Sexual Disorders

Sexual Disorders Nurses’ role in assessing the problems Categories of sexual disorders Causes of the disorders Related issues Issues involved • Legal – consent vs. coercion • Moral – norms, standards, values • Effect – level of functioning, self-esteem, relationships with others • Sexuality – experience of one’s sexual self Categories • Sexual dysfunction disorders – Sexual response cycle. – Emotional, physiological, medications, chemicals • Paraphilias – Pedophilia, exhibitionism, voyeurism, incest, fetishism, frotteurism, sexual masochism, sexual sadism – Lifelong, chr. disorder • Gender identity disorders – transexualism – Depression due to difficulty finding an accepting partner Criteria for gender identity disorderChildren • A strong & persistent cross-gender identification – Stated desire or insistence that he/she is the other sex – In boys, dressing in female attire; in girls, wearing only masculine clothing – Make-believe play or fantasies of being the other sex – Desire to participate in games & pastimes of other sex – Prefers playmates of other sex • Feelings of discomfort with own sex or inappropriateness in gender role of own sex Criteria for gender identity disorderAdolescents & Adults • A strong & persistent cross-gender identification – Stated desire to be the other sex – Frequently passes as the other sex – Desires to be treated as the other sex – Conviction that he/she has typical feelings & reactions of other sex • Feelings of discomfort with own sex or inappropriateness in gender role of own sex Female sexual dysfunction Problem Inhibited desire Orgasmic dysfunction Dyspareunia Vaginismus Phase Arousal Orgasmic Any phase Orgasmic if vaginal penetration Major symptom No lubrication, little interest Inability to have orgasm most of the time Pain Involuntary, painful spasms Male sexual dysfunction Problem Inhibited desire Erective incapacity Premature ejaculation Orgasmic dysfunction Dyspareunia Phase Arousalexcitement Ditto Orgasmic Orgasmic Major Symptom No erection, no interest No or partial erection Ejaculation before he wishes Inability to ejaculate Any phase Pain Biological Causes of Sexual Disorders • General illness – cold, fatigue, influenza, renal and urologic disorders • Severe and persistent dis – DM, MS, • Hormonal disorder – hypopituitary dis. DM. • Alcohol and drug use • Pain – arthritis, back pain, obesity, vaginal infection, • Age – perimenopausal and postmenopausal • Others – radiation therapy Drug-induced sexual dysfunction • • • • • • • • Alcohol – libido, sperm production Tobacco – small peripheral vasculature CNS depressants – benzodiazepine ie Valium Barbiturates – phenobarbital, secobarbital Antipsychotics – Thorazine, Mellaril, Stelazine Antidepressants – Elavil, Tofranil, Norpramin, Anticonvulsant – Dilantin, Others – Lithium, Marijuana, Cocaine, Inderal, Psychological Causes of Sexual Disorders • • • • • Ignorance, lack of knowledge Anxiety, fear of failure, poor body image Partner’s or self’s demand for performance Judgmental thought Poor relationship choices – lack of trust, power struggles • Childhood or adult sexual abuse or trauma • Major life change, lose partner Nursing diagnoses • • • • • • • Altered family process Altered sexuality patterns Anxiety Ineffective coping Knowledge deficit Social isolation Potential for violence: self-directed or other Nursing Care • Nurse-patient Relationship – accepting, empathic, nonjudgmental, • Self-awareness – discuss feelings with colleagues • Communication tech – • Sexuality – comfort level, privacy • Referrals – commonly used • Support groups for perpetrators and victims • Legal obligation – mandatory report of sexual abuse of children Dealing with the sexually inappropriate client • Set limit – firm, clear, consistent • Documentation – – client’s behavior (from the 1st episode throughout the history) – N’s actions taken • Consult with supervisor – getting support • Removing self from any contact with the client • Legal action Tips for Communication Giving rationale for question Giving statements of “generally”“normally” Identifying sexual dysfunction Identifying sexual myths Identifying feelings about masturbation, homosexuality 6. Obtaining and giving information 7. Closing the history – other questions? 1. 2. 3. 4. 