Nursing Skills Archives - Page 9 of 18

Diet for Chronic Kidney Disease

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Chronic Kidney Disease is characterised by progressive and irreversible loss of kidney function which occurs over a period of months or years. Ignoring chronic kidney disease leads to end-stage renal failure which requires dialysis or kidney transplantation. Adapting to a personalised diet for chronic kidney disease helps to prolong reaching end-stage renal failure through improvement in the patient’s nutritional status and compensation for the ongoing catabolic events.

Considerations ~ Diet for Chronic Kidney Disease

Personalised Modifications for patients undergoing dialysis are recommended in the following dietary aspects: calories, protein, sodium, potassium, phosphorus, calcium, fluids, carbohydrates, and cholesterol (fat).
Ideal Caloric Intake for adults undergoing dialysis = 35kcal/kg for individuals up to 60 years old; 30kcal/kg for individuals from 60 years old and for obese individuals.
Blood serum levels should be checked every few months so any diet-related adjustments are made earlier on.

A Diet for Chronic Kidney Disease requires ongoing monitoring of the patient’s Lab Results, Oral Intake, Nutritional Supplements, Dietary Reviews and Changes based on patient’s needs and results & most importantly Compliance to Medication and Diet.

Proteins

Proteins provide energy and help fight infection whilst maintaining fluid balance within the blood.

Proteins with high biological value = meat, fish, eggs, poultry, tofu, soya milk & dairy (beef/red meat is better than chicken for patients with kidney failure).

Proteins with low biological value = bread, grains, vegetables, dried beans, peas & fruit.

Phosphorus

Phosphorus helps build strong healthy bones whilst maintaining health within other parts of the body. It is found in almost all foods. In chronic kidney disease, the balancing of phosphorus during the kidneys’ filtering process is impaired, leading to an increase of phosphorus in the blood.

In a diet for chronic renal disease, high-phosphorus foods which include dairy products, dried beans and peas, nuts, bran cereals, whole wheat bread, meats, peanut butter and food additives should be limited or avoided as much as possible. Dietary intake of phosphorus in patients with chronic kidney disease should not exceed 1.5g per day.

Potassium

Potassium has an important role in heartbeat regulation. Potassium level should be monitored so hyperkalemia is avoided as this may lead to a myocardial infarction a.k.a. heart attack.

In a diet for chronic kidney disease, the dietary goal for potassium is between 2-3g per day. High-Potassium foods such as prunes, oranges, bananas, potatoes, tomatoes, brussel sprouts, spinach, beets, dried foods and milk should be avoided.

Sodium

Sodium has an important role in nerve and muscle function, as well as promotes water and electrolyte balance within the body. However, too much sodium in the blood may lead to hypertension and congestive heart failure.

In patients with chronic kidney disease, special attention should be given in controlling sodium intake. Patients on haemodialysis should consume between 2-4g of sodium per day. It is good to keep in mind that 1 teaspoon of salt contains 2000mg of sodium, thus, foods that are high in sodium such as processed and deli meats, canned soups and salty snacks should be avoided.

Fluids

Retrieved from https://www.luxuriousmagazine.com/drink-water-while-working-from-home/ on 26th December 2021

For a patient undergoing dialysis, fluid intake should be measured so the recommended intake amount is not exceeded. For patients undergoing haemodialysis, recommended fluid intake should take into consideration any fluid gains, blood pressure, and residual renal function. As for patients undergoing peritoneal dialysis, recommended fluid intake should be based on patient tolerance and minimum use of hypertonic solution for fluid balance maintenance.

Fluids include all drinks and foods that become liquid at room temperature, i.e. water, coffee and tea, soda, soups, juices, and jelly. Total intake of such fluids cannot exceed the individualised recommended amount which is usually between 1.5-2ltr per day.

Patients with kidney failure cannot get rid of extra fluid in their body, and so, the recommended daily intake shouldn’t be exceeded since extra fluid in patients with kidney failure results in oedema.

Calcium

Calcium in the body helps in building and maintaining strong bones, and has a role in the correct functioning of the nerves and muscles, including the heart.

Patients undergoing haemodialysis require balance, which is determined by the dietary calcium intake, vitamin D therapy, dialysate calcium levels, calcium supplements and calcium-based binders, as well as the monitoring of Parathormone or Parathyrin (hormone that regulates serum calcium concentration) by the physician.

Carbohydrates

Carbohydrates are nutrients which the body converts into glucose to produce energy for body function.

In patients with diabetes and chronic kidney disease, the ideal HgA1C is usually less than 7%.

Cholesterol

Cholesterol helps the body produce cell membranes, hormones and vitamin D. Too much cholesterol however may lead to cardiovascular disease, which incidentally is the most frequent cause of death in patients with kidney disease.

A diet for chronic kidney disease should take into consideration the individual’s metabolic profile, nutritional status, energy deficits, along with any other treatment goals.

