Lecture 4 Schiz

8/8/2019 Lecture 4 Schiz

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Nursing 292

Psychiatric Nursing

Schizophrenia and otherPsychotic Disorders



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Objectives

• Discuss neurobiological processes inschizophrenia

• Identify positive and negative symptoms ofschizophrenia

• Discuss the clinical course and complicationsof schizophrenia

• Develop a nursing care plan for managementof clients with hallucinations, delusions, andcommunication problems



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Objectives

• Understand Pharmacotherapy for Psychosis

– Target symptoms of antipsychotics

– Typical & atypical antipsychotics – Side-effects & nursing implications

– Antidyskinetic medications

• Discuss AIMS

• Nursing interventions for clients & familieswith chronic mental illness



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Schizophrenia

• Psychotic symptoms for at least 6months not related to medical condition

or substance use• Impaired social, academic and

occupational functioning

• Can be single episode, episodic,continuous, in full or partial remission.



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Schizophrenia

• Paranoid type – suspicious, may be argumentative,auditory hallucinations are common

• Disorganized type (hebephrenic) – giggling, bizarrebehavior, impaired socialization and affect

• Catatonic type – extreme psychomotor retardation(stupor) or purposeless movements (excitement)

• Undifferentiated – bizarre behavior, hallucinations,delusions

• Residual type – psychotic symptoms, history ofschizophrenia



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• 0.5-1% prevalence

• Onset most common during late adolescence

• Third most disabling disease along with cardiacproblems and cancer, 10 years loss to normal lifespan

• 30% schizophrenics attempt suicide at least 1 X, 10%die due to suicide

• High costs due to direct care and lost productivity

• Lengthy and frequent hospitalizations

• Family chaos



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Schizophrenia

• The word schizophrenia is derived

from the Greek words skhizo (split)

and phren (mind) - to describe the“split mindedness” or separationamong affect, cognition and

emotions



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Nature of the Disorder

• Schizophrenia disturbs

–Thought processes (delusions)

–Perception (hallucinations)

–Affect (impaired socialization)

–Speech & Behavior (disorganized, bizarre)



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Nature of the Disorder (cont.)

• Premorbid behavior of the client with

schizophrenia can be viewed in fourphases.



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First Phase

Schizoid personality

• Indifferent, cold, and aloof, these people

are loners. They do not enjoy closerelationships with others.



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Second Phase

Prodromal phase

• These people are socially withdrawn and

show evidence of peculiar or eccentricbehavior

• Neglect of personal hygiene and grooming

• Blunted or inappropriate affect• Disturbances in communication

• Bizarre ideas

• Lack of initiative



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Third Phase

Schizophrenia

• In the active phase of the disorder,

psychotic symptoms are prominent –Delusions

–Hallucinations

–Disorganized speech and behavior –Impairment in work, social

relations, and self-care



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Fourth Phase

Residual phase –Symptoms similar to those of the

prodromal phase

–Flat affect and impairment in role

functioning are prominent



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Positive and Negative

Symptoms

• Hallucinations

• Delusions• Thought disorders

• Disorganizedspeech andbehaviors

• Affective flattening

• Anhedonia• Avolition

• Attentional problems

• Alogia



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Nursing Assessment

• ABCs of Mental Status

– Appearance & Affect

– Behavior

– Cognitive Functioning

– Speech



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Thought Content

• Delusions

– False personal beliefs

– Inconsistent with reality

– Not generally accepted by others withsame cultural background

– Content relates to underlying anxiety orfear



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Thought Content (cont.)

Types of Delusions (False Beliefs) – Delusions of Persecution (threatened) – Delusions of Grandeur (special powers)

– Delusions of Reference (insignificant remarkshave personal meaning – newspaper headlines)

– Delusions of Control (another person controlsthoughts, behavior – thought broadcasting,thought insertion)

– Somatic Delusions (about bodily function – disease, pregnancy)

– Nihilistic Delusions (nonexistence of self, worldending)



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Thought Content (cont.)

Other types of thought disturbance

– Religious Preoccupation (use religious

ideas to explain behavior)

– Paranoia (suspicious; food poisoned)

– Magical Thinking (thoughts or behavior cancause or prevent something happening)



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Thought Content (cont.):

Perceptions• Hallucinations - False sensory perceptions

– Auditory (most common in schizophrenia) – Visual – Tactile – Olfactory – Gustatory

