MENTAL HEALTH REVISION QUESTIONS

1. MANIA
Mina a 20-year-old female is brought to your psychiatry department dressed
all colorfully and speaking so fast, laughing uncontrollably and appearing
very excited. A diagnosis of mania is made.
a) Define Mania 5%
b) State 3 predisposing factors to mania 15%
c) Using the nursing care plan identify 6 problems that she may present with
and discuss how you will manage them 60%
d) Outline 5 points that you will include in the Psychiatric rehabilitation of
Mina 20%
e) Outline 3 drugs that can be given, stating the dose, frequency, side
effects and nursing implication 30%

MANIA.
Define Mania 5%
- Mania is a condition characterized by an elevated, expansive or irritable
mood and psychomotor acceleration.
- Mania is an abnormally elevated mood state characterized by such
symptoms as inappropriate elation, increased irritability, severe insomnia,
grandiose notions, increased speed and/or volume of speech,
disconnected and racing thoughts, increased sexual desire, markedly
increased energy and activity level, poor judgment, and inappropriate
social behavior.
State 3 predisposing factors to mania 15%
1.Biological Factors
• Genetics: mania and major depression is hereditary in nature. First degree
relatives or children of people with these disorders are more likely to
develop the mood disorder than people in the general population.
• Biochemistry: research has shown that people with depression have less
of the neurotransmitter serotonin, whilst those with mania have too much
of serotonin and epinephrine.
2.Social Factors
• Social factors: stressful life events, lack of social support and
environmental stress and poverty can predispose a person to mood
disorders.
3. Neural anatomical factors
• Right sided lesions in the limbic system, temporobasal areas, basal
ganglia and thalamus can predispose an individual to main
4. Medications
• Some medications such as antidepressants, amphetamines, high doses of
anti-consultants and narcotics are known for initiating manic episodes.

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f) Outline 5 points that you will include in the Psychiatric
rehabilitation of Mina 20%
Re-establishing contact with the family and the community.
- Each patient on the programme should receive his share of restored
community contact.
- Telephone call/letter writing hours should be the first step.
- Take them through letter writing.
- Re-train them in social skills.
- Allow the patient to practice the skills in real life.
- Role play and rehearsal and provide feedback.
Carefully structured programmes of daily activity
- Waking hours should involve constructive social learning.
- Un-training must be replaced by re-training.
- Diculturation must be replaced by reculturation
- Baseline measurement should be undertaken to assess areas of
deficiency.
- A thought out time table of activities for each patient is essential.
- Work therapy may beneficial.
- Avoid boring and monotonous tasks.
- Hobbies and simple creative activities.
- Access to domestic appliances for them to do things for themselves.
- Patients should be encouraged to choose their own food, clothing, and
sort out their finances.
Eradicating browbeating and teasing
- Teaching should be by example.
- Problems of over-crowding & understaffing should be addressed.
- Encourage therapeutic nurse patient relationships.
Loss of personal friends, possessions and events.
- Encourage the patient to personalize their room/space.
- Photographs, souvenirs, books, etc as a mark of personal territory.
- Personal clothing should be encouraged.
- Birthdays should be celebrated.
- The kitchen can be contacted to bake a cake for the patient.
- Provide simple birthday card.
Awareness of prospects outside the hospital
- Prospects of accommodation, employment, social activities should be
displayed on the notice board.

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 - Discharged patients who have adapted successfully into the community
can provide motivation to patients.
- NGO/Voluntary organizations may arrange social/creative activities with
patients.
- Rehabilitation should lead to discharge.
- Discharge may initially be to half-way homes

b) Identify 5 problems that Muna may present with and discuss how
you will manage them using a nursing Care plan (50%)- see
attached nursing care plan.
NURSING CARE PLAN FOR MANIA
Proble Nursing Goal Intervention/ rationale Evaluatio
m diagnosis n
Risk of Risk for Client will - Remove all injurious objects Patient’s
injury to injury to self experience from the patient’s room to safety
self and and others no physical prevent injuries. maintained
others related to injury - Put the patient in seclusion , evidenced
extreme room when she/he is violent to by patient
hyperactivity prevent injury to others. exhibiting
. Evidenced - Administer tranquilizers such no
by increased as haloperidol or physical
agitation and chlorpromazine to quickly injury
lack of relief agitation. obtained
control over - Reduce environmental stimuli, while
purposeless ensure soft lighting, low noise experiencin
and and simple room décor to g
potentially prevent unnecessary hyperactiv
injurious stimulation of the patient e
movements - limit group activities and behaviour
observe patient’s behaviour
frequently
- Stay with the client and offer
support and provide a feeling
of security.
Imbalan Imbalanced Client will - Provide the client with high Patient
ced nutrition less consume nutritious finger meals and nutritional
nutrition than body sufficient drinks that can be consumed status
less requirement finger foods while on the run improved
than related to and in - Ensure availability of snacks evidenced
body patient’s between- on the unit all the time by patient
require inability to meal - Maintain accurate record of gaining
ments sit long snacks to intake and output. and
enough to meet - Weigh the patient daily to maintainin
eat meals recommende assess nutritional status. g weight
evidenced by d daily - Determine the patient’s during
loss of allowances favourite foods and ensure hospitalizat
weight. of nutrients they are provided ion and
24 hours of - Administer vitamins and patient’s

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 hospitalisatio mineral supplements ability to
n prescribed by the physician verbalize
- As agitation reduce sit with the
the patient and encourage the importance
patient to eat. of good
- Educate the client on the nutrition.
importance of adequate
nutrition.
Impaire Impaired Client will - Set limits on manipulative Patients’
d social social demonstrate behaviours and explain to interaction
interacti interaction use of client what you expect and with others
on. related to appropriate what the consequences are if improved
disturbed interaction the limits are violated. evidenced
thought skills within - Avoid arguing, bargaining, or by patient
processesevi 1 week reasoning with the client, relating
denced by instead follow through with well with
Discomfort in consequences if limits are others
social violated as consistency is without
situations. essential for success of this manipulati
intervention. ng them
- Provide positive reinforcement for self-
for non-manipulative gratificatio
behaviours. n.
- Help client recognize
consequences of own
behaviours and refrain from
attributing them to others.
- Help client identify positive
aspects about self, recognize
accomplishments, and feel
good about them to stop
patient from manipulating
others for self-gratification.
Insomni Insomnia Patient will - Provide a quiet environment, The
a related to be able to with a low level of stimulation patient’s
excessive acquire 6 to to promote sleep sleep
hyperactivity 8 hours of - Monitor the patient’s sleeping pattern
evidenced by uninterrupte patterns. improved
pacing in the d sleep - Provide structured schedule of evidence
hall way within 1 activities that includes by the
during week of established times for naps or patient’s
sleeping hospitalizatio rest. ability to
hours. n - Assess client’s activity level fall asleep
and intervene as patient may within 30
collapse from high levels of minutes of
exhaustion. retiring and
- Before bedtime, provide sleeping
nursing measures that for 6 to 8
promote sleep, such as back hours per
rub; warm bath; warm, non- night

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 stimulating drinks; soft music; without
and relaxation exercises. medication
- Prohibit intake of caffeinated .
drinks, such as tea, coffee, and
colas to avoid stimulating the
CNS which may interfere with
the client’s achievement of
rest and sleep.
- Administer sedatives as
ordered, to assist client
achieve sleep until normal
sleep pattern is restored
Disturbe Disturbed Client will be - Observe client for signs of Patient’s
d sensory able to hallucinations such as laughing sensory
sensory perception define and or talking to self and intervene perception
percepti related test reality, early. normalized
on toSleep eliminating - Avoid touching the client , evidenced
deprivation the before warning him or her that by the
evidenced by occurrence you are about to do so as patient’s
Hallucination of sensory client may perceive touch as ability to
s. misperceptio threatening and respond in an differentiat
ns. aggressive manner e between
within the - Portrayan attitude of reality and
first 72 hours acceptance to encourage the unrealistic
of client to share the content of events or
hospitalizatio the hallucination with you in situations.
n order to prevent possible
injury to the client or others
from command hallucinations.
- Avoid reinforcing the
hallucination by using words
such as “the voices” instead of
“they” when referring to the
hallucination because Words
like “they” validate that the
voices are real.
- Try to distract the client away
from the misperception by
Involvement in interpersonal
activities and explanation of
the actual situation, this will
bring the client back to reality.
Self- Self-care Patient will - Encourage the patient to bath The
care deficit maintain and supervise the patient patient’s
deficit related to good during bathing. hygiene
cognitive personal - Encourage the patient to wash status
impairment hygiene his/her clothes when dirty. improved
evidenced by throughout - Encourage the patient to brush evidenced
patient hospitalizatio teeth every after each meal by the
looking n - Encourage and supervise the patient

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 untidy. patient in maintaining her/his looking,
hair. smart all
the time .
Disturbe Disturbed Client will be - Convey your acceptance of The
d thought able to client’s need for the false patient’s
thought processes recognize belief, while letting him or her thought
process related and know that you do not share processes
es toBiochemic verbalize the delusion. improved
al alterations when - Do not argue or deny the evidenced
evidenced thinking is belief to avoid jeopardizing the by the
bydecreased non–reality- development of a trusting patient’s
ability to based. relationship. ability
grasp ideas within 1 - Use reasonable doubt as a toreflect an
week of therapeutic technique: e.g. “I accurate
hospitalizatio understand that you believe interpretati
n this is true, but I personally on of the
find it hard to accept. environme
- Reinforce reality by talking nt.
about real events and real
people. Use real situations and
events to divert patient from
long, tedious, repetitive
verbalizations of false ideas.
- Give positive reinforcement
toenhances self-esteem as
client begins to differentiate
between reality-based and
non–reality-based thinking.

c) Discuss six (6) basic counselling skills. (30)- 5 marks each=2/3

1.Attending
• Patients in distress are acutely aware of the attention/inattention of the
attending nurse, and are sensitive to both verbal/non-verbal cues.
• A nurse or counselor must show through their body position and facial
expression that they are paying attention—for example, by directly facing
the client and making good eye contact.
• Attending involves ‘SOLER’ behaviors
-S – Sit squarely,
-O – Open posture
-L – Lean forward
-E – Eye contact
-R – Relax as you listen
• Attending skills also means the way you receive a client, being polite,
kind and friendly
2.Listening
• Listening includes hearing what the patient has to say, gathering and
processing information, and observation of non-verbal cues.

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• It requires more than a physical relationship, but should involve personal
contact during consultation.
• Active listening demonstrates empathy—letting clients know that they are
being fully listened to and understood.
3.Clarifying
• Clarifying is an attempt to understand a client’s statements.
• Asking clients to give examples to clarify what they mean can help you
understand better.
• Other strategies used to clarify something the client has said include
summarizing, at the beginning, during and at the end of a session.
4.Paraphrasing
• The nurse determines the basic message in a patient’s statement, and
then rephrases it, or restates the sentence in similar words used by the
patient.
• It gives an opportunity to test your understanding of what is being
communicated
5.Asking questions / Probing
• Probing is a counselor’s use of a question or statement to direct the
client’s attention inward to explore his/her situation in more depth.
• A probing question, sometimes called an “open-ended question”, requires
more than a one word (yes, no) answer from the client.
• When phrased as a statement, the probe contains a strong element of
direction by the counselor; e.g. “Tell me more about your relationship
with your parents,” or “Suppose we explore a little bit more your ideas
about what an alcoholic is.”
6.Summarizing
• To summarize is to select the key points or basic meanings from the
client’s verbal content and feelings and tie them together.
• This should not include the assumption of the counselor.
• Summarizing then, is a review of the main points already discussed in
the session to ensure continuity in a focused direction.
7.Challenging
• The counselor invites the client to examine thoughts and observable
behaviors that are self-defeating and change such thoughts and
behaviors for the better.
• She / he might ask this question to challenge a belief: “What is your
evidence for this belief?” or challenge clients to explore
behavioral consequences.

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 SCHIZOPHRENIA.
Mr. Mbangu a 35-year-old farmer of Nanzele is admitted to a psychiatric unit.
A full psychiatric assessment was done and a diagnosis of schizophrenia was
made.
a. Define schizophrenia. 5%
b. Discuss the three sub-types of schizophrenia 15%
Describe five (5) cardinal signs of schizophrenia 15%
c. Discuss 3 drugs that you will give Mr.Mbangu indicating the dose, mode of
action, frequency and side effects. 30%
d. Describe the management of Mr. Mbangu from admission. 50%

SCHIZOPHRENIA
a) Schizophrenia is a serious mental disorder characterized by loss of
contact with the reality (psychosis), hallucinations, delusions (false
beliefs), abnormal thinking, and disrupted work and social functioning.
(Altman L. K. et al 1997).
Schizophrenia is a psychotic disorder characterized by loss of contact with
the environment, by noticeable deterioration in the level of functioning in
everyday life, and by disintegration of personality expressed as disorder of
feeling, thought (as delusions), perception (as hallucinations), and behaviour
Or
Schizophrenia is a psychiatric syndrome in which specific psychological
symptoms lead, in most cases, to disintegration of personality.
b. State 5 types of schizophrenia (20 marks) (4 marks each)
1. Simple schizophrenia
- The onset is in adolescence.
- Condition characterized by insidious development of eccentric behavior,
apathy, a shallow affect, social withdrawal, a lack of drive and initiative,
and declining performance at work.
- Delusions and hallucinations are uncommon.
- Prognosis very poor. Since clear schizophrenic symptoms are absent,
simple schizophrenia is difficult to identify reliably.
2. Hebephrenic schizophrenia
- Onset in adolescence or early 20s.
- Patients often appear silly and childish in their behavior.
- Affective symptoms (flattened affect and incongruity) and thought
disorder are prominent.
- Delusion is common and not highly organized.
- Hallucinations also are common, and are not elaborate.

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- Though onset is usually insidious, some cases begin suddenly, with
marked depression and anxiety.
3. Catatonic schizophrenia
- Onset later than in hebephrenia and is usually acute.
- Characterized by motor symptoms and by changes in activity between
excitement and stupor.
- Patient may have one (or a combination) of several forms of the following
catatonic symptoms described below:-
 Catatonic stupor or mutism: Patient does not appreciably respond to
the environment or to the people in it. Despite appearances, these
patients are often thoroughly aware of what is going on around them.
 Catatonic negativism: Patient resists all directions of physical attempts
to move him or her.
 Catatonic rigidity: Patient is physically rigid
 Catatonic posturing: Patient assumes bizarre or unusual postures.
 Catatonic excitement: Patient is extremely active and excited.
Delusions, hallucinations and affective symptoms occur, but are usually less
obvious
4. Paranoid schizophrenia
- Develops later (in the 30s or 40s) than other forms of schizophrenia.
- This is the most stable and common subtype.
- Paranoid delusions are predominant.
- Patients are often uncooperative and difficult to deal with and may be
aggressive, angry, or fearful.
- Thought disorder and affective change are usually inconspicuous.
- Hallucinations (auditory) are often present. Personality is well integrated.
5. Residual schizophrenia
After many years and repeat episodes, the active symptoms of schizophrenia
‘burn out’ and the patient displays symptoms of residual phase (e.g.
dullness, social with drawl, flat or inappropriate affect, eccentric behavior,
loosening of association, illogical thinking, lacking in interest, volition or
imagination).

c. Medication
1. Tranquilizers like chlorpromazine or lagarctil tablet or injection up to
800mg in divided doses of 400mg twice daily.
Action: depresses cerebral cortex, hypothalamus, blocks neural transmition.
Side effects:
- Hypertension and tachycardia
- Dry mouth, nausea, vomiting, anorexia

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- Urinary retention and impotence
2. Trifluoperazine or stelazine
Dose: 5mg twice daily
Side effects: Headache, cardiac arrest, jaundice, dry mouth to mention
but a few.
3. Thioridazine or mellaril
Dose: 25-100mg8 hourly until desired response.
Side effects: Dry skin, nausea, vomiting and constipation
Long acting drugs
4. Fluphenazine or modecate
Dose: 25 mg per month
Side effects: Jaundice, weight gain, tachycardia

5. Haloperidol 1.5-3mg

e. Predisposing factors 15%

BIOPSYCHOSOCIAL
Biological
1. Genetic theories – Schizophrenia may be genetic (about 1 in 3 cases).
Twin and family studies show that schizophrenia is inheritable. The closer
one’s relative is, the higher the possibility of inheritance. People with a
‘lighter’ genetic load may require environmental triggers, eg. Perinatal
trauma, family stresses, whilst those with greater genetic predisposition
may develop schizophrenia on a genetic basis alone or with minimal
environmental triggering.
2. Biochemical theories – The dopamine hypothesis states that there is over
activity in the mesolimbic pathways.
3. Obstetric complications and injuries
4. Left or mixed handedness
5. Lower birth order if from large family
6. Head injury
7. Epilepsy, Mental retardation
Psychosocial
Psychological life events are emotionally arousing or threatening
experiences, (Brown &Birley 1968), For example:
1. Moving house
2. Having visitors to stay
3. Witnessing an accident
4. Separation – from close friend or relative
5. Promotion at work

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 6. Social factors such as family factors and high expressed emotion.
(c) State 5 signs and symptom of schizophrenia (10 marks)
Positive and negative symptoms of schizophrenia.
POSITIVE SYMPTOMS NEGATIVE SYMTPOMS
Content of Thought Affect
Delusions Inappropriate affect Inappropriate affect
Religiosity Bland or flat affect Bland or flat affect
Paranoia Apathy Apathy
Magical thinking Volition
Form of Thought Inability to initiate goal-directed
Associative looseness Neologisms activity
activity Emotional ambivalence
Concrete thinking Impaired Interpersonal functioning
Clang associations and Relationship to the External
Word salad World
Circumstantiality Autism
Tangentiality Deteriorated appearance
Mutism Psychomotor Behavior
Perseveration Anergia
Perception Waxy flexibility
Hallucinations Posturing
Illusions Pacing and rocking
Sense of Self Associated Features
Echolalia Anhedonia
Echopraxia Regression
Identification and Imitation
Depersonalization

(d) Using the nursing care plan identify 5 problems that patient will present
with.
 Altered thought process
 Emotional stress
 Inadequate nutritional intake
 Risk of psychotic relapses
 Social isolation related to lack of trust, delusional thinking etc evidenced
by sad, dull affect, staying alone in a room, uncommunicative, no eye
contact.
 Sensory perceptual alteration (Auditory/Visual)
 Impaired verbal communication
 Self-care deficit

11
  Sleep pattern disturbance
 Risk of injury
ii. Using the nursing care plan discuss how you will manage Mr
Shimwelenganya using the 5 problems identified above
Probl Nursing Goal/ 2 Nursing Intervention 4 Evaluation
em 1 Diagnosis 2 Objectiv 1
e
Risk Risk of injury Patient - Monitor patient closely all the - Patient
of associated to will be time for living agitated will
injury agitation free from patient alone be may eventuall
resulting from injury dangerous to both himself y calm
impulsive througho and other patients down
behaviours ut - If violent, use physical after a
hospitalis restraint according to the period of
ation facility’s policy to ensure seclusion
patient’s safety and that of and
others e.g. seclusion sedation.
- Reduce environment
stimulation to lessen client’s
impulsivity, agitation &
prevent injury.
- Administer anti psychotic
drugs such as
Chlorpromazine as per chart
to calm patient
Risk Risk of psychotic Patient - Ensure that Patient takes - Patient
of relapse related will medication as scheduled. will
psych to low levels of comply to - Patient should not stop taking continue
otic compliance to treatmen medication as this increases showing
relaps treatment t the risk of relapses. signs of
e througho - Monitor plasma concentration improve
ut of patient’s drugs. Low ment
hospitaliz plasma concentration means evidence
ation patient has not been d by
compliant patient’s
- Mouth checks may be acceptab
necessary after medication le
administration to ensure that behaviou
drugs has been swallowed rs and
moods

Self Self care deficit -Patient - Establish routine times for - Patient
care related to loss of will show self-care and add more will
deficit mobility, independ complex tasks as client perform
general ence in improves. Routine and self care

12
 debilitation and self care structure tends to organize activities
possible activities and promote reality in client’s within
depression througho world. level of
evidenced by in ut - Assist in personal hygiene, his
ability to hospitaliz appropriate dress and ability.
manage ation grooming until client is able to
activities of -To function independently to
daily living and encourag prevent physical
unkempt e patient complications and preserve
appearance. to self-esteem.
perform - Provide and promote privacy
own care during bathing .
activities- Ensure that patient’s unit is
within well cleaned
level of
- Patient’s bed linen should be
activities. changed whenever necessary.
- Advise family to bring
toothbrush and paste for
patient to use when cleaning
mouth
Inade Inadequate Patient - Monitor caloric intake as - Patient
quate nutritional will indicated. demonst
nutriti intake related to demonstr - Provide small frequent rates
onal psychotic ate feeding as indicated. feeding
intake behaviours feeding - Provide a well balanced diet patterns
(excitement) patterns to meet the body or
and emotional or requirements behavior
lability behavior - Serve hot food to prevent to
(depressive to gastro intestinal infections. maintain
mood), maintain - Promote a pleasant appropri
evidenced by appropria environment for eating and ate
observed te weight keep patient company to weight.
dysfunctional througho promote appetite
eating pattern, ut - Involve patient and family in
Poor muscle hospitaliz planning for meals to gain
tone, ation cooperation
underweight - Encourage family to provide
which is not well home prepared foods to
ideal for height promote appetite.
and frame. - Monitor patient’s weight on
regular basis to assess
nutritional status.
Sleep -Sleep patterns Patient - Assess the sleeping patterns or -The patient
patter disturbance will have habits. will report
ns which may be stabile -Explain to patient about ward improveme

13
distur related to sleeping routine and procedures. nt in sleep
bance hallucinations, patterns - Provide comfortable bedding patterns.
/ delusions, fear, througho and some of patient’s -Patient will
Interr environmental ut possession. verbalize
upted changes and hospitaliz -administer antipsychotics. sense of
sleep facility routines ation -Encourage physical activity well
and during the day. beingand
restlessness. sense of
-Interrupted feeling
sleep and rested.
awakening
earlier than
desired
evidenced by
reports of not
sleeping.
Emot Emotional patient - Adopt an accepting and Patient will
ional stress which will be consistent approach with the show signs
stres may be related relieved patient. of
s to anxiety from - Establish a therapeutic nurse- emotional
disorders, emotional client relationship until trust stability
hallucinations, stress has been established.
delusions, fear, througho - Educate on stress
environmental ut management skills to
changes and hospitaliz promote self confidence
facility routines ation - Teach on behavioral
evidenced by modification to promote
restlessness independency
sleep. - Provide reality-based
explanations for distorted
body images to gain
cooperation.
Alter Altered thought Patient - Encourage same staff to work Patient will
ed process related will with client as much as have
thou to psychotic develop possible to promote developed
ght disorder appropri development of trusting appropriat
proce evidenced by ate relationship. e thought
ss Hyper thought - Avoid physical contact as process as
vigilance, process suspicious clients may evidenced
Distractibility, througho perceive touch as a by
Inappropriate ut threatening gesture appropriat
non–reality- hospitaliz - Avoid laughing, whispering, or e
based thinking, ation talking quietly where client behaviour.
Inaccurate can see but not hear what is
interpretation being said. Suspicious clients

14
 of environment often believe others are
discussing them,
and secretive behaviors
reinforce the paranoid
feelings.
- Be honest and keep all
promises to promote a
trusting relationship.

