CLASSIFICATION & MANAGEMENT OF PSYCHIATRIC DISORDERS

U N I T 3
11/6/2019PREPARED BY ; JONES H.M-MBA
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MENTAL HEALTH AND
PSYCHIATRIC NURSING

CLASSIFICATION AND MANAGEMENT OF
PSYCHIATRIC DISORDERS
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 2 main classifications:
 Neurosis
 Psychosis
1. Neurosis( minor)
 Category of mental disorders in which the symptoms
are distressing to the person, reality testing is intact,
behaviour does not violet gross social norms and
there is no apparent organic cause.

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 Neurosis is classified into
 Anxiety
 Obsessive Compulsive Neurosis and
 Hysterical Neurosis

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A. Anxiety disorders
 Are characterized by their predominant symptoms
of anxiety and avoidant behaviour (depression).
Causes of neurotic disorders like anxiety may be
linked to the following:
 (i) Emotional conflict
 (ii) Maladjustment to life situations
 (iii) Some genetic and constitutional factors

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A. Anxiety disorders
Symptoms
Diaphoresis (profuse sweating)
Experiencing feelings of unreality about
self or environment.
Fear of dying or going crazy
Palpitations or tarchycardia
trembling

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Medications
 Antiaxiety drugs
 Benzodiazepines e.g Diazepam (valium) 30mg
 Antidepresants e.g Citalopram (celexa) 40mg
 Monoamine oxidase inhibitors are used in clients with
severe panic disorders. Eg. Phelzine (nardil) 45mg

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Nursing Interventions
 Take full history of the illness including mental
assessment.
 Explore the stimuli that trigger a panic attack.
 E.g. have client identify and discuss sources of
frustration, anxiety, conflicts and unmet needs.
 Teach client ways to inhibit the anxiety response
through the use of problem solving and logical
analysis.
 e.g. coming up with a list of possible solutions and
seeking feedback from others.

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 Promote recognition of the self-limiting aspect of
panic attacks in order for the client to begin to
develop a sense of control over them.
 Instruct the client about relaxation techniques to
eliminate physical tensions that precede panic
attacks.
 After client achieves control over symptoms, explore
with client the underlying conflicts.

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 Encourage the clients to use the group for support
and reassurance.
Family care
 Educate family members about panic disorder and
how to work with the client.
 Have family develop effective communication skills
to decrease underlying conflict between members.
 Promote honest, open expression and discussion of
feelings.

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Obsessive-compulsive disorder
 An anxiety disorder characterised by recurrent and
persistent thoughts, ideas and feelings of obsessions
or compulsions sufficiently severe to cause marked
distress, consume considerable time, or significantly
interfere with the patient’s occupational, social or
interpersonal functioning.

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Etiology
 Genetic factors
 Evidence of brain disorder
 Abnormal serotonergic function
 Excessive demands during and early intensive toilet training
Obsession and compulsive criteria
Obsession
 Recurrent and persistent thoughts, impulses, or images are
experienced during the disturbance as intrusive and
inappropriate and cause marked anxiety or distress.
 The thoughts, impulses, or images are not simply excessive
worries about real-life problems.

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 The person attempts to ignore or suppress such
thoughts or impulses or to neutralise them with
some other thought or action.
 The person recognises that the obsessional thought,
impulses or images are a product of one’s own mind.
 For instance, fear of dirt and germs, fear of
burglary or robbery.

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Compulsion
 The person feels driven to perform repetitive
behaviours or mental acts in response to an
obsession or according to rules that one deems must
be applied rigidly.
 The behaviours or mental acts are aimed at
preventing or reducing stress or prevent some
dreaded event or situation; however, these
behaviours or mental acts either are not connected in
a realistic way with what they are designed to
neutralise or prevent or are clearly excessive.

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Examples
 Excessive hand washing
 Repeated checking of door and window locks.
 Excessive straightening, ordering or of arranging
things.
 Repeated words or prayers silently.

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Diagnosis
 To diagnose the obsessive compulsive disorder, the following three
features should be present.
 The patient realizes that the feeling, thought or action is irrational,
with a subjective feeling of compulsion
 He has tried to resist it
 Resistance leads to an increase in tension or anxiety
Management
 Counseling
 Chemotherapy: anxiolytic drugs, tricyclic antidepressants are
effective in reducing obsessional symptom.
 Behaviour therapy: exposure to any environmental cues that
increase obsessional rituals
 Psychotherapy

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B. Dissociative Disorders
 A client with dissociative disorder experiences
disturbance in the integrated functions of memory,
identity, conciousness or perception of the environment.
 This alteration in mental functioning can occur suddenly
or gradually and can progress from a transient to a
chronic condition.
 If there is an alteration in memory, significant personal
events will not be remembered.
 When the disturbance is in the identity, the person’s
usual personality is temporarily forgotten or a new one
may be assumed.

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 The client may feel as though the sense of reality is
gone (derealization) and this can be manifested by
the sensation of not feeling human or feeling
disconnected from ones body parts
(depersonalization).
 Typically, dissociation is a mechanism used to
protect the self and obtain relief from overwhelming
anxiety.

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 Orient client to the current surroundings if necessary.
 Encourage the client to verbalize emotions.
 Work with the client to identify how the anxiety is
manifested.
 Encourage the client to discuss what is remembered.
 Instruct the family about the disorder, treatment and
how to cope with the client,s memory.

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Hysteria
 A general state of tension or excitement in a person
characterised by unmanageable fear and temporary loss
of control over the emotions.
Symptoms and Signs
 History may reveal the sudden onset of a single
debilitating sign or symptom that prevents normal
function of the affected body part, such as paralysis of a
leg.

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Treatment
 Psychotherapy
 Family therapy
 Relaxation therapy
 Behaviour therapy or
 Hypnosis

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 Patient may describe a recent and severe
psychologically stressful event that preceded the
symptom.
 Physical examination findings are inconsistent with
the primary symptom e.g tendon reflexes may be
normal in a paralysed part of the body.

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Nursing intervention
 Help the patient maintain integrity of the affected
system.
 Regularly exercise the paralyzed limbs to prevent
muscle wasting.
 Frequently change the bedridden patient’s position
to prevent pressure ulcers.

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 Ensure adequate nutrition, even if the patient is
complaining if GI distress.
 Provide a supportive environment and encourage the
patient to discuss the stress that provoked the
conversion disorder (hysteria).
 Don’t force the patient to talk, but convey a caring
attitude to help him/her share his/her feelings.

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 Don’t insist that the patient use the affected system.
 This will only anger him/her and prevent a
therapeutic relationship.
 Include the patient’s family in all care.
 They may be part of the patient’s stress and they are
essential to support the patient and help him regain
normal function.