– Kinetic• Illusions – misperceptions of real externalstimuli



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Disorganized Thoughts

• Change topics - Looseness of association

• Nonsensical speech -Neologisms – new

words• Concrete thinking – literal interpretations of

environment

• Clang associations – often rhyming

• Word salad – random words without meaning

• Repeat another’s words – Echolalia



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Disorganized Thoughts

• Circumstantiality – overly detailed

• Tangentiality – unrelated topics; doesn’t

get to the point

• Mutism – inability or refusal to speak

• Perseveration – repeats same idea over

and over



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Disorganized Behavior

• Repeat actions of others – Epraxia

• Catatonia – decreased reactivity to

surroundings – Catatonic stupor (immobility, posturing,

waxy flexibility, mutism)

– Excitement (unprovoked, excessive motoractivity)



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Complications

• Risk of Suicide

• Risk of Chronic Fluid Imbalance – polydipsia, water intoxication, seizures,hyponatremia, (heavy smokingincreases risk)

• Medication side-effects



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Case Study

35 year old man admitted to inpatientpsychiatric unit from ER. Appearsrestless and disheveled. History of pasthospitalization for schizophrenia.

Patient reports frightening voices tellinghim he is no good and would be betteroff dead. Verbally threatened staff inER. Has history of suicide attempts inthe past. Mother reports increasedisolation since he stopped medications.



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Nursing Diagnoses

• Risk for self and other directed violence

• Bathing/hygiene self-care deficit

• Ineffective therapeutic regimenmanagement

• Social isolation

• Disturbed sensory perception: auditoryhallucinations



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Other Nursing Diagnoses

• Disturbed thought processes

• Impaired verbal communication

• Disabled family coping

• Ineffective health maintenance



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Outcomes

• Will not harm self or others

• Will shower and wash clothes

• Will be compliant with medications

• Will exhibit less agitated behavior

• Will decrease hallucinations



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Nursing Interventions• Establish trusting relationship

• Monitor symptoms & intervene early

• Facilitate adherence to medications

• Distract client from hallucinations

• Provide safe, structured environmentand reduce stimuli in environment

• Connect symptom improvement tomedication effect



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Nursing Interventions

• Risk for violence: – Protect client from harming self or others

– Decrease stimuli

– Remove dangerous objects – Provide physical outlets

– Medications

– Observation – Assess for suicidal ideation



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• Disturbed thought processes (delusions): – Reassure in safe place (Delusions are based on anxiety &

fear) – Help identify underlying fear (may reduce delusions)

– Acceptance but do not share belief – Do not challenge delusional thinking (they are not rational) – Use “reasonable doubt” – Talk about real events and people; don’t dwell long time on

irrational thoughts

– Provide reality based activities to help client understandwhat is real and what is not – If suspicious, avoid touch, laughing or talking where client

can see but not hear (reduce sense of being threatened) – If suspicious, use same staff as much as possible



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• Disturbed sensory perception (Hallucinations): – Observe for signs client is hallucinating

– Early interventions can prevent aggression

– Evaluate content of hallucinations (commands) – Do not touch without warning; allow space

– Accepting, non-judgmental attitude

– Do not reinforce hallucination, say “voices”

– Reassure voices may be frightening, but not real

– Help client learn relationship between anxiety and thehallucination; explore what precipitates hallucination

– Provide reality based activities to help distract fromhallucinations and reduce anxiety



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• Impaired verbal communication: – Seek validation & clarification (“Do you mean...?”) – Give feedback (“I do not understand what you

mean.”) Helps client see he is not understood and engages client in improving communication – Consistent staff assignments to promote trust – Convey empathy: “Verbalize the implied”; “That

must have been upsetting.”

– Anticipate and meet client’s needs for safety andcomfort until able to communicate effectively

– Orient to reality; call by name



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• Social Isolation

– Acceptance

– Brief, frequent contacts

– Slow introduction to group activities

– Initially accompany to groups to help client

feel more secure – Give recognition for interactions with others



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Evaluation

• Absence of threats to safety of self andothers

• Takes medications as prescribed

• Interacts appropriately with others

• Participates in unit activities and groups

• Begins to modify responses tohallucinations



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Client and Family Education

• Nature of illness – what to expect; howto manage symptoms

• Role of stress and coping skills

• Medication: dose, side-effects, not stop

• Contact info for health care provider

• Social skills training

• Support services



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Treatment Modalities: Social

• Milieu therapy – group and socialinteraction, rules, expectations, relationships,structure

• Family therapy – education, support, andconflict resolution

• Assertive Community Treatment (ACT) – comprehensive community based treatment;case management model; team approach:SA treatment, education, mobile crisis,rehabilitation, work training



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Etiology

• No single etiological factor

• Genetic link & familial pattern

• Combination genetic & environmental

• Environmental (viruses, stress)• Neurodevelopmental disorders – early delays

in motor, cognitive, social functioning

• Neurostructural / neurodegenerative factors – enlarged ventricles, decreased gray matter;decreased frontal lobe volume



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Etiology (cont.)

