MENTAL HEALTH: CHAPTER 16: SCHIZOPHRENIA:

6 Long Lasting Injections:

(Formerly called depot injections) - Last 2-4 weeks

Shared Psychotic Disorder (OUTLINE):

- 2 people share a delusion - Usually submissive one can have rapid recovery when moved away from the dom.

Negative (Soft) Symptoms Of Schizophrenia: Flat Affect:

- Absence of any facial expression that would indicate emotions or mood

Negative Symptoms Are:

- Being more introverted and socially withdrawing from others

Nihilistic Delusions:

- Beliefs that organs aren't working/rotting away or that some part of body is horribly disfigured

Cultural Differences: Jikoshu-Kyofu:

- Fear of offending with your body odor - Japan

Echopraxia:

- Imitating someone

Schizophrenia: Cultural Considerations: Culture-Bound Syndrome: Jkoshu-Kyofu:

- Is a condition characterized by a fear of offending others by emitting foul body odor. - This was first described in Japan in the 1960s and has two subtypes, either with or without delusions

Relating To Others:

- It's difficult for someone who does not have a clear self-concept

Side Effects of Antipsychotic Medications and Nursing Interventions: Neuroleptic Malignant Syndrome (NMS):

- Side Effects of Antipsychotic Medications

Some Reasons Clients Don't Take Their Medications:

- Side effects - Difficulty remembering - Difficulty adhering to a routine - Financial barrier - Lack of knowledge/transportation for refill - Believing he does not need to take them

Negative (Soft) Symptoms Of Schizophrenia: Alogia:

- Tendency to speak little or to convey little substance of meaning (poverty of content)

Schizophrenia: Treatment: Psychopharmacology: Second Generation Antipsychotics:

- The atypical, or second-generation, antipsychotic medications are both dopamine and serotonin antagonists - . The second-generation antipsychotics not only diminish positive symptoms but also lessen the negative signs of lack of volition and motivation, social withdrawal, and anhedonia for many clients.

Schizophrenia: Assessment: Sensorium & Intellectual Processes: Auditory Hallucination:

- The most common type, involve hearing sounds, most often voices, talking to or about the client. - There may be one or multiple voices; a familiar or unfamiliar person's voice may be speaking

Schizophrenia Affects:

- Thoughts, perceptions and behavior - Diagnostic purposes most have symptoms for at least 6 months

Related Disorders: Shared Psychotic Disorder (folie a deux):

- Two people share a similar delusion. - The person with this diagnosis develops this delusion in the context of a close relationship with someone who has psychotic delusions, most commonly siblings, parent and child, or husband and wife. - The more submissive or suggestible person may rapidly improve if separated from the dominant person.

Side Effects of Antipsychotic Medications and Nursing Interventions: Anticholinergic Side Effects: Dry Mouth:

- Use ice chips or hard candy for relief.

Client Experiencing Delusion:

- Utterly believes them to be true and can NOT be convinced they are false

Somatic Delusions:

- VAGUE and unrealistic beliefs about client's health

Neuroleptics =

Antipsychotic Medications

Is the following statement true or false? Positive symptoms of schizophrenia include a flat affect and social withdrawal.

False - Rationale: Flat affect and social withdrawal are negative symptoms of schizophrenia.

5. When the client describes fear of leaving his apartment as well as the desire to get out and meet others, it is called a.ambivalence. b.anhedonia. c.alogia. d.avoidance.

a.ambivalence.

Schizophrenia: Psychopharmacology: Maintenance Therapy:

- 6 antipsychotics are available as long-acting injections (LAIs), formerly called depot injections, for maintenance therapy. They are the following: 1. Fluphenazine (Prolixin) in decanoate and enanthate preparations 2. Haloperidol (Haldol) in decanoate 3. Risperidone (Risperdal Consta) 4. Paliperidone (Invega Sustenna) 5. Olanzapine (Zyprexa Relprevv) 6. Aripiprazole (Abilify Maintena) - The vehicle for the first two conventional antipsychotic injections is sesame oil; therefore, the medications are absorbed slowly over time into the client's system. - The effects of the medications last 2 to 4 weeks, eliminating the need for daily oral antipsychotic medication - The duration of action is 7 to 28 days for fluphenazine and 4 weeks for haloperidol. - The other four second-generation antipsychotics are contained in polymer-based microspheres that degrade slowly in the body. - It may take several weeks of oral therapy with these medications to reach a stable dosing level before the transition to depot injections can be made. - Therefore, these preparations are not suitable for the management of acute episodes of psychosis. - They are, however, useful for clients requiring supervised medication compliance over an extended period. - In addition, some studies have shown that the second-generation LAIs are more effective than oral forms of the medication in controlling negative symptoms and improving psychosocial functioning - Yet, clinicians may be reluctant to prescribe the LAIs because they assume patients are reluctant to have injections.

Schizophrenia: Psychosocial Treatment: Cognitive Enhancement Therapy (CET):

- A newer therapy, cognitive enhancement therapy (CET), combines computer-based cognitive training with group sessions that allow clients to practice and develop social skills. - This approach is designed to remediate or improve the clients' social and neurocognitive deficits, such as attention, memory, and information processing. - The experiential exercises help the client take the perspective of another person, rather than focus entirely on him or herself. - Positive results of CET include increased mental stamina, active rather than passive information processing, and spontaneous and appropriate negotiation of unrehearsed social challenges. - CET has also been effective in decreasing substance misuse in people with schizophrenia

Negative (Soft) Symptoms Of Schizophrenia:Avolition Or Lack Of Avolition:

- Absence of will, ambition, or drive to take action or accomplish tasks

Schizophreniform:

- Acute psychosis that lasts less than 6 months - Anything over and the diagnosis is changed to schizophrenia

Side Effects of Antipsychotic Medications and Nursing Interventions: Akathisia:

- Administer medications as ordered; assess for effectiveness.

Side Effects of Antipsychotic Medications and Nursing Interventions: EPS or Neuroleptic-Induced Parkinsonism:

- Administer medications as ordered; assess for effectiveness.

Side Effects of Antipsychotic Medications and Nursing Interventions: Dystonic Reaction:

- Administer medications as ordered; assess for effectiveness; reassure client if he or she is frightened.

Schizophrenia: Cultural Considerations: Culture-Bound Syndrome: Zar:

- An experience of spirits possessing a person, is seen in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies. - The afflicted person may laugh, shout, wail, bang his or her head on a wall, or be apathetic and withdrawn, refusing to eat or carry out daily tasks. - Locally, such behavior is not considered pathologic.

Schizophrenia: Assessment: General Appearance & Motor Behavior & Speech:

- Appearance may vary widely among different clients with schizophrenia. - Some appear normal in terms of being dressed appropriately, sitting in a chair conversing with the nurse, and exhibiting no strange or unusual postures or gestures. - Others exhibit odd or bizarre behavior. - They may appear disheveled and unkempt with no obvious concern for their hygiene, or they may wear strange or inappropriate clothing (for instance, a heavy wool coat and stocking cap in hot weather). - Overall, motor behavior may also appear odd. - The client may be restless and unable to sit still, exhibit agitation and pacing, or appear unmoving (catatonia). - He or she may also demonstrate seemingly purposeless gestures (stereotypic behavior) and odd facial expressions, such as grimacing. - The client may imitate the movements and gestures of someone whom he or she is observing (echopraxia). - Rambling speech that may or may not make sense to the listener is likely to accompany these behaviors. - Conversely, the client may exhibit psychomotor retardation (a general slowing of all movements). - Sometimes the client may be almost immobile, curled into a ball (fetal position). - Clients with the catatonic type of schizophrenia can exhibit waxy flexibility; they maintain any position in which they are placed, even if the position is awkward or uncomfortable. - The client may exhibit an unusual speech pattern. - Two typical patterns are word salad (jumbled words and phrases that are disconnected or incoherent and make no sense to the listener) and echolalia (repetition or imitation of what someone else says). - Speech may be slowed or accelerated in rate and volume; the client may speak in whispers or hushed tones or may talk loudly or yell. - Latency of response refers to hesitation before the client responds to questions. - This latency or hesitation may last 30 or 45 seconds and usually indicates the client's difficulty with cognition or thought processes.

Types Of Delusions: Grandiose Delusions:

- Are characterized by the client's claim to association with famous people or celebrities, or the client's belief that he or she is famous or capable of great feats. - Examples: The client may claim to be engaged to a famous movie star or related to some public figure, such as claiming to be the daughter of the president of the United States, or he or she may claim to have found a cure for cancer.

Types Of Delusions: Somatic Delusions:

- Are generally vague and unrealistic beliefs about the client's health or bodily functions. - Factual information or diagnostic testing does not change these beliefs. - Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in the brain.

Unusual Speech Patterns of Clients with Schizophrenia: Clang Associations:

- Are ideas that are related to one another based on sound or rhyming rather than meaning. - Example: "I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill."

Types Of Delusions: Nihilistic Delusions:

- Are the client's belief that his or her organs aren't functioning or are rotting away, or that some body part or feature is horribly disfigured or misshapen.

