Sexual Disorders
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Nursing management in eating disorders
Imbalanced nutrition less than body requirements related to refusal to eat/ drink, self induced vomiting, abuse of laxatives/ diuretics evidenced by loss of weight, poor muscle tone and skin turgor, lanugo, bradycardia, hypotension, cardiac arrythmias, pale, dry mucous membranes
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Explain the client the privileges and restrictions will be based on compliance with treatment and direct weight gain
Do not focus on food and eating
Weigh client daily, immediately upon arising and following first voiding
Stay with client during established time for meals. (30 minutes ) and 1 hour after meals
If weight loss occurs, use restrictions
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Ineffective denial related to retarded ego development and fear of losing the only aspect of life over which client perceives some control evidenced by inability to admit the impact of maladaptive eating behaviors on life pattern
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Develop a trusting relationship
Convey positive regard
Avoid arguing or bargaining with the client
Encourage client to verbalize feelings
Help clients to recognize ways in which he or she can gain control over these problematic areas of life.
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Disturbed bodyimage or low self esteem related to retarded ego development and dysfunctional family system evidenced by distorted body image, difficulty accepting positive reinforcement, depressed mood and self deprecating thoughts
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Help client to develop a realistic perception of body image and relationship with food
Promote feelings of control with in the environment through participation and independent decision making
Help client realize that perfection is unrealistic, and explore this need with him
7 imbalanced nutrition more than body requirements related to compulsive over eating evidenced by weight gain more than 20% over expected body weight for age and height
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Encourage client to keep a diary of ood intake
Discuss feelings and emotions associated with eating
With the input from client, formulate an eating plan
Identify realistic increment goals for weekly weight loss
Plan progressive exercise programme
Provide instructions about medications to assist with weight loss , if ordered by physician
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Disturbed body image/ low self esteem related to dissatisfaction with appearance, evidenced by verbalization of negative feelings about the way he or she looks and desire to lose weight
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Assess clients feelings and attitudes about being obese
Ensure the client has privacy during self care activities
Explore the coping patterns of client
Determine the motivation of client in weight loss
Reflect on strengths and accomplishments of client
Refer to support or group therapy
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Sexual
Disorders
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Categories of sexual disorders
Sexual dysfunctions
Paraphilias
Gender identity disorders
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Sexual dysfunctions
It prevents or reduces an individuals enjoyment of normal sex and prevent or reduce the normal physiological changes brought on normally by sexual arousal.
It may occur because of fatigue, sickness, alcohol, or drugs
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Types
Desire phase
Hypo active desire- complete or almost absence of desire to have any type of sexual activity
Aversion to sex- it repulses the person from sexual thoughts and activity
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Arousal phase
Erectile dysfunction (in males, inability to attain enough erection for coitus)
Sexual arousal disorder (in females, inability to become sexually aroused in spite of the activities)
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Orgasm phase
Pre mature ejaculation (before the end of coitus)
Ejaculatory incompetence (lack or delay in reaching orgasm)
Inhibited female orgasm (lack or delay in reaching orgasm in females)
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Sexual pain disorders
Dyspareunia (painful intercourse in females)
Vaginismus (involuntary spasmodic muscle contractions at the entrance to the vagina when an attempt is made to insert penis, resulting it as a painful act)
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Gender identity disorder F64
It leads to confusion, vagueness or conflict in their feelings about their own sexual identity. There is a struggle between the individual’s anatomical sex gender and subjective feelings about choosing a masculine or feminine style of life.
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Transsexualism
There is a persistent and significant sense of discomfort regarding one’s anatomical sex and a feeling that it is inappropriate to one’s perceived gender.
GID of childhood
Duel role transvestism – it is characterized by wearing clothes of the opposite sex in order to enjoy the temporary experience of membership of the opposite sex.
Intersexuality- the patient has gross anatomical or physiological features of the other sex
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causes
Physiological
Injuries to spine
Enlarged prostate gland
Diseases like, diabetic neuropathy, multiple sclerosis, tumors
Drugs like, alcohol, nicotine, narcotis, stimulants, antihypertensives, anti histamines
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Endocrine disorders (thyroid, pitutary or adrenal gland problems)
Hormonal deficiencies (low testosterone, estrogen, or androgens)
Problem with blood supply
Birth defects
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Psychological factors
Physical changes may generate psychological reactions that compound the dysfunction
Mood disorders (low desire and arousal)
Women with anxiety disorders ( low desire, arousal and orgasm)
Various fears, being vulnerable, being rejected, or of losing control and low self esteem.