Fast Foods, Italian & Asian foods

FAST FOODS

Fast foods are high in sodium content as they are usually pre-salted;
Fast food fries and baked potatoes are high in potassium – chronic kidney failure patients should ask for smaller and (if possible) unsalted servings;
Sauces, condiments and dressings should be avoided as these are high in sodium;
Balancing fast food with other food choices is recommended- ideally one should opt for healthier options in the day’s additional meals;
Broiled, steamed and grilled items are better options when compared to deep fried foods;
Larger-sized beverages should be avoided as these may lead to fluid overload
Removing the skin from fast foods reduces the fat and sodium content

ITALIAN CUISINE

The Italian cuisine has a lot of foods to offer for patients on a diet for chronic kidney disease;
Red sauces contain potassium;
White sauces contain a high amount of phosphorus;
Pesto is made of garlic, basil and oil, making it an ideal choice;
With salads or breads, one should ask for no olives and cheese, and request the dressing on the side;
Pasta dishes like lasagna, cannelloni and ravioli should be avoided since these are high in sodium, high in potassium and high in phosphorus.

ASIAN CUISINE

Asian cuisine typically contains a high amount of sodium. Asian soups and broth-cooked noodles should be avoided;
Chinese foods typically contain a large amount of sauces and condiments which are high in sodium and MSG (Monosodium Glutamate – water, sodium and glutamate). Ideal Asian food choices in a diet for chronic kidney disease include egg rolls, steamed rice, and stir-fry vegetable dishes without sauces;
Japanese foods typically contain more spices but less sodium. Ideal Japanese food choices in a diet for chronic kidney disease include sashimi and sushi (avoid california rolls with avocado), and grilled fish or chicken without sauces;
Thai foods typically contain more spices but less sodium. Ideal Thai food choices in a diet for chronic kidney disease include spring rolls, steamed rice, and grilled fish and chicken dishes without sauces.

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Haemodialysis, Peritoneal Dialysis and Kidney Transplantation

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In normal renal physiology, the kidneys remove waste and excess water from the body and release hormones such as renin (which regulates blood pressure), erythropoietin (which stimulates red blood cell production), and vitamin D (which promotes normal bone structure). However, in kidney failure or End Stage Renal Disease (ESRD), renal function becomes compromised and waste products and toxic materials start to accumulate rather than get excreted. This may cause permanent irreversible damage to the body’s cells, tissues, and organs. In End Stage Renal Disease, the kidneys function at less than 20% of their required capacity, and renal replacement therapy in the form of haemodialysis, peritoneal dialysis or kidney transplantation becomes a requirement.

Risk Factors for End Stage Renal Disease

inflammatory diseases
chronic infections
chronic diseases
blockage in the urinary collecting system
genetic disorders (rare)

Symptoms of End Stage Renal Disease

itching
nausea and vomiting
puffiness surrounding the eyes
swollen hands and ankles
lack of appetite
decreased urination
haematuria (blood in the urine)
anaemia
sleep disturbances
hypertension

If creatinine level in the blood increases to 900μmol/l and kidney failure is confirmed, treatment can be initiated in the form of dialysis (haemodialysis or peritoneal dialysis) or kidney transplant.

Haemodialysis vs Peritoneal Dialysis

Haemodialysis

Haemodialysis is a process that works based on the principle of diffusion, by which the blood of a patient with end stage renal disease is pumped out of the body and into a machine to be filtered and cleaned from excess waste products and water.

Haemodialysis is a fast process in which most often, the patient ends up feeling exhausted. The patient may also experience a hypovolaemic shock, which can be reversed quickly through the same pump by IVI (reversal usually takes just around 2 minutes to be completed).

The higher the bloodflow, the better the blood filtration; the larger the needle, the better the bloodflow.

Heparin is administered so as to help avoid blood clotting during the haemodialysis process.

The Haemodialysis process should be repeated 3 times a week on alternate days for 3 to 5 hours per visit.

HAEMODIALYSIS ADVANTAGES:

performed in the dialysis centre amongst healthcare professionals
regular contact with other service receivers and providers
permanent access required via an internal route
treatment is performed 3 times per week

HAEMODIALYSIS DISADVANTAGES:

traveling to and from dialysis centre is required per treatment
restricted diet and fluid intake required
fixed schedule for treatment
minimum two needle sticks are performed per treatment
rendered immobile during treatment

‘Washout Syndrome’ in Haemodialysis

weakness
fatigue
tremor
starts towards end of treatment or minutes following treatment
lasts 30 minutes or 12-14 hours in a dissipating form

Peritoneal Dialysis

In peritoneal dialysis, dialysis solution is passed into the peritoneal cavity through a catheter. With this method, it is the peritoneum itself that acts as a filter.