Schizophrenia: Assessment: Sensorium & Intellectual Processes: Command Hallucinations:

- Are voices demanding that the client take action, often to harm the self or others, and are considered dangerous.

Unusual Speech Patterns of Clients with Schizophrenia: Neologisms:

- Are words invented by the client. - Example: "I'm afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?"

Schizophrenia: Community-Based Care: Assertive Community Treatment Programs:

- Assertive community treatment programs have shown success in reducing the rate of hospital admissions by managing symptoms and medications; assisting clients with social, recreational, and vocational needs; and providing support to clients and their families. - The psychiatric nurse is a member of the multidisciplinary team that works with clients in assertive community treatment programs, focusing on the management of medications and their side effects and the promotion of health and wellness.

Establish Baseline Data:

- Assess for previous hx with schizophrenia to establish baseline data, previous suicide attempts, history of violence/aggression, clients perception of current situation

Side Effects of Antipsychotic Medications and Nursing Interventions: Anticholinergic Side Effects: Blurred Vision:

- Assess side effect, which should improve with time; report to physician if no improvement.

Side Effects of Antipsychotic Medications and Nursing Interventions: Tardive Dyskinesia:

- Assess using tool such as AIMS; report occurrence or score increase to physician.

Schizophrenia: Cultural Considerations:

- Awareness of cultural differences is important when assessing for symptoms of schizophrenia. - Ideas that are considered delusional in one culture, such as beliefs in sorcery or witchcraft, may be commonly accepted by other cultures -. Also, auditory or visual hallucinations, such as seeing the Virgin Mary or hearing God's voice, may be a normal part of religious experiences in some cultures. - The assessment of affect requires sensitivity to differences in eye contact, body language, and acceptable emotional expression; these vary across cultures.

Schizophrenia: Intervention: Teaching The Client & Family Education: Teaching Self-Care & Proper Nutrition:

- Because of apathy or lack of energy over the course of the illness, poor personal hygiene can be a problem for clients who are experiencing psychotic symptoms as well as for all clients with schizophrenia. - When the client is psychotic, he or she may pay little attention to hygiene or may be unable to sustain the attention or concentration required to complete grooming tasks. - The nurse may need to direct the client through the necessary steps for bathing, shampooing, dressing, and so forth. - The nurse gives directions in short, clear statements to enhance the client's ability to complete the tasks. - The nurse allows ample time for grooming and performing hygiene and does not attempt to rush or hurry the client. - In this way, the nurse encourages the client to become more independent as soon as possible—that is, when he or she is better oriented to reality and better able to sustain the concentration and attention needed for these tasks. - If the client has deficits in hygiene and grooming resulting from apathy or lack of energy for tasks, the nurse may vary the approach used to promote the client's independence in these areas. - The client is most likely to perform tasks of hygiene and grooming if they become a part of his or her daily routine. - The client who has an established structure that incorporates his or her preferences has a greater chance for success than the client who waits to decide about hygiene tasks or performs them randomly. - For example, the client may prefer to shower and shampoo on Monday, Wednesday, and Friday upon getting up in the morning. - This nurse can assist the client to incorporate this plan into the client's daily routine, which leads to it becoming a habit. - The client thus avoids making daily decisions about whether or not to shower or whether he or she feels like showering on a particular day. - Adequate nutrition and fluids are essential to the client's physical and emotional well-being. - Careful assessment of the client's eating patterns and preferences allows the nurse to determine whether the client needs assistance in these areas. - As with any type of self-care deficit, the nurse provides assistance as long as needed and then gradually promotes the client's independence as soon as the client is capable. - When the client is in the community, factors other than the client's illness may contribute to inadequate nutritional intake. - Examples include lack of money to buy food, lack of knowledge about a nutritious diet, inadequate transportation, or limited abilities to prepare food. - A thorough assessment of the client's functional abilities for community living helps the nurse plan appropriate interventions.

Schizophrenia: Community-Based Care: Behavioral Home Health Care:

- Behavioral home health care is also expanding, with nurses providing care to persons with schizophrenia (as well as other mental illnesses) using the holistic approach to integrate clients into the community. - Although much has been done to give these clients the support they need to live in the community, there is still a need to increase services to homeless persons and those in prison with schizophrenia.

Schizophrenia In The Brain:

- Brain scans show decrease volume and abnormal function of the temporal and frontal areas of the brain - Temporal: •Positive symptoms •Negative symptoms Frontal • Affect, difficulty with problem solving, and impoverished thinking •Lack of motivation and anhedonia

Extrapyramidal Side Effects:

- Can be treated with diphenhydramine and cogentin (side effect of constipation)

Cenesthetic Delusions:

- Can feel a body function that is usually undetectable (like formation of urine)

Related Disorder: Catatonia:

- Catatonia is characterized by marked psychomotor disturbance, either excessive motor activity or virtual immobility and motionlessness. - Motor immobility may include catalepsy (waxy flexibility) or stupor. - Excessive motor activity is apparently purposeless and not influenced by external stimuli. - Other behaviors include extreme negativism, mutism, peculiar movements, echolalia, or echopraxia. - Catatonia can occur with schizophrenia, mood disorders, or other psychotic disorders.

Side Effects of Antipsychotic Medications and Nursing Interventions: Sedation:

- Caution about activities requiring client to be fully alert, such as driving a car.

Side Effects of Antipsychotic Medications and Nursing Interventions: Photosensitivity:

- Caution client to avoid sun exposure; advise client when in the sun to wear protective clothing and sunscreen.

Antipsychotic Drugs: First Generation:

- Chlorpromazine (Thorazine) - Perphenazine (Trilafon) - Fluphenazine (Prolixin) - Thioridazine (Mellaril) - Mesoridazine (Serentil) - Thiothixene (Navane) - Haloperidol (Haldol) - Loxapine (Loxitane) - Molindone (Moban) - Perphenazine (Etrafon) - Trifluoperazine (Stelazine)

Schizophrenia:

- Chronic syndrome with multiple symptoms and presentations that medication can control - Onset can be abrupt/insidious - Diagnosis made after manifestation of positive symptoms in late adolescents/early adulthood (15-25 in men & 25-35 in women)

Signs That Client May Be Having An Auditory/Visual Hallucination But Keeping It A Secret:

- Client is taking turns listening and talking when no one is there - Laughing inappropriately for no reason - Mumbling/mouthing words to himself

Anhedonia:

- Client reports feeling depressed and having no pleasure or joy in life

Schizophrenia: Intervention: Teaching Family & Client Education: Teaching Proper Social Skills:

- Clients may be isolated from others for a variety of reasons. - The bizarre behavior or statements of the client who is delusional or hallucinating may frighten or embarrass family or community members. - Clients who are suspicious or mistrustful may avoid contact with others. - Other times, clients may lack the social or conversation skills they need to make and maintain relationships with others. - Also, a stigma remains attached to mental illness, particularly for clients for whom medication fails to relieve the positive signs of the illness. - The nurse can help the client develop social skills through education, role modeling, and practice. - The client may not discriminate between the topics suitable for sharing with the nurse and those suitable for using to initiate a conversation on a bus. - The nurse can help the client learn neutral social topics appropriate to any conversation, such as the weather or local events. - The client can also benefit from learning that he or she should share certain details of his or her illness, such as the content of delusions or hallucinations, only with a health care provider. - Modeling and practicing social skills with the client can help him or her experience greater success in social interactions. - Specific skills such as eye contact, attentive listening, and taking turns talking can increase the client's abilities and confidence in socializing.

Sense Of Boundary:

- Clients may not have sense of boundary such as touching others without warning or invitation, intruding into other's living spaces, talking or caressing inanimate objects, and engaging in socially inappropriate behaviors (masturbating, undressing, urinating in public)

Schizophrenia: Community-Based Care: Housing W/ Family Or Independentl:

- Clients with schizophrenia are no longer hospitalized for long periods. - Most return to live in the community with assistance provided by family and support services. - Clients may live with family members, independently, or in a residential program such as a group home where they can receive needed services without being admitted to the hospital.

Schizophrenia: Psychosocial Treatment: Social Skills Training:

- Clients with schizophrenia can improve their social competence with social skill training, which translates into more effective functioning in the community. - Basic social skill training involves breaking complex social behavior into simpler steps, practicing through role-playing, and applying the concepts in the community or real-world setting.

Schizophrenia: Assessment: Physiological & Self-Care Considerations:

- Clients with schizophrenia may have significant self-care deficits. - Inattention to hygiene and grooming needs is common, especially during psychotic episodes. - The client can become so preoccupied with delusions or hallucinations that he or she fails to perform even basic activities of daily living. - Clients may also fail to recognize sensations such as hunger or thirst, and food or fluid intake may be inadequate. - This can result in malnourishment and constipation. - Constipation is also a common side effect of antipsychotic medications, compounding the problem. - Paranoia or excessive fears that food and fluids have been poisoned are common and may interfere with eating. - If the client is agitated and pacing, he or she may be unable to sit down long enough to eat. - Occasionally, clients develop polydipsia (excessive water intake), which leads to water intoxication. Serum sodium levels can become dangerously low, leading to seizures. - Polydipsia is usually seen in clients who have had severe and persistent mental illness for many years as well as long-term therapy with antipsychotic medications. - It may be caused by the behavioral state itself or may be precipitated by the use of antidepressant or antipsychotic medications - Sleep problems are common. Hallucinations may stimulate clients, resulting in insomnia. - Other times, clients are suspicious and believe harm will come to them if they sleep. - As in other self-care areas, the client may not correctly perceive or acknowledge physical cues such as fatigue. - To assist the client with community living, the nurse assesses daily living skills and functional abilities. - Such skills—having a bank account and paying bills, buying food and preparing meals, and using public transportation—are often difficult tasks for the client with schizophrenia. - He or she might never have learned such skills or may be unable to accomplish them consistently.

