Renal physiology is the study of the physiology of the kidney, specifically at the level of the nephron, which is the smallest functional unit of the kidney where blood entering the kidney goes through the process of filtration.
Overview of Renal Physiology
3 Important Functions of the Nephrons:
control blood concentration and volume through selected removal of water and solutes
regulate blood pH
remove toxic waste from the blood
Through these functions, materials from the blood is removed, others which are required are returned, and the remaining unneeded material is excreted collectively as urine. In other words, urine formation requires Glomerular Filtration, Tubular Reabsorption and Tubular Secretion.
Renal Physiology – Glomerular Filtration
Glomerular Filtration occurs in the renal corpuscle of the kidneys across the endohelial-capsular membrane, which results in the fluid called glomerular filtrate ( 150 lt in adult females; 180 lt in adult males). The blood plasma in the afferent arterioles which become the glomerular filtrate is called the filtration fraction.
Retrieved from https://slidetodoc.com/renal-functions-gfr-learning-objectives-enumerate-general-functions/ on 5th December 2021
Retrieved from https://slideplayer.com/slide/10629513/36/images/34/Glomerular+Filtration.jpg on 15th December 2021
Understanding the Glomerular Filtration Process
Pressures Causing Filtration & GFR Regulation
The Glomerular Filtration Rate (GFR) is the amount of filtrate formed in all the renal corpuscles of both kidneys per minute (rate in males = 125ml/min; rate in females = 105ml/min). Maintenance of a constant GFR ensures that useful substances are not lost.
A change in GFR indicates a change in the net filtration pressure – if the glomerular blood hydrostatic pressure (GBHP) falls to 45mmHg, the filtration process is halted as the opposing pressures equal to 45mmHg.
There are 3 mechanisms which control GFR by adjusting the blood flow into and out of the glomerulus, and by altering the glomerular capillary surface area for the process of filtration:
Renal Autoregulation: Through the Myogenic Mechanism, stretching triggers contraction of smooth muscle cells in the afferent arteriole wall, causing normalisation of the renal blood flow and GFR within seconds following a change in blood pressure. Additionally, through the Tubuloglomerular Feedback, increased distal tubular sodium chloride concentration causes the release of adenosine, leading to a series of events that help regulate the GFR.
Neural Regulation: The Sympathetic Nervous System, which supplies the renal blood vessels, is responsible for the release of norepinephrine. Through Moderate Sympathetic Stimulation, norepinephrine activates the a1 (alpha-1 adrenergic) receptor in the afferent and efferent arterioles, causing vasoconstriction, causing blood flow restriction, leading to a slight GFR decrease. In Greater Sympathetic Stimulation, vasoconstriction of the afferent arterioles predominates; blood flow in the glomerular capillaries is decreased, leading to a decrease in GFR.
Hormonal Regulation: Angiotensin II, which is a vasoconstrictor, acts on the afferent and the efferent arterioles, reducing blood flow leading to a decrease in the GFR. Additionally, Atrial Natriuretic Peptide (ANP) is released through the stretching of the atrial walls when there is an increase in blood volume, leading to an increase in capillary surface area, causing an increase in the GFR.
Renal Physiology – Tubular Reabsorption
In the average adult, the Glomerular Filtration Rate (GFR) is approximately 125ml/min, meaning that around 180 litres are filtered in one day. However, only around 1ltr a day is excreted as urine by the body. This happens because throughout the filtration process, around 99% of the filtrate is reabsorbed back into the blood in what is called tubular reabsorption.
In tubular reabsorption, the proximal convoluted tubule cells process and reabsorb over 80% of the glomerular filtrate, whilst other parts of the nephron ensure homeostasis by controlling excretion amounts of electrolytes, water and hydrogen ions. Through tubular reabsorption, the following are reabsorbed back into the blood stream:
Sodium
Potassium
Calcium
Chloride
Bicarbonate
Phosphate
Peptides and small proteins are also reabsorbed through pinocytosis.
Substances completely reabsorbed from the filtrate are:
Water
Proteins
Chloride
Sodium
Bicarbonate
Glucose
Potassium
Urea and Uric Acid are partially reabsorbed from the filtrate.
Retrieved from https://baujiti.home.blog/2013/09/25/urine-formation-form-iii/ on 5th December 2021
Renal Physiology – Tubular Secretion
Tubular Secretion, which occurs in the proximal and distal tubules as well as in the collecting dugt, removes certain materials from the body such as Potassium ions, Hydrogen ions, Ammonium ions, Creatinine, and drugs.; it also helps control the blood’s pH.
Renin-Angiotensin-aldosterone System (RAAS)
Retrieved from https://step1.medbullets.com/renal/115016/renin-angiotensin-aldosterone-system on 15th December 2021
Aldosterone causes increased sodium and water reabsorption from the distal tubule and collecting ducts, leading to an increase in the extracellular fluid volume. This allows the restoration of the blood pressure to its normal state. Additionally, Aldosterone has an affect on the secretion of potassium by the distal convoluted tubule and collecting duct.
Antidiuretic Hormone
The AntiDiuretic Hormone, which is produced by the hypothalamus, controls the concentration of the urine to be excreted.
When the blood-water concentration is low, ADH is released, which increases the permeability of the plasma membranes of the cells of the distal tubules and the collecting ducts. Increased permeability causes more water molecules to pass into the cells, and then into the blood.
With no ADH, the ducts become impermeable to water, causing water to be expelled into urine.
Atrial Natriuretic Peptide
Increased blood volume causes the atrial walls to stretch, leading to the release of the Atrial Natriuretic Peptide (ANP). ANP inhibits the reabsorption of sodium and water in the proximal convoluted tubule and collecting duct, suppresses the secretion of aldosterone, and suppresses the secretion of ADH. This results in increased excretion of sodium ions (natriuresis) and increased urine output (diuresis), leading to a decrease in the blood volume and blood pressure.
Note…
Tubular Reabsorption REMOVES substances from the filtrate into the blood… Tubular Secretion ADDS materials to the filtrate from the blood.
Renal Physiology – Solute Reabsorption
Solute Reabsorption happens within the ascending limb of the loop of henle.
Summary…
Retrieved from https://www.researchgate.net/figure/Nephron-segments-and-their-main-physiological-function-The-nephron-is-the-functional_fig1_321907177 on 15th December 2021
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Psychosis is a condition affecting the way in which the brain processes information, causing loss of touch with reality. An individual with psychosis may see, hear, or believe things which are not real, to a point where it becomes hard to dissociate what is true from what is not. Psychosis symptoms include delusions, hallucinations, abnormal behaviour and incoherent speech.