There are two different peritoneal dialysis methods:

Continuous Ambulatory Peritoneal Dialysis (CAPD) performs 4 exchanges throughout the day in 45 mins per session;
Automated Peritoneal Dialysis (APD) performs an exchange during the night while the patient is asleep.

PERITONEAL DIALYSIS ADVANTAGES:

the patient is directly involved in self-care
the patient has more control over self-treatment
may be performed during the night (using the Automated Peritoneal Dialysis method)
less restrictions required in relation to diet and fluids
this method is the closest to normal kidney function
ideal for patients with underlying heart disease due to it causing less severe cardiovascular instabilities

PERITONEAL DIALYSIS DISADVANTAGES:

body image change
4 exchanges are required per day
permanent external catheter
risk of infection
storage space is required for supplies
in Automated Peritoneal Dialysis, the patient is restricted/tied to the dialysis machine during the night

PERITONITIS:

If bacteria manages to travel into the peritoneum, the patient suffers from peritonitis, which is an inflammation of the peritoneum. This causes the peritoneum to weaken, and eventually, may require the patient to be switched to haemodialysis instead.

Kidney Transplantation

In kidney transplantation, a (compatible) kidney is removed from a living (donor) relative, friend, or a brain-dead individual, and is then surgically placed into the patient with end stage renal disease.

Unfortunately, this method is not always recommended. Medication is given to patients following kidney transplantation which suppresses their immune system so the body accepts the new kidney. This however may worsen the patients’ general health, and so, for this reason, a patient may not be deemed fit enough to undergo kidney transplantation.

KIDNEY TRANSPLANTATION ADVANTAGES:

better quality of life
better health
no diet and fluid intake restriction required
frequent dialysis treatment is not required
reduced medical cost
less severe cardiovascular instabilities are caused in patients with underlying cardiovascular disease

KIDNEY TRANSPLANT DISADVANTAGES:

surgery-related pain and discomfort
risk of kidney transplant rejection by the patient’s body
increased risk of infection
ongoing medication is required for life
frequent visits to the physician are required

Additional Notes…

Kidney function includes: removal of waste products, maintaining water balance, maintaining electrolyte balance, maintaining pH balance, Vitamin D metabolism, and excretion of drugs and poison.

A higher amount of creatinine is usually found in men, and especially in individuals with a higher muscle mass.

Urea results from breakdown of protein. In pregnancy, urea is very low as protein is required for fetal growth.

The kidneys have no function in temperature control.

Hypertension causes kidney damage over the years, unless controlled.

Obesity is a risk factor for kidney failure.

Kidney failure causes water imbalance in the body. If water is consumed excessively by a patient with kidney failure, oedema may result. Thus, water should be consumed in moderation.

The normal range of potassium level should be between 3.5-5.1; At potassium level 7, muscles cease to work – this includes the cardiac muscle a.k.a. the heart.

A patient with renal failure is prone to acidosis. Urine is acidic, and so, if a patient with kidney failure doesn’t excrete urine as necessary, the acid stays in the blood, leading to acidosis.

NSAIDs such as Catafast, Voltaren, Brufen and Arcoxia cause kidney problems if taken long term, thus, should be consumed under medical supervision.

EGFR stands for Estimated Glomerular Function Rate – which is an estimate of how the filtration in the kidneys is functioning. A normal EGFR is usually around 100. An adult around 60 years of age normally has an EGFR of about 70. An EGFR of 15 shows urgent dialysis requirement.

Chronic Renal Failure can only be indicated by blood tests and urine sampling. An EGFR of around 50 usually exhibits no symptoms. Patients with renal failure usually start exhibiting certain symptoms when the EGFR is somewhere between 10-30 – when dialysis should have been started at around EGFR 50.

In diabetes, hyperfiltration of the kidneys is commonly found due to the kidneys being uncontrollable. In this case, glucose should be eliminated if possible, so as to promote a decrease in the damage being incurred to the body through hyperfiltration. During hyperfiltration, EGFR is usually somewhere around 120-130, however, at some point it drops abruptly to around 30 or less, indicating kidney failure.

Following kidney transplantation, the new kidney is not placed in its usual location – it is placed under the belt, to the side. Due to this positioning, a patient with a kidney transplant can easily rupture if the abdomen is hit, and so, sports, fighting, etc., are not recommended for such patients.

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Common Kidney Diseases

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In normal renal physiology, the kidneys remove waste and excess water from the body and release hormones such as renin (which regulates blood pressure), erythropoietin (which stimulates red blood cell production), and vitamin D (which promotes normal bone structure). However, when kidney disease is involved, renal function becomes compromised and waste products and toxic materials start to accumulate rather than get excreted. This may cause permanent irreversible damage to the body’s cells, tissues, and organs. In this blogpost we are going to go through the most common kidney diseases.