Schizophrenia: Intervention: Coping With Inappropriate Behaviors:

- Clients with schizophrenia often experience a loss of ego boundaries, which poses difficulties for themselves and others in their environment and community. - Potentially bizarre or strange behaviors include touching others without warning or invitation, intruding into others' living spaces, talking to or caressing inanimate objects, and engaging in socially inappropriate behaviors such as undressing, masturbating, or urinating in public. - Clients may approach others and make provocative, insulting, or sexual statements. - The nurse must consider the needs of others as well as the needs of clients in these situations. - Protecting the client is a primary nursing responsibility and includes protecting the client from retaliation by others who experience the client's intrusions and socially unacceptable behavior. - Redirecting the client away from situations or others can interrupt the undesirable behavior and keep the client from further intrusive behaviors. - The nurse must also try to protect the client's right to privacy and dignity. - Taking the client to his or her room or to a quiet area with less stimulation and fewer people often helps. - Engaging the client in appropriate activities is also indicated. For example, if the client is undressing in front of others, the nurse might say, "Let's go to your room and you can put your clothes back on." (encouraging collaboration/redirecting to appropriate activity) - If the client is making verbal statements to others, the nurse might ask the client to go for a walk or move to another area to listen to music. - The nurse should deal with socially inappropriate behavior nonjudgmentally and matter-of-factly. - This means making factual statements with no overtones of scolding and not talking to the client as if he or she were a naughty child. - Some behaviors may be so offensive or threatening that others respond by yelling at, ridiculing, or even taking aggressive action against the client. - Although providing physical protection for the client is the nurse's first consideration, helping others affected by the client's behavior is also important. - Usually, the nurse can offer simple and factual statements to others that do not violate the client's confidentiality. The nurse might make statements, such as "You didn't do anything to provoke that behavior. Sometimes, people's illnesses cause them to act in strange and uncomfortable ways. It is important not to laugh at behaviors that are part of someone's illness." (presenting reality/giving information) - The nurse reassures the client's family that these behaviors are part of the client's illness and not personally directed at them. - Such situations present an opportunity to educate family members about schizophrenia and help allay any feelings of guilt, shame, or responsibility. - Reintegrating the client into the treatment milieu as soon as possible is essential. - The client should not feel shunned or punished for inappropriate behavior. - Health care personnel should introduce limited stimulation gradually. - For example, when the client is comfortable and demonstrating appropriate behavior with the nurse, one or two other people can be engaged in a somewhat structured activity with the client. - The client's involvement is gradually increased to small groups and then to larger, less structured groups as he or she can tolerate the increased level of stimulation without decompensating (regressing to previous, less effective coping behaviors).

Schizophrenia: Assessment: Mood & Effect:

- Clients with schizophrenia report and demonstrate wide variations in mood and affect. - They are often described as having flat affect (no facial expression) or blunted affect (few observable facial expressions). - The typical facial expression is often described as masklike. - The affect may also be described as silly, characterized by giddy laughter for no apparent reason. - The client may exhibit an inappropriate expression or emotions incongruent with the context of the situation. - This incongruence ranges from mild or subtle to grossly inappropriate. - For example, the client may laugh and grin while describing the death of a family member or weep while talking about the weather. - The client may report feeling depressed and having no pleasure or joy in life (anhedonia) - Conversely, he or she may report feeling all-knowing, all-powerful and not at all concerned with the circumstance or situation. - It is more common for the client to report exaggerated feelings of well-being during episodes of psychotic or delusional thinking, and a lack of energy or pleasurable feelings during the chronic, or long-term, phase of the illness.

Schizophrenia: Assessment: Delusions:

- Clients with schizophrenia usually experience delusions (fixed, false beliefs with no basis in reality) in the psychotic phase of the illness. - A common characteristic of schizophrenic delusions is the direct, immediate, and total certainty with which the client holds these beliefs. - Because the client believes the delusion, he or she, therefore, acts accordingly. - For example, the client with delusions of persecution is probably suspicious, mistrustful, and guarded about disclosing personal information; he or she may examine the room periodically or speak in hushed, secretive tones. - External contradictory information or facts cannot alter these delusional beliefs. - If asked why he or she believes such an unlikely idea, the client often replies, "I just know it." - Initially, the nurse assesses the content and depth of the delusion to know what behaviors to expect and to try to establish reality for the client. - When eliciting information about the client's delusional beliefs, the nurse must be careful not to support or challenge them. - The nurse might ask the client to explain what he or she believes by saying, "Please explain that to me" or "Tell me what you're thinking about that."

Antipsychotic Drugs: Second Generation:

- Clozapine (Clozaril) - Risperidone (Risperdal) - Olanzapine (Zyprexa) - Quetiapine (Seroquel) - Ziprasidone (Geodon) - Palpiperidone (Invega) - Iloperidone (Fanapt) - Asenapine (Saphris) - Lurasidone (Latuda)

Schizophrenia: Agranulocytosis:

- Clozapine has the potentially fatal side effect of agranulocytosis (failure of the bone marrow to produce adequate white blood cells). - Agranulocytosis develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. - This side effect may not be manifested immediately but can occur as long as 18 to 24 weeks after the initiation of therapy. - The drug must be discontinued immediately. - Clients taking this antipsychotic must have weekly white blood cell counts for the first 6 months of clozapine therapy and every 2 weeks thereafter. - Clozapine is dispensed every 7 or 14 days only, and evidence of a white blood cell count above 3,500 cells/mm3 is required before a refill is furnished.

Schizophrenia: Psychosocial Treatment: Cognitive Adaptation Training:

- Cognitive adaptation training using environmental supports is designed to improve adaptive functioning in the home setting. - Individually tailored environmental supports such as signs, calendars, hygiene supplies, and pill containers cue the client to perform associated tasks. - This psychosocial skill training was more effective when carried out during in-home visits in the client's own environment rather than in an outpatient setting.

Schizophrenia: Intervention: Using Therapeutic Communication:

- Communicating with clients experiencing psychotic symptoms can be difficult and frustrating. - The nurse tries to understand and make sense of what the client is saying, but this can be difficult if the client is hallucinating, withdrawn from reality, or relatively mute. - The nurse must maintain nonverbal communication with the client, especially when verbal communication is not successful. - This involves spending time with the client, perhaps through fairly lengthy periods of silence. - The presence of the nurse is a contact with reality for the client and can also demonstrate the nurse's genuine interest and caring to the client. - Calling the client by name, making references to the day and time, and commenting on the environment are all helpful ways to continue to make contact with a client who is having problems with reality orientation and verbal communication. - Clients who are left alone for long periods become more deeply involved in their psychosis, so frequent contact and time spent with a client are important even if the nurse is unsure that the client is aware of the nurse's presence. - Active listening is an important skill for the nurse trying to communicate with a client whose verbalizations are disorganized or nonsensical. - Rather than dismissing what the client says because it is not clear, the nurse must make efforts to determine the meaning the client is trying to convey. - Listening for themes or recurrent statements, asking clarifying questions, and exploring the meaning of the client's statements are all useful techniques to increase understanding. - The nurse must let the client know when his or her meaning is not clear. - It is never useful to pretend to understand or just to agree or go along with what the client is saying; this is dishonest and violates trust between client and nurse. - The nurse must let the client know when his or her meaning is not clear. - It is never useful to pretend to understand or just to agree or go along with what the client is saying; this is dishonest and violates trust between client and nurse. Nurse: "How are you feeling today?" (using a broad opening statement) Client: "Invisible." Nurse: "Can you explain that to me?" (seeking clarification) Client: "Oh, it doesn't matter." Nurse: "I'm interested in how you feel; I'm just not sure I understand." (offering self/seeking clarification) Client: "It doesn't mean much." Nurse: "Let me see if I can understand. Do you feel like you're being ignored, that no one is really listening?" (verbalizing the implied)

Schizophrenia: Community-Based Care: Community Support Programs/Case Management Services:

- Community support programs are often an important link in helping people with schizophrenia and their families. - A case manager may be assigned to the client to provide assistance in handling the wide variety of challenges that the client in community settings faces. - The client who has had schizophrenia for some time may have a case manager in the community. - Other clients may need assistance to obtain a case manager. - Depending on the type of funding and agencies available in a particular community, the nurse may refer the client to a social worker or may directly refer the client to case management services. - Case management services often include helping the client with housing and transportation, money management, and keeping appointments as well as with socialization and recreation. - Frequent face-to-face and telephone contact with clients in the community helps address clients' immediate concerns and avoid relapse and rehospitalization. - Common concerns of clients include difficulties with treatment and aftercare, dealing with psychiatric symptoms, environmental stresses, and financial issues. - Although the support of professionals in the community is vital, the nurse must not overlook the client's need for autonomy and potential abilities to manage his or her own health.