Psychotic Episode Risk Factors
Severe Stress
Lack of Sleep
Alcohol Abuse Withdrawal Symptoms
Psychiatric Conditions – dementia, schizophrenia, severe depression, bipolar disorder
Schizophrenia, Schizotypal and Delusional Disorder
Schizophrenia
Schizophrenia is a chronic severe mental disorder affecting 20 million individuals worldwide. It may affect educational and occupational performance due to its effect on perception, mood, thinking, behaviour and contact with reality.
Individuals with schizophrenia are unfortunately more prone to stigma, discrimination, and violation of human rights, and are up to 3 times more likely to die early than the majority of the population, often due to preventable diseases eg. infections, metabolic disease and cardiovascular disease.
Through appropriate medicinal treatment and psychosocial support, schizophrenia can be treated.
Epidemiology
Negative symptoms onset tends to occur 5 years prior to the initial psychotic episode
Children of individuals with schizophrenia tend to have lower IQ, poor attention skills, poor social adjustment, and symptoms related to thought disorder.
Individuals with schizophrenia tend to differ from their peers in developmental markers throughout childhood, especially when it comes to developmental milestones, cognitive function levels, educational achievements, neurological and motor development, social competence and psychological disturbances.
Schizophrenia Risk Factors
40% increased risk if both parents have schizophrenia
10% increased risk if first-degree relative has schizophrenia
3% increased risk if second-degree relative has schizophrenia
10% increased risk if born in winter
2-4 times higher risk if living in urban areas
having older parents
having an over-protective dominant mother and an over-submissive father
experiencing hostility between parents
experiencing highly expressed emotions
having an infection during the fetal development stage
abnormalities in pregnancy and delivery
2nd trimester maternal influenza
low birth weight
fetal malnutrition
use of cannabis (past or present)
NOTE: A stressful life event may serve as a precipitating factor for the onset of schizophrenia, usually happening about 3 weeks later.
The Dopamine Hypothesis of Schizophrenia
The dopamine hypothesis goes back to the 1960’s and 1970’s when studies involving amphetamine (which increases dopamine levels) showed an increase in psychotic symptoms, whilst reserpine (which depletes dopamine levels) showed a reduction in psychotic symptoms.
The original dopamine hypothesis stated that hyperactivity of dopamine resulted in symptoms of schizophrenia, and drugs that blocked dopamine reduced psychotic symptoms.
There is however little direct evidence that abnormal dopaminergic transmission causes schizophrenia.
Retrieved from https://commons.wikimedia.org/wiki/File:Schizophrenia_brain_large.gif on 11th December 2021
The 3 Phases of Schizophrenia
Phase 1: PRODROMAL PHASE:
75% of individuals with schizophrenia experience the prodromal stage. Signs and symptoms experienced in this phase include:
Decline in normal functioning precedes the 1st psychotic episode
Social withdrawal
Irritability
Physical complaints
Poverty of speech
Peculiar behaviour
Role functioning impairment
Lack of initiative, interests or energy
Personal hygiene and grooming impairment
Unusual perceptions
New interest in religion or the occult, odd beliefs or magical thinking
Management of the Prodromal Phase focuses on the prevention of psychological and social disruption that results from psychosis. Anti-depressants, anxiolytics and mood stabilisers help the individual to deal with the symptoms. Anti-psychotics should be prescribed and started early, since studies indicate better prognosis. Psychoeducation of the individual and main caregivers increase coping mechanisms in relation to dealing with schizophrenia, while education about coping strategies in relation to stress help as prophylaxis against impending psychosis. Observation and monitoring should be performed in frequent intervals.
Phase 2: PSYCHOTIC (ACUTE) PHASE:
Positive symptoms
Perceptual disturbances such as auditory hallucinations
Delusions
Disordered thought process
Auditory hallucinations, which are frequently experienced in schizophrenia, include simple noises, complex sounds, voices, music, single words, whole conversations, commands or running commentary.
Visual hallucinations rarely occur without other kinds of hallucinations, but are less frequent than auditory hallucinations.
Other type of hallucinations may be olfactory (smells that aren’t truly present), tactile (sensation of touch or movement on the skin or inside the body) or gustatory (taste).
Delusions may be classified as primary (occurring occasionally) or secondary (preceded by a hallucination). Persecutory Delusions are delusions in which the person thinks that people are trying to inflict harm; Delusions of Reference are delusions which hold direct reference to the person (eg. television program referring to the individual with schizophrenia); Delusions of Control are delusions in which the person feels or beliefs that he/she is being controlled by someone else; Delusions of Possession of Thought are delusions in which the person feels thoughts are being inflicted, withdrawn or forecast on him/her.
In Disorder of Thoughts, the person has difficulty dealing with abstract ideas, and may experience mystical ideas. The person also features loosening of association (where ideas seem confused), pressure of thought (rapid, abundant and varied thoughts), poverty of thought (slow, few and unvaried thoughts) and blocking of thoughts (where the mind seems to go blank).
Phase 3: RESIDUAL (CHRONIC) PHASE:
Happens between psychotic episodes
Features negative symptoms such as social withdrawal
Odd thinking
Odd behaviour
Negative symptoms include the flat effect, in which reduced expression of emotions on the face or voice can be noted; alogia (reduced speech), avolition (inability to start and sustain activities), anhedonia (inability to experience pleasure), asociality (social withdrawal) and being reluctant to perform daily tasks.
Diagnosis
Schizophrenia can be diagnosed by:
taking a detailed history
excluding other possible conditions
excluding substance abuse and withdrawal
noting positive, negative and cognitive symptoms
noting that symptoms are experienced frequently
noting impaired social and occupational functioning
at least experienced for 1 month
Differential diagnosis include:
F21: Schizotypal Disorder
F22: Persistent Delusional Disorder
F23: Acute Transient Psychotic Disorder
F24: Induced Delusional Disorder
F25: Schizoaffective Disorder
Retrieved from https://www.verywellmind.com/schizotypal-personality-disorder-4689994 on 12th December 2021
Retrieved from https://www.verywellhealth.com/delusions-5113070 on 12th December 2021
Drug-induced psychosis refers to a psychotic episode which is directly related to abuse of an intoxicant, such as an illicit intoxicant, use of prescription medication without GP direction, or excessive use of alcohol or other legal substances.
Drug-induced psychosis happens when a person takes too much of a certain drug, or as an adverse reaction following the mixing of substances, or during drug withdrawal, or if the person has underlying mental health issues.
Drug detox can help reverse the effects of drug-induced psychosis.
Institutional Neurosis is a psychiatric disorder where a person assumes a dependent role and passively accepts a paternalist approach following long-time confinement in a hospital, mental hospital, prison, or such institutions.
In institutional neurosis, the person features signs of apathy, lack of initiative, loss of interest, submissiveness, and at times lack of emotional expression.
