Thinking, feeling, and behaving act reciprocally on metabolism so that the first indicators of organic illness may be changes in mood, thoughts, and behaviors.1 Based on this mutuality, it becomes increasingly hard to differentiate organic and functional disorders on the basis of symptoms aîone. Symptoms are often nonspecific to the dispersion of the psychiatric and organic illnesses they precede. Although the specific physiologic process is not clear, relationships within cross-sectional data reflect cases of medical illness among those experiencing psychiatric disorders.2 Many common physical illnesses are associated with delirium, dementia, depression, and behavioral disturbances.
The three cases discussed in this article illustrate patients with known psychiatric episodes. These patients were found to have serious organic illness seemingly accountable for the presenting psychiatric state. Assessing organic brain syndrome is inadequate based solely on mental status and clinical presentation.
Within the assessment phase of the nursing process, the nurse gathers data about the client from available sources. This information is then categorized and analyzed using scientific knowledge to explain and to predict client manifestations of actual or potential problems.3 Inherent to a holistic assessment is the patterning of psychological, genetic, developmental, social, and biological interactions occurring between the client and his or her environment. Required in the assessment is an understanding of normal aging patterns and the ability to avoid salient behaviors and thoughts that can influence a clinician's thinking.
National standards of practice, educational preparation, and licensing laws support use of a diagnosis by professional nurses to describe actual or potential health problems. Gordon4 describes categorizing a cluster of signs and symptoms as part of the diagnostic process. First though, a nurse needs to know what is to be assessed in order to gather specific data.
Often, the clusters of client responses to organic and psychiatric illness are hidden by bizarre symptoms, uncommunicativeness, previous psychiatric history, age, physical appearance, and lack of resources. This article's intent is not to prove causality, but to highlight the incidence of similar symptoms coinciding with organic states. These cases present psychotic patients admitted to a county psychiatric facility after emergency room screening in a community general hospital.
Case 1 - This was the second psychiatric hospitalization for S., a 58-yearold housewife who completed the 12th grade. Six months prior to admission S. complained of vertigo, and discontinued her prescribed thiothixene 5 mg twice daily. The patient refused to talk or leave the house. She constantly pulled out her hair. Her husband reported that S., refusing to eat, required spoon feeding. S. presented with no verbal responses. She became angry and combative when refusing to bathe. On mental status examination, S, maintained eye contact and obeyed verbal commands. She responded to questions by nodding her head. Her arms continually flailed with hands in clenched position. S. appeared older than her stated age, and she seemed preoccupied. Affect was blunted; her mood dysphoric. S. 's husband denied that S. experienced auditory or visual hallucinations, suicidal or homicidal ideation. A memory assessment was not possible.
The patient's past psychiatric history revealed treatment by a private psychiatrist for "anxiety and passing out" in 1963. The patient's brother died of liver disease prior to her first illness in 1963 . S. then underwent 12 electric convulsant shock treatments with resultant social withdrawal. In 1978 S. was admitted to a state psychiatric hospital for 30 days with behavior similar to her presenting state, except she experienced auditory hallucinations. Her diagnosis at that time was catatonic schizophrenia. S. smoked three packs of cigarettes per day and drank three cups of coffee. Her mother died in a psychiatric facility and had a history of alcohol dependence.
On admission, an EKG revealed paroxysmal atrial tachycardia with left anterior hemiblock. Urea nitrogen was 24, lactic dehydrogenase (LDH) 318. The patient's later diagnosis included cerebral arteriosclerosis, arteriosclerotic heart disease, and malnutrition. Case 2 - B., a 64-year-old married woman with multiple psychiatric admissions, was discharged from a long-term psychiatric hospital seven months prior to admission. B. 's referral diagnosis was "disorientation, confusion, and an acute psychotic episode." Although she behaved normally three days prior to admission, on admission B. was incoherent; no interpersonal contact could be established. Mood lability and looseness of associations were noted. The patient was found wandering the streets in a confused, agitated, and disoriented state prior to admission. B . appeared to be her stated age. She required seclusion due to her agitated state. Mood was expansive and irritable; affect was labile. Speech was loud with persistent cursing. Although the patient did not answer questions, she seemed to understand the content of what was said to her. No eye contact was established.
During the hospitalization, B. experienced difficulty sleeping. She was often restless, combative, incontinent of urine, and unable to feed herself. A past psychiatric history revealed that at age 32, B. exhibited similar symptoms after the birth of her second child. Later, at 57, she was hospitalized in a community hospital; the details are not known. B. was again hospitalized in 1976, at age 58, for a three-year duration; her diagnosis was chronic undifferentiated schizophrenia with affective features. The symptoms of the patient's previous states were similar to her admitting presentation.