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2. Psychosis (Major)
 A general term referring to mental disorders having
marked impairment of behaviour, perception, mood
and/or intellectual functions.
 The following are the types of psychotic disorders:

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Schizophrenia
 Disorder characterized by the presence of
communication, language, thought, perception,
affect and behaviour disturbances.
Symptoms
 Auditory hallucinations
 Thought insertion or withdrawal
 Delusions
 Poor hygiene
 Social withdrawal
 Hoading (keeping rubbish)

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Types of Schizophrenia
1. Disorganized schizophrenia
 Behaviour is typically regressive and primitive (childish
behaviour) e.g. gigling.
2. Catatonic schizophrenia
 Manifest in form of stupor (semi-conciousness), mutism,
waxy flexibility, negativism.
3. Paranoid schizophrenia
 Patient exhibit extreme suspiciousness of others;
delusions of persecutory, hallucinations ( auditory or
visual).

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Medication
 Antipsychotic drugs
 Chlorpromazine 50-100mg tid or b.d or
 Haloperidol 5-10mg b.d.
 Modecate 25mg im monthly also used for maintainance in chr.
Schizophrenia.
 Hospitalization needed for both first episodes of
schizophrenia and acute relapses
 Talk to the client in simple, direct and honest manner.
 Vague or complicated interactions promote mistrust.

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 Do not challenge the content of disorganized
thoughts.
 encourage client to discuss feelings associated with
disturbing thoughts.
 Discussion of feelings can help focus the interaction on a
reality-based situation.
 Establish frequent, brief contacts with client.
 Be judicious about touching the client.
 Clients with schizophrenia are mistrustful of closeness
and physical touch can be threatening.

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Bipolar Affective Disorder
 Major mental disorder that can manifest as either
mania or depression.
Mania
 With manic episode, the client experiences a
euphoric, expansive, or irritable mood.
Clinical Features
 Mood elevation
 Talkativeness, due to rapid thought process.
 Distractibility or inability to concentrate on one activity
at a time.

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 Extravagance, due to delusions of importance and rapid
thought process.
 Increased libido
 Weight loss due to hyperactivity
 Insomnia due to rapid thought processes and hyperactivity
 Delusions of importanc

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Medications
Mania without psychotic symptoms
 Haloperidol 1.5mg-3mg bd or tds po daily.
 Carbamazepine 200mg tds po daily.
 Lithium carbonate 1.5-2g daily but not
recommended in children.

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Mania with psychotic symptoms
 Haloperidol 10mg im stat, then 5mg im tds for 24
hours; then 5mg bd or tds po daily if condition
stabilises.
 Lithium carbonate is given for maintenance at
between 0.4-1.0mmol/Li+/litre

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 Help client to identify and discuss behaviours that
interfere with appropriate interactions with others.
 Prepare client for building daily social relationships
by role playing and practicing new skills.

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 Help client identify comfortable and uncomfortable
situations and how stress may cause reliance on
defensive behaviours.
 Assist with the development of new relationships
and social skills.
 Assist the family to understand the bipolar disorder
and its impact on the couple and family
relationships.
 Encourage the family to discuss their fears and
feelings.

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Depression
 Disorder that presents a clinical course that is manifested
by the occurrence of one or more major depressive episodes
and atleast one hypomanic (mild elation) episode.
Symptoms
 Depressed mood
 Loss of interest or enjoyment
 Reduced energy
 Insomnia or hypersomnia, due to worry
 Reduced libido
 Guilty feelings
 Suicidal ideation
 Feelings of worthlessness

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Medication
Mild/moderate depressive illness
 Amitryptiline (triptizol)50-75mg OP/IM b.d or tds.
 Then follow up every 5-7 days and gradually increase
the dosage up to 300mg.
 Fluoxetime 20mg once daily.

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Severe depressive illness with psychosis
 Amitrtyline 75mg initally orally daily in divided
doses, increaded to 200mg daily or
 Fluoxetine 20mg once daily.
 Chlopromazine 100mg im tds in 24 hours and
continued orally if the condition stabilises.

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 Take full case history including mental status
examination.
 Rule out any physical illness.
 Prepare client for building daily social relationships
by role playing and practicing new skills.
 Identify current life problems or social stress.
 Focus on small specific steps pts/family might take
towards reducing or improving mgt of the problem.

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ORGANIC DISORDERS
 Results from any physiological condition or
pathophysiologic process that is capable of
destroying or altering brain tissue that in turn
impair cerebral functioning.
Causes of organic mental disorders
 Infections e.g. malaria
 Meningitis
 HIV
 substance intoxication or withdrawal
 Vascular disorders
 Electrolyte imbalance
 Hypo and hyperglycaemia

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 Organic mental disorders can be classified into:
delirium and dementia.
A. Dementia
 It is the loss of intellectual abilities (remembering,
thinking, judging etc) of sufficient severity to
interfere with social and occupational functioning
 It is an organic mental disorder characterised by
amnesia, disorientation, impaired intellectual
functioning and affective dysfunction.

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Types of Dementia
1. Pre-Senile Dementia
 Comes before age of 65 which is xrised by gradual
decline in personal care, errors in judgment,
impaired capacity for abstract thought , apathy,
irritability, night hallucinations, rambling incoherent
speech.
 Associated with alzhemer’s disease.

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2. Senile Dementia
 Occurs after age 65 as a result of normal age
processes.
 It includes the following characteristics:
 Gradual rise in difficulty in
 thinking,
 Remembering,
 Communicating and
 Relating to others.

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Signs and Symptoms
Dysmnesia
 An impairement in the ability to retain and recall
information.
 E.g and old lady who puts a kettle on for a cup of tea
and while waiting she forgets why she is waiting and
decides to do something else.
 In the meantime the water boils away and kettle
handle burns out.
 Client can still recall events that occurred before
memory loss.

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Disorientation
 Is loss of ones bearing or position with regards to
time place and identity.
 E.g. an old person could arise in the middle of the
night or early in the morning, thinking its already
day time preparing to leave home for shopping.
Impaired intellectual function
 Includes disturbance in the following:

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 Calculation
 Comprehension
 Recall and general information and ability to learn new tasks.
Affective dysfunction
 Person will have emotional liabilities (emotion will
fluctuate).
Attention disorder

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Management
Investigations
 Blood tests
 RPR
 Malaria parasites
 Blood chemistry
 Brain scan
 X-Ray

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Treatment
Supportive
 Provide good physical care e.g good nutrition
 Provide eye glasses due to impaired vision.
 Hearing aids.
 Protect client from sustaining injuries.
 Protect client from getting intoxicated with medicines.
 Client should be kept in familiar setting. E.g. things in
the environment where client is should be placed in the
same position.

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 Encourage family participation in the care of the
client.
 Frequent orientation and reminding client of time
and place.
 Discuss news with client.
 Use calendars, radios on daily activities.
 Help to maintain client’s self esteem. e.g. treat them
as adults, accept them as individuals.
 Call them by their names.
 Avoid putting client in darkroom due to poor vision.

