Presentation of physical health and mental illness 1 1 Introduction to physical health in mental illness 1 2 Introduction to key concepts in measuring health and illness 14 3 Principles of physical health assessment in mental health care 27. Physical health and well-being in practice 160 8 Medicines, adverse drug reactions and physical health 160 9 Physical health emergencies in mental health settings 185 10 Practical steps to improve people's physical health.
An introduction to physical health in mental illness
Introducing physical health and mental illness
Introduction
Nash (2005) suggests that this lack of focus on physical health compromises the idea of holistic care in mental health practice. Therefore, the physical health of MHSUs must be part of a holistic assessment that includes social, emotional, economic and psychological needs.
What do we know about physical health in people with severe mental illness?
What is health?
6 Health as physical fitness Athletic or sporty, and for women with a good external appearance. 8 Health as a social relationship Health is defined as having good relationships with others – especially for women.
Health beliefs
Yet Ruari's health beliefs indicate that he is aware of the need to take asthma medication and that he has even reduced his smoking. What GPs need to do is use Ruari's health beliefs about his asthma as a metaphor for his mental illness - the need to take treatment and keep taking it.
Factors that influence physical health in people with mental illness
It is also important not to confuse health beliefs with insight, as health beliefs will influence responses to health and also the therapeutic nurse-patient relationship. But everyone tells me I'm mentally ill and I should take the other tablets, but I don't feel ill.
The impact of lifestyle factors on the physical health of mental health service users
Lifestyle factors that cause obesity, such as low levels of exercise and poor diet, are prevalent in people with mental illness (Brown et al. 1999). However, people need to be fully informed about the risks of making unhealthy decisions, and research shows that MHSUs rarely receive the same health promotion advice or interventions as the general population (Burns and Cohen 1998).
Genetic factors
40–60 percent of MHSUs with schizophrenia, compared to 27 percent in the general population (von Hausswolff-Juhlin et al. 2009). The result is a dual diagnosis – a serious mental illness and a chronic physical problem – that can exacerbate the exclusion of MHSUs who may be too physically ill to take advantage of employment or educational opportunities.
Adverse drug reactions
The results of higher exposure to adverse lifestyle choices include an increased risk of developing severe and complex long-term physical conditions such as T2D, coronary heart disease (CHD), stroke and respiratory disorders associated with drinking tobacco.
Influence of social factors on the physical health of mental health service users Having a diagnosis of mental illness negatively impacts on MHSUs’ socio-economic circum-
People with mental health problems are often overrepresented in the lower social classes. 2002) found that 70 percent of people with psychotic disorders are economically inactive. 81 percent of respondents believed that mental health problems increased the likelihood of having a low income.
Barriers to physical health care for mental health service users
Social exclusion often results in reduced social networks, including health networks, which can further exacerbate both psychological and physical health problems. What other factors may act as barriers to physical health care in your MHSU group.
Healthcare professionals’ attitudes
MHSUs feel that their physical symptoms are attributed to their mental illness and perceived inattention to problems.
Diagnostic overshadowing
Mental health professionals’ skills
Health organization factors
Service users have poor physical health and poor health care outcomes, yet receive fewer, or less effective, physical health care services. For example, only 25 percent of MHSUs with abnormal blood pressure (BP), only 20 percent of those with abnormal lipid levels, and only 53 percent of those with abnormal blood glucose or HbA1c received treatment.
Partisan implementation of health policy
Lawrence and Kisely (2010) believe that poor physical health outcomes in MHSUs are related to disparities in health care delivery that stem from health care provider issues. Meeting the diverse and complex health needs across many services (eg, mental health, acute health care and primary care) is essential to ensure good health outcomes.
Conclusion
For example, a poor lifestyle can obviously increase the risk of poor health, but lifestyle choices can be limited by social factors such as social class, health inequality and social exclusion. Adverse drug reactions also increase the risk of physical illness for MHSUs, while family history can further complicate potential outcomes.
Summary of key points
This chapter should help you to critically examine the idea that ill health in MHSUs is solely related to lifestyle factors. All practitioners must continuously reflect on their attitudes, approaches to physical care for MHSUs, knowledge and skills, and ensure that they have fair and equitable access to physical health care services.
2 An introduction to key concepts in measuring
Defining epidemiology
What is public health?
Defining some key public health concepts
Demographics
Health statistics
People with schizophrenia are almost twice as likely to get bowel cancer (the second most common cause of cancer death in the UK). There is a poor prognosis with physical illness: 22 percent of people with CHD who have schizophrenia die, compared with 8 percent of people who do not have SMI.
