3.0 INTRODUCTION

Classification or taxonomy is a process by which complex trends are organized into

groups, classes or ranks, in order to put together things that must be similar to each other

58
 and to isolate those that are different. You will discover in this unit that mental disorder
can be broadly classified into two. The disorder can either be minor (neurotic) or major
(psychosis). Major mental disorders (psychoses) are further divided into Functional
psychoses and organic psychoses. Functional psychoses are major mental disorders with
no demonstrable physical cause. Organic psychoses are major mental disorders with
demonstrable physical cause.

COURSE OBJECTIVE
 Apply knowledge and skills of managing psychiatric disorders

3 UNIT OBJECTIVES

At the end of this unit, you should be able to:

-Describe the management of patients with neurotic disorders

- Demonstrate the skills of managing a patient with psychosis

- Apply knowledge and skill of managing a patient with personality disorders

a. NEUROSIS

The following are examples of neuroses that you will learn in this section:

(i). Anxiety Neurosis

(ii) Obsessive Compulsive Neurosis

(iii) Hysterical Neurosis

Let us now look at each one of the mentioned neurosis in details

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ANXIETY

You should be familiar with the concept anxiety by now. This is the same concept that you
looked at in Psychology. Remember, we defined anxiety as a state of apprehension and
impending doom

Causes of neurotic disorders like anxiety may be linked to the following:

(i) Emotional conflict

(ii) Maladjustment to life situations

(iii) Some genetic and constitutional factors

Anxiety falls on a continuum. It ranges from mild, moderate, severe and Panic state. Panic state
is the worst form of anxiety. An individual in a panic state is completely frozen. Self awareness
is completely absent. He/she cannot perform and will need assistance to function. Hallucinations
can be experienced in a panic state.

General features of anxiety

 Shortness of breath
 Choking
 Palpitations and accelerated heart rate
 Chest discomfort or pain
 Sweating
 Dizziness, unsteady feeling of fainting
 Nausea or abdominal distress
 Depersonalization or derealisation
 Numbness or tingling sensation
 Flushes or chills
 Trembling or shaking
 Fear of dying
 Fear of going crazy or doing something uncontrolled

Management

60
  Benzodiazepines control panic attacks when given in high doses e.g. Diazepam
 Antidepressants e.g imipramine control panic attacks
 Patients who hyperventilate can practice controlled breathing first under
supervision and then on their own.
 Ensure caffeine free diet because it can worsen the situation

OBSESSIVE COMPULSIVE NEUROSIS

Obsessive compulsive disorder is characterized by obsessional thinking, compulsive behavior,

and varying degree of anxiety, depression, and depersonalization. The condition is less frequent
than anxiety neuroses and is more common in women than in men.

Etiology

1. Genetic factors
2. Evidence of brain disorder

3. Abnormal serotonergic function

4. Excessive demands during and early intensive toilet training

The main clinical features are as follows;

1. Obsessional rituals
The patient has to do things in a particular order, or a certain number of times. For
example putting on socks always starting with the left foot, or washing hands three times
they wash at all.
2. Obsessional doubts
Obsesional doubts make the patient wonder if something really happened. Eg patient may
go back to check if he really closed the door
3. Obsessional rumination
These are internal debates in which arguments for and against even the simplest everyday
actions are reviewed endlessly.
4. Obsessional phobias

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 In obsessional phobia, the patient usually has a fear that she will do something wrong
against her better judgement. Eg. The mother may be afraid of knives, because she thinks
she will kill the baby
Diagnosis
To diagnose the obsessive compulsive disorder, the following three features should be
present.
(a) The patient realizes that the feeling, thought or action is irrational, with a subjective
feeling of compulsion
(b) He has tried to resist it
(c) Resistance leads to an increase in tension or anxiety

Differentials

Generalised Anxiety Disorder (GAD), Panic disorder, Phobic disorder, depressive disorders,
schizophrenia. Organic cerebral disorders

Management

 Counseling
 Chemotherapy: anxiolytic drugs, tricyclic antidepressants are effective in reducing
obsessional symptom.
 Behaviour therapy: exposure to any environmental cues that increase obsessional rituals
 Psychotherapy

CONVERSION AND DISSOCIATIVE DISORDERS

Previously known as hysteria, these are conditions in which physical symptoms and certain
mental symptoms occur without the physical pathology with which they are usually associated
and with psychological causes. It is hypothesized that by developing the symptom, the patient
ends by avoiding a situation of unbearable anxiety. This advantage granted by the symptom is
called the primary gain. The disorders are more common in females than in males and tend to
begin before the age of 35.

Etiology

Emotional conflict

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(ii) Maladjustment to life situations

(iii) Some genetic and constitutional factors

Dissociative disorders

The patient behaves as if the brain is not functioning properly

(a) Dissociative amnesia

Patients are unable to recall long periods of their lives and sometime deny any knowledge of
their previous life or personality identity.

(b) Dissociative fugue

The patient not only looses their memory but also wander away from their usual surroundings.
When found, they usually deny all memory of their whereabouts during the period of wondering
and may also deny knowledge of personal identity.

(c) Dissociative stupor

Patients show the characteristics features of stupor as in schizophrenia. They are motionless and
mute and do not respond to stimulation, but they are aware of their surroundings.

(d) Ganser syndrome

The patient gives approximate answers to questions designed to test intellectual functions. Each
answer is one greater than the correct answer e.g. 2+2=5; 2+5=6

Conversion disorder

This disorder mimics the effects of physical illness. The disorder is divided as follows:

 With motor symptoms or deficits

Symptoms include: psychogenic paralysis, gait disorder, tremor, dysphonia and mutism, and
globus hystericus (feeling of lump in the throat)

 With sensory symptoms or deficits

Symptoms include: aneasthesia, parasthesia, hyperaesthesia, pain, deafness and blindness

63
  With seizure and convulsions

Psychogenic convulsions can be distinguished from epilepsy in three ways;

(a) The patient does not become unconscious, though he may inaccessible.
(b) The pattern of movements does not show a regular and stereotyped form of seizure
(c) There is no incontinence, cyanosis, or injury and tongue is not bitten.

Epidemic hysteria

Occasionally, conversion disorder spreads within a group of people an epidemic

 This spread happens most often in closed groups of young women, for example in girls
school.
 Usually anxiety has been heightened among the members of the group by some threat to
the community, such as the possibility of being involved in an epidemic of actual and
serious physical disease present in the neighborhood.
 Typically the epidemic starts in one person and spreads to others.
 Symptoms are variable, but fainting and dizziness are common

Management

 Counseling
 Closing the institution for epidemic hysteria
 Carry out appropriate investigations to rule out physical causes
 Do not neglect the patient
 Treat any form of anxiety

REACTIVE DEPRESSION
Depression is a mood disorder where the mood and vitality are lowered to the point of
distress. Reactive depression is a neurosis. It is also known as exogenous depression
because the cause is considered to be coming from outside
Etiology
The cause for this type of depression is known. It is due to traumatic experiences in life
like:
 Bereavement

64
  Failing an important exam
 Loosing important property
 Chronic illness

Clinical features

 Loss of appetite

 Insomnia

 Patient may be mute or monosyllabic (response using just one word as opposed to
providing detailed explanation)

 Loss of libido

 Neglect of body hygiene

 Patient may avoid social contact

 Extreme sadness and crying at times

 Psychomotor retardation

 Suicidal ideas may be present

 Poor concentration.

Management

1. Psychotherapy. This is the treatment of choice

2. Observe patient closely in case patient has suicidal ideation

3.2PSYCHOSIS

Affective disorders

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MANIA

Mania is an affective disorder which presents with elation of mood and increased psychomotor
activities

A mild form of mania is called hypomania

Etiology: The cause is unknown

Clinical features

 Grandiose ideas (Ideas of self exaltation)

 Talkative, pressure of speech

 Chance association (commenting on anything within sight)

 Flight of ideas

 Exaggerated type of dressing, often using bright colours

 Pleasurable activities with painful consequences e.g. increased spending, increased

libido, speeding, substance use

 Irritability

 Increased psychomotor activity

 Impulsivity

Management

 Give antipsychotics e.g. Haloperidol

 Elecroconvulsive therapy can be done

 Ensure patient is well hydrated and fed because there may be risk of dehydration and
starvation as the patient may not find time to eat due to increased activities and
distractability

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PSYCHOTIC DEPRESSION

Psychotic depression is also known as endogenous depression. It is a psychosis

Etiology:The cause is unknown

Clinical features

 Psychomotor retardation

 Sad facial expression

 Lack of response to humour

 Slow and soft speech

 Significant weight loss when not dieting

 Insomnia or hypersomnia

 Fatigue or loss of energy every day

 Feeling of worthlessness or inappropriate guilt

 Diminished ability to concentrate

 Suicidal ideas

Management

 Antidepressants can be given e.g. Imipramine, Amitryptiline 25mg to 75mg

 Electroconvulsive therapy can be done

 Psychotherapy

Behavioural therapy

SCHIZOPHRENIA

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The most common psychotic disorder and the most difficult to define and describe. The reason
for this difficulty being that over many years, to date, many divergent concepts of schizophrenia
have been held in many countries and by different psychiatrists.

Schizophrenia is a psychiatric syndrome in which specific psychological symptoms lead, in most

cases, to disintegration of personality. The symptoms interfere with thinking, emotion, motor
behavior, and volition (will power). The abnormal thinking leads to misinterpretation of reality
with development of fantasy thinking, delusions and hallucinations. Insight is always lost to a
variable degree.

Subtypes of schizophrenia

1. Simple schizophrenia
Onset in adolescence. Condition characterized by insidious development of eccentric behavior,
apathy, a shallow affect, social withdrawal, a lack of drive and initiative, and declining
performance at work. Delusions and hallucinations are uncommon. Prognosis very poor. Since
clear schizophrenic symptoms are absent, simple schizophrenia is difficult to identify reliably.

2. Hebephrenic schizophrenia
Onset in adolescence or early 20s. Patients often appear silly and childish in their behavior.
Affective symptoms (flattened affect and incongruity) and thought disorder are prominent.
Delusion is common and not highly organized. Hallucinations also are common, and are not
elaborate. Though onset is usually insidious, some cases begin suddenly, with marked depression
and anxiety.

3. Catatonic schizophrenia
Onset later than in hebephrenia and is usually acute. Characterized by motor symptoms and by
changes in activity between excitement and stupor. Patient many have one (or a combination) of
several forms of the following catatonic symptoms described below:-

Catatonic stupor or mutism: Patient does not appreciably respond to the environment or to the
people in it. Despite appearances, these patients are often thoroughly aware of what is going on
around them. Catatonic negativism: Patient resists all directions of physical attempts to move
him or her.
Catatonic rigidity: Patient is physically rigid.
Catatonic posturing: Patient assumes bizarre or unusual postures.
Catatonic excitement: Patient is extremely active and excited.

Delusions, hallucinations and affective symptoms occur, but are usually less obvious

4. Paranoid schizophrenia
Develops later (in the 30s or 40s) than other forms of schizophrenia. The most stable and
common subtype. Paranoid delusions are predominant. Patients are often uncooperative and
difficult to deal with and may be aggressive, angry, or fearful. Thought disorder and affective
change are usually inconspicuous.

68
Hallucinations (auditory) are often present. Personality is well integrated.

5. Residual schizophrenia

After many years and repeat episodes, the active symptoms of schizophrenia ‘burn out’ and the
patient displays symptoms of residual phase (e.g. dullness, social with drawl, flat or
inappropriate affect, eccentric behavior, loosening of association, illogical thinking, lacking in
interest, volition or imagination).

Diagnosis
Schneider’s first rank symptoms in the diagnosis of schizophrenia (provided there is no evidence
of organic disease) are as follows: (see also ICD 10).

1. Thought with drawl (belief that thought are being taken out of one’s mind)
2. Thought insertion (belief that thoughts are being put into one’s mind)
3. Thought broadcasting (belief that thoughts become known to others)
4. Echoing thoughts (hearing thoughts spoken aloud)
5. Hearing hallucinatory voice discussing ones thoughts and behavior in third person, or passing
a
Running commentary (e.g. ‘he is doing in now’)
6. Passivity feelings (belief that thoughts and behavior are being influenced or controlled by
external
forces.
6. Primary or autochthonous delusions, or delusional perception
.
Management

 Hospitalization needed for both first episodes of schizophrenia and acute relapses
 Various neuroleptics can be used – see table provided in this section
 There are advantages in a few days of observation without drugs, although some acutely
disturbed patients may require immediate treatment.
 For acutely disturbed patients the sedative effects of chlorpromazine are useful. An
alternative
Approach is to use a modest dose of a high potency agent with additional benzodiazepine
treatment (e.g. diazepam 5-20mg.
 Oral medication usually given at this stage, although occasional IM doses may be needed
for
Patients who exhibit acutely disturbed behavior and are unwilling to comply with oral
treatment.
 After the first few days medication is continued at a constant daily amount for several
weeks,
Gradually changing to twice daily dosage or a single dose at night.

69
 Prescribe antiparkinsonian drugs (e.g. artane) if side effects are troublesome, but they
need not be given routinely.
 ECT indicated mainly in catatonic stupor and severe depressive symptoms. Also in
patients whose symptoms have not responded to adequate antipsychotic drug therapy.
Other management

Psychotherapy
 Psychoanalytic psychotherapy: Suitable for patients with good motivation and
productivity.
 Group therapy: But of little benefit in the acute stage of the disorder.
 Supportive therapy: for patients who are resettling after the resolution of an acute illness.
 Behavioral treatment: Methods include social skills training, using positive and negative
reinforcement to change behavior. Behaviour therapy is based on learning theory which
postulates that problem behaviours (i.e., almost any of the manifestations of psychiatric
conditions) are involuntarily acquired due to inappropriate learning. Therapy concentrates
on changing behavior.

 Cognitive therapy: Attributes emotional difficulties to faulty thinking or beliefs

(cognition) that lead to counterproductive behavior. Psychiatric conditions presumably
improve when the patient’s thinking is more accurate and when the behavior is more
appropriate. Thus the therapist works with the patient to identify and correct
misperceptions (one by one) and (mis) behaviours.

Dosage of some antipsychotic drugs

Relative dose Maximum dose

Drug (oral – mg) (mg)
Chlorpromazine 100 1000
Thioridazine 100 800
Trifluoperazine 5 20
Fluphenazine 2 20
Haloperidol 2 100
Fluphenthixol 1 18
Sulpiride 200 2400
Clozapine 60 900

DEMENTIA

Introduction

Poor memory and disorientation were once considered a normal part of aging. It was believed
that if one lived long enough, such impairments were unavoidable. Currently, dementia is
70
considered an abnormal state with many causes that can often be identified. Dementia is an
important concern in the field of psychiatry and in Zambia dementia is a condition that has not
been understood quite well. The Zambian culture strongly believes in magic and witchcraft and
most people with dementia have become victims of torture and even death. The Malota
compound in Livingstone and Kalulushi cases were both dementia victims. Both cases became
suspects of witchcraft and unfortunately the elderly lady in Kalulushi was even murdered.

Definition of dementia: Dementia is defined as global or total intellectual decline of sufficient

severity to impair social and/or occupational functioning that occurs in normal consciousness,
(Steele,2010 :3).The term dementia describes symptoms of a large group of illnesses that cause a
progressive decline in a person’s functioning such as loss of memory, intellect, rationality and
social skills.

There are four key elements to the definition of dementia,( Steele,2010:5):

1. Global impairment. Dementia impairments in are total. The impairments occur in more
than just memory. Most dementia patients experience impairments in reasoning, using
and understanding language, recognizing what one perceives through the senses,
coordinating learned motor movements, planning and decision-making.
2. Decline. The impairments represent a decrease from a previous level of functioning. To
recognize a reduction, it is crucial for the nurse to know the patient’s previous level of
functioning unless members of the family or significant others give correlated
information.
3. Severity. Impairments are severe enough to interfere with normal functioning in
everyday life. Examples are a person who was living independently and begins to make
poor financial decisions or forgets how to cook a meal, although the person could
previously perform those tasks. Getting lost while walking from a nearby church,
neighbourhood and driving can also indicate severe impairment.

71
 4. Normal consciousness. These impairments occur in a normal state of consciousness;
patients are awake and alert. This is distinguished from an abnormal state of
consciousness, such as drowsiness, stupour or coma, seen in delirium.

CAUSES OF DEMENTIA

There are many brain disorders that cause dementia. The currently recognized causes of
dementia are represented in the pie chart shown in the Figure below and each type has a
distinctive profile of symptoms and course (Steele, 2010).

In the box below are the Four A’s of Alzheimer Disease

 Amnesia: Memory impairment

 Aphasia: Communication impairment
 Apraxia: Impairment in performing motor movements
 Agnosia: Impairment in recognition of what is taken in through the senses

Causes of dementia in %

10%
15%
Alzheimer's dementia
Vascular Demntia
50% Frontal-Temporal Lobe dementia
Dementia with Lewy bodies
Other
15%
10%

1. Alzheimer’s dementia 50%

2. Vascular dementia 10%

72
 3. Frontal-Temporal Lobe 15%
4. Dementia with Lewy bodies 15%
5. Other 10%
 ALZHEIMER’S DISEASE

Alzheimer disease (AD) is the most common cause of dementia and thus the most common type
that nurses encounter in clinical practice. AD is an incurable neuro- degenerative disease. The
hallmark pathology of AD includes amyloid plaques and neurofibrillary tangles in the brain. One
also sees general shrinkage of the brain and a decrease in the number of functioning neurons.

 SIGNS AND SYMPTOMS OF DEMENTIA

In the early stages of dementia, people function relatively normal with minimum support. As
dementia progresses, more specific symptoms occur (such as difficulty with speech and
language, poor judgement and lack of insight). Difficulty with personal care tasks (such as
bathing) and other everyday tasks (such as cooking, shopping and managing money) may
become evident, (Stuart & Laraia, 2005).

Often there are enduring changes in personality and behaviour as well. People with dementia can
be perceived to be aggressive, uncooperative and unpredictable. They may also present with
hallucinations and delusions. These ‘behaviours of concern’ and others can best be classified as
‘behavioural and psychological symptoms of dementia’.

All signs and symptoms are due to progressive damage to the brain for example, damage to the
limbic system is associated with memory dysfunction, unstable mood and personality changes
(Steele, 2010). The behaviours are not the result of deliberate attempts to be difficult or to upset
carers.

 TYPES OF DEMENTIA

Dementia can be caused by a number of disease processes. Approximately 60 per cent of people
with dementia have (i)Alzheimer’s disease, a consequence of degenerative brain changes as an
individual age. (ii) Vascular dementia result from small brain infarcts; small brain
haemorrahges. Dementia related to (iii) Parkinson’s disease is also common and (iv) excessive
alcohol consumption is another prevalent cause. Other illnesses (such as (v) multiple sclerosis,

73
(vi) HIV/AIDS, (vii) Huntington’s disease and (viii) Creutzfeldt-Jacob disease) are less
common.


 ONSET AND COURSE OF DEMENTIA

In Alzheimer’s disease, the onset is insidious, generally occurring after the age of 55 and
increasing in frequency of occurrence with advancing age (Steele, 2010). Dementia is an
incurable illness with failing brain functioning and increasing physical disability leading to total
dependence on others for all care.

 DIFFICULTIES WITH DIAGNOSIS

It is important to understand the difference between dementia, delirium and depression.

Depression and delirium are treatable conditions that present similar to dementia. Remember that
all three conditions can be present and that dementia increases the risk for delirium. Common
precipitating factors for delirium include infection, medication interactions and surgery.

Differentiating between Dementia, Delirium and Depression and (three Ds) requires skilled
assessment. The differences and similarities are outlined in the Table below. Be alert to co-
morbid substance misuse as complex co-morbidities may mask substance misuse and the impact
of co-occurring problems.

 DELIRIUM, DEMENTIA AND DEPRESSION (Stuart & Laraia, 2005).

The three Dementia Delirium Depression

Ds
• Repetitiveness of thought
• Reduced interests
• Difficulty making
Thoughts logical connections
• Slow processing of thoughts
• Often a disturbed 24 hour
clock mechanism (later in
the disease process)
• Bizarre and vivid thoughts
• Frightening thoughts and
ideas
• Often paranoid thoughts
• Confusion disturbs sleep
(may have a reverse sleep-
wake cycle)
• Often slowed thought
processes
• May be preoccupied
by sadness and
hopelessness
• Negative thoughts
about self
• Reduced interest
• Early morning waking
or
intermittent sleeping

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Sleep
• Increasingly impaired sense
Orientation of time and place
• Usually gradual, over
Onset several years
• Insidious in nature
• Impaired recent memory
• As disease progresses, long
Memory term memory also affected
and • Other cognitive deficits
cognition such as in word finding,
judgement and abstract
thinking
Duration • Months or years and
progressive degeneration
Course • May be variable depending
throughout on type of dementia
the Day
Alertness • Usually normal
• May be able to conceal
or compensate for
Other
deficits (early)
 TREATMENT FOR DEMENTIA
In general, non-pharmacological approaches are first-line treatment for behavioural and
psychological symptoms of dementia. If symptoms are moderate to severe and impact on the
• Nocturnal confusion patterns (in atypical
• Vivid and disturbing cases,
nightmares too much sleep)
• Fluctuating impairment of • Usually normal
sense of
time, place and person
• Acute or sub acute (hours or • Usually over days or
days) weeks
• May coincide with
life changes
• Immediate memory impaired • Recent memory
• Attention and concentration sometimes impaired
impaired • Long-term memory
generally intact
• Patchy memory loss
• Poor attention
• Usually brief — hours to • At least two weeks
days (but can last months in (but can be several
some cases) months to years
• Fluctuates — usually worse • Commonly worse in
at night in the dark the morning with
• May have lucid periods improvement as the day
continues.
• Fluctuates — lethargic or
hypervigilant • Normal
• May occur as a consequence • Often masked
of a drug interaction or • May or may not have
reaction, physical disease, past history.
psychological issue or
environmental changes
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person’s (or the carer’s) quality of life or functioning, medication may be needed, often in
conjunction with non-pharmacological interventions.

The person with dementia, the family and carers will need much support, education and
counselling to help them understand and cope with what can be a distressing illness. A problem-
solving approach that is preventative rather than reactive may help to identify situations that
trigger a particular behaviour, which can then be avoided or modified.

 NON-PHARMACOLOGICAL STRATEGIES

Non-pharmacological strategies need to be based on an understanding of the individual’s

strengths and deficits. A ‘catastrophic reaction’ may result when the person’s ability to cope is
exceeded by the demands of the caregiver. This may be in the form of aggression or other
distressed behaviour.

Communication strategies should include using clear, plain language and short sentences that
convey one idea at a time. Use of gestures, pictures and body language can enhance the
effectiveness of the message.

It is helpful to use the ‘ABC’ model. This looks at the:

Activating event i.e. what happens before the client reacts?

Behaviour i.e. how does the client reacts to the stimulus?

Consequences i.e. What happens after the behaviour?