Outline 5 points that you will include in the Psychiatric

rehabilitation of Chanda Zulu (15
marks)
- Psychiatric rehabilitation 15 marks ( 3% each)
Psychiatric rehabilitation involves making interventions to improve
performance of people with serious and persistence mental illness and
enhance their recovery in the following areas:
 Social (through social skills training)
 Educational
 Occupational (through Vocational skills training and supported
employment)
 Behavioral (Behavioural therapy)
 Cognitive (Cognitive behavior therapy)
The interventions are done in the patient’s chosen environment which may
be home (activities of daily living), work and school. Different professionals
may be involved such as occupational therapists, rehabilitation assistants,
social workers, psychologists, counselors and nurses. Interventions focus on
emphasizing strengths. Strengths may be related to:
 recreational and leisure activities for example sports, outings, to
mention but a few.
 work skills in vocational trade institutes.
 educational accomplishments
 self-care skills
 special interests
 talents and abilities
 positive interpersonal relationships

AGGRESSION
Aggression is one of the common sign that are exhibited by mentally ill
patients
a) Define aggression 5%

15
b) Explain five (5) risk factors of aggression
20%
c) State 3 types of aggression
6%
d) Explain 5 causes of aggression in psychiatric patients 15%
e) Discuss the nursing intervention during an episode of aggression 40%
f) Discuss how you would prevent episode of aggression in the ward 25%
a) i) Define aggression 5%
- Aggression refers to behavior that is intended to cause harm or pain
which can be either physical or verbal.
- Aggression is an overt, often harmful, social interaction with the intetion
of inflicting damage or other unpleasantness upon other individual. It may
be in retaliation or without provocation.
- Aggression is being hostile towards someone or something else,
undermining their rights and self-esteem. It involves both physical and
verbal aggressions.
ii) Outline five (5) predisposing factors to aggressive behavior
20% - 2/3
1. Presence of comorbid
2. Intoxication/ Substance abuse such as alcohol, drugs and others
3. Personality characteristics such as antisocial personality trait influence
the use of violent acts as a means to achieve certain goals.
4. Inadequacy – inability to live up to expectation.
5. Serious obstacle – when one is faced with serious obstacles in life that
may threaten their goals.
6. Chaotic or unstable home situation or hospital
7. Genetic factors - Aggressive behaviour is more likely to be inherited
and as such it is considered as being familial.
Chromosomal influences: XYY syndrome contributes to aggressive
behavior. The person with this syndrome are tall, below average
intelligence and likely to be in conflict with the law.
8. Neurophysiological disorders
Epilepsy of temporal lobe and frontal lobe origin results in episodic
aggression and violent behavior.
Tumors in the brain, particularly in the areas of the limbic system and the
temporal lobe
Trauma to the brain, resulting in cerebral changes
Disease such as encephalitis have been implicated in the predisposition to
aggression and violent behavior.
9. Psychological factors
Intrinsic behaviours
Freud’s view:
Sigmund Freud held the view that all human behavior stems either directly
or indirectly from two instincts. In this frame work, aggression was viewed
simply as a reaction to blocking or thwarting of libidinal impulses and was

16
neither an automatic nor an inevitable part of life. Thus according to him,
aggression primarily stems from the redirection of the self-destructive death
instinct away from the self and towards others.
Learned behavior
According to learning theory, aggression is primarily a learned form of social
behavior. The learning of aggressive behavior occurs by observation and
modeling. For example, a child watches an angry parent strikes out another
person. Learning aggressive behavior also takes place by direct experiences.
The person feels anger and behaves aggressively. If behaving aggressively
brings rewards, the behavior is encouraged.
10. Social factors
Frustration: The single most potent means of inciting human beings to
aggression is frustration. This hypothesis indicated that frustration always
leads to a form of aggression and that aggression always stem from
frustration. However, Frustrated persons do not always respond with
aggressive thoughts and words, or deeds. They may show a wide variety of
reactions ranging from resignation, depression and despair to attempts to
overcome the sources of frustration.
Direct provocation: Evidence indicates that physical abuse and verbal
taunts from others often elicit aggressive actions.
Observational learning: in this case, observers acquire new means of
harming others not previously present in their behavior
Disinhibition: A person’s restraint or inhibition against performing
aggressive action is weakened as a result of observing others engaging in
such behavior.
11. Environmental factors
Noise: several studies have reported that persons exposed to loud, irritating
noise direct stronger assaults against others than those not exposed to such
environmental

b) State three (3) types of aggression 15% - 2/3

1. Affective/controlled/emotional aggression. This is the purposeful or
goal-oriented type of aggressions which can be controlled. It is also
referred to proactive aggressive behavior which is calculated and planned
action that has some motives other than harming someone. E.g. bullying.
2. Hostile/retaliatory/reaction aggression. This is a response to
provocation which is unplanned and impulses are usually responses to
feelings of anger or fear. e.g. punching someone who insults him or her.
3. Instrumental aggression - aggression aimed at obtaining an object,
privilege or space with no intent to harm the other person.
4. Hostile aggression - is intended to harm another person, such as
hitting, kicking, or threatening to beat up someone.

17
5. Relational aggression - a form of hostile aggression that does damage
to another's peer relationships, as in social exclusion or rumour
spreading.

c) Explain five (5) causes of aggression in psychiatric patients

15% - 2/3
1. Psychiatric disorders with hallucinations, delusions and poor impulse
control related to neuron-psychiatric deficits such as psychotic organic
brain syndrome or mental retardation.
2. Underlying personality characteristics such as antisocial personality traits
also may influence the use of violent acts as a means to achieve certain
goals.
3. Environmental factors associated with aggressive behaviour include a
chaotic or unstable home or hospital situation, which may encourage
maladaptive aggressive behaviors
4. Substance abuse has the largest correlation with violent behaviour
5. Infections such as malaria.
6. Cerebral neoplasms
7. Intoxication/ Substance abuse such as alcohol, drugs and others
8. Dependence
9. The disease itself
10. Chaotic or unstable home situation or hospital
d) Discuss the nursing intervention during an episode of aggression
45%
- Be aware of factors that increases the likelihood of violent behavior or
that signify a build-up of agitation
- Talk with the client in a low, calm voice, use simple, clear, direct speech;
repeat if necessary
- Approach the client in a calm, matter-of-fact manner
- Always maintain control of yourself and the situation; remain calm, if you
do not feel competent in dealing with the situation, obtain assistance as
soon as possible.
- Decrease environmental stimulation by turning stereo or TV of or lowering
the volume; lowering the lights; asking other clients, visitors or others to
leave the area.
- Try to help the client express these feelings, verbally or physically, in
nondestructive ways (remain with the client and listen, use
communication technique
- Do not use physical restraints or techniques without sufficient reason

18
- Be aware of PRN medication and procedures for obtaining seclusion or
restraint orders
- In the triggering phase, the nurse should approach the client in a
nonthreatening, calm manner in order to de-escalate the client’s emotion
and behavior.
- Conveying empathy for the client’s anger or frustration is important.
- The nurse can encourage the client to express his or her angry feelings
verbally, suggesting that the client is still in control and can maintain that
control.
- Use of clear, simple, short statements is helpful.
- The nurse should allow the client time to express himself or herself. The
nurse can suggest that the client go to a quiet area or may get assistance
to move other clients to decrease stimulation. Medications (PRN, or as
needed) should be offered, if ordered.
- As the client’s anger subsides, the nurse can help the client to use
relaxation techniques and look at ways to solve any problem or conflict
that may exist (Marder, 2006).
- Physical activity, such as walking, also may help the client relax and
become calmer
- If these techniques are unsuccessful and the client progresses to the
escalation phase (period when client builds toward loss of control), the
nurse must take control of the situation.
- The nurse should provide directions to the client in a calm, firm voice. The
client should be directed to take a time-out for cooling off in a quiet area
or his or her room.
- The nurse should tell the client that aggressive behavior is not acceptable
and that the nurse is there to help the client regain control.
- If the client refused medications during the triggering phase, the nurse
should offer them again. If the client’s behavior continues to escalate and
he or she is unwilling to accept direction to a quiet area, the nurse should
obtain assistance from other staff members. Initially, four to six staff
members should remain ready within sight of the client but not as close
as the primary nurse talking with the client.
- This technique, sometimes called a “show of force,” indicates to the client
that the staff will control the situation if the client cannot do so.
Sometimes the presence of additional staff convinces the client to accept
medication and take the time-out necessary to regain control
- When the client becomes physically aggressive (crisis phase), the staff
must take charge of the situation for the safety of the client, staff, and

19
 other clients. Psychiatric facilities offer training and practice in safe
techniques for managing behavioral emergencies, and only staff with such
training should participate in the restraint of a physically aggressive
client.
- The nurse’s decision to use seclusion or restraint should be based on the
facility’s protocols and standards for restraint and seclusion. The nurse
should obtain a physician’s order as soon as possible after deciding to use
restraint or seclusion.
- Four to six trained staff members are needed to restrain an aggressive
client safely. Children, adolescents, and female clients can be just as
aggressive as adult male clients.
- The client is informed that his or her behavior is out of control and that
the staff is taking control to provide safety and prevent injury.
- Four staff members each take a limb, one staff member protects the
client’s head, and one staff member helps control the client’s torso, if
needed.
- The client is transported by gurney or carried to a seclusion room, and
restraints are applied to each limb and fastened to the bed frame.
- If PRN medication has not been taken earlier, the nurse may obtain an
order for intramuscular (IM) medication in this type of emergency
situation.
As noted as the client regains control (recovery phase), he or she is
encouraged to talk about the situation or triggers that led to the aggressive
behavior.
- The nurse should help the client relax, perhaps sleep, and return to a
calmer state it is important to help the client explore alternatives to
aggressive behavior by asking what the client or staff can do next time to
avoid an aggressive episode.
- The nurse also should assess staff members for any injuries and
complete the required documentation such as incident reports and flow
sheets.
- The staff usually has a debriefing session to discuss the aggressive
episode, how it was handled, what worked well or needed improvement,
and how the situation could have been defused more effectively.
- It also is important to encourage other clients to talk about their feelings
regarding the incident. However, the aggressive client should not be
discussed in detail with other clients.
In the post crisis phase, the client is removed from restraint or seclusion as
soon as he or she meets the behavioral criteria.

20
- The nurse should not lecture or chastise the client for the aggressive
behavior but should discuss the behavior in a calm, rational manner.
- The client can be given feedback for regaining control, with the
expectation that he or she will be able to handle feelings or events in a
nonaggressive manner in the future.
- The client should be reintegrated into the milieu and its activities as soon
as he or she can participate.

g) CHILD ABUSE
Annette Sampa, a girl of 10 years is brought to the CBV department by her
neighbour who reports that the step mother to Annette physically abuses
her.
a. List 5 signs of possible physical abuse 10%
b. State 4 types of child abuse 20%
c. State 5 factors that predispose to child abuse
20%
d. Explain 5 effects of child abuse 20%
e. Discuss 5 roles you would use to prevent and manage child abuse
30%

CHILD ABUSE
i) List 5 signs of possible physical abuse 10%
1. Bite marks
2. Burn marks e.g. Cigarette burns
3. Bruising
4. Injuries inconsistent with the child’s age
5. Torn frenulum
6. Finger marks
ii) State 4 types of child abuse 20%
1. Physical abuse
- Is a deliberate, non-accidental physical assault on a child that results in
physical harm. E.g. battering, kicking, burning, biting excessive or
inappropriate discipline, cheap labour and any other bad actions that
could result in injury or death.
2. Emotional/ Psychological Abuse
- Is when parent or guardian constantly yells, degrades, isolates, threatens,
exploits and terrorizes a child to a point of causing serious behavioural
and emotional problems. E.g. if a child is often enough told that he or she
is no good, they may believe and act accordingly

21
- Is deliberate harming of a child by insulting, belittling or threatening that
child. Every child abused in any way suffers emotional abuse
3. Sexual abuse
- Engagement by an adult of a child in any sexual activity which that child
does not fully understand & to which one cannot give informed consent.
Adult abuses his power for sexual gratification. Any sexual activity with
the child is abusive even if there is no overt force used and even if the
adult claims that the child initiated the activity. E.g. sexual abuse includes
incest, defilement, fondling a child, making child fondle abuser’s genital,
showing nudity & pornographic materials to a child, using child for
prostitution.
4. Social Abuse/Neglect
- Is failure to provide children with basic needs such as food, shelter,
clothing and health care?
- Is a pattern of behaviour which occurs over a period of time and can
cause physical and emotional harm to a child.
5. Child Labour/Economic Abuse
- This means using children for purposes of material or financial gain.
- Child labour exploits the child in that it takes away their childhood,
putting an adult role at tender ages. This is characterized by all or some
of the following:
-Inadequate remuneration for work done
-Long hours of work with little or no rest at all
-Unhealthy work conditions
6. Child trafficking
f. State 5 factors that predispose to child abuse
20%
1. Poverty
2. Broken homes
3. Death of parents or guardians due to AIDS
4. Step or foster child
5. Premature baby – neglect
6. Child with a mental or physical defect
g. Explain 5 effects of child abuse 20%
1. Mental disorders/retardation
2. Disabilities
3. Depression
4. Fear/phobia
5. Disease

22
 6. Pregnancy
h. Discuss 5 roles you would use to prevent and manage child abuse
30%
1. Care Giving - To reduce the stress that encourages abusive behaviour as
well as to protect the abused or threatened persons
- Be able to recognize the signs of an abused child by using diagnostic
criteria.
- If a child is for example found with an infection or any injuries, he or
should be treated accordingly.
2. Change Agent - Needs to be alert not only to actual child abuse but also
to those conditions that are breeding grounds for abuse
3. Educator - should give health education to school going children on child
abuse.
informs the children which places to go to incase they are abused e.g.
churches, various shelters for support like YWCA
Parents can be taught acceptable and effective ways to discipline children
so that limits are maintained without causing emotional or physical harm
4. Counseling - should strengthen individuals and families so they can cope
more effectively with stressors and demands and reducing the destructive
elements.
5. Advocator - can advocate for teachers in the community to do child
counseling so that they have the skills and knowledge on how to deal with
such issues.
6. Collaborator - must report suspected child abuse to relevant authorities
e.g. victim support unit.

h) SUBSTANCE ABUSE
Mr. Chibwe male 32 years has been brought to your mental health unit
history of taking kacasu (local beer) almost on daily basis. This has led to
self-neglect and he can no longer eat his food. Alcoholism is now of public
concern in Mr. Chibwe’s village.
a) Define substance abuse 5%
b) Discuss three (3) predisposing factors to substance abuse 15%
c) Discuss the effects of substance abuse 35%
d) You wish to advocate the end of substance abuse in Mr. Chibwe’s village.
Discuss five (5) principles that you would employ 45%

SUBSTANCE ABUSE
a) Define substance abuse 5%
- The use of drugs to excess in order to alter consciousness

23
b) Discuss three (3) predisposing factors to substance abuse
15%
1 Societal or Community Factors such as;
- Lows and normative behavior, e.g. encouragement of youth drinking in
the media and absence of legal enforcement of underage age drinking.
- Availability, i.e. easy access via the home or adults purchasing for minors
or minors being sent to buy liquor for adults consistently.
- Extreme economic deprivation, for example, escapist drinking to cope
with hush realities of everyday life.
- Neighborhood disorganization, e.g. undermine sense of security and
purpose in life.
School Factors
- Low commitment to school, e.g. school expectations and career
expectations being low.
- Academic failure, e.g. poor attendance, poor grades and under
achievements.
- Early persistent behavior problems, e.g. a child who exhibits high
aggression and attention problems. A small child who beats others and is
isolated may turn to alcohol abuse in adulthood.
Family Factors
Being a child in a dysfunctional family, thus;
- Parents are alcohol abusers, (role modeling influence).
- Poor family management practices, e.g. failure to monitor children,
inconsistent parenting practices, or harsh discipline.
- Family conflicts, e.g. marital dysfunction or partner violence.
Peers
Associating with alcohol using peers
Individual Factors
- Psychological, e.g. genetic susceptibility to alcohol or misjudgment about
level of intoxication.
- Associated to mental disorders, e.g. antisocial personality disorders,
phobic disorders and major depressive disorders.
- Primary abuse of other substances.

c) Discuss the seven (7) phases of alcohol intoxication 35%

When a person consumes alcohol, the full effects may take some time to
become apparent. Depending on a number of factors—including the amount
consumed, the rate of consumption, gender, body weight, and whether the
drinking episode took place on an empty or full stomach —there are
somewhat predictable stages of alcohol intoxication through which the
individual may progress as their drinking continues.

24
Stage 1: Sobriety, or Subclinical Intoxication
the individual is unlikely to appear intoxicated, though certain tests may
detect impairment. Depending on the individual, judgment and reaction time
may be slightly impaired.
Stage 2: Euphoria - In this stage, the individual may feel more confident,
may be more talkative and animated, and may feel slightly euphoric.
Inhibitions also begin to decline. Most people refer to this stage as being
“tipsy.”
While many of the effects of alcohol may be pleasurable to the drinker, the
negative effects of alcohol, such as impaired judgment, memory, and
coordination begin to appear at this time. In this stage, a person’s motor
responses may be significantly more delayed.
Stage 3: Excitement - They may begin to experience emotional instability, a
lack of critical judgment, and a significant delay in reaction time. They may
start slurring their speech.They may also experience:
 Impaired perception and memory.
 Vision issues, including decreased peripheral vision, blurriness, and
delayed glare recovery.
 Loss of balance.
 Drowsiness.
 Nausea and vomiting.
Those around the person will likely notice that they are visibly drunk.
Stage 4: Confusion - Characterized by emotional upheaval and
disorientation. Coordination is markedly impaired, to the extent that the
person may not be able to stand up, may stagger if walking, and may be
very dizzy.
Those in this stage of intoxication are highly likely to forget things that
happen to or around them. “Blacking out” (losing memory of events that
occurred while drinking) without actually passing out can happen at this
stage. In addition, a person may have and markedly increased pain
threshold, meaning they could injure themselves and not feel the effects
until later.
Stage 5: Stupor - Someone in this stage is extremely intoxicated and in
dangerous territory, as they are at great risk of alcohol poisoning and
death.They have likely lost a significant amount of motor function, are not
responding to stimuli (or responding very slowly) and may be:
 Unable to stand or walk.
 Stuporous or completely passed out.
 Unable to voluntarily control certain bodily functions, such as maintaining
continence.