B. 's medical history included cataracts with narrow angle glaucoma and variocosities. B. was previously prescribed propranolol hydrochloride 10 mg twice daily, nitroglycerin 2.5 mg twice daily, haloperidol 5 mg three times a day, benztropine mesylate 1 mg every day, acetazolamide, and pilocarpine hydrochloride eye drops. An admission EKG revealed an acute anterior wall myocardial infarction with an old existing posterior wall infarction. LDH was 252. There were no complaints of chest pain or shortness of breath. B. was transferred to a coronary care unit within a general hospital where she was diagnosed as having ischemie heart disease, arteriosclerotic heart disease, postacute myocardial infarction, and glaucoma.
Case 3 - This was one of 15 psychiatric hospitalizations for this 57-year-old housewife who lived with her husband. Prior to admission, D. and her husband were robbed of vacation funds. Shortly after the robbery, D. became increasingly anxious. By one week prior to admission, she was disoriented to person, experiencing middle-of-thenight awakening and loss of appetite. Not trusting herself to use a matchbook, D. instead used gas jets to light matches. The patient's husband recognized D. was experiencing a "nervous breakdown" by her "classic signs" of aggressiveness, perseveration, an inability to cook or clean, dysphoria, and an uncertainty about the future. D. was unable to state her difficulties. Her husband noted D. became lost after locking herself out of the house.
Prior to admission, D. was stabilized on trifluoperazine hydrochloride 5 mg per day. Her diagnosis on admission was chronic schizophrenia. D. was confused, disoriented to place, incontinent of urine, with a recent memory impairment. She appeared to be her stated age. Her affect was blunted, and her speech was characterized by poverty of content. D. was not easily understood. When asked where she was, D. responded, "I'm standing still shining shoes. I'm all broke and bent. "She was unable to repeat three numbers and seemed perplexed about her identity.
A past psychiatric history included prescriptions of neuroleptic drugs since age 18, along with 14 psychiatric hospitalizations since age 29. Two sisters exhibited psychiatric disorders similar to D. 's. The details are not available.
D. 's medical history revealed D. had a subtotal gastrectomy. Her blood pressure was 220/90, hematocrit 26.6, hemoglobin 9, iron 23, and total ironbinding capacity 464. D. was transferred to a general hospital with a diagnosis of hypochromic and pernicious anemia. She was prescribed 500 milliequivalent B12 weekly, folie acid 1 mg daily by mouth, and ferrous sulfate one tablet twice daily. D. returned to the psychiatric facility presenting with confusion disorientation, but responding to simple, concrete questions.
These cases demonstrate a constellation of behavioral and psychological signs of organicity. Each patient was unable to describe her experiences. Each experienced a deterioration in daily functioning with mood changes and agitation. The patients were unable to maintain a coherent stream of thought; their reasoning, goal-directed behavior, sîeep-wakefulness cycle, and psychomotor activities were impaired. With random, haphazard symptoms and global cognitive impairments, the women met DSM III5 criteria for delirium.
Patients with delirium manifest global cognitive changes correlated to cerebral pathology. A clouding consciousness, attentional and perceptual changes (illusions or hallucinations, especially visual), incoherent speech, disturbances in sleep-wakefulness cycle, psychomotor disturbances, disorientation, and memory impairment are all indicators of delirium. These signs may develop over a short period of time (hours to days) and may fluctuate, becoming worse at night. Prodromal symptoms of anxiety, restlessness, insomnia, agitation, or a hypersensitivity to light and sound may be elicited from a family member. To complete the picture, a client's delirium may precipitate residual symptoms of an organic mental disorder or a psychiatric illness.
Through retrospective inquiries from patients, relatives, and general practitioners, and hospital notes of 35 patients, Lloyd and Cawley6 described 16 of the patients as being psychiatrically ill at the time of infarction. In 19 patients, psychiatric morbidity had been precipitated by a myocardial infarction. The three patients described in this article presented with cardiovascular disease. The first patient also had cerebral arteriosclerosis and malnutrition; the second, a superimposed dehydration; and the third, a history of a subtotal gastrectomy with B,2 and folate deficiencies. Changes in cognition, behavior, and coordination occur slowly in those clients with pernicious anemia.
It is early detection and treatment that lead to reversal of neurological and psychiatric symptoms. Mental changes include suspiciousness, irritability, visual and auditory hallucinations, agitation, mania, incontinence, and seizures. The elderly are not only prone to cerebral pathology, but to delirium caused by diseases and drugs. Analgesics, antiarrhythmic agents, antibiotics, anticonvulsants, antihistamines, antihypertensives, antiinflammatory agents, antineoplastic, and antiparkinsonian drugs, along with sympathomimetics and vitamins, may induce organic mental disorders. Of note, relatives recalled the patients exhibiting similar behaviors during previous psychiatric illnesses. With scanty histories, the organicity was suspected through clinical presentation, laboratory tests, diagnostic procedures, and family input.