Prevalence
Incidence
Mortality rate
Standardized mortality ratio
This means that MEHSUs are 2.5 times more likely to die from cardiovascular and respiratory diseases and five times more likely to die from infections than the general population.
Life expectancy
Morbidity rate
Risk
Risk factors for physical illness in MHSUs are the same as for the general population. The challenge for us is to replicate these categories of risk factors for the different conditions presented by MHSUs.
What does this mean for mental health service users?
When we explore disease, we need to examine risk factors that may increase the risk of developing a physical condition. You will be aware of a number of risk factors that can lead to lung cancer, the most serious of which is smoking.
Putting these statistics to use
Health needs assessment
Now that we know the key areas of concern – obesity, diabetes, cardiovascular disease, respiratory disease and infections – we need to start integrating other NSFs, such as those for CHD (DH 2000) and the various NICE guidelines, into our work routine. at least at the level of screening and referral. Health needs are relative to the individual and we can have a system for negotiating our health, such as being a social smoker. We know that smoking is bad for us, so we minimize the conditions in which we do it.
Caseload profiling
It is disempowering for MHSUs to minimize their needs through diagnostic overshadowing (see Chapter 1) or to allow them to remain unmet because mental health practitioners or services are not up to the challenge of the physical health agenda. However, it must be recognized that needs can be identified, but interventions are not desired; For example, MHSUs who smoke may refuse interventions such as a smoking cessation program.
Screening for physical conditions in mental health service users
Potential benefits of health needs assessment
Prevalence of inactivity Barriers to physical activity (This may include frailty in the elderly). The challenge for mental health nurses - meeting the physical health needs of mental health service users.
The challenge for mental health nurses – meeting the physical health needs of mental health service users
Improved physical health of MHSUs Whose responsibility is for improving physical health – mental health services or primary care services. Trainees must develop skills in public health techniques such as screening, physical health education and health promotion.
3 Principles of physical health assessment in
For example, Nash (2005) found that although practitioners reported having physical care skills, these were taught as part of their student nurse training and 42 per cent of the sample had been qualified for more than ten years.
Why physical assessment skills?
Inter-professional working in physical assessment
Practical aspects of physical assessment
What does physical assessment tell us?
Physical illness masking and mimicking mental illness
Core skills in undertaking physical assessment
Communication skills
Questions: Open-ended questions are used for global assessment and to get an overview of MHSU, e.g. Reassurance: Try not to make the MHSU more anxious – they may be unaccustomed to seeing you in a physical health role.
Interpreting verbal cues from the mental health service user
How are you feeling today?' Closed questions, on the other hand, are used for more concrete assessment, e.g. If the assessment is complex, summarize at intervals to ensure you have an accurate account.
Observation Box 3.4
It is important to have basic knowledge and skills when it comes to physical assessment. However, it is important not to assume too much and that appropriate clinical measurements are taken to confirm our observations.
Attitude
Observation is an important aspect of physical assessment as it can provide important information without asking questions. It is important that we use our senses when we 'observe' and not rely solely on direct questions and answers.
Clinical assessment of physical health
The principle of observation in physical health is the same, although more technical, when baseline observations or signs and symptoms of physical illness are recorded and reported.
Specific techniques
Assessment aids
Psychiatric nurses may not take all of the measurements listed in Table 3.2; eg. will spirometry be performed in primary care or acute health conditions. For example, if someone wants to know if they have a sexually transmitted disease (STD), a blood sample can be taken and sent to the laboratory.
Performing a physical assessment
MHN must provide the service user with reassurance and a clear explanation of the procedure. However, if MHSU wants to know their HIV status, this usually requires pre- and post-test counseling, and consult your local policy.
The general survey
General approaches to physical assessment
Head-to-toe approach
Chest pain, hypertension, tachycardia/bradycardia, shortness of breath, pain on breathing, labored breathing, wheezing, cough (dry or productive), previous respiratory disease - chest infections, COPD, current asthma, smoking history, use of accessory muscles, finger clubbing.
Body systems approach
Sexual activity and use of contraception, visible discharge, odors, presence/history of rash indicative of a sexually transmitted infection (STD). Pain – frequency, urgency, retention or difficulty urinating, color/odor of urine, presence of blood in urine or stool.
Problem-centred approach
Given the prevalence of increased morbidity in MHSUs, there is a likelihood of more than one complaint occurring, such as cough, chest pain, difficulty breathing (see Box 3.6). Problems should therefore be listed in order of severity to safely prioritize needs and give further structure to the assessment.
Physical assessment and history-taking
Taking a family history
Linking the structure and process during the physical assessment
However, the assessment remains to be holistic, with all observations accurately captured and recorded and communicated to the team and MHSU. These should be suitable with timely follow-up and further referral if anything is discovered.
