CHILD AND ADOLESCENT PSYCHIATRIC DISORDERS
Some people face various psychiatric problems in child and adolescent.
These problems can be due to factors like development, mongolism or mental retardation, lack of prenatal, natal and postnatal care.
Nutritional factors or physical disease or brain damage can lead to mental disorders.
Psychiatric Factor: Difficulty in adapting to interpersonal relationships, personality traits, environmental changes, all these factors affect the nature of a person.
Environmental changes are the main cause of behavior disorder in children.
Various developmental, disruptive, anxiety and eating disorders and sleeping and sexual disorders are seen in this age.
DEVELOPMENTAL DISORDERS
Developmental disorders include mental retardation (MR), pervasive developmental disorders, and specific developmental disorders.
MENTAL RETARDATION
Mental retardation is called intellectual disability. It causes loss of intellectual function and adaptive behavior of a person. It affects daily social and functional skills. Mental retardation also causes loss of thinking, learning, social and occupational function. Patient’s IQ level is 70. is less than
Mental retardation is most common in boys than girls.
CAUSES OF MENTAL RETARDATION
Genetic factors
Chromosomal Abnormalities
Down’s syndromes
Fragile X syndrome
Trisomy X syndrome
Turner syndrome
Cat-cry syndrome
Prader-Willi syndrome
•Cranial malformation
Hydrocephalus
Phenylketonuria
Wilson’s disease
Galactosemia
•Gross brain disease
Tuberous sclerosis
Neurofibromatosis
Epilepsy
Pre-natal factors:
Rubella
Cytomegalovirus
Syphilis
Toxoplasmosis
Herpes simplex
•Endocrine factors
Hypothyroidism
Hypoparathyroidism
Diabetes mellitus
•Physical damage and disorders
Injury
hypoxia
radiation
Hypertension
Anemia
Emphysema
Toxemia in Toxemia
Placenta previa
Cord prolapse
Nutritional growth retardation
Peri-natal factors:
Birth asphyxia
Difficult birth
Prematurity
Kernicterus
Postnatal factors:
Encephalitis
measles (measles)
Pertussis
Meningitis
Septicemia
•lead poisoning
Environmental and socio-cultural factors:
Cultural Deprivation
Low Socio Economic States
Child abuse
CLASSIFICATION OF MENTAL RETARDATION
(1).Mild mental retardation (IQ 50-70).
It is the most common type of mental disorder. 80-85% of MR patients belong to this group. Motor and sensory deficits are slight.
Language and social behavior develop normally. Can achieve academic level of 6 to 8 standard.
(2). Moderate mental retardation (IQ 35-50)
10% of mentally retarded patients fall into this category. They can work and perform self-care tasks with moderate supervision.
They usually acquire communication skills in childhood and are able to live and work successfully in groups, communities.
(3). Severe mental retardation (IQ 20-35)
Severe mental retardation is recognized early in life with poor motor development and absent or delayed speech and communication skills.
(4). Profound mental retardation (IQ below 20)
This group constitutes 1-2% of all mentally retarded. Developmental milestones not achieved require constant nursing care and monitoring.
CLINICAL FEATURES OF MENTAL RETARDATION
Developmental milestones not achieved.
Cognitive function loss
Intellectual development markers are not achieved
Learning Disability
Psychomotor skills deficit
Difficulty performing self-esteem
Depression
Language development does not happen
DIAGNOSIS OF MENTAL RETARDATION
History Collection
Collect history from relatives and care-takers, collect comprehensive history of patient.
Physical Examination
Examining the patient from head to toe and assessing abnormalities.
Neurological examination
Perform a neurological examination to examine the nervous system.
MSE (Mental States Examination)
It often helps to begin the interview with the patient’s strengths and areas of interest rather than problems.
Milestone Development Assessment
Conducting Milestone Development Assessment of the child so that information is obtained whether their development is delayed or not.
Investigation
Urine and blood examination (for metabolic disorders)
Amniocentesis (for chromosomal disorders of the infant)
Creatine kinase
Very long chain fatty acids (for peroxisomal disorders)
Hearing and Speech Evaluation
EEG (when seizures are present)
Imaging studies
•CT Scan
•Brain MRI
Psychological tests
•Stanford Binet Intelligence Scale
•Wechsler Intelligence Scale (WISC)
•Bailey Scales of Infant Development
TREATMENT MODALITIES
Behavior Management
environmental supervision
Child development needs and problems should be monitored.
Programs that maximize speech, language, cognitive, psychomotor, social, self-care and occupational skills.
Conduct ongoing evaluation for overlapping psychiatric conditions such as depression, bipolar disorder, and ADHD.
Family therapy helps parents develop coping skills and deal with guilt or anger.
Early intervention programs should be conducted for children younger than 3 years with mental retardation.