Psychosis Management
The APA Guidelines for Schizophrenia divide management in 3 phases:
Acute Phase: treatment for acute psychotic episode lasting 4-8 weeks
Stabilisation Phase: time-limited transition to continuing treatment lasting up to 3 months (in reality, sometimes this phase takes more than 3 months as many individuals with psychosis keep switching from the stabilisation phase to the stable phase over and over)
Stable Phase: stable treatment
Retrieved from https://login.medscape.com/login/sso/getlogin?wcode=102&client=205502&urlCache=aHR0cHM6Ly93d3cubWVkc2NhcGUub3JnL3ZpZXdhcnRpY2xlLzUwNzg1OA&sc=ng&scode=msporg on 12th December 2021
Psychosocial Interventions
Individual Therapy
Social Skills Training
Family Therapy
Vocational Rehab and Supported Employment
Cognitive Behavioural Therapy
Electroconvulsive Therapy (ECT)
ElectroConvulsive Therapy (ECT) induces brain seizure and momentary unconsciousness; this method can be considered for treatment of resistant schizophrenia, such as in catatonic stupor (significantly decreased reactivity to environmental stimuli and events), worsening of symptoms regardless of medication, and in individuals exhibiting high risk of suicide, homicide or physical assault.
NOTE: In Malta this method is not used in the case of schizophrenia.
Psychopharmacology
All persons making use of anti-psychotics need to undergo ECG PR interval monitoring at least every 3 months since these medications may cause heart problems if used long term especially in high doses.
1st Generation Typical Anti-Psychotics eg. Haloperidol (seranace), Chlorpromazine (largactil) and Trifluoperazine (stelazine) act by inhibiting central dopaminergic neurotransmission, whilst producing antagonism at cholinergic, histamine and alpha receptors, causing extrapyramidal symptoms. These drugsmay also be used for their sedative side-effects.
NOTE: In Malta, the use of Chlorpromazine (largactil) led to long-term psychotic patients to be finally discharged after many years in a mental health facility.
2nd Generation Atypical Anti-Psychotics eg. Clozapine (clozaril), Risperidone (risperdal), Quetiapine (seroquel), Olanzapine (zyprexa) and Aripriprazole (abilify) act on both dopamine and serotonin receptors. They are effective at dealing with both positive and negative symptoms, with a lower risk of extrapyrimidal effects.
Retrieved from https://www.slideserve.com/dai/7-clozapine-resistant-schizophrenia on 12th December 2021
Clozapine
Clozapine is only supplied upon prescription and blood results. Baseline blood tests that include full blood count, blood glucose, and liver function, as well as an ECG and weight, should be taken prior to administration of the drug.
Clozapine side effects include agranulocytosis (low number of granulocytes – type of white blood cells – in the blood) and extrapyramidal symptoms (EPS) such as tardive dyskinesia (involuntary neurological movement disorder), parkinsonism (a combination of movement abnormalities as seen in Parkinson’s disease such as tremor, slow movement, impaired speech or muscle stiffness) and dystonias (a movement disorder in which muscles contract involuntarily causing repetitive/twisting movements).
Clozapine administration requires monitoring for side-effects especially in the initiation phase, blood temperature monitoring, as well as weekly blood tests for WBC (number of white blood cells) for the first 18 weeks, every 2 weeks for the first year, followed by monthly testing.
Extrapyramidal Symptoms:
Retrieved from https://nursekey.com/antipsychotics-and-anxiolytics/ on 12th December 2021
Retrieved from https://www.verywellhealth.com/parkinsonism-causes-symptoms-and-treatment-5189631 on 12th December 2021
Neuroleptic Malignant Syndrome
Neuroleptic Malignant Syndrome is a life-threatening reaction to anti-psychotic drugs in which the person experiences fever, altered mental status, muscle rigidity, and autonomic dysfunction within hours or days of exposure to the drug. A patient with NMS may die within a few hours if untreated.
Retrieved from https://www.slideshare.net/AdeWijaya5/neuroleptic-malignant-syndrome-125151824 on 12th December 2021
Psychosis Nursing Approach
immediate goal as in all types of mental health problems is to prevent harm to self and others
establish a therapeutic nurse-patient relationship
notice signs or symptoms of hallucinations
acknowledge that hallucinations and other positive symptoms may be true to the person but not true to others
encourage the person to describe the positive symptoms being experienced, as well as related thoughts and feelings
provide help in the development or maintenance of life skills
offer support to the person and family/caregivers
Psychosis Nursing Care Plan
The following Psychosis Nursing Care Plan is based on the situation shown in the above video…
Immediate Goals
establish a therapeutic nurse-patient relationship based on trust and understanding
compile full history including current psychotic episode and any other similar episodes in the past
compile a list of current medications and other comorbidities to ensure that therapy suggested is suitable for the person
offer support to the person and his mother by providing information about the condition
person should be prescribed anti-psychotics so as to tackle psychotic symptoms
refer for psychological therapy such as CBT or Individual Therapy
suggest Family Therapy if lack of understanding between the person and his mother is evident, so as to promote understanding and support within the family unit
since the person feels safe at his parents’ house, it could be suggested that he moves back in with his parents for the time being until his condition is stabilised and under control; this could also mean that the person starts to eat well again as he may feel safer
Short Term Goals
review situation and make adjustments to the plan accordingly
review medication and see if any changes in dose or type of prescribed drugs need to be adjusted/changed, especially in the case of undesired side-effects
educate about compliance to medication so as to avoid relapse as much as possible
educate the person about the importance of continuing psychological therapy so coping techniques can be learned
review food intake and fluid intake and ensure the person has started eating/drinking again
teach the importance of keeping with follow-up appointments
Long Term Goals
re-assess symptoms
review medication and psychological therapy and their effectiveness
consider change of treatment if need be
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Mania is the main feature of bipolar disorder. A manic episode is a state of mind characterised by high energy, excitement, and euphoria over a period of time. The experienced extreme change in mood and cognition can easily interfere with the person’s school, work, or home life.