Essential equipment for a physical assessment
Issues concerning consent and physical assessment Box 3.7 Case example
Physical assessment of a non-consenting mental health service user
Documentation and record-keeping
All clinical measurements should be performed even if they fall within 'normal' ranges or if no problems are identified. For example, a blank entry may be assumed to mean 'no problem noted', but it may also indicate that this part of the assessment has been omitted.
Barriers to using physical assessment skills
This chapter has outlined three approaches that can be used as a framework for structuring physical assessment. 2 In what ways can the role of the MHN and the physician be duplicated in physical assessment.
Clinical skills for physical assessment in mental
Physical assessment skills for practice
Physicians should wash their hands and/or use an alcohol-based hand sanitizer before and after contact with MHSU. Clinicians should also remember the practical aspects of physical assessment described in Chapter 3 when performing clinical observations.
Clinical governance
However, skills can be learned and it is important that our repertoire of physical care skills continues to grow. This can be reflected in our post-registration education, where we can opt for physical health courses such as tissue viability or performing EKGs.
Rationale for taking baseline observations
Homeostasis
Components of a homeostatic system
If the increase in temperature is due to infection, white blood cells are sent to fight infection, the endocrine systems slow down metabolism to prevent more heat from being generated until temperature returns to normal.
Observation
Clinical skills used routinely in mental health care Temperature
Baseline observations show fever, so more information is required regarding the nature of the suspected infection. Pathology blood tests are required to determine the exact nature of the infection and to prescribe the antibiotic – complete blood count (FBC) including white cell count.
Pulse
Be careful not to put too much pressure on the pulse point as this will be uncomfortable and may make the pulse more difficult to detect. 8 Communicating Findings 1 Inform MHSU of the outcome and be prepared to answer any questions.
Blood pressure Box 4.7
Exercise
Two types of conditions can be responsible for this: physiological factors such as illness or poor technique.
Electrocardiogram
11 Communicating Findings 1 Inform MHSU of the outcome and be prepared to answer any questions. If the ECG is an emergency, the MHSU should be reassured and the procedure explained to them.
Pulse oximetry
The MHSU should be lying and since they have to move out, it is important to preserve their privacy and dignity. If equipment is not responding the way you expected, check the MHSU's vital signs.
Respiration
You should not take a pulse oximetry measurement from a location where a BP cuff is attached, as inflating the cuff will decrease blood flow and give a false reading. You should also know and understand your local policy and procedures for the use of pulse oximetry.
Collecting a sputum sample
Instruct the MHSU to briefly rinse the mouth with water and expel it into the kidney container. If MHSU uses an inhaler, it may be necessary to use this to prevent an asthma attack.
Peak flow
Urinalysis
If immediate intervention is needed or for continuity of care. 10 Communicate findings. 3 Record findings in the MHSUs. If the reagent strip is outdated or has not been stored properly, it may have reacted to moisture in the air.
Measuring body mass index
Urinalysis can be a useful test for monitoring glucose and ketone levels, which are important in screening for T2D.
Waist circumference and waist-to-hip ratio
Blood glucose
When well, the nurse's role will be to review MHSU's blood glucose levels in MHSU's own medical record. Carlos must monitor his blood sugar twice daily: (1) before breakfast and (2) before going to bed.
Blood tests Box 4.10
Night staff should be aware of the care plan to reduce Carlos' inappropriate nighttime snacking and promote continuity of care. However, it is important that practitioners have the background knowledge of what the blood is being tested for and what this could mean for the physical and mental health of the MHSU.
Physical assessment
31 percent of people with schizophrenia and cardiovascular disease are diagnosed under the age of 55, compared with 18 percent of others with cardiovascular disease. 22 percent of people with CHD who have schizophrenia die, compared with 8 percent of individuals without serious mental illness (DRC 2006).
Risk factors for cardiovascular disease
Does caffeine affect blood pressure?
Ethnicity and hypertension
Anatomy and physiology of the cardiovascular system
Structure of the heart
The endocardium, the innermost layer of smooth membrane, allows blood to flow easily through the heart. The heart needs its own blood supply, and the myocardium receives it from the right and left coronary arteries.
How the heart works
The myocardium, the middle layer of heart tissue, contains heart muscle fibers that allow the heart to contract during beating. Deoxygenated blood leaves the heart via the cardiac veins and returns to the right atrium, where it is carried to the lungs.
Blood flow through the heart
The pericardium, the outermost layer, consists of two components: the fibrous pericardium prevents the heart from overextending and holds it in place within the thoracic cavity, while the serous pericardium serves to lubricate the heart and reduce friction during systole and diastole. prevent.