NURSING MANAGEMENT OF MENTAL RETARDATION
Common Nursing Diagnoses of Mental Retardation
Impaired verbal communication
Altered Growth and Development
Self-care deficit
Impaired social interaction
Ineffective Coping
Impaired Health Maintenance
Impaired Verbal Communication:
Consistency should be maintained in staff assignment.
Free and open communication with patients and relatives.
The client’s needs must be met until a satisfactory communication pattern is established.
Look at the words the client speaks and also assess whether they differ from the norms or not.
Identify non-verbal gestures or signals that can be used to convey the client’s needs if the client is unable to communicate verbally.
Child’s growth and development should be assessed at regular intervals.
Helping the family to set realistic goals for the child.
Early infant stimulation programs should involve family members.
To anchor the child to learn self-care activities.
Balance diet and nutrition should be provided.
•Self care deficit
Aspects of self-care that may be within the client’s capacity should be identified.
Work on one aspect of self-care at a time.
Provide simple, concrete explanations and positive feedback for effort.
When improvement is achieved in one aspect of self-care, move on to another aspect and increase the client’s independence.
Be with the client during interactions with others on the unit.
Explaining to other clients the meaning behind some of the client’s non-verbal gestures and signals.
Use simple language to explain to the client what type of behavior is acceptable and what type of behavior is not acceptable.
Establishing a process for correcting behavior by providing positive feedback for appropriate behavior and negative reinforcement for inappropriate behavior.
PREVENTION OF MENTAL RETARDATION
•Primary Prevention
Good antenatal, intranatal and postnatal care.
Improvement in the socio-economic condition of the community.
Public Education.
Genetic counseling for patients at risk.
Screening for syphilis and AIDS.
Vaccination of girls with rubella vaccine.
Prevention measures should be taken to reduce child abuse, road traffic accidents and home accidents.
•Secondary prevention
Prove rapid detection and treatment of preventable disorders.
Amniocentesis and MTP(Medical Termination of Pregnancy).
Rapid detection of diseases that can be corrected.
Preventing further damage to impaired children.
Physical and psychological treatment through medicine and behavior modification.
Hospitalization and custodial care of people with severe mental retardation or psychological problems.
Educate and train mentally retarded persons to avoid handicap.
Planning for mental retarded child according to their problems and capacity.
PERVASIVE DEVELOPMENTAL DISORDERS (PDD)
PDD is a group of disorders in which the development of communication skills and socialization is delayed.
CLASSIFICATION OF PDD
(Classification of PDA)
Autism
Asperger syndrome
Rett Syndrome
PDD-NOS (Pervasive Developmental Disorder-Not Otherwise Specified)
CDD (Childhood Disintegrative Disorders)
AUTISM OR AUTISTIC DISORDERS
Autism is a developmental disorder that affects areas of the brain in which communication and social skills are impaired and restricted and repetitive behaviors are observed. It shows abnormal development that occurs before the age of 3 years.
CAUSES OF AUTISM
Genetics: Autism can be caused by genetic factors.
Neurological : Brain structure abnormalities
Developmental problems: Postnatal neurological infections
Perinatal factors: Maternal bleeding and drug side effects
Parental factor : Parental rejection, parental stress.
Environmental factors: Smoking, alcohol, infectious diseases, pesticides etc.
Congenital rubella.
EARLY SIGNS OF AUTISM
Do not have eye contact
Social withdrawal
Learning Difficulty
Inappropriate laughing
CLINICAL FEATURES
Speech difficulty
Inappropriate laughing or crying
Oversensitive
Play with toys inappropriately.
MANAGEMENT OF AUTISM
Social education programs and early intervention will increase the child’s learning and communication capacity and improve relationships.
Severity of disruptive behavior should be reduced.
Stimulants such as smethylphenidate reduce impulsivity and overactivity in some children when no other drugs are effective for the treatment of autism.
SSRI antidepressants are useful for managing irritability, compulsive behavior, and withdrawal.
Family counseling helps to better understand the disorder.
NURSING MANAGEMENT OF AUTISM
Use words carefully when talking to a verbal autistic child.
Advise parents to have close, face-to-face contact with the child to promote communication.
Teach parents a daily routine, including proper times for waking up, getting dressed, eating, and attending school.
Suggest parents use a picture board showing activities during the day to help the child transition more.
ASPERGER’S SYNDROME
Asperger’s syndrome is a neurological-developmental disorder that affects a person’s behavior, use of language and communication, and social interaction. In this, the person laughs without reason and does not fear.
In this syndrome, a person focuses on one topic and repeats the same behavior over and over again. It is more likely to occur in boys than in girls.
Asperger’s syndrome does not have a specific cause but may be caused by genetic factors.
Social skills training, language-speech therapy, cognitive behavioral therapy, parent education training are effective for management.