Cognitive Enhancement Therapy:

- Compound-based cognitive training with a group to practice social skills

Positive (Hard) Symptoms Of Schizophrenia: Flight Of Ideas:

- Continuous flow of verbalization in which the person jumps rapidly from one topic to another

Schizophrenia: Intervention: Teaching The Client & Family:

- Coping with schizophrenia is a major adjustment for both clients and their families. - Understanding the illness, the need for continuing medication and follow-up, and the uncertainty of the prognosis or recovery are key issues. - Clients and families need help to cope with the emotional upheaval that schizophrenia causes. - Identifying and managing one's own health needs are primary concerns for everyone, but this is a particular challenge for clients with schizophrenia because their health needs can be complex and their ability to manage them may be impaired. - The nurse helps the client manage his or her illness and health needs as independently as possible. - This can be accomplished only through education and ongoing support. - Teaching the client and family members to prevent or manage relapse is an essential part of a comprehensive plan of care. - This includes providing facts about schizophrenia, identifying the early signs of relapse, and teaching health practices to promote physical and psychological well-being. Early identification of these relapse signs has been found to reduce the frequency of relapse; when relapse cannot be prevented, early identification provides the foundation for interventions to manage the relapse. - For example, if the nurse finds that the client is fatigued or lacks adequate sleep or proper nutrition, interventions to promote rest and nutrition may prevent a relapse or minimize its intensity and duration. Nurse: "How have you been sleeping lately?" Client: "Oh, I try to sleep at night. I like to listen to music to help me sleep. I really like country-western music best. What do you like? Can I have something to eat pretty soon? I'm hungry." Nurse: "Can you tell me how you've been sleeping?" - The nurse can use the list of relapse risk factors in several ways. - He or she can include these risk factors in discharge teaching before the client leaves the inpatient setting so that the client and family know what to watch for and when to seek assistance. - The nurse can also use the list when assessing the client in an outpatient or clinic setting or when working with clients in a community support program. - The nurse can also provide teaching to ancillary personnel who may work with the client so they know when to contact a mental health professional. - Taking medications as prescribed, keeping regular follow-up appointments, and avoiding alcohol and other drugs have been associated with fewer and shorter hospital stays. -In addition, clients who can identify and avoid stressful situations are less likely to suffer frequent relapses. - Using a list of relapse risk factors is one way to assess the client's progress in the community. - Families experience a wide variety of responses to the illness of their loved one. - Some family members might be ashamed or embarrassed or frightened of the client's strange or threatening behaviors. - They worry about a relapse. - They may feel guilty for having these feelings or fear for their own mental health or well-being. - If the client experiences repeated and profound problems with schizophrenia, the family members may become emotionally exhausted or even alienated from the client, feeling they can no longer deal with the situation. - Family members need ongoing support and education, including reassurance that they are not the cause of schizophrenia. - Participating in organizations such as the Alliance for the Mentally Ill may help families with their ongoing needs.

Antipsychotic Medications:

- DON'T cure schizophrenia, they manage it (like Alzheimer's)

Intensity Of Psychosis:

- Decreases with age

Psychosis:

- Delusions - Hallucinations - Poor insight and judgement - Loss of contact with reality

Schizophrenia: Assessment: Self-Concept:

- Deterioration of the concept of self is a major problem in schizophrenia. - The phrase loss of ego boundaries describes the client's lack of a clear sense of where his or her own body, mind, and influence end and where those aspects of other animate and inanimate objects begin. - This lack of ego boundaries is evidenced by depersonalization, derealization (environmental objects become smaller or larger or seem unfamiliar), and ideas of reference. - Clients may believe they are fused with another person or object, may not recognize body parts as their own, or may fail to know whether they are male or female. - These difficulties are the source of many bizarre behaviors such as public undressing or masturbating, speaking about oneself in the third person, or physically clinging to objects in the environment. - Body image distortion may also occur.

Second Generation:

- Dopamine and serotonin antagonists

First Generation:

- Dopamine antagonists

Schizophrenia: Extrapyramidal Side Effects:

- EPSs are reversible movement disorders induced by neuroleptic medication. - They include dystonic reactions, parkinsonism, and akathisia.

Schizophrenia: Mental Health Promotion: Accurate Identification Of Those At Risk:

- Early intervention in schizophrenia is an emerging goal of research investigating the earliest signs of the illness that occurs predominately in adolescence and young adulthood. - Accurate identification of individuals at highest risk is key to early intervention - Initiatives of early detection, intervention, and prevention of psychosis have been established to work with primary care providers to recognize prodromal signs that are predictive of later psychotic episodes, such as sleep difficulties, change in appetite, loss of energy and interest, odd speech, hearing voices, peculiar behavior, inappropriate expression of feelings, paucity of speech, ideas of reference, and feelings of unreality. - After these high-risk individuals are identified, individualized intervention is implemented, which may include education or stress management or neuroleptic medication or a combination of these. - Treatment also includes family involvement, individual and vocational counseling, and coping strategies to enhance self-mastery. - Interventions are intensive, using home visits and daily sessions if needed.

Different Therapies:

- Electric shock therapy, insulin shock therapy, and surgery all pretty much became obsolete methods of treatment since creation of Thorazine (first generation antipsychotic)

Side Effects of Antipsychotic Medications and Nursing Interventions: Weight Gain:

- Encourage balanced diet with controlled portions and regular exercise; focus on minimizing gain.

Schizophrenia: Intervention: Establishing A Therapeutic Relationship:

- Establishing trust between the client and the nurse also helps allay the fears of a frightened client. - Initially, the client may tolerate only 5 or 10 minutes of contact at one time. - Establishing a therapeutic relationship takes time, and the nurse must be patient. - The nurse provides explanations that are clear, direct, and easy to understand. - Body language should include eye contact, but not staring, a relaxed body posture, and facial expressions that convey genuine interest and concern. - Telling the client one's name and calling the client by name are helpful in establishing trust as well as reality orientation. - The nurse must carefully assess the client's response to the use of touch. - Sometimes gentle touch conveys caring and concern. - At other times, the client may misinterpret the nurse's touch as threatening and therefore undesirable. - As the nurse sits near the client, does he or she move or look away? Is the client frightened or wary of the nurse's presence? If so, that client may not be reassured by touch but frightened or threatened by it.

Ethnicity & Psychotropic Medications:

- Ethnicity may also be a factor in the way a person responds to psychotropic medications. - This difference in response is probably the result of the person's genetic makeup. - Some people metabolize certain drugs more slowly, so the drug level in the bloodstream is higher than desired. - In a study on poor treatment response, researchers found subtherapeutic plasma levels in some individuals despite having been administered therapeutic doses of the medication - Black ethnicity was a factor associated with low plasma levels, causing the researchers to postulate that standard drug doses were not leading to therapeutic levels. - Changing doses or changing the antipsychotic medication may be indicated in people with subtherapeutic plasma levels who have poor response to treatment.

Excess Dopamine In Brain:

- Excess dopamine is thought to be a cause - Antipsychotics block dopamine receptors •Reduce positive symptoms - Clozapine •Both dopamine and serotonin •Effective at reducing psychotic symptoms and making negative symptoms better

Catatonia (OUTLINE):

- Excessive motor activity or motionless

Positive (Hard) Symptoms Of Schizophrenia: Ideas Of Reference:

- False impressions that external events have special meaning for the person

Positive (Hard) Symptoms Of Schizophrenia: Hallucinations:

- False sensory perceptions or perceptual experiences that do not exist in reality

Families Guilt:

- Families may feel guilty or responsible for client's diagnosis of schizophrenia

Schizophrenia: Psychosocial Treatment: Family Education Therapy:

- Family education and therapy are known to diminish the negative effects of schizophrenia and reduce the relapse rate. - Although inclusion of the family is a factor that improves outcomes for the client, family involvement is often neglected by health care professionals -. Families often have a difficult time coping with the complexities and ramifications of the client's illness. - This creates stress among family members that is not beneficial for the client or family members. - Family education helps make family members part of the treatment team. - Education course developed by the National Alliance for the Mentally Ill. - In addition, family members can benefit from a supportive environment that helps them cope with the many difficulties presented when a loved one has schizophrenia. - These concerns include continuing as a caregiver for the child who is now an adult; worrying about who will care for the client when the parents are gone; dealing with the social stigma of mental illness; and, possibly, facing financial problems, marital discord, and social isolation. - Such support is available through the National Alliance for the Mentally Ill and local support groups. - The client's health care provider can make referrals to meet specific family needs.