Common Kidney Diseases

Polycystic Kidney Disease
Hypertensive Nephrosclerosis
Glomerulonephritis / Glomeruloscleroisis
Urinary Tract Infections
Kidney Stones
Diabetic Kidney Disease
Analgesic Nephropathy

Polycystic Kidney Disease

One of the most common kidney diseases is polycystic kidney disease, which is acquired genetically. In polycystic kidney disease, fluid-filled cysts develop within the kidneys. These cysts replace normal kidney tissue, leading to end-stage renal disease.

Polycystic Kidney Disease can be either DOMINANT or RECESSIVE. In the Dominant form, a parent who has the genetic disease passes it to the child (50% chance).

Signs & Symptoms

dull pain at the side of the abdomen and the back
upper abdominal discomfort
frequent UTIs
haematuria (blood in the urine)
hypertension

Treatment

control hypertension
treat UTIs with antibiotics
maintain kidney health if diagnosed with chronic kidney disease
provide dialysis or opt for kidney transplantation if diagnosed with end-stage renal disease
administer analgesics for pain relief or opt for the shrinking or resection of the cysts through surgery

Hypertensive Nephrosclerosis

Hypertensive Nephrosclerosis is progressive kidney damage resulting from untreated longstanding hypertension due to blood vessel thickening.

Signs & Symptoms

headaches
neck discomfort
nausea
vomiting
easily tired
proteinuria (protein in the urine)

Treatment

encourage regular exercise
encourage decrease in dietary salt (maximum 2g daily)
administer hypertensives to control hypertension

Glomerulonephritis & Glomerulosclerosis

Glomerulonephritis is the inflammation of the glomeruli (where filtration takes place) in the kidneys. The onset of glomerulonephritis can be either chronic or acute. It can be caused by IgA nephropathy (inflammation in the kidney tissue), Streptococcus bacteria, and autoimmune disease. Similarly, Glomerulosclerosis is the scarring of the glomeruli in the kidneys.

Signs & Symptoms

swelling in the leg/s
haematuria
proteinuria (produces frothy urine)
dark or pink-coloured urine
additional signs in relation to comorbidities such as diabetes or autoimmune disease eg. weight loss, skin rash, arthritis…

Treatment

control hypertension
suggest dietary modifications
promote a better lifestyle
administer medication for the reduction of urinary protein
administer medication for inflammation suppression eg. steroids

Urinary Tract Infections (UTI)

Urinary Tract Infections occur when microorganisms attach to the urethra and start multiplying. This is a common occurrence in women. If left untreated, urinary tract infections may result in pyelonephritis – an infection of the kidneys, which can cause permanent kidney damage.

Conditions such as diabetes, use of a urinary catheter, abnormalities of the urinary tract, pregnancy, or obstructed urine flow (due to kidney stones or an enlarged prostate) increase the risk of acquiring a urinary tract infection.

Signs & Symptoms

increased frequency of urination
increased urgency to urinate
painful urination
pain in the lower abdomen
hot foul-smelling urine
nausea
vomiting
haematuria
fever

Treatment

encourage increased fluid intake
administer antibiotics to treat infection

Kidney Stones

Kidney stones a.k.a. renal calculi, nephrolithiasis or urolithiasis, are hard deposits of minerals and salts which form within the kidneys. Kidney stones are more common in men between 20-40 years of age.

Signs & Symptoms

extreme localised pain
painful and/or difficult urination
inability to pass urine (if kidney stone obstructs urine outlet completely due to large size)
haematuria (due to abrasion caused by the traveling kidney stone)

Treatment

encourage increased water intake (most stones may pass through if not too big)
administer pain relief
administer medication to break down large kidney stones
shockwave therapy
surgery (cystoscopy or open surgery)

Diabetic Kidney Disease

One of the most common kidney diseases is Diabetic Kidney Disease. Diabetes is the most common cause of end-stage renal disease. Diabetes (type 1 and type 2) damage the blood vessels in the kidneys. Additionally, hypertension in diabetics increase the risk for diabetic nephropathy. Diabetic Kidney Disease is most commonly found in chronic and poorly controlled diabetics.

Signs & Symptoms

itching
lethargy
nausea
vomiting
weight loss
nocturia (increased need for urination at night)
swelling in the leg/s
proteinuria (produces frothy urine)
hypertension

Treatment

treat urinary tract infections if present (common occurrence in diabetics)
diabetes control
blood pressure control
encourage low protein diet
administer medication to reduce protein excretion

Analgesic Nephropathy

Long-standing analgesic ingestion is a risk factor for chronic kidney disease. Analgesics such as NSAIDs are commonly used by individuals with conditions that require constant need of pain relief, but such medications increase the risk of end-stage renal disease.