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Symptomatic treatment
 Psychiatric symptoms require small doses of appropriate
medication.
 E.g. if pt is restless, aggressive you can give haldo 0.5mg
tds P.O.
 Largactil 25mg tds P.O smal dose.
 If there is non-psychiatric anxiety give diazepam 2mg bd.
 If there is depression give imipramine 75mg daily.
 If there is insomnia give flurazepam 15mg orally.

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Personality Disorders
 Personality is the total constitution of an individual
which include the body, and the behaviour.
 Personality disorder is a disorder characterized by
inability to learn from past experience; there is no
remorse (can’t regret) and antisocial behaviour.

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Categories of Personality Disorders
1. Paranoid personality disorder
 Characterised by
 pervasive mistrust and suspicion of others.
 Constant preocupation with ideas that others will play
tricks, exploit, or inflict harm.
 Often on guard for present dangers perceived to be all
round them.
 Tend to be secretive, hypersensitive, jealous,
argumentative and aggressive.

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 Avoid intimate relationships, and
 Demonstrate exaggerated self-importance and self
sufficiency.
 Often lonely.
Admission into hospital
 Hospitalised when their behaviour is out of control
in response to a threat perceived as overwhelming
or immediate.
 Respond with anger or rage and hence potential for
violence.

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2. Schizoid personality disorder
 Basic features of this disorder include:
 Non involvement in interpersonal or social
relationships, hence keep people at an emotional
distance.
 Shy and introverts;
 Respond with short answers and do not initiate
spontaneous conversation.
 Fantasy and daydreaming may be more gratifying
compared with real persons and situations.

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Management
 Build trust in the patient.
 Identify appropriate verbal expression of feelings.
 Involve patient in group activities in order to
increase social skills.

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3. Antisocial personality disorder
 Characterised by a pattern of irresponsible and
antisocial behaviour in which the rights of others are
violated.
 The individual must be at least 15 years of age and
has history of conduct disorder before age of 15
years.

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4. Avoidance personality disorder
 Characterized by social withdrawal due to extreme
sensitivity to rejection.
 Symptoms include unwillingness to enter into
relationship, unless given strong guarantees of
uncritical acceptance.
 They have low self esteem.
 Social withdrawal inspite of a desire for affection and
acceptance.

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5. Dependant personality disorder
 The individual with this disorder withdraws due to
extreme sensitivity to rejection.
 He passively allow others to assume responsibility
for major areas of life coz of their inability to
function independently.
 The individual lacks self confidence.

UNIT 4
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MENTAL HEALTH
AND PSYCHIATRIC
NURSING

CONDITIONS NOT ATTRIBUTED TO
MENTAL DISORDERS
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INTRODUCTION
Children with mental retardation
and giftedness are not mentally ill.
In addition, epilepsy is not a
mental illness either.
Epilepsy and mental retardation
are neurological conditions.

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

MENTAL DISORDERS
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INTRODUCTION
 Children with mental retardation and giftedness have
special education needs because of their extremes of
intelligence.
 No matter how we choose to define and assess
intelligence, it is true that there will be a wide range of
individual differences.
 For example, intelligence tests compare people's scores
to averages of others of the same chronological age, so
most people by definition show average intelligence
scores.

MENTAL DISORDERS
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GENERAL OBJECTIVE
 At the end of the discussion student should be able to
manage children with special education needs and clients
with epilepsy
SPECIFIC OBJECTIVES
 At the end of the unit, the student should be able to:
 Describe the management of children with special education needs.
 Describe the management of clients with epilepsy.

MANAGEMENT OF CHILDREN WITH
SPECIAL EDUCATION NEEDS
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MENTAL RETARDATION
DEFINITION:
 Mental Retardation is a disorder in which a person’s
overall intellectual functioning is well below average,
with an intelligence quotient (IQ) around 70 or less.
 Individuals with mental retardation also have a
significantly impaired ability to cope with

MENTAL DISORDERS
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MENTAL RETARDATION
DEFINITION:
 common life demands and lack some daily living
skills expected of people in their age group and
culture.
 The impairment may interfere with learning,
communication, self-care, independent living, social
interaction, play, work, and safety.

MENTAL DISORDERS
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MENTAL RETARDATION
DEFINITION:
 Mental retardation appears in childhood, before age
18.
 In the United Kingdom the term mental retardation
is interchangeable with the term ‘learning disability’.

MENTAL DISORDERS
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MENTAL RETARDATION
INCIDENCE: - About 1 percent of the general
population has mental retardation, although some
estimates range as high as 3 percent.
 Mental retardation is slightly more common in males
than in females.
 It occurs in people of all racial, ethnic, education,
and economic backgrounds.

MENTAL DISORDERS
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MENTAL RETARDATION
DEGREES OF SEVERITY
There are four degrees of severity of mental retardation
based on IQ score:
 Mild retardation (IQ range 50-55 to about 70).
 Moderate (IQ range 35-40 to 50-55).
 Severe (IQ range 20-25 to 35-40).
 Profound (IQ level below 20-25).
 People of average intelligence, score from about 90 to 110
on IQ tests.

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

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

MENTAL DISORDERS
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MENTAL RETARDATION
Severe
 Severe retardation affects 3 to 4 percent of
mentally retarded individuals.
 Severely retarded individuals may learn to talk
during childhood and develop basic self-care
skills.
 In adulthood they can perform simple tasks with
close supervision.
 They often live in group homes or with their
families.

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

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

MENTAL DISORDERS
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MENTAL RETARDATION
DISODERS THAT OCCUR AS A FOETUS
DEVELOPS DURING PREGNANCY
 A variety of problems during a woman’s pregnancy
can cause mental retardation in her child.
 Malnutrition;
 Mother use alcohol or drugs;

MENTAL DISORDERS
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MENTAL RETARDATION
DISODERS THAT OCCUR AS A FOETUS DEVELOPS
DURING PREGNANCY
 environmental toxins such as lead and mercury;
 viral infections, including rubella (see German Measles) and
cytomegalovirus;
 An untreated diseases such as diabetes mellitus.
 Fetal alcohol syndrome results from excessive consumption of
alcohol during pregnancy, including premature birth, very low
birth weight, and stresses to the fetus such as deprivation of
oxygen.

MENTAL DISORDERS
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MENTAL RETARDATION
Problems that occur during or after birth
 Infectious diseases during childhood, which are
easily preventable through immunization, also can
cause mental retardation when they result in
complications.
 For example, measles, chicken pox, and whooping
cough may lead to encephalitis and meningitis,
which can damage the brain.

MENTAL DISORDERS
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MENTAL RETARDATION
 Physical trauma to the brain can also cause mental
retardation.
 Brain damage may result from accidental blows to the
head,
 Near drowning,
 Severe child abuse, and
 Childhood exposure to such toxins as lead and mercury.