The cardiac conduction system
Cardiac repolarization
Cardiac electrical activity: PQRST waves
When these waves are disharmonic – either too fast (tachycardia) or too slow (bradycardia) – we have an abnormal cardiac cycle.
The cardiac cycle
Significance for mental health service users
Pathophysiology of coronary heart disease
Disorders of the cardiovascular system
Cardiac arrhythmias
Conduction disorders Atrial fibrillation
Treatment of atrial fibrillation
Ventricular fibrillation
Cardiac arrest
Other coronary problems
Angina
These will help reduce risks such as high cholesterol, help reduce obesity by lowering BMI, and help control glucose and diabetes. Help control blood cholesterol and BP levels – statins help lower cholesterol levels, which can lead to atherosclerosis.
Heart block
Increase blood flow to your heart – Glyceryl trinitrate (GTN) increases blood flow to the heart by widening blood vessels and allowing more blood to circulate. Reduce the work your heart has to do – beta blockers lower the heart rate and limit the amount of work the heart has to do.
Heart failure
Reduce the chance of developing blood clots – aspirin is an anti-platelet medicine that reduces the 'sticking' of platelets; Prasugrel is a platelet inhibitor that stops platelets from clumping together and forming a blood clot. Glyceryl trinitrate comes in a spray, tablet, or patch form and is taken when symptoms occur or to prevent symptoms from developing.
Congestive cardiac failure
You should also ensure that infection control mechanisms are in place to minimize the risk of hospital-acquired infections and ensure safe disposal of clinical waste. Communicating progress with the interprofessional team will also play an important role, as will supporting the MHSU and their family/carer during the post-operative and recovery period.
Assessing cardiovascular health in mental health service users
MHSU will need a place to express their concerns, so you should be there to provide support and reassurance. You will act as a liaison between the CCU team, MHSU and their family and your team, helping to explain procedures, why they are needed and keeping your team informed.
Abnormal pulse
Tachycardia
Bradycardia
In a mental health context, an irregular pulse may be associated with anxiety, ADRs such as cardiac arrhythmias, infection, hypoglycemia, or hypovolemia.
Hypertension
Other factors in cardiovascular assessment
Other physiological signs
Using health promotion with mental health service users with coronary heart disease
For cardiovascular disease, medications such as statins are prescribed to lower cholesterol in conjunction with primary prevention measures outlined above. This stage is more advanced than primary or secondary prevention and may involve invasive interventions such as heart surgery, which will require intensive follow-up care.
Care planning
Treating and managing coronary heart disease
Medications used to treat coronary heart problems
Secondary prevention involves managing the early stages of conditions, reducing their impact on the MHSU's health and well-being. Encourage MHSUs to vent feelings and develop psychological coping strategies, or acceptance of the condition.
Alpha blockers
These medications can be taken in different forms and you should be aware of this to avoid mismanagement. This is also an important factor for MHSU education: that they are aware of the route of administration when self-medicating.
Beta blockers
Angiotensin-converting enzyme inhibitors
Calcium channel blockers
Diuretics
Loop diuretics
Statins
Blood-thinning agents
Orthostatic hypotension
Symptoms of orthostatic hypotension The symptoms of orthostatic hypotension include
The internal body environment is monitored. Basic observations – Erin explains that blood pressure should be monitored both lying and standing to assess the degree of change. monitoring physical interventions such as medications. evaluating the effectiveness of the treatment. reviewing the care plan if the condition worsens. The physical environment will be adapted to assist with getting up and standing, e.g. high back seats, toilet handles 2 Breathing Breathing should also be monitored:. posture while sitting or lying down. quit smoking – consult a smoking cessation specialist and use nicotine replacement aids. continued) of orthostatic hypotension, as these symptoms may be due to natural causes, such as the aging process.
Treatment of orthostatic hypotension
Older MHSUs are particularly vulnerable to orthostatic hypotension because the natural aging process can contribute to it.
Care planning for orthostatic hypotension
Finally, physicians must be aware of safety issues when planning the care of people with coronary problems. This will include their knowledge of the desired and unwanted effects of medications – those for mental health problems and those for coronary problems.
6 Assessing respiratory health in mental health
Do your MHSUs cough?
Why do they cough?
Because they smoke
In an observational prevalence study in the United Kingdom, Filik et al. 2006) found that people with SMI had lower lung function compared to the general population, with a higher risk of respiratory symptoms such as shortness of breath, sputum production and wheezing. In an American study, Himelhoch et al. 2004) surveyed a random sample of 200 MHSUs to estimate the prevalence of COPD.