Documenting these can provide clues to patterns and the triggers of behaviour.

 PHARMACOLOGICAL STRATEGIES

Currently there is no cure for dementia, but drugs such as cholinesterase inhibitors (for example,
donepezil, galantamine and/or rivastigmine) may help to slow the progress of the disease in the
early stages. Memantine, which inhibits the release of glutamate (a neurotransmitter), is
indicated for more advanced disease and may be used in conjunction with a cholinesterase
inhibitor. Antipsychotic medication is most effective in the treatment of psychotic symptoms
(such as hallucinations and delusions) and behavioural symptoms (such as physical aggression).

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Newer antipsychotic medications appear to be at least as effective as conventional neuroleptics,
but have fewer side effects. Those with strong extrapyramidal effects (such as muscle rigidity,
tremour and Parkinsonism) may be avoided in favour of those with sedating qualities, (Stuart &
Laraia,2005).

When the person is severely agitated and as a result, distressed or representing a danger to
himself, herself or others, sedation (a waking calm) is indicated. However, care needs to be taken
to avoid oversedation (drowsiness), which ironically increases confusion and exposes the person
to other risks such as falls, immobility, hypotension and reduced engagement.

Benzodiazepines with lower toxicity and shorter half-life (for example, temazepam, and/or
oxazepam) are preferred to longer-acting agents (for example, diazepam, and/or nitrazepam).

Antidepressant medications are underused in people with dementia, despite the common
occurrence of depression in dementia and the documented therapeutic value of these drugs. Some
people may present as agitated when suffering a depressive disorder.

Research in the United States of America shows that giving a client suffering from dementia a
cocktail of vitamins, such as Folic acid,B12 and B6 improves memory. This treatment has to be
given simultaneously once daily (OD) for one month and then the client to be observed for signs
of improvement.

 GOALS FOR NURSING A PERSON WITH DEMENTIA

Appropriate goals for caring for a person with dementia in a community or hospital setting
include:

 Develop a relationship with the person based on empathy and trust.

 Provide an environment that supports flexible but anticipated routines.
 Maintain a safe environment for the person, yourself and other staff.
 Promote the person’s engagement with their social and support network.
 Ensure effective collaboration with other relevant service providers, through development
of effective working relationships and communication.
 Support and promote self care activities for families and carers of the person with
dementia.

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  GUIDELINES FOR RESPONDING TO A PERSON WITH DEMENTIA

The following guidelines will assist in nursing a person with dementia.

 Arrange for a review of the person’s medication and an initial or follow-up psychiatric
assessment if their care plan needs reviewing. A mental health assessment may be
appropriate to undertake — see the MIND Essentials resource ‘What is a mental health
assessment?’.
 A person’s cultural background can influence the way symptoms of mental illness are
expressed or understood. It is essential to take this into account when formulating
diagnosis and care plans.
 Explain to the person who you are, what you want to do and why.
 Smile — the person is likely to take cues from you, and will mirror your relaxed and
positive body language and tone of voice.
 Move slowly, you may have a lot to do and be in a hurry, but the person is not. Imagine
how you would feel if someone came into your bedroom, pulled back your blankets and
started pulling you out of bed without even giving you time to wake up properly.
 If the person is resistant or aggressive but is not causing harm, leave him or her alone.
Give the person time to settle down and approach the task later.
 Distract the person by talking about things he or she enjoyed in the past and by giving
him or her a face washer or something to hold while you are providing care.
 Do not argue with the person. The brain of a person with dementia tells the person that he
or she cannot be wrong.
 If the person is agitated, maintain a quiet environment. Check noise levels regularly and
reduce them if necessary y by turning off the radio and television.
 Provide orientating cues such as a clock and calendar.
 Give the person a comfortable space. Any activity that involves invasion of personal
space increases the risk of assault and aggression.
 Always provide care from the side (not the front) of the person. If you stand in front, you
are easily hit or kicked if the person becomes aggressive.
 Be vigilant if the person is climbing out of bed. Refer to your workplace policy on
restraint. If you cannot work out a reason for this behaviour, you might walk with the

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 person or engage him or her in an activity. This helps to maintain his or her mobility, and
eventually he or she may tire and go back to bed. Encourage family or volunteers to help
with this.
 Monitor compliance with medication and general physical health (including nutrition,
weight, blood pressure, etc).
 Monitor food and fluid intake and elimination — dehydration or constipation can
exacerbate confusion.
 People with dementia are at increased risk of developing delirium, so be aware of risk
factors for delirium (such as medication interactions, infection and the postoperative
period).
 Provide family members and carers with information about the illness if appropriate, as
well as reassure and validate their experiences with the person. Encourage family
members and carers to look after themselves and seek support if required.
 Be aware of your own feelings when nursing a patient with dementia. Arrange for
debriefing for yourself or any colleague who may need support or assistance — this may
occur with a clinical super visor or an Employee Assistance Service counsellor (Steele,
2010).

HIV/AIDS RELATED PSYCHOSIS

Introduction

People with HIV infection are at risk of developing psychiatric symptoms and disorders similar
to those seen in general population. Even before infection people at risk of acquiring HIV may
come from certain populations such as injection drug users and others with substance abuse or
dependence in whom there is a higher than average risk for psychiatric illness. Symptoms of
anxiety and depression may be related to apprehension about the disease progression and death,
sadness from loss of health and the virus invading the central nervous system.

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 Psychosis is more common among people with HIV infection than the general population
whereas factors contributing may include direct effect of HIV on CNS, opportunistic infection,
CNS neoplasm, medications, substance use disorder and other psychological stresses (McDaniel
et al., 2000).

New-onset psychosis can occur in the setting of HIV infection for instance as an opportunistic
infection (like CNS lymphoma), with AIDS-related dementia, as medication side-effect, or with
asymptomatic HIV infection (Perry & Jacobsen, 1986).

Generally such psychosis occurs in the later stages of HIV infection, usually in the context of
AIDS. Less often it occurs with positive past psychiatric history, no antiretroviral therapy and
lower global cognitive performance compared to non-psychotic HIV-positive subjects (De
Ronchi et al., 2000).

 MANAGEMENT OF PSYCHOSIS IN HIV INFECTED INDIVIDUALS

EVALUATION: The clinical evaluation of HIV-AIDS patients with psychotic symptoms

requires broad history taking and physical examination, to rule out other known causes of
psychosis. A careful history should include information about the onset and course of the
patient’s symptoms. Signs of medical illness, drug intoxication, or medication toxicity should be
considered during the examination (Nebhinani & Mattoo, 2013).

TREATMENT: Medication side-effects and drug–drug interactions are important

considerations when patients are prescribed antipsychotic agents for the treatment of new-onset
psychosis while concomitantly receiving HAART. For example, the enzymatic inhibition seen
with protease inhibitors may lead to increased serum levels of antipsychotic agents and a greater
potential for side-effects. Similarly, the ability of protease inhibitors and some atypical
antipsychotic agents to cause weight gain and dyslipidaemia may lead to negative long-term
outcomes such as diabetes, hypercholesterolemia, and cardiovascular events. The ability of some
antiretroviral agents (e.g. zidovudine, efavirenz) to cause CNS effects (e.g. nightmares,
hallucinations) may also complicate the treatment of psychiatric disorders. Caution should thus

80
be exercised when deciding on the pharmacological treatment of psychosis in HIV-infected
individuals, (Nebhinani & Mattoo,2013 ).

As patients with HIV-associated psychosis are more sensitive to extrapyramidal side effects, so
they require lower doses than other patients with psychosis. The use of atypical antipsychotics in
the treatment of new-onset psychosis in HIV positive persons has proven helpful in reducing
cases of extrapyramidal symptoms. For example the use of Risperidone (1mg-3.3 mg),
Olanzapine (10 mg) and Clozapine (mean 27 mg) given in smaller dosages minimize
extrapyramidal symptoms. These antipsychotics fall in the Atypical(new generation
antipsychotics) while the old generation antipsychotics also called Typical antipsychotics follow
the same trend of smaller dosages( i.e. Chlorpromazine, Haloperidol, Trifluoperazine,
Thioridazine and Fluphenazine Depot).

Thus, since patients with HIV-associated psychosis are more sensitive to extrapyramidal side
effects, consequently they need lower doses of antipsychotic drugs than other patients’ with
psychosis.

 PERSONALITY DISORDERS

INTRODUCTION

People vary in the ways that they view themselves and others, engage in relationships and cope
with hardships. It is quite common for these characteristics to occasionally interfere with a
person’s ability to cope with life and may also lead to difficulties in social interactions. When
these difficulties are extreme and persistent and when they lead to significant personal and/or
social problems, they are described as personality disorders. Personality hypothesis was guided
by psychoanalytic or Freudian ideas of the Id, Ego and Superego.

Personality disorders may perhaps be defined as deeply-rooted, inflexible patterns of relating to

others that are maladaptive and cause significant impairment in social and/or occupational
functioning, (Alwin,et al,2006).

Personality, defined psychologically, is the set of enduring behavioral and mental traits that
distinguish human beings. Hence, personality disorders are defined by experiences and behaviors
that differ from societal norms and expectations. Those diagnosed with a personality disorder

81
may experience difficulties in cognition, emotiveness, interpersonal functioning or control of
impulses. In general, personality disorders are diagnosed in 40–60 percent of psychiatric
patients, making them the most frequent of all psychiatric diagnoses.

These behavioral patterns in personality disorders are typically associated with substantial
disturbances in some behavioral tendencies of an individual, usually involving several areas of
the personality, and are nearly always associated with considerable personal and social
disruption. A person is classified as having a personality disorder if their abnormalities of
behavior impair their social or occupational functioning. Additionally, personality disorders are
inflexible and pervasive across many situations, due in large part to the fact that such behavior
may be ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and
are, therefore, perceived to be appropriate by that individual. This behavior can result in
maladaptive coping skills, which may lead to personal problems that induce extreme anxiety,
distress or depression. These patterns of behavior typically are recognized in adolescence and the
beginning of adulthood and, in some unusual instances, childhood.

AETIOLOGY

 Biological, genetic and psychosocial factors during childhood and adolescence contribute
to the development of personality disorders.

 The prevalence of personality disorders in monozygotic twins is several times higher than
in dizygotic twins.

Types of personality disorders

Paranoid personality disorder:

 Characterized by a pattern of irrational suspicion

 mistrust of others

 Interprets innocent actions to be negative

 Defensive

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Schizoid personality disorder:

 lacks of interest and avoids social relationships

 restricted emotional expression

 Lacks humour

 Apathetic

 Enjoys solitary activities

Antisocial personality disorder

 disregard for and violation of the rights of others,

 lack of empathy

 Always in conflict with the law

 Starts enganging in sexual activities at a tender age

 Make irresponsible parents

 Unable to learn from past experiences

 Lies alot

Borderline personality disorder

 pervasive pattern of instability in relationships, self-image, identity, behavior and affects

often leading to self-harm and impulsivity

Narcissistic personality disorder

 a pervasive pattern of grandiosity

 Attention seekers

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  Exhibitionists

 Always asks for favours

Avoidant personality disorder

 pervasive feelings of social inhibition and inadequacy

 extreme sensitivity to negative evaluation

Dependent personality disorder

 Pervasive psychological need to be cared for by other people.

Obsessive-compulsive personality disorder

 Rigid conformity to rule

, perfectionists

TREATMENT

 Personality disorders are generally very difficult to treat, especially since few patients
are aware that they need help. The disorders tend to be chronic and lifelong.

 In general, pharmacologic treatment has limited usefulness and is based on individual

exceptions except in treating coexisting symptoms of depression, anxiety, and the
like.

 Psychotherapy and group therapy are usually the most helpful treatment modalities.

References

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  American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental
Disorders

 Kernberg, O. (1984). Severe Personality Disorders. New Haven, CT: Yale University
Press, IS

 WHO (2010) ICD-10: Disorders of adult personality and behaviour

CONCLUSION

Psychiatric illnesses are predominantly difficult to classify since it is the complete person and not
a particular part which is disordered. The arrangement of things into groups or categories is
necessary for the formulation of our ideas and communication to other professionals or people.
Categories are not truths but man-made divisions created for convenience and are of value as
long as they serve a useful purpose. Classification of illness is thus useful as much as it helps to
classify concepts about the kind of the disorder and to assist with its treatment.

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 SUMMARY

You have learnt two different ways of classifying mental disorders i.e. what we can refer to as
modern and old methods of psychiatric disorders’ classification. I am confident that you have
had good tutorials that have enhanced your skills in psychiatric nursing and psychiatry in
general. Classification of diseases helps health personnel in communicating amongst themselves.

6.0 UNIT 3. REVIEW QUESTION

REFERENCES/FURTHER READING

Adedotun, A. (2005). Basic Psychiatry and Psychiatric Nursing. Ile-Ife: Basag Enterprises.

Sreevani, R. (2004). A Guide to Mental Health and Psychiatric Nursing. New-Delhi: Jaypee
Brothers Medical Publishers (P) Ltd.

The ICDIO Classification of Mental and Behavioural Disorders, Clinical Description and
Diagnostic Guidelines. (2007). World Health Organization. Oxford University Press

UNIT 4:CONDITIONS NOT ATTRIBUTED TO MENTAL DISORDERS THAT ARE A

FOCUS OF ATTENTION AND TREATMENT

INTRODUCTION

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You are most welcome to the fourth unit in mental health and Psychiatric Nursing. In
this unit we are going to discuss two topics. The topics are management of children with
special education needs and management of epilepsy. In UNIT, three (3) we covered
major and minor mental illnesses. Children with mental retardation and giftedness are
not mentally ill. In addition, epilepsy is not a mental illness either.

Epilepsy and mental retardation are neurological conditions. These disorders result from
abnormalities in the structure (anatomy) and functioning (physiology) of various parts of
the nervous system. This can in turn result in a range of symptoms. Individuals with
special learning needs or epilepsy are more likely to develop mental illness than the
general population.

Activity

Read your Psychology in Nursing notes on Mental Retardation and Giftedness.

Read your Anatomy and Physiology notes on the Central Nervous System.

Read your Fundamentals of Nursing notes on Epilepsy.

Children with mental retardation and giftedness have special education needs because
of their extremes of intelligence. No matter how we choose to define and assess
intelligence, it is true that there will be a wide range of individual differences. For
example, intelligence tests compare people's scores to averages of others of the same
chronological age, so most people by definition show average intelligence scores. But
what about those whose Intelligence Quotient (IQ) scores are significantly below
(mental retardation) or above average (gifted)? What outcomes are common for these
individuals? This is what we will discuss in this lesson today.

In Psychology in Nursing you covered Mental Retardation and Gifted child from a
physical point of view, that is, the definitions, degree of retardation and giftedness and

87
management; I hope you have read through your past course content in Psychology so
that you may easily understand what we are going do to today.

In this unit we will review some details that you covered in Psychology in Nursing. In the
review we will define mental retardation, state incidence, explain degrees of severity
and outline causes of mental retardation. We will then proceed to discuss the
management of children with mental retardation and those with giftedness. Finally, we
will cover epilepsy from a physical point of view and then from a mental health point of
view.

GENERAL OBJECTIVE4.0: Manage children with special education needs and clients
with epilepsy

SPECIFIC OBJECTIVES

At the end of the unit, the learner should be able to:

4.1 Describe the management of children with special education needs.

4.2 Describe the management of clients with epilepsy.

4.1 MANAGEMENT OF CHILDREN WITH SPECIAL EDUCATION NEEDS

MENTAL RETARDATION

I ‘am sure that you should have heard about the term mental retardation. What do
you know about mental retardation?

DEFINITION: Mental Retardation is a disorder in which a person’s overall intellectual

functioning is well below average, with an intelligence quotient (IQ) around 70 or less.
Individuals with mental retardation also have a significantly impaired ability to cope with
common life demands and lack some daily living skills expected of people in their age
group and culture.

The impairment may interfere with learning, communication, self-care, independent

living, social interaction, play, work, and safety. Mental retardation appears in childhood,

88
before age 18. In the United Kingdom the term mental retardation is interchangeable
with the term ‘learning disability’.

INCIDENCE: - About 1 percent of the general population has mental retardation,

although some estimates range as high as 3 percent. Mental retardation is slightly more
common in males than in females. It occurs in people of all racial, ethnic, education, and
economic backgrounds.

DEGREES OF SEVERITY

There are four degrees of severity of mental retardation based on IQ score:

1. Mild retardation (IQ range 50-55 to about 70).

2. Moderate (IQ range 35-40 to 50-55).
3. Severe (IQ range 20-25 to 35-40).
4. Profound (IQ level below 20-25).

People of average intelligence, score from about 90 to 110 on IQ tests.

Now, let us go into a little bit of details about each of the above types

1. Mild

Mildly affected individuals often cannot be distinguished from normal children until they
attend school. They may be labeled as slow learners by their teachers. Although they
learn more slowly, people with mild retardation usually can develop academic skills
equivalent to the sixth-grade level. As adults, they can work and live in the community if
helped when they experience unusual social or economic stress. Some may marry and
have children.

2. Moderate

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People with moderate retardation can progress to about the second-grade level in
academic skills. By adolescence, they usually have good self-care skills—such as
eating, dressing, and going to the bathroom—and can perform simple tasks. As adults,
most can work at unskilled or semiskilled jobs with supervision.

3. Severe

Severe retardation affects 3 to 4 percent of mentally retarded individuals. Severely

retarded individuals may learn to talk during childhood and develop basic self-care
skills. In adulthood they can perform simple tasks with close supervision. They often live
in group homes or with their families.

4. Profound

About 1 to 2 percent of retarded people have profound mental retardation and requires
constant care. Profoundly retarded individuals can understand some language, but they
have little ability to talk. They often have a neurological condition that accounts for their
retardation.

Having looked at the different types of mental retardation, what could be some of the
causes of mental retardation?

Here are some of the causes

CAUSES

1. Genetic conditions
2. Disorders that occur as a fetus develops during pregnancy
3. Problems during or after birth.

Genetic causes
Chromosomal disorders such as Down syndrome. Down syndrome occurs when
people inherit all or part of an extra copy of a pair of chromosomes known together as
chromosome 21. Although regarded as genetic disorders, chromosomal disorders are
not necessarily inherited. Both parents may have normal genes, with the defect

90
resulting from a random error when chromosomes reproduce.

Disorders that occur as a fetus develops during pregnancy

A variety of problems during a woman’s pregnancy can cause mental retardation in her
child.

a. Malnutrition;
b. Mother use alcohol or drugs;
c. environmental toxins such as lead and mercury;
d. viral infections, including rubella (see German Measles) and cytomegalovirus;
e. An untreated diseases such as diabetes mellitus.
f. Fetal alcohol syndrome results from excessive consumption of alcohol during
pregnancy, including premature birth, very low birth weight, and stresses to the
fetus such as deprivation of oxygen.

Problems that occur during or after birth

a. Infectious diseases during childhood, which are easily preventable through

immunization, also can cause mental retardation when they result in
complications. For example, measles, chicken pox, and whooping cough may
lead to encephalitis and meningitis, which can damage the brain.
b. Physical trauma to the brain can also cause mental retardation.
c. Brain damage may result from accidental blows to the head,
d. Near drowning,
e. Severe child abuse, and
f. Childhood exposure to such toxins as lead and mercury.
g. Experts believe that poverty and a lack of stimulation during infancy and early
childhood can be factors in mental retardation.
h. Children raised in poor environments are more likely to experience malnutrition,
lack of routine medical care, and environmental health hazards.

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MANAGEMENT OF CHILDREN WITH LEARNING DISABILITIES (L D) OR MENTAL
RETARDATION

Provision of care and support should always be within a therapeutic environment or an

appropriate setting. Support may be general or specific.

General support

Care is provided by usual care givers who are parents, relatives and sometimes even
maids that remain with these children when parents are at work. Other health workers
such as physiotherapists and community nurses promote a normal environment by
encouraging care to take place at home, integration in cases where the degree of
retardation is only mild or moderate into mainstream schools; use of local community
resources in for instance whatever assets are available in that community that could be
used to care for these children such as physiotherapy, meeting in a central accessible
point once per week for two hours.

Specific support

Special support addresses particular needs. These needs include Special Education,
parental support groups, and maladaptive (abnormal) behaviors. Often, more
specialized environments are necessary, if disabilities are too severe to manage with
standard community resources. Such disabilities include severe and profound learning
disability (LD), severe treatment resistant epilepsy, aggressiveness, co morbid
psychiatric disorder, respite placements.

EPILEPSY AND LEARNING DISABILITIES

Epilepsy may occur in people with Learning Disabilities. It may begin at any age, and
multiple forms may occur in the same individual. Frequent epileptic seizures may lead to
(or worsen) permanent loss of intellectual functioning (acquired epileptic aphasia),
progressive partial seizures.

Treatment

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 - The neurologist deals with this area & therefore the psychiatrist needs to work
with other specialists. Choice of treatment will depend on:

- Accurate classification of the type of seizures or epilepsy

- Possible drug interactions

- Minimizing side effects (esp. cognitive impairment)

PREVENTION OF MENTAL RETARDATION (LEARNING DISABILITY)

1. Screening programs for at risk infants and children during under five clinics, ANC
and other children’s clinic for example in paediatrics, neonatal clinics by nurses
and other health workers.
2. Adult screening tests can identify carriers of other conditions before couples
conceive a child.
3. Individuals and couples with a family history of mental retardation can seek
genetic counseling to evaluate their own risks and need for screening.
4. Specialized laboratory tests, including amniocentesis, can detect Down
syndrome and other genetic disorders in the early stages of pregnancy.
5. Proper prenatal care, avoidance of alcohol and drugs during pregnancy, and
routine immunization against measles and other childhood diseases can prevent
some forms of retardation. This can be done by nurses working in such settings
when these children are brought to ANC and under five clinics.

Let us now discuss the treatment and care of a child with mental retardation

TREATMENT AND CARE

1. Some individuals diagnosed with mild mental retardation as children may

gradually develop new skills through early intervention and educational services.
2. As adults, they may function in everyday life at a level that no longer warrants a
diagnosis of retardation.
3. All but the most profoundly retarded people usually can best develop their full
potential by living in the community.

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 4. Most people with mental retardation have the capacity to learn, advance
intellectually, develop job and social skills, and become full participants in
society. They may marry, have families, and be indistinguishable from other
people.
5. In order to achieve their potential, mentally retarded children need special
education and training, which ideally begins in infancy and continues until they
establish an adult role.

What do you think is the role of a nurse in managing a child with mental
retardation?

THE ROLE OF A NURSE IN MANAGING CHILDREN WITH LEARNING

DISABILITIES / MENTAL RETARDATION

Psychological care

When parents realize that their child is not like other children, that is, developing
normally, it takes some time to register this in their minds and lives. They go through
The Grieving Process. The length of this grieving process may vary depending on the
psychological, social and medical support and expertise availed to them.

Absence or lack of inadequate medical expertise, psychological and social support will
without any doubt lead to poor care of the child by its caregivers or parents. The child
might even be abused, sometimes unknowingly because of the denial, anger and
depression that many parents experience. The mentally disabled child will be at risk of
being harmed, since it is so vulnerable.