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Previous experiences
Past negative sexual or other experiences may lead to low self esteem, shame or guilt
Emotional, physical, or sexual abuse during childhood or adolescence
Early traumatic loss of parent or other loved one
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Contextual causes
Relationship context- lack of trust, negative feelings, reduced attraction toward a sex partner
Sexual context- surroundings that not be sufficiently erotic, private or safe.
Cultural context- cultural restrictions
Distractions with family, work or finance
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Management
Assessment
Medical history
Relationship with partner
Current sexual context
Effective triggering factors
Inhibitors of arousal
Orgasms dyspareunia
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Self image
Developmental history
Past sexual experiences
Personality factors
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Treatment
Hormone replacement
Identify and treat cause
Couple therapy
Drug therapy
Topical applications
Psychoanalytic psychotherapy
Group psychotherapy hypnosis
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Nursing management
Establish therapeutic relationship
Accept the client as he is
Allow the patient to express his feelings
Teach relaxation techniques
Motivate the client to discuss physiological changes occurring in the body
Understand cultural, social, ethnic, racial, religious factors
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Educate client regarding sexuality and sexual functioning
Remove misconception in partners
Motivate them to develop improved relationship
Provide conducive environment to the clients to have verbal catharsis
Provide adequate counseling
Help them in planning and executing treatment regimen
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Health education
Follow doctors advice
Limit alcohol and smoking
Deal with anxiety and emotional problems effectively
Develop healthy communication with partner
Do not force
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Nursing diagnosis
Disturbed personal identity related to parenting patterns that encourage culturally unacceptable behaviors for assigned gender evidenced by statements of desiring to be of the opposite gender, exhibiting behaviors culturally associated with the opposite gender
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Spend time with client and show positive regard
Be aware of own feelings and attitude towards the client and his behavior
Allow client to describe his or her perception of problem
Discuss with him the types of behaviors that are more culturallyacceptable
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Impaired social interaction related to social and culturally unacceptable behaviors evidenced by peer rejection and identification with members of the opposite gender
. Low self esteem related to rejection by peers.
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Personality disorders
Definition
DSM IV defines personality disorders, only when personality traits are inflexible and maladaptive, and cause either significant functional impairment or subjective distress
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James Pritchard, father of personality disorders defines personality disorders as
“a morbid perversion of natural feelings, afflictions, inclinations, temper, habit, moral disposition, and natural impulses with out any remarkable disorder or defect of the intellect or knowing and reasoning faculties and particularly with out any insane illusion or hallucination.”
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classification
ICD- 10 (F60- F69)
Paranoid PD
Schizoid PD
Dissocial PD (antisocial)
Emotionally disturbed PD
A. impulsive type
B.borderline type
Histrionic PD
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Obsessive Compulsive PD
Anxious Avoidant PD
Dependent PD
Other specific PD (narcissistic PD)
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DSMIV classification
A.
In DSM IV, it is coded on axis II and divided in to three clusters.
Cluster A- paranoid, schizoid, schizotypal
B.
C.
Cluster B (dramatic, emotional and erratic, antisocial, histrionic, narcissistic)
Cluster C (anxious and fearful, avoidant, dependent, obsessive compulsive)
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Incidence
General population – 5-10%
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Incidents
Exact cause is unknown
Genetic
Biological
Social
Psychological
Developmental
Environmental
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Genetic
Biological basis of brain function and personality structure is influenced by genetic factor
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Biological factors
Poor regulation of brain circuits that control emotion , increases the risk
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Psychodynamic theories
Suggests that deficiencies in ego and superego development
Deficiencies may relate to mother- child relationships marked by unresponsiveness, over protectiveness or early seperation
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other related factors
Maternal deprivation- antisocial personality
Childhood abuse- borderline personality
Failure to resolve oedipal complex and excessive use of repression – histrionic personality
Fixation in the oral stage- dependent personality
Absence of trust- paranoid personality.