25
 Vomiting.
Someone in this stage should get medical help. Individuals left to “sleep it
off” may end up suffering from slowed breathing or respiratory arrest or may
choke on their own vomit. Other risks include hypothermia, arrhythmia, and
seizures.7
Stage 6: Coma - Respiration and circulation are severely depressed, motor
response and reflexes are markedly decreased, and the person’s body
temperature drops. The person who has reached this stage is at risk of
death.
Stage 7: Death - Unable to sustain their vital life functions, and the risk of
respiratory arrest and death is significant.

d) You wish to advocate the end of substance abuse in Mr. Chibwe’s

village. Discuss five (5) principles that you would employ
45%
1. Uniqueness: View each client and a problem he/she presents as unique
2. Neutrality: Create a non-judgmental atmosphere in which the client is
encouraged to express himself openly, frankly and freely.
3. Acceptance: Continually emphasize an attitude of high regard for the
client as a person.
4. Flexibility: Always proceed as if client is right in what he says, how he
tells the story, and ways in which he wants to solve the problem.
5. Inclusiveness: Avoid the temptations to focus upon a particular
behaviour feelings or experience as if the resolution of a client’s problem
lies in each of these.
6. Autonomy: Demonstrate a belief in the client that he has the capacity
and ability to take experience for choices. Decisions and actions.
7. Realism: Direct efforts toward helping the client identify and fulfill his
goals and needs within the limitations of his capacity, potential and
circumstances.
8. Empowerment: Structure each of the session in such a way that the
client is enabled to develop and improve his life skills needed to cope with
his problem situations.
9. Mutuality: Continually emphasize that counseling is a shared and
sharing relationship achieved between counselor and client.

i) DEMENTIA
Mrs Mulanga an 80-year- old women is brought to your psychiatry
department with history of forgetting everything, a diagnosis of
Dementia is made.
a. Define dementia 5%

26
b. Mention 4 key elements in the definition of dementia
20%
c. State 4 types of dementia 20%
d. State 5 causes or factors that predispose to dementia
15%
e. Explain 5 signs and symptoms of dementia 10%
f. Describe the management of a patient with dementia
30%
DEFINITION
a. Definition of dementia: Dementia is defined as global or total
intellectual decline of sufficient severity to impair social and/or
occupational functioning that occurs in normal consciousness.
- The term dementia describes symptoms of a large group of illnesses that
cause a progressive decline in a person’s functioning such as loss of
memory, intellect, rationality and social skills.
b. 4 types of dementia (20 marks).
Dementia can be caused by a number of disease processes.
1. Alzheimer’s disease; a consequence of degenerative brain changes as
an individual age.
2. Vascular dementia; result from small brain infarcts; small brain
haemorrhages.
3. Parkinson’s disease
4. Substance-Induced Persisting Dementia / Excessive alcohol
consumption
5. Other illnesses (such as multiple sclerosis, HIV/AIDS
6. Huntington’s disease is a progressive brain disorder caused by a single
defective gene on chromosome 4 — one of the 23 human chromosomes
that carry a person’s entire genetic code.
7. Creutzfeldt-Jacob disease)
8. Dementia Due to Head Trauma
9. Down syndrome — also known as trisomy 21 — is a condition in
which a person is born with extra genetic material from chromosome 21,
one of the 23 human chromosomes. All human chromosomes usually
occur in pairs, with one copy inherited from a person’s mother and one
from the father. Most people with Down syndrome have a full extra copy
of chromosome 21, and so they have three copies instead of the usual
two. Scientists think the extra copy results from a random error in the
specialized cell division that produces eggs and sperm.
10. Lewy body dementia (LBD) is a type of progressive dementia that
leads to a decline in thinking, reasoning and independent function

27
 because of abnormal microscopic deposits that damage brain cells over
time
11. Frontotemporal dementia (FTD) or frontotemporal degenerations
refers to a group of disorders caused by progressive nerve cell loss in the
brain's frontal lobes (the areas behind your forehead) or its temporal
lobes (the regions behind your ears
12. Korsakoff syndrome is a chronic memory disorder caused by severe
deficiency of thiamine (vitamin B-1).

c. 4 key elements in the definition of dementia (20 marks)

There are four key elements to the definition of dementia
1. Global impairment. Dementia is a syndrome characterized by
progressive, usually irreversible, global cognitive deficits (Semple et al,
2005). The impairments occur in more than just memory. Most dementia
patients experience impairments in reasoning, using and understanding
language, recognizing what one perceives through the senses,
coordinating learned motor movements, planning and decision-making.
2. Decline. The impairments represent a decrease from a previous level of
functioning. To recognize a reduction, it is crucial for the nurse to know
the patient’s previous level of functioning unless members of the family or
significant others give correlated information.
3. Severity. Impairments are severe enough to interfere with normal
functioning in everyday life. Examples are a person who was living
independently and begins to make poor financial decisions or forgets how
to cook a meal, although the person could previously perform those tasks.
Getting lost while walking from a nearby church, neighbourhood and
driving can also indicate severe impairment.
4. Normal consciousness. These impairments occur in a normal state of
consciousness; patients are awake and alert. This is distinguished from an
abnormal state of consciousness, such as drowsiness, stupor or coma,
seen in delirium.

d. Nursing care (40 marks)

GOALS FOR NURSING A PERSON WITH DEMENTIA
Appropriate goals for caring for a person with dementia in a community or
hospital setting include:
 Develop a relationship with the person based on empathy and trust.
 Provide an environment that supports flexible but anticipated routines.

28
 Maintain a safe environment for the person, yourself and other staff.
 Promote the person’s engagement with their social and support network.
 Ensure effective collaboration with other relevant service providers,
through development of effective working relationships and
communication.
 Support and promote self-care activities for families and carers of the
person with dementia.
GUIDELINES FOR RESPONDING TO A PERSON WITH DEMENTIA
The following guidelines will assist in nursing a person with dementia.
 Arrange for a review of the person’s medication and an initial or follow-up
psychiatric assessment if their care plan needs reviewing. A mental health
assessment may be appropriate to undertake — see the MIND Essentials
resource ‘What is a mental health assessment?’.
 A person’s cultural background can influence the way symptoms of
mental illness are expressed or understood. It is essential to take this into
account when formulating diagnosis and care plans.
 Explain to the person who you are, what you want to do and why.
 Smile — the person is likely to take cues from you, and will mirror your
relaxed and positive body language and tone of voice.
 Move slowly, you may have a lot to do and be in a hurry, but the person is
not. Imagine how you would feel if someone came into your bedroom,
pulled back your blankets and started pulling you out of bed without even
giving you time to wake up properly.
 If the person is resistant or aggressive but is not causing harm, leave him
or her alone. Give the person time to settle down and approach the task
later.
 Distract the person by talking about things he or she enjoyed in the past
and by giving him or her a face washer or something to hold while you are
providing care.
 Do not argue with the person. The brain of a person with dementia tells
the person that he or she cannot be wrong.
 If the person is agitated, maintain a quiet environment. Check noise levels
regularly and reduce them if necessary y by turning off the radio and
television.
 Provide orientating cues such as a clock and calendar.
 Give the person a comfortable space. Any activity that involves invasion
of personal space increases the risk of assault and aggression.
 Always provide care from the side (not the front) of the person. If you
stand in front, you are easily hit or kicked if the person becomes
aggressive.

29
 Be vigilant if the person is climbing out of bed. Refer to your workplace
policy on restraint. If you cannot work out a reason for this behaviour, you
might walk with the person or engage him or her in an activity. This helps
to maintain his or her mobility, and eventually he or she may tire and go
back to bed. Encourage family or volunteers to help with this.
 Monitor compliance with medication and general physical health
(including nutrition, weight, blood pressure, etc).
 Monitor food and fluid intake and elimination — dehydration or
constipation can exacerbate confusion.
 People with dementia are at increased risk of developing delirium, so be
aware of risk factors for delirium (such as medication interactions,
infection and the postoperative period).
 Provide family members and carers with information about the illness if
appropriate, as well as reassure and validate their experiences with the
person. Encourage family members and carers to look after themselves
and seek support if required.
Be aware of your own feelings when nursing a patient with dementia.
Arrange for debriefing for yourself or any colleague who may need support or
assistance — this may occur with a clinical super visor or an Employee
Assistance Service counsellor.

e. IEC
1. DRUG COMPLIANCE - Monitor compliance with medication and general
physical health
2. NUTRITION - (Monitor food and fluid intake and elimination - dehydration
or constipation can exacerbate confusion.
3. IEC ON THE COMPLICATIONS - People with dementia are at increased
risk of developing delirium, so be aware of risk factors for delirium (such
as medication interactions, infection and the postoperative period).
4. IMPORTANCE OF REVIEW DATE
5. IEC ON DISEASE PROCESS - family members and carers with
information about the illness if appropriate, as well as reassure and
validate their experiences with the person. Encourage family members
and carers to look after themselves and seek support if required.

30
 DEPRESSION
a) State 5 predisposing factors to depression (25%) 5 marks each -
2/3
1.BIOLOGICAL THEORIES
• Biochemical Studies: has associated symptoms of depression with a
functional deficiency of norepinephrine, serotonin and dopamine.
• The level of dopamine in the mesolimbic system of the brain is thought to
have an influence over human mood and behaviour.
2. Genetics-
• Twin studies suggest a genetic factor of illness of about 50% in
monozygotic twins.
• Family studies show that major depression is 1.5 to 3 times more common
among first degree biological relatives.
3. Neuroendocrine disturbances
• This has been found to contribute to the pathogenesis of persistence of
depressive illness.
4.Electrolyte disturbances
• Excessive levels of sodium bicarbonate or calcium can produce symptoms
of depression
5.Hormonal disturbances
• An imbalance of the hormones estrogen and progesterone has been
implicated in the predisposition to premenstrual dysphoric disorder.
• It is postulated that excess estrogen or high estrogen to progesterone
ratio during the luteal phase during the menstrual cycle is responsible for
the symptoms associated premenstrual syndrome
6.Psychoanalytic Theories - These theorists contended that depression
occurs as a result of an early life loss (Freud 1957) he viewed depression as
the aggressive instinct inappropriately directed at self, often triggered by the
loss of a loved one or object
7.Cognitive theory - The Theory by Beck, et al. (1979) proposed that the
primary disturbance in depression is cognitive rather than affective.
Cognitive theorists believe that depression is the product of negative
thinking.
8.Object loss theory-This theory suggest that depressive illness occurs as
a result of having been abandoned or separated from a significant other
during first 6 months eg the mother.
• Absence of attachment which may be physical to emotional leads to
feelings of helplessness and despair that contributes to lifelong pattern of
depression in response to loss.
9.Learning theory- by Seligman (1973)- Model of helplessness.

31
• A similar state of helplessness exists in human beings who have
experienced numerous failures (either real or perceived).
• The individuals abandon any further attempt to succeed.

j) GENERALISED ANXIETY DISORDER

Mr Mutale a 30-year-old man has been admitted to your ward with symptoms
of generalized anxiety disorder.
a) Define generalised anxiety disorder
5%
b) List 5 clinical manifestations of generalised anxiety disorders. 5%
c) Explain on the four levels of anxiety.
20%
d) What nursing interventions are you going to employ in your care for Mr
Mutale. 50%
e) Outline 5 advantages of nurse patient relationship
25%
f) Discuss the 4 phases of nurse patient relationship
40%

GENERALIZED ANXIETY DISORDER (GAD)

a) Definition of generalised anxiety disorder (6%)
Generalized anxiety disorder is characterized by chronic, unrealistic, and
excessive anxiety and worry. The symptoms have existed for 6 months or
longer and cannot be attributed to specific organic factors, such as caffeine
intoxication or hyperthyroidism.
b) List 5 clinical manifestations of generalised anxiety disorders. (20
marks)
SIGNS AND SYMPTOMS OF ANXIETY 2/2 (mentioning/explaining)
Psychological arousal
- Fearful anticipation
- Irritability
- Sensitivity to noise
- Poor concentration
- Worrying thoughts
Autonomic arousal
Gastrointestinal
- Dry mouth
- Difficulty in swallowing
- Epigastric discomfort
- Excessive wind
- Frequent or loose motions
Respiratory
- Constriction in the chest

32
 - Difficulty inhaling
Cardiovascular
- Palpitations
- Discomfort in the chest
- Awareness of missed heartbeats
Genitourinary
- Frequent or urgent micturition
- Failure of erection
- Menstrual discomfort
- Amenorrhoea
Muscle tension
- Tremor
- Headache
- Aching muscles
Hyperventilation
- Dizziness
- Tingling in the extremities
- Feeling of breathlessness
Sleep disturbance
- Insomnia
- Night terror

Explain on the four levels of anxiety 2/2 (20%)

1. Mild anxiety is a sensation that something is different and warrants
special attention.
- Sensory stimulation increases and helps the person focus attention to
learn, solve problems, think, act, feel, and protect himself or herself.
- Mild anxiety often motivates people to make changes or to engage in
goal-directed activity.
- For example, it helps students to focus on studying for an examination.
2. Moderate anxiety
- is the disturbing feeling that something is definitely wrong; the person
becomes nervous or agitated.
- In moderate anxiety, the person can still process information, solve
problems, and learn new things with assistance from others.
- He or she has difficulty concentrating independently but can be
redirected to the topic.
- For example, the nurse might be giving preoperative instructions to a
client who is anxious about the upcoming surgical procedure. As the nurse
is teaching, the client’s attention wanders but the nurse can regain the
client’s attention and direct him or her back to the task at hand.
3. Severe anxiety

33
- More primitive survival skills take over, defensive responses ensue, and
cognitive skills decrease significantly.
- A person with severe anxiety has trouble thinking and reasoning.
- Muscles tighten and vital signs increase.
- The person paces; is restless, irritable, and angry; or uses other similar
emotional–psychomotor means to release tension.
4. Panic
- The emotional–psychomotor realm predominates with accompanying
fight, flight, or freeze responses.
- Adrenaline surge greatly increases vital signs.
- Pupils enlarge to let in more light, and the only cognitive process focuses
on the person’s defence.

d) What nursing interventions are you going to employ in your care

for Mr Mutale. (50 marks) 2marks for assessment then 12 marks
for each heading
First and foremost, the nurse must assess the person’s anxiety level because
that determines what interventions are likely to be effective.
Mild anxiety is an asset to the client and requires no direct intervention.
People with mild anxiety can learn and solve problems and are even eager
for information. Teaching can be very effective when the client is mildly
anxious.
In moderate anxiety, the nurse must be certain that the client is following
what the nurse is saying. The client’s attention can wander, and he or she
may have some difficulty concentrating over time. Speaking in short, simple,
and easy to-understand sentences is effective; the nurse must stop to ensure
that the client is still taking in information correctly.
The nurse may need to redirect the client back to the topic if the client goes
off on an unrelated tangent.
When anxiety becomes severe, the client no longer can pay attention or
take in information. The nurse’s goal must be to lower the person’s anxiety
level to moderate or mild before proceeding with anything else. It is also
essential to remain with the person because anxiety is likely to worsen if he
or she is left alone. Talking to the client in a low, calm, and soothing voice
can help. If the person cannot sit still, walking with him or her while talking
can be effective. What the nurse talks about matters less than how he or she
says the words. Helping the person to take deep even breaths can help lower
anxiety.
During panic-level anxiety, the person’s safety is the primary concern. He
or she cannot perceive potential harm and may have no capacity for rational

34
thought. The nurse must keep talking to the person in a comforting manner,
even though the client cannot process what the nurse is saying. Going to a
small, quiet, and non-stimulating environment may help to reduce anxiety.
The nurse can reassure the person that this is anxiety, that it will pass, and
that he or she is in a safe place. The nurse should remain with the client until
the panic recedes. Panic-level anxiety is not sustained indefinitely but can
last from 5–30 minutes.

Outline 5 advantages of nurse patient relationship (20 marks)

ADVANTAGES OF A NURSE PATIENT RELATIONSHIP
- Through establishment of a nurse-pt relationship, clients learn to transfer
their relationship with the nurse to relationships with significant others
because the nurse acts as a role model.
- Therapeutic relationships are goal oriented. The nurse and client decide
together what the goal of the relationship will be.
- The goal of a therapeutic relationship may be based on a problem solving
model.
- Therapeutic use of self is whereby the nurse uses her personal qualities to
establish the relation and to give care to the patient. To use oneself in a
therapeutic way one needs to have a great deal of self awareness skills.
Eg. Don’t use the patient to direct your feelings for someone in your life.
- The relationship is the means by which the nursing process is
implemented. Through the relationship problems are identified and
resolution is sought.

PHASES OF A NURSE PATIENT RELATIONSHIP (40 marks)

The relationship is divided into 4 phases:
1. Pre interaction
The nurse and patient first meet during this phase.
The nurse’s primary concern is to find out why the patient sought help, &
together with patient formulate objectives on what should be achieved in the
relationship
- Tasks:
- Establish a climate of trust, understanding, acceptance, and open
communication.
- Formulate a contract with the patient
2. Orientation (Introduction)
- Elements of a Nurse-Patient Contract:
- Names of individuals

35
- Roles of nurse and patient
- Responsibilities of nurse and patient
- Expectations of nurse and patients
- Purpose of the relationship
- Meeting location and time
- Conditions for termination
- Confidentiality
3. Working
- Most of the therapeutic work is carried out in this phase.
- Problems (reasons patient sought for help) are dealt with using problem
solving approach.
- Actual behavioural change is the focus of this phase.
- The psychiatric nursing skills are used to bring about this behavioural
change.
4. Termination
- Prepare the patient for termination by decreasing visits, incorporating
others into meetings, or changing location of meetings.
- Clarify reason for such changes so pt does not interpret it as rejection by
the nurse.
- Mutually explore feelings of rejection, loss sadness and anger etc.
- Review progress of therapy and attainment of goals.
Therapeutic Nursing Interventions are composed of nursing care directed
towards the patient with the aim of helping him or her recover. Such
interventions are best made within the nurse patient relationship utilizing the
nursing process.

k) MENTAL ILLNESS
Person Ngungu, aged 37, is admitted to the ward after becoming agitated
and hearing voices that tell him to cause violence to his family. He has been
diagnosed with paranoid schizophrenia which has developed over the past 6
months.
a) Define psychosis 5%
b) Mention 5 common mental illness in Zambia 10%
c) State five (5) factors that contribute to mental illness
20%
d) State five (5) signs and symptoms of mental illness
20%

36
e) Outline the Mental Status Examination on psychiatric patient.
30%
f) State 5 factors which maintain mental health
20%
g) State five roles of physical therapy in improving mental health
30%
h) Discuss five physical activities that can improve one’s mental health

a. Psychosis is psychological or Behavioural manifestation and/or

impairment in functioning due to social, psychological, genetic,
physical/chemical or biological disturbance.
Psychosis is a behavioral or mental pattern that causes significant
distress or impairment of personal functioning.
b. Define mental illness. 5%
- Mental illness is psychological or behavioural manifestation and/or
impairment in functioning due to social, psychological, genetic,
physical/chemical or biological disturbance.
- A mental illness or psychiatric disorder is a behavioral or mental pattern
that causes significant distress or impairment of personal functioning.
- Mental illnesses are health conditions involving changes in emotion,
thinking or behavior (or a combination of these). Usually associated with
distress and/or problems functioning in social, work or family activities.

c. Mention 5 common mental illness in Zambia 10%

1. Anxiety
2. Obsessive Compulsive Neurosis
3. Hysterical Neurosis
4. Mania
5. Depression
6. Bipolar disorders.
7. Schizophrenia
8. Psychosexual
9. Alcohol use disorders
Outline Five (5) predisposing factors or aetiology or causes of
mental illness (25%) -2/3
1. Genetics (heredity) - Many mental disorders tend to run in families,
suggesting that people who have a family member with a mental disorder
are more likely to develop a mental disorder. Mental disorders do occur in
people who have a first-degree relative with the disorder, such as a

37
 parent, brother, or sister. People who have second-degree relatives
(aunts, uncles, grandparents, or cousins) with the disease may also
develop mental disorder more often than the general population.
2. Different Brain Chemistry and Structure - Some mental disorders
have been linked to an abnormal balance of special chemicals in the brain
called neurotransmitters like dopamine and glutamate, and possibly
others. Chemical abnormalities are known to play a role in some mental
disorders like schizophrenia. Neurotransmitters help nerve cells in the
brain communicate with each other. If these chemicals are out of balance
or are not working properly, messages may not make it through the brain
correctly, leading to symptoms of mental disorder.
3. Brain Defects or Injury- Defects in or injury to certain areas of the brain
has also been linked to some mental disorders.
4. Prenatal Damage - Some evidence suggests that a disruption of early
fatal brain development or trauma that occurs at the time of birth -- for
example, loss of oxygen to the brain may be a factor in the development
of certain conditions, such as autism.
5. Alcohol and substance abuse - Long-term alcohol and substance
abuse, in particular, has been linked to anxiety, depression, and paranoia.
6. Psychological Factors - Psychological factors have been identified and
linked to mental disorders and the notable ones include:
- Severe psychological trauma suffered as a child, such as emotional,
physical, or sexual abuse.
- An important early loss, such as the loss of a parent.
- Neglect.
- Poor ability to relate to others.
7. Environmental Factors. Certain stressors within the environment can
trigger a mental disorder in a susceptible person. These stressors may
include:
1. Death or divorce.
2. A dysfunctional family life.
3. Living in poverty.
4. Feelings of inadequacy, low self-esteem, anxiety, anger, or loneliness.
5. Changing jobs or schools....
6. Social or cultural expectations (For example, a society that associates
beauty with thinness can be a factor in the development of eating
disorders.)
7. Life events, stresses and relationships. Maltreatment in childhood and in
adulthood, including abuse, physical, emotional abuse, domestic violence
and bullying, has been linked to the development of mental disorder,

38
 through a complex interaction of societal, family, psychological and
biological factors.
8. Poor nutrition and exposure to pollutants, such as lead may play a role in
the development of mental disorders.
9. Poor general health has been found among individuals with severe mental
disorders thought to be due to direct factors including diet, substance
use, effects of medication and social economic disadvantages.
10. Parenting skills, parental depression, divorce have been known to play
a role in the aetiology of mental disorders.
11. Early social privation or lack of ongoing harmonious secure committed
relationships has been implicated both in childhood (including institutional
care) and also through life span relationships. This is very evident during
adolescence.

c. Discuss any five signs and symptoms of mental illness (30%) -2/4
1. Derealisation: Feelings of unrealness involving the outer environment.
2. Depersonalization: Feelings of unrealness, such as if one is “outside” of
the body and observing his own activities.
3. Suicidal and homicidal ideation: Suicidal and homicidal ideation
requires further elaboration with comments about intent and planning
(including means to carry out plan).
4. Anhedonia: loss of interest in previously pleasurable activities
5. Amnesia: Amnesia is a partial or total loss of memory.
6. Apathy: Can be defined as an absence or suppression of emotion,
feeling, concern or passion. Further, apathy is an indifference to things
generally found to be exciting or moving.
7. Neologisms: Invention of new words by the patient.
8. Clanging association: Speech based on sound, such as rhyming and
punning rather than logical connections.
9. Perseveration: Repetition of phrases or words in the flow of speech.
10. Ideas of reference: Interpreting unrelated events as having direct
reference to the patient, such as believing that the television is talking
specifically to them.
11. Tangentiality: Thought that wanders from the original point.
12. Circumstantiality: Unnecessary digression, which eventually reaches
the point.
13. Echolalia: Echoing (repeating) of words and phrases.
14. Flight of ideas: Accelerated thoughts that jump from idea to idea,
typical of mania.