Early identification and intervention

To avoid all these complications the nurse must be alert to quickly identify children with
mental retardation so that they can receive the needed care from a very young age,
since the brain has been known to grasp and learn skills better, at a tender age. As a
nurse you then need to counsel the mother or care givers and facilitate for available

94
services such as physiotherapy, medical and surgical interventions if needed, special
education, and psychosocial support.

A nurse also facilitates for any medical and surgical interventions, and provide primary,
secondary and tertiary health services to improve the quality of life of children with
learning disabilities.

Prevention of Mental Retardation

The role of the nurse starts prenatally (before pregnancy) by counseling and giving
Information, Education and Communication to would be mothers and fathers to prevent
the disorder.

It continues during the antenatal period with measures that foster a healthy pregnancy
and normal growth and development of the fetus such as a good diet, treatment of any
existing diseases in the mother and avoiding environmental hazards.

In labour, good care such as frequent observations to quickly identify anything that
could go wrong thereby causing harm to the fetus.

During delivery the midwife must avoid birth asphyxia and trauma by continued
alertness for any delays in labour.

In the postnatal period and during the early years of a child’s life nurses and midwifes
must ensure that the child receives immunizations from childhood diseases that may
lead to brain damage in good time and completes them. Nurses must ensure that other
diseases like malaria are prevented and if they occur prompt treatment must be given.

In the period of adolescence we as nurses must ensure that we advice parents and
support them in caring for their children because this is the time when they sometimes
try to experiment with behaviors that are risky such as substance abuse, use of fire
arms, driving their parent’s car when they have no license, and wrong sexual practices.
These behaviours could put them at risk of accidents and diseases that might damage
their brain thereby leading to mental retardation.

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Now let’s look at the Psychiatric co morbidity in the learning disability population. You
might wonder what this could be. Well, this simply means the psychiatric problems that
may be seen in a child with learning disability.

PSYCHIATRIC CO MORBIDITY IN THE LEARNING DISABILITY [L.D.](MENTAL

RETARDATION) POPULATION.

Abnormal behaviors that occur in the mental retardation population

- Psychiatric disorders occur more frequently in the Learning Disability (LD)

population than the general population. They include:

- Schizophrenia – Symptoms in severe LD include unexplained aggression, bizarre

behaviours, mood lability, increased mannerisms and stereotypies.

- Bipolar Affective Disorder – Symptoms include hyperactivity, wandering, mutism,

temper tantrums.

- Depressive disorder

- Biological disorders more marked, with diurnal variations. Suicidal thoughts / acts
may occur in border line – moderate LD.

- Anxiety disorders, Obsessive Compulsive Disorder, Attention Deficit Hyperactive

Disorder, & personality disorder.

Behavioural disorders and ‘challenging’ behaviour

These are pathological behaviours that are common in the LD population. They create a
significant burden for parents / carers. They are as follows:

- Antisocial – shouting, screaming, general noisiness, anal poking/faecal smearing

(may reflect constipation), self induced vomiting/choking, stealing.

- Aggressive outbursts – against persons or property

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 - Self injurious behavior – skin picking, eye gouging, head banging, face beating
(more common in severe/profound LD.

- Social withdrawal

- Stereotypic behaviours (some of which may be injurious)

- Hyperactive disruptive behaviours

- Repetitive communication disturbance

- Anxiety fearfulness

When these behaviours are particularly severe, they are often termed
‘challenging’.Management of children with mental retardation is done while they
continue to live in their homes. The best way to care for these children is to allow them
to continue to be with their loved ones in a familiar and caring environment. They have
to be encouraged to work on their strengths or strong points or activities they are good
at, with assistance from their caregivers. Caregivers and parents need a lot of
counseling and social support from nurses for such an environment to be achieved.

The role of the nurse in management of children with L.D. is to participate with other
members of the Multi disciplinary Team (psychiatrist, clinicians, neurologist,
psychologist, sociologist, physiotherapist and surgeon) in delivering and facilitating
psychosocial support for both the affected child and his or her care giver, as follows:

Having looked at the role of a Nurse in managing a child with learning disabilities, now
let us further look at the treatment modalities that can be employed.

Treatment methods

The different types of psychological therapies are administered by psychologists. You

will need to read on the different psychological approaches which you covered in
Psychology in Nursing to understand them better. However, the nurse should involve

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herself by ensuring that patients receive treatments prescribed, and participate in the
simpler ones such as the behavioral and cognitive ones. These treatments work for
children with mild and moderate mental retardation because they are able to think and
reason fairly well.

Behavioural treatments: Based on operant conditioning. Behaviour may be shaped

towards the desired final modification through the rewarding of small, achievable
intermediate steps. In school good behavior can be rewarded with material items,
privileges and ‘star’ charts, when a certain level is achieved.

- May be used to help teach basic skills (feeding, dressing, toileting),

- establish normal behavior patterns (sleep),

- or more complex skills (social skills, relaxation techniques, assertive training).

- May also be used to alter maladaptive patterns of behavior (inappropriate sexual

behavior, phobia)

Cognitive Therapy

You will remember Cognitive Therapy from the different psychological theories that you

covered in Psychology of Nursing (READ AND REVISE). Cognitions are thoughts or

thinking patterns. These thinking patterns can become negative. For example the child
begins to think that they are not good enough to be alive, or that they cannot achieve
anything in life, leading to poor self esteem, anxiety and depression.

Cognitive therapy is treatment that is targeted at changing the negative thoughts and
replacing them with thoughts that increase the self esteem (self respect) of a person.
When self esteem is increased the behavior will also improve and feelings of anger, will
be dealt with. This means that in the case of children with borderline, mild or moderate
LD, cognitive approaches may be adapted for teaching of:

- problem solving skills

- management of anxiety disorders

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 - depression,

- dealing with issues of self esteem,

- anger management, and

- treatment of offending behaviours (eg. sex offenders).

Psychodynamic therapies

Psychoanalysis is helpful in addressing issues of emotional development, relationships,

adjustments to life events (losses, disabilities, and bereavements). They range from
basic supportive psychotherapy, to more complex group and family therapies. In
psychoanalysis the therapist uses probing and open ended questions to bring out
hidden feelings that are the cause of abnormal behavior from the subconscious mind of
a client. Such feelings originate from early traumatic childhood experiences. Once they
are brought to awareness with the help of the counselor or therapist ways can be found
to resolve them.

Pharmacological treatments

Please check with your pharmacology notes on the actual names of the drugs,
side effects, dosages, actions and nursing implications.

- For children that need medications the nurse must ensure that they are reviewed
regularly to supply drugs and observe any side effects. Co morbid physical
disorders (epilepsy, constipation, cerebral palsy) increase the need to monitor
side effects.

- Antipsychotics

- Used to treat co morbid psychiatric disorders and acute behavioral disturbance,

autistic disorders, self injury, social withdrawal, ADHD – Attention Deficit
Hyperactive Disorders and tic disorders.

- Antidepressants

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 - Effective in depression, OCD – Obsessive Compulsive Disorder, anxiety
disorders, violence, self injury, ‘non specific’ distress.

- Anticonvulsants

For underlying epilepsy and in episodes of difficulty in controlling movements.

Conclusion

Children with mental retardation are prone to developing behavioural disorders, and
psychiatric problems. Nurses must be observant so that when the need arises they are
managed in the community using different psychological approaches and medication
and if the condition worsens admission may be needed for further management.

GIFTEDNESS

“Giftedness” is defined as exceptionally advanced performance or the potential for

outstanding performance in intellectual, creative, leadership, artistic, or specific
academic fields. Children who demonstrate outstanding talents come from all social,
cultural, and economic groups.

Educators believe that gifted students require special education services because their
learning needs differ significantly from those of the general population.

CHARACTERISTICS OF GIFTED CHILDREN

1. They learn more rapidly and are able to understand more abstract and complex
ideas.
2. They are also able to transform existing knowledge into new and useful forms,
and to create new knowledge recognized for its originality, complexity, and
elegance. Special education services and facilities for gifted children may
enhance these abilities.
3. In addition, some gifted learners may require special counseling services to
address social or emotional adjustment issues that are complicated by their
exceptional abilities.

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WAYS TO IDENTIFY GIFTED CHILDREN

In developed countries schools rely on intelligence tests to identify gifted students. It is

recommended that aptitude tests developed by individual schools, classroom
observational records, and performance assessments be combined to come up with a
final result.

SPECIAL EDUCATION NEEDS OF GIFTED CHILDREN

Children who are gifted may be prone to boredom and rejection from peers. To avoid
this, they can be educated in the following ways:

1. Acceleration - Gifted children may study a specially modified curriculum or may

progress through academic subjects at an accelerated pace. Acceleration
involves adapting education programs so that students may progress through
particular subject material quicker than usual. These modifications may take
place within the regular classroom setting or they may involve changing the
child’s placement (jumping grades) in school. Some gifted children gain early
entrance to kindergarten, skip grades, enter college earlier than usual, or take
specific courses with older children. Ideal programs for gifted students consider
the individual needs of children and offer multiple options for services. These
programs generally involve both advanced course materials and acceleration.
2. Enrichment – Children remain in the same grade, but with a curriculum that is
supplemented by a variety of activities.
3. Current practice - Many educators advocate placing gifted students in regular
classrooms with students of diverse ability levels, an educational method known
as inclusion. However, considerable evidence suggests that regular classroom
teachers do not receive the training and support to appropriately modify the
curriculum to meet the needs of gifted students.

Many educators also claim that minorities and economically disadvantaged children are
underrepresented in educational programs for gifted students. At the same time, limited

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funding for education in general restricts efforts to nurture the talents of all gifted
children.

THE NURSE’S ROLE IN GUIDING AND COUNSELLING GIFTED CHILDREN

Nurses must reassure parents and caregivers that these children can be assisted. Refer
these children to appropriate members of the Multi Disciplinary Team such as
psychologists for intelligence tests. The psychologists will then advice what to do.

DESCRIBE THE MANAGEMENT OF CLIENTS WITH EPILEPSY

EPILEPSY

SEIZURE - An abnormal, sudden excessive, uncontrolled electrical discharge of

neurons within the brain that may result in alteration in consciousness, motor, or
sensory ability and or behaviour. If the electrical disturbance is limited to only one area
of the brain, then the result is a partial seizure. For example, the client may experience
confusion, loss of awareness, aimless movements, or uncontrolled body movements. If
the electrical disturbance affects the entire brain, the result is a generalized seizure.

In Anatomy and Physiology you learned how nerve cells (neurons) in the brain pass on
messages to each other through electrical impulses. When these electrical impulses
become excessive or uncontrolled, a seizure results.

Activity

To understand the definition of seizure better, read your Anatomy and Physiology
notes on Diseases of the Central Nervous System.

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Epilepsy or a seizure disorder is a chronic condition that is characterized by recurrent
seizures. Many clients with epilepsy have more than one seizure type and may have
other symptoms as well.

INCIDENCE

It is a common neuronal problem affecting individuals irrespective of their age, sex,

location or geographical positions.

CAUSES

Most cases, are idiopathic (of unknown cause), however there are certain factors
associated with the disease.

1. Genetic predisposition- 30% of patients with epilepsy have first degree relatives with
seizure, mode of inheritance are uncertain just thought to be due to low seizure
threshold.
2. Trauma- diffused cerebral damage result from either systemic infections or a direct
trauma to the brain in cases of accidents, birth injury or trauma.
3. Poisoning- commonly caused by drugs which may include alcohol and
phenothiazides (antidepressants).
4. Brain tumours and abscesses- masses or lesions in the cortex can cause epilepsy.
5. Encephalitis and other inflammatory conditions.

TYPES OF SEIZURES

There are over 30 types of seizures. We shall look at 2 types of seizures. These are
partial seizures and generalized seizures.

1. Partial seizures are of focal onset, which means that they originate in a specific
area of the brain. They are further subdivided into simple partial, complex partial and
absence seizures. We shall proceed to discuss each one of them in turn:

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SIMPLE PARTIAL SEIZURES
People with Simple Partial seizures experience the following:
 Uncontrollable jerky movements of body part
The twitching may start in the thumb and then spread to affect the hand and arm and
possibly include the affected side of the body ( Jacksonian seizure)
 Sight and hearing impairement
 Sudden sweating and flushing
 Nausea
 Feelings of fear
 The patient may or may not lose consciousness. The affected part may become
paralysed for some time called Todd’s paralysis.

COMPLEX PARTIAL SEIZURE

 Also called temporal lobe epilepsy because they arise from lesions in one or both
temporal lobes of the brain. May also arise from the frontal lobe. In addition, they
have also been termed psychomotor seizures because they cause strange
behaviours as well as movements.
 Seizure may be preceeded by an aura which is a warning sensation
characterized by feelings of fear, abdominal discomfort, dizziness, or strange
odors and sensations.
 Then the affected individual may appear to be in a trance (staring at nothing)
 Followed by an episode of altered behaviour in which the patient performs a
series of repeated movements in which a patient may continually rub his hands
or smack his lips continually (automatisms) with no control over body
movements.
 Occasionally, a prolonged period of confusion lasting for hours to days with
differing levels of awareness and strange behaviours may develop.

ABSENCE SEIZURE OR PETIT MAL

 A brief and sudden loss of consciousness which onlookers often do not notice.

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  Typically occurs in childhood and is often only noticed as the child falls further
behind with school work
 Symptoms that are noticeable or observable may be slight such as upward
staring of the eyes.
 Staggering gait
 Twitching of the facial muscles
 No aura
 The person will often resume activity previously involved before seizure in
without realizing that the seizure has occurred.
 In complex absences, automatism, as previously described accompanies the
brief alteration in consciousness.
 Absences seizures are often precipitated by hyperventilation and flashing lights

2. GENERALISED SEIZURES OR GRANDMAL EPILEPSY

It is one of the commonest types and almost always occurs in stages.

i. Prodromal phase: is the phase before the actual seizure. It may last for hours to
days, and is characterized by a change in the patient’s mood.

- In most cases, patient may become aware of this and adjust his or her treatment.

ii. Aural- Premonition: This stage may last for seconds or minutes. Patient
experiences sensation of either smell or feeling of crawling insects on their body,
ringing in their ears and flashes of light.

- At this stage if there is any one near the patient they should assist the patient as
follows:

- Make patient lie down especially in lateral position in a safe place.

- Roll a small handkerchief and place it in between the upper teeth to avoid patient
biting the tongue.

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- Be near them and observe.

iii. Tonic stage: There is stiffening of the body, jaw closes tight and the patient may
utter a sound mistaken for a cry as there is partial closure of the epiglottis. Increased
forceful discharge of motor impulses causes muscle contraction and if the patient
was standing, he falls down due to loss of consciousness. A patient may bite his
tongue since his teeth are clenched. The process may last for a few minutes and if
pad is not placed in aura stage, you may not be able to do so due to muscle rigidity.

- Loosen all tight clothing i.e. tie, belt, and cuff.

- Roll patient to a semi prone position or lateral, remove any dangerous items near
the patient. Put soft material under the patient’s head to prevent damage to head.

- Advice onlookers to move away so that when the patient wakes up he or she is
not embarrassed.

- While twitching observe closely to see which part of the body started twitching
first.

iv. Clonic stage: This is the stage of violent convulsions, frothing from the mouth
due to increased salivation and patient can chew his tongue. If lying in supine
position can aspirate his saliva and choke.

Phase can last for seconds in some patients and several minutes in other patients.

There is throwing of arms and legs and can bang his head against anything that is
nearby.

Patient has tachycardia and is sweating.

- Do not restrict the patient’s movements but remove any dangerous objects
nearby. Restrictions can lead to fractures.

- Try to put a cushion under the patient’s head for protection.

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 v. Comatose stage or stage of relaxation: This is when movements cease and
patient become flaccid and may go into a comatose stage which may lead to a deep
sleep.

May last for several minutes after which the patient gains normal consciousness,
some patients may become confused, others may complain of weakness and
headache or generalized body pains. Some patients may become violent.

- When the muscles relax, clear airway by putting them in a safer position, lateral
or semi prone position to aid drainage of secretions.

- Wipe out secretions, if messed, clean him up.

- In a hospital situation, tongue biting can be prevented by use of a padded

spatula. The head may be protected by a small pillow, or towel and if possible put
mattress on the floor. Suction machine must be available for sucking.

- Oxygen apparatus should be available.

The grandmal or generalized seizure may also be described in the following

manner:
“In a second type of epilepsy, known as generalized seizure, tonic clonic, grand mal, or
convulsion, the whole brain is involved. This type of seizure is often signaled by an
involuntary scream, caused by contraction of the muscles that control breathing.

As loss of consciousness sets in the person falls to the ground and the entire body is
gripped by a jerking muscular contraction. The face reddens (in people with light colour
skin), breathing stops, and the back arches. Subsequently, alternate contractions and
relaxations of the muscles throw the body into sometimes violent agitation such that the
person may be subject to serious injury. After the convulsion subsides, the person is
exhausted and may sleep heavily. Confusion, nausea, and sore muscles are often
experienced upon awakening, and the individual may have no memory of the seizure.

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Attacks occur at varying intervals, in some people as seldom as once a year and in
others as frequently as several times a day. About 8 percent of those subject to
generalized seizures may have status epilepticus, in which seizures occur successively
with no intervening periods of consciousness. These attacks may be fatal unless treated
promptly with the drug diazepam.”

Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.

POSSIBLE PRECIPITATING FACTORS FOR SEIZURES

CONDITIONS FACTORS

Physical • Overexertion

• Sleep deprivation

• Alteration in bowel elimination

• Fever

• Recent head trauma

• Concurrent illness/infections

• Over-hydration

• Excesses in caffeine, sugar, and other

foods

Psychosocial / emotional Stress

• Depression

• Anxiety

• Psychosis

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 • Anger

POSSIBLE PRECIPITATING FACTORS FOR SEIZURES continued

CONDITIONS FACTORS

Metabolic and Electrolyte • Low blood glucose

Imbalance
• Low sodium

• Low calcium

• Low magnesium

• Dehydration

• Hyperventilation

Medication or chemical • Withdrawal of alcohol or other sedative

agents

• Administration of drugs with pro-convulsant

properties (e.g., central nervous system

stimulants and anticholinergics including

over the counter antihistamines)

• Most dopamine blocking agents

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 CONDITION FACTORS
CONTINUED FROM ABOVE:
• Newer antipsychotics, particularly clozapine
Medication or chemical

• Antidepressants, especially buproprion

• Immune suppressants such as cyclosporine

• Antibiotics such as quinolones or

imipenem/cilastatin

• Toxins

Hormonal variations
• Menstruation

• Ovulation

• Pregnancy

Environmental • Particular odors

• Flashing lights

• Certain types of music

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7. Provide other supportive therapy as ordered by primary care prescriber or according
to facility protocol.

 After the Seizure: (Post ictal Stage)

1. After the seizure activity has ceased, record the presence of the following conditions
and their duration in the individual’s record. Continue to assess until person returns to
baseline.
a. gag reflex, decreased
b. headache (character, duration, location, severity)
c. incontinence (bladder and bowel)
d. injury (bruises, burns, fractures, lacerations, mouth trauma)
e. residual deficit
- behavior change
- confusion
- language disturbance
- poor coordination
- weakness/paralysis of body part(s)
- sleep pattern disturbance
2.Allow the individual to sleep;
- reorient upon awakening.(The individual may experience amnesia;
reorientation can help regain a sense of control and help reduce anxiety

3. Conduct a post seizure evaluation

a. What was the person doing prior to the seizure?
b. Was this the first seizure?
c. Review current medications including recent changes in medicine and/or dose.
d. Other illnesses?
e. Possible precipitating factors

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REHABILITATION AND SOCIAL SUPPORT OR SUBSEQUENT CARE OF EPILEPSY

OBJECTIVES

1. To prevent further fits

2. To give adequate information about long term self care in avoiding further episodes
of fits.

General Health
1. Avoid constipation, excessive fatigue, hyperventilation and stress because they may
MEDICAL MANAGEMENT

Diagnosis

 History and clinical presentation

 Electro encephalogram to check for the waves of the brain.
 Lumbar puncture to rule out meningitis
 Skull x-ray will be done to rule out brain lesions such as tumours.
 C.T scan
 Supportive investigations such as blood for urea and electrolytes and blood sugar.

DRUGS

Drugs used are known as antiepileptic or anticonvulsant drugs.

Depending condition of the patient, they can be given single drug or as a combination.

DIAZEPAM (VALIUM)

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10mg IV, stat during a seizure

Side effects are drowsiness and dependency.

PHENYNTOIN (DIPHENYLHYDANTOIN)

200- 400mg OD, P.O depending on condition or frequent attacks.

It prevents spread of seizure activities to adjunct areas.

Side effects: Ataxia, Sedation, mental confusion, nausea and vomiting and slurred
speech

PHENOBARBITONE

60- 120mg PO, IM, or 60mg B.D PO.

Side effects: Ataxia, Skin Rash and anaemia

During the acute attack of seizures patient may receive valium 10mg, IV stat.

N.B Once the treatment is started, it is better to continue on the same drug.

STATUS EPILEPTICUS

These are recurrent seizures without any recovery period. It is a medical emergency
and is usually common in children and patients with intracranial lesions. Patients usually
die due to exhaustion.

Child under 12years 300-400mcg/kg repeated after 10 minutes.

Adults Status Epilepticus Management: mhGAP epilepsy guidelines (WHO)

 Insert IV line

 Administer 5ml of 50% glucose

 Give Diazepam 10mg x1 and repeat after 10 minutes if seizures do not stop.

 Prepare for possible ventilator support.

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  Phenobarbitone 10-15 mg/kg i.v. (dilute in 100ml NS and infuse over 30min)

 Can give additional 5mg/kg i.v. if seizures do not stop

 Consider ICU transfer if concern for respiratory compromise.

NURSING MANAGEMENT DURING EPILEPTIC ATTACK

OBJECTIVES

1. To prevent the patient from suffering harm as a result of the seizure

2. To maintain airway
3. To control fits

The nurse should have an understanding of seizures as well as the

medications, interventions, and monitoring strategies used to control seizures and to
minimize their negative impact on the quality of life.

 Before a seizure occurs:

1. Safety measures should be taken if there is an indication that the person is
experiencing an aura before the onset of a seizure, (e.g., have the individual lie down).
2. Determine if changes can be made in activities or situations that may trigger seizures.
3. Keep the bed in a low position with side rails up, and use padded side rails as
needed.
(These precautions help prevent injury from fall or trauma.)

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4. Individuals with mental retardation or other developmental disabilities may have
altered bowel habits, slowed activity, and /or decreased motor skills before a seizure.