MENTAL DISORDERS
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MENTAL RETARDATION
 Experts believe that poverty and a lack of
stimulation during infancy and early childhood can
be factors in mental retardation.
 Children raised in poor environments are more likely
to experience malnutrition, lack of routine medical
care, and environmental health hazards.

MENTAL RETARDATION
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 Provision of care and support should always be
within a therapeutic environment or an appropriate
setting.
 Support may be general or specific.
General support
 Care is provided by usual care givers who are
parents, relatives and sometimes even maids that
remain with these children when parents are at
work.

MENTAL RETARDATION
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General support
 Other health workers such as physiotherapists and
community nurses promote a normal environment by
encouraging care to take place at home, integration in cases
where the degree of retardation is only mild or moderate into
mainstream schools;
 use of local community resources in for instance whatever
assets are available in that community that could be used to
care for these children such as physiotherapy, meeting in a
central accessible point once per week for two hours.

MENTAL RETARDATION
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Specific support
 Special support addresses particular needs.
 These needs include Special Education, parental
support groups, and maladaptive (abnormal)
behaviors.
 Often, more specialized environments are necessary,
if disabilities are too severe to manage with standard
community resources.

MENTAL RETARDATION
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Specific support
 Such disabilities include severe and profound
learning disability (LD), severe treatment resistant
epilepsy, aggressiveness, co morbid psychiatric
disorder, respite placements.
EPILEPSY AND LEARNING DISABILITIES
 Epilepsy may occur in people with Learning
Disabilities.

MENTAL DISORDERS
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EPILEPSY AND LEARNING DISABILITIES
 It may begin at any age, and multiple forms may
occur in the same individual.
 Frequent epileptic seizures may lead to (or worsen)
permanent loss of intellectual functioning (acquired
epileptic aphasia), progressive partial seizures.

MENTAL DISORDERS
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Treatment
 The neurologist deals with this area & therefore the
psychiatrist needs to work with other specialists.
 Choice of treatment will depend on:
 Accurate classification of the type of seizures or epilepsy
 Possible drug interactions
 Minimizing side effects (esp. cognitive impairment)

PREVENTION OF MENTAL
RETARDATION (LEARNING DISABILITY)
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 Screening programs for at risk infants and children
during under five clinics, ANC and other children’s clinic
for example in paediatrics, neonatal clinics by nurses and
other health workers.
 Adult screening tests can identify carriers of other
conditions before couples conceive a child.
 Individuals and couples with a family history of mental
retardation can seek genetic counseling to evaluate their
own risks and need for screening.

PREVENTION OF MENTAL
RETARDATION (LEARNING DISABILITY)
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 Specialized laboratory tests, including amniocentesis, can
detect Down syndrome and other genetic disorders in the
early stages of pregnancy.
 Proper prenatal care, avoidance of alcohol and drugs during
pregnancy, and routine immunization against measles and
other childhood diseases can prevent some forms of
retardation.
 This can be done by nurses working in such settings when
these children are brought to ANC and under five clinics.

TREATMENT AND CARE
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 Some individuals diagnosed with mild mental
retardation as children may gradually develop new skills
through early intervention and educational services.
 As adults, they may function in everyday life at a level
that no longer warrants a diagnosis of retardation.
 All but the most profoundly retarded people usually can
best develop their full potential by living in the
community.

TREATMENT AND CARE
88
 Most people with mental retardation have the capacity to
learn, advance intellectually, develop job and social
skills, and become full participants in society.
 They may marry, have families, and be indistinguishable
from other people.
 In order to achieve their potential, mentally retarded
children need special education and training, which
ideally begins in infancy and continues until they
establish an adult role.

THE ROLE OF A NURSE IN MANAGING
CHILDREN WITH LEARNING DISABILITIES
/ MENTAL RETARDATION
89
Psychological care
 When parents realize that their child is not like other
children, that is, developing normally, it takes some
time to register this in their minds and lives.
 They go through The Grieving Process of which the
length may vary depending on the psychological,
social and medical support and expertise availed to
them.

90
 Absence or lack of inadequate medical expertise,
psychological and social support will without any
doubt lead to poor care of the child by its caregivers
or parents.
 The child might even be abused, sometimes
unknowingly because of the denial, anger and
depression that many parents experience.
 The mentally disabled child will be at risk of being
harmed, since it is so vulnerable.

91
Early identification and intervention
 To avoid all these complications the nurse must be alert
to quickly identify children with mental retardation so
that they can receive the needed care from a very young
age, since the brain has been known to grasp and learn
skills better, at a tender age.
 As a nurse you then need to counsel the mother or care
givers and facilitate for available services such as
physiotherapy, medical and

THE ROLE OF A NURSE IN
MANAGING CHILDREN WITH
LEARNING DISABILITIES / MENTAL
RETARDATION
92
 surgical interventions if needed, special education,
and psychosocial support.
 A nurse also facilitates for any medical and surgical
interventions, and provide primary, secondary and
tertiary health services to improve the quality of life
of children with learning disabilities.

Prevention of Mental Retardation
93
 The role of the nurse starts prenatally (before
pregnancy) by counseling and giving Information,
Education and Communication to would be mothers
and fathers to prevent the disorder.
 It continues during the antenatal period with
measures that foster a healthy pregnancy and normal
growth and development of the fetus such as a good
diet, treatment of any existing

94
 diseases in the mother and avoiding environmental
hazards.
 In labour, good care such as frequent observations to
quickly identify anything that could go wrong
thereby causing harm to the fetus.
 During delivery the midwife must avoid birth
asphyxia and trauma by continued alertness for any
delays in labour.

95
 In the postnatal period and during the early
years of a child’s life nurses and midwifes
must ensure that the child receives
immunizations from childhood diseases that
may lead to brain damage in good time and
completes them.
 Nurses must ensure that other diseases like
malaria are prevented and if they occur
prompt treatment must be given.

96
 In the period of adolescence as nurses must
ensure that we advice parents and support
them in caring for their children because this
is the time when they sometimes try to
experiment with behaviors that are risky such
as substance abuse, use of fire arms, driving
their parent’s car when they have no license,
and wrong sexual practices.
 These behaviours could put them at risk of
accidents and diseases that might damage
their brain thereby leading to mental
retardation.

PSYCHIATRIC CO MORBIDITY IN THE
LEARNING DISABILITY [L.D.](MENTAL
RETARDATION) POPULATION.
97
Abnormal behaviors that occur in the mental
retardation population
 Psychiatric disorders occur more frequently in the Learning
Disability (LD) population than the general population. They
include:
 Schizophrenia – Symptoms in severe LD include unexplained
aggression, bizarre behaviours, mood lability, increased
mannerisms and stereotypies.
 Bipolar Affective Disorder – Symptoms include hyperactivity,
wandering, mutism, temper tantrums.

98
 Depressive disorder
 Biological disorders more marked, with diurnal
variations. Suicidal thoughts / acts may occur in
border line – moderate LD.
 Anxiety disorders, Obsessive Compulsive Disorder,
Attention Deficit Hyperactive Disorder, &
personality disorder.