Signs & Symptoms

haematuria
proteinuria (produces frothy urine)
lethargy
lack of appetite
nausea
vomiting
swelling of the leg/s

Treatment

reduce as much as possible the use of analgesics
special precaution should be taken by individuals with known kidney disease so as to reduce or possibly eliminate the use of analgesics

Additional Notes…

In patients with kidney disease:

teach patient about the importance of fluid restriction – patient should not drink more than 1.5ltr per day
teach patient about sodium restriction
with regards to nursing documentation, food charting as well as intake & output charting are important

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Eating Disorder Signs, Symptoms & Recommended Treatment

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An eating disorder is a psychiatric disorder in which severe disturbances in eating behaviours and related thoughts and emotions are experienced. Most often, signs and symptoms of an eating disorder are first experienced in adolescence or early adulthood, with the onset usually being a stressful life event. Eating disorder types include:

Anorexia Nervosa
Bulimia Nervosa
Binge Eating
Pica
Pervasive Arousal Withdrawal Syndrome (PAWS)

An Eating Disorder is NOT a Lifestyle Choice!

Anorexia Nervosa

An individual with anorexia nervosa aims to lose weight deliberately through restricted dietary choices, excessive exercise, induced vomiting, appetite suppressants, and diuretics.

Anorexia Nervosa symptoms include:

muscle weakness
irregular menstrual cycle
hair thinning
dental problems
impaired functioning of the immune system

Common comorbidities of anorexia nervosa include depression, OCD, social phobia, and PTSD.

Bulimia Nervosa

Bulimia Nervosa features similar psychological features in anorexia nervosa. An individual with this eating disorder experiences excessive worry about ways to control body weight, and so, aims to eat excessive amounts of food, followed by induced vomiting. These bingeing episodes usually happen several times a week.

Individuals with bulimia nervosa may have a history of anorexia nervosa, with the switch to bulimia nervosa frequently resulting from worrying of family members or friends.

NOTE: Body weight of individuals with bulimia nervosa may range from slightly underweight to obese.

Pica

Pica, which is an eating disorder that commonly affects children under the age of 6, is the persistent eating of substance which have no nutritional value such as clay, dirt, and flaking paint. Pica can feature as an individual psychopathological behaviour, or as one of the symptoms of another psychiatric disorder, such as autism.

Common causes of Pica include malnutrition and iron-deficiency anaemia.

Diagnosis requires the eating disorder to be developmentally inappropriate, and to persist for at least a month.

Pervasive Arousal Withdrawal Syndrome PAWS

Pervasive Arousal Withdrawal Syndrome (PAWS) a.k.a. Pervasive Refusal Syndrome is characterised by food and drink refusal with sudden onset following a tough health-related situation such as illness, pain or virus, or a traumatic event. PAWS is in fact commonly experienced by child refugees.

Refusal of food and drink may also be accompanied by social withdrawal, partial or complete lack of self-care, and partial or complete mobilisation refusal.

An individual with Pervasive Arousal Withdrawal Syndrome quite commonly resists any encouraging attempts of interaction or food/drink intake.

Eating Disorder Treatment

Psychopharmacology

Anti-depressants
Anti-psychotics
Mood stabilisers

Psychosocial Interventions

Individual psychotherapy
Group psychotherapy
Family psychotherapy
Medical care
Nutritional Counseling
Cognitive Behavioural Therapy CBT

In Malta, individuals with eating disorders can be referred to Dar Kenn Għal Saħħtek, which offers day services as well as in-patient services.

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Obsessive Compulsive Disorder OCD and Dissociative Disorder DD

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Obsessive Compulsive Disorder OCD

Obsessive Compulsive Disorder a.k.a. OCD is a common chronic long-lasting disorder in which an individual experiences uncontrollable repeated obsessions or behaviours. Children and adolescents may experience Obsessive Compulsive Disorder too, with multiple obsessions and compulsions possibly changing content over time.

Common obsessions include excessive fear of dirt, germs or sickness, excessive fear of a loved one being in danger, obsessions related to religion or sex, as well as an uncontrollable need for symmetry and exactness.

Common compulsions include ritualistic handwashing, repetitions, checking, counting, ordering, hoarding, and touching.

Tic Disorder

Tourette Syndrome (TS) is a condition related to the nervous system which causes individuals to experience tics. Tics are sudden, rapid, non-rhythmic twitches and movements (motor tics) or sounds (vocal tics) that affected individuals repeat over and over, with no control whatsoever. Children who are diagnosed with tic disorder can also exhibit associated behavioural difficulties.

Dissociative Disorder DD

Dissociative disorder is a mental disorder involving disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity. Individuals with dissociative disorders experience problems with day-to-day functioning as they tend to escape reality involuntarily. This disorder has been linked with childhood trauma.

Dissociative disorder symptoms may include amnesia, disturbances in sense of self, trance-like states, rapid mood shifts and behaviour, knowledge-memory-skills access fluctuations, hallucinations (auditory and visual), and vivid imaginary friendships (in children and adolescents). Stress tends to exacerbate these symptoms.