 During a seizure: (Ictal stage)

1. When a seizure occurs, observe and document the following:
a. Date, time of onset, duration
b. Activity at time of onset
c. Level of consciousness (confused, dazed, excited, unconscious)
d. Presence of aura (if known)
e. Movements:
i. Body part involved
- Progression and sequencing of activity (site of onset of first movement is
very important as well as pattern, order of progression, or spreading
involvement)
- Symmetry of activity
- Unilateral or bilateral

ii. Type of motor activity

- clonic (jerking)
- myoclonic (single jerk of muscle or limb)
- tonic (stiffening)
- abnormal posturing movements,
- dystonia,
- eyes: eye deviation, open, rolling or closed, eyelids flickering
- head turning,
- twitching

f. Respirations (impaired/absent; rhythm and rate)

g. Heart (rate and rhythm)

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h. Skin changes
- color/temperature;
- pale/cyanotic, (also check lips, earlobes, nailbeds)
- cool/warm;
- perspiration/clammy)

i. Gastrointestinal
- belching
- flatulence
- vomiting

j. Pupillary size, symmetry, and reaction to light

k. Changes in sensory awareness (auditory, gustatory, olfactory, vertiginous, visual)

l. Presence of other unusual and/or inappropriate behaviors

2. Ensure adequate ventilation.

a. Loosen clothing, postural support devices and/or restraints.
b. DO NOT try to force an airway or tongue blade through clenched teeth. (Forced
airway insertion can cause injury.)
c. Turn the person into a side-lying position as soon as convulsing has stopped. (This
will help the tongue return to its normal front-forward position and will also allow
accumulated saliva to drain from the mouth.)

3. Protect the person from injury (e.g., help break fall, clear the area of furniture).

4. DO NOT restrain movement. (Trying to hold down the person's arms or legs will not
stop the seizure. Restraining movement may result in musculoskeletal injury.)

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5. Remain with the person and give verbal reassurance. (The person may not be able
to hear you during unconsciousness but verbal assurances help as a person is
regaining
consciousness.)

6. Provide as much privacy as possible for the individual during and after seizure
activity.
trigger seizures.
2. Seizures may increase around the time of menses.
3. Fever may trigger seizures, therefore, the fever and underlying cause must be
treated. If antibiotics are ordered, interactions with AEDs should be evaluated.
4. Environmental and recreational risk factors that should be avoided or minimized:
a. Electric shocks
b. Noisy environments
c. Bright, flashing lights
d. Poorly adjusted televisions or computer screens
5. Showers, rather than tubs baths, should be taken, when possible.
6. Good oral hygiene and regular visits to the dentist are important to minimize effects of
gingival hyperplasia that can occur from some AEDs.

Diet
1. A well balanced diet should be eaten at regular times.
2. Coffee and other caffeinated beverages should be limited to a moderate amount.
3. Fluid intake should be between 1,000 to 1,500 ml per day (depending on the
weather).
4. Alcoholic beverages should be avoided.

Physical Activity

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1. Regular activity and exercise should be encouraged. Activity tends to inhibit rather
than increase seizures. However, over-fatigue and hyperventilation should be avoided.
When possible, exercise should take place in climate-controlled settings.
2. Activities that could harm the patient should be avoided because of the temporary
loss of control that occurs without warning.
 The person may swim if accompanied by someone who knows what to do if a
seizure occurs. The person should wear a life jacket and stay in relatively
shallow water to facilitate seizure management should a seizure occur.
 Individuals with epilepsy should refrain from operating hazardous machinery.
3. Regular sleep patterns are important.

4. Information Education and Communication (IEC) to Family and Friends:

Family and friends should know what to do in the event of a seizure occurring.
Give IEC as follows:
 Loose clothing around neck
 Cushion head with pillow
 Remove hard and sharp objects from the area
 Never insert objects into patient’s mouth during seizure.
 After seizure turn head to one side to drain secretions from mouth
 Upon waking reorient on:
- Time

- Place

- What happened (seizure)

- What patient was doing at time of seizure

PSYCHIATRIC COMPLICATIONS OF EPILEPSY

INTRODUCTION

Psychiatric co morbidity is common in people with epilepsy. You will remember having
learned about Epilepsy in Fundamentals of Nursing and in our previous lesson. We

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discussed the definition, types and management of epilepsy. People with epilepsy have
a twofold probability of developing psychiatric disorders than in the general population.
Between 10% and 50% of patients with epilepsy have psychiatric symptoms.

Many different types of psychiatric disorders are associated with epilepsy. They include
cognitive, affective, emotional, and behavioural disturbances. Ictal means seizure.
Behavioural disturbances occur in relation to seizures. These can occur before (pre-
ictal), during (ictal), after (post-ictal), or between (inter-ictal) seizures.

PRE-ICTAL PSYCHIATRIC DISTRUBANCES

Vague symptoms known as prodromal symptoms may be experienced hours to days

before a seizure. They include increasing tension, irritability, anxiety and depression
generally increasing as the seizure approaches. An aura may occur just before the
seizure and may consist in derealisation and depersonalization experiences, perceptual
experiences (auditory, visual, sensory, and olfactory hallucinations or illusions).

ICTAL PSYCHIATRIC DISTURBANCES

Ictal psychiatric disturbances (those directly related to seizure activity) are common and
diverse. During a seizure the following can occur:

 Transient confusional states

 Affective disturbances

 Anxiety

 Automatisms - are stereotyped movements that tend to be disorganized and

purposeless (although complex actions may be carried out).

 Abnormal behaviours (especially in partial seizures)

 Abnormal mental state may be the only sign of non convulsive (complex partial or
absence) status epilepticus and this diagnosis can be easily overlooked.

 Psychoses may occur as an ictal phenomena (perceptual disorders)

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  Ictal violence is extremely rare.

POST-ICTAL DISTURBANCES

Psychiatric disturbances may occur in the hours following a seizure. Psychotic

symptoms are seen in about 10%. They may be due to long duration of epilepsy and
structural brain lesions. They may occur as part of a delirium (confusional state with
disorientation, inattention, variable levels of consciousness, and sometimes paranoia) or
in clear consciousness. Post ictal violence is rare but may be secondary to psychotic
experiences. If violence does occur, it is extreme, recurrent, stereotyped, and more
likely to occur in men, after a cluster of seizures. There is usually amnesia of the event.

INTER-ICTAL PSYCHIATRIC DISTURBANCES

 Brief psychosis may occur unrelated to a seizure, even when there is good
control of epilepsy.

 Chronic ‘schizophrenia-like’ psychosis: A chronic schizophrenia like psychotic

illness is 6-12 times more common in people with epilepsy than in the general
population. It is particularly associated with left temporal lobe epilepsy, early
severe epilepsy and in women with epilepsy. The onset of this illness is often 10-
15 years after the diagnosis of epilepsy has been made.

 Other disorders include cognitive impairments, personality difficulties in a few

people, depression (dysthmia), suicide and deliberate self harm is more frequent
in people with epilepsy than in the general population, and higher still in people
with temporal lobe epilepsy.

OTHER PRESENTATIONS OF PSYCHIATRIC DISORDERS IN PEOPLE WITH

EPILEPSY

1. Cognitive deterioration is a common outcome of chronic epilepsy and is caused by a

number of factors including repeated seizures with cerebral hypoxia as well as the
effects of chronic anti-convulsant therapy.

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2. Neurosis – There is an increased prevalence of conversion disorder in epileptics,
including an increased risk of ‘pseudo seizures’.

3. Mania in right Temporal Lobe Epilepsy (TLE).

4. Epileptic personality syndrome – This is controversial and is associated with

Temporal Lobe Epilepsy. Traits include religiosity, hypo sexuality, ‘viscosity of
personality’, ie, a personality that is not easy to get along with.

5. Violence – also a controversial issue. There is an increased risk of violence and

aggression in people with TLE (a lesion can lead to psychotic and manic symptoms)
or Frontal Lobe epilepsy (personality and judgement affected, which leads to
aggression). Anti-convulsants are often effective in reducing aggressive outbursts.

SOCIAL ASPECTS OF EPILEPSY

1. The quality of life will depend on the severity of the seizure disorder and any
presence of structural brain pathology.

2. A diagnosis of epilepsy can also result in stigma with far reaching social
implications.

3. Restrictions on driving are a major burden on many patients.

TREATMENT OF EPILEPSY

The drug treatment of epilepsy is undertaken by neurologists. When planning treatment

it is important to distinguish between peri-ictal and inter-ictal psychiatric disorders.

 Peri-ictal – Treatment is aimed at control of seizures.

 Inter-ictal – Treatment is similar to that of non-epileptic patients, though it should

be remembered that psychotropic drugs may increase seizure frequency.

ROLE OF A NURSE

Most patients with epilepsy are managed while they continue to live in the community.
During this time, they attend outpatient clinic regularly for reviews and collection of

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medication. Transient behavioral disturbances may occur but are successfully handled
by caregivers who constantly need support and health education from nurses and other
health workers.

However, in the event of behavioral disturbances worsening and posing a danger to self
and others hospitalization may be indicated.

SUMMARY

We have come to the end of unit 4 in which we discussed the management of children
with special educational needs and individuals with epilepsy. We saw that these two
conditions are neurological in nature. This means they come about as a result of
involvement of the brain cells or neurons. In epilepsy, seizures occur due to abnormal
discharge of electrical impulses in the brain nerve cells. During a seizure there are
varying abnormalities in behavior and when they occur repeatedly it is called epilepsy.
In mental retardation there is damage to the nerve cells for different reasons. This
damage leads to intellectual impairement of varying degrees.

SELF TEST

.1. What should you observe during a seizure? .a.

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b.

c.

d.

e.

2. Two main types of seizures are …………………………………………………and

………………………………………………………………………….

3. Match the following nursing interventions in column II with those in column I (stage of
seizure) by drawing a line from column I to the corresponding responses or answers in
column II.

COLUMN I COLUMN II

Before seizure 1. Observe and document seizure activity

2Ensure adequate ventilation

3Protect patient from injury

4Do not refrain movement

5 Remain with the patient and give verbal

reassurance

6Provide as much privacy as possible

Ictal 7Allow to sleep

8Upon waking orient

9Carry out post seizure observations

Post ictal 10Have the patient lie down

11. Make changes to reduce triggers in the

environment

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 12. If in hospital nurse on low bed with rails or
floor bed

4. Epilepsy is a psychiatric condition

True/False

5. Sort the following jumbled factors that precipitate seizures and list them under the
appropriate conditions.

CONDITIONS FACTORS

Physical • Concurrent illness/infections

Stress

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 • Depression

• Anxiety

• Psychosis

• Over-hydration

• Excesses intake of caffeine, sugar, and

other foods

CONDITION FACTORS

Metabolic and Electrolyte • Low blood glucose

Imbalance
• Hyperventilation

• Withdrawal of alcohol or other sedative

agents

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 • Administration of drugs with pro-convulsant

properties (e.g., central nervous system

stimulants and anticholinergics including

over the counter antihistamines)

Medication or chemical • Most dopamine blocking agents

Low sodium

• Low calcium

• Low magnesium

• Dehydration

ANSWERS TO SELF ASSESSMENT

1. Observations during a seizure
 Date,time of onset, duration
 Level of consciousness (confused, dazed etc)
 Presence of aura (if known)
 Movements
 Body part involved
 Progression and sequencing of activity
 Type of motor activity

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  Respirations
 Heart rate and rhythm
 Skin changes
2.Grand Mal and Petite Mal
3. Before seizures
 If in hospital, nurse on low bed with rails or floor bed
 Have patient lie down
 Make changes to reduce triggers in the environment
ICTAL STAGE
 Observe and document seizure activity
 Ensure adequate ventilation
 Protect patient from injury
 Do not restrain movements
POST ICTAL
 Carry out post seizure observations
 Upon waking orient
 Allow to sleep
 Remain with the patient and give verbal reassurance
4.False
5. PHYSICAL CONDITIONS
 Concurrent illness/infections
 Anxiety
 Psychosis
 Depression
METABOLIC AND ELECTROLYTE IMBALANCE
 Low blood glucose
 Hyperventilation
 Over-hydration
 Low sodium
 Low calcium

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  Low magnesium
 Excess intake of caffeine, sugar and other foods
MEDICATION OR CHEMICAL
 Most dopamine blocking agents
 Administration of drug with pro-convulsant properties e.g. central nervous
system stimulants and anticholinergics.
 Withdrawal of alcohol or other sedative agents

You are now provided with glossary as you might have faced a challenge with certain
words.

GLOSSARY

Co morbidity is the simultaneous appearance of two or more psychiatric or physical

illnesses.

Cerebral Palsy is a brain disorder or condition caused by brain damage around the time
of birth and marked by lack of muscle control, especially in the limbs.

Quality of life: Contentment with everyday life: the degree of enjoyment and satisfaction
experienced in everyday life as opposed to financial or material wellbeing.

Respite: Short term stay at a facility. A break from care giving needed to avoid care
giver burn out.

Placement: Is a long term stay at a facility.:

Disability: Is the consequence of an impairment that may be physical, cognitive, mental,

sensory, emotional, developmental, or some combination of these.

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Impairment: To cause to diminish, as in strength, value, or quality; for example, an injury
that impaired my hearing.

REFERENCES1. Adedotun, A. (2005). Basic Psychiatry and Psychiatric Nursing. Ile-Ife:

Basag Enterprises.

2. Sreevani, R. (2004). A Guide to Mental Health and Psychiatric Nursing. New-Delhi: Jaypee
Brothers Medical Publishers (P) Ltd.

3. The ICDIO Classification of Mental and Behavioural Disorders, Clinical Description and
Diagnostic Guidelines. (2007). World Health Organization. Oxford University Press

4. Blackburn, R. (1993). Clinical Programmeswith Psychopaths. In Clinical Approaches to the

Mentally Disordered Offender (eds. K. Howells& C. R. Hollin).Chichester: Wiley.

5. De Ronchi D, Faranca I, Forti P, Ravaglia G, Borderi M,Manfredi R, (2000). Development of

acute psychotic disorders and HIV-1 infection. Int. J Psychiatry Med:173-183.

6. Haworth, E. & Cournos, F. (2006). Psychiatric aspects of HIV / AIDS. 1sted. Philadelphia:
Lippincott Williams & Wilkins.

7. McDaniel JS, Chung JY, Brown L., (2000). Practice guidelines for the treatment of patients
with HIV/AIDS. American Journal of Psychiatry Vol.157:1-62.

8. Nebhinani N, & Mattoo S.K,(2013) . Psychiatric morbidity in HIV-positive subjects: A study

from India. J Psychosomatic Research; Vol.70:449-454.

9. Perry S, Jacobsen P. (1986). Neuropsychiatric manifestations of AIDS-spectrum disorders.

Hospital Community Psychiatry Vol.37:135-142.

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131
UNIT 5: THE ABUSED CHILD
INTRODUCTION

Welcome to unit 5. In this unit you will learn on The Abused Child. Child Abuse
commonly occurs within a relationship of trust or responsibility and is an abuse of power
or a breach of trust. Abuse can happen to a child regardless of their age, gender, race
or ability. Abusers can be adults (male or female) and other young people, and are
usually known to and trusted by the child and family.

While physical injuries may or may not be immediately visible, abuse and neglect can
have consequences for children, families, and society that last lifetimes, if not
generations. The impact of child abuse and neglect is often discussed in terms of
physical, psychological, behavioral, and societal consequences. In reality, however, it is
impossible to separate them completely. Physical consequences, such as damage to a
child's growing brain, can have psychological implications such as cognitive delays or
emotional difficulties.

In our lesson today, we are going to define the terms ‘abuse’ and ‘child abuse’, explain
types of abuse, state abuse of children with disabilities, outline warning signs of child
abuse and neglect, state effects of child abuse; and outline risk factors for child abuse
and neglect.

GENERAL OBJECTIVE

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At the end of this lesson students should be able to demonstrate an understanding on
of an abused child and its management.

SPECIFIC OBJECTIVES

At the end of the unit the learner should be able to:

5.1 Explain types of abuse.

5.2 Demonstrate skills in the management of an abused child.

5.3 Explain the rehabilitation process and types of social support.

5.1 TYPES OF ABUSE

There are four main types of child abuse: physical abuse, sexual abuse, emotional
abuse and neglect. The abuser may be a family member, or they may be someone the
child encounters in a residential setting such as next door neighbours, or in the
community, including during sports and leisure activities. An individual may abuse or
neglect a child directly, or may be responsible for abuse because they fail to prevent
another person harming that child.

a) Physical abuse

Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding,
drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may
also be caused when a parent or carer fabricates the symptoms of, or deliberately
induces, illness in a child.

b) Sexual abuse

Sexual abuse involves forcing or enticing a child or young person to take part in sexual
activities, including prostitution, whether or not the child is aware of what is happening.
The activities may involve physical contact, including penetrative (e.g. rape, buggery or
oral sex) or non-penetrative acts. They may include non-contact activities, such as

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involving children in looking at, or in the production of, sexual online images, watching
sexual activities, or encouraging children to behave in sexually inappropriate ways.

c) Emotional abuse

Emotional abuse is the persistent emotional maltreatment of a child such as to cause

severe and persistent adverse effects on the child’s emotional development. It may
involve conveying to children that they are worthless or unloved, inadequate, or valued
only insofar as they meet the needs of another person. It may feature age or
developmentally inappropriate expectations being imposed on children. These may
include interactions that are beyond the child’s developmental capability, as well as
overprotection and limitation of exploration and learning, or preventing the child
participating in normal social interaction.

It may involve seeing or hearing the ill-treatment of another. It may involve serious
bullying, causing children frequently to feel frightened or in danger, or the exploitation or
corruption of children. Some level of emotional abuse is involved in all types of
maltreatment of a child, though it may occur alone.

d) Neglect

Neglect is the persistent failure to meet a child’s basic physical and/or psychological
needs, likely to result in the serious impairment of the child’s health or development.
Neglect may occur during pregnancy as a result of maternal substance abuse. Once a
child is born, neglect may involve a parent or care giver failing to:

- provide adequate food, clothing and shelter (including exclusion from home or
abandonment)

- protect a child from physical and emotional harm or danger

- ensure adequate supervision (including the use of inadequate care-givers)

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 - ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.
Examples of neglect could include: not ensuring children are safe; exposing them to
undue cold or heat, or exposing them to unnecessary risk of injury.

ABUSE OF CHILDREN AND YOUNG PEOPLE WITH A DISABILITY

Let us reflect on children with mental and physical disabilities whom you have
encountered in your neighbourhood, church and market place. If there is anyone most
prone to all the types of abuse we have just looked at, it is children with disabilities.
They may also find it more difficult to recognize and report abuse, and to be believed.

Factors that put children with disabilities at risk of abuse

Have you reflected, or thought carefully of children that you know who are disabled?
What factors put them at risk or make them more vulnerable to abuse than other
children? Let us together consider the following factors.

For example, if their disability means that they:

- Have limited life experiences and so have not developed the social skills needed
to work out what the behaviour and attitudes of others mean. This could make
them less able to understand what is appropriate and inappropriate behaviour.

- Have been encouraged to comply with other people’s wishes and not to question
authority figures.

- Are afraid to challenge potentially abusive situations because of fear of the

consequences. It is often easier to be compliant and pleasing rather than risk
angering an authority figure and getting into trouble.

- May not be able to report abuse either because there is no-one they can report it
to or because they do not have the appropriate language to use.

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 - May not be able to recognise that abuse has taken place.

- Feel powerless because they have to depend on others for personal support.

- May not be able to physically remove themselves from abusive situations.

- Are not believed because their authority figures cannot accept that anyone would
abuse a disabled child.

- May not have anybody they can trust and confide in.

- May feel guilt or shame about the abuse which prevents them from reporting it.

- May not have a sense of ownership of their own bodies because they are so
used to being examined physically by others as part of their medical and physical
care.
- Have low self-esteem and a poor self image.

- In addition to the four main types of abuse shown above (sexual, physical,
emotional and neglect) children with a disability in residential homes or other
institutions might experience:

Institutional abuse - when staff in a home or other institutions sacrifice the needs,
wishes and lifestyle of a disabled child in favour of the institution's regime. For example,
by showing lack of respect for a child's dignity or privacy, or denying them opportunity to
make day-to-day choices or decisions about their life.

Financial abuse - deliberate misuse and exploitation of a disabled child's money or

possessions. For example, if the child is not allowed to spend their money as they wish,
or if someone takes it from them to spend on themselves.

Child abuse and reactive attachment disorder

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Severe abuse early in life can lead to reactive attachment disorder. Children with this
disorder are so disrupted that they have extreme difficulty establishing normal
relationships and attaining normal developmental milestones. They need special
treatment and support.

EFFECTS OF CHILD ABUSE

Studies have shown that there are strong associations between exposure to child abuse
in all its forms and higher rates of many chronic conditions.

Psychological effects

Children with a history of neglect or physical abuse are at risk of developing psychiatric
problems such as:

1. A disorganized attachment style. Disorganized attachment is associated with a

number of developmental problems, including dissociative symptoms, anxiety,
depressive, and acting out symptoms
2. When some of these children become parents, especially if they suffer from
posttraumatic stress disorder (PTSD), dissociative symptoms, and other
sequelae of child abuse, they may encounter difficulty when faced with their
infant and young children's needs and normative distress, which may in turn lead
to adverse consequences for their child's social-emotional development.
3. Victims of childhood abuse also suffer from different types of physical health
problems later in life such as chronic headache, abdominal, pelvic, or muscular
pain with no identifiable reason.
4. Childhood emotional and sexual abuses are strongly related to adult depressive
symptoms. Childhood verbal abuse can lead to anger-hostility than any other
type of abuse.
5. Lack of affection, parental discord, the prolonged absence of a parent, or a
serious illness affecting either the mother or father can lead to depression in
adulthood.

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Physical effects

1. Children who are physically abused are likely to receive bone fractures,
particularly rib fractures
2. They may have a higher risk of developing cancer.
3. Children who experience child abuse & neglect are more likely to be arrested as
juveniles, more likely to be arrested as adults, and more likely to commit violent
crime.
4. The immediate physical effects of abuse or neglect can be relatively minor
(bruises or cuts) or severe (broken bones, hemorrhage, or even death). In some
cases the physical effects are temporary; however, the pain and suffering they
cause a child should not be discounted. Meanwhile, the long-term impact of child
abuse and neglect on physical health is just beginning to be explored. The long-
term effects can be:
5. Shaken baby syndrome. Shaking a baby is a common form of child abuse that
often results in permanent neurological damage (80% of cases) or death (30% of
cases). Damage results from intracranial hypertension (increased pressure in the
skull) after bleeding in the brain, damage to the spinal cord and neck, and rib or
bone fractures (Institute of Neurological Disorders and Stroke, 2007).
6. Impaired brain development. Child abuse and neglect have been shown, in some
cases, to cause important regions of the brain to fail to form or grow properly,
resulting in impaired development. These alterations in brain maturation have
long-term consequences for cognitive, language, and academic abilities.
7. Foster children between 1 and 2 years of age are at medium to high risk for
problems with brain development.
8. Poor physical health. Several studies have shown a relationship between various
forms of household dysfunction (including childhood abuse) and poor health.
9. Adults who experienced abuse or neglect during childhood are more likely to
suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high
blood pressure, and ulcers.