RETT’S SYNDROME
Rett’s syndrome is a neurodevelopmental disorder, which occurs almost exclusively in females. This disorder was first described by Australian pediatrician Andreas Rett.
In this condition, purposeful movement of the hand like touching, grasping etc. is lost, and speech loss is also seen.
While Rett’s syndrome cannot be cured, medications such as carbamazepine and levodopa are useful.
CHILDHOOD DISINTEGRATIVE DISORDERS (CDD) CHILDHOOD DISINTEGRATIVE DISORDERS
Called Heller syndrome, language, motor skills and social functions do not develop properly. It is more common in girls than boys.
No specific cause of CDD has been found.
SPECIFIC DEVELOPMENTAL DISORDER OF SPEECH AND LANGUAGE
SPEECH DISORDERS
STUTTERING
It involves frequent repetition of syllabus or words by the person with hesitation and halting. This disorder occurs in about 1 percent of children. It is also called stammering.
LISPS
There are many types of speech impediments called sigmatisms.
CAUSES OF SPEECH AND LANGUAGE DISORDERS
Brain Injury
Neurological disorders
Hearing loss
Mental retardation
Drug abuse
Child abuse
TREATMENT OF SPEECH AND LANGUAGE DISORDERS
Psychotherapy
Speech therapy
Special Education
LANGUAGE DISORDERS
EXPRESSIVE APHASIA
The ability to produce language is lost, with the person unable to speak or write.
RECEPTIVE APHASIA
In it, the person cannot speak meaningful words, it is also called Wernix’s aphasia. Which is caused by damage to the vernix area of the brain.
INFANTILE ACQUIRED APHASIA
It has aphasia with convulsants, it is a very rare condition.
TREATMENT OF LANGUAGE DISORDERS
Speech therapy
Pharmacotherapy
•Cholinergic drugs : Donepezil, Aniracetam
DISRUPTIVE BEHAVIOR DISORSERS
ADHD (ATTENTION-DEFICIT HYPERACTIVITY DISORDERS). (Attention Deficit Hyperactivity Disorder)
ADHD is a neurobehavioral developmental disorder that is a childhood disorder characterized by attention deficit and hyperactivity disorder. ADHD patients have impulsive behavior.
Lacks attention in school work and play activities, acts before thinking and is very active.
ETIOLOGY OF ADHD
Genetics: Siblings are more likely to have ADHD and identical twins are more likely to have ADHD.
Neurotransmitters: Low levels of dopamine (leading to hyperactivity and low levels of norepinephrine (inattention).
Perinatal Factors: Smoking and alcohol use during pregnancy.
•lead exposure
•Birth complications
Psycho-social factor
•Family pattern abnormalities
•Maternal mental disorders
Alcoholism (parents)
CLINICAL FEATURES OF AUTISM
Poor attention
Inability to complete tasks
•Easily distracted
•Problems with organization
Hyperactivity and Impulsivity
•Physical or verbal activity
•Start answering before the question is finished.
•Always seem to be on the go.
MANAGEMENT OF ADHD
Pharmacological treatment is the first line treatment for ADHD.
Stimulants: Stimulants will reduce hyperactivity and impulsivity. Amphetamines and methylphenidate.
Non-stimulants: bupropion and atomoxetine
Antidepressants : Imipramine
•Behavioral therapy: Behavior patterns can be changed by identifying the child’s home and school environment and giving clear direction and commands.
•Alternatives therapy: occupation, diet manipulation, body treatment, allergy treatment, attention training and visual training etc.
•Special Education : Providing special education when required.
•Social skills training: Social skills training is effective.
Creating a clear schedule and maintaining a routine.
Make sure to give instructions and explain them in simple words.
More and more surveillance
Maintain communication with the child’s teacher.
Family counseling can be helpful.
NURSING CARE OF PATIENT WITH ADHD
A safe environment should be provided
Developing trusting relationship with child and parent.
Reducing anxiety through verbal intervention.
Do not keep harmful things around the child.
Using behavior modification techniques to change behavior.
Providing Adequate Supervision and Help.
Allowing the child to express his emotions and feelings.
Explaining positive parenting techniques to parents or family members.
Parents should maintain communication with child’s teachers.
Referred to another guidance clinic for further help and counselling.
Child’s deliberate behavior should be identified.
CONDUCT DISORDERS
Conduct disorders are severe emotional and behavioral disorders in which the child does not follow society and violent behavior is observed.