Treatment for dissociative disorders includes a combination of psychotherapy and medication. Although difficult to treat, early identification and intervention increases the chance of affected individuals being able to lead healthy and productive lives.

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Anxiety and Depression in Children and Adolescents

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Depression in Children

One of the top 5 most common mental health disorders in children is depression. Diagnosing depression in children is quite challenging since they may still experience periods of normal functioning despite their underlying disorder. As for diagnosing depression in adolescents, it becomes difficult to distinguish between the normal teen-related mood changes and those that come with depression. Nevertheless, early diagnosis is important since if depression in children is overlooked, it may persist through adulthood.

Signs and Symptoms of Depression in Children

persistent low mood
persistent sadness
lack of interest in activities they used to enjoy
a lingering feeling of tiredness and exhaustion
lethargy
agitation
sleeping too much or too little
eating too much or too little
feeling numb/emotionless
ongoing guilty feelings
poor memory
poor concentration
lack of self-esteem
lack of self-confidence
self-harming thoughts
suicidal thoughts

Anxiety and Depression in Children

Anxiety Disorders in Children

Separation Anxiety Disorder – child experiences fears related to an attachment figure being harmed or dying

Social Phobia a.k.a. Social Anxiety Disorder – fear of being watched and judged by others

Generalised Anxiety Disorder – worrying on different events or circumstances

Specific Phobia – fear of a particular object or stimulus

Panic Disorder – sudden panic attacks related to somatic and cognitive sensations

Emotional Unstable Personality Disorder EUPD

Emotionally Unstable Personality Disorder a.k.a. Borderline Personality Disorder is the most common type of personality disorder. EUPD causes intense fluctuating emotions that may last for a few hours to several days at a time. Emotions experienced may include impulsivity, risky behaviour, suicidal thoughts, and possibly self-harm.

A diagnosis of Emotionally Unstable Personality Disorder is usually given in adulthood as the related symptoms are associated with a lifelong personality disorder.

Substance Abuse

Substance abuse refers to the use of illegal drugs or prescription drugs or over-the-counter drugs or alcohol for purposes other than those for which they are meant to be used, or in excessive amounts.

Alcohol, marijuana and opiates mimic depression symptoms, causing lack of concentration, lack of motivation, and low energy. On the other hand, Amphetamine and Cocaine mimic mania symptoms. Substance abuse tends to trigger social, physical, emotional, and occupational problems.

Individuals with Bipolar Disorder and Depression have an increased risk of substance abuse.

NOTE: Substance abuse does not rule out a mood disorder.

Self-Harm

Self-harm a.k.a. self-injury is a behavioural act in which an individual intentionally harms him/herself, usually without suicidal intention. Adolescents may seek to self-harm as a way of expressing tension, low self-esteem, physical discomfort, and pain. At times, self-harm is sought as a risk-taking act, rebellion against parents, or as an attention-seeking behaviour. However, self-harm can indicate severe psychiatric disorders such as depression, psychosis and PTSD.

Self-harming behaviour is also associated with children having developmental delays, including Autism Spectrum Disorder, and those who have experienced abuse or abandonment.

Suicide

Suicide is one of the main causes of death in children and adolescents. Severe bullying increases the risk of suicide. Additionally, being diagnosed with depression, ADHD, anxiety disorder, Attention Deficit Disorder (ADD), bipolar disorder, or schizophrenia during childhood also puts the child at a higher risk of suicide.

Reference: https://save.org/about-suicide/

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Conduct Disorder CD and Oppositional Defiant Disorder ODD

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Conduct Disorder

Conduct Disorder (CD) is the most common psychiatric disorder in the world. It is characterised by persistent anti-social behaviour where social rules are repeatedly broken and aggressive acts are repeatedly performed with the aim of upsetting others. Many children and adolescents with a Conduct Disorder diagnosis grow up into anti-social adults.

Conduct Disorder Signs & Symptoms

repetitive and persistent violation of societal norms, rules, laws, and basic rights of others
aggression, property destruction, theft, and deceitfulness
behavioural severity that leads to significant impairment in various areas of functioning
prolonged behavioural pattern lasting a year or more (thus, isolated criminal acts do not lead to a Conduct Disorder diagnosis)

Reference: https://www.icd10data.com/ICD10CM/Codes/F01-F99/F90-F98/F91-

Oppositional Defiant Disorder

Oppositional Defiant Disorder (ODD), a disruptive disorder which often accompanies ADHD, features ongoing behavioural patterns that cause significant impairment in a child’s social, academic and occupational life.