Risk factors affecting respiratory function
This may be a contributing factor in the higher mortality rates from cardiovascular and respiratory disorders with an SMR of 250 (Harris and Barraclough 1998).
Reasons for respiratory disorders in people with mental illness
Anatomy and physiology of the respiratory system
Like the heart, the lungs have a pleural membrane that holds them in place, and this contains a lubricant that allows for painless breathing. But if there is an imbalance, then this is detected by chemoreceptors located in the aorta and carotid arteries.
How the lungs work
They send a message to the medulla oblongata (control center), which instructs the lungs to speed up breathing to increase oxygen intake. External respiration is the diffusion of oxygen and carbon dioxide between the alveoli and the blood in the lungs.
The significance of respiration for mental health practitioners
Internal respiration occurs at the cellular level with diffusion of oxygen and carbon dioxide between the blood and the cells. However, smoking inhibits the action of the cilia and alveolar macrophages, reducing their effectiveness, which is one reason why smokers are vulnerable to frequent respiratory infections.
Smoking
Smoking prevalence in mental health
Effects of smoking on the body
Why is smoking more prevalent in mental health?
Smoking and psychotropic medications
Smoking and illicit substances
Disorders of the respiratory system
Lung cancer
You will monitor the MHSU's mental status for signs of depression and hopelessness, while working with the cancer nurse to monitor their physical status. In the event that palliative care is required, assure the MHSU and their family that physical suffering will be minimized through an MHSU-focused pain management plan.
Chronic obstructive pulmonary disease
This test will be administered in primary care or general medical settings, as spirometers are generally not available in mental health units. This will be interprofessional and require liaison with primary care and specialist medical services.
Cough
However, they should also be encouraged to be independent and walk lightly. Folk remedies can also be used by MHSUs; For example, in Ireland, a knob of butter is used on the bridge of the nose to reduce congestion.
Tuberculosis
We need to explain the need for constant contact as a way to ensure their physical well-being as well as health education and health promotion. It is very important that you are up to date on all your vaccinations and in this case it is the BCG vaccination.
Asthma
Although MHSUs may be compliant with inhaler therapy, they may not receive optimal doses if their technique is faulty, which can contribute to poor asthma management. They suggest that education of MHSUs in proper inhalation technique is an important factor in effectively treating asthma.
Pneumonia
Hydration: Reduce the risk of dehydration by ensuring adequate fluid balance as the MHSU may be dependent on staff to deliver fluids. Skin: Encourage MHSU to refrain from continuous lying and sitting to reduce the risk of pressure sores.
Respiratory assessment Box 6.8
They may need to do chest massage, which will help the MHSU to cough up and expel sputum.
Breathlessness
Visual observation
Auditory observation
Inspection
Palpation
Auscultation and percussion
Clinical observations
Emergency respiratory assessment
Smoking cessation
Indeed, NICE (2006c) recommends that short-term smoking cessation interventions should include, among other things, counseling MHSUs to stop smoking and referring them to smoking cessation services. Practitioners should be able to provide smoking cessation/cessation support contacts; in the UK, these would be telephone numbers for the NHS Stop Smoking Services.
Cutting down to quit
Finally, smoking cessation should not just be an issue for MHSUs; if you smoke, you may also need to try to quit.
How effective is smoking cessation?
Smoking cessation: the challenges and rewards
Using Roper et al.'s (1996) activities of daily living model, we can design and structure a care plan for someone with respiratory illness. Again, our role in care planning will depend on the severity of the manifestation, but we will be able to screen for respiratory distress and participate in the interprofessional care plan.
Treating and managing respiratory illness Clinical priorities include
Yes, they cough all the time because they may have a smoking-related respiratory disorder
7 Assessing nutrition, diet, and physical activity
Lifestyle factors that cause obesity, such as low levels of exercise and poor diet, are present in people with mental illness (Brown et al. 1999). Kendrick (1996) found that of 101 people with serious mental illness living in the community, 26 were clinically obese.
Reasons for high prevalence of obesity in mental health care
Citrome and Vreeland (2009) state that obesity is one of the most common physical health problems in people with SMI. 1998) found that people with schizophrenia make poor dietary choices characterized by a high-fat, low-fiber diet.
Nutrients and nutrition
The result of the factors listed in Table 7.2 is that MHSUs are at increased risk of higher mortality and morbidity due to physical conditions and their complications. Negative symptoms hinder ability to participate in physical activity programs Stigma – negative staff attitudes toward ability to change lifestyle. Source: adapted from Nash (2010).
Carbohydrates
Increased exposure to health inequalities and social exclusion Increased exposure to lifestyle risk factors.