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 10. On the other hand, there are some children who are raised in child abuse, but
who manage to do unexpectedly well later in life regarding the preconditions.
Such children have been termed dandelion children, as inspired from the way
that dandelions seem to prosper irrespective of soil, sun, drought, or rain. Such
children (or currently grown-ups) are of high interest in finding factors that
mitigate the effects of child abuse.

RISK FACTORS FOR CHILD ABUSE AND NEGLECT

While child abuse and neglect occurs in all types of families—even in those that look
happy from the outside—children are at a much greater risk in certain situations.

- Domestic violence. Witnessing domestic violence is terrifying to children and

emotionally abusive. Even if the mother does her best to protect her children and
keeps them from being physically abused, the situation is still extremely
damaging. If you or a loved one is in an abusive relationships, getting out is the
best thing for protecting the children.
- Alcohol and drug abuse. Living with an alcoholic or addict is very difficult for
children and can easily lead to abuse and neglect. Parents who are drunk or high
are unable to care for their children, make good parenting decisions, and control
often-dangerous impulses. Substance abuse also commonly leads to physical
abuse.
- Untreated mental illness. Parents who suffering from depression, an anxiety
disorder, bipolar disorder, or another mental illness have trouble taking care of
themselves, much less their children. A mentally ill or traumatized parent may be
distant and withdrawn from his or her children, or quick to anger without
understanding why. Treatment for the caregiver means better care for the
children.
- Lack of parenting skills. Some caregivers never learned the skills necessary for
good parenting. Teen parents, for example, might have unrealistic expectations
about how much care babies and small children need. Or parents who where
themselves victims of child abuse may only know how to raise their children the

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 way they were raised. In such cases, parenting classes, therapy, and caregiver
support groups are great resources for learning better parenting skills.
- Stress and lack of support. Parenting can be a very time-intensive, difficult job,
especially if you’re raising children without support from family, friends, or the
community or you’re dealing with relationship problems or financial difficulties.
Caring for a child with a disability, special needs, or difficult behaviors is also a
challenge. It’s important to get the support you need, so you are emotionally and
physically able to support your child.

5.2 MANAGEMENT OF AN ABUSED CHILD

When parents or caregivers and sometimes neighbours, teachers and other members
of the community discover that a child is being abused they will report to the police who
will in turn refer them to the hospital. Sometimes the child and its parents may go
straight to the hospital in urgent cases, upon which emergency care is given. Care is
usually given on an outpatient basis unless the child has injuries that need inpatient
observations, investigations and care.

In the management of an abused child we will describe immediate and emergency care,
outline ways of early identification and assisting children going through abuse; explain
how children who have undergone abuse are counseled and state referrals for
appropriate interventions.

IMMEDIATE AND EMMERGENCY CARE

Immediate and emergency care of an abused child is carried out by the Multi
Disciplinary team comprising of physician, surgeon, nurse and anesthetist. As a nurse
you must remember that you will be the first medical worker to see or receive the child.
Upon receiving the patient the following assessment is conducted:

History taking- Nursing history should be carefully documented and include direct
quotations of questions and answers. Such nursing history can be compared later to
other histories for inconsistencies. History will follow the format that is in your procedure
manual and learning guide for paediatrics. As a nurse you will find that the child may not

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trust you enough to say anything, especially that she or he may associate all adults with
whatever abuse he or she has just experienced.

You need to be patient and create a relationship in which you show the child non
judgemental acceptance and empathetic understanding concerning the abuse they
have experienced. Many children will blame themselves thinking it is their fault that they
were physically or sexually abused. You need to reassure them that it is not their fault
and you with other professionals will protect them from further harm.

It might also be advisable to know who caused the injury because if that person is
present during the history taking and physical examination the child may not cooperate
with the assessment.

Physical examination – The child should be examined systematically and thoroughly

paying more attention to areas of the body that have been injured or harmed.

Investigations – Depending on history obtained and findings during physical

examination, different types of investigations can be undertaken such as x-rays of the
skull, limbs, rib cage and spine; full blood count, HIV test and so on.

Treatment – In the case of a seriously physically abused child priority include the
following:

- Recognition of airway

- Breathing

- Circulatory problems

- Instituting airway and ventilator management

- Establishing vascular access for fluid resuscitation and medication

administration.

Hospitalize the abused child if seriously injured (and remember to carry out
observations of vital signs, and any other nursing care such as pain management that

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may be needed during hospitalization) or if safety cannot be otherwise be guaranteed. If
very serious admit to Intensive Care Unit. Then report to police and child protection
services.

Psychological care – Crisis intervention is done immediately after the trauma, once the
immediate and emergency management has been delivered. Crisis intervention - is a
short term therapy which starts immediately after trauma. It is usually limited to 6 weeks.

The first stage of crisis intervention involves carthasis or ventilation of feelings. Second
stage involves the problem-solving approach of counseling. The third stage is
considering and exploring future coping methods to prevent a similar crisis occurring,
and how the client would resolve such a situation if it occurs again.

The family as a whole may also be going through a difficult time, so they will need
support and encouragement.

EARLY IDENTIFICATION OF AN ABUSED CHILD

A child will not always report having abused. Sometimes they may fear being blamed of
they may not want their parents to separate if it is one of the parents that is abusing the
child.

Warning signs of child abuse and neglect

The earlier child abuse is discovered, the better the chance of recovery and appropriate
treatment for the child. Child abuse is not always obvious. By learning some of the
common warning signs of child abuse and neglect, nurses, other health workers,
teachers, and community workers, can detect the problem as early as possible and get
both the child and the abuser the help they need.

Warning signs of emotional abuse in children

- Excessively withdrawn, fearful, or anxious about doing something wrong.

- Shows extremes in behavior (extremely compliant or extremely demanding;
extremely passive or extremely aggressive).

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 - Doesn’t seem to be attached to the parent or caregiver.
- Acts either inappropriately adult (taking care of other children) or inappropriately
infantile (rocking, thumb-sucking, tantruming).

Warning signs of physical abuse in children

- Frequent injuries or unexplained bruises, welts, or cuts.

- Is always watchful and “on alert,” as if waiting for something bad to happen.
- Injuries appear to have a pattern such as marks from a hand or belt.
- Shies away from touch, flinches at sudden movements, or seems afraid to go
home.
- Wears inappropriate clothing to cover up injuries, such as long-sleeved shirts on
hot days.

Warning signs of neglect in children

- Clothes are ill-fitting, filthy, or inappropriate for the weather.

- Hygiene is consistently bad (unbathed, matted and unwashed hair, noticeable
body odor).
- Untreated illnesses and physical injuries.
- Is frequently unsupervised or left alone or allowed to play in unsafe situations
and environments.
- Is frequently late or missing from school.

Warning signs of sexual abuse in children

- Trouble walking or sitting.

- Displays knowledge or interest in sexual acts inappropriate to his or her age, or
even seductive behavior.

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 - Makes strong efforts to avoid a specific person, without an obvious reason.
- Doesn’t want to change clothes in front of others or participate in physical
activities.
- An STD or pregnancy, especially under the age of 14.
- Runs away from home.

5.3 REHABILITATION AND SOCIAL SUPPORT FOR ABUSED CHILDREN

Research has shown that children cope with traumatic events in a similar manner to
adults, that is, they develop Post Traumatic Stress Disorder (PTSD) in which there is re
experiencing of the event (flashbacks), avoidance (phobia), and arousal
(hyperventilation, tachycardia, sweating, frequency).

Cognitive Behavior therapy has been proven, again through research and controlled
trials to be the best therapeutic approach for children and adolescents who experience
trauma related symptoms such as anxiety or mood disorders.

Children who have undergone abuse are counseled and ways of preventing further
abuse are explored and identified. Any referrals for appropriate interventions are made.

To prevent the many complications that can occur to children who have been abused
they have to undergo psychological and social rehabilitation which is directed towards
restoring their emotions (anger, fear, anxiety) thinking patterns (negative thoughts such
as ‘I am worthless, I don’t deserve to live, it was my fault’ etc., and social interactions
(social isolation due to aggressiveness, stigma from peers as a result of abuse etc.) to
the previous level before the abuse occurred.

Abuse leads to anxiety disorders such as PTSD and depression which you covered in
unit 3.

Activity

Before you continue with this part of the lesson on rehabilitation and social support, go

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back to unit 3 and read on Post Traumatic Stress Disorder (PTSD), depression and
phobia.

Now list the causes, and forms of counseling that is given for each of them.

We are therefore going to concentrate on the commonly noticed complications which

include Post Traumatic Stress Disorder (PTSD), excessive aggression towards peers,
symptoms of anxiety, and depression. These are best treated with Cognitive Behavior
Therapy (CBT) which you covered in Psychology in Nursing. Cognitive Behaviour
Therapy is working with the child to change his or her distressing thoughts into good
thoughts about him or herself.

When one has a good thought, for instance, that the abuse that occurred was not their
fault, then they feel happier. When one feel happier the behavior also changes and the
child ceases to be aggressive. CBT has been known to be effective in the treatment of
children who have been abused under the following conditions:

- The child has to be safe from the offender or unsupportive and non believing
family members for ethical reasons and effective treatment.

- The Cognitive Behavioral Therapy being given should be abuse or trauma

focused to help the child adjust to the experience of having been abused. CBT
should focus therefore, on the abuse itself as well as addressing:

 The child’s thinking patterns (the child will tend to blame him or herself
especially in sexual abuse) should be addressed.

 The child’s affective response (anxiety, fear, anger and depression).

 Behavioral reaction to the abuse such as aggression.

TREATMENT APPROACH OF COGNITIVE BEHAVIOR THERAPY

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1. Help and encourage the child to talk and think about the abuse and neglect
without embarrassment or significant anxiety.

2. Help the child to calm down and express feelings about the abuse (catharsis).

3. Reduce intensity and frequency of behavioral and emotional symptoms.

4. Clarify and change distorted, inaccurate, or unhealthy thinking patterns that might
negatively affect the child’s view of self and others.

5. Help the child develop healthier attachments.

6. Strengthen the child’s coping skills.

7. Enhance social skills.

8. Educate the child regarding self protective strategies.

 The child should be helped to recognize that it is adults rather than children who
are responsible for healthy parent child interactions.

 Gradual exposure or discussion of abuse experiences helps to reduce the child’s

anxiety and embarrassment and provides opportunities to modify inaccurate or
self defeating thinking processes.

 Relaxation training further addresses child’s fear or anxiety reaction to abuse

related cues and can stabilize feelings of anxiety, depression and anger.

 Educational approaches helps child to understand what causes hyperventilation,

tachycardia, feelings of faintness.

 Social skills training is used to teach child coping strategies in response to abuse
to improve the child’s functioning with others (family and peers).

 Supportive techniques – to enable the child cope with un supportive family

members, upcoming court proceedings and negative reactions from peers.

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  Education in use of self protective strategies to minimize likelihood that child will
be abused / neglected again.

 It is important to establish a safety plan within the home, recognize signs of

danger, identify support persons in the child’s environment to decrease the
secrecy within previously abusive / neglectful families. This in turn is expected to
minimize the risk of repeated abuses.

 Counseling methods should be appropriate, for example play therapy using toys
and puppets. Art therapy in which a child is given plain paper with crayons or
paints and asked to draw what happened to them and how they are feeling about
it. Therapeutic games and stories.

Altogether, the process of CBT should be able to last for 12 to 16 sessions. One
supportive caregiver should be present at all times.

SOCIAL SUPPORT

Apart from the child being counseled, non offending care givers, family members and
offending care givers who have admitted that he or she committed the abuse also
undergo counseling individually to identify issues related to development of abuse.

When this individual therapy has succeeded family therapy has be undertaken to assist
the family have a conducive and abuse free home environment. Family therapy also
sensitizes the caregivers to avail social support to the abused child so as to enable her
recover quickly with as few complications as possible.

Social Support also includes nurses’, psychologists, social welfares, and Police Victim
Support Units involvement.

PREVENTION

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Resources for child-protection services are sometimes limited. A considerable number
of traumatized abused children do not gain access to protective child-protection
strategies.

It is believed that only when "lower-level violence" of children ceases to be culturally

tolerated will there be changes in the victimization and police protection of children.

In Lusaka there are NGOs that offer child protection services, such as “Children in
Distress”. And YWCA, and Victim Support Units in Police Stations.

Early identification and assistance of children undergoing child abuse, in primary health
care settings, inpatient and the community at large.

Counseling of such children and their caregivers or parents.

Linking up children who are abused with appropriate interventions, care and referral
services.

SUMMARY

In this unit (5) on The Abused Child, we have defined key terms such as abuse and
child abuse, explained types of abuse, stated abuse of children with disabilities; outlined
warning signs of child abuse and neglect, and stated effects of child abuse. In addition,
we have outlined risk factors for child abuse and neglect.

Child abuse is mistreatment of a child and usually occurs within our own homes.
Sometimes it takes long for it to be know that a child is being abused. Nurses’ role is to
be on the look out for children that have been abused so that they may be removed out
of such an environment and the necessary treatment instituted and the perpetrators
brought to book.

To assist you understand certain concepts here is the glossary that you might find
useful.

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GLOSSARY
DISABILITY: Disability: Is the consequence of an impairment that may be physical,
cognitive, mental, sensory, emotional, developmental, or some combination of these.

REHABILITATION – is the process of enabling a mentally ill person to return to the

highest possible level of functioning in their psychological (mind) and social (interaction
with other people) functioning (activity or role assigned to somebody).

SOCIAL SUPPORT – refers to the various type of support a person gets from friends,
family and medical or mental health professionals, that keeps one mentally strong in
difficult times. It consists in informational support (Information Education and
Communication) from medical or mental health workers, material (usually from friends
and relatives and social welfare centres), and emotional support (from friends, relatives,
psychologists, and nurses).

ABUSE - To abuse is to use or treat someone wrongly or badly, especially in a way that
is to your own advantage (Cambridge Advanced Learner’s Dictionary, 2005:5).

CHILD ABUSE - Child abuse is any form of physical, emotional or sexual mistreatment
or lack of care that leads to injury or harm (neglect).

DANDELION – Weed with bright yellow flowers, known to be resistant to adverse

weather conditions.

RESOURCES – Reserve supply of money, labour, materials, psychological capability to

solve problems etc.

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SELF TEST

ANSWER THE FOLLOWING QUESTIONS.

1. List the four main types of child

abuse. .........................................,................................................................
......................................................................................................................

...........................................................................................................

............................................................................................................

2. Mention five (5) psychological effects of child abuse.

i. .................................................................................

ii. …………………………………………………………..

iii. …………………………………………………………..

iv. …………………………………………………………….

v. …………………………………………………………….

vi. ……………………………………………………………..

vii. ……………………………………………………………..

viii. …………………………………………………………….

3. List five (5) physical effects of child abuse.

i. ………………………………………………………………

ii. …………………………………………………………….

iii. ……………………………………………………………..

iv. ……………………………………………………………..

v. ………………………………………………………………

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 vi. ………………………………………………………………

vii. ………………………………………………………………..

4. List immediate and emergency management of an abused child.

i. ………………………………………………………………

ii. ……………………………………………………………..

iii. ……………………………………………………………..

iv. ……………………………………………………………..

v. ……………………………………………………………….

vi. ……………………………………………………………..

vii. ………………………………………………………………….

viii. ………………………………………………………………….

ix. ……………………………………………………………………

x. ……………………………………………………………………

5. Mention ways of rehabilitating and giving social support to an abused

child:

i. …………………………………………………………………………

ii. …………………………………………………………………………

iii. ………………………………………………………………………..

iv. ………………………………………………………………………

v. ………………………………………………………………………

vi. ……………………………………………………………………..

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 vii. ………………………………………………………………………

viii. ……………………………………………………………………….

ix. ……………………………………………………………………….

x. ………………………………………………………………………..

ANSWERS TO SELF TEST

2. Physical (hitting, shaking, throwing, poisoning, drowning,

burning,suffocating)

Sexual (forcing to take part in sexual activity, fondling showing

pornographic material)

Emotional (depriving of love)

Neglect (fail to provide food, fail to provide cloths, fail to protect)

2. Psychological effects: dissorganised attachment, post traumatic stress disorder, anger

hostility, depression, chronic headache, abdominal pains.

3. physical effect: fractured bones-ribs, risk of cancer, shaking baby syndrome (permanent
neurologic damage), poor physical health, impaired brain.

4. Immediate emergency and social support: history taking, physical exams, investigations,
clear air-way, breathing properly, circulation is okey, hospitalization, psychological care

5. Ways of rehabilitating and giving social support: cognitive behavioral therapy, child has to
be safe from offenders, help and encourage the child to talk, help child develop healthier
attachments, strengthen the child’s coping skills, enhance social skills, educate the child
regarding self protection, counsel family members and offending care givers, family therapy.

REFERENCES

1. Adedotun, A. (2005). Basic Psychiatry and Psychiatric Nursing. Ile-Ife: Basag Enterprises.

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2. Sreevani, R. (2004). A Guide to Mental Health and Psychiatric Nursing. New-Delhi: Jaypee
Brothers Medical Publishers (P) Ltd.

3. The ICDIO Classification of Mental and Behavioural Disorders, Clinical Description and
Diagnostic Guidelines. (2007). World Health Organization. Oxford University Press

4. Blackburn, R. (1993). Clinical Programmeswith Psychopaths. In Clinical Approaches to the

Mentally Disordered Offender (eds. K. Howells& C. R. Hollin).Chichester: Wiley.

5. De Ronchi D, Faranca I, Forti P, Ravaglia G, Borderi M,Manfredi R, (2000). Development of

acute psychotic disorders and HIV-1 infection. Int. J Psychiatry Med:173-183.

6. Haworth, E. & Cournos, F. (2006). Psychiatric aspects of HIV / AIDS. 1sted. Philadelphia:
Lippincott Williams & Wilkins.

7. McDaniel JS, Chung JY, Brown L., (2000). Practice guidelines for the treatment of patients
with HIV/AIDS. American Journal of Psychiatry Vol.157:1-62.

8. Nebhinani N, & Mattoo S.K,(2013) . Psychiatric morbidity in HIV-positive subjects: A study

from India. J Psychosomatic Research; Vol.70:449-454.

9. Perry S, Jacobsen P. (1986). Neuropsychiatric manifestations of AIDS-spectrum disorders.

Hospital Community Psychiatry Vol.37:135-142.

UNIT 6: PSYCHOSEXUAL DISORDERS

Introduction

Welcome to unit 6. In this unit we shall look at the definition of psychosexual disorders, different
types of psychosexual disorders and their management. Human sexual behaviour should be
considered in the context of the whole personality. Normal sexual behavior takes a wide range of
forms and depends upon moral, social and logical norms in a given culture or community. The
aim of sexual behaviour is pleasure and the relief of sexual tension. Pathological behavior may
be a presenting symptom of an existing disorder or transient manifestation of an emotional or
personality disorder or of organic disease Normal sexuality

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Normal sexual behaviour is generally described as a sexual act between consenting adults,
lacking any type of force and performed in a private setting in the absence of unwilling
observers. Abnormal and unwanted sexual behaviour therefore would be considered as any act
that does not meet the criteria set out in this definition.

General objective

At the end of the unit the learner should be able to show an understanding of psychosexual
disorders and manage a client with psychosexual disorder.

Specific objective

At the end of the unit the learner should be able to:

6.1 Define psychosexual disorder(6.2 Explain the different types of psychosexual disorders

6.3 Describe the specific management of a client with psychosexual disorders

Now, try to define the term psychosexual disorder.Dont despair if your answer is wrong.

6.1: Definition of psychosexual disorder

It is failure to achieve an erection in full view of normal agreement of a sexual act between two
mature individuals of the opposite sex.

Masters & Johnson’s (1970) observes that the physiological process of sexual intercourse
involves increasing levels of vasocongestion and myotonia (tumescence) and the subsequent
release of the vascular activity and muscle tone as a result of orgasm (detumescence). The
process occurs in the four phases of excitement, plateau, orgasm and resolution.

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Excitement: This is brought on by physiological stimulation fantasy in the presence of loved
object: physical stimulation including stroking or kissing or both. It may last several minutes to
several hours.

Plateau: This is a continuous stimulation and characterized by an increase in intensity. It lasts

from 30 seconds to several minutes depending up on the sexual stimuli and drive.

Orgasm: This involves subjective sense of ejaculatory inevitability which triggers the man’s
orgasm. It lasts from 3 - 45 seconds. The ejaculation consists of about one teaspoonful (2.5ml) of
fluid and contains about 120 - 250 million sperm cells.

Resolution: Resolution through orgasm is characterized by a subjective sense of well being. If

orgasm occurs resolution is rapid. If it doesn’t occur, resolution may take 2 - 6 hours.

Sexual response for the female

Whether explicitly stated or not, discussion of ‘normal’ female sexual response sometimes seems
to imply that a woman should reach orgasm during intercourse, preferably without manual
stimulation. Yet millions of women do not fit this description and some may feel deficient. One
of the most common complaints women bring to sex therapists is a socially defined dysfunction:
they reach orgasm only through manual or oral stimulation of the clitoris, or only when the
intercourse is combined with such direct stimulation. In fact, this is normal.

Okey. Now having looked at the definition of psychosexual disorder, let us now briefly review
some of the causes.

Causal Factors in Human Sexual Dysfunction

Most causes of sexual dysfunction seem traceable to psychological rather than physical causes.
The following psychosocial factors are commonly found:

Defective learning: Masters & Johnson consider inadequate learning to be the primary cause of
orgasmic dysfunction in females. In vaginismus,a somewhat different conditioning pattern may
have occurred, leading the female to associate vaginal penetration with pain, either physical,

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psychological or both. On the other hand, in males a first sex experience with a prostitute, or
some other situation in which harried ejaculation was necessary, may result in premature
ejaculation. Once this pattern is established the individual may be unable to break the
conditioned response.

Feelings of fear, anxiety and inadequacy: Males who suffer from impotence are often
anxious, frustrated and humiliated by their inability to produce or maintain an erection.
Premature ejaculation can also lead to feelings of inadequacy and guilt.
Interpersonal problems (conflict with others)
Changing male-female relationships: Many men consider themselves as supposedly
‘dominant’ partners who take the initiative in sexual relations. This may not always be
appropriate in modern relationships.
Homosexuality and other factors
Drugs affect sexual functioning

Drugs can lead to the following sexual dysfunctions:

I) Impaired ejaculation - Guanathidine

- Bethamedine

- Thioridazine (Melleraril) .

II) Decreased libido and impotency

- a. Oral contraceptive

- b. Sedatives

- c. Major tranquilizers (e.g. Chlorpromazine (Largactil).

- d .Lithium

- e. Methyldopa

- f. Clamidine

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Sexual disorders can be symptomatic of biological problems, intra- psychological conflicts,
interpersonal differences or a combination of these. The sexual function can be adversely
affected by stress of any fixed emotional disorders and by a lack of sexual knowledge.