39
15. Loosening of associations: Illogical shifting between unrelated
topics.
16. Pressured speech: Rapid speech, which is typical of patients with
manic disorder.
17. Poverty of speech: Minimal responses, such as answering just “yes
or no.”
18. Thought Blocking: Sudden cessation of speech, often in the middle
of a statement.
19. Delusion: False belief not true to fact ordinarily accepted by other
members of the person’s culture.
20. Hallucinations: Sensory perceptions that occur in the absence of an
actual external stimulus. They may be auditory, visual, olfactory,
gustatory or tactile.

d. Outline the Mental Status Examination on psychiatric patient.

30%
Mental state examination is done on admission to arrive at the diagnosis and
weekly to assess the effectiveness of the drugs and improvement of the
patient. During examination, the following should be done: 1%
APPEARANCE 3%
- Note the wellbeing of the patient if he is generally health or physically
sick
- Also note the dressing as too many clothes or poor buttoning of the shirts
may indicate mental disorder
- Assess if the patient looks tensed up
GENERAL BEHAVIOUR 3%
- Assess the psychomotor activities which may be very fast or very slow
- Is the patient destructive, restless, uncooperative or spitting anyhow
- Is the patient banging tables in the examination room?
- Is the patient showing interest when he is being talked to?
- Assess for any mannerisms like shaking legs excessively
TALK/SPEECH 3%
- Assess how the patient talks
- Is the talk coherent or incoherent?
- Is the patient talking very fact of very slow?
- How is the flow of information?
- How is the torn of the voice, if the tone is very high, it may mean that the
patient is aggressive and if very low, it may mean that the patient is
depressed
MOOD/AFFECT 2%
- Mood is the inner feeling and affect is what the patient is expressing
- Assess if the mood is in line with the affect
40
- If you can’t tell whether the patient is happy or sad, write blunt.
THOUGHT PROCESS 8%
The patient presents with all sorts of delusions like:
DELLUSSIONS OF GUITY: The patient always blames himself and this
common in depressed patients.
DELLUSSIONS OF CONTROL: The patient always feels there is someone
who is in control of his life. This is common in schizophrenic patients.
GRANDOIS DELLUSSIONS: The May delusions of being a king or a queen
and he behaves like that. However, a schizophrenic patient will mention of
being a king or queen, but he will not behave like that.
PARANOID DELLUSSION: The patient is always being suspicious and thinks
someone wants to kill him.
PERCECUTORY DELLUSSIONS: The patient feels unsafe with someone
they love most. They think they can kill them.
PERCEPTUAL PROCESSES: The patent exhibits hallucinations that are in
form of the 5 senses, that is:
TACTILE HALLUCINATIONS: The patient feels insects are moving on his
skin. This is common in patients with alcohol withdraw.
GUSTATORY/OFFACTORY HALLUCINATIONS: Gustatory means taste and
olfactory means smell. The patient experiences bad taste and smell even
when something is tasting and smelling nice. This is common in epileptic
patients that are in the aura stage.
VISSUAL HALLUCINATIONS: The patient misinterprets what he sees. He
can mistake a belt for a snake.
COGNITIVE ASSESSMENT 8%
Level of consciousness: Check if the patient looks confused, sedated or
stuporous Check if the patient is rousable by verbal stimuli or by pain
Orientation: Check if the patient is fully oriented to place, person or time.
Place: Where are you today? Or in what particular building are you?
Time: What is today’s date?
Person: What is your name?
Attention: Assess if the patient is able to concentrate on one aspect or he
easily gets destructed
Memory: Test for the following:
Remote memory: Check if the patient is able to recall events or information
that occurred a long time ago, that is, years ago
Recent memory: Check if the patient is able to recall events or information
that occurred the past few weeks
Immediate memory: Assess if the patient is able to recall events or
information he has just been exposed to.

41
Judgement: Give the patient a hypothetical situation and assess how he is
going to make judgement. For example, if his house in which there was
k2000 000 and his baby was set on fire, ask him which one among the two
would he rescue first? If he says money, then judgement poor.
Insight: Assess if the patient is aware of his own condition and reasons for
admission. So insight may be lacking, partial or present.
IMPRESSION: 1%
PLAN OF ACTION: 1%
- Medical management:
- Nursing management:

e. State 5 factors which maintain mental health

1. Good nutrition
2. Exercises
3. Healthy living
4. Good temperament
5. Good social and emotional skills (emotional self-regulation)
6. Positive coping style
7. Good attachment to parents/carers/mentors
8. Family support – family /parental care
9. Mental health promotional activities in schools (e.g. child-friendly
schools);
10. Support to children e.g. skills building programmes, child and youth
development programmes);
11. Consistency (environment, circumstances, persons
12. Academic achievement-
13. Participation in community networks - early childhood
interventions (e.g. home visits for pregnant women, pre-school psycho-
social activities, combined nutritional and psycho-social help for
disadvantaged populations)
14. Economic security - programmes targeted at vulnerable groups,
including minorities, indigenous people, migrants and people affected by
conflicts and disasters (e.g. psycho-social interventions after disasters);
- Socio-economic empowerment of women (e.g. improving access to
education and microcredit schemes);
15. Physical and psychological safety - violence prevention
programmes (e.g. community policing initiatives
16. Mental health at work place - mental health interventions at work
(e.g. stress prevention programmes);
17. Social support for elderly populations (e.g. befriending initiatives,
community and day centers for the aged)
18. Community development programmes (e.g. 'Communities That Care'
initiatives, integrated rural development).

42
f. As a nurse working in the mental health unit, what measures
would you put in place to try and reduce stigma against the
mentally ill patients? (40%) - minimum 5 points 3/5
1. We need to develop anti stigma programs with substantive
elements targeting all types of stigma paying attention to the following:
- Myths about the causes of mental disorders.  Causes of mental
disorders.  Ensuring that our communities have a deep understanding of
what mental illness is.
- Creating recognition and understanding of mental disorder stigma
including what it is; how it is harmful to ourselves, our families and our
communities and the role each person has to play in reducing it.
2. We need to translate the existing mental health policies and
develop institutional and care practice plans and activities to improve
mental health and reduce the burden of mental disorders.
3. We need to support the new legislation which intends to guarantee
human rights, ensure mental health integration into general health care
like what has been stipulate in the Mental Health Act No. 6 of 2019.
4. We need to advocate for inclusion in our health care settings -
mental health agenda in all clinical activities (budgeting, drug supply and
programming).
5. Ensure the availability and access of essential medicines for
people living with mental disorders by including psychotropic drugs in
the general health care essential drug kit. Since medicines are often not
available in health-care facilities, patients and families need to be helped
to access them.
6. Talk openly about mental health. “Mental illness touches so many
lives and yet it’s kept as a great secret for the people who are suffering
from mental illness.
7. Educate yourself about mental health. “Challenge people respectfully
when they are perpetrating stereotypes and misconceptions. Speak up
and educate them.”
8. Be conscious of your language. Don’t use mental illnesses as
adjectives. “Saying someone is “retarded” or use words like crazy,
psycho, lunatic, etc.
9. Encourage equality in how people perceive physical illness and mental
illness. “We should explain mental illness as similar to any other illness.
When someone acts differently or “strange” during diabetic shock we
don’t blame them for moral failings.”
10. Show empathy and compassion for those living with a mental health
condition. Listening is one of the most important ways one can show
empathy. Listening without judgment or preconceived notions about
mental illness and being open to what the person is sharing will go a long
way.

43
11. Stop the criminalization of those who live with mental illness. The
criminalization of mental illness has wide ranging and devastating
consequences. For example: Individuals with psychiatric diseases like
schizophrenia and bipolar disorder are 10 times more likely to be in a jail
or prison than a hospital bed.
12. Push back against the way people who live with mental illness are
portrayed in the media. “Research suggests most media portrayals of
mental illness are stereotypical, negative or flat-out wrong.”
13. See the person, not the illness. Strive to listen and understand rather
than judge. Focus on the individual instead of the illness.
14. Advocate for mental health reform. “It’s empowering people
whenever and wherever you can. It’s also writing legislators. It’s also
talking in front of a board of commissioners to advocate for continued
mental health funding… It’s doing the right thing and treating others
justly.”
15. Don’t label people who have a mental illness. Don’t say, “He’s
bipolar” or “She’s schizophrenic.” People are people, not diagnoses.
Instead, say, “He has a bipolar disorder” or “She has schizophrenia.” And
say “has a mental illness” instead of “is mentally ill.” This is known as
“person-first” language, and it’s far more respectful, for it recognizes that
the illness doesn’t define the person.
16. Don’t be afraid of people with mental illness. Yes, they may sometimes
display unusual behaviors when their illness is more severe, but people
with mental illness aren’t more likely to be violent than the general
population. In fact, they are more likely to be victims of violence. Don’t
fall prey to other inaccurate stereotypes from movies, such as that of the
disturbed killer or the weird co-worker.
17. Don’t use disrespectful terms for people with mental illness. In a
research study with British 14-year-olds, teens came up with over 250
terms to describe mental illness, and the majority was negative. These
terms are far too common in our everyday conversations. Also, be careful
about casually using “diagnostic” terms to describe everyday behavior,
like “That’s my OCD," or, "She’s so borderline.” Given that 1 in 4 adults
experience a mental illness, you quite likely may be offending someone
and not be aware of it.
18. Don’t be insensitive or blame people with mental illness. It would be
silly to tell someone to just “buckle down” and “get over” cancer. The
same applies to mental illness. Also, don’t assume that someone is okay
just because they look or act okay or sometimes smile or laugh.
Depression, anxiety, and other mental illnesses can often be hidden, but

44
 the person can still be in considerable internal distress. Provide support
and reassurance when you know someone is having difficulty managing
their illness.
19. Be a role model. Stigma is often fueled by lack of awareness and
inaccurate information. Model these stigma-reducing strategies through
your own comments and behavior and politely teach them to your friends,
family, co-workers and others in your sphere of influence. Spread the
word that treatment works and recovery is possible. Changing attitudes
takes time, but repetition is the key, so keep getting the word out to bring
about a positive shift in how we treat others.

We need to know that some words and acts could be poison and
others could heal. For poisonous words, we do not have to speak them. For
acts that create a distance, we do not need to do them.

SUICIDAL ATTEMPT
Mrs. Nyambe went through various stages of the grieving process after
losing her husband 6 months ago and made several attempt to take her life.
She is admitted to the acute ward following suicidal attempts
a) i. Explain three (3) significant loses that may lead to grieving 15%
ii. State five (5) stages of grieving (Grieving process)
15%
b) Explain three (3) types of suicide 15%
c) What are some of the circumstances that may complicate grieving 35%?
d) Outline the management of a client who has three previous attempts of
suicide while on the ward 20%
e) Mention 5 causes of suicide 20%

a. Significant loses that may lead to grieving

Relationship Changes
Divorce or separation (loss for any family member)
Marriage or commitment to someone
Birth of a child or child leaving home
Friendship changes
Life Changes
Death of a spouse, family member, or friend.
Pregnancy or loss of a pregnancy.
Loss of a child to adoption.
Loss of a beloved pet.
Health Changes

45
Personal injury or illness
Changes in family member’s health
Job/School-related Change
Gain or loss of a promotion or career opportunity
New work conditions, hours, or responsibility
Graduation
Moving
Retirement
Other Changes
Loss of income or financial readjustment
Types of suicide
1. Egoistic suicide. This type of suicide occurs when the degree of social
integration is low. When a person commits this type of suicide they are
not well supported in a social group. They feel like they are an outsider or
loner and the only people they have in this world are themselves. They
often feel very isolated and helpless during times in their lives when they
are under stress.
2. Altuistic suicide. This type of suicide occurs when the degree of social
integration is too high. When a person commits this type of suicide they
are greatly involved in a group. All that they care about are that group’s
norms and goals and they completely neglect their own needs and goals.
They take their lives for a cause. A good example of this would be a
suicide bomber.
3. Anomic Suicide. This kind of suicide is related to too low of a degree of
regulation. This type of suicide is committed during times of great stress
or change. Without regulation, a person cannot set reachable goals and in
turn people get extremely frustrated. Life is too much for them to handle
and it becomes meaningless to them. An example of this is when the
market crashes or spikes.
4. Fatalistic suicide. People commit this suicide when their lives are kept
under tight regulation. They often live their lives under extreme rules and
high expectations. These types of people are left feeling like they’ve lost
their sense of self.

b. Five (5) stages of grieving (Grieving process)

1. Denial: “This can’t be happening to me.”
2. Anger: “Why is this happening? Who is to blame?”
3. Bargaining: “God Make this not happen to me, and in return I will ____.”
4. Depression: “I’m too sad to do anything.”
5. Acceptance

d. Factors circumstance that can complicate grieving.

1. No previous experience with significant loss, death, or grief

46
2. Other recent losses
3. A personal history involving multiple losses
4. Little or no support from friends or family
5. Societal norms that trivialize and negate the loss
6. Insensitive comments from others about the loss
7. Feelings of guilt or responsibility for a death
8. Untimely deaths like those of children
9. Deaths that happen suddenly, without warning
10. Deaths that occur after long, lingering illnesses
11. Deaths that have no known cause or that could have been prevented
12. An unexplained disappearance
13. Not being present at death
14. Not viewing the body after death
15. Witnessing a painful or traumatic death
16. Deaths that occur in conjunction with other significant life events like
birthdays, holidays, or a divorce
17. After death anniversary dates and holidays
18. Stories in the media that misrepresent or cast doubt on medical
treatment procedures
19. Advice based on others’ negative experiences with death or on
inaccurate information about normal grief

Risk Factors
1. Alcohol and substance abuse/use.
2. Abuse in childhood.
3. Family history of suicide.
4. Grief, bereavement/loss of an important relationship.
5. History of prior suicide attempt.
6. Hopelessness/helplessness.
7. Legal or disciplinary problems.
8. Physical illness, chronic pain, terminal illness.
9. Psychiatric illness (e.g., bipolar disorder, depression, schizophrenia).
10. Poor support system, loneliness.

l) COMMUNITY PSYCHIATRY

47
You have just been posted to work as a Nurse in a Psychiatric ward. You soon
discover that there is a high number of relapses with patients coming from
the nearby Compound.
a. Define community psychiatry
(5%)
b. Discuss the three levels of mental illness prevention that you are going
to employ in your efforts to alleviate the problem of relapses.
(60%)
c. After discharging the patients from the Hospital, you decide to provide
aftercare services.
i. Describe the aftercare services that you will provide for them.
(10%)
ii. Explain why aftercare is important.
(10%)
iii. What things will you include in your aftercare plan.
(10%)
d. State four (4) roles of a nurse in community psychiatry
16%
e. After discharging the patients from the Hospital, you decide to provide
aftercare services.
- Describe the aftercare services that you will provide for them.
9%
- State five (5) points why home visits is important as part of aftercare
10%

Definition of community psychiatry

Psychiatry focusing on detection, prevention and early treatment and
rehabilitation of emotional and behavioral problems as they occur in the
community.

Levels of mental health prevention

Prevention means keeping a disorder from occurring, in this case preventing
mental illness.
- It is carried out through specific protective measures (promotional
activities) and reducing risk factors in the lives of individuals, families and
communities.
- In the community, mental health prevention occurs at three levels:
Primary, secondary and tertiary.
1. Primary Prevention

48
Primary prevention involves both mental health promotion (enhancing
protective factors) and prevention of disorders (reducing risk factors) in the
lives of individuals.
Promotional and preventive activities in mental health care delivery
therefore overlap and are targeted towards:
- Assisting individuals to increasingly cope effectively with stress.
- Target and diminish stressors in the environment. This is done through
educating at risk groups in the following ways:
I. Teaching parenting skills and child development to prospective new
parents.
II. Teaching physical and psychological effects of alcohol, drugs to primary
and secondary pupils.
III. Teaching techniques of stress management to anyone who desires to
learn.
IV. Teaching groups of individuals ways to cope with the changes associated
with various maturational changes (adolescence, motherhood, menopause,
retirement) etc
V. Teaching the concepts of mental health to various groups within the
community.
VI. Providing education and support to unemployed or homeless individuals.
2. Secondary level (Treatment)
It is in the secondary level of prevention that treatment takes place to
reduce the severity of mental illness as follows:
- This is decreasing or reducing the prevalence of psychiatric illness by
shortening the course of the illness. This is accomplished through early
identification of problems and ‘prompts’ initiating of effective treatment.
- Nursing in secondary prevention focus on recognition of symptoms and
provision of a referral for treatment.
- Ongoing assessment of individuals at high risk of mental illness, is done
during home visits, day care, PHC clinics, or any setting where screening
of high risk individuals may occur.
- Provision of care for individuals in whom illness symptoms have been
assessed eg: counseling, medication, support during high levels of stress
(crisis intervention), suicide & child abuse hotlines, rape & victims of
domestic violence drop in centres Eg. Young Women Christian
Association[YWCA].
- Referral for investigations and treatment of individual in whom illness
symptoms have been identified.
- The treatment given after referral may include medical and psychiatric
medications, and other types of therapies.
49
 3. Tertiary level (Rehabilitation
- This is the reduction of residual defects that are associated with severe
illness such as loss of social skills, inability to earn a living, side effects of
neuroleptics (drugs used in mental illness), stigma and discrimination.
- Most common illnesses with residual defects are epilepsy and
schizophrenia. This is accomplished in two ways:
1. Preventing complications of the illness.
2. Promoting rehabilitation that is directed towards achievement of
each individual’s maximum level of function.
Nurses’ role in tertiary prevention
Nursing in Tertiary prevention focus on clients to enable them learn or
relearn socially appropriate behaviours; so that they may be able to achieve
a satisfying role within the community. For example:-
- Teaching the client daily living skill
- Encouraging independency his/her inability
- Through social skills training
- Assertiveness training
- Anger management techniques
- Referring clients to various aftercare services after discharge
- Aftercare homes such as Chawama old people’s home, support groups,
and day treatment programmes.
- Monitoring effectiveness of aftercare services through home visits.

Why aftercare is necessary/importance

1. Patterns that lead to substance abuse are hard to erase. Therefore
stresses associated with abstinence and recovery is reduced.
2. The patient has a daily routine to follow.
3. Old companions and stresses that return are prevented, upon discharge.
4. Aftercare prevents faulty thinking patterns of relying on drugs rather than
other people, of not asking for help, and of not sharing important feelings.