Negative (Soft) Symptoms Of Schizophrenia: Anhedonia:

- Feeling no joy or pleasure from life or any activities or relationships

Negative (Soft) Symptoms Of Schizophrenia: Apathy:

- Feelings of indifference toward people, activities, and events

Positive (Hard) Symptoms Of Schizophrenia: Delusions:

- Fixed false beliefs that have no basis in reality

Negative (Soft) Symptoms:

- Flat affect - Social withdrawal - Lack of volition (lack of ambition to complete tasks)

Delusions:

- For someone experiencing delusions, DON'T confront, argue, play along, or reinforce the delusion. - Rather acknowledge it then help them back to reality - Tactile delusions common in someone going through alcohol withdrawal and uncommon in schizophrenia

Positive (Hard) Symptoms Of Schizophrenia: Associative Looseness:

- Fragmented or poorly related thoughts and ideas

Personal Space:

- Give client complete personal space to enhance his comfort of security

Positive (Hard) Symptoms Of Schizophrenia: Ambivalence:

- Holding seemingly contradictory beliefs or feelings about the same person, event, or situation

Neuroleptic Malignant Syndrome (NMS):

- Idiosyncratic reaction to antipsychotic - DC right away

Twins:

- If one twin is diagnosed with schizophrenia, the other has 50% chance of developing it

Positive (Hard) Symptoms Of Schizophrenia: Echopraxia:

- Imitation of the movements and gestures of another person whom the client is observing

Schizophrenia: Psychosocial Treatment: Individual & Group Therapy:

- In addition to pharmacologic treatment, many other modes of treatment can help the person with schizophrenia. - Individual and group therapies, family therapy, family education, and social skills training can be instituted for clients in both inpatient and community settings. - Individual and group therapy sessions are often supportive in nature, giving the client an opportunity for social contact and meaningful relationships with other people. - Groups that focus on topics of concern such as medication management, use of community supports, and family concerns have also been beneficial to clients with schizophrenia

High Relapse:

- In patients with noncompliance to medication, substance abuse, caregiver criticism, and negative attitude toward treatment

Schizophrenia: Immediate-Term Course:

- In the years immediately after the onset of psychotic symptoms, two typical clinical patterns emerge. - In one pattern, the client experiences ongoing psychosis and never fully recovers, though symptoms may shift in severity over time. - In another pattern, the client experiences episodes of psychotic symptoms that alternate with episodes of relatively complete recovery from the psychosis.

Patients Who Have Insidious Onset:

- In younger years of schizophrenia have poorer outcomes

Negative (Soft) Symptoms Of Schizophrenia:Avolition: Inattention:

- Inability to concentrate or focus on a topic or activity, regardless of its importance

Side Effects of Antipsychotic Medications and Nursing Interventions: Anticholinergic Side Effects: Constipation:

- Increase fluid and dietary fiber intake; client may need a stool softener if unrelieved.

Side Effects of Antipsychotic Medications and Nursing Interventions: Anticholinergic Side Effects: Urinary Retention:

- Instruct client to report any frequency or burning with urination; report to physician if no improvement over time.

Side Effects of Antipsychotic Medications and Nursing Interventions: Orthostatic Hypotension:

- Instruct client to rise slowly from sitting or lying positions; wait to ambulate until no longer dizzy or light-headed.

Schizophrenia: Intervention: Implementing Interventions For Hallucinations:

- Intervening when the client experiences hallucinations requires the nurse to focus on what is real and to help shift the client's response toward reality. - Initially, the nurse must determine what the client is experiencing—that is, what the voices are saying or what the client is seeing. - Doing so increases the nurse's understanding of the nature of the client's feelings and behavior. - In command hallucinations, the client hears voices directing him or her to do something, often to hurt him or herself or someone else. - For this reason, the nurse must elicit a description of the content of the hallucination so that health care personnel can take precautions to protect the client and others as necessary. The nurse might say, "I don't hear any voices; what are you hearing?" (presenting reality/seeking clarification) - This can also help the nurse understand how to relieve the client's fears or paranoia. For example, the client might be seeing ghosts or monster-like images, and the nurse could respond, "I don't see anything, but you must be frightened. You are safe here in the hospital." (presenting reality/translating into feelings) - This acknowledges the client's fear but reassures the client that no harm will come to him or her. - Clients do not always report or identify hallucinations. - At times, the nurse must infer from the client's behavior that hallucinations are occurring. - Examples of behavior that indicate hallucinations include alternately listening and then talking when no one else is present, laughing inappropriately for no observable reason, and mumbling or mouthing words with no audible sound. - A helpful strategy for intervening with hallucinations is to engage the client in a reality-based activity, such as playing cards, participating in occupational therapy, or listening to music. - It is difficult for the client to pay attention to hallucinations and reality-based activity at the same time, so this technique of distracting the client is often useful. - It may also be useful to work with the client to identify certain situations or a particular frame of mind that may precede or trigger auditory hallucinations. - Intensity of hallucinations is often related to anxiety levels; therefore, monitoring and intervening to lower a client's anxiety may decrease the intensity of hallucinations. - Clients who recognize that certain moods or patterns of thinking precede the onset of voices may eventually be able to manage or control the hallucinations by learning to manage or avoid particular states of mind. - This may involve learning to relax when voices occur, engaging in diversions, correcting negative self-talk, and seeking out or avoiding social interaction. - Teaching the client to talk back to the voices forcefully may also help him or her manage auditory hallucinations. - The client should do this in a relatively private place rather than in public. - There is an international self-help movement of "voice-hearer groups," developed to assist people to manage auditory hallucinations. - One group devised the strategy of carrying a cell phone (fake or real) to cope with voices when in public places. - With cell phones, members can carry on conversations with their voices in the street—and tell them to shut up—while avoiding ridicule by looking like a normal part of the street scene. - Being able to verbalize resistance can help the client feel empowered and capable of dealing with the hallucinations. - Clients can also benefit from openly discussing the voice-hearing experience with designated others. - Talking with other clients who have similar experiences with auditory hallucinations has proved helpful, so the client doesn't feel so isolated and alone with the hallucination experience. - Some clients wanted to discuss the hallucinations with their community mental health nurse to better understand the hallucinations and what they might mean.

Schizophrenia: Assessment: Sensorium & Intellectual Processes: Gustatory Hallucination:

- Involve a taste lingering in the mouth or the sense that food tastes like something else. - The taste may be metallic or bitter or may be represented as a specific taste.

Schizophrenia: Assessment: Sensorium & Intellectual Processes: Visual Hallucination:

- Involve seeing images that do not exist at all, such as lights or a dead person, or distortions such as seeing a frightening monster instead of the nurse. - They are the second most common type of hallucination.

Schizophrenia: Assessment: Sensorium & Intellectual Processes: Olfactory Hallucinations:

- Involve smells or odors. - They may be a specific scent such as urine or feces or a more general scent such as a rotten or rancid odor. - In addition to clients with schizophrenia, this type of hallucination often occurs with dementia, seizures, or cerebrovascular accidents.

Types Of Delusions: Persecutory/Paranoid Delusions:

- Involve the client's belief that "others" are planning to harm him or her or are spying, following, ridiculing, or belittling the client in some way. - Sometimes the client cannot define who these "others" are. - Examples: The client may think that food has been poisoned or that rooms are bugged with listening devices. Sometimes the "persecutor" is the government, FBI, or another powerful organization. - Occasionally, specific individuals, even family members, may be named as the persecutor.

Types Of Delusions:Sexual Delusions:

- Involve the client's belief that his or her sexual behavior is known to others; that the client is a rapist, prostitute, or pedophile or is pregnant; or that his or her excessive masturbation has led to insanity.

Schizophrenia: Assessment: Sensorium & Intellectual Processes: Cenesthetichallucinations:

- Involve the client's report that he or she feels bodily functions that are usually undetectable. - Examples would be the sensation of urine forming or impulses being transmitted through the brain.

Unusual Speech Patterns of Clients with Schizophrenia: Word Salad:

- Is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. - Example: "Corn, potatoes, jump up, play games, grass, cupboard

Schizophrenia: Cultural Considerations: Culture-Bound Syndrome: Bouffee Delirante:

- Is a syndrome found in West Africa and Haiti, characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomotor excitement. - It is sometimes accompanied by visual and auditory hallucinations or paranoid ideation

Schizophrenia: Cultural Considerations: Culture-Bound Syndrome: Qi-gong Psychotic Reaction:

- Is an acute, time-limited episode characterized by dissociative, paranoid, or other psychotic symptoms that occur after participating in the Chinese folk health-enhancing practice of qi-gong. - Especially vulnerable are those who become overly involved in the practice.

Schizoaffective Disorder:

- Is diagnosed when the client is severely ill and has a mixture of psychotic and mood symptoms. - The signs and symptoms include those of both schizophrenia and a mood disorder such as depression or bipolar disorder.

Schizophrenia: Cultural Considerations: Culture-Bound Syndrome: Ghost Sickness:

- Is preoccupation with death and the deceased frequently observed among members of some Native American tribes. - Symptoms include bad dreams, weakness, feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss of consciousness, confusion, feelings of futility, and a sense of suffocation.

Unusual Speech Patterns of Clients with Schizophrenia: Echolalia:

- Is the client's imitation or repetition of what the nurse says. Example: Nurse: "Can you tell me how you're feeling?" Client: "Can you tell me how you're feeling, how you're feeling?"