6.2: Types of Sexual Dysfunctions:

1.Erectile dysfunction or impotence: This is characterized by an inability to achieve or

maintain an erection sufficient for successful sexual intercourse. In primary impotence the man is
not able to have erection at all in his sexual life. In secondary impotence, the man has
successfully achieved vaginal penetration at some time in his sexual life but is later unable to do
so. But In selective impotence, the man is unable to do so in certain circumstances but not in
others.

2.Premature ejaculation: This occurs when the man recurrently achieves orgasm and
ejaculation before he wishes to do so. It is more common today among college educated men
than among men with less education and it is thought to be related to their concern for partner
satisfaction. About 40% of men treated for sexual disorders have premature ejaculation as the
chief complaint.

There are three types of premature ejaculation known as:

a. Habitual premature ejaculation

b. Acute onset premature ejaculation

c. Insidious onset premature ejaculation

Frigidity (inhibited sexual excitement) in female: This is characterized by the inability of the
female to express sexual satisfaction. Its chef physical manifestation is a failure to produce the
characteristic lubrication of the vulva and vaginal tissue during sexual stimulation, a condition
that may make coitus uncomfortable.

Inhibited Female orgasm (anorgasmia): This is characterized by a recurrent and persistent

inhibition of the female orgasm as manifested by a delay in or absence of orgasm following a
normal sexual excitement phase during sexual activity, It refers to the inability of the women to
achieve orgasm by masturbation or coitus.

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Dyspareunia: This is a recurrent and persistent pain during coitus in either the man or the
women. It often coincides with vaginismus. It is due to physical factors like trauma,
inflammation, endometritis. It can also result from psychological cause.

Vaginismus: This is an involuntary constriction of the outer one third of the vagina that prevents
penetration, insertion and coitus. It is less prevalent than anorgasmia. It often affects highly
educated women and those in higher socioeconomic groups. Sexual trauma as rape may result in
vaginismus.

You might also need to know that there are other serious sexual disorders. These are basically
known as sexual perversion or Paraphilias

These are characterized by a sexual behavior which is not customarily accepted.

1. Homosexuality: This involves the attraction for sexual relation with persons of the same sex.
Homosexuality between women is termed as lesbianism. In most cultures it is not considered a
misrepresentation or perversion.

2. Exhibitionism: This is sexual gratification by genital exposure in public. It is found in men

who have directed towards children of either sex. It is a form of homosexuality and tends to
occur in impotent males.

3. Pedophilia: This is a sexual deviation in which there is unusual sexual interest directed
towards children of either sex. It tends to occur in impotent males.

4. Voyeurism: It is sexual gratification from observing others engaged in sexual activity.

5. Fetishism: This is a male sexual deviation in which the deviant is unable to love a person
sexually because of immature sexual development. This involves sexual contact with inanimate
article or fetish, such as clothes.

6. Transvestitism: This involves sexual arousal and satisfaction by wearing the clothes
appropriate to the opposite sex.

7. Sadism: This involves a sexual gratification from inflicting of pain on one's sexual partner.

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8. Transsexualism: This involves a persistent sense of discomfort about one’s anatomic sex and
wish to live as a member of the opposite sex.

9. Masochism: This involves the enjoyment of pain, humiliation and punishment by the sexual
partner.

10. Zoophilia (bestiality): This involves obtaining sexual gratification through contact with
animals.

11. Rape: Violence and the lack of consent by the sexual partner are the elements in rape that
makes it both criminal and deviant.

12. Incest: This involves sexual union of close relatives. This is a taboo (unmentionable,
unthinkable, prohibited) that is one of the strongest in our culture.

13. Nymphomania: This is excessive sexual derive or desire in females.

14. Satyriasis: This is excessive sexual drive or desire in males.

15. Telephone scatology: Sexual gratification is achieved by telephoning someone and making
rude/vulgar remarks or remaining silent on the line.

16. Frotteurism: Sexual excitement is achieved by touching and rubbing against a non
consenting person and even ejaculating on that person or woman.

6.3 MANAGEMENT OF CLIENTS WITH PSYCHOSEXUAL DISORDERS

The nurse must examine their feelings about her/his own sexuality before she /he is able to care
for the patients who sexually act out or present symptoms of sexual disorders. Nurses are not
immune to the development of identity disorders, an unresolved Oedipal or Electra complex, or
psychosexual dysfunction. Feelings of disgust, contempt, anger or fear need to be identified and
explored so that they do not interfere with the development of a therapeutic relationship. This is
one of the reasons patients do better with a team approach rather than with individual therapy.
The quality of nursing care will depend on the nurse’s ability to be nonjudgmental and to
understand the behavior of a patient who is sexually acting out.

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Nursing intervention for patients who exhibits symptoms of sexual disorders also includes
planning care to meet the basic human needs, providing a protective care for the patient,
exploring methods to re-channel sexually unacceptable behaviour and participation in a variety
of therapies, including behavior therapy, and psychotherapy.

The nurse must also assume the role of patient advocate to ensure the promotion of sexual health
when the opportunity occurs.

Table 2: Nursing diagnoses and interventions for patients who exhibit symptoms of sexual
disorders

Nursing diagnoses Nursing interventions

Alteration in pattern of sexuality: impulsive
sexual actions resulting In physical contact
Alteration in pattern of sexuality: verbal
comments with sexual overtones
sexuality: Masturbatory behaviour
Explain to the patient that touching makes you feel
uncomfortable. Ask the patient to explain his
feelings the time he acted impulsively - Explore the
meaning of specific behaviour. Be firm but
nonjudgmental when setting limits. Be consistent.
Intervene in any overt acts towards other patients.
Explain to the patient that he must respect the
rights of others. Avoid placing the patient in
activities requiring physical contact. Provide
protective isolation for other patients if necessary
since his overt behavior may provoke hostility.
Respond by recognizing the patient’s feelings (i.e.,
“it must be difficult to be away from your
fiancée”). Allow the patient to ventilate the reason
for his comment without encouraging his
behaviour. Explore alternative ways to channel the
patient’s advances to result in a more positive
outcome.
Request that the patient limit his activity to private
area to avoid offending others. Intervene in any
attempt by the patient to involve others in his
activity. Explore the meaning behind the patient’s
behaviour. Discuss alternative behaviour with the
patient.

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Sexual dysfunction owing to increased anxiety. Encourage verbalization of feelings. Explore
reasons for increased anxiety. Assess the patient’s
knowledge of cause of sexual dysfunction. Inform
the patient of various resources available (e.g., sex
education courses, clinics, counseling therapy, and
reference books). Administer any prescribed anti-
anxiety agents.

SUMMARY

It is clear from this unit that homosexuality and people’s public dehumanizing sexual behaviours
cannot be left undiagnosed in terms of psychosexual dysfunctioning. Human sexuality is not
smooth throughout the life span. Any psychological disturbance may render an individual sexual
displeasure since sex is enjoyed by way of a peaceful mind.An observation may be made towards
any person who continuously engages into pornographic material and would otherwise be
certified having a psychosexual disorder. We looked at normal human sexuality, psychosexual
dysfunctions including certain medicines that may cause sexual dysfunctions in detail. A
diversity of factors that may lead to sexual dysfunctions was also dealt with in this unit. Nursing
care of clients experiencing sexual dysfunctions has outstandingly been tackle as well.

SELF TEST QUESTIONS

1. List at least four types of drugs which can affect libido and cause impotency.

2. List at least five (5) types of psychosexual dysfunctions.

3. Sadism is a sexual gratification from inflicting of pain on one’s sexual partner.

(A). False (B). True

4. Lesbianism between women is called homosexuality

(A). True (B). False

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5. Mention four successive processes of human normal sexual responses you have learnt in this
unit.

ANSWERS

3. Oral contraceptive, sedatives, major tranquilizers, lithium, methyldopa,

clamidine

4. Erectile dysfunction or impotence, Premature ejaculation, Frigidity,

inhibited female orgasm,dyspareunia, vaginismus

5. B

6. F

7. Excitement, plateau, orgasm, resolution

UNIT 7

UNIT TITLE: MANAGEMENT OF A CLIENT WITH PSYCHIATRIC EMERGENCY

Introduction

Welcome to unit 7. This unit looks at clients with psychiatric emergencies and how they can be
managed. You will meet clients with psychiatric emergencies in almost all health facility settings
regardless of what services they offer.

GENERAL OBJECTIVE

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Show an understanding of Psychiatric emergencies and management

SPECIFIC OBJECTIVES

At the end of the unit the learner should be able to

7.1 Enumerate suicidal attempt

7.2 Identify aggressive patients

7.3 Identify depressed patients

7.4 Explain alcohol intoxication

7.5 Discuss drug poisoning

7.6 Describe drug and substance abuse

7.1: SUICIDAL ATTEMPTS

DEFINITION: A failed suicide attempt (Latin: tentamen suicidii), or nonfatal suicide attempt, is
a suicide attempt from which the actor survived. (e.n Wikipedia.org/wiki/failure suicide)

7.2: AGGRESSIVE PATIENTS

INTRODUCTION

Aggression arises from an innate drives or occurs as a defense mechanism and is manifested
either by constructive or destructive acts directly towards self or others. Aggressive people
ignore the rights of other people. They must fight for their own interests and they expect same
from others. An aggressive approach to life may lead to physical or verbal violence. The
aggressive behavior often covers a basic lack of self confidence. Aggressive people enhance to
their self esteem by overpowering others and there by proving their superiority. They try to cover
up their insecurities and vulnerabilities by acting aggressive.

Meaning

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Anger: Anger is defined as a strong uncomfortable emotional response to provocation that is
unwanted and incongruent with one’s values, beliefs or rights.

Aggression: Aggression refers to behavior that is intended to cause harm or pain. Aggression
can be either physical or verbal.

Characteristics of aggressive behavior

Aggressive behavior is communicated verbally or non verbally

Aggressive people may invade the personal space of others

They may speak loudly and with greater emphasis

They usually maintain eye contact over a prolonged period of time so that the other person
experiences it as an intrusive

Gestures may be emphatic and often seem threatening. (For example they may point their figure,
shake their fists, stamp their feet or make slashing motion with their hands)

Posture is erect and often aggressive people lean forward slightly towards the other person. The
overall impression is one of power and dominance

Types of aggression

Instrumental aggression -- aggression aimed at obtaining an object, privilege or space with no

deliberate intent to harm another person

Hostile aggression -- Aggression intended to harm another person, such as hitting, kicking, or
threatening to beat up someone.

Relational aggression -- A form of hostile aggression that does damage to another's peer
relationships, as in social exclusion or rumor spreading

Moyer Classification

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 Moyer (1968) presented an early and influential classification of seven different forms of
aggression, from a biological and evolutionary point of view.

Predatory aggression: Attack on prey by a predator.

Inter-male aggression: Competition between males of the same species over access to resources
such as females, dominance, status, etc.

Fear-induced aggression: Aggression associated with attempts to flee from a threat.

Irritable aggression: Aggression induced by frustration and directed against an available target.

Territorial aggression: Defense of a fixed area against intruders, typically conflicts.

Maternal aggression: A female's aggression to protect her offspring from a threat. Paternal
aggression also exists.

Instrumental aggression: Aggression directed towards obtaining some goal, considered to be a

learned response to a situation.

7.3: DEPRESSED PATIENT

DEFINITION:

Depression is a state of low mood and aversion to activity that can affect a person's thoughts,
behavior, feelings and sense of well-being. Depressed people may feel sad, anxious, empty,
hopeless, worried, helpless, worthless, guilty, irritable, hurt, or restless.

Causes

Life events

Life events and changes that may precipitate depressed mood include childbirth, menopause,
financial difficulties, job problems, loss of a loved one/family member or friend, natural disasters
such as earthquakes, hurricanes, tornadoes, etc. relationship troubles, separation, bereavement
and catastrophic injury.

Medical treatments

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Certain medications are known to cause depressed mood in a significant number of patients.
These include hepatitis C drug therapy and some drugs used to treat high blood pressure, such as
beta-blockers or reserpine.

Non-psychiatric illnesses

Depressed mood can be the result of a number of infectious diseases, neurological conditions
and physiological problems including hypoandrogenism (in men), Addison's disease, Lyme
disease, multiple sclerosis, chronic pain, stroke, diabetes,cancer,sleep apnea, and disturbed
circadian rhythm. It is often one of the early symptoms of hypothyroidism (reduced activity of
the thyroid gland). For a discussion of non-psychiatric conditions that can cause depressed mood,
see Depression (differential diagnoses).

Psychiatric syndromes

A number of psychiatric syndromes feature depressed mood as a main symptom. The mood
disorders are a group of disorders considered to be primary disturbances of mood. These include
major depressive disorder (MDD; commonly called major depression or clinical depression)
where a person has at least two weeks of depressed mood or a loss of interest or pleasure in
nearly all activities; and dysthymia, a state of chronic depressed mood, the symptoms of which
do not meet the severity of a major depressive episode. Another mood disorder, bipolar disorder,
features one or more episodes of abnormally elevated mood, cognition and energy levels, but
may also involve one or more depressive episodes.When the course of depressive episodes
follows a seasonal pattern, the disorder (major depressive disorder, bipolar disorder, etc.) may be
described as a seasonal affective disorder.

Outside the mood disorders: borderline personality disorder commonly features depressed mood;
adjustment disorder with depressed mood is a mood disturbance appearing as a psychological
response to an identifiable event or stressor, in which the resulting emotional or behavioral
symptoms are significant but do not meet the criteria for a major depressive episode; and
posttraumatic stress disorder, an anxiety disorder that sometimes follows trauma, is commonly
accompanied by depressed mood.

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7.4 Alcohol intoxication

Definition- intoxication (also known as drunkenness or inebriation) is a physiological state

induced by the consumption of alcohol.

Etiology

Common symptoms of alcohol intoxication include slurred speech, euphoria, impaired balance,
loss of muscle coordination (ataxia), flushed face, dehydration, vomiting, reddened eyes, reduced
inhibitions, and erratic behavior. Sufficiently high levels of blood-borne alcohol will cause coma
and death from the depressive effects of alcohol upon the central nervous system.

• Causes and effect

Intoxication is the consequence of alcohol entering the bloodstream faster than it can be
metabolized by the liver. Some effects of alcohol intoxication are central to alcohol's desirability
as a beverage and its history as the world's most widespread recreational drug.

• Common effects are -euphoria and lowered social inhibitions. Other effects are
unpleasant or dangerous because alcohol affects many different areas of the body at once
and may cause progressive, long-term harm when consumed in excess.

Stages of alcohol intoxication

1- Euphoria
Difficulty concentrating
Talkative
Lowered inhibitions
Brighte r color in the face
Fine motor skills are lacking

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2-Excitement
Senses are dulled
Poor coordination
Drowsy
Beginnings of erratic behavior
Slow reaction time
Impaired judgment

3- Confusion
Exaggerated emotions
Difficulty walking
Blurred vision
Slurred speech
Pain is dulled

4- Stupor
Cannot stand or walk
Vomiting
Unconsciousness is possible
Decreased response to stimuli
Apathetic

5- Coma
Unconscious
Low body temperature
Possible death
Shallow breathing
Slow pulse

6- Death
Death as a result of respiratory arrest

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• Pathophysiology

• Alcohol is metabolized by a normal liver at the rate of about one ounce (one two-ounce
shot of spirits, a normal beer, a regular sized glass of wine) every 90 minutes. An
"abnormal" liver with conditions such as hepatitis, cirrhosis, gall bladder disease, and
cancer will have a slower rate of metabolism. Ethanol is metabolised to acetaldehyde by
alcohol dehydrogenase (ADH), which is found in many tissues, including the gastric
mucosa. Acetaldehyde is metabolised to acetate by acetaldehyde dehydrogenase
(ALDH), which is predominantly found in liver mitochondria. Acetate is used by the
muscle cells to produce acetyl-CoA using the enzyme acetyl-CoA synthetase, and the
acetyl-CoA is then used in the citric acid cycle.It takes roughly 90 minutes for a healthy
liver to metabolize a single ounce, approximately one hour per standard unit

Diagnoses

diagnosis relies on a blood test for alcohol, usually performed as part of a toxicology
screen.

Blood alcohol content (BAC), also called blood alcohol concentration, blood ethanol
concentration, or blood alcohol level is most commonly used as a metric of alcohol
intoxication for legal or medical purposes. Blood alcohol content is usually expressed as
a percentage of alcohol (generally in the sense of ethanol) in the blood. For instance, a
BAC of 0.10 means that 0.10% (one tenth of one percent) of a person's blood, by volume
(usually, but in some countries by mass), is alcohol.

Management

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 • Acute alcohol poisoning is a medical emergency due to the risk of death from respiratory
depression and/or inhalation of vomit if emesis occurs while the patient is unconscious
and unresponsive. Emergency treatment for acute alcohol poisoning strives to stabilize
the patient and maintain a patent airway and respiration, while waiting for the alcohol to
metabolize:Also:

• Protect vital signs by monitoring ABCs, or Airway, Breathing, and Circulation; that is, if
the person is thought to be at risk for severe respiratory depression, consider an
endotracheal tube to protect the airway and assist with breathing.

• Protect the airway from aspirating stomach contents that could cause aspiration
pneumonia.

• Treat hypoglycaemia (low blood sugar) with 50ml of 50% dextrose solution and saline
flush, as ethanol induced hypoglycaemia is unresponsive to glucagon.

• Follow-up

Prognosis

• A normal liver detoxifies the blood of alcohol over a period of time that depends on the
initial level and the patient's overall physical condition. An abnormal liver will take
longer but still succeed, provided the alcohol does not cause liver failure.

• People who have been drinking heavily for several days or weeks may have withdrawal
symptoms after the acute intoxication has subsided.

• A person who consumes a dangerous amount of alcohol persistently can develop memory
blackouts and idiosyncratic intoxication or pathological drunkenness symptoms.

• Long-term persistent consumption of excessive amounts of alcohol can cause liver

damage and have other deleterious health effects.

7.5 Drug poisoning

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 • Definition –

• Poisoning can result from an overdose of either prescribed drugs or drugs that are bought
over the counter. It can also be caused by drug abuse or drug interaction. Accidental and
intentional poisonings or drug overdoses constitute a significant source of aggregate
morbidity, mortality, and health care expenditure.

• The effects vary depending on the type of drug and how it is taken (see table below).
When you call the emergency services, give as much information as possible. While
waiting for help to arrive, look for containers that might help you to identify the drug.

Drug Effects of p
upper abdo
nausea & vo
Asprin
Painkillers
(swallowed) ringing in th
‘sighing’ wh
confusion a
 upper
 nause
Paracetamol  ringin
(swallowed)  ‘sighi
 confu
 dizzin

 little
abdom
vomi
 irreve
occur
(maln
increa

171
 lethargy and s
leading to
unconsciousn
Nervous system depressants and Barbiturates and benzodiazepines
tranquillisers (swallowed) shallow breat
weak, irregula
abnormally slo
pulse.
 excitable,
behaviour
Amphetamines (including Ectasy) and LSD  sweating
Stimulants and hallucinogens
(swallowed); cocaine (inhaled)  tremor of
 hallucinat

 small pup
 sluggishn
possibly l
unconscio
Narcotics Morphine, heroin (commonly injected)  slow, shal
may stop
 needle ma
infected.

 nausea an
 headache
Glue, lighter fuel  hallucinat
Solvents
(inhaled)  possibly,
 rarely, car

Nursing Management

Goals -

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To maintain breathing and circulation

To arrange removal to hospital. If the casualty is conscious:

• Help them into a comfortable position

• Ask them what they have taken

• Reassure them while you talk to them

. Monitor and record vital signs - level of response, pulse and breathing - until medical
help arrives

• Look for evidence that might help to identify the drug, such as empty containers. Give
these samples and containers to the paramedic or ambulance crew.

If the casualty becomes unconscious:

• open the airway and check breathing be prepared to give chest compressions and rescue
breaths if necessary place them into the recovery position if the casualty is unconscious
but breathing normally.

• DO NOT induce vomiting.

Prevention and Control

• Reduce Access to Drugs

• Reduce Inappropriate Prescription Use

Develop education materials specifically for chronic pain patients addressing use, misuse and
proper storage and disposal

• Substance Abuse Primary Prevention

Provide targeted education to youth professionals based on evidence-based practice

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• Early Intervention, Treatment & Recovery

• Overdose Intervention/Harm Reduction

7.6 Drug and Substance Abuse

• Definition- What is a drug?

A chemical substance which when taken changes the functioning of the body and the
mind.

• What is drug use?

Using a drug for its intended purpose, eg use of anti-malarialtablets to treat malaria,
panadol to relieve pain etc.

• What is drug abuse?

is an intense desire to use increasing amounts of a particular substance or substances to

the exclusion of other activities. Improper use of drugs, e.g. taking piriton to sleep instead
of using it to treat allergy, sniffing glue instead of using it as an adhesive.

• Categories of drugs abused

- Illicit (illegal) for example Heroine, Cocaine, Chang'aa,Bhang, Kuber, Mandrax.

- Licit (legal) drugs for example Alcohol (Beer, Wines & Spirits) Tobacco, Miraa.

• Commonly abused drugs

-Alcohol, Chang'aa, Cigarettes, Bhang, Miraa, Mandrax, Glue,Cocaine, Heroine, misuse

of prescription drugs.

Causes of abuse

• Peer influence

• Low self-esteem

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• Media influence (TV, magazines, internet)

• Rebellion against parents, teachers, religion etc

• Curiosity

• Lack of knowledge of drugs

• Poor role models .

• Frustrations from home, school, body changes etc

. Inability to achieve goals set thus feeling like a failure

• False ideas and perceptions. e.g. bhang enhances academic performance .

Effect of abuse

• Poor memory

• Reduced reasoning capacity

• Truancy and poor performance in school, sports and other activities.

• Poor concentration

• Dropping out of school.

• Suspension and expulsion from schools .

• Risky sexual behavior leading to early pregnancy & HIV/AIDS

• Crimes like theft, violence,rape,incest,bestiality(sex with animals) leading to legal

implications .

• Poor health

• Personal neglect

• Withdrawal and isolation from society

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 • Being shunned by the society .

• Personal guilt

• Poor relations with parents, teachers, siblings and peers .

• Physical and psychological addiction .

• Overdose of drugs can lead to DEATH.

Warning Signs of Commonly Abused Drugs

Marijuana: Glassy, red eyes; loud talking, inappropriate laughter followed by sleepiness; loss of
interest, motivation; weight gain or loss.

Stimulants (including amphetamines, cocaine, crystal meth): Dilated pupils; hyperactivity;

euphoria; irritability; anxiety; excessive talking followed by depression or excessive sleeping at
odd times; may go long periods of time without eating or sleeping; weight loss; dry mouth and
nose.

Depressants (including Xanax, Valium, GHB): Contracted pupils; drunk-like; difficulty

concentrating; clumsiness; poor judgment; slurred speech; sleepiness.

Heroin: Contracted pupils; no response of pupils to light; needle marks; sleeping at unusual
times; sweating; vomiting; coughing, sniffling; twitching; loss of appetite.