Aftercare services
Aftercare requires that upon discharge, persons recovering from mental
illness need continuing care to prevent relapse and other complications
occurring. Such continuing care ensures that patients continue to receive
support and care after discharge, in the community. It includes:
1. Regular reviews in the OPD.
2. Home visits, especially if they are unable to come to the OPD for
review.

50
 3. Referral to aftercare centers.
4. Support groups
5. Group homes
6. Villages

Aftercare includes a structured (routine) plan for the following:

1. Relapse prevention
2. Active participation in continuing treatment.
3. Belonging to a support group.
4. Continued access to the original professional treatment center as
needed

Roles of a nurse
1. Consultative role – Giving advice to other professionals in the
community about the type and level of nursing care required for given
client groups.
2. Clinical role – Providing direct nursing care to the patients in the
community through home visits.
3. Therapeutic role – Employing psychotherapeutic and behavioral
methods for management of patients.
4. Assessor / Researcher – The nurse may assess the care given to clients
and may also assess the outcome of ongoing care programmes.
5. Educator – Creating awareness in the community about mental health
and mental illness with special focus on vulnerable groups
6. Trainer / facilitator – Training of other professional community leaders,
school teachers and other care giving professionals in the community.
7. Manager/Administration – Manager of the resources, planning and co-
ordination.
8. Liaison role
9. – Nurses working in the community help clients and their families by
bridging the gap between the client and the hospital.
10. Nurses also network (link up with or connect to) with NGOs and other
resources in the community to meet the needs of patients.
11. They link patients to various institutions.
12. Advocacy – Nurses speak out for the rights and interests of clients in
the community by raising awareness of clients’ needs in places of
employment, school and markets.
13. This they do by sensitizing the public, NGOs, policy makers and service
providers on the plight of clients.

51
Importance of home visits
1. You can get to meet and know other family members.
2. It reduces the number of readmissions.
3. It helps in the drug monitoring and compliance.
4. It provides H/E to the client & family members.
5. It allows the nurse to see if the patient is able to apply social skills taught.
6. Helps the nurse assess whether the patient is able to carry out the
Activities of Daily Living (ADLs).
7. Enables the nurse give family therapy as well as the community. By so
doing it reduces stigma.
8. Makes the patient feel cared for. .
9. It educates the family members to cope with the disease of the patient

m) OBSESSIVE COMPULSIVE DISORDER

Mariana, aged 22 years is a student at Chilonga College of nursing who
shares a room with three other students. Her room mates complain that she
constantly arranges things in a certain way and baths for more than 30
minutes.
a. Define Obsessive Compulsive Disorder 5%
b. State five (5) symptoms of Obsessive Compulsive Disorder 25%
c. Describe the management of Mariana while at College 60%
d. Mention five (5) psychiatric co-morbidity in Obsessive Compulsive
Disorder 15%
OBSESSIVE COMPULSIVE DISORDER
Mariana, aged 22 years is a student at Chilonga College of nursing who
shares a room with three other students. Her room mates complain that she
constantly arranges things in a certain way and baths for more than 30
minutes.
C. Define Obsessive Compulsive Disorder 5%
- Obsessive Compulsive Disorder (OCD) is a disorder of the brain and
behavior. OCD causes severe anxiety in those affected.
OCD involves both obsessions and compulsions that take a lot of time and
get in the way of important activities the person values.

52
D. State five (5) symptoms of Obsessive Compulsive Disorder
25%
1. Repeatedly bathing, showering, or washing hands.
2. Refusing to shake hands or touch doorknobs.
3. Repeatedly checking things, such as locks or stoves.
4. Constant counting, mentally or aloud, while performing routine tasks.
5. Constantly arranging things in a certain way.
6. Eating foods in a specific order.
7. Being stuck on words, images or thoughts, usually disturbing, that won't
go away and can interfere with sleep
8. Repeating specific words, phrases, or prayers.
9. Needing to perform tasks a certain number of times.
10. Collecting or hoarding items with no apparent value.
11. Fear of dirt or contamination by germs.
12. Fear of causing harm to another.
13. Fear of making a mistake.
14. Fear of being embarrassed or behaving in a socially unacceptable
manner.
15. Fear of thinking evil or sinful thoughts.
16. Need for order, symmetry, or exactness.
17. Excessive doubt and the need for constant reassurance.

E. Describe the management of Mariana while at College 60%

Diagnosis
- The person has repetitive behaviors (eg, hand washing, ordering,
checking) or mental acts (eg, praying, counting, repeating words silently)
that the person feels driven to perform in response to an obsession or
according to rules that must be applied rigidly
- The behaviors or mental acts are aimed at preventing some dreaded
event or situation; however, these behaviors or mental acts either are not

53
 connected in a realistic way with what they are designed to neutralize or
prevent or are clearly excessive…
Nursing management
The most important considerations regarding OCD and living on campus
include:
Being aware of disorders such as OCD, as well as understanding of others
and being knowledgeable of residence hall policies
One of the greatest challenges tends to be living with roommates..
• If you/your roommate are having disagreements due to a pre-existing
condition such as Obsessive Compulsive Disorder, first have a
conversation to identify where each person is coming from.
• If you feel that you are unable to understand each other and need further
assistance, you should go to your resident advisor (RA). RA’s are
equipped with certain tools/training to deal with day-to-day conflicts. One
tool example is a standard roommate agreement developed by the Office
of Residence Life. This agreement covers many of the living arrangement
aspects that may be affected by compulsions, such as cleaning and sleep
preferences.
• Should the situation escalate, you should reach out to the hall director
(commonly referred to as the RD or CD) of your building. This person will
give you a better idea of what your options may be as far as long term
solutions (room changes, etc.) and may identify the most valuable
campus resources to help those involved in the situation.
F. Mention five 5 psychiatric co-morbidity in Obsessive Compulsive
Disorder 15%
OCD is an Anxiety Disorder and can be associated with:
1. Attention deficit hyperactive disorder (ADHD
2. ASD
3. Mood Disorders (Depression, Bi –Polar)
4. Tic Disorders
5. Panic Disorders
6. Psychosis

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7. Hoarding

Nursing problems
• Reduced quality of life
• Reduced quality in relationships
• Inability to do work in school
• Inability to complete homework
• Reduction in psycho-social functioning

Complications
OCD lead to…….
• Difficulty in Completing Work
• Agitation
• Conflicts
• Depression
• Isolation
• Difficulty Working in Group
• Lack of Sleep
• Family/Roommate Conflicts

8. EPILEPSY
Mary, a 17-year-old grade 10 at Lupili Secondary School was picked from
Shoprite where she convulsed and had froth at the mouth. A diagnosis of
Epilepsy is finally made.
a) Define Epilepsy 5%)
b) State 5 causes of Epilepsy (20%)
c) Describe five stages of a grandmal seizure (25%)
d) Discuss five (5) points why epilepsy is a mental condition 15%
e) Discuss 5 psychiatric disorders resulting from epilepsy
f) Describe the management under the following headings; medical and
nursing care before, during and after a seizure.
50%
g) You are required to draw a rehabilitation plan for Mary, identify five (5)
community based structures that you would work with and explain their
roles
i) Define Epilepsy 5%
- Epilepsy is a condition characterized by repeated seizures due to a
disorder of the brain cells.

55
- It is a Central Nervous System disorder characterized by recurrent attacks
of seizures due to an abnormal electrical discharge by the cerebral cortex
with or without loss of consciousness.

ii)State two (2) main classification of seizures 5%

1. Partial
2. Generalized
h) Describe five (5) stages of a grandmal seizure 20% - 2/3
1. 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.
2. 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.
3. 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.
4. 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.
There is throwing of arms and legs and can bang his head against
anything that is nearby.
Patient has tachycardia and is sweating.
5. 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.

i) Describe the management under the following headings; medical

and nursing management before, during and after a seizure.
50%
Medication 5%
- 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.

56
- Phenobarbitone 10-15 mg/kg i.v (dilute in 100ml NS and infuse over
30min)
- Can give additional 5mg/kg i.v if seizures do not stop
- Consider ICU transfer if concern for respiratory compromise.
BEFORE A SEIZURE OCCURS: 10%
- 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).
- Determine if changes can be made in activities or situations that may
trigger seizures.
- Keep the bed in a low position with side rails up, and use padded side rails
as needed.
(These precautions help prevent injury from fall or trauma.)
- Individuals with mental retardation or other developmental disabilities
may have altered bowel habits, slowed activity, and /or decreased motor
skills before a seizure.
DURING A SEIZURE: (ICTAL STAGE) 20%
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
Body part involved - 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.
Type of motor activity - clonic (jerking) - myoclonic (single jerk of - tonic
(stiffening) - abnormal posturing movements, - dystonia
Eyes: eye deviation, open, rolling or closed, eyelids flickering - head turning,
- twitching
Respirations (impaired/absent; rhythm and rate)
Heart (rate and rhythm)
Skin changes - color/temperature; - pale/cyanotic, (also check lips,
earlobes, nailbeds) cool/warm; - perspiration/clammy)
Gastrointestinal - belching - flatulence - vomiting
Pupillary size - symmetry, and reaction to light
Changes in sensory awareness (auditory, gustatory, olfactory, vertiginous,
visual) Presence of other unusual and/or inappropriate behaviors
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.)
Protect the person from injury (e.g., help break fall, clear the area of
furniture).

57
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.)
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.)
Provide as much privacy as possible for the individual during and after
seizure activity.
Provide other supportive therapy as ordered by primary care prescriber
or according to facility protocol.
AFTER THE SEIZURE: (POST ICTAL STAGE) 15%
After the seizure activity has ceased, record the presence of the
following conditions and their duration in the individual’s record. 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
- behavior change
- confusion
- language disturbance
- poor coordination
- weakness/paralysis of body part(s)
- sleep pattern disturbance
Allow the individual to sleep;reorient upon awakening. (The individual
may experience amnesia; reorientation can help regain a sense of control
and help reduce anxiety
Conduct a post seizure evaluation
a. What was the person doing prior to the seizure?
b. Was this the first seizure?
c. Review current medications including recent changes in medicine and/or
dose.
d. Other illnesses?
e. Possible precipitating factors

j) Discuss five (5) points you would include in your Information,

Education and Communication (IEC) to Mary and her family 20%
-2/3
1. Medication - Information about prescribed anticonvulsant drugs is
provided.
- The client and family should be alerted to the potential side-effects and
are advised to get in touch with the doctor if they occur.
- They should know that if a drug is not tolerated that there are others that
will be prescribed until optimal control of fits with minimal side effects is
achieved.

58
- The drug must be taken at the prescribed frequency even though there
are no seizures: - effective blood levels of the drug must be maintained by
compliance with the prescribed dosage and frequency.
2. Advisednot to consume alcohol
3. Drug doses must not be altered except with the doctor's approval: the
drug is prescribed on individual basis according to the type, severity and
frequency of the seizure's and the individual's response.
4. The patient is cautioned against the taking of any non- prescription drugs.
5. The patient should visit the doctor regularly: Blood serum levels of
the anticonvulsant drug are determined and dosage adjusted if
indicated.Since a blood dyscrasia is a potential side effect of many of the
drugs used blood cell counts, haematocrit and bleeding time are
evaluated regularly and patient and family informed.
6. The patient and family are requested to keep a record of seizures which
includes antecedent events or any known or suspected precipitating
factors (S).
7. Joining support groups - Information about the Epilepsy Association
may be very useful. The mutual support offered to the patient and family
by such groups such as this can be invaluable.
8. Identification - A medic alert identification bracelet or pendant should
be worn so that appropriate care can be given during a fit or an
emergency.
The patient should always carry the names, addresses and telephone
numbers of persons' to be contacted.
9. To ensure safety to self and others - advised against driving, cycling
or operating at heights or where there is loud noise or flashing lights.
10. Prevention of seizures - Any Sport engaged in should not stimulate
seizures or dangerous. He should be advised against swimming.

e. Discuss five (5) points why epilepsy is a mental condition 15%

a. Behavioral and cognitive disturbances associated with seizures
Increasing tension, irritability and depression are sometimes apparent as
prodromata for several days before a seizure. Transient confusional states,
hallucinations, affective disturbances, automatisms and other abnormal
behaviors may occur during seizures (particularly complex partial seizures),
and after seizures (usually those involving generalized convulsions, and
complex partial seizures)
b. Psychiatric and cognitive disorders associated with the
underlying cause
The underlying cause of epilepsy may contribute to intellectual impairment
or personality problems, especially if there is extensive brain damage. For
example, epilepsy is more common in the mentally retarded, than among
people with normal intelligence.

59
c. Inter-ictal disorders
Personality disturbance: Epileptic personality is said to be characterized
by egocentricity, irritability, religiosity and quarrelsomeness. When such
personality changes occur, social factors probably play an important role in
etiology, such as the social limitations imposed on them, their own
embarrassment, and reactions of the other people. Also, brain damage can
contribute to the development of personality disorder.
d. Inter-ictal psychosis
Some patients with temporal lobe epilepsy may develop a psychosis that
resembles schizophrenia
e. Depression and other emotion disorders - Depression and certain
other emotional disorders are more common in people with epilepsy than
in the general population.

MANAGEMENT ACCORDING TO SYMPTOMS

Providing safe environment
- Restrict environmental stimuli, keep unit calm and well illuminated
- As the patient is responding to a terrifying unrealistic world of
hallucinatory and illusions, continuous observation and care is needed to
protect him from himself and others
Alleviating patients fear and anxiety
- Remove any object in the room that seem to be a source of
misinterpreted perception
- There should always be somebody at the patient’s bedside reassuring and
supporting; as much as possible have the same person all the time by the
patient’s bedside
Meeting the physical needs of the patient
- Maintain intake and output chart
- Hygienic needs should be taken care of
- Monitor vital signs
- Use appropriate nursing measures to reduce high fever, if present
Facilitate orientation
- Have a calendar in the room, repeatedly explain to the patient where he
is and what date, day and time it is
- Introduce people with name even if the patient misidentifies the people

DEPRESSION
a. State 5 predisposing factors to depression (25%) 5 marks each -
2/3

60
1.BIOLOGICAL THEORIES
• Biochemical Studies: has associated symptoms of depression with a
functional deficiency of norepinephrine, serotonin and dopamine.
• The level of dopamine in the mesolimbic system of the brain is thought to
have an influence over human mood and behaviour.
2. Genetics-
• Twin studies suggest a genetic factor of illness of about 50% in
monozygotic twins.
• Family studies show that major depression is 1.5 to 3 times more common
among first degree biological relatives.
3. Neuroendocrine disturbances
• This has been found to contribute to the pathogenesis of persistence of
depressive illness.
4.Electrolyte disturbances
• Excessive levels of sodium bicarbonate or calcium can produce symptoms
of depression
5.Hormonal disturbances
• An imbalance of the hormones estrogen and progesterone has been
implicated in the predisposition to premenstrual dysphoric disorder.
• It is postulated that excess estrogen or high estrogen to progesterone
ratio during the luteal phase during the menstrual cycle is responsible for
the symptoms associated premenstrual syndrome
6.Psychoanalytic Theories - These theorists contended that depression
occurs as a result of an early life loss (Freud 1957) he viewed depression as
the aggressive instinct inappropriately directed at self, often triggered by the
loss of a loved one or object
7.Cognitive theory - The Theory by Beck, et al. (1979) proposed that the
primary disturbance in depression is cognitive rather than affective.
Cognitive theorists believe that depression is the product of negative
thinking.
8.Object loss theory-This theory suggest that depressive illness occurs as
a result of having been abandoned or separated from a significant other
during first 6 months eg the mother.
• Absence of attachment which may be physical to emotional leads to
feelings of helplessness and despair that contributes to lifelong pattern of
depression in response to loss.
9.Learning theory- by Seligman (1973)- Model of helplessness.
• A similar state of helplessness exists in human beings who have
experienced numerous failures (either real or perceived).
• The individuals abandon any further attempt to succeed.

61
• Seligman theorized that learned helplessness pre-disposes individuals to
depression by imposing a feeling of lack of control over their life situation
f. Discuss the nursing care you will provide to Mwika throughout
hospitalization (50)
Environment
• The patient should be kept in a room close to the nurse’s station for close
observation
• The environment must be clean and well ventilated
• It should be safe from any dangerous objects, knives, razors
• If possible a TV can be placed there to divert the patient’s negative
thoughts
• If the patient is threatening suicide, take their clothes because they would
use that as means to harm themselves
Nutrition
Nurse should identify unmet physical needs.
- Ask for the patient’s favorite food
- Encourage relatives to bring the patient’s favorite food
- Serve the patient small and attractive potions of food
- Talk to the patient as they’re having their meals and encourage them to
eat
- Monitor the patients weight
Hygiene
• Encourage personal hygiene
• Supervise baths
• Encourage patient to;
• make their beds
• Brush their teeth
• Cut off long nails
• Wash their clothes
• Wash their hair and comb it neatly
• Change their beddings and linen whenever necessary
Individual psychotherapy
• Interpersonal psychotherapy focuses on client’s current interpersonal
relations
• Counsel the patient
• Show sympathy
• Encourage patient to form friendship with fellow patients and avoid being
alone
• Encourage patients to share their worries and counsel accordingly
• Encourage them to take medications
62
Habit training
• Train the patient in normal habits, such as relating with others in
respectable and meaningful ways
• Put the patient in groups so as to encourage group activities to reduce on
alone time and boredom
• Train patients in social skills they may have lost such as doing their own
laundry, keeping the eating utensils clean
Observations
• Observe Vital signs as the patient may have other illness apart from
depression
• Observe for Side effects of drugs and inform doctor
• Monitor bowel and bladder activities to rule out constipation
Occupational therapy
• Help the patient to re acquiring the lost skills by applying the psychiatry
nursing skills in the daily care provided
• Encourage patient to take part in skills training sessions and ensure
patient is involved in return demonstrations of the skills
• Observe to see whether patient applies the learnt skills in their daily lives
• Reinforce skills that patients may still be struggling with through
demonstration of the same skills several times
Diversional therapy
Provide a TV in the patient’s ward
If patient is able to read provide novels, magazines and news papers
Involve patient in group games and encourage them to participate fully
Arrange for Traditional dance times and music and involve the patient to
keep their mind busy and away from their usual sad thoughts
Cognitive Therapy
Teach the patient taught to control thought distortions that are considered to
be a factor in the development and maintence of mood disorders
The general goal of this therapy is to obtain symptom relief and assist the
client in identifying dysfunctional patterns of thinking and behaving
Elimination
Patient may have constipation associatedwith low dietary therefore provide a
regime of moderate exercises Coupled with oral fluids and some dietary
roughage.
Medication – I will ensure the patient receives the prescribed drugs and
takes them correctly
• Observe the patient when taking drugs to ensure that they swallow and
not spit out the medication
• Observe for any side effects of drugs and report

63
IEC
• Advise the patient to avoid being alone as the company of others can help
the patient to recover
• Advise the patient to Co-operate and take the prescribed drugs for quick
recovery.
• On discharge advise the patent to keep review dates
• Encourage patient to avoid situations that may escalate the problem and
teach patient how to handle situations that may predispose them to a
new episode of depression
g. Discuss the four quadrants of the Johari window (20%)
The Johari Window consists of four quadrants that represent the total self as
follows:
Quadrant 1 – Known to self and others. It includes the behaviours, feelings,
and thoughts known to the individual and others. Also known asarena
Quadrant 2 – Known only to others. (It is an open secret!). It includes all the
things that others know but the individual does not know.it is also known as
a blind spot
Quadrant 3 – Known only to self. This quadrant includes the things about
self that only the individual knows. It is then up to the individual whether or
not to disclose this information its also called a façade (mask)
Quadrant 4 – Known neither to self nor to others, it represents the
individual's behaviors or motives which are not recognized by anyone. It is
also called (unknown).

11. MENTAL RETARDATION

Define intellectual disability
- Intellectual disability (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.
- Mental retardation is defined by deficits in general intellectual functioning
and adaptive functioning and measured by an individual’s performance on
intelligence quotient (IQ) tests (American Psychiatric Association [APA],
2000).
Describe the three main causes of intellectual disability
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

64
parents may have normal genes, with the defect resulting from a random
error when chromosomes reproduce.
Disorders that occur as a fetus develops during pregnancy
A variety of problems during a woman’s pregnancy can cause
mental retardation in her child.
Malnutrition
Mother use of alcohol or drugs;
environmental toxins such as lead and mercury;
viral infections, including rubella (see German Measles) and
cytomegalovirus;
An untreated disease 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.
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.
Physical trauma to the brain can also cause intellectual disability.
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.
Experts believe that poverty and a lack of stimulation during infancy and
early childhood can be factors for intellectual disability.
Children raised in poor environments are more likely to experience
malnutrition, lack of routine medical care, and environmental health hazards.
State the classification/ degree of severity of intellectual disability
(20 marks) 5 marks each, 2 for mentioning and 3 for explaining
There are four degrees of severity of Intellectual Disability based on IQ score:
Mild disability (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.
1. Mild (IQ range 50-55 to about 70). Or
(50-70)
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 disability

65
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.
2. Moderate (IQ range 35-40 to 50-55). Or (35-
50)
People with moderate disability 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.
3. Severe (IQ range 20-25 to 35-40). or (20-35)
Severe disability affects 3 to 4 percent of individuals intellectually disabled.
Severely disability 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.
4. Profound (IQ level below 20-25) or (less than 20)
About 1 to 2 percent of disabled people have profound intellectual disability
and requires constant care. Profoundly disabled individuals can understand
some language, but they have little ability to talk. They often have a
neurological condition that accounts for their disability.