Proteins
Fats
Omega-3 fatty acids
Vitamins and vitamin deficiency
Vitamin D is found in eggs, liver and fish; it is also synthesized in the body naturally from sunlight. Vitamin E deficiency can cause problems of the neuromuscular, vascular and reproductive systems (Vitamin and Mineral Expert Group 2003).
Minerals
Fat-soluble vitamins that can be stored by the body, and therefore a daily intake is not really necessary (Kozier et al. 2008); examples include vitamins A, D, E, and K. Water-soluble vitamins that cannot be stored by the body and therefore a daily supply is required (Kozier et al. 2008); examples include vitamin C and B-complex vitamins B1, B2 and B12.
Obesity
You will need to have basic knowledge about the role of carbohydrates, fats and proteins in diet. Meeting the nutritional needs of all service users is one of many areas where the MHN will need to practice their teamwork and communication skills.
Relevance of obesity to mental health
How can we help MHSUs, like Abdul, with similar social problems that affect physical health.
Assessing and managing obesity
Screening for obesity risk factors Rationale
Care plans should be designed to reduce weight or, in the case of ADRs, slow the rate at which weight is gained. The care plan should be clearly documented and reviewed according to local and professional standards.
Aims
This gives MHSU proof of achievement, which can increase motivation and self-esteem. Changes should be planned and staged rather than 'all or nothing' as failure to achieve can reduce motivation.
Implementation
Increasing physical activity
Psychological support
Pharmacological treatment
These interventions should also be considered for inpatients who would not have to wait for discharge to receive this from their GP. Mental health nurses need to be aware of the adverse effects and contraindications of such medications when co-prescribed with psychotropic medications.
In extreme cases
Evaluation
Physical activity Box 7.6
However, the BHF (2012) found low percentages of adults meeting this target: in Scotland, 45 per cent of men reported meeting this target, compared with 39 per cent in England, 37 per cent in Wales and 33 per cent in Northern Ireland. It is important that physical activity is adapted to each MHSU's specific needs and abilities.
Assessing capability for physical activity
Department of Health (DH 2011) physical activity guidelines for UK adults recommend at least 150 minutes (2.5 hours) of moderate-intensity activity in 10-minute or more bouts per week. This may include input from a physiotherapist or qualified sports therapist to ensure that exercise plans take into account the individual needs of MHSUs, such as safe exercise for MHSUs with movement disorders.
Accessing opportunities for physical exercise
Diet and nutrition
Relevance to mental health
Aims of a healthy diet
General dietary advice
Effects of adverse drug reactions on diet and nutrition
Effects on swallowing that compromise nutrition include confusion, delirium, cough, esophageal ulcers, changes in smell and taste, sedation, and inattention.
Cultural and religious factors
General assessment of nutritional state
Malnourishment
Skills for assessing nutritional state Core skills include
Weight loss
Physical effects of poor nutrition in anorexia nervosa
There may be genetic predisposition to obesity (Loos and Bouchard 2003), past medical history of diabetes. Body mass index can be monitored monthly and weight can be measured more than once a day (to detect large intakes of water to mask true weight).
Monitoring physical health in low weight
Management of weight loss
An inter-professional team approach
A specialist mental health dietitian should be consulted regarding malnutrition and any nutritional supplements required. Good connections will also have to be made with the GP team that provides primary care, so that there is continuity of care after discharge.
Social assessment
They can also provide the service user with individually tailored information and a meal plan. Mental health nurses must be able to effectively monitor the results of various clinical tests (e.g. blood tests) and report any abnormal values to the treating consultant.
Fluid balance
If a urinalysis is performed, be aware that old urine may yield a false positive for high pH or bilirubinuria. If it is secondary to heart disease, the heart condition must be treated and managed effectively.
Diabetes
Another cause of overhydration is a phenomenon whereby an individual develops a compulsion to drink too much water. Overhydration can lead to water intoxication, which is different from polydipsia as described earlier, but more similar to dipsomania – a compulsion to drink alcohol to excess (see Ferrier 1985).
Homeostasis of glucose control
If they do not take diuretics and complain about the frequency of micturition, this may be a sign of diabetes mellitus. Overhydration can lead to hyponatremia, a condition in which there are low levels of sodium in the blood due to dilution by excessive water intake.
What we know about diabetes
Having a balanced diet is important for maintaining effective diabetes control, as it will help maintain blood glucose within a certain target range and reduce the risk of complications such as hypoglycemic coma.
What we know about diabetes in mental health service users
Causes of diabetes in mental health service users
A review by Smith and colleagues (M. Smith et al. 2008) found that newer atypical medications have a 30 percent increased risk of diabetes compared to typical medications. The review by Smith and colleagues indicates that any evidence for such a link is weak, but suggests that clinicians 'implement protocols for identifying physical illnesses, particularly diabetes, in people with schizophrenic illness' (M. Smith et al.