Inhalants (glues, aerosols, vapors): Watery eyes; impaired vision, memory and thought;
secretions from the nose or rashes around the nose and mouth; headaches and nausea; appearance
of intoxication; drowsiness; poor muscle control; changes in appetite; anxiety; irritability; lots of
cans/aerosols in the trash.

Hallucinogens (LSD, PCP): Dilated pupils; bizarre and irrational behavior including paranoia,
aggression, hallucinations; mood swings; detachment from people; absorption with self or other
objects, slurred speech; confusion.

Preventive strategies

• Involve yourself in pleasurable activities like games, drama, clubs and societies etc

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 • Develop a good reading culture .

• Apply critical thinking e.g. asking yourself, why am I doing this? What for? What are
the consequences of my actions?

• Develop mechanisms for dealing with difficulties, issues .

• Choose friends wisely .

• Develop your personal potential such as creativity,

• Appreciate, love and accept yourself as you are .

• Identify and pursue your purpose in life .

• Self awareness: identify your capabilities, strength, limitations,weaknesses and appreciate

them .

• Be aware of your physical, mental and emotional changes taking place during
adolescence and learn to cope

Further reading

-www.emedicine health.com/alcohol intoxication/article-em.htm

http://www.helpguide.org/mental/drug_substance_abuse_addiction_signs__effects_treatments.ht
m

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UNIT 8 FORENSIC PSYCHIATRY

INTRODUCTION

Welcome to this unit on forensic psychiatry. Forensic psychiatry deals with some of the
most disturbed and difficult to manage patients in psychiatric practice. You have learned
about these patients in the past units on personality disorder, psychiatric emergency,
psychosexual and disorders.

It focus the assessment and treatment of mentally disordered offenders, and other
patients, presenting with severe mental disorder in association with significant
behavioural disturbance. Treatment settings vary from high security hospitals through to
medium secure units and community forensic services, as well as the opportunity to
treat patients in prison settings. Knowledge of the law in relation to clinical practice is
central to the work and there is regular involvement with criminal justice agencies.

Forensic psychiatry is a multi-professional discipline where it is the norm to function as

part of a clinical team which will include psychologists, occupational therapists,
clinicians and social work colleagues as well as community forensic psychiatric nurses.
Most forensic services operate from well-equipped, purpose built modern facilities. The
patients are invariably fascinating, with complex, often multiple psychopathology. The
range of referrals is immense, covering minor and very serious offenders, non-offenders
with worrying behaviours and requests for advice from the courts, the probation service,
the prison service and psychiatric colleagues.

In this unit, we will define key terms used in forensic psychiatry, outline types of patients
that need forensic psychiatry, describe care of patients during detention; and discuss
referral and discharge during forensic psychiatry and describe the nursing management
of forensic patients.

GENERAL OBJECTIVES

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At the end of this unit students should be able to acquire knowledge and understanding
of forensic psychiatry.

SPECIFIC OBJECTIVES
8.1 Define key terms used in forensic psychiatry.
8.2 Outline types of patients that need forensic psychiatry.
8.3 Describe forensic psychiatric care of patients during detention.
8.4 Discuss referral and discharge during forensic psychiatry.

8.1 DEFINITIONS OF KEY TERMS

a. Forensic
Pertaining to or applied in legal proceedings.

b. Forensic psychiatry
It is the branch of psychiatry that deals with the assessment and treatment of mentally
disordered offenders and includes those areas where psychiatry interacts with the law.
c. Forensic nursing
It is defined as a subspecialty of nursing that has as its objective assisting the mental
health and legal systems in serving individuals who have come to the attention of both.

8.2 TYPES OF PATIENTS THAT NEED FORENSIC PSYCHIATRY

The patient in the forensic setting is guilty of committing a crime believed to be caused
by their mental illness. Alternatively, the forensic psychiatric patient might have
committed a crime independently of their mental illness, but is presently too ill to
participate in court proceedings.

For example, a patient experiencing symptoms of schizophrenia might injure a neighbor

because he or she heard voices stating that the neighbor intended to harm her or him.
This is quite different from a patient who injures someone whilst their illness is stable. A
patient judged to have committed a crime in connection with a mental illness might be
found not guilty by reason of insanity. A ruling is made by the courts in which the patient

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is confined until such a time it is deemed by the treatment facility that the patient is no
longer a threat to society.

The following are types of patients that are admitted to forensic facilities:
a. Anti social personality disorder – is more strongly related to offending and
violence. Aspects related to offending in a person with personality disorder
include impulsivity, lack of empathy, paranoid thinking, poor relationships with
others, problems with anger and assertiveness.
b. Substance dependence (alcohol and drugs such as cocaine, heroine, chamba)
Intoxication reduces inhibitions and is strongly associated with crimes of
violence, including murder. Neuropsychiatric complications of alcoholism may
also be linked with crime.
c. Learning disability – People with learning disability may commit offences
because they do not understand the implications of their behavior, or because
they are susceptible to exploitation by other people. Eg. Property offences,
sexual offences such as indecent exposure by males & arson.
d. Mood disorder – Depressive disorder is sometimes associated with shop lifting
and may also lead to homicide & suicide. Manic patients may spend excessively
and fail to pay. They are also prone to irritability and aggression leading to crimes
of violence.
e. Schizophrenia and other psychotic disorders – are associated with violence
especially if paranoid or coupled with substance abuse.
f. PTSD in cases where battered women have killed a battering partner.
g. Morbid jealousy
h. Organic mental disorders – Dementia and delirium. Eg aggression
i. Epilepsy – Violence is commoner in the post ictal state than ictally.

8.3 FORENSIC PSYCHIATRIC CARE OF PATIENTS DURING DETENTION

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In Zambia mentally disordered offenders are cared for under the Penal Code 87 and
Prisons Act of the Zambian Constitution as follows:
- Presumption of sanity: Every person is presumed to be of sound mind, and to
have been of sound mind at any time which comes in question, until the contrary
is proved. When a person getting psychiatric treatment commits a serious
offence while they are not documented legally that they are suffering from mental
disorders, such a person is liable to prosecution until proven mentally ill by a
qualified and registered psychiatrist.

- Insanity: A person is not criminally responsible for an act or omission if at the

time of doing the act or making the omission he is, through any disease affecting
his mind, incapable of understanding what he is doing, or of knowing that he
ought not to do the act or make the omission. But a person may be criminally
responsible for an act or omission, although his mind is affected by disease, if
such disease does not in fact produce upon his mind one or other of the effects
above mentioned in reference to that act or omission.

- Defence of diminished responsibility: Where a person kills or is a party to the

killing of another, he shall not be convicted of murder if he was suffering from
such abnormality of mind (whether arising from a condition of arrested or
retarded development of mind or any inherent causes or is induced by disease or
injury) which has substantially impaired his mental responsibility for his acts or
omissions in doing or being party to the killing.” (Laws of Zambia).

CORRESPONDENCE DURING DETENTION

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During detention correspondence between the courts of law and the head of the
psychiatric department is entered into concerning the detention and care of patients
using the following methods:

- Adjudication order forms: Is to hear and settle a case by judicial procedure. In the
case of forensic patients it means the patient has to be tried before a court of
law, and it has to be determined whether they are guilty of a crime or not.
However, before they can be tried, two psychiatrists have to examine and
determine whether they are competent to stand trial or not.

- Control order forms: After an adjudication order has been made, the courts shall
make a control order, for the control, care or detention of the patient, specifying
that the patient be detained in a prescribed place whilst his or her case
undergoes judicial review. The patient may therefore be transferred from prison
to the prescribed place, in Zambia, Chainama East / hospital.

- Detention Order form – This is a form that restrains the client with mental illness
to be admitted in a mental hospital for a minimum of 14 days after which
psychiatric personnel should furnish a report to the magistrate about their
findings concerning the patient. (See involuntary or compulsory admission under
unit two)

- Court reports: Psychiatrists provide a report of the patient’s progress whilst in

detention. Court reports – are required by the prosecution, court and lawyer. The
reports consists of a psychiatric assessment, that should be objective, and
professional, and should not be influenced by which ‘side’ has made the request.
The report should indicate whether the offender was mentally insane at the time
of committing the crime or not. It should also indicate the competence of the
mentally disordered offender to stand trial, and whether he understands what he
has been accused of, and the meaning of pleading guilty or not guilty.

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 - Give evidence in criminal proceedings on the patient’s dangerousness, so that a
suitable sentence may be made.

- Transfer Order form – This is a form that is used when transferring a patient with
mental illness from one hospital to another. It has to be duly filled in by a senior
magistrate in the subordinate court.

TREATMENT SETTINGS FOR MENTALLY DISORDERED OFFENDERS

In Zambia according to the Mental disorders Act of 1951, mentally disordered offenders
are treated in all hospitals administered by the Government; and all places declared to
be prisons under section three of the Prisons Act; under compulsory detention
(Detention Order) to safe guard the lives and property of the public.

While prisons focus solely on control these forensic facilities focus on both control and
treatment. Buildings are therefore designed for maximum security to prevent patients
escaping. Prison warders guard these facilities.

- In Zambia Chainama East is used to confine people who have committed

homicide or grievous bodily harm to others, as a result of being insane. Like a
prison, Chainama East is a secure environment with strict rules and regulations
to ensure safety and security to prevent patients escaping. Individuals admitted
to this place have been charged with criminal offences and are deemed too
dangerous to live in the community.
- Chainama East is also used to care for persons that develop mental disorder and
therefore require psychiatric treatment and care whilst in prison.
- Those who have committed violence against property as a result of insanity are
kept in the acute wards in Chainama.

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 - Female offenders are detained in the acute female ward of Chainama Hills
Hospital and are guarded by female prison warders.

LEAVE OF ABSENCE

Detained patients cannot go on leave or be discharged from the hospital as long as they
are a danger to others and to property.

ABSCONDING

Immediately it is noticed that a patient has absconded, the police and relatives should
be notified, indicating the date, time, circumstances under which the patient absconded
and clothes they were last seen wearing, and direction which they took. A search by
police is instituted. This should be documented in the nurses’ and ward report.

SEXUALITY

Sexual offences tend to be repeated because patients with psychosexual disorders may
not cooperate with treatment as we saw when we covered that particular unit. (The most
common offences are indecent assault of women, indecent exposure, unlawful
intercourse with girls under 16, rape, paedophilia.)

For this reason psychiatrists may be asked to give an opinion on an offender’s

dangerousness, which if present may lead to long periods in confinement. Treatment of
sex offenders can only be carried out if the offender admits to having committed the
crime and if he or she is willing to undergo therapy with a view to changing his or her
sex offending behavior.

Victims of crime are referred to appropriate services where they are given the
necessary psychological support available within the community and mental health
department. For example women and child shelters, victim support unit in police,

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support groups, Non Governmental Organizations such as Young Women’s Association
(YWCA), Children In Need, orphanages, voluntary counselors, Child Counselors at ‘A’
Block in University Teaching Hospital and so on.

FORENSIC PSYCHIATRIC NURSING CARE

The forensic focus for nursing is the therapeutic nursing inventions targeted at patient’s
behaviours (psychiatric symptoms) that cause him/her to commit crimes. Nursing
interventions therefore, are directed towards reducing the frequency and severity of
these behaviors.

You have covered these interventions when learning about counseling during
psychology and also in UNIT 2 on psychiatric nursing skills. Remember to continue
utilizing The Nursing Process to give individualized care to these patients. Each
abnormal behavior will be assessed, a nursing diagnosis made and intervention
planned and then implemented. However common interventions in Forensic nursing
include the following:

- Crisis intervention
This treatment helps patients cope with the crisis brought about by their criminal
behavior and subsequent detention in their lives, and to learn effective ways of dealing
with future difficulties. Treatment is aimed at reducing emotional arousal that takes
place during a crisis together with any accompanying behavioral disorganization. This is
done by reassuring the patient and enabling him/her to have an opportunity to express
emotions, in a supportive environment (empathy, non judgmental).

Anxiolytic medication may be required for a few days. Once emotional arousal has been
contained, a problem solving approach is used, in which the nurse in collaboration with
the patient helps identify and list problems that are causing distress. (Check for problem
solving counseling in Psychology in Nursing).

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 - Rehabilitation
In order for patients in this setting to be eligible for return to the community, both the
criminal act and the psychiatric illness must be addressed. If anger is behind the
criminal act specific programs targeting anger management should be offered.

- Suicide prevention – treatment for depression and close observation by staff in

ward and relatives in community if discharged.

- Behavior management – any abnormal behavior such as being anti social or

manipulative is treated using behavior modification training.

- Substance abuse treatment – Detoxification is done in the psychiatric unit and

thereafter the patient is referred and connected to long term support groups.

- Discharge planning – begin to plan for the discharge of the patient together with
him/her and relatives with the input of the MDT. The way forward and how he/she
will go back into the community.

Special challenges a nurse faces with forensic patients

Since forensic patients have two main problems; namely the serious crime they have
committed and the mental disorder that caused them to commit that crime, he or she
becomes very complicated and difficult to manage. In fact, forensic patients are well
known as being very dangerous, both to each other, and to staff caring for them.

- Potential for Physical Violence: Since most patients admitted to a forensic setting
have a history of criminal behavior, they pose a high risk of physical violence to
both staff and fellow patients. This can be prevented or reduced by training
forensic nurses in violence prevention and management techniques. If a nurse
has been exposed to physical violence they must be supported and undergo
debriefing.

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 - Verbal abuse: Daily stress of verbal abuse of nurses need to be addressed so as
to maintain staff morale. It is addressed by support from senior nurses in which
the affected nurses are given the opportunity to reflect on and discuss reactions
to patients.

- Difficulties in the nurse patient relationship: Physical or verbal abuse disturbs the
forming of a meaningful nurse-patient relationship.

To be able to carry out the above mentioned nursing interventions the forensic nurse
functions as follows:

Functions of a forensic nurse

 Patient advocate
 A trusted counselor
 A provider of primary, secondary, and tertiary health care interventions.

8.4 REFERRAL / DISCHARGE

Forensic offenders are reviewed every fourteen days by two different psychiatrists
under the Detention Order. Their confinement in a mental hospital tends to be for long
periods of time until it is determined that they no longer pose a danger to the public and
to property; again by two psychiatrists who get their views from the observations and
assessments by nurses, psychologists and other members of the MDT.

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According to His Excellency’s Pleasure (This is Prerogative of Mercy of the President
where he pardons prisoners that have been recommended by both prison and mental
health personnel); the psychiatrists will complete a medical certificate in which a
patient’s mental fitness is confirmed. It is this certificate that the court will use to either
discharge or reduce the sentence, or sentence a mentally disordered offender.

SUMMARY
The focus of forensic psychiatry is the assessment and treatment of mentally disordered
offenders, and other patients, presenting with severe mental disorder in association with
significant behavioural disturbance. In Zambia most of the forensic patients are treated
at Chainama Hills Hospital because it is one of the places designated by the Zambian
constitution.

In this unit we have defined key terms used in forensic psychiatry, outlined types of
patients that need forensic psychiatry, described forensic psychiatric care of patients
during detention; and discussed referral and discharge of forensic patients. Finally, we
have described the nursing management of forensic patients.

SELF TEST
MATCH THE FOLLOWING FORMS USED IN FORENSIC PSYCHIATRY (COLUMN 1)
WITH THE CORRESPONDING DESCRIPTION IN (COLUMN 2).

COLUMN 1 COLUMN 2
1. Adjudication forms …………..Ensures patient is admitted for 14 days.
2. Control order forms……………The patient has to be tried before courts of law.
3. Transfer order forms…………..Courts determine where patient will be detained.

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 4. Detention Order forms………...Used to transfer patients with mental illness.

UNIT 9:COMMUNITY PSYCHIATRY

INTRODUCTION

Community Psychiatry involves delivering mental health care to clients while they
continue to live in their homes. You will remember from Unit one (1) in which you
covered the history of Mental Health and Psychiatry that before the 20 th Century,
treatment took place in mental health institutions. Following deinstitutionalization, where
psychiatry is practiced, shifted from the mental institutions to the community.

This shift into community care required a range of different and new skills, performed by
a correspondingly broad range of professionals (sociologists, psychologists,
psychiatrists, mental health nurses) and non professionals such as community mental
health workers, and neighbourhood health committees. In addition, emphasis was
placed on the client as part of a family and wider community. Service delivery in
communities would occur outside health institutions, such as in client’s home, Out
Patients Department (OPD), vocational training centers, and after care centres or group
homes.

In this way, community mental health services would lessen social exclusion and
stigma, as well as reduce neglect of human rights often encountered in mental
hospitals. For mental health to be delivered effectively in the community, interventions
are carried out on the following levels: promotional activities, and primary, secondary
and tertiary prevention.

Promotional activities foster good mental health whereas prevention is concerned with
avoiding disease. In all levels the nurse has a special role to play, which includes the
following: Consultant, clinical, therapeutic, assessor, researcher, educator, trainer,
fascilitator, manager and liaison. In this unit we will define key terms used in community
psychiatry, explain the concept of community mental health services in Zambia and
outline levels of prevention in mental health.

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GENERAL OBJECTIVE

Describe care of patients with mental disorders in the community.

Welcome to unit 9,here we will talk about terms used in community psychiatry as
well as concept or your perception towards community mental health services.We
shall further outline the levels of intervention in mental health.

SPECIFIC OBJECTIVES

At the end of the unit the learner should be able to:

9.1 Define key terms used in community psychiatry.

9.2 Explain the concept of community mental health services in Zambia.

9.3 Outline levels ofIntervention in mental health

9.4 Role of a Nurse

9.1 DEFINITION OF KEY TERMS USED IN COMMUNITY PSYCHIATRY

In this section we shall define terms that shall often be used in this unit (9) on
Community Psychiatry.

Community Psychiatry

- Psychiatry focusing on detection, prevention and early treatment and

rehabilitation of emotional and behavioral problems as they occur in the
community.

- Community mental health services support or treat people with mental health
problems whilst they continue to live in their own homes.

Institutionalism is a pattern of passive dependent behavior observed among

psychiatric inpatients, which is characterized by hospital attachment and resistance to
discharge.

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Deinstitutionalization

- At the patient level, it refers to the transfer of a patient hospitalized for extended
periods of time to a community setting.

- At the mental health care system level, it refers to a shift in the focus of care from
long term institutions to the community, accompanied by discharging long-term
patients, and avoiding unnecessary admissions.

Severe mental disorders are mental illnesses characterized by functional disability

(inability to function in the following areas: occupational, social, ADLs).

Mental health promotion is a means of reaching the goal of good mental health
through actions that are taken for the purpose of fostering, protecting and improving
mental health.

Primary prevention is preventing psychiatric illness rather than treating it. This is done
by first identifying at risk groups, and then promoting their mental health through
educating them.

Secondary prevention is reducing the number of existing mental illnesses through

screening early diagnosis, prompt treatment and education of signs and symptoms.

Tertiary prevention

- Attempts to reduce the severity of a mental disorder and its associated disability
through rehabilitation activities or

- The prevention of long term disability from chronic and persistent severe mental
illness. Such disability includes poor social integration, aggression, indecent
behaviors, etc.

Psychiatric rehabilitation is the range of social educational, occupational, behavioral

and cognitive interventions used to increase the role performance of persons with
serious and persistent mental illness and to enhance their recovery (Burton, 1999) cited
by Stuart and Sundeen, 2006.

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Protective factors is having sufficient autonomy in order to exercise some control in
response to adversity or adverse events. Psychological support from a spouse, family,
friends and health providers.

Resilience is bouncing back from life’s adversities.

Risk factors are those hazards that, if present for a given individual, make it more likely
for them to develop a disorder. For example, bio-psychosocial factors. Lack of social
support, inability to read, exposure to bullying etc.

Resource - To provide an organization or department with money or equipment, useful

possessions, material and can be human as well.

Concept is a way of doing or perceiving something. A method, plan, or type of design.

9.2 EXPLAIN THE CONCEPT OF COMMUNITY MENTAL HEALTH SERVICES IN

ZAMBIA

In order for us to understand where we are as a country in regard to community mental

health, we need to go back and briefly examine the historical background of community
psychiatry.

Background of community psychiatry

You will remember that in UNIT 1, you covered history of mental health and care of
psychiatric patients. At first mentally ill patients were cared for in large mental hospitals
known as Asylums. This led to large groups of patients getting admitted and cared for in
mental institutions for long periods of time, even years. This led to institutionalism in
which they developed certain behaviours:

Signs of institutionalism

- Dependency

- lack of initiative

- inability to solve problems

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 - not able to make decisions

- Not able to live outside the mental institution

Patients were so dependent that they became helpless and as a result were mistreated
and exploited by the health professionals with minimal information of their condition,
concerning:

- Course

- Prognosis

- Care and treatment was minimal

To put an end to the exploitation of patients who were institutionalized, and improve
quality of care to patients with mental illness, the large hospitals were downsized or
closed. This process led to deinstitutionalization.

Deinstitutionalization

- Instead, mental annexes were opened at general & central hospitals.

- Consequently, people with mental illness were returned to the community to live
there.

- Other reasons for deinstitutionalization included, high costs of institutional care,

discovery of psycho tropics, and civil rights activism.

- People in the community were not prepared for the influx of patients from mental
institutions which led to some undesirable effects.

Effects of deinstitutionalization

- Barriers of social inclusion leading to stigma and prejudice

- Poor social skills eg. inappropriate behaviors in public places such as shops or
restaurants or churches.

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 - Community not ready to receive patients, so they got readmitted into state
hospitals.

- Some other patients fell into the criminal justice system

- Still others became homeless or vagrants.

- In Western countries others were taken into nursing homes, especially the
elderly.

- Families were not prepared for the treatment responsibilities they had to assume.

- This plight of pts led to advocacy efforts and movements by consumers, families,
mental health professionals and other NGOs.

Introduction of community mental health services

- The plight of mentally ill people in the community the world over, was taken into
account during the Alma-Ata International Conference on Primary Health Care in
1978.

- In the following year, community psychiatry was introduced in Zambia.

- Measures were put in place to develop community mental health services

through integration into the existing Primary Health Care system, as proposed at
the conference.

- It was proposed that there should be a mental health component in which

Community Health Workers with support from Neighbourhood Health
Committees and technical guidance from mental health professionals would after
a six week training course:

a) Give mental health education

b) Identify and refer patients or persons with emotional problems, serious mental
illness, epilepsy, learning disabilities and behavioral problems.

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 c) Encourage compliance to medication and keeping of review dates.

d) Encourage acceptance of patients within the community.

e) Collect and compile simple data about mentally ill in the community.

Community mental health services in Zambia today

- The Mental Health Policy of Zambia, which guides the development of Mental
Health Services in the country, outlines the fact that

- Disabilities that result from neurological, mental, and psychosocial disorders shall
be reduced through community rehabilitation.

- To ensure that mental health services are delivered to the community,

- The strategic Plan for 2007-2011 has outlined how service providers are to
deliver services at community level as follows:

a) Conducting public educational programmes to create awareness of mental health

issues.

b) Providing care and support skills to neighborhood health committees through

short courses and supervisory guidance

c) Networking with NGOs with similar interests to promote mental health and
prevent mental health problems in communities. Such NGOs include user and
careers groups.