Discuss the role of the nurse in managing Chanda.

THE ROLE OF A NURSE IN MANAGING CHILDREN WITH LEARNING
DISABILITIES / MENTAL RETARDATION
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. The length of this grieving
process may vary depending on the psychological, social and medical
support and expertise availed to them.
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.
Early identification and intervention
To avoid all these complications, the nurse must be alert to quickly identify
children with intellectual disability so that they can receive the needed care
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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 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 intellectual disability
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 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.
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.
In the period of adolescence, we as nurses must ensure that we advise
parents and support them in caring for their children because this is the time
when they sometimes try to experiment with behaviours 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 intellectual disability.

Mention five (5) psychiatric co-morbidity in the intellectual disabled

population (15%)
Abnormal behaviours that occur in the mental retardation
population
Psychiatric disorders occur more frequently in the Intellectual Disability
population than the general population. They include:

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1. Schizophrenia – Symptoms in severe LD include unexplained aggression,
bizarre behaviours, mood lability, increased mannerisms and
stereotypies.
2. Bipolar Affective Disorder – Symptoms include hyperactivity, wandering,
mutism, temper tantrums.
3. Depressive disorder
4. Biological disorders more marked, with diurnal variations. Suicidal
thoughts / acts may occur in border line – moderate LD.
5. Anxiety disorders, Obsessive Compulsive Disorder, Attention Deficit
Hyperactive Disorder, & personality disorder.
14. INSTITUTIONALISATION
Definition of Institutionalization
This is the patient response to long term institution care or the impact that
an institution has on the patient’s self-concept.

Presentation of an institutionalized patient

1. Apathy: the patient will show lack of enthusiasm, motivation and energy
in many ward activities. Patient experiences lack of emotional expression.
2. Lack of initiative: the patient may be limited in reasoning and thinking
due to long stay in the rigid structured institution. The patient might be
unable to reason on their own as effective as they can when they are at
home, this makes them unable to develop new knowledge and skill for
dealing with life’s situations and problem solving.
3. Dependency: this is the reliance of the patient on the staff to make
decisions and doing things for them. This is so because the patient lacks
self-direction.
4. Passive submission: this is the obeying or following instructions and
commands without questioning. This results from the patient’s
dependency on the staff for almost everything making them believe that
everything the staff says is the right thing.
5. No feeling of resentment: the patient are unable to identify and react
to the wrong things in an institution as wrong ward even if it involves
violets their rights.
6. Depersonalisation: due to the new norms and routine activities that are
instituted in the patient’s mind, the patient may forget who they really are
which includes their personal interests, abilities, strengths and weakness.
7. Depressive features such as sense of worthlessness, hopeless and
helpless may develop in a patient that has being in an institution for a
long period of time.

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8. Institutional neurosis: this manifests as a result of the demands of the
institution which leads to disabilities in the social, emotional and life skills
of the patient.
9. Institutionalism: this is the impoverishment of the thoughts, feelings
and initiative and social activities in self-expression.
10. Social breakdown syndrome: this is the loss of normal role
functioning with the varying degree of exclusion from typical family and
community roles.
11. Stooped posture and shuffling gait: this result from lack of
adequate exercises, immobility and reduced self-esteem.
12. Deteriorate in personal habits: this is the inability to carry out
activities of daily living on their own as a result of total dependence.
13. Regressive behaviour: the patient may return to an earlier or
previous less developed condition or way of behaving.
14. Reduced intellectual functioning and delayed development:
exposing the patents to prescribed fixed ways of coping and solving
problems for a long period makes them unable to develop new and
advanced ways of dealing and coping with life’s situation.

FACTORS CONTRIBUTING TO INSTITUTIONALISATION

1. Loss of contact with the outside world: this contributes to the patient
being institutionalised in the sense that the patient is not visited
frequently while in the hospital due to several factors such as the
distances from the relatives place to the hospital being too long, this
make the patient feel as though they are neglected, heart and not cared
for. As a result they will resort to remain in the institution.
2. Loss of personal possession or belongings: multiple losses such as
loss of property, relationships or employment (resigned under medical
groups) for the patient who has stayed in the ward for a long period of
time, may cause the patient to think and believe that they have nothing
to live for outside the hospital because all or most of their important
possessions are gone. For this reason the patient will resort to stay in the
hospital.
3. Lack of recognition for important personal events: life’s important
events such as birthdays, anniversaries and special holidays gives the
patient hope to live a functional and productive life outside the hospital.
Due to the nature of illness and prolong stay in the hospital the patient
may fail to recognize and appreciate the importance of such events.
Hence they resort to stay in the hospital.
4. Encouraging dependency rather than independency by the nurse:
this contributes to institutionalisation in the sense that nurses do not
actively involve patients in structuring daily activities, planning and

69
 decision making for daily activities. For this reason the patient rely on the
staff and because of this they feel that they cannot function on their own
outside the hospital.
5. Lack of social support: the patient who lives with unsupportive
relatives at home may lead to the patient being institutionalized. This is
because the care the patient needs from the family and friends might not
be in accordance to their expectations compared to the care received
from health workers in the hospital. The unsupportive home environment
makes it had for the patient to be re-integrated back in their homes,
hence they resort to remain in the hospital.
6. Continuous sedation of the patient: sedating the patient every time
they become aggressive, agitated, violent, and restless or “out of
control”. Makes the feel as if they have no control over their own
behaviour. This contributes the already affected self-concept there by
making the patient feels like they can’t functions in the outside world
where there is no sedation hence choose to continue living in the hospital.
7. Stigma and discrimination: the negative attitude and name which the
people outside the hospital have toward people with mental illness, such
as not allowing them to participate in certain activities, giving them food
separately, calling them bad name, etc. for this reasons the patient will
choose to remain in the hospital where they think they are accepted and
safe.
8. Prognosis of the condition: chronic conditions such as schizophrenia
and dementia might require long term management which leads long
term hospitalisation.
9. Presentations or manifestations of the illness: clinical
manifestations such as violent behaviour, aggressiveness, anti-social etc.,
will make it hard for other people including the family to accept the
patient at home, hence the patient will be confined to the hospital for the
comfort of others.
10. Poor social economic status: this leads to poverty in which the
family is not able to meet the demands of the patient such as paying for
any damage caused by the patient or just meeting the patient’s basic
needs may lead to institutionalisation in that the family might committee
the patient to the hospital or the patient can choose be in the hospital
where some of the basic needs such as food, shelter, water, etc. are
meet.
11. Poor attitude to the patient by the staff: dehumanising and
authoritarian staff attitude toward the patients makes them feel hopeless.
Non-autonomous attitudes of the staffs to the patient makes them feel
completely useless in that they have no say in their own care, in
additional to this teasing, name calling, demining, overlooked, makes the

70
 patient feel un human and worthless. This leads to institutionalisation in
that the patient will believe that they are actually useless and worthless
and lost hope for a productive life outside the hospital.

MANAGEMENT OF THE PATIENT WHO HAS DEVELOPED

INSTITUTIONALISATION
1. Establishing of a therapeutic relationship: creating a therapeutic
relationship based on trust, respect, acceptance, unconditional positive
regard and empathic understanding will help in both preventing and
treating the effects of institutionalisation. Trust and positive regard will
help the nurse to treat the patient in a more humanly manner, respecting
and accepting the patient as an individual will convey a feeling of self-
worthy leading to improved self-concept making the patient develop new
hope for the functional and productive life outside the hospital.
2. Restoration of the patient’s contact with the outside world: the
patient’s relatives and friends should be encouraged to frequently visit
the patient while in the hospital. This will strengthen the social support
system which conveys the feeling of being loved and cared for in the
patient. For the patient who has stabilised he/she should be either
discharged if he or is unpredictable a short leave can be given. This is to
maximise the patient’s interaction with the world outside the hospital
environment.
3. Preventing loss of patient’s personal belongings: a nurse as an
advocator will advocate for the patient’s property and personal
belongings by collaborating with organisation or other government
departments that upholds the patient’s rights. Also assures the patient
that their possessions are safe and secured. This is done in order to give
the patient something to make his/her life outside of the institution more
meaningful and worthy living. Due to the long hospitalisations most of the
patient losses their jobs which makes them loss hope on their survival in
the outside world, for this reason the nurse will again advocate for the
patient’s job security by working with the labour ministry or can help the
patient develop skills through the occupational therapy or other
organisations that empowers people with disabilities, this will enable the
patient to be able provide for themselves in the outside world.
4. Enabling the patient to recognise important life’s event and
appreciate their values: the patient’s family and friends should
encouraged to remember and honour important events and dates in the
patient’s life such as birthdays, anniversaries and special holidays. The
family should be also be encouraged to celebrate this holiday together
even when he or she is still in hospital. This will remind the patient of old

71
 good times which will keep the values attributed to such events which will
give the patient reasons for getting out of the hospital.
5. Facilitating independency rather than dependency: the patient
should be involved in structuring daily actives such as planning for meals,
cooking, bathing, washing etc. this will help the patient to use their
initiative and helps in discussion making. The nurses should also avoid
doing things on behalf of the patient instead they should guide the patient
taking into consideration their abilities and mental state. This will not only
enable the patient to do things on their own, but also enhance their sense
of self-worth.
6. Strengthening the social support system and reduce
dehumanising attitude toward at the patient at home: the family
should be taught on the nature of the illness explaining clearly on the
aetiological factors, clinical manifestation and the process of the illness.
This will help the family understand why the patient behaves in a
particular way which will cause them to accept the patient. Acceptance
and understanding the patient will prevent the family from having a
negative attitude toward the patient and they won’t be able to mistreat
the patient by teasing, beating or exploiting them. This will make a home
environment more conducive for the patient there by reducing the need
for long term hospitalisation.
7. Good and non-authoritative staff attitude to the patient:
dehumanising and authoritative attitude staff attitude makes the patient
feel hopeless. In the hope to overcome hopelessness instituted by the
staff members as they manage the patient in the hospital, the staffs
should have a positive attitude toward the patient, this can be achieved
by treating the patient as an individual, with respect, empathy,
unconditional positive regard and acceptance.
8. Reducing stigma and discrimination: the public must be given
enough information with regard to mental illness. This can be achieved
through outreach programmes, using the media such as television, radios,
magazines, etc. the emphasis should be on the causes, manifestations
and prognosis of mental illness. This will be done in order to clear out the
misconception that people have on mental illness there by reducing
stigma and discrimination which will make it is for the patient to be
integrated back into the society.
9. Facilitating home care for chronic conditions: the family should be
taught on how they can care for the patient with a sable choric condition
effectively at home so that the patient can be discharged soon after
stabilizing, this will short the hospitalization time. The patient should be
integrated into community based care programmes in which he/she can
get help within while at home. The patient should be transferred to the

72
 community mental health nurse who will conduct frequent home based
care. This will enable the patient to receive care in their home
environment in full support of their family, it will also help the nurses to
assess and modify the patient’s home environment.
10. Minimising sedation: the nurses must reduce on the use of chemical
restrains such as sedative drugs to control the patient’s maladaptive
behaviour such as aggression, agitation, severe restlessness etc, instead
they should use other means to control these behaviour. Alternative ways
that the nurse can use to control the patient behaviour includes the
following; limit setting, time out, token economy etc. this will enable the
patient to gain control over their behaviour and enhances their self-
esteem hence restoring their hope.
11. Deinstitutionalisation: the patient shouldn’t be kept in the hospital
for a long period of time, the reason for hospitalization of the patient
should be to manage the patient in their acute state but soon after
stabilising the patient should be discharged.
12. Improving the economic status and reducing poverty: a nurse as
a liaise officer, will work with support groups to intervene and help the
patient and family in providing economic support and also providing skills
which will help them earn a living and be able to meet their basic needs.

HEALTH PROMOTION
The current ministry of Health Policy focuses on public Health with
emphasis on health promotion and disease prevention. You happen
to implement the above policy in your community
A) Explain the three (3) levels of prevention in relation to mental
illness to the student nurses 30%
B) You are trying to find out the prevalence of mental illness in
the community, discuss four (4) data collection techniques
40%
C) Explain the importance of follow up visits/home visits in
relation to psychiatric patients 30%

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 A) LEVELS OF PREVENTION OF MENTAL HEALTH
I. Primary prevention. This is defined as reducing the incidence of mental
illness/ disorders within the population. It mainly targets individuals and
the environment and emphasis is twofold: Assisting individuals to increase
the abilities to cope with stress within the environment. Targeting and
diminishing harmful forces (stressors within the environment).Nursing in
primary intervention is fused on targeting groups at risk and the provision
of education programs such as teaching physical and psychosocial effects
of alcohol and drugs to primary and secondary school children. Teaching
techniques of stress management to virtually anyone when desires to
learn. Teaching the concepts of mental illness within the community.
II. Secondary prevention: This is accompanied through early
identification of problems and prompts initiation of treatment. Nursing in
secondary prevention focuses on recognition of symptoms and provision
of referrals for treatment for example ongoing assessment of individuals
of high risk of mental illness. This is done through home visit, day care,
community health centers or any setting where screening of high risk
individuals might occur. Provision of care for individuals in whom illness
symptoms have been assessed and the type of care is done through
counselling, medication, admission, health education as well as support
III. Tertiary prevention. This is defined as reducing the residual defects
that are associated with severe or chronic mental illness. This is
accomplished in two ways: Prevention of complication of illness.
Promoting rehabilitation that is directed towards achievements of each
individual’s maximum level of functioning. Nursing in tertiary prevention
focuses on helping the clients to earn or re-learn socially appropriate
behaviors so that they can achieve a satisfying role within the community.
E.g. Monitoring effectiveness of after care services through home visits or
follow up appointments in community mental health centers .Referring
clients for various after care services e.g. supports groups, day
treatments programs, psychosocial rehabilitation programs etc. Teaching
the clients the daily living skills and encouraging independence to his or
her maximum ability.
(B ) Use of Available Information
Depending on the type of information that is needed, a researcher can use
the already available information. For example, if the researcher needs
information on the prevalence of disease from a particular geographical area
during a certain period of time, he can simply request for the hospital and
health centre record books and retrieve the information. Or if the information
is readily available from Management Health Information System, the

74
researcher can simply request for a print out. Another example is the birth
registration records kept by the registration office. In order to retrieve the
information in its original state, the researcher may need to design a
checklist or a compilation sheet or form.
Observing
When using this technique, the researcher need to systematically select,
watch and record the behaviors and characteristics of the people, objects or
situations. Observation of human behavior can be done in two ways:
Participant observation: This is when the observer takes part in the situation
he or she observes. Non-participant observation:This is when the observer
watches the situation, openly or concealed, but does not participate.
Observations are important because they give additional, more accurate
information on behavior of people than interviews or questionnaires.
Observations can be used to check on information collected especially on
sensitive topics such as alcohol or drug use, or stigmatization of epilepsy, or
AIDS patients. Or they may be a primary source of information. Information
can be obtained using tools such as scale, thermometer, eyes, tape
measures, microscopes etc. Information obtained through observations can
be recorded using either a checklist, or compilation sheets. Checklist and
data compilation sheets are also called data collection tools.
Interviewing
An interview is a data-collection technique that involves the researcher
asking questions to the respondents while the respondent provides answers.
Interviewing should be carried out in a conversation manner.
The answer - question session during interviews can be recorded either by
writing down the responses or using a tape recorder. Interviews can be
conducted with varying degrees of flexibility such as high and low degrees.
The degrees of flexibility are outlined below:
High degree of flexibility: These use loosely structured methods of asking
questions. There are no restrictions as to what or how the respondent should
answer. Data collection tools such as unstructured questionnaires or
interview schedules can be used. The interviewer is allowed to ask additional
questions to clarify issues. Loosely structured methods are used when there
is little knowledge of the problem or situation for example in exploratory
studies or in case studies.
Low grade flexibility: This method uses questionnaires that have a fixed list
of questions with fixed or pre-categorized answers. The methods are used
when the researcher has less knowledge about the expected answers and
when the number of participants to be interviewed is large.

75
Administering written questionnaires
A written questionnaire is a data collection tool that the respondent has to
answer by writing in the questionnaire according to the instructions given. A
written questionnaire is also called a self-administered questionnaire.
Questionnairecan be sent by mail. Clear instructions should be given to
respondent on how to answer and where to post the filled in questionnaire.
Respondents can be gathered in one area at the same time. Oral or written
instructions are given to them and respondents fill in the questionnaire. The
questionnaires are then collected from the respondents. The questionnaires
can also be delivered to the respondents by hand and then collected later
on. It involves close and open ended questions. Open-ended type of
questions allows the respondent to express themselves freely. The kind of
data collected from open-ended type of questions is called qualitative data.
Open-ended questions allow flexibility in the sense that the respondents are
not restricted or the degree of restriction is minimal. Closed-ended questions
do not allow the respondent or the interviewer to express themselves or seek
clarification respectively. They are used to collect quantitative data. Both
types of questions can be used in a questionnaire. Use of both flexible
(qualitative methods) and non - flexible (quantitative methods) is helpful in
that they complement each other.
(C) Purpose of home visit
- Home visit is done in order to assess the patient’s response to
treatment
- In order to assess the level of drug compliance in cases of defaulters.
- In order to assess the home environment if there are any triggering
factors such as family support, stigma and discrimination. The
structure of the house can also show the economic status of the
patient e.g poverty.
- Assessment of family dynamics
- Assessment of social support system available
- Assessment of coping strategies
- Physical assessment such as nutrition
ALCOHOLISM
Mr Mbuzi phiri male aged 36 years married with 4 children is
admitted to Chainama Hills Hospital with history of alcohol abuse.
The wife said her husband sometimes experiences tremor. He has
been suspended at work for absenteeism. The wife explains that he
has impaired thinking and hallucinations as well. On examination a
provisional diagnosis of alcoholism was made.

76
 A) State six (6) social effects of alcohol abuse
20%
B) Discuss how alcohol abuse can be prevented 30%
C) Describe in details the management of Mr. Mbuzi
50%
SIX (6) SOCIAL EFFECTS OF ALCOHOL
1. Disruption of marriages; alcohol can lead to disruption of marriages in
that people who take alcohol tend to have impaired judgment which can
lead to violence in homes causing disruption of a marriage.
2. Unemployment. Alcohol leads to poor work performance and absenteeism
which leads to loss of jobs.
3. Poverty; this can occur due to employment loss and because alcoholics
tend to use most of their finances on alcoholism leading to poverty.
4. Road traffic accidents; alcohol leads to impaired judgment which can lead
to road traffic accidents.
5. Serious illnesses; alcohol deteriorates the health status e.g. it causes
hypertension, liver cirrhosis, peripheral neuropathy
6. Increased reckless behaviors; alcohol increases the libido of someone
causing them to be involved in reckless behaviors such as having sex with
different ladies which also leads to the development of sexually
transmitted diseases.
PREVENTION OF ALCOHOL ABUSE
1. Sensitization of the community on the dangers of alcohol abuse. This can
be done through the media, music, drama e.t.c.
2. Organizing school health services in the community; this involves
screening of pupils for substance abuse and educating them on the
dangers of substance abuse.
3. Recreational activities. The community should identify community based
programs to occupy the youths and unemployed in order to reduce
idleness, hence reducing substance abuse.
4. Reporting people selling illegal substances to relevant authorities.
5. Conducting counselling sessions; when patients are cancelled about the
dangers of substance abuse, it helps them to understand the effects of
substance abuse which helps to prevent substance abuse.
6. Conducting group therapies within the hospital; this therapy helps the
clients to understand more about substance abuse, its effects and how it
can be avoided, hence it helps clients prevent substance abuse
MANAGEMENT OF MR NJOBVU WITH ALCOHOL ABUSE

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Management of alcohol abuse generally involves immediate intervention,
nursing management, pharmacological management, counselling and
managing the side effects of drugs
IMMEDIATE MANAGEMENT
Since the patient is presenting with alcohol withdrawal symptoms, therefore
the immediate intervention will involve calming the patient by administering
benzodiazepines such as diazepam 10mg iv. If the patient is a danger to self,
others or property, will make sure the patient is observed throughout his
stay at OPD. Removing any dangerous objects which the patient can use to
harm against self or others, will help ensuring safety for the patient and
others. A full diazepam detox regime will be prescribed by the clinician. The
initial dose of this treatment regime can either be commenced from the filter
clinic or on the ward depending on the severity of the condition. Patient shall
require to take treatment for five (5) days and the route of administration
will depend on the patient’s condition.
TREATMENT REGIME GUIDELINE FOR DIAZEPAM IV (MODERATE – SEVERE
CONDITION)
Day 1……10mg QID
Day 2……10mg TDS
Day 3……10mg BD
Day 4……5mg BD
Day 5……5mg OD
NURSING MANAGEMENT
PATIENTS SAFETY AND ENVIRONMENT
Patient’s safety in the environment is the nursing priority when nursing a
patient with alcohol abuse. The environment should be free from any
dangerous objects that the patient can use to harm himself as the patient is
prone to falls. The patient should be searched in his pockets for dangerous
items that he can use to injure himself. Since, Mr. Mbuzi is experiencing
withdrawal symptoms is likely to be anxious, therefore I will orient the
patient on the ward environment and I will make sure that the environment
is quiet, adequate lighting system with low stimulation as such environment
is favored for alcohol abusers. In addition, monitor the risk of falls and ensure
enough night light to reduce perceptual errors which may exacerbate the
anxiety levels and psychotic phenomenon.
Detoxification of alcohol is the initial treatment for alcohol abusers who
experience alcohol withdrawal symptoms. I will do a full detoxification to Mr.
Mbuzi using diazepam for five days as prescribed as it helps to alleviate
withdrawal symptoms and separate the patient from alcohol related social
and environment stimuli that may increases the risks of relapse.