Behavioral and mood changes in which organic features play an influencing role have been noted.7'13 Koranyi14 reviewed the literature of the past 40 years in which somatic conditions were related to psychiatric symptoms in 9% to 42% of the cases. It is difficult to assess if preexisting psychiatric illnesses contribute to a presenting picture in which the organic component coexists with psychiatric signs. When Hall15 examined state hospital psychiatric patients prior to admission, he found organically caused or exacerbated psychiatric illness in 45% of these cases. It may be the stress of a major physical illness that exacerbated existing, untreated mental disorders.
Koranyi14 reported a reversibility of mental state once the underlying abnormality was treated, and a similarity between physical illness and presenting psychiatric symptomology. Two patients were described by Arons and Joseph16 with psychiatric states in remission, but each developed symptoms of an acute clinical psychosis identical to their previous psychiatric state. In each case, the patient was found to have significant organic illness, which was largely responsible for the acute psychosis.
An exacerbation of original psychotic symptoms with prescribed fluphenazine enanthate was reported by Van Pulten and Mutalipassi.17 Walker18 documented drug-induced delirium with disorientation, agitation, and hallucinations, which he explained to be a result of the anticholinergic properties of phenothiazines. Walker also described a chronically ill population experiencing an exacerbation or elaboration of preexisting symptoms.
The mimicking syndrome, irrespective of incidence, carries a risk of morbidity. Psychiatric patients with asymptomatic coronary heart disease may be more prone to sudden death due to agitation and intensified arousal.19 Silent myocardial infarctions in psychotic patients have been reviewed.20 It may be that the "silence" of organicity and some myocardial infarctions are actually an inability to separate physical symptoms and their psychological consequences. Before the appearance of psychiatric symptoms, patients often are not aware that the physical illness is producing any symptoms; these patients do not volunteer complaints. A detailed history is required to delineate the onset of a major psychiatric symptom, previous level of functioning, personality changes, and the interactions of medications and medical history.
A nursing assessment includes the client interview, a past psychiatric history, and social, occupational, and family history. Often, the family's perception of previous levels of functioning and psychological Stressors provides valuable information. By describing previous effective treatments, prescribed and over-the-counter medications, hallucinations, delusions, and suicidali ty, the family is able to organize their thinking. With this ability to organize, the family gains some control of the anxiety associated with hospitalization. The family may even identify similarities and differences in the client's behavior from previous organic or psychiatric illness.
The mental status exam is included in the initial assessment and performed at intervals to document behavioral, cognitive, and emotional changes in the client. As a systematic behavioral tool, the mental status exam focuses on important cognitive and emotional functions commonly disturbed in clients with organic brain disease and psychiatric illness.
It includes level of consciousness, appearance, behavior, speech, emotional state, content of thought, examination of cognitive functions, insight, and judgment. Each exam is performed to meet needs of a particular client and situation. The clinician needs to spend only a brief time with a client who is uncomfortable, delusional, or hallucinating to record verbatim responses. Neuroleptics, reality orientation, and safety interventions become essential. Any specific impairment (eg, memory, attention span, aphasia) may require further neuropsychiatrie testing.
Nursing Assessment Guidelines
The following assessment considerations lead to nursing actions affecting a client's care and well-being. They may spur further exploration of organic or psychiatric illness based on a client's responses.
* Note the conditions at the time of interview that may influence results. A client's experience with drugs, alcohol, sleep disturbances, and acuteness of present illness requires documentation.
* Consider client's formal education, mental retardation, level of intelligence, or cultural deprivation.
* While assessing the content of thought, the nurse should be alert to the meaning the client attaches to content.
* Family members' input is needed to screen out metabolic-infectious states , hereditary-degenerative diseases, encephalopathies, malignancies, and chemical excesses.
* The family or staff may be so influenced by the client's mood and behavior that significant information is overlooked.
* Deficits in physical endurance, orientation, or memory attention and lethargy with fluctuating levels of consciousness, along with confabulation all require a more complete assessment. Lethargy requires immediate intervention.
* There is a difference between a complaint of a memory disturbance and an actual memory deficit.
* Suicidality may be expressed in risktaking behavior, such as eating inadequately or neglecting to take prescribed medication. Vague expressions of hopelessness or death wish must be explored with the client to determine serious intention or plan.
* Clients at risk for suicidal behavior are those who live alone, have a chronic debilitating illness, a history of drug or alcohol abuse, and suicide attempts.
* Potentially reversible dementias resemble irreversible dementias.
* Organic brain syndrome may be superimposed on existing schizophrenia or affective and personality disorders.
* Illness may aggravate an underlying dementia.
In the three clinical cases, data were collected throughout the clients' hospitalization. As a client's behavior is clustered to arrive at possible explanation of the behavior, the nurse becomes accountable in the application of theory to practice. Utilizing systematic observations of phenomena at hand, the nurse is initially free to explore and describe what he or she sees.
Holistic assessments are essential to distinguish a client's response to potentially reversible dementias from response to irreversible dementias. Illness may aggravate underlying dementias or, as I believe occurred in these clients, may mimic a past psychiatric illness.
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