Manic Episode Symptoms
increased energy
overactivity
‘snapping’ words (pressure of speech)
difficulty in attaining attention
inflated self-esteem, overconfidence and grandiose ideas
flight of ideas
irritability
lack of social inhibitions
mood elevation
may experience psychotic symptoms
HypoMania Symptoms
HypoMania is a mild form of mania featuring elation and hyperactivity. HypoMania symptoms are not severe and do not disrupt the person’s lifestyle. Symptoms of HypoMania include:
mild mood elevation that persists for at least several days
increased energy
increased sociability
increased talkativeness
increased over-familiarity
increased libido
mild over-spending
possible impairment of attention and concentration
decreased need for sleep
Manic Episode Causes
organic brain lesions
increased stress level
lack of sleep or changes in the individual’s sleep pattern
use of recreational drugs
alcohol use
seasonal changes
significant life change/s
childbirth
Manic Episode Nursing Approaches
Address the physical, psychological and social consequences following a manic episode
If a mood-stabilising drug is prescribed, ensure that no major problems are experienced as side effects, and that the person can maintain a therapeutic drug level within the body
Once the manic episode subsides, discuss with the person possible trigger factors and encourage self-managing strategies for better coping with future manic episodes
Encourage adequate fluid and food intake
Discuss self-activities which can be managed by the person in a safe way
Encourage activities which can be performed during night-time with the least noise possible so others’ sleep pattern is not interrupted
Consider night-time sedation to ensure adequate sleep
Bipolar Affective Disorder is characterised by two or more episodes in which the person’s mood and activity levels are significantly disturbed, featuring periods of mood elevation (mania) and periods of low mood (depression). In total there are 9 sub-types of Bipolar Affective Disorder.
Retrieved from https://lifeease.in/bipolar-disorder/ on 2nd December 2021
Cyclothymia is a milder chronic form of bipolar disorder which lasts at least 2 years (in adults; in children and adolescents it lasts at least 1 year). In cyclothymia, mood swings are unrelated to life events and they usually initiate early in adult life.
Cyclothymia is characterised by multiple periods of hypomanic and depressive symptoms that do not meet the criteria for mania or major depressive episode, that cause significant distress or impairment, and which are ongoing for more than 2 months at a time.
Bipolar Disorder Management
PSYCHOLOGICAL MANAGEMENT: CBT, Interpersonal Therapy or Behavioral Couples Therapy
PHARMACOLOGICAL MANAGEMENT: Mood Stabilisers including Lithium, Anti-Epileptics (Sodium Valproate– Epilim), Anti-Psychotics, and Anti-Depressants (prescribed as short-term treatment when the person is in the depressive stage). Other mood stabilisers include Carbamazepine (Tegretol – DO NOT use in pregnancy) and Lamotrigine (limited evidence, thus usually avoided).
Lithium
1st line treatment for Bipolar Affective Disorder
If highest therapeutic dose is not effective enough, Lithium is coupled with Sodium Valproate (NOT for child-bearing aged females), Anti-Depressants (Fluoxetine) and Anti-Psychotics (Olanzapine)
Blood should be tested after the first week of treatment, followed by re-testing every 3 months in the first year, and every 6 months in the years to follow, to ensure Lithium level is kept within the therapeutic range, i.e. 0.6-0.8mmol/ltr
Side Effects:
increased weight
GI disturbances
oedema in the ankle region
tremors
polyuria (increased amount and frequency of urination)
polydipsia (increased thirst and fluid intake)
chronic kidney failure (in long term lithium treatment)
hypothyroidism (in long term lithium treatment)
Manic Episode Nursing Care Plan
The following Manic Episode Nursing Care Plan is based on the situation shown in the above video…
Immediate Goals
compile full history including current manic episode and any possible other similar episodes in the past
compile a list of current medications and other comorbidities to ensure that therapy suggested is suitable for the person
explain to the person that while you believe that his reality includes certain aspects such as God speaking to him or ideas with numbers and cancer treatment, all this is not part of my (and others’) reality
the person should be prescribed a mood stabiliser such as Lithium, to be started immediately
refer for psychological therapy such as CBT
ensure the person accepts the need for psychological and pharmacological treatment; if not, consider possibility for detainment
Short Term Goals
review symptoms and situation
order lithium blood test within a week to ensure the lithium level of the person is within the therapeutic range i.e. between 0.6-0.8mmol/ltr
review medication and see if any changes in dose or additional psychotic drugs need to be prescribed along Lithium
educate about compliance to medication
make sure that the person has started to sleep adequately; prescription for sleeping pills should be considered so the person can rest well during the night
educate the person about the importance of continuing psychological therapy eg. CBT so coping techniques can be learned to avoid relapse
encourage nutritional food intake and adequate fluid intake and if need be encourage nutritional support through the help of a nutritionist
teach the importance of keeping with follow-up appointments
encourage person to restart investing time in past or new hobbies to keep self occupied
Long Term Goals
review symptoms and situation
review medication and psychological therapy and their effectiveness
order follow-up blood tests every 3 months for the first year, and every 6 months thereof, to keep testing Lithium level, ensuring it stays within normal range as long as person stays on lithium treatment
ensure person is eating and drinking adequately
ensure person is sleeping well at night
teach person to notice things that may have triggered past manic episodes, and ways to cope so as to avoid rebound manic episodes as much as possible
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Nephrectomy is a surgical procedure in which all or part of a kidney is removed. During a radical nephrectomy, a complete kidney is removed and structural adjustments may be made. In a partial nephrectomy, only diseased kidney tissue is removed.