CAUSES OF CONDUCT DISORDERS
Genetics factor
Organic Factors (Brain Damage)
Biochemical factor
Psychosocial factors
Child abuse
Family conflict
Drug, alcohol abuse -parents
poverty
SYMPTOMS OF CONDUCT DISORDERS
Bullying others
Committing Rep
Harming other people
To use weapon
robbery
Lying
breaking and entering
Destroying property
Skip school
Drug, alcohol intake
Sexual Behavior
fight
TREATMENT MODALITIES
Medication
•Anticonvulsant
Psychotherapy
Guidance and counselling
Social Skills Training
•Role playing
•Behavior modification
LEARNING DISORDERS
DYSLEXIA
It is a learning disorder in which there is difficulty in reading and spelling. Slow reading and slow speech are seen in it. Dyslexia has normal vision and normal intelligence.
DYSCALCULIA
Dyscalculia is a learning disorder. The ability to calculate is lost in it. Mathematical ability is lost in it. Which is seen in organic brain syndrome.
DYSGRAPHIA
Dysgraphia is a learning disability in which there is difficulty in writing such as handwriting, poor spelling and difficulty in selecting correct words. Dysgraphia can affect both children and adults.
CAUSES
Genetics: If learning disability runs in one family, other members are likely to have it.
Pregnancy and birth problems: Injuries during child birth or after birth can also cause learning disabilities.
•Alcohol, drug abuse
After Birth:
•Nutritional deprivation
•Toxic substances
MANAGEMENT
A preventive approach to instruction in handwriting, spelling, and composition for children who already have reading difficulties is effective in improving these children’s spelling and reading abilities.
Speech therapy, occupational therapy and behavioral therapy are effective.
Some medications are also given to relieve symptoms.
Parents and teachers should support, train and communicate with the child.
Provide psychological support and teach coping strategies.
TIC DISORDERS
Involuntary, abnormal and sudden and frequent contractions of face, throat and shoulder muscles such as eye blinking, frequent shoulder raising etc. are seen in tic disorder. It is more common in males.
CAUSES OF TIC DISORDERS
Idiopathic (exact cause not known)
Neurogenic: Dopamine levels are elevated due to stress and sleep pattern abnormalities
CLASSIFICATION OF TIC DISORDERS
Motor tics
Verbal tics
Motor tics
DIAGNOSTIC EVALUATION
Medical history
Neurological history
Physical Examination
TREATMENT OF TIC DISORDERS
Drug therapy:
•Antipsychotic : Haloperidol
•Antihypertensive : Clonidine
Psychotherapy:
•CBT : Cognitive Behavioral Therapy
•Family therapy
•Counseling
•Relaxation technique
SEPARATION ANXIETY DISORDERS (SAD)
When a child is separated from a parent or caregiver, it cries and becomes distressed. The child has an emotional attachment with the parent and when separated, the child has excessive anxiety.
SIGN AND SYMPTOMS
Anxiety
Depression
fear
Nightmare
Palpitation
Rapid breathing
MANAGEMENT OF SAD
CBT (Cognitive Behavioral Therapy)
Play therapy
Family therapy
Relaxation technique
Teachers Training
Parental counselling
SELECTIVE MUTISM
Selective mutism is an anxiety disorder in which a person is unable to speak in certain social situations, such as not communicating with classmates or relatives at school. It usually begins in childhood and, if untreated, into adulthood. can stay
CAUSES OF SELECTIVE MUTISM
•Anxiety disorders
•poor family relationship
•Self esteem problems
MANAGEMENT OF MUTISM
Pharmacologic treatment
•SSRIs antidepressants
•Antianxiolytic medicine
therapy
•Family therapy
•Individual psychotherapy
•Teachers Training
ELIMINATION DISORDERS
elimination disorders)
ENURESIS
Involuntary urination is seen in children up to the age of 5 years without any physical abnormality, which is also called bedwetting. Bedwetting occurs 2-3 times every week for 3 months continuously.
CAUSES OF ENURESIS
Idiopathic (exact cause not known)
Genetics factor
Psychiatric disorders
Psychosocial Factors: Emotional disturbance, parent’s death, sibling rivalry (sibling conflict), anxiety, depression, school phobia
A stressful life event
Family Problems: Broken Family, Disturbed Family,
Small bladder capacity
UTI (Urinary Tract Infection)
Improper toilet training
Diabetes mellitus
Neurological disorders
Sleep problems
MANAGEMENT OF ENURESIS
Tricyclic antidepressants: Imipramine (25/75mg/day)
Parental Counseling and Minimizing Handicap
Using psychotherapy and behavioral modification techniques etc
Assessment of enuresis by appropriate history collection and examination.
Provide daytime bladder training and increase bladder holding time.
Before doing bedwetting, the child should be awakened from sleep and aware for urination.
In nocturnal enuresis, fluid restriction should be maintained after 8 pm.
A conditioning device, which causes an alarm to sound as soon as urine touches the bedsheet. It is important to check the child’s hearing before star ting treatment. If used properly, it is an effective method of treatment.
ENCOPRESIS
Encopresis is the process of involuntarily faeces anytime and anywhere, despite physiologically possible bowel control.