Unusual Speech Patterns of Clients with Schizophrenia: Perseveration:

- Is the persistent adherence to a single idea or topic and verbal repetition of a sentence, phrase, or word, even when another person attempts to change the topic. Example: Nurse: "How have you been sleeping lately?" Client: "I think people have been following me." Nurse: "Where do you live?" Client: "At my place people have been following me." Nurse: "What do you like to do in your free time?" Client: "Nothing because people are following me."

Unusual Speech Patterns of Clients with Schizophrenia: Verbigeration:

- Is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. - Example: "I want to go home, go home, go home, go home."

Unusual Speech Patterns of Clients with Schizophrenia: Stilted Language:

- Is use of words or phrases that are flowery, excessive, and pompous. - Example: "Would you be so kind, as a representative of Florence Nightingale, as to do me the honor of providing just a wee bit of refreshment, perhaps in the form of some clear spring water?"

Schizophrenia: Outcome Identification:

- It is likely that the client with an acute psychotic episode of schizophrenia will receive treatment in an intensive setting, such as an inpatient hospital unit. - During this phase, the focus of care is stabilizing the client's thought processes and reality orientation as well as ensuring safety. - This is also the time to evaluate resources, make referrals, and begin planning for the client's rehabilitation and return to the community. Examples of outcomes appropriate to the acute, psychotic phase of treatment are: 1. The client will not injure him or herself or others. 2. The client will establish contact with reality. 3. The client will interact with others in the environment. 4. The client will express thoughts and feelings in a safe and socially acceptable manner. 5. The client will participate in prescribed therapeutic interventions. - Once the crisis or the acute, psychotic symptoms have been stabilized, the focus is on developing the client's ability to live as independently and successfully as possible in the community. - This usually requires continued follow-up care and participation of the client's family in community support services. - Prevention and early recognition and treatment of relapse symptoms are important parts of successful rehabilitation. - Dealing with the negative signs of schizophrenia, which medication generally does not affect, is a major challenge for the client and caregivers. Examples of treatment outcomes for continued care after the stabilization of acute symptoms are: 1. The client will participate in the prescribed regimen (including medications and follow-up appointments). 2. The client will maintain adequate routines for sleeping and food and fluid intake. 3. The client will demonstrate independence in self-care activities. 4. The client will communicate effectively with others in the community to meet his or her needs. 5. The client will seek or accept assistance to meet his or her needs when indicated. - The nurse must appreciate the severity of schizophrenia and the profound and sometimes devastating effects it has on the lives of clients and their families. - It is equally important to avoid treating the client as a "hopeless case," someone who no longer is capable of having a meaningful and satisfying life. - It is not helpful to expect either too much or too little from the client. - Careful ongoing assessment is necessary so that appropriate treatment and interventions address the client's needs and difficulties while helping the client reach his or her optimal level of functioning.

Schizophrenia: Assessment: Judgement & Insight:

- Judgment is frequently impaired in the client with schizophrenia. - Because judgment is based on the ability to interpret the environment correctly, it follows that the client with disordered thought processes and environmental misinterpretations will have great difficulty with judgment. - At times, lack of judgment is so severe that clients cannot meet their needs for safety and protection and place themselves in harm's way. - This difficulty may range from failing to wear warm clothing in cold weather to failing to seek medical care even when desperately ill. - The client may also fail to recognize needs for sleep or food. - Insight can also be severely impaired, especially early in the illness, when the client, family, and friends do not understand what is happening. - Over time, some clients can learn about the illness, anticipate problems, and seek appropriate assistance as needed. - However, chronic difficulties result in clients who fail to understand schizophrenia as a long-term health problem requiring consistent management.

Anhedoria:

- Lack of enjoyment from activities

Elderly Considerations:

- Late-onset schizophrenia refers to development of the disease after age 45; schizophrenia is not initially diagnosed in elder clients. - Psychotic symptoms that appear in later life are usually associated with depression or dementia, not schizophrenia. - People with schizophrenia do survive into old age with a variety of long-term outcomes. - They have an increased risk of developing dementia -Approximately one-fourth of the clients experienced dementia, resulting in a steady, deteriorating decline in health; another 25% actually have a reduction in positive symptoms, somewhat like a remission; and schizophrenia remains mostly unchanged in the remaining clients.

Cultural Differences: Locura:

- Latinos

Tardive Dyskinesia:

- Long-term use of antipsychotics - DC and/or change the antipsychotic

Schizophrenia: Intervention: Teaching Family & Client Education: Medication Management:

- Maintaining the medication regimen is vital to a successful outcome for clients with schizophrenia. - Failing to take medications as prescribed is one of the most frequent reasons for recurrence of psychotic symptoms and hospital admission. - Clients who respond well to and maintain an antipsychotic medication regimen may lead relatively normal lives with only an occasional relapse. - Those who do not respond well to antipsychotic agents may face a lifetime of dealing with delusional ideas and hallucinations, negative signs, and marked impairment. - Many clients find themselves somewhere between these two extremes. - There are many reasons why clients may not maintain the medication regimen. - The nurse must determine the barriers to compliance for each client. - Sometimes clients intend to take their medications as prescribed but have difficulty remembering when and if they did so. - They may find it difficult to adhere to a routine schedule for medications. - Several methods are available to help clients remember when to take medications. - One is using a pillbox with compartments for days of the week and times of the day. - After the box has been filled, perhaps with assistance from the nurse or case manager, the client often has no more difficulties. - It is also helpful to make a chart of all administration times so that the client can cross off each time he or she has taken the medications. - Clients may have practical barriers to medication compliance, such as inadequate funds to obtain expensive medications, lack of transportation or knowledge about how to obtain refills for prescriptions, or inability to plan ahead to get new prescriptions before current supplies run out. Clients can usually overcome all these obstacles once they have been identified. - Sometimes clients decide to decrease or discontinue their medications because of uncomfortable or embarrassing side effects. - Unwanted side effects are frequently reported as the reason clients stop taking medications. - Interventions, such as eating a proper diet and drinking enough fluids, using a stool softener to avoid constipation, sucking on hard candy to minimize dry mouth, or using sunscreen to avoid sunburn, can help control some of these uncomfortable side effects - Some side effects, such as dry mouth and blurred vision, improve with time or with lower doses of medication. - Medication may be warranted to combat common neurologic side effects such as EPSs or akathisia. - Some side effects, such as those affecting sexual functioning, are embarrassing for the client to report, and the client may confirm these side effects only if the nurse directly inquires about them. - This may require a call to the client's physician or primary provider to obtain a prescription for a different type of antipsychotic. - Sometimes a client discontinues medications because he or she dislikes taking them or believes he or she does not need them. - The client may have been willing to take the medications when experiencing psychotic symptoms but may believe that medication is unnecessary when he or she feels well. - By refusing to take the medications, the client may be denying the existence or severity of schizophrenia. - These issues of noncompliance are much more difficult to resolve. - The nurse can teach the client about schizophrenia, the nature of chronic illness, and the importance of medications in managing symptoms and preventing recurrence. For example, the nurse could say, " - This medication helps you think more clearly" or "Taking this medication will make it less likely that you'll hear troubling voices in your mind again." - Even after education, some clients continue to refuse to take medication; they may understand the connection between medication and prevention of relapse only after experiencing a return of psychotic symptoms. - A few clients still do not understand the importance of consistently taking medication and, even after numerous relapses, continue to experience psychosis and hospital admission fairly frequently.

Early Detection & Aggressive Treatment:

- Medications and psychosocial interventions (psychopharmatherapy) of first psychotic episode is essential to promote improved insight, quality of life, and social functioning

Cultural Differences: Zar:

- Middle East & North Africa

Schizoaffective Disorder (OUTLINE):

- Mixture of psychotic and mood symptoms - Psychotic: Delusions/hallucinations - Mood: Bipolar (depression, mania, or both)

Schizophrenia: Neuroleptic Malignant Syndrome (NMS):

- NMS is a serious and frequently fatal condition seen in those being treated with antipsychotic medications. - It is characterized by muscle rigidity, high fever, increased muscle enzymes (particularly, creatine phosphokinase), and leukocytosis (increased leukocytes). - It is estimated that 0.1% to 1% of all clients taking antipsychotics develop NMS. - Any of the antipsychotic medications can cause NMS, which is treated by stopping the medication. - The client's ability to tolerate other antipsychotic medications after NMS varies, but use of another antipsychotic appears possible in most instances.

Cultural Differences: Ghost Sickness:

- Native Americans

Pretending To Understand:

- Never pretend to understand or just go along with what client is saying if you truly don't understand as this a violation of trust in the therapeutic relationship

Schizophrenia: Assessment: Sensorium & Intellectual Processes: Kinesthetic Hallucinations:

- Occur when the client is motionless but reports the sensation of bodily movement. - Occasionally, the bodily movement is something unusual, such as floating above the ground.

Types Of Delusions: Religious Delusions:

- Often center around the second coming of Christ or another significant religious figure or prophet. - These religious delusions appear suddenly as part of the client's psychosis and are not part of his or her religious faith or that of others. - Examples: The client claims to be the Messiah or some prophet sent from God and believes that God communicates directly to him or her or that he or she has a special religious mission in life or special religious powers.