Retrieved from https://www.fatihatugmd.com/kidney-cancer on 8th December 2021
Indications
renal tumor
polycystic (bleeding or infected) kidneys
massive trauma to the kidneys
elective kidney removal for donation purpose
Laparoscopic Nephrectomy vs Open Nephrectomy
In an open nephrectomy, an 18cm incision is made, while in laparoscopic nephrectomy, 5 puncture sites are made. This means that laparoscopic nephrectomy:
is less painful
requires no suturing and no staples
requires a shorter hospital stay
promotes faster recovery time
Nephrectomy Perioperative Care
Nephrectomy Preoperative Nursing Care
Apart from following the usual preoperative nursing care requirements, in nephrectomy preoperative nursing care, the nurse should:
discuss procedure including incision location (flank incision on affected side) and possible tubes, drains and stent use during/after procedure with the patient
inform patient about possible muscle aches following surgery due to side-lying positioning during surgery
help in reducing surgery-related anxiety in the patient and family members by answering to any arising questions
report significant abnormal laboratory values such as bacteriuria (bacteria in the urine) and blood coagulation abnormalities
Nephrectomy Postoperative Nursing Care
Apart from following the usual postoperative nursing care requirements, in nephrectomy postoperative nursing care, the nurse should:
monitor and document accurately the patient’s fluid intake and output; record urine output every 1-2 hours following surgery and measure drainage from drains and drainage on dressings (weigh dry vs used dressing) and record separately; Total urine output should be at least 0.5ml/kg/hr; observe and document urine colour and consistency (any mucus, blood, sediment present?); intake should exceed output since excretion includes sweat; if patient’s output exceeds intake, there could be an underlying renal issue
monitor patient weight daily using same scale and with patient wearing similar clothing; increased weight may indicate fluid retention, which increases the patient’s risk for heart failure
monitor patient’s respiratory status to identify any possible acute deterioration signs early on (a rapid weak pulse is expected following surgery due to post-op shock); ensure the patient has adequate ventilation; patient may be reluctant to turn, cough and breathe deeply due to incisional pain, thus ensure comfort and ability to perform coughing and deep-breathing exercises (a spirometer or other respiratory devices may be used every 2 hours while the patient is awake) – ensure patient receives necessary pain medication; (Renal surgery often involves the removal of the 12th rib)
monitor abdominal distension – during surgery, the abdomen is usually inflated with gases so organs are separated for easier surgical access; oral intake should be restricted until bowel sounds become present (usually 24-48 hours post-op); during this time, patient should be put on IV fluids
NOTE: The kidneys are responsible for the regulation of extracellular fluid and composition, erythropoietin production, vitamin D activation, and acid-base balance regulation. Thus…
Fluid retention increases the remaining kidney’s workload since it has to perform all these functions independently
Patient Discharge Plan
teach patient to avoid bending (or if really necessary, bending from the knees and not the waist), avoid heavy lifting (<5lbs) and avoid strenuous activity
teach patient to avoid making multiple trips up and down the stairs, but that it’s okay to use the stairs sparingly during the first week following discharge
emphasise that driving should be avoided for at least 4 weeks following surgery; patient may resume driving only after pain medication is stopped and if pain free
teach patient that while showering, incision site should be gently washed with soap and water, rinsed well and pat-dry; bathing should be avoided until the incision is fully healed (inform patient that steri-strips applied during an open nephrectomy fall off in about a week)
encourage a well-balanced diet since this promotes healing and good bowel function
teach patient to avoid constipation, and that if constipated, prune or orange juice should be tried; increasing water intake to 6-8 glasses of water per day may help; over-the-counter laxatives may also help
The nurse should emphasise the importance of contacting the physician IMMEDIATELY if:
chills or a fever of 101 degrees fahrenheit or more develops
severe uncontrollable pain develops
surgical incision becomes red or swollen
the surrounding skin of the incision becomes warmer and redder than other areas
incision site is oozing
incision site has an opening
passing urine becomes difficult
urine output decreases
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Benign Prostatic Hyperplasia is a benign enlargement of the prostate gland. This occurs in around 50% of 50+ males and in over 90% of 80+ males, with a quarter of men requiring some type of treatment by the age of 80. Benign Prostatic Hyperplasia is known as the most common urologic problem encountered in adult males.
Etiology and Pathophysiology of Benign Prostatic Hyperplasia
In ageing males, an imbalance within the endocrine system (gradual decline in hormones during the andropause phase and/or accumulation of dihydroxytestosterone and/or decrease in testosterone resulting in greater estrogen proportion in the blood) may cause Benign Prostatic Hyperlasia.
Risk Factors for Benign Prostatic Hyperplasia
ageing
obesity
sedentary lifestyle
alcohol consumption
smoking
diabetes
family history of BPH in first-degree relatives (parent or sibling)
Clinical Manifestations of BPH
Clinical manifestations of Benign Prostatic Hyperplasia are usually gradual in onset, resulting from urinary obstruction by the enlarged prostate. These include:
urinary stream caliber and force decrease
difficulty in initiating voiding
intermittent voiding
dribbling a few cc’s of urine following complete urination
increased frequency of urination
a sense of urination urgency
dysuria (burning, tingling, or stinging sensation in the urethra and meatus whilst voiding)
pain in the bladder
incontinence
nocturia (waking up multiple times at night to urinate)
TURP is a surgical procedure in which obstructive prostate tissue is removed through the use of a resectoscope which is inserted via the urethra.
TURP increases quality of life
TURP is low risk
80-90% excellent outcome due to improvement in symptoms and urinary flow
Retrieved from https://mgmhealthcare.in/our-specialties/renal-sciences/transurethral-resection-of-the-prostate-turp/ on 7th December 2021
TURP is performed under anaesthesia (spinal or general) and requires the patient to be kept for up to 2 days at the hospital.
A resectoscope is inserted via the urethra and obstructive prostate tissue is removed.
Following the procedure, a 3-way indwelling catheter is inserted into the bladder for haemostasis purposes as well as to facilitate urine drainage.
During the first 24 hours following the procedure, the bladder is frequently irrigated so as to prevent obstruction from mucus and blood clots.
In TURP there is no external surgical incision done, and so, post-op care requires no surgical wound care.
TURP Preoperative Nursing Care
Educate patient about procedure
Discuss possible complications
Inform about incontinence and urine dribbling for up to a year post-surgery, and the role of Kegel exercises in providing assistance with this problem
Inform patient about retrograde ejaculation (sexual climax reached, but semen enters bladder rather than emerging from penis – not harmful, but may cause infertility)
Gain informed consent
Ensure optimum cardiac, respiratory and circulatory status (decreased risk for complications)
Prophylactic antibiotic treatment is prescribed/initiated
Medical pre-op investigations are carried out (CBC, U&E, MSU – midstream specimen urine, blood group, cross match)
Glycerin suppositories are administered the night prior to surgery
Patient should be kept NBM for 8 hours pre-op
TURP Postoperative Nursing Care
Monitor vital signs every 15 minutes in the first hour post-surgery, followed by re-monitoring every 4 hours
If patient received epidural anaesthesia, monitor epidural site, monitor extremities every hour for the first 12 hours, monitor intake and output, and keep patient on bed-rest as per anaesthetist’s recommendations
Reassure patient so as to avoid/reduce anxiety
Observe for signs of haemorrhage
Maintain urinary drainage
Maintain urethral catheter patency
Avoid over-distention of bladder (may lead to haemorrhage)
Administer pain medication
Administer anti-cholinergic drugs (drugs that block the action of acetylcholine – reduce bladder spasms)
Maintain bed-rest for 24 hours post-op
Promote comfort through appropriate patient positioning
Administer medication to promote soft-stools so as to avoid straining (which may lead to haemorrhage)
Encourage ambulation as soon as possible to prevent complications such as embolism, thrombosis and pneumonia
Encourage patient to talk about sexual dysfunction fears and promote discussion with partner
Teach methods of urinary control eg. kegel exercises
Encourage foods and fluids if tolerated (unless contraindicated, oral fluids should be encouraged from day 1)
Empty urine bag and measure urine output; document on fluid balance chart
Provide catheter care as necessary; If urine is clear, remove catheter on day 1
Assist patient when taking a shower on day 1 (patient should be able to self-care on day 2)
Promote oral care and assist on day 1 if necessary
Precautions
If body temperature exceeds 38.5 degrees celsius, blood and urine culture, CBC and chest x-ray should be performed, followed by paracetamol administration and assistance in bringing fever down.