5. Conclusions • Sexual dysfunctions r/t psychological, physiological, & pharmacological factors • Paraphilias involve sexual activity with objects, children, and consenting or nonconsenting adults • Efforts to achieve sexual pleasure do not give individuals the right to violate the rights of others through coercion & control • Gender identity disorder in adults involves persistent discomfort with one’s biological sex. • Normalize a range of sexual behaviors in counseling, helping the pt to discuss his feelings about himself & his problems. N ’s primary role is referral; Eating Disorders Criteria for diagnoses Signs & symptoms Etiology Issues in treatment Care plan Significance - Eating disorder • Strikes earlier in adolescence; prevalence is 0.5-2% in US. • The average age dropped from 14.5 years (2001) to 12 years (2003) • Ranked as the nation’s 3rd worst health problem for girls younger than 18, trailing obesity and asthma • High-achieving children from successful, middle-class families -- most vulnerable • Involves dysregulation of multiple neurotranmitters and behavioral, cultural, and familial factors Anorexia Nervosa (Dx) • Refusal to maintain BW at a minimum level • Fear of gaining weight • Overvaluing of shape or weight or denial of seriousness of low weight • Absence of at least 3 consecutive menstrual cycles • Restricting & binge-eating/purging type Anorexia Nervosa Insidious onset on the “perfect little girl” Category: dieter & purgers Socially isolated/withdrawal Competitive & obsessive about their activities • Complications: hypotension, bradycardia, hypothermia, constipation, dry skin,… • Mortality rate : 8-18% • • • • Etiology • • • • • • Biological – G-I problems, serotonin level Sociocultural – thin ideal Family – genetics, enmeshed R, conflict… Cognitive – attention calling, controlling Behavioral - reinforced Psychodynamic – Freud’s basic drive Interesting numbers Average women 5’4’’ 145 lbs 11-14 36-37’’ 29-31’’ 40-42’’ Barbie 6’0’’ 101 lbs 4 39’’ 19’’ 33’’ Height Weight Dress size Bust Waist Hips Store mannequin 6’0’ NA 6 34’’ 23’’ 34’’ Nursing Diagnoses • Altered nutrition: less than body requirements • Decreased cardiac output • Risk for injury (electrolyte imbalance) • Body image disturbance • Anxiety • Low self-esteem Nursing Care • • • • • • • • IPR – enemy vs. ally Close observation Body weight, eating behavior, activity level Self-esteem – listening, strengths, Making contract with the client Health education – weightlifting > running Family involvement, social skill training Others: anxiety, depression … Bulimia Nervosa (dx) • Uncontrolled binge eating • Control shape and weight by extreme dieting, excessive exercising, self-induced vomiting, taking laxatives or diuretics, using diet pills, abuse of enemas • Persistent over concern with body shape and weight Bulimia Nervosa • Adolescent or early adulthood; female • Chronic & intermittent • Anxious, lonely, bored, uncontrollable craving for food • Medical complications • Depression Etiology Biological – hypothalamic dysfunction Sociocultural – Family – enmeshed, noncohesive Cognitive & behavioral – low self-esteem, extreme concerns about body shape and weight, strict dieting, binge eating, compensatory behavior • Psychodynamic • • • • Nursing Diagnoses • Altered nutrition: less than body requirements • Powerlessness • Fluid volume deficit • Ineffective individual coping • Disturbance in body image • Anxiety Nursing Care • • • • • • • N-Pt R – help-seeking vs. manipulation Pt’s feeling about their behaviors Respect vs. embarrassment Reinforce the strengths Health education – sense of control Social skill training vs. loneliness Psychopharmacology - antidepressants Dieting Myths • Myth 1: Skipping meals is a good way to lose weight • Myth 2: fasting is a good way to cleanse the body • Myth 3: Eating after 8pm causes weight gain • Myth 4: Certain foods, like grapefruit or cabbage soup, can burn fat. Dieting Myths (cont’d) • Myth 5: Eating red meat makes it harder to lose weight. • Myth 6: You must avoid all fast food when dieting • Myth 7: Low-fat and no-fat foods are much lower in calories Highlight on caring for the clients with eating disorder • To get people to acknowledge their illness – 5-15% are men; most often at age 14 and then again at age 18 – Helpful flag – a significant weight changes – Constipation, abdominal pain and bloating, cold intolerance, and wither lethargy or excess energy; low blood pressure and pulse rate, sometime with peripheral edema • They need to reach out for help Sleep Disorder Physiology of sleep • Sleep Stages – NREM Sleep – REM Sleep • Sleep-Regulating Processes – Circadian Rhythm • Endogenous vs. exogenous factor – Homeostasis • Balance o f sleep and awake Influences on Sleep • Developmental Changes – – – – – Newborns and Infants Children Adolescents Young and Middle Adults Older Adults – myth • Amount of sleep=F (genetics, preferences, lifestyle, environment) Influences on Sleep (Cont’d) • Medical Disorders and Treatments ie. Asthma, hyperthyroidism, COPD • Drugs and Chemical Substances ie alcohol, lithium, cocaine-> CNS was affected • Circadian rhythm - Jet lag Sleep Disorders • Etiology • Signs and Symptoms/Diagnostic Criteria • Dyssomnias: abnormalities in the amount, quality, or timing of sleep – – – – Narcolepsy breathing-related sleep disorders periodic limb movement disorder insomnia • Parasomnias: abnormal behavioral or physiological events associated with sleep – sleepwalking – tooth grinding Narcolepsy • Def: excessive daytime sleepiness, associated with cataplexy • Etiology: unknown; might r/t genetics • incidence: 0.02-0.16% • Symptoms: begins in adolescence & young adulthood. Every aspect of daily life is affected. Depression is common • Treatment – stimulant ie Ritalin; TCA • Care – scheduled naps Obstructive Sleep Apnea – Hypopnea Syndrome (OSAHS) • Etiology: collapse of the upper airway • Symptoms: hypopnea & apnea, snore loudly, gasp or choke during sleep, lapses in memory, slowed reaction time, falling asleep while working • Prevalence: middle-aged men; women in the menopausal years • Risk factor: obesity & large neck OSAHS • Care: sleep in side-lying or prone position. Weight loss • Implications: May lead to hypertension, heart failure, stroke Periodic Limb Movement Disorder (PLMD) & Restless Leg Syndrome (RLS) • Def & symptoms: legs move repetitively during the night -> frequent nighttime arousal; nonrestorative sleep and excessive daytime sleepiness – Prevalence: 3.9% • RLS – associated with disagreeable leg sensations, ie pain, cramping an itching at bedtime – Prevalence: 5.5% – aging and female • Both PLMD & RLS are associated with musculoskeletal disorder, heart disease, OSAHS, cataplexy, mental health problems, & physical activity near bedtime PLMD & RLS • Treatment • Others – musculoskeletal disorders, heart dis. OSAHS, Sleep Deprivation • Effects on functioning – accident, gastrointestinal, psychiatric, and cardiovascular dis. • Implications for health care workers - Insomnia – Most prevalent sleep disorder • Def: difficulty initiating or maintaining sleep for at least 1 month and it is not part of another sleep disorer • Primary Insomnia – no identified cause • Psychophysiologic Insomnia • Implications: distress in social, occupational, or other areas of functioning Insomnia – Predisposing factors • Genetics, personality, copying style • Normal developmental events ie pregnancy, postpartum period, menopause • Environmental/situational characteristics • Medical disorders, acute illness • Psychiatric disorders, • Drugs/ substances Sleep deprivation • Def: a persistent or recurrent pattern of sleep disruption -> excessive sleepiness or insomnia resulting from a mismatch between the person’s sleep-wake schedule and circadian sleep-wake pattern • Cause significant stress or impairs social or occupational functioning – Decreased alertness & vigilance, slow cognition … – Motor vehicle accidents, major industrial accidents Partial sleep deprivation • Work related (shiftwork) – – 20% of pop works shifts beyond typical working hours – Biologic rhythms disturbed – Alertness, memory, cognition impaired – Leads to G-I, cardiovascular dis. – Risk factor for injury Comorbidities & Dual Diagnoses • 40-45% of insomnia & hypersomnia pt has mentally ill • Mood Disorders – 4x higher • Anxiety Disorders – can’t relax, can’t sleep • Schizophrenia • Substance abuse Interdisciplinary Goals & Treatment • Sleep Hygiene – habit & structure; routine, environment, • Cognitive-Behavioral Treatment – sleep restriction, relaxation, stimulus control • Hypnotic Drugs – benzodiazepines, reduce anxiety and promote sleep • Nonbenzodiazepines ie zolpidem (Ambien), zaleplon (Sonata) less likely to produce tolerance or hangover • • • • Application of the nursing process for the client with sleep disorders Assessment Nursing Diagnosis Planning Implementation – – – – – Treat primary medical or psychiatric illness Education and counseling Referral to a sleep disorders center Structuring the environment to promote sleep Reduce risk for accidents and injury • Evaluation