Toilet training is achieved by the age of 2-3 years but this condition is seen after the age of 4 years.
CAUSES OF ENCOPRESIS
Genetic factors
Improper toilet training
Mental retardation
Sibling Rivalry
Spinal cord injury
Childhood schizophrenia
Autistic Disorder.
Hyperkinetic disorder
Laxative drug abuse
Separation anxiety
MANAGEMENT OF ENCOPRESIS
•Pharmacological management
Bowel wash and/or enema should be given initially if required.
A prescription benzodiazepine
Bulking agents such as lactulose
Suppositories
therapy
Behavioral techniques
Individual psychotherapy
Family therapy
Parents Counseling
NURSING MANAGEMENT Nursing Management
The best treatment of encopresis is prevention. Toilet training should be made as consistent and easy as possible.
Family environment should be warm and understanding.
A child’s emotional disturbance should not be ignored and should be dealt with at the earliest.
There should be direct communication between family members and reduce family stress and tension.
Educating the parents about the child’s maturation process.
Helping with individual psychotherapy and asking parents not to blame the child.
SLEEP, EATING AND SEXUAL DISORDERS (Sleep, eating and sexual disorders).
EATING DISORDERS
An eating disorder is a psychological disorder characterized by abnormal eating habits such as inadequate food intake or excessive food intake that harms a person’s physical and emotional health. Eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder. is
CAUSES OF EATING DISORDERS
Eating disorders can be caused by biological, psychological and environmental reasons.
Genetic factor:-
Some studies suggest that eating disorders can be caused by genetic factors.
Biochemical:-
Eating behavior is a complex process controlled by the neuro-endocrine system of which the neuro-endocrine pituitary adrenal axis (HPA axis) is a major component. De-regulation of the HPA axis associated with eating disorders may be due to irregularities in the manufacture, amount and transmission of neurotransmitters, hormones or neuropeptides such as serotonin, norepinephrine and dopamine etc.
Leptin and Ghrelin
The circulating level of both these hormones is an important factor for weight control. Both these hormones are associated with obesity. Effects are seen in the pathophysiology of anorexia nervosa and bulimia nervosa.
immune system
According to the study, many patients with anorexia nervosa and bulimia nervosa have elevated levels of autoantibodies, which affect hormones and neuropeptides that regulate appetite control and stress response.
infection
A pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection, which can cause anorexia nervosa to develop.
Lesions and tumors
According to the study, a lesion on the right frontal lobe or temporal lobe indicates the pathological symptoms of an eating disorder. A tumor in the brain region suggests an abnormal eating pattern.
Brain calcification
Anorexia nervosa can occur due to calcification i.e. calcium deposits in the right thalamus.
Obstetric complications
-Maternal anemia (anemia during pregnancy)
-Pre-term birth (baby born before 32 weeks)
a) Child Maltreatment
Child maltreatment, which includes physical, psychological and sexual abuse, studies show that child maltreatment causes a variety of psychiatric disorders, including eating disorders.)
b) Social isolation
In social isolation, a person feels isolated from society and can be stressful, depressed and anxious. In an attempt to correct this stressful feeling, the person engages in emotional eating. In which food works as a source of comfort.
c) Parental influence
-Family genetic factor
-Dietary choice depends on culture
-Eating Patterns
-Interpersonal relationship of parent and child
-Parental pressure.
d) Peer pressure
Peer pressure is a contributor to body image concerns and attitudes toward eating in their teens and early twenties.
e)Cultural pressure –
“Cultural pressure on thinness, which is high in Western society. The ideal body type is portrayed by media, fashion and the entertainment industry.” Cultural pressure on women to be thin is an important factor in eating disorders.
ANOREXIA NERVOSA (anorexia nervosa)
DEFINITION
Anorexia nervosa involves an aversion to food that leads to starvation and emaciation.
causes. There is fear of gaining weight, so the person intakes inadequate food and loses weight. It is a serious illness. It is more common in females after puberty.
ETIOLOGY
•Genetic factor: It is more common in monozygotic twins.
•Biochemical factor: Hypothalamic function may be disturbed.
•Psychological Factors: Childhood personality traits that cause eating disorders.
•Social factor: Thinness (thinness) is also a reason for developing anorexia nervosa.
•Other Factors: Modelling, Ballet Dance, Long Distance Runners etc.
TYPES
1) Restricting type:
In it, a person eats less and does excessive exercise, fasting and dieting.
Purge Type:
Sometimes a person self-induces vomiting after eating too much, and misuses diuretic and laxative medicines.
CLINICAL FEATURES
Weight loss
Insomnia
Hypothermia
Russell’s sign (vomiting with fingers in mouth).