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 THERAPEUTIC COMMUNICATION
Communicate to the patient and the family about the nature of severity and
duration of the symptoms and the role of medication during the treatment of
Mr Mbuzi. Explaining all appropriate intervations to relatives and Mr Mbuzi
clearly and in the friendly manner to alley anxiety.
OBSERVATIONS AND PHYSICAL EXAMINATION
Since Mr Mbuzi is experiencing alcohol withdrawal symptoms, he is likely to
have unstable vital signs, therefore I will ensure that the blood pressure,
temperature, pulse and respiration are checked regularly to notice any
deviation from the normal. Physical examination should also be conducted to
rule out certain medical disorders that can occur comorbid with alcoholism
which can exacerbate withdrawal symptoms and complicate treatment. I will
also observe if the patient is responding well to treatment and monitor the
patients eating patterns.
NUTRITION
Most of the alcoholics exhibit vitamin deficiencies, presumably due to poor
diet habits as well as from alcohol induced changes in the digestive tract that
impairs the absorption of nutrients into the blood stream. I will give folic acid
to Mr Mbuzi for two weeks as it helps in the synthesis of the cells genetic
material and maturation of certain blood cells. I will also administer thiamine
100 mg / day orally for 5 days (or longer if required) as it helps in the
metabolism of sugars for energy and it prevent the development of
thiamine-deficiency syndromes such as Wernicke’s encephalopathy.
HYDRATION AND COLLECTION OF ELECTROLYTE IMBALANCE
Mr NJOBVU is at risk of being dehydrated as he might start sweating and
fever due to hyperactivity of autonomic nervous system induced by alcohol, I
will ensure that he takes enough fluids as they are essential for the
performance of the physiological processes and to maintain the function of
the vital organs such as the heart and the kidney. I will also collect
electrolyte imbalances by administering magnesium, phosphate and sodium
as they help in the metabolism in order to prevent life threatening metabolic
disorders. Magnesium supplements also helps to reduce the occurrence of
seizures.
MEDICATION
Other medications, such as low dosages of antipsychotics can be given to
mr Mbuzi with cautions when psychotic features are present as
antipsychotics have the tendence of lowering seizure thresh hold and can
induce alcohol withdrawal seizures. Antiemetics such as promethazine can
be prescribed if the patient is having nausea nad vomiting . Acomprosate is
used to augment treatment, and is then carried on into long term use to

79
reduce the risk of relaps.. Acomprosate 600 mg
(2 tabs) tds is indicated especially when susceptible to drinking cues or
drinking triggered by withdrawal symptoms . It lowers potential for drug
addictions and need normal renal function. Side effects include diarrhoea,
headache, nausea. After Mr. Mbuzi has stabilized, I will prepare him for
interventions that aim at long term alcoholism management (rehabilitation)
INFORMATION, EDUCATION AND COMMUNICATION
- As the patient stabilizes, I will explain about the importance of staying
away from alcohol as this will help on a good prognosis and prevent
relapse cases.
- Patient’s family shall be counseled on Mr Mbuzi’s condition. This will
ensure the family to take appropriate care and support necessarily
- Mr Mbuzi will be canceled on the dangers of alcohol abuse and the social
and health effects that alcohol can cause.
- The patient will be advised to be staying away from the influence of
alcohol especially his old associates in order to prevent alcohol relapse
cases.
- Prior to discharge, Mr. mbuzi will advised to undergo rehabilitation. This
will help him cope with his new life style. Rehabilitation will involve skills
such as problem solving skills, anger management skills, etc.

STIGMA
You are a mental health nurse working at one of the Rural Health
Centres in the country. The local volunteers engaged to support
people with mental illness within the catchment area informs you
that the greatest challenge faced by individuals with mental illness
in the community is stigma.
A) Define the two (2) forms of stigma likely to be experience by
people suffering from mental illness 10%
B) State five (5) factors that contribute to stigma against clients
with mental illness 20%
C) Explain five (5) effects stigma may have on the recovery
process from mental illness 20%
D) Describe the program that you may develop within your
catchment area aimed at reducing stigma against people with
mental illness 50%

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Forms of stigma
A) Self-stigma is where the client is self-stigmatised due to mental
illness from the public.
B) The other form of stigma is Public stigma is where the public
stigmatises people with mental illness. They are considered to be of no
value to the society.

B) Factors that contribute to stigma against clients with mental

illness 20%
 One of the factors that contribute to stigma against people with mental
illness is the lack of knowledge about cause of mental illness. They
believe that mental illness is caused by supernatural powers or evil spirits
hence this makes them stigmatise people with mental illness.
 The other factor that contribute to stigma is the side effects of
medication that they are given to treat their condition, people usually
experiences severe side effects that are unusual know that they are
suffering from mental disorder hence they stop medication.
 Course and duration of mental illness condition is also the cause of stigma
for they believe that mental illness cannot be healed hence when one
suffer from a mental disorder he is considered to be a permanent patient.
 Relapse are at fault of causing stigma among people with mental illness
when these patient are not compliant to medication regimen, they tend to
relapse hence causing stigma.
 The myth that people have towards mental illness.
C)
 Stigma has a greater effects on the recovery process of mental illness in
that people are reluctant to seek medical help at early stage of the illness
and this makes it difficult for the illness to be completely treated because
it has already progressed.

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 People stopped going to psychiatric hospitals to collect medication and
this has really reduced the rate of people attending psychiatric clinics and
hospital hence increase in the number of relapse.
 Patients because of stigma they loss employment as they are considered
to be non-functional once they suffer from mental illness.
 Poor funding by the government

D)The programmes that can be developed in the community to

reduce stigma include the following:
- Sensitizing the community on the causes of mental illness
- Use of mass media will reduce stigma
- Educating the community on substances like alcohol and others as they
are at high risk of causing mental illness
- Provide employment to the people who have recovered from mental
disorder
- Offer housing to people with mental illness, because patients with no
accommodation move anyhow
- Social network between the mentally ill patients and the general public
- Implement and advocating for mental health act to be enacted in
parliament

ELECTRO-CONVULSIVE THERAPY (ECT

Mr. Mulenga, a 36 year old man is due to undergo Electro-convulsive
therapy (ECT). ECT remains controversial for many Psychiatric
Practitioners. One of the important ethical aspects of ECT is whether
the therapeutic benefits out-weigh the risk. Given that there is no
conclusive evidence to identify ECT as the treatment of choice in
major depression, each case needs individual assessment.
A) Discuss the preparation of Mr. Mulenga before he undergoes
ECT 25%
B) Lithium carbonate is usually given to patients with psychiatric
depression
(i) List five (5) side effects of the drug 10%
(ii) Outline the specific nursing care for the management of the
side effects identified in (i) 25%
C) State five (5) side effects of ECT 15%

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D) Explain five (5) roles of the community psychiatric nurse
towards Mr. Mulenga upon his discharge 25%

ELECTROCONVULSIVE THERAPY (ECT)

Electroconvulsive therapy is the artificial induction of a grandma seizure
through the application of electrical current to the brain. The stimulus is
applied through electrodes that are placed either bilaterally in the front-
temporal region, or unilaterally on the non-dominant side
Parameters of electrical current applied
Standard dose according to American psychiatric Association, 1978
 Voltage- 70-120 volts
 Duration- 0.7-1.5seconds
Types of ECT
Direct ECT- in this, ECT is given in the absence of anesthesia and muscular
relaxation. This is not a commonly used method now.
Modified ECT: here ECT is modified by drug-induced muscular relaxation and
general anesthesia.
Indications
A) Major depression, especially with suicidal risk
B) Severe catatonia
C) Severe psychosis (F20 or mania)
D) Organic mental disorders
Contraindications
(A) absolute:
Raised ICP (intracranial pressure)
(B) Relative
-cerebral aneurysm
-cerebral hemorrhage
-brain tumor
-acute myocardial infarction
-retinal detachment
SIDE EFFECTS OF ECT
-Memory impairment
-Drowsiness, confusion and restlessness-
-Poor concentration, anxiety
-Headache, weakness/fatigue, backache, muscle aches
-Dryness of the mouth, palpitations, nausea, vomiting
-Unsteady gait
-Tongue bite and incontinence

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ROLE OF THE NURSE
Pre-treatment evaluation
- detailed medical and psychiatric history, including history of allergies
- An informed consent should be taken. Allay any unfounded fears and
anxieties regarding the procedure.
- Patient should be on empty stomach for 4-6hrs prior to ECT.
- Withhold night doses of drugs, which increase seizure threshold like
diazepam, barbiturates and anticonvulsants.
-Withhold oral medications in the morning
- Head shampooing in the morning since oil cause impedance of passage of
electricity to brain.
- Any jewellery, prosthesis, dentures, contact lens, metallic objects and tight
clothing should be removed from the patients body.
- Empty bladder and bowel just before ECT
- Administer of 0.6mg atropine IM 30minutes before ECT or IV just before ECT

Intra-procedure care
-Place the patient comfortably on the ECT table in supine position
-Assist in administering the anesthetic agent (thiopental sodium) and muscle
relaxant –succinylcholine
-Since the muscle relaxant paralyzes all muscles including respiratory
muscles, patient airway should be ensured and ventilator support should be
started.
-Mouth gag should be inserted to prevent possible tongue bite.
-The place (s) of electrode placement should be cleaned with normal saline
or 25% bicarbonate solution, or a conducting gel applied
-Monitor voltage, intensity and duration of electrical stimulus given
-100% oxygen should be administered
-Monitor vital signs during seizure , ECG, oxygen saturation EEG etc
-Record the findings and medicines given in the patient chart.
Post-procedure care
-Monitor vital signs
-Continue oxygenation till spontaneous respiration starts
-Assess for post-ictal confussion and restlessness
-Take safety precautions to prevent injury (side-lying position and suctioning
to prevent aspiration of secretions, use of side rails to prevent falls)
-If there is severe post-ictal confussion and restlessness, IV diazepam may be
administered
-Reorient the patient after recovery and stay with the patient until fully
oriented.

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-Document any findings as relevant in the patients record

MENTAL ILLNESS
a) Define mental illness. 5%

- Mental illness is psychological or behavioural manifestation and/or impairment in

functioning due to social, psychological, genetic, physical/chemical or biological
disturbance.
- A mental illness or psychiatric disorder is a behavioral or mental pattern that causes
significant distress or impairment of personal functioning.
- Mental illnesses are health conditions involving changes in emotion, thinking or behavior (or
a combination of these). Usually associated with distress and/or problems functioning in
social, work or family activities.
b) Outline Five (5) predisposing factors or aetiology or causes of mental illness (25%)
1. Genetics (heredity)
Many mental disorders tend to run in families, suggesting that people who have a family member
with a mental disorder are more likely to develop a mental disorder. Mental disorders do occur in
people who have a first-degree relative with the disorder, such as a parent, brother, or sister.
People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the
disease may also develop mental disorder more often than the general population.
2. Different Brain Chemistry and Structure Some mental disorders have been linked to an
abnormal balance of special chemicals in the brain called neurotransmitters like dopamine and
glutamate, and possibly others. Chemical abnormalities are known to play a role in some mental
disorders like schizophrenia. Neurotransmitters help nerve cells in the brain communicate with
each other. If these chemicals are out of balance or are not working properly, messages may not
make it through the brain correctly, leading to symptoms of mental disorder.
3. Brain Defects or Injury
Defects in or injury to certain areas of the brain has also been linked to some mental disorders.

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4. Prenatal Damage Some evidence suggests that a disruption of early fatal brain development
or trauma that occurs at the time of birth -- for example, loss of oxygen to the brain may be a
factor in the development of certain conditions, such as autism.
5. Alcohol and substance abuse. Long-term alcohol and substance abuse, in particular, has been
linked to anxiety, depression, and paranoia.
6. Psychological Factors. Psychological factors have been identified and linked to mental
disorders and the notable ones include:
 Severe psychological trauma suffered as a child, such as emotional, physical, or sexual abuse.
 An important early loss, such as the loss of a parent.
 Neglect.
 Poor ability to relate to others.
Environmental Factors. Certain stressors within the environment can trigger a mental disorder in
a susceptible person. These stressors may include:
7. Death or divorce.
8. A dysfunctional family life.
9. Living in poverty.
10. Feelings of inadequacy, low self-esteem, anxiety, anger, or loneliness.
11. Changing jobs or schools....
12. Social or cultural expectations (For example, a society that associates beauty with thinness
can be a factor in the development of eating disorders.)
13. Life events, stresses and relationships. Maltreatment in childhood and in adulthood, including
abuse, physical, emotional abuse, domestic violence and bullying, has been linked to the
development of mental disorder, through a complex interaction of societal, family, psychological
and biological factors.
14. Poor nutrition and exposure to pollutants, such as lead may play a role in the development of
mental disorders.
15. Poor general health has been found among individuals with severe mental disorders thought
to be due to direct factors including diet, substance use, effects of medication and social
economic disadvantages.
16. Parenting skills, parental depression, divorce have been known to play a role in the aetiology
of mental disorders.

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17. Early social privation or lack of ongoing harmonious secure committed relationships has
been implicated both in childhood (including institutional care) and also through life span
relationships. This is very evident during adolescence.
c) DISCUSS ANY FIVE SIGNS AND SYMPTOMS OF MENTAL ILLNESS (30%)
1. Derealisation: Feelings of unrealness involving the outer environment.
2. Depersonalization: Feelings of unrealness, such as if one is “outside” of the body and
observing his own activities.
3. Suicidal and homicidal ideation: Suicidal and homicidal ideation requires further elaboration
with comments about intent and planning (including means to carry out plan).
4. Anhedonia: loss of interest in previously pleasurable activities
5. Amnesia: Amnesia is a partial or total loss of memory.
6. Apathy: Can be defined as an absence or suppression of emotion, feeling, concern or passion.
Further, apathy is an indifference to things generally found to be exciting or moving.
7. Neologisms: Invention of new words by the patient.
8. Clanging association: Speech based on sound, such as rhyming and punning rather than logical
connections.
9. Perseveration: Repetition of phrases or words in the flow of speech.
10. Ideas of reference: Interpreting unrelated events as having direct reference to the patient,
such as believing that the television is talking specifically to them.
11. Tangentiality: Thought that wanders from the original point.
12. Circumstantiality: Unnecessary digression, which eventually reaches the point.
13. Echolalia: Echoing (repeating) of words and phrases.
14. Flight of ideas: Accelerated thoughts that jump from idea to idea, typical of mania.
15. Loosening of associations: Illogical shifting between unrelated topics.
16. Pressured speech: Rapid speech, which is typical of patients with manic disorder.
17. Poverty of speech: Minimal responses, such as answering just “yes or no.”
18. Thought Blocking: Sudden cessation of speech, often in the middle of a statement.
19. Delusion: False belief not true to fact ordinarily accepted by other members of the person’s
culture.

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20. Hallucinations: Sensory perceptions that occur in the absence of an actual external stimulus.
They may be auditory, visual, olfactory, gustatory or tactile.
d) As a nurse working in the mental health unit, what measures would you put in place to try and
reduce stigma against the mentally ill patients? (40%) Student should at least come up with at
least 10 points What can we do to reduce and prevent mental health related stigma? There are
number of steps we can take to reduce and overcome mental health related stigma.
1. We need to develop anti stigma programs with substantive elements targeting all types of
stigma paying attention to the following:
 Myths about the causes of mental disorders.  Causes of mental disorders.  Ensuring that
our communities have a deep understanding of what mental illness is.
 Creating recognition and understanding of mental disorder stigma including what it is; how it
is harmful to ourselves, our families and our communities and the role each person has to play in
reducing it.
2. We need to translate the existing mental health policies and develop institutional and care
practice plans and activities to improve mental health and reduce the burden of mental disorders.
3. We need to support the new legislation which intends to guarantee human rights, ensure
mental health integration into general health care like what has been stipulate in the Mental
Health Act No. 6 of 2019.
4. We need to advocate for inclusion in our health care settings - mental health agenda in all
clinical activities (budgeting, drug supply and programming).
5. Ensure the availability and access of essential medicines for people living with mental
disorders by including psychotropic drugs in the general health care essential drug kit. Since
medicines are often not available in health-care facilities, patients and families need to be helped
to access them. 6. Talk openly about mental health. “Mental illness touches so many lives and
yet it’s kept as a great secret for the people who are suffering from mental illness.
7. Educate yourself about mental health. “Challenge people respectfully when they are
perpetrating stereotypes and misconceptions. Speak up and educate them.”
8. Be conscious of your language. Don’t use mental illnesses as adjectives. “Saying someone is
“retarded” or use words like crazy, psycho, lunatic, etc.
9. Encourage equality in how people perceive physical illness & mental illness. “We should
explain mental illness as similar to any other illness. When someone acts differently or “strange”
during diabetic shock we don’t blame them for moral failings.”
10. Show empathy & compassion for those living with a mental health condition. Listening is
one of the most important ways one can show empathy. Listening without judgment or

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preconceived notions about mental illness and being open to what the person is sharing will go a
long way.
11. Stop the criminalization of those who live with mental illness. The criminalization of mental
illness has wide ranging and devastating consequences. For example: Individuals with
psychiatric diseases like schizophrenia and bipolar disorder are 10 times more likely to be in a
jail or prison than a hospital bed.
12. Push back against the way people who live with mental illness are portrayed in the media.
“Research suggests most media portrayals of mental illness are stereotypical, negative or flat-out
wrong.”
13. See the person, not the illness. Strive to listen and understand rather than judge. Focus on the
individual instead of the illness.
14. Advocate for mental health reform. “It’s empowering people whenever and wherever you
can. It’s also writing legislators. It’s also talking in front of a board of commissioners to advocate
for continued mental health funding… It’s doing the right thing and treating others justly.”
15. Don’t label people who have a mental illness. Don’t say, “He’s bipolar” or “She’s
schizophrenic.” People are people, not diagnoses. Instead, say, “He has a bipolar disorder” or
“She has schizophrenia.” And say “has a mental illness” instead of “is mentally ill.” This is
known as “person-first” language, and it’s far more respectful, for it recognizes that the illness
doesn’t define the person.
16. Don’t be afraid of people with mental illness. Yes, they may sometimes display unusual
behaviors when their illness is more severe, but people with mental illness aren’t more likely to
be violent than the general population. In fact, they are more likely to be victims of violence.
Don’t fall prey to other inaccurate stereotypes from movies, such as that of the disturbed killer or
the weird co-worker.
17. Don’t use disrespectful terms for people with mental illness. In a research study with British
14-year-olds, teens came up with over 250 terms to describe mental illness, and the majority was
negative. These terms are far too common in our everyday conversations. Also, be careful about
casually using “diagnostic” terms to describe everyday behavior, like “That’s my OCD," or,
"She’s so borderline.” Given that 1 in 4 adults experience a mental illness, you quite likely may
be offending someone and not be aware of it.
18. Don’t be insensitive or blame people with mental illness. It would be silly to tell someone to
just “buckle down” and “get over” cancer. The same applies to mental illness. Also, don’t
assume that someone is okay just because they look or act okay or sometimes smile or laugh.
Depression, anxiety, and other mental illnesses can often be hidden, but the person can still be in
considerable internal distress. Provide support and reassurance when you know someone is
having difficulty managing their illness.