Schizophrenia: Assessment: Sensorium & Intellectual Processes:

- One hallmark symptom of schizophrenic psychosis is hallucinations (false sensory perceptions, or perceptual experiences that do not exist in reality). - Hallucinations can involve the five senses and bodily sensations. - They can be threatening and frightening for the client; less frequently, clients report hallucinations as pleasant. - Initially, the client perceives hallucinations as real, but later in the illness, he or she may recognize them as hallucinations. - Hallucinations are distinguished from illusions, which are misperceptions of actual environmental stimuli. - For example, while walking through the woods, a person believes he sees a snake at the side of the path. - On closer examination, however, he discovers it is only a curved stick. - Reality or factual information corrected this illusion. Hallucinations, however, have no such basis in reality. - During episodes of psychosis, clients are commonly disoriented to time and sometimes to place. - The most extreme form of disorientation is depersonalization, in which the client feels detached from his or her behavior. - Although the client can state his or her name correctly, he or she feels as if his or her body belongs to someone else or that his or her spirit is detached from the body. - Assessing the intellectual processes of a client with schizophrenia is difficult if he or she is experiencing psychosis. - The client usually demonstrates poor intellectual functioning as a result of disordered thoughts. - Nevertheless, the nurse should not assume that the client has limited intellectual capacity based on impaired thought processes. - It may be that the client cannot focus, concentrate, or pay adequate attention to demonstrate his or her intellectual abilities accurately. - The nurse is more likely to obtain accurate assessments of the client's intellectual abilities when the client's thought processes are clearer. - Clients often have difficulty with abstract thinking and may respond in a literal way to other people and the environment. - For example, when asked to interpret the proverb, "A stitch in time saves nine," the client may explain it by saying, "I need to sew up my clothes." - The client may not understand what is being said and can easily misinterpret instructions. - This can pose serious problems during medication administration. - For example, the nurse may tell the client, "It is always important to take all your medications." The client may misinterpret the nurse's statement and take the entire supply of medication at one time.

Onset Of Schizophrenia:

- Onset is gradual/slow •Men develop symptoms between 18-25 •Women develop symptoms between 25-35

Schizophrenia: Onset:

- Onset may be abrupt or insidious, but most clients slowly and gradually develop signs and symptoms such as social withdrawal, unusual behavior, loss of interest in school or at work, and neglected hygiene. - The diagnosis of schizophrenia is usually made when the person begins to display more actively positive symptoms of delusions, hallucinations, and disordered thinking (psychosis). - Regardless of when and how the illness begins and the type of schizophrenia, consequences for most clients and their families are substantial and enduring. - When and how the illness develops seems to affect the outcome. - Age at onset appears to be an important factor in how well the client fares; those who develop the illness earlier show worse outcomes than those who develop it later. - Younger clients display a poorer premorbid adjustment, more prominent negative signs, and greater cognitive impairment than do older clients. - Those who experience a gradual onset of the disease (about 50%) tend to have a poorer immediate- and long-term course than those who experience an acute and sudden onset. - Approximately one-third to one-half of clients with schizophrenia relapse within 1 year of an acute episode. - Higher relapse rates are associated with non-adherence to medication, persistent substance use, caregiver criticism, and negative attitude toward treatment

Types Of Delusions: Referential Delusions:

- Or ideas of reference involve the client's belief that television broadcasts, music, or newspaper articles have special meaning for him or her. - Examples: The client may report that the president was speaking directly to him on a news broadcast or that special messages are sent through newspaper articles.

Accepting Forms Of Intervention For Delusions:

- Orientation to reality - Engaging in positive self-talk - Distraction - Forcefully talking back to the delusion ("**** off") - Ignoring the delusional thoughts

Positive (Hard) Symptoms Of Schizophrenia: Bizarre Behavior:

- Outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior

Positive (Hard) Symptoms Of Schizophrenia: Perseveration:

- Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic

Schizophrenia: Biological Theories: Immunovirologic Factors:

- Popular theories have emerged, stating that exposure to a virus or the body's immune response to a virus could alter the brain physiology of people with schizophrenia. - Although scientists continue to study these possibilities, few findings have validated them. - Cytokines are chemical messengers between immune cells, mediating inflammatory and immune responses. - Specific cytokines also play a role in signaling the brain to produce behavioral and neurochemical changes needed in the face of physical or psychological stress to maintain homeostasis. - It is believed that cytokines may have a role in the development of major psychiatric disorders such as schizophrenia - Recently, researchers have been focusing on infections in pregnant women as a possible origin for schizophrenia. - Waves of schizophrenia in England, Wales, Denmark, Finland, and other countries have occurred a generation after influenza epidemics. - Also, there are higher rates of schizophrenia among children born in crowded areas in cold weather, conditions that are hospitable to respiratory ailments

Schizophrenia: Positive/Negative Symptoms:

- Positive symptoms: excessive distorted thoughts and perceptions •Hallucination (auditory or visual; sometimes tactile) •Always assess for command hallucinations •Delusions (thoughts)-fixed beliefs - Negative symptoms: describe emotions and behaviors •Interfere with daily functions •Alogia-poverty of speech •Avolition/lack of volition-lack of ambition or drive to complete task •Anhedonia-no joy from activities or relationships •Affect is flat (no emotion), socially withdrawn, catatonia, apathy - Medications are used to control positive symptoms

Schizophrenia: Mental Health Promotion: Goal Of Psychiatric Rehabilitation:

- Psychiatric rehabilitation has the goal of recovery for clients with major mental illness that goes beyond symptom control and medication management - Working with clients to manage their own lives, make effective treatment decisions, and have an improved quality of life—from the client's point of view—are central components of such programs. - Mental health promotion involves strengthening the client's ability to bounce back from adversity and to manage the inevitable obstacles encountered in life. - Strategies include fostering self-efficacy and empowering the client to have control over his or her life; improving the client's resiliency, or ability to bounce back emotionally from stressful events; and improving the client's ability to cope with the problems, stress, and strains of everyday living.

Negative (Soft) Symptoms Of Schizophrenia: Catatonia:

- Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance

Positive (Hard) Symptoms:

- Psychotic behavior - Delusions - Hallucinations - Grossly disorganized thinking/speech/behavior - Most medications control positive symptoms

Schizophrenia: Assessment: Sensorium & Intellectual Processes: Tactile Hallucinations:

- Refer to sensations such as electricity running through the body or bugs crawling on the skin. - Tactile hallucinations are found most often in clients undergoing alcohol withdrawal; they rarely occur in clients with schizophrenia.

Schizophrenia: Cultural Considerations: Culture-Bound Syndrome: Locura:

- Refers to a chronic psychosis experienced by Latinos in the United States and Latin America. - Symptoms include incoherence, agitation, visual and auditory hallucinations, inability to follow social rules, unpredictability, and, possibly, violent behavior.

Waxy Flexibility:

- Remaining in same position for long periods of time, even if uncomfortable

Perseveration:

- Repeating a word/phrase or adherence to a single idea

Echolalia:

- Repeating what someone says

Negative (Soft) Symptoms Of Schizophrenia: Blunted Affect:

- Restricted range of emotional feeling, tone, or mood

Schizophrenia: Intervention: Promoting The Safety Of The Client & Others:

- Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. - The client may be paranoid and suspicious of the nurse and the environment and may feel threatened and intimidated. - Although the client's behavior may be threatening to the nurse, the client is also feeling unsafe and may believe his or her well-being is in jeopardy. - Therefore, the nurse must approach the client in a nonthreatening manner. - Making demands or being authoritative only increases the client's fears. - Giving the client ample personal space usually enhances his or her sense of security. - A fearful or agitated client has the potential to harm him or herself or others. - The nurse must observe for signs of building agitation or escalating behavior such as increased intensity of pacing, loud talking or yelling, and hitting or kicking objects. - The nurse must institute interventions to protect the client, nurse, and others in the environment. - This may involve administering medication; moving the client to a quiet, less stimulating environment; and in extreme situations, temporarily using seclusion or restraints.

Schizophrenia Spectrum Disorders:

- Schizophrenia - Schizoaffective - Schizotypal - Brief psychotic disorder - Delusional schizophreniform disorder - Substance/medication-induced psychotic disorder

Schizophrenia: Assessment:

- Schizophrenia affects thought processes and content, perception, emotion, behavior, and social functioning; however, it affects each individual differently. - The degree of impairment in both the acute or psychotic phase and the chronic or long-term phase varies greatly; thus, so do the needs of and the nursing interventions for each affected client. - The nurse must not make assumptions about the client's abilities or limitations solely on basis of the medical diagnosis of schizophrenia. - For example, the nurse may care for a client in an acute inpatient setting. - The client may appear frightened, hear voices (hallucinate), make no eye contact, and mumble constantly. - The nurse would deal with the positive, or psychotic, signs of the disease. - Another nurse may encounter a client with schizophrenia in a community setting who is not experiencing psychotic symptoms; rather, this client lacks energy for daily tasks and has feelings of loneliness and isolation (negative signs of schizophrenia). - Although both clients have the same medical diagnosis, the approach and interventions that each nurse takes would be different.