Oppositional Defiant Disorder Signs & Symptoms

bad temper
easily annoyed
angry or resentful
spiteful or vindictive
defying rules
refusing to comply with requests
argumentative with adults
deliberately seeks to annoy others
blaming others for own mistakes

Reference: https://icd.who.int/browse10/2019/en#/F91.3

Overview of CD, ODD & More…

Risk Factors for Conduct Disorder & Oppositional Defiant Disorder

anti-social parents
anti-social peers
lack of parental supervision
disruptive family behaviour
child abuse
child neglect
negative parental discipline
cold parental attitude
parental conflict
low family income
low IQ / low academic achievement
impulsiveness
attending high-crime-incidence schools
living in a high-crime-incidence neighbourhood

Treatment for CD & ODD

Psychosocial Interventions

Parental Training
Limit Setting Implementation
Cognitive Behavioural Therapy (CBT)
Family Therapy

Psychopharmacology

Stimulants – help reduce aggression
Anti-Depressants – SSRIs help reduce impulsive and aggressive behaviour
Lithium and Anti-Convulsants – help reduce aggression
Clonidine – help reduce impulsivity and aggression

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Attention Deficit Hyperactivity Disorder ADHD

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Attention Deficit Hyperactivity Disorder (ADHD) is one of the most common neuro-developmental disorders related to childhood. Although ADHD is most commonly diagnosed in childhood, it usually lasts well into adulthood. Children diagnosed with ADHD tend to find it hard to pay attention, are prone to controlling impulsive behaviour without any form of reflection, and are usually overactive.

Understanding ADHD – Simulation

Varying Types of Attention Deficit Hyperactivity Disorder

Predominantly Inattentive Presentation – characterised by distractibility, lack of organisational skills, lack of inability to complete tasks, and inability to follow instructions.

Predominantly Hyperactive-Impulsive Presentation – characterised by difficulty in being still, excessive fidgeting and movement, restlessness and impulsivity.

Combined Presentation – characterised by a combination of all symptoms: inattention, hyperactivity and impulsivity.

ADHD Diagnosis

For a child to be diagnosed with ADHD, the following must be evident in multiple settings eg. at home, at school, with friends, with family, even if in varying degrees:

at least 6 months of inattention (distractibility and organisational problems) with or without hyperactivity (lack of behavioural self-control/difficulty remaining still/excessive motor activity) and impulsivity (reacting to surrounding stimuli without thinking/reflecting on possible outcomes)
such behaviour needs to have a direct negative impact on the child’s functionality academically/occupationally or socially
deficit related to inattention, hyperactivity and impulsivity should be over the limit expected per child’s age

Reference: https://www.icd10data.com/ICD10CM/Codes/F01-F99/F90-F98/F90-

Attention Deficit Hyperactivity Disorder Risk Factors

Genetics
Premature birth / low birth weight
Head trauma
In-utero or childhood exposure to environmental toxins
In-utero exposure to alcohol and/or tobacco

ADHD Treatment

Psychosocial Interventions

Behaviour Management training for parents
Behavioural Interventions in the school setting
Organisational Skills Training

Psychopharmacology

Stimulants (fast effect) eg. Ritalin and Concerta
Non-Stimulants (slow-release yet longer effect) eg. Strattera (SNRI), and Clonidine (alpha-adrenergic agonist)

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Autism Spectrum Disorder

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Autism Spectrum Disorder (ASD) is a developmental disorder in which both communication and behaviour are affected. Signs and symptoms tend to start showing up during the first two years of life. A child with ASD exhibits issues related to social interaction, communication and play, and interest restrictions.

Autism Spectrum Disorder is considered to be a chronic disability. Through early intervention, symptoms can be improved.

Reference: https://www.nhs.uk/conditions/autism/

Understanding Autism – Simulation

Autism Spectrum Disorder Diagnosis

For an accurate Autism Spectrum Disorder diagnosis, a child’s developmental and behavioural history is required, from which certain criteria can be evident by the age of 3. These include:

inability to initiate and maintain social interaction
inability to initiate and maintain communication
behavioural patterns which are restrictive, repetitive and inflexible
unusual interests or activities which at times may seem excessive
impairment in functional abilities related to self, family, and society, including school/work

Note: Child may still exhibit intellectual functioning and language abilities.

Reference: https://icd.who.int/browse10/2019/en#/F84.0

Autism Spectrum Disorder Risk Factors

Genetic – having a sibling with ASD, or having certain chromosomal conditions such as tuberous sclerosis (genetic disorder which causes benign tumors to develop in various parts of the body) or fragile X syndrome (genetic condition which causes developmental issues such as learning disabilities and cognitive impairment).
Drugs – intake of certain drugs in pregnancy such as valproic acid (Epilim) and thalidomide (Thalomid)
Parental Age – the older the parents are when a child is born, the greater the risk for the child to develop ASD

Note: There is no scientific evidence suggesting that vaccines cause ASD.

Reference: https://www.cdc.gov/vaccinesafety/concerns/autism.html

Autism Spectrum Disorder Treatment

Psychopharmacology

ASD is linked to symptoms such as aggression, repetitive behaviour, irritability, anxiety and depression, hyperactivity, and attention deficit. Treatment for ASD may be prescribed with the aim of targeting such symptoms.