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19. Be a role model. Stigma is often fueled by lack of awareness and inaccurate information.
Model these stigma-reducing strategies through your own comments and behavior and politely
teach them to your friends, family, co-workers and others in your sphere of influence. Spread the
word that treatment works and recovery is possible. Changing attitudes takes time, but repetition
is the key, so keep getting the word out to bring about a positive shift in how we treat others.
20. We need to know that some words and acts could be poison and others could heal. For
poisonous words, we do not have to speak them. For acts that create a distance, we do not need
to do them
Words Can Be Poison or perpetuate stigma Words Can Heal or prevents stigma. Stigma
discourages people from getting help At any given time, one in four adults and one in five
children experience a mental health problem. Early and appropriate services can be the best
way to prevent an illness from getting worse. Many people don’t seek such services because they
don’t want to be labelled as mentally ill” or “crazy.” Here are six steps you can follow to help
end the stigma of mental illnesses:
1. Learn More. Many organizations sponsor nationwide programs about mental health and
mental illness.
2. Insist on accountable media. Sometimes the media portray people who have mental illnesses
inaccurately, and this makes stereotypes harder to change.
3. Obey the mental health law. The mental health law prohibits discrimination against people
with mental illness in all areas of public health and general health care.
4. Recognize and appreciate the contributions to society made by people who have mental
illnesses. People who have mental illnesses are major contributors to Zambian life - from the arts
to the sciences, from medicine to entertainment to professional sports.
5. Treat people with the dignity and respect we all deserve. People who have mental illnesses
may include your friends, your neighbors, and your family.
6. Think about the person – the contents behind the label. Avoid labeling people by their
diagnosis. Instead of saying, “She’s a schizophrenic,” say, “She has an illness. “Never use the
term “mentally ill.” Stigma keeps people from getting examined and treatment. Some health
workers are reluctant to treat people who have mental illnesses. Stigma leads to fear, mistrust,
and violence. Even though the vast majority of people who have mental illnesses are no more
violent than anyone else the average television viewer who watches Nigerian Movies sees three
people with mental illnesses each week – and most of them are portrayed as violent. Such
inaccurate portrayals people to fear those who have mental illnesses. Stigma results in prejudice
and discrimination. Many families try to prevent people who have mental illnesses from living
with them Stigma results in inadequate insurance cover Our heath system does not cover mental

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health services to the same degree as other illnesses. When mental illnesses are covered,
coverage may be inadequate.
“Mental illness is nothing to be ashamed of, but stigma and bias shame us all.” Bill Clinton.

QUESTION 2
a) i. Define defilement? 5%
Defilement is having sexual intercourse with a person (this includes both boys and girls) under
the age of 18 years. It doesn’t matter whether the person has given consent or not. The major
determinant in defilement is age.
ii. Outline 5 (five) Factors that could contribute to defilement cases in the community. 20%
1. Indecent dressing and inappropriate behaviour. E.g. small girls patronizing clubs and taverns
and drinking alcohol while implicitly dressed could be the main reasons why you find even big
men are being tempted to have carnal knowledge with small girls. 2. Sex boosters or Libido
enhancers: Traditional medicines and concoctions sold by traditional healers to men, especially
to have their private parts enlarged and libido enhancers.
3. Sexual perversity. This is a situation where those that are involved have no control over their
sexual desires and therefore, take advantage of young children left in their care.
4. Lack of adequate institutional day care centres for children and the prohibitive fees tend to
create a situation where children, especially those with working mothers are left in the care of
relatives or others who tend to abuse them.
5. Psychiatric disorders: Some perpetrators are known to be “Paedophiles” which is sexual
perversion in which children are the preferred sexual objects for reasons they may not even
comprehend.
6. Beliefs that having sex with a minor can cure HIV/AIDS. Witchdoctors were wrongfully
advising HIV and AIDS patients to sleep with minors in order to be cured, the prevalence of HIV
and AIDS, there are superstitions and beliefs that sex with a child cures HIV and AIDS, boosts
business potential, increases chances of promotions at places of work, or enhances other powers
such as witchcraft. This is usually done on advice of witchdoctors and traditional healers.
7. Lack of parental care. It is argued that the inability of most parents to provide adequately for
their children due to poverty forces girls into sexual relations with taxi-drivers, bus drivers and
others so that they raise some money to afford them to eat something or go to school. Parental
support is thus, lacking in many households today where it is found that parents spend less time
with their families. Some parents leave home early, leaving their children asleep and come back
very late when the children have already gone to bed. It is true that lack of parental care and

91
poverty can actually motivate some children to engage into child prostitution in order to make
ends meet and thereby escalate incidences of child defilement.
8. Inadequacy in housing could also cause a volatile situation that is likely to promote strange
behavioral patterns among members of a particular household. (Those mainly of extended family
setups) to live together in a house which does not have enough or adequate space. For example, a
family of eight or so members could be housed in a one bed roomed house. The husband and
wife who are the owners of the house could occupy the one bedroom, the rest of the family share
different corners, and may be the boys in one corner and the girls in the other. This creates a
vulnerable state. Sometimes, it has been taken for granted that a youngster of 3 years or so can
sleep with the elderly believing that nothing would happen to the child since s/he is in the care of
the elderly person.
9. Watching pornographic videos: Child defilement cases could also be escalated if watching of
pornographic videos in the home is allowed. With the coming of the internet, pornography is
more common than it used to be. These depict scenes of heterosexual, rape, oral, anal and group
sex, incest, bestiality and other loathsome out pouring of perversions. Repeated use of
pornography can interfere with the ability to enjoy and participate in normal marital intimacy, a
specialist in treating sex addiction, states that what starts as casual viewing of pornography can
eventually lead to deviant sexual acts.
10. Traditional and customary practices like initiation ceremonies and early marriages
perpetuate defilement of the girl-child. The lessons given during initiation ceremonies include
seductive scenes which the girl has to imitate and she can later put these lessons into practice by
engaging in sexual relationships.
11. Variation of culture to culture. In Zambia because of the popular belief that children are
‘safe’ HIV-free partners. Child sexual cleansing in a case where a widow or widower has sex
with a child to obtain cleansing and wade off the ghost of the deceased spouse from causing
trouble.
12. Quest for wealth: there is this belief that sex with children can bring about success in
business
13. Girls are defiled and sexually exploited just because they are girls-selling produce on the
streets, walking to school in rural areas and working as house servants.
14. Customary marriages were the girls are married off at a tender age due to poverty or certain
traditional belief or lack of education
b) EXPLAIN FIVE (5) SIGNS AND SYMPTOMS THAT YOU COULD OBSERVE IN A
CHILD THAT HAS BEEN DEFILED. (15%)
Though children may not speak about abuse, they may nevertheless communicate that something
significant and disturbing has happened to them in a non-verbal manner.

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1. Significant or sudden changes in mood or behavior may indicate a problem. Changes in mood
may include signs of depression: sadness, tearfulness, lethargy, anger, or mood swings.
2. Children may also begin isolating themselves, withdrawing from family or friends, spending
all of their time outside the home, experimenting with alcohol or drugs when this was not the
case in the past, or start acting out at home or at school. Conversely, promiscuity or sexually
suggestive behavior when this was not characteristic of the child in the past.
3. Sometimes victims of sexual abuse or assault will change their appearance and try to become
less attractive: wearing baggy, unattractive clothing, avoiding cosmetics, or failing to style their
hair. Or, youth may adopt a more seductive and sexualized manner of dress.
4. Other behavioral changes which may indicate abuse include: significant changes in sleeping
patterns and habits, significant or sudden changes in appetite and eating patterns, or significant
weight gain or loss. A heightened sense of vigilance, vulnerability and fearfulness, possibly
combined with a new sensitivity to startle, and a desire to withdraw socially may indicate the
presence of post-traumatic stress disorder (PTSD).
5. When children have been sexually assaulted (raped) they may show medical signs of their
attack including sexually transmitted infection, urinary tract infection and other hard-to-explain
injuries.
6. Some abused youth will act out their inner pain by self-harming; often by cutting themselves
with a blade in an effort to distract from emotional pain. Such intentional CUTTING is easy to
confuse with a suicide attempt though it is almost never that.
c) AS A COMMUNITY MENTAL HEALTH NURSES WHAT COULD YOUR ROLE IN
ADDRESSING THE SITUATION IN THE COMMUNITY. 30%
The following roles have been identified for nurses working in community health services:-
I. Consultative role – Giving advice to other professionals in the community about the type
and level of nursing care required for given client groups who has been defiled or
children who have suffered defilement.
II. Clinical role – Providing direct nursing care to the patients in the community through
home visits to the parents who have their child defiled.
III. Therapeutic role – Employing psychotherapeutic and behavioral methods for
management of defiled patients.
IV. Assessor / Researcher – The nurse may assess the care given to clients and may also
assess the outcome of ongoing care programs in prevention of defilement cases.
V. Educator – Creating awareness in the community about mental health and mental illness
with special focus on vulnerable groups and how to prevent the vice of defilement in the
community.

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VI. Trainer / facilitator – Training of other professional community leaders, school teachers
and other care giving professionals in the community in various prevention programs and
awareness in the community and what to do in case of child defilement.
VII. Manager/Administration – Manager of the resources, planning and co-ordination of
programs to do with prevention of defilements in the communities
VIII. Advocacy – Nurses speak out for the rights and interests of clients in the community by
raising awareness of clients’ needs in places of employment, school and markets. This
they do by sensitizing the public, NGOs, policy makers and service providers on the
plight of clients who have suffered defilement.
IX. Preventive roles: the uses primary, secondary and tertiary levels in identifying and
prevention of defilement cases in the community.
X. Law Enforcer: A nurse may be the health-care professional who must document these
activities as they are related to her by the patient or take photographs of injuries. In rape
cases, the nurse may be a member of the Sexual Abuse Response Team, or SART, who is
charged with collecting and preserving evidence. In many countries, nurses are mandated
reporters for domestic violence, child abuse and elder abuse.
XI. Maintenance of Ethics: Victims of abuse have been violated in physical, sexual or
emotional ways; nurses are expected to deliver care no matter how difficult or ugly the
situation may be. Nurses have an ethical expectation to be advocates for their patients,
which includes acting to protect them or support them in situations of abuse.
XII. Physical Care: sexually Abuse victims often require physical nursing care. In the
emergency room, this may include cleaning wounds or applying a dressing. If injuries are
severe, the patient may need surgery and nursing care during the convalescent period.
The nurse might provide medications for pain or help the patient learn to walk with
crutches. In addition, victims of abuse may need education for self-management if they
have injuries that will take some time to heal, such as broken bones.
XIII. Emotional Support: The empathetic nurse can help provide emotional support by
listening and allowing patients to express whatever they feel. Nurses offer an opportunity
to talk about feelings and may also be able to suggest a referral to a counsellor who is
experienced in dealing with abuse victims. The nurse may also be the first person to
recognize symptoms of depression or suicidal intent in an abuse victim.
EXPLAIN THE MEASURES THAT GOVERNMENT COULD PUT TO PREVENT CHILD
DEFILEMENT 30%
1. Establishment of stiffer punishments for the perpetuators of child defilement. Government will
continue working to ensure that the message gets to all the people and that the law will continue
to take its course in many issues of defilement. There is need to reinforce current legislative laws
to curb such vices across the country by providing tougher punishments on culprits which would
send a strong signal to would-be offenders.

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2. There is need to ensure that funding for sensitization programmes in communities is increased
to intensify on the programmes to do with child defilement.
3. Call upon all institutions, households and individuals to uphold the highest standards of
behaviours towards children both in their private and professional lives.
4. The Department of Child Welfare and Protection must have adequate facilities to house and
protect victims of this heinous form of violence against children.
5. The police must investigate and act on all child sexual abuse with the urgency it deserves.
6. The judiciary must expedite all sexual gender based violence cases involving children.
7. If it’s to do with fast healing from certain diseases then there is need to sensitise traditional
healers to start advising their clients to do away with the vice of child defilement adding that if it
also has to do with release from prison, there is equally need for more sensitization. A lot of
parties are involved in dealing with cases of child abuse, from medical specialists to youth care
workers and criminal justice authorities. The government wants them to work together in
response to cases of (suspected) child abuse. This is referred to as a multidisciplinary approach.
8. Stopping child defilement and minimizing the harm to the child When it comes to child
defilement, the main objective is to stop it from happening in the first place. When abuse does
occur, it needs to be identified at an early stage, so that it can be stopped and the harm to the
child can be minimized.
9. The ‘Signs of Safety’ method Professionals can use the Signs of Safety method for families in
which child defilement occurs. Together, the social worker and the family draw up a safety plan
for the child. The government is financing a research programme entitled Effective working
methods in the youth sector to find out if this method works.
10. Child protection If a child’s development is in jeopardy and the parent or parents are not
open to assistance, then child protection services may need to get involved. The court may
impose child protection measures in order to stop child defilement.
11. Child abuse is a criminal offence The court may impose treatment on the offender in order to
prevent repeat of child defilement. Government agencies are working with the police, the Public
Prosecution Service and other parties to improve the investigation and prosecution of offenders.
12. Support for victims of child abuse The Youth Care Office provides support to victims of
child abuse and their parents at their request. Different therapies and interventions are available.
13. Legal Frameworks that Protect Children under the Zambian Statutes in Zambia, laws related
to children are disseminated among different statutes.
14. Enforcing the children’s rights. Some children’s basic rights, like the right to citizenship, the
protection from exploitation, the right to life of an unborn child, the right to personal liberty of a

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minor, the right of young person’s not to be exploited, etc. are entrenched in the Constitution
(UN Human Rights Committee, 2007).
15. In addition to constitutional and statutory legislation, customary law also exists to regulate
matters concerning children.
16. The Victim Support Unit, the Child Justice Forum, the National Youth Policy and the
National Child Policy, and ministries: mainly the Ministry of Gender and Child Development,
the Ministry of Community Development, Mother and Child Health, the Ministry of Labour and
Social Security and the Ministry of Education
17. “The State shall protect the child from all forms of maltreatment by parents or others
responsible for child care and establish appropriate social programs for the prevention of child
abuse and treatment of victims,
18. “The State shall protect children from sexual exploitation, prostitution and involvement in
pornography and in particular take all appropriate national, bilateral and multilateral measures to
prevent: a] The inducement or coercion of a child to engage in any unlawful sexual activity; b]
The exploitative use of children in prostitution or other unlawful sexual practices; c] The
exploitative use of children in pornographic performances and material. From the foregoing, one
would assume that the Republic of Zambia has enough and adequate laws to protect its children.
19. Parents and Caregivers: Must ensure the environment in and around the home is safe for their
children.
20. Children: Must be given the confidence to report any form of abuse they experience to
parents, caregivers, police, their teachers or even their neighbors. They must be able to report in
the knowledge that they will be treated with dignity, sensitivity and confidence in all cases. 21.
Community members and local leaders:
Continue raising awareness at household and community level about the importance of
protecting children from sexual abuse. There is need to emphasize that No child (below 18 years)
can provide consent to sexual activities.
Ensure that all child abuse cases are reported to appropriate authorities including any incidents
where videos, photos or audio recordings of children being abused.
Community Child Welfare Committees must review their child safeguarding and protection
policies to ensure children are safe.

QUESTION 3
DEFINE A CRISIS. 5%

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A crisis is a critical event or point of decision which, if not handled in an appropriate and timely
manner (or if not handled at all), may turn into a disaster or catastrophe.
A crisis is any event that is going (or is expected) to lead to an unstable and dangerous situation
affecting an individual.
A crisis is a difficult or dangerous situation that needs serious attention.  A crisis is an
emotionally significant event or radical change of status in a person's life
DESCRIBE THE FOUR PHASES OF A CRISIS 40%
THE FOUR STAGES OF A CRISIS
STAGE ONE
1. In Stage One, the client focuses on the incident. This is the “breaking news” stage. “What
happened?” is the key question. And the news travels very fast in Stage One to Stage Two –
it doesn’t take long for the story to jump the “fire line.” The client makes preparations. Maps
and tests the message, he educates and informs people around him especially those he has
built credibility and trust.
2. STAGE TWO 2. Stage Two is characterized by the focus on the response. The light moves
quickly from the incident itself (although new facts will continue to emerge) to the “drama.”
How could this have happened? The focus is on be first, be right, be credible. The client
acknowledges that the problem is real. Client Empathize, client Informs, client Explains, and
Commits. This stage is key. This is the make it or break it stage, the reputation forming stage,
the stage where the rallying on social media sites, both negative and positive, becomes a
focal point.
3. STAGE THREE 3. Stage Three is the one best avoided, although inevitably we all want to go
there – yes, the Blame, Finger Pointing Stage. In this Finger Pointing Stage, everyone has an
opinion about you, Stage Three is all about blame with the key question focused on “why.”
Your crisis is beamed everywhere. This is the stage of maintenance. Help understand the
client understand the risk. Find other options to the crisis. Find out about the background of
the problem, Gain support, Listen to others
4. STAGE FOUR 4. The light begins to dim in Stage Four which is the fallout/resolution stage.
The spotlight now dims, but can easily be turned to full glare again if you slip up, or you
can’t take it back. Typically, this stage marks the end of the crisis; there is some resolution.
A stage to recovery during this stage client express relief and thanks, rebuilds trust, Listens to
the feedback and Admit the short comings
OUTLINE THREE (3) TYPES OF CRISIS (30%) THE 3 TYPES OF CRISIS
Crises can be divided into three categories:
1. Creeping Crises– this is crisis which is shadowed by a series of events that decision
makers don’t view as part of a pattern. For example

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  Lack of a rumor-control system, resulting in damaging rumors.
 Inadequate preparation for partial or complete interruption.
 Inadequate steps to protect life and property in the event of emergencies.  Inadequate
two-way communication with all audiences, internal and external.
2. Slow-Burn Crises – this is a type of crisis where there is advance warning, before the
situation can cause any actual damage. For example through:-
 Internet activism
 Most lawsuits.
 Most discrimination complaints.
 Company reputation
 Lack of regulatory compliance – safety, immigration, environment, hiring, permits,
etc.  Major operational decisions that may distress any important audience, internal or
external.
 Local/state/national governmental actions that negatively impact operations.
 Official/governmental investigations involving your healthcare organization and/or any
of its employees.
 Labor unrest.
 Sudden management changes – voluntary or involuntary.
 Marketing misrepresentation.
3. Sudden Crises– this is a type of crisis were damage has already occurred and will get
worse the longer it takes to respond
 Patient death – Your healthcare organization perceived to be liable in some way.
 Patient condition worsened – Your healthcare organization perceived to be liable in
some way.
 Serious on-site accident.
 Insane/dangerous behavior by anyone at a location controlled by your healthcare
organization.
 Criminal activity at a company site and/or committed by company employees.
 Lawsuits with no advance notice or clue whatsoever.
 Natural disasters.
 Loss of workplace/business interruption (for any reason).
 Fires.
 Perceptions of significant impropriety that damage reputation and/or result in legal
liability.
DISCUSS THE IMMEDIATE INTERVENTION TO HELP RESOLVE THE CRISIS 25%
Crisis intervention is an immediate and short-term psychological care aimed at assisting
individuals in a crisis situation in order to restore equilibrium to their bio-psycho-social
functioning and to minimize the potential of long-term psychological trauma.

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Crisis situations can be in the form of natural disasters, severe physical injury, sudden death of a
loved one, and specific emotional crises as a result of drastic transitions such as divorce, children
leaving home, and pregnancy, family and school violence or may be a sudden unexpected
medical results.  The priority of crisis intervention is counselling to hasten the process of and
achieve stabilization. Crisis interventions must be applied at the spur of the moment and in a
variety of settings, as trauma can arise instantaneously.
Prompt intervention – Since victims are initially at high risk for maladaptive coping or
immobilization. Providing intervention as quickly as possible is imperative.  Stabilization -
Resource mobilization should be immediately enacted in order to provide victims with the tools
they need to return to some sort of order and normalcy, in addition to enable independent
functioning.  Facilitate comprehension – processing the situation or trauma is necessary in
order for the sufferer to understand what the traumatic event was all about. This is done in order
to help the victim gain a better understanding of what has occurred and allowing him or her to
express feelings about the experience.
Problem-solving – The counselor should assist the victim(s) in resolving the issue within the
context of their situation and feelings. This is necessary for developing self-efficacy and
selfreliance.
Return to normalcy – counselor must help the victim get back to being able to function
independently by actively facilitating problem solving, assisting him/her in developing
appropriate strategies for addressing those concerns, and in helping putting those strategies into
action. This is done in hopes of enabling the victim to become self-reliant.
Ways to cope with crisis
Relaxation Training
Relaxation training is a technique that helps with stress management. Relaxation training
decreases the amount of stress endured in a crisis. Types of Relaxation Training consist of but
are not limited to: Deep breathing, Meditation, Music and art therapy.
Grounding Techniques.
Grounding is a practice that can help you deal with distressing feelings and refocus your on
what’s happening in the present moment. Grounding consists of both mental and physical
techniques to soothe stress. Before and after a grounding exercise, rate your distress as a number
between 1 and 10. Making note of how much stress decreased after a grounding exercise can
help you get a better idea of whether a particular technique works for you.
 Physical techniques: uses your five senses or tangible objects to help get through distress. For
Example, take a short walk: focus on your steps, count them. Notice the rhythm of your steps and
how it feels to put your foot on the ground and lift it again.

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 Mental techniques: uses mental distractions to redirect your thoughts away from distressing
feelings and back to reality For Example: Describe your favourite task. Think of an activity you
can do very well. Go through the process step-by-step, as if you’re giving someone else
instructions on how to do

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