In gross haematuria, IV therapy should be maintained, irrigation rate should be increased, temperature and pulse should be monitored hourly, haemoglobin should be checked, and penile tractions with 1 ltr bag of IV fluid for 20 mins on followed by 20 mins off.
If catheter is blocked, try to milk catheter according to unit practice; if unsuccessful, irrigate; if unsuccessful, notify surgeon but DO NOT remove catheter (in the 24 hours following TURP, nurses and junior doctors cannot re-catheterise patient).
In the case of failed TWOC (trial without catheter), re-insert catheter.
In the case of incontinence post TWOC, encourage use of pads and pants and teach pelvic floor exercises.
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The anatomy of the renal system covers 4 major related structures, namely the kidneys, the ureters, the bladder and the urethra. The renal system provides a way for metabolic wastes and excess ions to be filtered out of the blood along with water. Filtered product is then excreted as urine.
Retrieved from https://nurseslabs.com/urinary-system/ on 5th December 2021
Retrieved from https://open.oregonstate.education/aandp/chapter/25-1-internal-and-external-anatomy-of-the-kidney/ on 5th December 2021
Functions of the Kidneys
Excrete waste through urine
Regulate blood volume and blood composition – blood pH and solute concentration
Retrieved from https://www.youtube.com/watch?v=hEZicQa9zz8 on 20th June 2022
Blood Supply of the Kidneys
Retrieved from https://www.quora.com/What-is-the-path-of-blood-flow-through-the-renal-blood-vessels-blood-supply-and-venous-drainage on 5th December 2021
Kidney and Nephron Anatomy of the Renal System
The nephron is the main functional unit of the kidney.
Retrieved from https://www.niddk.nih.gov/news/media-library/9555 on 5th December 2021
There are 2 types of nephrons:
Cortical Nephron – has its glomerulus in the outer cortical zone, with its remaining part rarely penetrating the medulla. Cortical Nephrons amount to approximately 80% of all nephrons.
Juxtamedullary Nephron (juxta = near) – has its glomerulus close to the corticomedullary junction, with its other parts penetrating deeply into the medulla. Juxtamedullary Nephrons amount to approximately 20% of all nephrons.
Retrieved from https://www.youtube.com/watch?v=-F5pBWQqvG4 on 5th December 2021
The nephron consists of:
The Renal Corpuscle – consists of the Glomerulus and the Bowman’s Capsule, both of which help in the filtration of the blood plasma
The Renal Tubule – consists of the Proximal Convoluted Tubule, the Loop of Henle and the Distal Convoluted Tubule, all of which allow the filtered fluid to pass through
The Bowman’s Capsule
Retrieved from https://kidneystones.uchicago.edu/glomerular-filtration/ on 5th December 2021
The Endothelial-Capsular Membrane
The endothelial-capsular membrane is the most important aspect of the renal system in which most of the filtration takes place. It filters water and solutes in the blood. Large molecules eg. proteins and formed elements in the blood, are usually unable to pass through it, whilst the water and solutes which are filtered out of the blood pass into the capsular space, and then into the renal tubule.
Retrieved from https://slidetodoc.com/renal-functions-gfr-learning-objectives-enumerate-general-functions/ on 5th December 2021
The Proximal Convoluted Tubule
The proximal convoluted tubule is found in the cortex of the kidney. It reabsorbs 85% of water and sodium chloride as well as glucose which are present in the filtrate, resulting in a reduction in volume, yet no change in the osmolality of the filtrate.
Retrieved from https://baujiti.home.blog/2013/09/25/urine-formation-form-iii/ on 5th December 2021
Retrieved from https://slide-finder.com/match/Lab-Ex-56-.11360.43.html on 5th December 2021
The Ureters
The Ureters are 25-30cm long with a diameter of 1-10mm. These transport urine from the renal pelvis to the urinary bladder through peristaltic (1-5/min) contractions of the muscular walls of the ureters, with additional help by gravity and hydrostatic pressure.
The Urinary Bladder
The urinary bladder is a hallow distendible muscular organ that holds about 700-800ml of urine.
NOTE: In stress incontinence, the responsible muscle is called the external urethral sphincter. This is the same muscle which is trained in pelvic floor exercises.
Retrieved from https://favpng.com/png_view/urinary-bladder-anatomy-excretory-system-urine-autonomic-nervous-system-png/KhR153ik on 5th December 2021
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Rehabilitation nursing focuses on helping people with disabilities and chronic illnesses with the aim of restoring optimal function and health, as well as adapting to a different way of life. The nurse assists the patient to attain as much independence as possible whilst working as a part of a multidisciplinary team.
Rehabilitation is a lifelong process in which the (person) works with the family, the rehabilitation team and society to achieve his optimum level of functioning as a holistic person, with the goals of preventing secondary complications, fostering maximum independence, maintaining dignity and promoting quality of life.
Easton, 1999
Retrieved from https://www.who.int/disabilities/world_report/2011/report.pdf on 5th December 2021
Rehabilitation Goals
improving quality of life
maintaining dignity
emphasising patient’s abilities
maintaining or restoring optimum bodily function
encouraging adaptation to a different way of life where needed
encouraging self-care
encouraging independence
preventing complications
re-educating the patient
re-integrating into society
(Mauk, 2012)
Rehabilitation Centres
acute hospital wards
rehabilitation wards
geriatric day hospitals (eg. Karin Grech Hospital)
geriatric homes
outpatient therapy departments
health centres
psychiatric settings
stroke units (eg. RW8 in KGH)
keep fit classes
personal homes
The nurse is the one most frequently in contact with the patient, thus is able to offer the best continuity of care through rehabilitation nursing.
The four main role functions of rehabilitation nursing are:
Supportive
Restorative
Educative
Life Enhancing
According to the RCN Guidance, 2009, rehabilitation nursing is influential in the following categories:
essential nursing skills
therapeutic practice
coordination
empowerment and advocacy
clinical governance
advice and counseling
political awareness
education
Successful rehabilitation of a patient requires collaboration, communication and coordination.
Rehabilitation shouldn’t start once patient is discharged from acute care…it should start from the first day of admission and if possible in the pre-hospitalisation period.
Rehabilitation nursing involves the diagnosis and treatment of individuals and groups experiencing health problems as a result from altered functional ability, altered lifestyle, and preventative care for potential health problems.
Rehabilitation nursing provides the patients with comfort, therapy, and education, promotes adjustments to an altered lifestyle, and independence when achievable.
Rehabilitation nursing also entails holistic and compassionate palliative care through the provision of comfort and pain relief.