Soft hair in body
Bone thinning (osteopenia or osteoporosis)
Brittle hair
Nail biting (common)
Refuse eating
Dry and yellow skin
Mild anemia
Muscle weakness
Eating and after vomiting
Swallow Cheeks
Low libido
Constipation
Low blood pressure
Lethargy
irritation
DIAGNOSTIC TEST
History Collection
Physical Examination
ECG
Blood test
Hormone test
MANAGEMENT OF ANOREXIA NERVOSA
Hospitalization:
The patient is severely underweight and at physical risk
He needs to be hospitalized, so that his weight can be restored. Recovery in severe condition may take 5-6 years.
Antipsychotic drug:
The antipsychotic drug haloperidol is used to treat anorexia nervosa.
Antidepressants Drug:
The antidepressant drug imipramine is used for the treatment of anorexia nervosa.
Appetite stimulants are used to improve appetite for the treatment of anorexia nervosa.
Nutritional Supplements:
Nutritional supplements are an effective treatment. Vitamins B and C are given before feeding.
Psychological Therapy:
-Individual psychotherapy
-Behavioral therapy
-Family therapy
-CBT (Cognitive Behavioral Therapy)
-Motivational psychotherapy
NURSING MANAGEMENT OF ANOREXIA NERVOSA
Monitor the client’s weight.
Providing a nutritious diet to correct nutritional deficiencies.
Supervise the eating pattern of the client and provide a balanced diet.
Close observation of patients in the early stages of anorexia nervosa by keeping them in a single room.
Provide a balanced diet of 3000 calories to the patient in 24 hours.
Aim to gain 0.5 to 1 kg of weight every 7 days.
Giving medicine as per prescription.
(BULIMIA NERVOSA) (Bulimia Nervosa)
DEFINITION
In bulimia nervosa there are frequent episodes of food eating in unusually large amounts and there is no control over eating, the person overeats and self-induces vomiting to avoid weight gain or misuses diuretic and laxative medicines.
TYPES
(1) Purging type
The person overeats and self induces vomiting.
(2) Non-purging type
A person eats more and immediately does exercise/yoga and fasting.
ETILOGY
•Biochemical factor: Bulimia nervosa can develop due to decreased level of nor-epinephrine.
•Family disturbance or conflict
•Sexual abuse
•Maladaptive behavior
CLINICAL FEATURES
Fast eating
Non stop eating
Vomiting induction
Sore throat
Heart burn
Frequently depressed mood
Large amount of food eating
Gastroesophageal Reflux Disease (GERD)
Intestinal distress
irritation
Kidney problem
Severe dehydration
Amenorrhea in female (menstruation stop)
Fluid and Electrolyte Imbalance
Excessive exercise regimen
DIAGNOSTIC TEST
History Collection
Physical Examination
Blood test
ECG
Hormone test
MANAGEMENT
Psychotherapy
-Interpersonal therapy
-CBT (Cognitive Behavioral Therapy)
-Individual psychotherapy
-Family therapy
-Group support
Medicine
TCAs (Tricyclic Antidepressants) and SSRIs (Selective Serotonin Reuptake Inhibitors) Antidepressants are used for the treatment of bulimia nervosa.
•SSRIs Anti-depressants : Sertraline, Paroxetine, Fluvoxamine, Fluvoxatine etc.
NURSING MANAGEMENT OF BULIMIA NERVOSA
To assess vital signs.
Balancing electrolyte imbalances.
A trustful relationship should be established with the patient.
Collaborate with dietitian to motivate intake of nutritional diet and regular meals.
Providing education for healthy eating habits and coping mechanisms.
Family members should be involved in the treatment plan.
Providing psychological support and counselling.
Giving medicine as per prescription.
COMPLICATION
Heart disease
Tooth problem
Water Retention and Swelling
Electrolyte Imbalance
Food pipe (esophagus) damage
Smoking, alcohol abuse
BINGE EATING DISORDER
DEFINITION
Binge-eating disorder involves episodes of food intake in large amounts and frequently, and the person has no control over eating. In this, the person does not have the fear of gaining weight and self-induced vomiting is also not seen. In this, the person feels guilty. Continuous eating disorder causes obesity or overweight.
ETIOLOGY
Biological factor: This disorder develops when the hypothalamus does not send hunger or fullness related messages to the body.
Social factor: Peer pressure and emotional reasons can lead to binge eating disorder.
Psychological Factors: Depression or stress is linked to binge eating disorder.
CLINICAL FEATURES
Overweight
Obesity
Fast eating
Secret Eating
Continuous eating
Depression
Feel guilty after eating
High blood pressure
High cholesterol level
Fluid and Electrolyte Imbalance
irritation
GERD
MANAGEMENT
CBT (Cognitive Behavioral Therapy)
Interpersonal therapy
Family therapy
Self Help Group
Medication
•SSRIs Anti-depressants : Sertraline, Paroxetine, Fluvoxamine, Fluvoxatine etc.