Screening for and identifying Type 2 diabetes
Insulin resistance is another metabolic disorder defined as a disease process in which an individual becomes resistant to the inherent production of insulin (Jeffery 2003).
Prediabetes
Diagnosing diabetes
Managing Type 2 diabetes
If lifestyle factors are not sufficient to restore glycemic control, medications may be prescribed to achieve this. However, this drug may be contraindicated in MHSUs with renal impairment and should be considered with caution in those taking lithium.
Checklist prior to commencing an atypical antipsychotic
Complications of Type 2 diabetes
Watkins (2003) lists factors that increase the risk of CHD in patients with diabetes, such as smoking, hypertension, insulin resistance, Asian descent, microalbuminuria, diabetic nephropathy, poor glycemic control, and hyperlipidemia.
Health education and health promotion
Prevention Primary prevention
The aim is to improve the quality of life and reduce the impact of the condition in daily life. The goal here is to increase the MHSU's quality of life after a significant disabling event.
Metabolic syndrome
Service users have many of these risk factors, but screening for metabolic syndrome in mental health care is poor (Barnes et al. 2007, and see below). The sooner this is implemented, the better the health outcomes for service users will be.
Risk factors for metabolic syndrome
Screening for metabolic syndrome should be based on one of the above diagnostic criteria, but a practical problem may be, 'which criteria should we use?' This can be easily established by contacting the local endocrine or diabetes services to determine what criteria they. use and whether they would be applicable in a mental health context. What is clear is that there is no need to reinvent the wheel in terms of screening for metabolic syndrome.
Treatment of metabolic syndrome
At a community meeting on your ward, service users raise concerns about the lack of healthy options in the vending machines on the unit. Service users should be encouraged to increase fruit and vegetables in their diet and to exercise, particularly exercise that involves increased heart and lung activity.
What can the mental health nurse do to promote healthy eating and exercise?
Conclusions
Weight management and physical activity programs should be offered to all MHSUs, but especially to those taking atypical antipsychotic medications that cause weight gain. Practitioners should involve MHSUs and caregivers in plans to develop healthy lifestyles and physical activity regimens.
Physical health and well-being in practice
8 Medication, adverse drug
For example, in 1949, Cade, an Australian psychiatrist, found that lithium was effective in treating mania; however, in the same year, the US Food and Drug Administration banned lithium after deaths in patients with heart disease (Keltner and Folks 2005). This chapter includes blood as a component of the heart system, as some of the side effects are blood dyscrasias (ie, abnormalities in blood cell production) that can have serious implications for the MHSU immune system.
What does the brain do?
Neurotransmitters
Why ‘physical’ adverse drug reactions?
Increased levels may contribute to depression Decreased levels may contribute to Alzheimer's disease, Huntington's disease and Parkinson's disease. Increased levels can help reduce anxiety Decreased levels can contribute to mania, anxiety and schizophrenia.
Why monitor adverse drug reactions?
How do psychotropic medications work?
Adverse drug reactions with psychotropic medications
Antipsychotic medications
Typical antipsychotics
Atypical antipsychotics
For example, tardive dyskinesia has been reported with the atypical antipsychotics clozapine (Novartis 2013) and risperidone (Janssen Pharmaceuticals 2013), and blood dyscrasias (ie, agranulocytosis) can occur with typical antipsychotics such as chlorpromazine (BNF 201).
Antidepressants
These inhibitors work by blocking the enzymes that destroy neurotransmitters such as norepinephrine and serotonin. This is due to the possible interaction between MAOIs and tyramine, which can release neurotransmitters such as dopamine and norepinephrine.
Mood stabilizers
Benzodiazepines
Metabolic adverse drug reactions with medication
Bananas can be taken in small amounts, but if a severe headache or symptoms of hypertension occur, they should be evaluated immediately. This is not helped by the lack of specific guidance on metabolic control and monitoring and confusion about whose role this should be.
Second-generation antipsychotics and metabolic abnormalities
Obesity and weight gain
Factors that contribute to weight gain
Reduced self-esteem: MHSUs may have poor self/body image and therefore feel ashamed of exercise. Social exclusion: MHSUs may not have the resources or support to join gyms and the stigma of mental illness is another barrier.
Predictors of weight gain
Increased appetite: Weight gain is difficult to reverse – this can reduce MHSU's motivation to exercise or diet. Negative symptoms, as distinct from decreased motivation, are not a lifestyle choice, but rather a symptom of mental illness.