Psychosocial Interventions

Therapy can help a child with ASD to develop life skills, social skills, communicative skills, and language skills. Suggested therapy includes Behavioural Therapy, Psychological Therapy, and Educational Therapy.

Reference: https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

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Pain Management Nursing Interventions

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According to IASP, pain can be defined as “an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage”. Choosing the ideal pain management nursing interventions for a patient in pain depends on the accuracy in which pain assessment is carried out, correct diagnosis and adequate nursing care plan.

Pain Classification

Pain can be classified as ‘acute’ or ‘chronic’.

Acute pain acts as a warning, signalling that you’ve been hurt. It is typically mild and short-lasting, or severe, lasting for a few weeks or months, disappearing when the underlying cause of pain is treated (eg. surgical wounds, broken bones and childbirth). Acute pain is the result of noxious stimuli that activate nociceptors.

On the other hand, chronic pain can last for months or years, and has no definite cause (eg. arthritis, back and neck pain, fibromyalgia, CRPS and headaches). Chronic pain is the result of visceral or somatic nociceptors.

Acute Pain Management Goals

Analgesics: analgesia should be administered in a dose that is both effective yet minimal, so as to lessen the incidence of side effects;
Effectiveness: effective pain control promotes early mobilisation, less arising complications, shorter period of hospitalisation leading to lower costs, and more importantly, increased patient satisfaction.

Analgesics administered can be:

Multimodal Analgesics – a combination of different medicinal groups of pain relief such as local anaesthetics, opioids and NSAIDs;
Preemptive Analgesia – treatment is started prior to a surgical procedure so as to reduce sensitisation, which promotes a protective effect on the nociceptors and provides a reduction in post-operative pain and at times prevents chronic pain development;
Parenteral Analgesia – indicated for patients experiencing severe pain with associated nausea and vomiting who are unable to tolerate oral medication;
PCA (Patient-Controlled Analgesia) – a method which allows patients to self-administer predetermined doses of analgesia for pain relief;
Epidural Analgesia – administration of analgesics or anaesthetics into the epidural space for short-term and long-term pain management;

Retrieved from https://www.cfp.ca/content/56/6/514/tab-figures-data on 16th December 2021

Analgesic Medications

non-opioids

Non-narcotic, peripheral, mild and anti-pyretic agents…

pain management nursing interventions — Retrieved from https://knowledgeplus.nejm.org/blog/non-opioid-analgesics-role-in-pain-management/ on 16th December 2021

Opioids

Narcotic, central or strong agents…

Opioid Side Effects:

respiratory depression
sedation
nausea
vomiting
constipation
inadequate pain management
allergies
pruritis (irritation)
urinary retention
tolerance to medication
addiction to medication

Adjuvant pain medication

Corticosteroids a.k.a. steroids are anti-inflammatory agents prescribed for a wide range of conditions including auto-immune diseases (attn. may cause hyperglycaemia, moodiness, irritability, insomnia, bone weakness, immunocompromisation – prednisolone, prednisone, cortisone
Anti-Convulsants a.k.a anti-epileptic / anti-seizure drugs are pharmacological agents used to treat epileptic seizures- carbamazepine, valproate, clonazepam, phenytoin, gabapentin
Tricyclic Anti-Depressants – amitriptyline, desipramine, imipramine, nortriptyline
Bisphosphonates can help prevent or slow down osteoporosis, treat some types of cancer that cause bone damage, and treat high levels of calcium in the blood – pamidronate, calcitonin
Neuroleptics a.k.a. anti-psychotic medications are used to treat and manage symptoms of many psychiatric disorders – haloperidol, chlorpromazine, risperidone
Anxiolytics help prevent or treat anxiety symptoms or disorders – lorazepam

Non-Pharmacological Pain Management

heat
cold
laughter
music
physical therapy
massage therapy
aromatherapy
acupuncture
self-hypnosis
TENS (Transcutaneous Electrical Nerve Stimulation)
SCS (Spinal Cord Stimulation)

Pain Management Nursing Interventions

The nurse’s role with regards to pain management include:

acute pain management
help with self-care
providing reassurance to counteract anxiety
assisting at times of ineffective coping and fatigue
assisting with mobilisation
ensuring adequate nutrition
ensuring adequate sleep
providing education and assistance in a holistic manner

Maslow’s Hierarchy of Needs

Retrieved from https://www.simplypsychology.org/maslow.html on 16th December 2021

The Role of Psychosocial Care in Nursing

Psychosocial care involves the provision of care in a holistic way such that the psychological, social and spiritual requirements of the patient are collectively met. For the provision of psychosocial care, the nurse needs to:

have good verbal and non-verbal communication skills
be empathic and supportive
have the required knowledge and the ability of conveying medical information in an easily understood way

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