NURSING MANAGEMENT OF BINGE-EATING DISORDER
Monitor the patient’s mill time.
To assess vital signs.
Balancing electrolyte imbalances.
A trustful relationship should be established with the patient.
Collaborate with dietitian to motivate intake of nutritional diet and regular meal.
Providing education for healthy eating habits and coping mechanisms.
Family members should be involved in the treatment plan.
Setting and monitoring minimum weight goals.
Maintain intake output chart.
Encouraging patients to express their feelings.
Providing psychological support and counselling.
Giving medicine as per prescription.
COMPLICATION
Obesity
Heart disease
Tooth damage
Gastric rupture
Type 2 diabetes
Cancer
SLEEP DISORDERS
Sleeping disorders cause changes in sleeping patterns and habits and have a negative effect on health. Sleep disorders are a group of syndromes characterized by sleep disturbances, disturbances in sleep quality and timing, and altered sleep-related behavior and physiological conditions.
There are three types of sleep disorders.
Medical and Psychiatric Related Sleep Disorders
DYSSOMNIA
In dyssomnia, the sleep pattern changes and there is inability to sleep or excessive sleep. The types of which are as follows.
(1). Insomnia
Insomnia is called inadequate sleep. It is difficult to maintain sleep and sleep disturbance is seen. Insomnia is the most common common sleep disorder.
There are psychophysiological insomnia and idiopathic insomnia.
TREATMENT
Melatonin supplements and L-tryptophan, short acting benzodiazepines and zolpidem tablets are given for its management.
Psychotherapy
Behavioral therapy
Sleep restriction therapy
Stimulus control therapy
(2). Hypersomnia
Hypersomnia is called excessive sleepiness. Excessive daytime sleepiness is seen in this disorder.
It is characterized by drunkenness sleep.(The person needs more time to wake up and is confused during this period.)
It has many sub-types.
Post-traumatic hypersomnia: Excessive sleep due to central nervous system disturbances is called post-traumatic hypersomnia.
DIAGNOSIS
Sleep disturbance repeated daily for at least 1 month or shorter, disturbing social and occupational function.
TREATMENT
•Non sedatives SSRI(Selective Serotonin Reuptake Inhibitor) Antidepressants.
•TCA (tricyclic anti-depressants).
•MAOI (mono amine oxidase inhibitor).
•Sleep hygiene measurement
•Behavioral therapy
NARCOLEPSY
Narcolepsy is a chronic sleep disorder characterized by excessive daytime drowsiness and sudden sleep attacks. In it the patient falls asleep suddenly at any place. Narcolepsy is called excessive daytime sleepiness.
SYMPTOMS
Sleep attacks (most common)
TREATMENT
Stimulants medication (amphetamines)
•Antidepressants (more given when cataplexy symptoms are present.)
CIRACARDIAN RHYTHM SLEEP DISORDERS
Abnormalities in the length and timing of the sleep-wake cycle are seen in circadian rhythm disorders. Some common circadian rhythm disorders are given here.
Jet lag syndrome
It is called time zone syndrome. A person has difficulty in maintaining sleep. There is also difficulty in initiating sleep.
Which gets resolved in 2-7 days without treatment.
Shift work type
Symptoms of excessive sleepiness and insomnia are observed.
Delayed sleep phase
Late sleep in which a person does not sleep till late night.
Irregular sleep wake patterns
Sleep patterns are found to be irregular. It does not maintain a sleep pattern.
TREATMENT
Chronotherapy (regular waking time i.e. fixing a specific waking time every day).
Melatonin Supplement
Benzodiazepines
BREATHING RELATED DISORDERS
(1). Obstructive sleep apnea
Apnea (absence of breathing) is seen due to upper airway obstruction during sleep.
TREATMENT
Lose weight to lose weight.
CPAP (Continuous Positive Airway Pressure)
The cause of respiratory obstruction should be treated.
Abnormal behavior associated with the sleep-wake cycle. Parasomnias are a category of sleep disorder in which abnormal movements, behaviors, emotions, perceptions, and dreams occur between sleep stages during sleep.
Sleep/wake transition disorder
Walking during sleep causes difficulty from one stage of sleep to another.
Aerosol disorder
Abnormal aerosols are observed due to mechanism.
Somnabolism
Somnabolism is sleepwalking in which a person walks in his sleep.
Night Mares
Nightmares include terrifying dreams. The person wakes up from sleep, then cannot maintain sleep.
(Medical and Psychiatric Related Sleep Disorders)
Sleep disorder can be caused due to mental disorder.
Sleep disorders can be caused by neurological and other medical disorders.
ETIOLOGY OF SLEEP DISORDERS
Respiratory diseases like asthma and COPD can cause sleep disorders.
Heart disease and diseases of the digestive system like ulcerative colitis etc. are seen due to the condition.