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Neurosurgical nursing care involves caring of patients with neurosurgical conditions – conditions related to the brain, such as brain surgery, spinal surgery and neurological trauma. Patient-centered care is provided to the patient through a multidisciplinary team that includes consultants, HST (higher surgical trainees), BST (basic specialist trainees), HO (house officer), nurses, physiotherapists, occupational therapists, speech therapists, social workers, carers and cleaners.
Anatomy and Physiology of the Brain
Retrieved from https://www.news-medical.net/health/The-Anatomy-of-the-Human-Brain.aspx on 7th November 2021
The brain occupies 80% of the cranium and is comprised of 3 major structures – the Cerebrum, the Cerebellum and the Brainstem. It received 15% of cardiac output, consumes 20% of the body’s oxygen and requires constant circulation to function. Lack of blood supply to the brain results in unconsciousness within 10 seconds and death in 4-6 minutes.
Brain Tumors
Hydrocephalus
External Ventricular Drain
Haematoma
Preoperative Neurosurgical Nursing Care
Patient is orientated to the ward
Past medical and surgical history, social history, as well as list of current medications and allergies are attained
Neurological assessment is performed
Medical notes are attained
A consent form is signed by both the doctor and the patient or legal guardian or next of kin
Blood tests (including cross match) are performed and chased
Imaging results are attained
Pre-surgery fasting is required
Bowel preparation is required
Patient should be washed with Chlorhexidine and dressed up in a hospital gown and TED stockings
Head should be shaved
Certain medications may be omitted in the morning prior to the operation, or changed to IV
Patient pre-op (blue) checklist should be completed
Psychological care and support should be offered to the patient pre-op and post-op, and to family members whilst waiting for the patient to come up from surgery
Postoperative Neurosurgical Nursing Care
Neurological assessment should be performed at least hourly (more frequently if needed, depending on the patient’s condition and level of consciousness
Blood pressure monitoring and SPO2 should be performed continuously
Oxygen administration as required
Blood tests should be performed
Drain care may be required if the patient has a drain with suction, half suction or no suction
Intake and Output charting should be maintained
Urine catheter care should be maintained
Monitor patient for DVT – TED stockings should only be removed for bathing and monitoring purposes
Keep the patient and family updated of any procedures being carried out and reassure
aphasia (a condition which affects a person’s ability to speak, write and understand language, both verbal and written)
dysphagia (difficulty swallowing) – may lead to chest infection, poor nutritional intake, need for enteral feeding
bleeding
raised ICP due to post-op oedema and bleeding
loss of consciousness, confusion, nausea and/or vomiting
visual disturbance
gait disturbance (inability to walk normally)
hemiplegia (lack of limb power)
wound, chest, and/or CSF infection
DVT – LMWH (Low-Molecular-Weight-Heparin) and TED stockings
patient safety should be prioritised so as to avoid falls – assist patients in showering, ensure proper non-slip footwear and avoid slippery floors
constant supervision may be required in confused patients
Possible Post-Op Complication – Dysphagia
Assessing the Level of Consciousness in Neurosurgical Nursing Care
A state of general awareness of oneself and the environment, including the ability to orientate towards new stimuli
Hickey, 2003
Consciousness is a dynamic state resulting from integrated activities of the reticular formation and interaction with the cerebral cortex. To measure the level of consciousness of a patient, we need to measure the patient’s awareness and arousal levels, as well as if appropriate voluntary motor activities are being exhibited.
Do the patient’s eyes open spontaneously as you walk into the room? Or do they open themto command? What type of arousal level is required for this to be performed?
Is the patient aware of surroundings? Check if patient is orientated and notice communication – i.e. is speech delayed, slurred?
Is the patient drowsy and showing incomplete reaction to outside stimuli? Any signs of hallucinations, delusions or delirium?
Is the patient showing signs of stupor (mute, immobile and unresponsive but with open eyes and following external stimuli)?
Coma
A patient in a coma exhibits no voluntary movement or behaviour, and painful stimuli trigger no response. From this state, a patient can either recover to the original level of function (if cause is reversible), or is left with a degree of disabilities (in the case of irreversible damage), or ends up in a persistent vegetative state.
Persistent Vegetative State
Persistent Vegetative State is characterised by profound unresponsiveness in wakeful state as a result of brain damage at any level due to a non-functional cerebral cortex, lack of response to external stimuli, akinesia (loss/impairment of voluntary movement power), mutism (inability to speech), and inability to signal.
Locked-In Syndrome
In locked-in syndrome, the patient is fully aware and awake, has no loss of cognitive function, but is unable to move or communicate verbally due to complete paralysis of the body’s voluntary muscles, except the eyes.
Total locked-in syndrome is a version of the locked-in syndrome where the eyes are unable to move as well.
Brain Stem Death
A patient with brain stem death features irreversible unconsciousness with irreversible apnoea and irreversible loss of brain stem reflexes. Prior to being diagnosed with brain stem death, potential reversible causes such as hypothermia, metabolic causes and toxin/drug effect should be excluded.
Assessing the Level of Consciousness
The AVPU and the Glasgow Coma Scale are assessment tools which allow complete assessing of the conscious level of the patient. These can also be used within the Early Warning Score system.
Retrieved from https://www.researchgate.net/figure/Glasgow-Coma-Scale-and-Score-NICE-2003_tbl1_7857431 on 5th December 2021
Retrieved from https://twitter.com/usmleaid/status/473779270062313473 on 5th December 2021
Retrieved from https://www.ansaroo.com/question/what-can-be-the-causes-of-dilated-and-fixed-pupils on 5th December 2021
Retrieved from https://www.in.gov/bitterpill/files/1Healthcare_Provider_Toolkit_4.8_3.pdf on 5th December 2021
Rapid deterioration of neurological patients is quite possible, and an initial examination is never enough. Continuous neurological assessment AND consecutive neurocharting is a MUST for the identification of patient deterioration. This ensures early identification, management of reversible causes, and thus, reduction of permanent neurological deficit.
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A depressive episode is a period characterised by low mood in conjunction with other depressive symptoms which last for a minimum of 2 weeks.
Typical symptoms of a depressive episode include:
depressed mood
loss of interest and fun
increased fatigue
Other symptoms include:
reduced concentration
reduced self-esteem and self confidence
thoughts of guilt and unworthiness
pessimistic views about the future
ideas or acts of self-harm* and/or suicide
lack of sleep or too much sleep
loss of libido
loss or increase in appetite
psychomotor retardation and agitation
* self-harm doesn’t necessarily mean that the person is suicidal, however, it may be intensive, possibly leading to death
Mild Depressive Episode = 2 or more typical symptoms + 2 or more other symptoms for at least 2 weeks (non-intense symptoms which eventually stop)
Moderate Depressive Episode = 2 or more typical symptoms + 3 or more other symptoms for at least 2 weeks (person experiences difficulty continuing with social, work or domestic activities)
Severe Depressive Episode = all 3 typical symptoms + 4 or more other symptoms for at least 2 weeks (person is not able to continue with daily activities)
INTERPERSONAL PSYCHOTHERAPY (IPT): short-term psychodynamic therapy focusing on current relationships.