99
Abnormal behaviors that occur in the
mental retardation population
 Behavioural disorders and ‘challenging’
behaviour
 These are pathological behaviours that are
common in the LD population.
 They create a significant burden for parents /
carers. They are as follows:
Antisocial – shouting, screaming, general
noisiness, anal poking/faecal smearing (may
reflect constipation), self induced
vomiting/choking, stealing.
Aggressive outbursts – against persons or property

100
Behavioural disorders and ‘challenging’
behaviour
 Self injurious behavior – skin picking, eye gouging,
head banging, face beating (more common in
severe/profound LD.
 Social withdrawal
 Stereotypic behaviours (some of which may be
injurious)
 Hyperactive disruptive behaviours
 Repetitive communication disturbance

101
 Behavioural disorders and ‘challenging’
behaviour
Anxiety fearfulness
 When these behaviours are particularly severe,
they are often termed ‘challenging’.
 Management of children with mental retardation is
done while they continue to live in their homes.
 The best way to care for these children is to allow
them to continue to be with their loved ones in a
familiar and caring environment.

102
 Behavioural disorders and
‘challenging’ behaviour
 They have to be encouraged to work on their
strengths or strong points or activities they
are good at, with assistance from their
caregivers.
 Caregivers and parents need a lot of
counseling and social support from nurses
for such an environment to be achieved.

103
 Caregivers and parents need a lot of
counseling and social support from nurses
for such an environment to be achieved.
 The role of the nurse in management of
children with L.D. is to participate with
other members of the Multi disciplinary
Team (psychiatrist, clinicians, neurologist,

104
 psychologist, sociologist, physiotherapist
and surgeon) in delivering and facilitating
psychosocial support for both the affected
child and his or her care giver.

TREATMENT METHODS
105
 The different types of psychological therapies are administered by
psychologists.
 These treatments work for children with mild and moderate mental
retardation because they are able to think and reason fairly well.
Behavioural treatments: Based on operant conditioning.
 Behaviour may be shaped towards the desired final modification
through the rewarding of small, achievable intermediate steps.
 In school good behavior can be rewarded with material items,
privileges and ‘star’ charts, when a certain level is achieved.

TREATMENT METHODS
106
 May be used to help teach basic skills (feeding,
dressing, toileting),
 establish normal behavior patterns (sleep),
 or more complex skills (social skills, relaxation
techniques, assertive training).
 May also be used to alter maladaptive patterns of
behavior (inappropriate sexual behavior, phobia)

TREATMENT METHODS
107
 Cognitive Therapy
 Cognitions are thoughts or thinking patterns. These
thinking patterns can become negative. For example the
child begins to think that they are not good enough to be
alive, or that they cannot achieve anything in life, leading
to poor self esteem, anxiety and depression.
 Cognitive therapy is treatment that is targeted at
changing the negative thoughts and replacing them with
thoughts that increase the self esteem (self respect) of a
person.

TREATMENT METHODS
108
 When self esteem is increased the behavior will also improve
and feelings of anger, will be dealt with.
 This means that in the case of children with borderline, mild
or moderate LD, cognitive approaches may be adapted for
teaching of:
 problem solving skills
 management of anxiety disorders
 depression,
 dealing with issues of self esteem,
 anger management, and
 treatment of offending behaviours (eg. sex offenders).

TREATMENT METHODS
109
Psychodynamic therapies
 Psychoanalysis is helpful in addressing issues of
emotional development, relationships, adjustments to
life events (losses, disabilities, and bereavements).
 In psychoanalysis the therapist uses probing and open
ended questions to bring out hidden feelings that are the
cause of abnormal behavior from the subconscious mind
of a client.

TREATMENT METHODS
110
 Such feelings originate from early traumatic
childhood experiences.
 Once they are brought to awareness with the help of
the counselor or therapist ways can be found to
resolve them.
 Pharmacological treatments
 For children that need medications the nurse must
ensure that they are reviewed regularly to supply
drugs and observe any side effects.

TREATMENT METHODS
111
 Antipsychotics
 Antidepressants
 Effective in depression, OCD – Obsessive
Compulsive Disorder, anxiety disorders, violence,
self injury, ‘non specific’ distress.
 Anticonvulsants
 For underlying epilepsy and in episodes of difficulty
in controlling movements.

GIFTEDNESS
112
 “Giftedness” is defined as exceptionally advanced
performance or the potential for outstanding
performance in intellectual, creative, leadership, artistic,
or specific academic fields.
 Children who demonstrate outstanding talents come
from all social, cultural, and economic groups.
 Educators believe that gifted students require special
education services because their learning needs differ
significantly from those of the general population.

CHARACTERISTICS OF GIFTED
CHILDREN
113
 They learn more rapidly and are able to understand more
abstract and complex ideas.
 They are also able to transform existing knowledge into
new and useful forms, and to create new knowledge
recognized for its originality, complexity, and elegance.
 In addition, some gifted learners may require special
counseling services to address social or emotional
adjustment issues that are complicated by their
exceptional abilities.

WAYS TO IDENTIFY GIFTED CHILDREN
114
 In developed countries schools rely on intelligence
tests to identify gifted students.
 It is recommended that aptitude tests developed by
individual schools, classroom observational records,
and performance assessments be combined to come
up with a final result.

SPECIAL EDUCATION NEEDS OF GIFTED
CHILDREN
115
 Children who are gifted may be prone to boredom and rejection
from peers.
 To avoid this, they can be educated in the following ways:
Acceleration - Gifted children may study a specially modified
curriculum or may progress through academic subjects at an
accelerated pace.
 Acceleration involves adapting education programs so that students
may progress through particular subject material quicker than
usual.
 These modifications may take place within the regular classroom
setting or they may involve changing the child’s placement (jumping
grades) in school.

CHILDREN
116
 Some gifted children gain early entrance to
kindergarten, skip grades, enter college earlier than
usual, or take specific courses with older children.
 Ideal programs for gifted students consider the
individual needs of children and offer multiple
options for services.
 These programs generally involve both advanced
course materials and acceleration.

CHILDREN
117
 Enrichment – Children remain in the same grade, but
with a curriculum that is supplemented by a variety of
activities.
 Current practice - Many educators advocate placing
gifted students in regular classrooms with students of
diverse ability levels, an educational method known as
inclusion.
 However, considerable evidence suggests that regular
classroom teachers do not receive the training and
support to appropriately modify the curriculum to meet
the needs of gifted students.

THE NURSE’S ROLE IN GUIDING AND
COUNSELLING GIFTED CHILDREN
118
 Nurses must reassure parents and caregivers that
these children can be assisted.
 Refer these children to appropriate members of the
Multi Disciplinary Team such as psychologists for
intelligence tests.
 The psychologists will then advice what to do.