Complications of weight gain
Lifestyle advice, healthy eating plans and exercise have been shown to be helpful in the fight against obesity and diabetes. However, treatment-related weight gain may be an indicator of clinical improvement in MHSU (Expert Consensus Group 2005).
Managing weight gain as an adverse drug reaction
2003) found that those taking atypical medications were more likely to have glucose screening than those taking typical medications.
Cardiac system adverse effects
Disorders of cardiac conduction
Electrical activity of the heart
QT prolongation
The risk of sudden death may be associated with pre-existing heart disease (both diagnosed and undiagnosed). Psychiatric medications that induce QT prolongation include antipsychotics (both typical and atypical) and tricyclic antidepressants.
QRS prolongation
Practitioners should be extra vigilant of MHSUs taking medications that may cause syncope or orthostatic hypotension.
Poly-pharmacy
Myocarditis
Therefore, when MHSUs receiving clozapine present with the above symptoms, myocarditis should be considered as the primary cause. If myocarditis is suspected in someone taking clozapine, treatment should be stopped immediately (Novartis 2013) and MHSU should be referred to a cardiology specialist for further evaluation and treatment.
Pulmonary embolism
The blood
Blood composition
Haemopoiesis
Red blood cells
White blood cells
Thrombocytes (platelets)
Relevance for mental health nurses
Blood dyscrasias as adverse drug reactions
Clozapine monitoring
Other potential reactions
Anaemia
Aplastic anaemia
Megaloblastic anaemia
Anaemia due to low blood volume
Sickle cell anaemia
Assessment of anaemia
Treatment of anaemia
Other blood-related effects
Sexual dysfunction and adverse drug reactions
Managing sexual dysfunction, like treating most physical side effects, is a balance between MHSU's mental health and physical well-being. The result can be poor mental health and few/no side effects or good mental health and few/severe side effects.
Hyperprolactinaemia
Physical investigations, antipsychotic medications, and adverse drug reactions
It may be a symptom of the lack of regard for physical health that there is a lack of rating scales, or that rating scales tend to exclude physical ADRs. MHSUs who are on medication and who may not have monitored their physical health, so there is no credible baseline for comparison.
Time-scales
Plasma glucose and lipids (preferably fasting levels) should be measured three months after starting treatment (and within one month if taking olanzapine), and more frequently if there is evidence of elevated levels. How can you be sure that the lack of motivation stems from a general disinterest in physical health (which is shared by many in the general population) and is not a manifestation of negative symptoms of schizophrenia.
Medication monitoring Box 8.10
In a study of US MHSUs, Weiden et al. 2004) found that higher BMI and subjective discomfort due to weight gain were predictors of non-adherence. In a small study examining MHSUs' and physicians' concerns about side effects, Huffman et al. 2004) found that MHSUs rated cognitive slowing as more harmful, while MHSUs rated weight gain as more harmful than MHSUs or psychiatrists.
Ethical issues
Kurzthaler and Fleischhacker (2001) found weight gain to be a risk factor for nonadherence, reduced quality of life, and social withdrawal (ie, MHSUs not wanting to socialize). This is because MHSUs may not have received health promotion interventions regarding the importance of lifestyle factors or weight gain as a serious reaction.
Medication monitoring and carers/family members
Carers/family members undertake a major caring role for which mental health services should be extremely grateful. Mental health services have developed different support programs and educational support to help carers/family cope with their caring role.
Carer/family medication monitoring risks and dilemmas
If caregivers/family become involved in medication monitoring, they will need education to improve their knowledge and skills – from administration to recognizing side effects. However, carers/family may be forced to take on this role because mental health professionals do not tend to perform well in this area (see Nash 2011).
Physical health emergencies in mental health settings
Guidelines from NICE (2007a) recommend that staff caring for patients in acute hospital settings should have skills in monitoring, measurement, interpretation and rapid response to the acutely ill patient appropriate to the level of care they provide. The National Patient Safety Agency (2008) revealed wide variations in resuscitation standards in relation to mental health and learning disabilities.
Emergency medical equipment
What do we mean by medical emergencies in mental health?
Rapid medical emergency response is critical to the immediate and long-term health of MHSU. You should know the emergency medical assistance policy and emergency telephone number at your workplace.
Basic principles of first aid and basic life support
The primary goal of intervention in a medical emergency is to prevent further deterioration of physical health, including breathing and circulation. The outcome of any intervention is not guaranteed, but all possible interventions should be attempted and sustained until the MHSU has recovered, transferred to an appropriate medical facility, or declared dead by a physician.
What might cause collapse?
When it is determined that a person is unconscious, a primary examination is carried out which consists of checking the victim using the ABCDE system.
Respiratory arrest