COGNITIVE THERAPY: monitoring and identification of automatic thoughts, followed by replacement of negative thoughts with neutral or positive thoughts.
MINDFULNESS-BASED COGNITIVE THERAPY (MBCT): strategies such as meditation to help prevent relapse.
BEHAVIORAL ACTIVATION THERAPY (BA): increases participation in positive reinforcing activities that help disrupt depression, withdrawal, and avoidance.
BEHAVIORAL COUPLES THERAPY: enhances communication and satisfaction.
Biological Treatments
ElectroConvulsive Therapy (ECT): induces brain seizure and momentary unconsciousness; this method is reserved to individuals who do not respond to treatment.
Transcranial Magnetic Stimulation for Depression (TMS): in this method, which is reserved for those who fail to respond to first antidepressant, an electromagnetic coil is placed against the scalp.
Psychopharmacology for Depressive Episode
Monoamine Oxidase Inhibitors (MAOIs)
Phenelzine (Nardil); Isocarboxazid (Marplan)
Not supported as first line anti-depressants due to safety, tolerability, restrictive dietary requirements
Foods containing Tyramine such as dry, aged, fermented meat, aged cheese, marmite, tap beer, and sauerkraut should be avoided as these can trigger a hypertensive crisis
A hypertensive crisis is characterised by headaches, nausea, palpitations, vomiting, and sweating
Retrieved from https://www.uspharmacist.com/article/so-many-options-so-little-difference-in-efficacy-what-is-the-appropriate-antidepressant on 1st December 2021
Retrieved from https://www.uspharmacist.com/article/so-many-options-so-little-difference-in-efficacy-what-is-the-appropriate-antidepressant on 1st December 2021
Block the reuptake of serotonin on the pre-synaptic membrane
Retrieved from https://www.uspharmacist.com/article/so-many-options-so-little-difference-in-efficacy-what-is-the-appropriate-antidepressant on 1st December 2021
Block the reuptake of serotoninand norepinephrine on the pre-synaptic membrane
Retrieved from https://www.uspharmacist.com/article/so-many-options-so-little-difference-in-efficacy-what-is-the-appropriate-antidepressant on 1st December 2021
Nursing Approach to a Depressive Episode
Value the individual as a person with unique values and beliefs
Respect personal space
Reserve time to talk
Build therapeutic nurse-patient relationship in a non-judgemental way through active listening and simple questioning
Monitor the person’s physique – ask regarding sleeping pattern, weight fluctuations and fluid status
Monitor the person’s cognition – ask regarding interaction and conversation with others
Monitor the person’s behaviour – notice if the person is showing evident signs of self-neglect and psychomotor retardation
Keep a continuous risk-assessment, including risk of self harm and suicide
Depressive Episode Nursing Care Plan
The following Depressive Episode Nursing Care Plan is based on the situation shown in the above video…
Immediate Goals
compile full history including current depressive episode and any possible other similar episodes in the past
compile a list of current medications and other comorbidities to ensure that therapy suggested is suitable for the person
person should be prescribed psychopharmacological therapy such as SSRIs; to be started immediately
refer for psychological therapy such as CBT
ensure person safety especially with regards to suicidality
ensure that her children are being well cared for; encourage her to seek out help if need be
Short Term Goals
review medication and see if any changes in dose or type of prescribed drugs need to be adjusted/changed
educate about compliance to medication and the importance of avoiding any foods if the person has been prescribed MAOIs
make sure that the person has started to sleep adequately; prescription for sleeping pills should be considered so the person can rest well during the night
educate the person about the importance of continuing psychological therapy eg. CBT so coping techniques can be learned to avoid relapse or prolonged depressive episode
encourage nutritional food intake and adequate fluid intake and if need be encourage nutritional support through the help of a nutritionist
teach the importance of keeping with follow-up appointments
encourage the person to start investing some time daily of interaction/games with the children, even if it is a couple of minutes, increasing slowly
encourage social interaction and job retainment/attendance
encourage the person to restart investing time in her hobbies or pick up new hobbies
consider suggesting development of a routine including working hours and financial planning
explore the person’s relationships with family and partner and suggest Behavioral Couples Therapy
Long Term Goals
re-assess symptoms
review medication and psychological therapy and their effectiveness
consider change of treatment if need be
ensure job retainment
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Mood disorders are mental health issues which primarily affect a person’s emotional wellbeing through long periods of extreme happiness, sadness, or a combination of both. In general, mood changes are considered to be normal. However, when symptoms become persistent for several weeks or months, a mood disorder may be diagnosed. Mood disorders may cause behavioural changes, and at times may also affect a person’s ability to deal with day-to-day activities such as work and school.
Mood Disorders feature a change in mood (sustained emotional attitude) or affect (others’ perception of the person’s emotional state). This change is usually accompanied by a change in the overall activity level of the person, along with other symptoms secondary to or relevant to the said change. This period tends to be recurrent, with the onset of each individual episode being triggered by neurobiological or psychosocial factors.
Mood Disorders: 7 Main Categories
Manic Episode
Bipolar Affective Disorder
Depressive Episode
Recurrent Depressive Disorder
Persistent Mood (Affective) Disorder
Other Mood (Affective) Disorder
Unspecified Mood (Affective) Disorder
(ICD-10, WHO)
Neurobiological Factors Triggering Onset of Mood Disorders
Genetic
Neurotransmitters: norepinephrine, dopamine, and serotonin
Neuroendocrine System: overactivity of the hypothalamic-pituitary-adrenal axis
Retrieved from https://slideplayer.com/slide/4887500/ on 30th November 2021
Retrieved from https://slideplayer.com/slide/7060321/ on 30th November 2021
Retrieved from https://slideplayer.com/slide/4887500/ on 30th November 2021
Psychosocial Factors Triggering Onset of Mood Disorders
Life events eg. romantic breakup, job loss, death of a loved one, lack of support…
Interpersonal difficulties eg. high levels of expressed emotion by family member; marital conflicts
Rejection – caused by behaviour of depressed people eg. negative self disclosures, slow speech etc.
Neuroticism – trait disposition to experience negative affects, including anger, anxiety, self‐consciousness, irritability, emotional instability, and depression
Psychological Factors: Cognitive Theories
Overview of DSM-5
Retrieved from https://slideplayer.com/slide/8352303/ on 30th November 2021
ICD-10 vs DSM-5
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