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Clinical features
Paranoid personality disorder
Suspicious
Mistrustful
Sensitive
Argumentative
Stubborn
Self important
Hypertensive
Jealous and irritable
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Schizoid Personality disorder
Detachment
Social withdrawal
Loneliness
No close friends
Emotionally cold
Aloof
Humorless
Introspective
No desire of enjoyment
Inability to experience pleasure
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Schizotypal disorder
Odd thinking/ magical thinking
Social and interpersonal deficits
Inappropriate affect
Social withdrawal
Not fitting easily with others
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Antisocial (Dissocial) personality disorder
(sociopath/ psychopath)
Chronic antisocial behavior
Violates others rights
Unable to maintain consistent, responsible functioning
Failure to sustain relationships
Disregard for feeling of others
Impulsive actions
Low tolerance to frustration
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Tendency to cause violence
Lack of guilt
Failure to learn from experience
Failure to plan ahead
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Histrionic personality disorder
Excessive emotionality and attention seeking behavior
More in females
Dramatic emotionality
Emotional blackmail
Suicide attempts
Craving for novelty and excitement
Shallow and labile affectivity
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Attention seeking behavior
Over concern with physical attractiveness
Exaggerated vague speech
Self dramatization
Impulsivity
Suggestibility
Self indulgence and lack of consideration for others
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Narcissistic personality disorder
Self centered
Self absorbed
Lack of empathy for others
Takes advantage of others and uses them with out regard to their feelings
Inflated sense of self importance
Attention seeking, dramatic behavior
Unable to face criticism
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Lack of empathy
Exploitative behavior
Arrogance
Preoccupation with fantasies of success, power, beauty, brilliance or love
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Borderline personality disorder
Instability in interpersonal relationships
Unstable self image
Unstable emotions
Impulsivity
Lack of control on anger
Recurrent suicidal threats
Uncertainty about personal identity
Chronic feeling of personal emptiness
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Efforts to avoid abandonment
Acting out of feelings instead of expressing them appropriately or verbally
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Anxious (avoidant ) personality disorder
Feeling of inadequacy
Extreme social anxiety
Social withdrawal
Hypersensitivity to others opinions
Low self esteem, poor self confidenced
Persistent feeling of tension and apprehension
Inferiority complex
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Fear of criticism
Unwillingness to become involved with people
Excessive preoccupation with being criticized or rejected in society
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Dependent personality disorder
Submissive
Fear of separation or rejection
Subordination of one’s own needs
Unwillingness to make even reasonable demands on other people
Inability to take decision
Feeling helpless or uncomfortable when alone
Poor self esteem / self confidence
Obsessive compulsive
(Anankastic) personality disorder
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Pervasive desire for perfection
Intolerance to stand mistakes
Feeling of anger to others who do not cooperate
Feeling of excessive doubt and caution
Preoccupation with details, rules, lists, order or schedule
Perfectionism
Rigidity And stubbornness
High standards
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Treatment modalities
Manipulation of social environment
Individual and group psychotherapy
Therapeutic community
Behavioral therapy
Problem solving skills training
Occupational therapy
Recreational therapy
Interaction and guidance
Dialectical behavior therapy
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Medication if needed (small dose of neuroleptics- thiothixene, haloperidol, trifluoperazine)
These drugs reduce symptoms
MAOI in BPD
Lithium, Benzodiazepines, TCAs
SSRI
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Nursing Diagnosis
Impaired social interaction evidenced by inconsistent behavior
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Risk for self mutilation related to Parental emotional deprivation
Observe clients behavior frequently
Secure verbal contract from client
If self mutilation occurs, do not give positive reinforcement to this behavior as it adds additional attention
Encourage to talk feelings
Act as a role model for appropriate expression of angry feelings
Remove dangerous objects
Dysfunctional grieving related to maternal deprivation during rapprochement phase of development evidenced by depressed mood and acting out behaviors
Convey an accepting attitude
Identify the function that anger, frustration and rage serve for client
Encourage client to discharge anger by motor activities
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Explore the source of anger with client
Be aware of counter transference
Help the client to understand appropriate ways to express anger
Set limits
66 Impaired social interaction related to extreme fears of abandonment and engulfment evidenced by alternating clinging and distancing behaviors and staff splitting
Help client realize that you will be available with out reinforcing dependent behaviors
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Give positive reinforcement for independent behaviors
Rotate staff members to avoid client developing dependence
Explore feelings
Help client understand how these behaviors interfere with satisfactory relationships
Assist the client to work toward achievement of goal, consistently
Risk for other directed violence related to rage reactions, negative role modeling, inability to tolerate frustation
Convey an accepting attitude towards the client
Be honest , keep all promises
Maintain low stimuli in clients environment observe behavior frequently
Remove all dangerous objects
Encourage to verbalize feelings
Chemical and physical restraining if ne cessary