MANAGEMENT OF CLIENTS WITH
EPILEPSY
119
 EPILEPSY
 SEIZURE - An abnormal, sudden excessive,
uncontrolled electrical discharge of neurons within
the brain that may result in alteration in
consciousness, motor, or sensory ability and or
behaviour.
 If the electrical disturbance is limited to only one
area of the brain, then the result is a partial seizure.

EPILEPSY
120
 For example, the client may experience confusion, loss of
awareness, aimless movements, or uncontrolled body
movements.
 If the electrical disturbance affects the entire brain, the
result is a generalized seizure.
 Epilepsy or a seizure disorder is a chronic condition
that is characterized by recurrent seizures.
 Many clients with epilepsy have more than one seizure
type and may have other symptoms as well.

EPILEPSY
121
INCIDENCE
 It is a common neuronal problem affecting
individuals irrespective of their age, sex, location or
geographical positions.
CAUSES
 Most cases, are idiopathic (of unknown cause),
however there are certain factors associated with the
disease.

EPILEPSY
122
CAUSES
 Genetic predisposition- 30% of patients with epilepsy have first
degree relatives with seizure, mode of inheritance are uncertain just
thought to be due to low seizure threshold.
 Trauma- diffused cerebral damage result from either systemic
infections or a direct trauma to the brain in cases of accidents, birth
injury or trauma.
 Poisoning- commonly caused by drugs which may include alcohol
and phenothiazides (antidepressants).
 Brain tumours and abscesses- masses or lesions in the cortex can
cause epilepsy.
 Encephalitis and other inflammatory conditions.

EPILEPSY
123
 TYPES OF SEIZURES
 There are over 30 types of seizures. We shall look at
2 types of seizures. These are partial seizures and
generalized seizures.
 Partial seizures are of focal onset, which means
that they originate in a specific area of the brain.
 They are further subdivided into simple partial,
complex partial and absence seizures.

EPILEPSY
124
 SIMPLE PARTIAL SEIZURES
 People with Simple Partial seizures experience the
following:
 Uncontrollable jerky movements of body part
 The twitching may start in the thumb and then spread to
affect the hand and arm and possibly include the affected
side of the body ( Jacksonian seizure)
 Sight and hearing impairement

EPILEPSY
125
 Sudden sweating and flushing
 Nausea
 Feelings of fear
 The patient may or may not lose consciousness.
 The affected part may become paralysed for some
time called Todd’s paralysis.

EPILEPSY
126
TYPES OF SEIZURES
COMPLEX PARTIAL SEIZURE
 Also called temporal lobe epilepsy because they arise from
lesions in one or both temporal lobes of the brain. May also
arise from the frontal lobe. In addition, they have also been
termed psychomotor seizures because they cause strange
behaviours as well as movements.
 Seizure may be preceeded by an aura which is a warning
sensation characterized by feelings of fear, abdominal
discomfort, dizziness, or strange odors and sensations.

EPILEPSY
127
TYPES OF SEIZURES
COMPLEX PARTIAL SEIZURE
 Then the affected individual may appear to be in a trance
(staring at nothing)
 Followed by an episode of altered behaviour in which the
patient performs a series of repeated movements in which a
patient may continually rub his hands or smack his lips
continually (automatisms) with no control over body
movements.
 Occasionally, a prolonged period of confusion lasting for
hours to days with differing levels of awareness and strange
behaviours may develop.

EPILEPSY
128
TYPES OF SEIZURES
ABSENCE SEIZURE OR PETIT MAL
 A brief and sudden loss of consciousness which
onlookers often do not notice.
 Typically occurs in childhood and is often only noticed as
the child falls further behind with school work
 Symptoms that are noticeable or observable may be
slight such as upward staring of the eyes.
 Staggering gait

EPILEPSY
129
 Twitching of the facial muscles
 No aura
 The person will often resume activity previously involved
before seizure in without realizing that the seizure has
occurred.
 In complex absences, automatism, as previously described
accompanies the brief alteration in consciousness.
 Absences seizures are often precipitated by hyperventilation
and flashing lights

EPILEPSY
130
TYPES OF SEIZURES
GENERALISED SEIZURES OR GRANDMAL
EPILEPSY
 It is one of the commonest types and almost always
occurs in stages.
 Prodromal phase: is the phase before the actual
seizure. It may last for hours to days, and is characterized
by a change in the patient’s mood.
 In most cases, patient may become aware of this and
adjust his or her treatment.

EPILEPSY
131
TYPES OF SEIZURES
ii. Aural- Premonition: This stage may last for seconds or
minutes. Patient experiences sensation of either smell or
feeling of crawling insects on their body, ringing in their ears
and flashes of light.
 At this stage if there is any one near the patient they should
assist the patient as follows:
 Make patient lie down especially in lateral position in a safe
place.
 Roll a small handkerchief and place it in between the upper
teeth to avoid patient biting the tongue.
 Be near them and observe.

EPILEPSY
132
 iii. Tonic stage: There is stiffening of the body, jaw
closes tight and the patient may utter a sound mistaken
for a cry as there is partial closure of the epiglottis.
 Increased forceful discharge of motor impulses causes
muscle contraction and if the patient was standing, he
falls down due to loss of consciousness.
 A patient may bite his tongue since his teeth are
clenched.
 The process may last for a few minutes and if pad is not
placed in aura stage, you may not be able to do so due to
muscle rigidity.

EPILEPSY
133
 Loosen all tight clothing i.e. tie, belt, and cuff.
 Roll patient to a semi prone position or lateral, remove
any dangerous items near the patient.
 Put soft material under the patient’s head to prevent
damage to head.
 Advice onlookers to move away so that when the patient
wakes up he or she is not embarrassed.
 While twitching observe closely to see which part of the
body started twitching first.

EPILEPSY
134
iv. Clonic stage: This is the stage of violent
convulsions, frothing from the mouth due to
increased salivation and patient can chew his tongue.
If lying in supine position can aspirate his saliva and
choke.
 Phase can last for seconds in some patients and
several minutes in other patients.

EPILEPSY
135
iv. Clonic stage:
 There is throwing of arms and legs and can bang his head
against anything that is nearby.
 Patient has tachycardia and is sweating.
 Do not restrict the patient’s movements but remove any
dangerous objects nearby. Restrictions can lead to
fractures.
 Try to put a cushion under the patient’s head for
protection.

EPILEPSY
136
v. Comatose stage or stage of relaxation:
 This is when movements cease and patient become
flaccid and may go into a comatose stage which may lead
to a deep sleep.
 May last for several minutes after which the patient gains
normal consciousness, some patients may become
confused, others may complain of weakness and
headache or generalized body pains. Some patients may
become violent.

EPILEPSY
137
 When the muscles relax, clear airway by putting
them in a safer position, lateral or semi prone
position to aid drainage of secretions.
 Wipe out secretions, if messed, clean him up.