Sleep disorder occurs due to medical disorders like rheumatic disorders.
Depression, anxiety, and panic attacks can cause insomnia.
Sleep disorders are caused by neuromuscular diseases like neurodegenerative diseases, strokes, headache syndrome.
Allergies
Night shifts
Aging
Excessive stress
High Altitude (higher altitudes one lives in)
Poor ventilation
Genetic factor
Chronic pain
Environmental factors like heat, cold, noise.
Drug and alcohol abuse.
DIAGNOSIS OF SLEEP DISORDERS
History Collection
Physical Examination
EEG (Electroencephalogram) (to detect brain abnormalities.
Polysomnography (a type of sleep study) is a study of multi-parameter sleep that acts as a diagnosis tool for sleep medicine.
Genetic blood testing.
NURSING MANAGEMENT OF SLEEP DISORDERS
assessment
The patient’s activity should be assessed before sleep
Reasons for awakening from sleep should be assessed.
Assessing regularity of sleep patterns.
NURSING DIAGNOSIS
Disturbed sleep patterns related to (specific medical conditions) use of or withdrawal from substances, anxiety, depression, family patterns.
intervention
Promote sleep.
Ask the patient to do activities like music, relaxation exercises to prepare for sleep.
Avoiding deliberate exercise 1 hour before sleep.
Control the intake of caffeinated substances within 4 hours of sleep time.
Give high carbohydrate diet before sleep time.
Keep the room temperature between 68-72 degrees F.
Instruct the client not to use alcoholic substances to relax.
Ask not to smoke during sleep time.
Administering prescribed medicine.
•Risk for injury related to excessive sleeping, sleep terror, sleep walking.
intervention
Raise the side rail of the bed.
Keep the bed in low position.
Equip the bed with a bell that activates when the bed is excited.
Keep night lights on and arrange bedroom furniture in a way that promotes safety.
Administer drug therapy as ordered.
Disturbed sleep pattern disturbances related to enuresis.
intervention
Anatomical and urinary problems should be assessed.
Explain the availability of bed-wetting alarms.
Learn bladder stretching exercises.
Administer the medicine as per the physician’s order.
SEXUAL DISORDERS
Sexual disorders are difficulties experienced by an individual or a couple during any stage of normal sexual activity, including physical pleasure, desire, preference, orgasm.
Definition: Abnormal sexual interest and behavior is called paraphilia.
•Pedophilia: Getting sexual excitement from physical contact with children.
•Exhibitionism: Exposing one’s genitals in the public palace.
•Masochism: Refers to people who derive sexual excitement from their own pain.
•Sadism: Sadism refers to people who derive sexual excitement from the pain of another person (sexual partner).
•Fetishism: the opposite sex’s clothing, undergarments, and sexual pleasure. (clothing, underwear etc)
2.SEXUAL DYSFUNCTION (sexual dysfunction)
Definition: Problems or disorders that interfere with (interfere with) the normal sexual response cycle.
3.GENDER DYSPHORIA:
-Definition-Distress that may accompany a discrepancy between one’s experienced or expressed gender and the gender assigned to them at birth.
•Gender Identity Disorder: When a person, male or female, experiences confusion and conflict in their feelings about their own sexual identity.
•Transsexualism: Desire to be the opposite sex….
Dat. Male to become female and female to become male..
4.HYPERSEXUALITY(Hypersexuality (Compulsive Sexual Behavior Disorder):
Definition: Excessive and uncontrollable preoccupation with sexual thoughts, fantasies, or behavior.
Definition: A condition characterized by physical pain during sexual activity.
Definition: Persistently low or absent sexual interest or desire.
Definition: Aversion to and avoidance of sexual contact due to excessive fear, anxiety, or aversion.
MANAGEMENT
Treatment approaches often include psychotherapy, behavioral interventions and hypnosis, group therapy, and sometimes pharmacotherapy.
It is important for individuals with problems related to their sexual health to seek the help of qualified healthcare professionals who seek to resolve these issues with sensitivity and respect for diversity.
Hormonal replacement therapy such as estrogen, progesterone.
Causative factors should be identified for treatment.
Psychoanalytic psychotherapy and supportive psychotherapy.
NURSING MANAGEMENT OF SEXUAL DISORDERS
The patient’s sexual history and previous satisfaction level in the sexual relationship should be assessed.
Assay medications that affect libido.
Helping the therapist to plan behavior modification that will help change the patient’s behavior.
Refer for additional therapy or sex counseling if needed.
Maintaining the therapeutic nurse patient relationship and accepting the patient.
Relaxation techniques should be taught to relax and ask the patient to interact.
The patient should be educated about sexuality and sexual function.
Providing adequate counseling to the couple and removing misconceptions related to sexual function. Refer for additional counseling and sex therapy as needed