• BiochemicalFactors

•excess dopamine inlimbic system(Dopamine

Hypothesis)•Mechanism for positivesymptoms



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Etiology (cont.)

• Biochemical Factors (cont.)

– Abnormalities in other

neurotransmitters

•Norepinephrine

•Serotonin

•Acetylcholine

•Gamma-aminobutyric acid



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Other Influences (Etiology cont.)

• Psychological Factors – deficient egodevelopment, anxiety, ineffective

coping, regression• Environmental Factors

– Poverty/poor social conditions

–Stress – Families with high expressed emotion

(EE)



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Etiology (cont.)

• Conclusion: Theoretical Integration

–Schizophrenia is most likely a

biologically based disease, the onsetof which is influenced by factors in theinternal or external environment.



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Other Psychotic Disorders

• Schizophreniform disorder – symptoms< 6 mos; may not have significant

impaired functioning

• Schizoaffective disorder – symptoms of

schizophrenia and also majordepressive or bipolar symptoms



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Other Psychotic Disorders (cont.)

• Brief psychotic disorder – sudden onset following astressor; symptoms >1 day and <1 month; returns to pre-morbidfunctioning

• Shared psychotic disorder - client with close, dependentrelationship with someone with psychotic disorder (folie á deux)

• Psychotic disorder due to medical condition (see text)

• Substance-induced psychotic disorder



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Other Psychotic Disorders (cont.)

• Delusional disorder - The existence ofprominent, non-bizarre delusions

– Erotomanic type – Grandiose type

– Jealous type

– Somatic type – Persecutory type



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Basic facts about psychotropic

medications

• They work by altering or balancing brain

chemistry – affect neurotransmitters andneurotransmitter receptor sites

• They do not cure mental illness, but

work by getting and keeping symptomsin control.



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The nurse’s role in

psychopharmacology• Assessment, including personal and family

responsiveness to medications, and attitude

towards medications• Educating patients and family members

• Medication administration

• Monitoring of desired and side effects

• Connect positive effects to medication



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Antipsychotic Medications

Typical

Chlorpromazine (Thorazine)

Thioridazine (Mellaril)

Fluphenazine (Prolixin)

Perphenazine (Trilafon)Trifluoperzine (Stelazine)

Thiothixene (Navane)

Haloperidol (Haldol)

Atypical

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Ziprasidone (Geodon)

Clozapine (Clozaril)

Aripiprazole (Abilify)

Depot—Long acting preparations

Fluphenazine decanoate (Prolixin)

Haloperidol decanoate (Haldol)

Risperidone microspheres (Risperdal Consta)



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Drug Action

• Typical antipsychotics primary action isto block dopamine receptors (D2)

• Atypical antipsychotics block severalneurotransmitters: primarily serotonin(serotonin receptor, 5HT2-3) anddopamine (D1, D3, D2)

• Dopamine system stabilizer (Abilify)acts as dopamine agonist or antagonistin different areas of brain



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Target symptoms controlled by

antipsychotics• Agitation

• Apathy*

• Delusions

• Emotional withdrawal*

• Feelings of unreality• Hallucinations

• Ideas of reference

• Lack of motivation*

• Lack of pleasure*

• Lack of spontaneity*• Overreactive senses

• Paranoia

• Racing thoughts

• Rage

• Severe impulsiveness• Social discomfort or

isolation*

• Terror

• Unclear thoughts

• Uncontrollable hostility• Uncontrollable negativism

* Negative symptoms



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Common Side Effects

• EPS• Orthostatic Hypotension• Sedation• Weight Gain

• TemperatureDysregulation• Neuroleptic Malignant

Syndrome• Photosensitivity

• Seizures (Typicals,Clozaril)

• Hypergylcemia(Atypicals)• Hypercholesterolimia• Hypertriglycerides• Diabetes mellitus

• Agranulocytosis(Clozaril)

• Myocarditis (withClozaril)

• Prolonged QT (Invega,Geodon)

• Increased salivation(Abilify, Clozaril)



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Anticholinergic side effects

• Constipation

• Blurred vision

• Urinary retention or hesitancy

• Nasal congestion

• Dry mouth

Clozaril has strong potential for anticholinergic side

effects Water, sugar-free candy, alcohol-free, moisturizing

mouth wash, fiber, increased fluids



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Abnormal Glucose Metabolism

• Associated with atypical antipsychotics

• Before treatment assess for risk of

diabetes• Monitor FBS & lipid levels regularly

Associated with clozapine and olanzepine



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Blood Dyscrasias

• Agranulocytosis can occur in clients onclozapine (Clozaril)