EPILEPSY
138
 In a hospital situation, tongue biting can be prevented by
use of a padded spatula.
 The head may be protected by a small pillow, or towel
and if possible put mattress on the floor.
 Suction machine must be available for sucking.
 Oxygen apparatus should be available.

EPILEPSY
139
 The grandmal or generalized seizure may
also be described in the following manner:
 “In a second type of epilepsy, known as generalized
seizure, tonic clonic, grand mal, or convulsion, the
whole brain is involved.
 This type of seizure is often signaled by an
involuntary scream, caused by contraction of the
muscles that control breathing.

EPILEPSY
140
 As loss of consciousness sets in the person falls to the
ground and the entire body is gripped by a jerking
muscular contraction.
 The face reddens (in people with light colour skin),
breathing stops, and the back arches.
 Subsequently, alternate contractions and relaxations of
the muscles throw the body into sometimes violent
agitation such that the person may be subject to serious
injury.

EPILEPSY
141
 After the convulsion subsides, the person is exhausted
and may sleep heavily.
 Confusion, nausea, and sore muscles are often
experienced upon awakening, and the individual may
have no memory of the seizure.
 Attacks occur at varying intervals, in some people as
seldom as once a year and in others as frequently as
several times a day.

EPILEPSY
142
TYPES OF SEIZURES
 About 8 percent of those subject to generalized
seizures may have status epilepticus, in which
seizures occur successively with no intervening
periods of consciousness.
 These attacks may be fatal unless treated promptly
with the drug diazepam.”

EPILEPSY
143
MEDICAL MANAGEMENT
Diagnosis
 History and clinical presentation
 Electro encephalogram to check for the waves of the
brain.
 Lumbar puncture to rule out meningitis
 Skull x-ray will be done to rule out brain lesions such
as tumours.

EPILEPSY
144
MEDICAL MANAGEMENT
Diagnosis
 C.T scan
 Supportive investigations such as blood for urea and
electrolytes and blood sugar.
DRUGS
 Drugs used are known as antiepileptic or anticonvulsant
drugs.
 Depending condition of the patient, they can be given
single drug or as a combination.

EPILEPSY
145
MEDICAL MANAGEMENT
DRUGS
 DIAZEPAM (VALIUM)
 10mg IV, stat during a seizure
 Side effects are drowsiness and dependency.
 PHENYNTOIN (DIPHENYLHYDANTOIN)
 200- 400mg OD, P.O depending on condition or
frequent attacks.

EPILEPSY
146
MEDICAL MANAGEMENT
DRUGS
 It prevents spread of seizure activities to adjunct areas.
 Side effects: Ataxia, Sedation, mental confusion,
nausea and vomiting and slurred speech
 PHENOBARBITONE
 60- 120mg PO, IM, or 60mg B.D PO.

EPILEPSY
147
MEDICAL MANAGEMENT
DRUGS
 Side effects: Ataxia, Skin Rash and anaemia
 During the acute attack of seizures patient may
receive valium 10mg, IV stat.
 N.B Once the treatment is started, it is better to
continue on the same drug.

STATUS EPILEPTICUS
148
 These are recurrent seizures without any recovery
period.
 It is a medical emergency and is usually common in
children and patients with intracranial lesions.
 Patients usually die due to exhaustion.
 Child under 12years 300-400mcg/kg repeated after
10 minutes.

Adults Status Epilepticus
Management: guidelines (WHO)
149
 Insert IV line
 Administer 5ml of 50% glucose
 Give Diazepam 10mg x1 and repeat after 10 minutes
if seizures do not stop.
 Prepare for possible ventilator support.
 Phenobarbitone 10-15 mg/kg i.v. (dilute in 100ml NS
and infuse over 30min)

Adults Status Epilepticus Management:
guidelines (WHO)
150
 Can give additional 5mg/kg i.v. if seizures do not
stop
 Consider ICU transfer if concern for respiratory
compromise.

NURSING MANAGEMENT DURING
EPILEPTIC ATTACK
151
OBJECTIVES
 To prevent the patient from suffering harm as a
result of the seizure
 To maintain airway
 To control fits
 The nurse should have an understanding of
seizures as well as the medications, interventions,
and monitoring strategies used to control seizures
and to
minimize their negative impact on the quality of
life.

EPILEPTIC ATTACK
152
Before a seizure occurs:
1. Safety measures should be taken if there is an
indication that the person is experiencing an aura before
the onset of a seizure, (e.g., have the individual lie down).
2. Determine if changes can be made in activities or
situations that may trigger seizures.
3. Keep the bed in a low position with side rails up, and
use padded side rails as needed.

EPILEPTIC ATTACK
153
(These precautions help prevent injury from fall or
trauma.)
4. Individuals with mental retardation or other
developmental disabilities may have altered bowel
habits, slowed activity, and /or decreased motor
skills before a seizure.

EPILEPTIC ATTACK
154
During a seizure: (Ictal stage)
1. When a seizure occurs, observe and document the
following:
a. Date, time of onset, duration
b. Activity at time of onset
c. Level of consciousness (confused, dazed, excited,
unconscious)
d. Presence of aura (if known)
e. Movements:
i. Body part involved

EPILEPTIC ATTACK
155
- Progression and sequencing of activity (site of onset of
first movement is very important as well as pattern,
order of progression, or spreading
involvement)
- Symmetry of activity
- Unilateral or bilateral
ii. Type of motor activity
- clonic (jerking)

EPILEPTIC ATTACK
156
ii. Type of motor activity
- myoclonic (single jerk of muscle or limb)
- tonic (stiffening)
- abnormal posturing movements,
- dystonia,
- eyes: eye deviation, open, rolling or closed, eyelids
flickering
- head turning,
- twitching

EPILEPTIC ATTACK
157
f. Respirations (impaired/absent; rhythm and rate)
g. Heart (rate and rhythm)
h. Skin changes
- color/temperature;
- pale/cyanotic, (also check lips, earlobes,
nailbeds)
- cool/warm;
- perspiration/clammy)
i. Gastrointestinal
- belching

EPILEPTIC ATTACK
158
- flatulence
- vomiting
j. Pupillary size, symmetry, and reaction to light
k. Changes in sensory awareness (auditory, gustatory,
olfactory, vertiginous, visual)
l. Presence of other unusual and/or inappropriate
behaviors

EPILEPTIC ATTACK
159
2. Ensure adequate ventilation.
a. Loosen clothing, postural support devices and/or
restraints.
b. DO NOT try to force an airway or tongue blade through
clenched teeth. (Forced airway insertion can cause
injury.)
c. Turn the person into a side-lying position as soon as
convulsing has stopped. (This will help the tongue return
to its normal front-forward position and will also allow
accumulated saliva to drain from the mouth.)

EPILEPTIC ATTACK
160
3. Protect the person from injury (e.g., help break fall,
clear the area of furniture).
4. DO NOT restrain movement. (Trying to hold down the
person's arms or legs will not stop the seizure.
Restraining movement may result in musculoskeletal
injury.)
5. Remain with the person and give verbal reassurance.
(The person may not be able to hear you during
unconsciousness but verbal assurances help as a person
is regaining consciousness.)