- To ensure that these services are successfully provided, the Strategic Plan has
put in place measures to ensure that funding for community based mental health
activities is available.

- Currently. The Mental Disorders Act of 1951 is being repealed to pave way for a
new act.

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 - This new Act which is still in the form of a The Mental Health Services Bill, (2006)
sets a clear direction and focus for mental health services outside institutional
settings in the country.

Examples of community mental health services in Zambia

- Home visits

- Mental health corners in PHC clinics,

- Outreach clinics in Matero ref & Chilenje clinics

- Assessment of new cases at UTH clinic 6 and review of old cases as well at
Chainama OPD

- Counseling for emotional, substance abuse problems, mental disorders

9.3 LEVELS OF INTERVENTION IN MENTAL HEALTH

Levels of intervention or acting and taking a definite step to reduce symptoms or keep
mental illness from occurring include mental health promotion, prevention which can be
primary, secondary and tertiary. Promotion and prevention overlap in that prevention is
concerned with avoiding disease while promotion is about improving health and
wellbeing. Promotional activities may therefore be similar to preventive activities.

For example in a community you might facilitate a cooperative for vegetable growing so
that women generate an income for their daily needs and also improve on the nutritional
requirements of their children. By so doing you are promoting good mental health
because they will be relieved of stress. They do not have to go looking for money very
far from home. At the same time using the same activity you are preventing mental
illness developing from unresolved stress that results from poverty and malnutrition.

9.3.1 Mental health promotion

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Mental health promotion is any action taken to maximize mental health and well being
among populations and individuals.

Mental health promotion involves actions to create living conditions and environments
that support mental health and allow people to adopt and maintain healthy lifestyles.
These include a range of actions to increase the chances of more people experiencing
better mental health.

A climate that respects and protects basic civil, political, socio-economic and cultural
rights is fundamental to mental health promotion. Without the security and freedom
provided by these rights, it is very difficult to maintain a high level of mental health.

National mental health policies should not be solely concerned with mental disorders,
but should also recognize and address the broader issues which promote mental health.
This includes mainstreaming mental health promotion into policies and programmes in
government and business sectors including education, labour, justice, transport,
environment, housing, and welfare, as well as the health sector.

Specific ways to promote mental health include:

- early childhood interventions (e.g. home visits for pregnant women, pre-school
psycho-social activities, combined nutritional and psycho-social help for
disadvantaged populations);
- support to children (e.g. skills building programmes, child and youth development
programmes);
- socio-economic empowerment of women (e.g. improving access to education
and microcredit schemes);
- social support for elderly populations (e.g. befriending initiatives, community and
day centres for the aged);
- programmes targeted at vulnerable groups, including minorities, indigenous
people, migrants and people affected by conflicts and disasters (e.g. psycho-
social interventions after disasters);
- mental health promotional activities in schools (e.g. child-friendly schools);

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 - mental health interventions at work (e.g. stress prevention programmes);
- housing policies (e.g. housing improvement);
- violence prevention programmes (e.g. community policing initiatives); and
- community development programmes (e.g. 'Communities That Care' initiatives,
integrated rural development).

9.3.2 PREVENTION

Prevention means keeping a disorder from occurring, in this case preventing mental
illness.

- It is carried out through specific protective measures (promotional activities) and

reducing risk factors in the lives of individuals, families and communities.

- In the community, mental health prevention occurs at three levels: Primary,

secondary and tertiary.

Primary Prevention

Primary prevention involves both mental health promotion (enhancing protective factors)
and prevention of disorders (reducing risk factors) in the lives of individuals.

Promotional and preventive activities in mental health care delivery therefore overlap
and are targeted towards:

- A) Assisting individuals to increasingly cope effectively with stress.

- B) Target and diminish stressors in the environment. This is done through

educating at risk groups in the following ways:

I. Teaching parenting skills and child development to prospective new parents.

II. Teaching physical and psychological effects of alcohol, drugs to primary and
secondary pupils.

III. Teaching techniques of stress management to anyone who desires to learn.

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 IV. Teaching groups of individuals ways to cope with the changes associated
with various maturational changes (adolescence, motherhood, menopause,
retirement) etc

V. Teaching the concepts of mental health to various groups within the

community.

VI. Providing education and support to unemployed or homeless individuals.

9.3.3 SECONDARY PREVENTION (TREATMENT)

It is in the secondary level of prevention that treatment takes place to reduce the
severity of mental illness as follows:

- This is decreasing or reducing the prevalence of psychiatric illness by shortening

the course of the illness. This is accomplished through early identification of
problems and ‘prompt’ initiating of effective treatment.

- Nursing in secondary prevention focus on recognition of symptoms and provision

of a referral for treatment.

- Ongoing assessment of individuals at high risk of mental illness, is done during

home visits, day care, PHC clinics, or any setting where screening of high risk
individuals may occur.

- Provision of care for individuals in whom illness symptoms have been assessed
eg: counseling, medication, support during high levels of stress (crisis
intervention), suicide & child abuse hotlines, rape & victims of domestic violence
drop in centres Eg. Young Women Christian Association[YWCA].

- Referral for investigations and treatment of individual in whom illness symptoms

have been identified.

- The treatment given after referral may include medical and psychiatric
medications, and other types of therapies.

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9.3.4 TERTIARY PREVENTION (REHABILITATION)

- This is the reduction of residual defects that are associated with severe illness
such as loss of social skills, inability to earn a living, side effects of neuroleptics
(drugs used in mental illness), stigma and discrimination.

- Most common illnesses with residual defects are epilepsy and schizophrenia.
This is accomplished in two ways:

1. Preventing complications of the illness.

2. Promoting rehabilitation that is directed towards achievement of each

individual’s maximum level of function.

NURSES’ ROLE IN TERTIARY PREVENTION

Nursing in Tertiary prevention focus on clients to enable them learn or relearn socially
appropriate behaviours; so that they may be able to achieve a satisfying role within the
community. For example:-

- Teaching the client daily living skill

- Encouraging independency his/her inability

- Through social skills training

- Assertiveness training

- Anger management techniques

- Referring clients to various aftercare services after discharge (Matero, Sadzu,

Chilenje etc)

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 - Aftercare homes such as Chawama old people’s home, support groups, and day
treatment programmes

- Monitoring effectiveness of aftercare services through home visits

Consider in what area (or environment of choice) an individual can be rehabilitated in at

the time of initial diagnosis and upon recovery. Such areas may be social, occupational,
and Activities of Daily Leavings, so that the individual can get integrated into the
community.

AFTERCARE

Upon discharge, persons recovering from mental illness need continuing care to prevent
relapse and other complications occurring. Such continuing care ensures that patients
continue to receive support and care upon discharge, in the community. It includes:

1. Regular reviews in the OPD.

2. Home visits, especially if they are unable to come to the OPD for review.

3. Referral to aftercare centres.

Aftercare includes a structured (routine) plan for the following:

1. Relapse prevention

2. Active participation in continuing treatment.

3. Belonging to a self help group.

4. Continued access to the original professional treatment centre as needed.

WHY AFTERCARE IS NECESSARY

1. Patterns that lead to substance abuse are hard to erase such as stresses
associated with abstinence and recovery are reduced.

2. The patient has a daily routine to follow.

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 3. Old companions, and stresses that return are prevented, upon discharge.

4. Aftercare prevents faulty thinking patterns of relying on drugs rather than other
people, of not asking for help, and of not sharing important feelings.

AFTERCARE HOMES

Aftercare homes are hostels were homeless mentally ill people are taken upon
discharge.

In Lusaka there is Matero Aftercare centre for youths, Chawama Aftercare centre for the
elderly.

HALFWAY HOUSES

- Halfway houses are communal living situations that provide an orderly way of
doing things (routine), and support from those recovering from addiction. This
is for those who lack family support and who cannot live on their own.

- A halfway house is located in the community, so that recovering patients can

attend school or work during the day.

- Each evening they return to a supportive environment, for meals and

emotional sustenance.

- The stay ranges from one to four months.

- Halfway houses provide an effective transitional bridge from the therapeutic

inpatient to the outside community.

- In patients who have to attend outpatient treatment it is especially ideal. In

Zambia there is no halfway houses system.

GROUP LIVING – Group living is living with a large group of people or living in the
hospital unit, such as Chainama Hospital.

AFRO-VILLAGE SYSTEM – This consists of a group of villages where patients can

access pychiatric services on a community outreach basis.
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 - It is found in some parts of Africa, but not Zambia.

SELF-HELP GROUPS

Self-help groups are organized and led by patients or ex-patients who have learned
ways of overcoming or adjusting to their difficulties. The other group members benefit
from this experience, from the opportunities to talk about their own problems and
express their feelings and from mutual support. It is important that those who lead such
groups have appropriate training and support, so that they can cope up with group
processes that develop. Other groups have a professional advisor. Examples of self-
help group include:

- Alcohol Anonymous

- Weight watchers

- Groups for people with chronic conditions eg. NPLHA, Mental Health Users
Association etc

- Groups for people facing special problems such as parents with a

handicapped child etc.

9.4 ROLES OF A NURSE IN THE DELIVERY OF MENTAL HEALTH SERVICES IN

THE COMMUNITY

The nurse should approach interventions with flexibility and resourcefulness to meet the
broad range of needs represented in a patient with mental disabilities. The following
roles have been identified for nurses working in community health services:-

1. Consultative role – Giving advice to other professionals in the community about

the type and level of nursing care required for given client groups.

2. Clinical role – Providing direct nursing care to the patients in the community
through home visits.

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 3. Therapeutic role – Employing psychotherapeutic and behavioral methods for
management of patients.

4. Assessor / Researcher – The nurse may assess the care given to clients and may
also assess the outcome of ongoing care programmes.

5. Educator – Creating awareness in the community about mental health and mental
illness with special focus on vulnerable groups

6. Trainer / facilitator – Training of other professional community leaders, school

teachers and other care giving professionals in the community.

7. Manager/Administration – Manager of the resources, planning and co-ordination.

8. Liaison role

– Nurses working in the community help clients and their families by bridging the gap
between the client and the hospital.

- Nurses also network (link up with or connect to) with NGOs and other resources
in the community to meet the needs of patients.

- They link patients to various institutions.

9. Advocacy – Nurses speak out for the rights and interests of clients in the
community by raising awareness of clients’ needs in places of employment,
school and markets.

- This they do by sensitizing the public, NGOs, policy makers and service
providers on the plight of clients.

10. Preventive roles as earlier seen, under primary, secondary and tertiary
levels.

HOMEVISITS

- Follow up visits are important for a patient who has been discharged.

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 - They can also be conducted to assess the home environment before discharge.

- They are important because:-

1. You can get to meet and know other family members.

2. It reduces the number of readmissions.

3. It helps in the drug monitoring and compliance.

4. It provides H/E to the client & family members.

5. It allows the nurse to see if the patient is able to apply social skills taught.

6. Helps the nurse assess whether the patient is able to carry out the Activities of
Daily Living (ADLs).

7. Enables the nurse give family therapy as well as the community. By so doing it
reduces stigma.

8. Makes the patient feel cared for.

9. It educates the family members to cope with the disease of the patient.

Conclusion

Where mental health care was practiced changed from the mental health institutions to
the community in the 20th Century. This development resulted from deinstitutionalization
of patients that had become institutionalized in mental hospitals.

In Zambia, despite the structure of comprehensive health services being available, for
integration, some barriers still have to be overcome to integrate mental health into PHC
services. To overcome these barriers, a new Mental Health Services Bill, currently
under debate will bring about improvement of care of patients in the community
because it clearly directs delivery of mental health services in the community.

There are 3 levels of intervention in mental health care in the community. They are
primary, secondary and tertiary interventions. In all the 3 levels the nurses play various

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roles in delivering mental health care in the community. The roles include the following:
Consultative, clinical, therapeutic, assessor/researcher, educator, trainer / facilitator,
liason, advocacy, manager / administrator.

UNIT 10: ADVOCACY

GENERAL OBJECTIVE

Welcome once again to this interesting topic[ADVOCACY IN PSYCHIATRY NURSING].Here

we shall define Advocacy,Principles of advocacy,Nurses rights and patients right in advocacy,
community participation and partnership and vulnerable populations.

SPECIFIC OBJECTIVE

a. Definition and Principles of advocacy

b. Nurses and Patients rights

c. Community participation and partnership

d. Vulnerable populations

10.1 ADVOCACY- is commonly understood to mean speaking, pleading or interceding

for someone else. ‘In relation to people with mental health problems or learning
difficulties, it has the rather different meaning of helping people to be heard, and
ensuring that what they say influences the decisions of clinical staff’ (Royal College of
Psychiatrists 1999: p. 6).

Who is an advocate- An advocate is someone who can both listen to you and speak for you
in times of need.

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Why advocacy:

Having a mental health problem, or experiencing mental distress, often means that your
opinions and ideas are not taken seriously, or that you are not offered the opportunities and
choices you would like. Being labeled with a diagnosis of mental illness is often linked to
poverty, unemployment and exclusion from everyday life. In its simplest form, advocacy can
mean just listening respectfully to someone.

10.1Principles of Advocacy

Advocacy is a process of supporting and enabling people to:

• express their views and concerns

• access information and services

• defend and promote their rights and responsibilities

• explore choices and options.

Advocacy gaols:

Problem Solving
•Empowering Complainants
• Promoting the Healing Process

Characteristic of Advocacy

• Empowering and representation

• Independent advocates-express their partner view without prejudice to themselves.

• Inclusive-everyone should be able to access an advocate.

• Impartial- must not judge their partner

• Confidential-must keep information shared secret.

• Free advocacy services –must be free to the recipient

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 Types of Advocacy

Self-advocacy

• Self-advocacy is about speaking up for yourself and making your views and wishes clear.
Most local user and survivor groups promote and include self-advocacy.

• Group advocacy

Group advocacy (also known as collective advocacy) is where a group of people with
similar experiences meet together to put forward shared views. Local mental health service-
user groups, support groups and patient councils are all examples of group advocacy.

Peer advocacy-

is support from someone with experience of using mental health services. Peer advocates
can draw on their own experiences to understand and empathise with the person they are
working with. Working with a peer advocate makes it easier for advocate and user to have an
equal relationship. Some peer advocates and advocacy schemes work on an entirely
voluntary basis, but the majority are now funded user- and survivor-run schemes with paid
workers.

Formal, professional, or paid advocacy

Many voluntary organisations have developed advocacy services, which train and pay
some or all of the advocates to work with anyone who wants to use their service. Although
not always the case, this kind of advocacy is usually focused on short-term or ‘crisis’ work,
rather than providing long-term support. Many of the advocates working for formal advocacy
services are also users and survivors.

• Citizen advocacy

Citizen advocacy matches people with partners who are members of their local
community. Citizen advocacy partnerships tend to be long-term, supportive relationships.
Most citizen advocacy schemes have paid coordinators, who train and support unpaid
volunteer partners. As well as helping with specific situations, citizen advocacy partnerships

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are intended to support vulnerable people so that they can take a greaterpart in the life of
their community

• Legal advocacy

People with specialist knowledge and training, such as lawyers and advice workers, are
sometimes called ‘legal advocates’. Legal advocates differ from other mental health
advocates in that they represent people in formal settings, such as courts, tribunals or

complaints processes. A legal advocate will often give advice and express their opinion about
the best course of action.

b. Nurses and clients rights

Nurses rights

The International Council of Nurses’ (ICN) Code of Ethics also includes a central role
for advocacy. As with the definition offered by Benner, the role of collaboration with
patients, other healthcare providers, and society is evident in these statements from the
ICN Code of Ethics for Nurses:

• In providing care, the nurse promotes an environment in which the human rights, values,
customs and spiritual beliefs of the individual, family and community are respected.

The Code of Ethics describes the responsibility of the nurse to work through appropriate
channels to address concerns about the healthcare environment. In addition, the Code of
Ethics identifies a range of advocacy skills and activities that nurses are expected to
demonstrate. These activities promote the profession and form the basis of the advocacy role
for the professional nurse.

• The skills include service to the profession through teaching, mentoring, peer review,
involvement in professional associations, community service, and knowledge
development/dissemination (ANA, 2001). These activities and skills form the basis of
advocacy role of the professional nurse.

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 • The nurse ensures that the individual receives sufficient information on which to base
consent for care and related treatment.

• The nurse shares with society the responsibility for initiating and supporting action to
meet the health and social needs of the public, in particular those of vulnerable
populations.

Clients rights

Advocacy under the Mental Capacity Act 2005The Mental Capacity Act 2005 applies to people
who lack themental capacity to make a particular decision. The Act statesthat in certain
situations, an Independent Mental CapacityAdvocate (IMCA) must be appointed to help people
who lackcapacity to make a decision and have no one else to speak ontheir behalf. This could
happen when an NHS body wants toprovide ‘serious medical treatment’ or there are plans
toprovide the person with long-term accommodation in hospital or a care home.

This includes people who have been detained under the MHA for longer than 72 hours, such as
those under sections 2 and 3, and people living in the community under Mental Health Act
guardianship, conditional discharge and supervised community treatment. Others who are not
‘qualifying patients’ but who are receiving treatment in hospital for mental health problems may
also be entitled to IMHA support if they are considering certain treatments under the MHA, such
as neurosurgery and electro convulsive therapy. The experience of an in-patient admission,
whether voluntary or under a section of the Mental Health Act (MHA), can be confusing and
disempowering. Exercising your right to be informed and involved in your own care and
treatment is difficult when you are distressed or when your views may be discounted as part of
your ‘illness’. In hospital, an advocate will help you get information about your legal rights, your
medication or discharge plans.

10.3 Community participation and partnership

In the community, an advocate might assist you with a benefit claim, finding the right
housing, or getting the community care services you want. An advocate can provide support

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if you want to complain about services you are not happy with. They might also help you
find out about work, education or leisure opportunities in your area.

.10.4 Vulnerable Populations

Vulnerable populations are groups that are not well integrated into the health care
system because of ethnic, cultural, economic, geographic, or health characteristics. This
isolation puts members of these groups at risk for not obtaining necessary medical care,
and thus constitutes a potential threat to their health. Commonly cited examples of
vulnerable populations include racial and ethnic minorities, the rural and urban poor,
undocumented immigrants, and people with disabilities or multiple chronic conditions.

Health Domains of Vulnerable Populations

The health domains of vulnerable populations can be divided into 3 categories: physical,
psychological, and social.

Physical domain:

• Those with physical needs include high-risk mothers and infants, the chronically ill and
disabled, and persons living with HIV/acquired immunodeficiency syndrome.4 Chronic
medical conditions include respiratory diseases, diabetes, hypertension, dyslipidemia, and
heart disease.

• Psychological domain:

• In the psychological domain, vulnerable populations include those with chronic mental
conditions, such as schizophrenia, bipolar disorder, major depression, and attention-
deficit/hyperactivity disorder, as well as those with a history of alcohol and/or substance
abuse and those who are suicidal or prone to homelessness.

• Social domain

In the social realm, vulnerable populations include those living in abusive families, the
homeless, immigrants, and refugees

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• Conclusion

Every nurse in every setting has the opportunity to make a positive impact on the
profession through advocating daily for nurses and the nursing profession. It is an
exciting time to be a nurse. Healthcare is changing and the role and practice of the
professional nurse is changing along with it. Advocacy skills are becoming increasingly
important in this ever-changing world.

Opportunities abound for point-of-care nurses to advocate both for nurses and for the
profession. Point-of-care nurses have an opportunity to build on their public image of being
the most trusted profession by communicating and advocating for a more accurate view of
their contributions to healthcare and society.

• Managers and administrators work daily, advocating to obtain adequate resources for
their nursing staff and to promote positive work environments. Nurse educators play a
critical role in preparing nurses to strengthen the profession through advocacy. Every
nurse in every setting has the opportunity to make a positive impact on the profession
through advocating daily for nurses and the nursing profession.

Further reading

• Advocating Globally to Shape Policy and Strengthen Nursing’s Influence

David Benton, BSc, MSc, MPhil, RGN, RMN, FRCN (January 31, 2012)

• Patient Advocacy in the Community and Legislative Arena

Mary A. Maryland, PhD, MSN, APN-BC; Rose Iris Gonzalez, PhD, RN (January 31,
2012)

• Role of Professional Organizations in Advocating for the Nursing Profession

Jennifer H. Matthews, PhD, RN, A-CNS, CNE, FAAN (January 31, 2012)

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 • The Voice of Florence Nightingale on Advocacy
Louise C. Selanders, RN, EdD, FAAN; Patrick C. Crane, MSN, RN (January 31, 2012)
• Author. (2009). Advocacy. (2009a). Merriam-Webster collegiate dictionary (11th ed).
Springfield, MA: Merriman-Webster Incorporated.
• Author. (2009). Influence. (2009b). Merriam-Webster collegiate dictionary (11th ed).
Springfield, MA: Merriman-Webster Incorporated.
• Alliance for Justice. (nd). What is advocacy? Definitions and examples. Retrieved May
13,2011, from www.aji.org/for-non-profits-foundations/advocacy
• Almidei, N. (2010). So you want to make a difference: Advocacy is the key. (16th ed.)
Washington DC: OMB Watch.
• American Nurses Association. (2001). Code of ethics for nurses with interpretive
statements. Silver Spring, MD: Nursesbooks.org.
• American Nurses Association. (2010). Scope and standards of practice (2nd ed.). Silver
Spring, MD: Nursesbooks.org.

SELF TEST

MULTIPLE CHOICE QUESTIONS

ENCIRCLE THE LETTER WHICH CORRESPONDS TO THE BEST RESPONSE

1. Primary prevention is when:

a. Treatment is given to reduce severity of mental illness.

b. Education is given to at risk groups.

c. Measures to reduce residual effects of severe mental illness are undertaken.

d. Health and wellbeing of individuals is improved.

2. Secondary prevention is:

a. Treatment is given to reduce severity of mental illness.

b. Education is given to at risk groups.

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 c. Measures to reduce residual effects of severe mental illness are undertaken.

d. Health and wellbeing of individuals is improved.

3. Tertiary prevention is:

a. Treatment is given to reduce severity of mental illness.

b. Education is given to at risk groups.

c. Measures to reduce residual effects of severe mental illness are undertaken.

d. Health and wellbeing of individuals is improved.

4. Deinstitutionalization is:

a. Actions that foster good mental health

b. When people with mental illness are treated in the ward

c. Passive dependent behavior.

d. Transfer of patients from a hospital to the community.

5. Institutionalism is:

a. Actions that foster good mental health

b. When people with mental illness are treated in the ward

c. Passive dependent behavior.

d. Transfer of patients from a hospital to the community.

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6. Mental Health Promotion is:

a. Actions that foster good mental health

b. When people with mental illness are treated in the ward

c. Passive dependent behavior.

d. Transfer of patients from a hospital to the community.

ANSWER

1] B 2] A 3] C 4] D 5] C 6 ]A

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