– Baseline WBC & absolute neutrophil count(ANC) and weekly X 6 months

– Continued monitoring every 2 weeks

– Monitor monthly after 1 year

– Observe for signs of infection (fever, sorethroat)

– Stop medication immediately



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Other side-effects of antipsychotics

• Sexual side effects: delay in orgasm, reducedsex drive, amenorrhea

• Orthostatic hypotension: monitor BP seated

and standing; fliuds, falls risk, changeposition slowly (clozaril, thorazine, mellaril)• Photosensitivity• Hypersalivation – drooling (Clozaril)

• QT prolongation (Mellaril, Geodon, Invega)• Weight gain• Sedation



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Extrapyramidal (Muscular) Side

Effects• Dystonic Reaction – involuntary muscle

reactions mostly involving neck and face;sudden onset often in initial days of treatment

– Torticolis

– Oculogyric crisis (eyes roll up, lateral gaze)

– Tongue protrudes

– Involuntary smileTreat with IV Valium, Banadryl; 100%

curable

Extrapyramidal (Muscular)



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Extrapyramidal (Muscular)Side Effects (cont.)

• Akasthisia—motor restlessness (legs),can’t stop moving, anxious, very

uncomfortable. Untreated can lead tosuicide.

Treat with anticholinergic med, valium,

propanolol. Preventable and reversible.

Extrapyramidal (Muscular)



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Extrapyramidal (Muscular)Side Effects (cont.)

• Parkinsonism—drug induced, mimics Parkinson’s.Develops gradually often early in treatment (days tomonths). Client often not bothered or aware. – Akinesia: weakness, fatigue, lack of movement, slow

movements, facial masking, decreased blinking, drooling(decreased swallowing)

– shuffling gait – tremors – Rigidity, cogwheeling – Stooped posture

Treat by decreasing or changing antipsychotic med; low dose,short-term anticholinergic (careful in elderly)

E t id l (M l ) Sid



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Extrapyramidal (Muscular) SideEffects (cont.)

• Tardive Dyskinesia: late onset, often irreversible

– Random, involuntary movements of arms, legs

– Dystonia – neck twisting

– Finger rubbing or jerking

– Twitching or over-activity of the tongue

– Exaggerated blinking

– Puckering or chewing movements of the mouth – Tic-like movements of the face



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Antidyskinetic Medications—used to treatmuscular side effects of antipsychotics

• Benztropine (Cogentin)

• Biperiden (Akineton)

• Orphenadrine (Norflex)

• Diphenhydramine (Benadryl)

• Procyclidine (Kemadrin)

• Trihexyphenidyl (Artane)

• Amantadine (Symmetrel)



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AIMS

• Abnormal involuntary movement scale



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Neuroleptic Malignant

Syndrome• Elevated CPK

• Elevated Temperature

• Autonomic instability—Hypertension

• Tachycardia

• Diaphoresis

• Muscle rigidity— “Lead Pipe Rigidity”

• Stop medication and Treat Symptoms• Deteriorating mental status

Can be fatal. Stop antipsychotic med immediately.



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Chronic Illness

• Chronic illness, mental and physical,includes all diseases or disorders that

remain with the individual for the rest ofthe client’s lifetime once the conditionhas been diagnosed.



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Chronic Mental Illness

• All psychiatric disorders have the

potential to persist and become chronicwith the following having the mostpotential to do so:

– Schizophrenia – Major depressive disorder

– Bipolar disorder



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Management & Treatment

• The nursing plan needs to be individualized, realistic,integrated with other members of the psychiatricteam

• Actively involve family members and the client inplanning

• Provide counseling for grief and loss for the familyand the individual

• Individual, group, and family psychotherapy canbenefit the client and significant others



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Management & Treatment

• Stress management

• Empowerment

• Crisis intervention

• Psychiatric rehabilitation• Psychoeducation

• Basic cognitive and academic skills training

• Social skills training

• Vocational training• Interpersonal skills building

• Behavior modification

• Medication management.



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Psychiatric Rehabilitation

• Relearning skills and competencies neededfor successful interpersonal, social, andvocational functioning

– Psychoeducation – Medication management

– Academic skills

– Social skills

– Stress Management – Behavior modification

– Vocational training



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Psychoeducation• Psychoeducation involves teaching clients,

their families and significant others about: – the disease or condition (i.e. the specific chronic

mental illness)

– types of psychotherapy – medication management

– complementary therapies

– compliance with different treatment modalities

– rehabilitation – signs of relapse

– community resources

– coping skills



Recovery Model

• Consumers have primary control overdecisions about their own care

• Based on concepts of strength &empowerment

• Control and choice in treatment leads to

increased control & initiative in theirlives

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Lecture 4 Schiz