EPILEPTIC ATTACK
161
6. Provide as much privacy as possible for the
individual during and after seizure activity.
7. Provide other supportive therapy as ordered by
primary care prescriber or according to facility
protocol.
After the Seizure: (Post ictal Stage)
1. After the seizure activity has ceased, record the
presence of the following conditions and their
duration in the individual’s record.

EPILEPTIC ATTACK
162
After the Seizure: (Post ictal Stage)
 Continue to assess until person returns to
 baseline.
a. gag reflex, decreased
b. headache (character, duration, location, severity)
c. incontinence (bladder and bowel)
d. injury (bruises, burns, fractures, lacerations, mouth
trauma)
e. residual deficit

EPILEPTIC ATTACK
163
 After the Seizure: (Post ictal Stage)
- behavior change
- confusion
- language disturbance
- poor coordination
- weakness/paralysis of body part(s)
- sleep pattern disturbance
2.Allow the individual to sleep; reorient upon awakening.

EPILEPTIC ATTACK
164
(The individual may experience amnesia;
reorientation can help regain a sense of control and
help reduce anxiety
3. Conduct a post seizure evaluation
a. What was the person doing prior to the seizure?
b. Was this the first seizure?

EPILEPTIC ATTACK
165
Review current medications including recent changes
in medicine and/or dose.
d. Other illnesses?
e. Possible precipitating factors

REHABILITATION AND SOCIAL
SUPPORT
166
OBJECTIVES
 To prevent further fits
 To give adequate information about long term self care in
avoiding further episodes of fits.
General Health
1. Avoid constipation, excessive fatigue, hyperventilation
and stress because they may trigger seizures.
2. Seizures may increase around the time of menses.

SUPPORT
167
General Health
3. Fever may trigger seizures, therefore, the fever and
underlying cause must be treated. If antibiotics are
ordered, interactions with AEDs should be evaluated.
4. Environmental and recreational risk factors that should
be avoided or minimized:
a. Electric shocks
b. Noisy environments

SUPPORT
168
General Health
b. Noisy environments
c. Bright, flashing lights
d. Poorly adjusted televisions or computer screens
5. Showers, rather than tubs baths, should be taken, when
possible.
6. Good oral hygiene and regular visits to the dentist are
important to minimize effects of gingival hyperplasia
that can occur from some AEDs.

SUPPORT
169
Diet
1. A well balanced diet should be eaten at regular
times.
2. Coffee and other caffeinated beverages should be
limited to a moderate amount.
3. Fluid intake should be between 1,000 to 1,500 ml
per day (depending on the weather).
4. Alcoholic beverages should be avoided.

SUPPORT
170
Physical Activity
1. Regular activity and exercise should be encouraged.
Activity tends to inhibit rather than increase seizures.
However, over-fatigue and hyperventilation should be
avoided. When possible, exercise should take place in
climate-controlled settings.
2. Activities that could harm the patient should be avoided
because of the temporary loss of control that occurs
without warning.

SUPPORT
171
 The person may swim if accompanied by someone
who knows what to do if a seizure occurs.
 The person should wear a life jacket and stay in
relatively shallow water to facilitate seizure
management should a seizure occur.
 Individuals with epilepsy should refrain from
operating hazardous machinery.
 Regular sleep patterns are important.

SUPPORT
172
Information Education and Communication
(IEC) to Family and Friends:
 Family and friends should know what to do in the event
of a seizure occurring.
 Give IEC as follows:
 Loose clothing around neck
 Cushion head with pillow
 Remove hard and sharp objects from the area
 Never insert objects into patient’s mouth during seizure.

SUPPORT
173
Information Education and Communication
(IEC) to Family and Friends:
 After seizure turn head to one side to drain secretions
from mouth
 Upon waking reorient on:
 Time
 Place
 What happened (seizure)
 What patient was doing at time of seizure

PSYCHIATRIC COMPLICATIONS OF
EPILEPSY
174
 People with epilepsy have a twofold probability of
developing psychiatric disorders than in the general
population.
 Between 10% and 50% of patients with epilepsy have
psychiatric symptoms.
 Many different types of psychiatric disorders are
associated with epilepsy.

EPILEPSY
175
 They include cognitive, affective, emotional, and
behavioural disturbances.
 Ictal means seizure.
 Behavioural disturbances occur in relation to
seizures. These can occur before (pre-ictal), during
(ictal), after (post-ictal), or between (inter-ictal)
seizures

EPILEPSY
176
PRE-ICTAL PSYCHIATRIC DISTRUBANCES
 Vague symptoms known as prodromal symptoms
may be experienced hours to days before a seizure.
 They include increasing tension, irritability, anxiety
and depression generally increasing as the seizure
approaches.

EPILEPSY
177
ICTAL PSYCHIATRIC DISTURBANCES
 Ictal psychiatric disturbances (those directly related to
seizure activity) are common and diverse. During a
seizure the following can occur:
 Transient confusional states
 Affective disturbances
 Anxiety
 Automatisms - are stereotyped movements that tend to
be disorganized and purposeless (although complex
actions may be carried out).

EPILEPSY
178
 Abnormal behaviours (especially in partial seizures)
 Abnormal mental state may be the only sign of non
convulsive (complex partial or absence) status
epilepticus and this diagnosis can be easily
overlooked.
 Psychoses may occur as an ictal phenomena
(perceptual disorders)

EPILEPSY
179
INTER-ICTAL PSYCHIATRIC DISTURBANCES
 Brief psychosis may occur unrelated to a seizure, even
when there is good control of epilepsy.
 Chronic ‘schizophrenia-like’ psychosis: A chronic
schizophrenia like psychotic illness is 6-12 times more
common in people with epilepsy than in the general
population.
 It is particularly associated with left temporal lobe
epilepsy, early severe epilepsy and in women with
epilepsy.

EPILEPSY
180
 The onset of this illness is often 10-15 years after the
diagnosis of epilepsy has been made.
 Other disorders include cognitive impairments,
personality difficulties in a few people, depression
(dysthmia), suicide and deliberate self harm is more
frequent.

EPILEPSY
181
POST-ICTAL DISTURBANCES
 Psychotic symptoms are seen in about 10% due to long
duration of epilepsy and structural brain lesions which
may occur as part of a delirium (confusional state with
disorientation, inattention, variable levels of
consciousness, and sometimes paranoia) or in clear
consciousness.
 If violence does occur, it is extreme, recurrent,
stereotyped, and more likely to occur in men, after a
cluster of seizures.
 There is usually amnesia of the event.

OTHER PSYCHIATRIC COMPLICATIONS
OF EPILEPSY
182
 Cognitive deterioration
 Neurosis
 Mania
 Epileptic personality syndrome
 Violence

END
183
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