Schizophrenia: Introduction:

- Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movements, and behavior. - It cannot be defined as a single illness; rather, schizophrenia is thought of as a syndrome or as a disease process with many different varieties and symptoms, much like the varieties of cancer. - For decades, the public vastly misunderstood schizophrenia, fearing it as dangerous and uncontrollable and causing wild disturbances and violent outbursts. - Many people believed that those with schizophrenia needed to be locked away from society and institutionalized. - Only recently has the mental health community come to learn and educate the community at large that schizophrenia has many different symptoms and presentations and is an illness that medication can control. - Thanks to the increased effectiveness of newer atypical antipsychotic drugs and advances in community-based treatment, many clients with schizophrenia live successfully in the community. - Clients whose illness is medically supervised and whose treatment is maintained often continue to live and sometimes work in the community with family and outside support.

Schizophrenia: Assessment: Thought Process & Content:

- Schizophrenia is often referred to as a thought disorder because that is the primary feature of the disease: - Thought processes become disordered, and the continuity of thoughts and information processing is disrupted. - The nurse can assess thought process by inferring from what the client says. - He or she can assess thought content by evaluating what the client actually says. - For example, clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute (thought blocking). - They may also state that they believe others can hear their thoughts (thought broadcasting), that others are taking their thoughts (thought withdrawal), or that others are placing thoughts in their mind against their will (thought insertion). - Clients may also exhibit tangential thinking, which is veering onto unrelated topics and never answering the original question: - Circumstantiality may be evidenced if the client gives unnecessary details or strays from the topic but eventually provides the requested information: Nurse: "How have you been sleeping lately?" Client: "Oh, I go to bed early, so I can get plenty of rest. I like to listen to music or read before bed. Right now I'm reading a good mystery. Maybe I'll write a mystery someday. But it isn't helping, reading I mean. I have been getting only 2 or 3 hours of sleep at night." - Poverty of content (alogia) describes the lack of any real meaning or substance in what the client says: Nurse: "How have you been sleeping lately?" Client: "Well, I guess, I don't know, hard to tell."

Schizophrenia: Onset & Statistics:

- Schizophrenia is usually diagnosed in late adolescence or early adulthood. - Rarely does it manifest in childhood. The peak incidence of onset is 15 to 25 years of age for men and 25 to 35 years of age for women. - The prevalence of schizophrenia is estimated at about 1% of the total population. - In the United States, this translates to nearly 3 million people who are, have been, or will be affected by the disease. - The incidence and the lifetime prevalence are roughly the same throughout the world

Schizophrenia: Seizures:

- Seizures are an infrequent side effect associated with antipsychotic medications. - The incidence is 1% of people taking antipsychotics. The notable exception is clozapine, which has an incidence of 5%. - Seizures may be associated with high doses of the medication. - Treatment is a lowered dosage or a different antipsychotic medication.

Outcome:

- Should be client's ability to re-establish contact with reality

Schizophrenia: Assessment: Roles & Relationships:

- Social isolation is prevalent in clients with schizophrenia, partly as a result of positive signs such as delusions, hallucinations, and loss of ego boundaries. - Relating to others is difficult when oneself concept is not clear. - Clients also have problems with trust and intimacy, which interfere with the ability to establish satisfactory relationships. - Low self-esteem, one of the negative signs of schizophrenia, further complicates the client's ability to interact with others and the environment. - These clients lack confidence, feel strange or different from other people, and do not believe they are worthwhile. - The result is avoidance of other people. - The client may experience great frustration in attempting to fulfill roles in the family and community. - Success in school or at work can be severely compromised because the client has difficulty thinking clearly, remembering, paying attention, and concentrating. - Subsequently, he or she lacks motivation. - Clients who develop schizophrenia at young ages have more difficulties than those whose illness developed later in life because they did not have the opportunity to succeed in these areas before the illness. - Fulfilling family roles, such as that of a son or daughter or sibling, is difficult for these clients. - Often, their erratic or unpredictable behavior frightens or embarrasses family members, who become unsure what to expect next. - Families may also feel guilty or responsible, believing they somehow failed to provide a loving supportive home life. - These clients may also believe they have disappointed their families because they cannot become independent or successful.

Negative (Soft) Symptoms Of Schizophrenia: Asociality:

- Social withdrawal, few or no relationships, lack of closeness

Alogia:

- Speak very little or poverty of content in speech

Side Effects of Antipsychotic Medications and Nursing Interventions: Seizure:

- Stop medication; notify physician; protect client from injury during seizure; provide reassurance and privacy for client after seizure.

Brief Psychotic Disorder (OUTLINE):

- Sudden onset of one psychotic behavior that can last 1 day to 1 month

Positive Symptoms Are:

- Talking a lot and outwardly engaging in behavior

Schizophrenia: Tardive Dyskinesia:

- Tardive dyskinesia, a late-appearing side effect of antipsychotic medications, is characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet. - These involuntary movements are embarrassing for clients and may cause them to become more socially isolated. - Tardive dyskinesia is irreversible once it appears, but decreasing or discontinuing the medication can arrest the progression. - In addition, newly approved medications to treat tardive dyskinesia, valbenazine (Ingrezza) and deutetrabenazine (Austedo, Teva), are now available - Clozapine (Clozaril), an atypical antipsychotic drug, has not been found to cause this side effect, so it is often recommended for clients who have experienced tardive dyskinesia while taking conventional antipsychotic drugs.

Schizophrenia: Biological Theories: Genetic Factors:

- The biologic theories of schizophrenia focus on genetic factors, neuroanatomic and neurochemical factors (structure and function of the brain), and immunovirology (the body's response to exposure to a virus). - Most genetic studies have focused on immediate families (i.e., parents, siblings, and offspring) to examine whether schizophrenia is genetically transmitted or inherited. - Few have focused on more distant relatives. - The most important studies have centered on twins; these findings have demonstrated that identical twins have a 50% risk of schizophrenia; that is, if one twin has schizophrenia, the other has a 50% chance of developing it as well. - Fraternal twins have only a 15% risk. This finding indicates a genetic vulnerability or risk of schizophrenia. - Other important studies have shown that children with one biologic parent with schizophrenia have a 15% risk; the risk rises to 35% if both biologic parents have schizophrenia. - Children adopted at birth into a family with no history of schizophrenia but whose biologic parents have a history of schizophrenia still reflect the genetic risk of their biologic parents. - All these studies have indicated a genetic risk or tendency for schizophrenia, but Mendelian genetics cannot be the only factor; identical twins have only a 50% risk even though their genes are 100% identical. - Rather, recent studies indicate that the genetic risk of schizophrenia is polygenic, meaning several genes contribute to the development

Related Disorder: Schizophreniform Disorder:

- The client exhibits an acute, reactive psychosis for less than the 6 months necessary to meet the diagnostic criteria for schizophrenia. - If symptoms persist over 6 months, the diagnosis is changed to schizophrenia. - Social or occupational functioning may or may not be impaired.

Related Disorder: Brief Psychotic Disorder:

- The client experiences the sudden onset of at least one psychotic symptom, such as delusions, hallucinations, or disorganized speech or behavior, which lasts from 1 day to 1 month. - The episode may or may not have an identifiable stressor or may follow childbirth.

Schizophrenia: Intervention: Implementing Interventions For Delusional Thoughts:

- The client experiencing delusions utterly believes them and cannot be convinced that they are false or untrue. - Such delusions powerfully influence the client's behavior. - For example, if the client's delusion is that he or she is being poisoned, he or she will be suspicious, mistrustful, and probably resistant to providing information and taking medications. - The nurse must avoid openly confronting the delusion or arguing with the client about it. - The nurse must also avoid reinforcing the delusional belief by "playing along" with what the client says. - It is the nurse's responsibility to present and maintain reality by making simple statements such as "I have seen no evidence of that." (presenting reality) or "It doesn't seem that way to me." (casting doubt) - As antipsychotic medications begin to have a therapeutic effect, it will be possible for the nurse to discuss the delusional ideas with the client and identify ways in which the delusions interfere with the client's daily life. - The nurse can also help the client minimize the effects of delusional thinking. Distraction techniques, such as listening to music, watching television, writing, or talking to friends, are useful. - Direct action, such as engaging in positive self-talk and positive thinking and ignoring the delusional thoughts, may be beneficial as well.

Related Disorders: Delusional Disorder:

- The client has one or more non-bizarre delusions—that is, the focus of the delusion is believable. - The delusion may be persecutory, erotomanic, grandiose, jealous, or somatic in content. - Psychosocial functioning is not markedly impaired, and behavior is not obviously odd or bizarre.

Schizophrenia: Long-Term Course:

- The intensity of psychosis tends to diminish with age. - Many clients with long-term impairment regain some degree of social and occupational functioning. - Over time, the disease becomes less disruptive to the person's life and easier to manage but rarely can the client overcome the effects of many years of dysfunction. - In later life, these clients may live independently or in a structured family-type setting and may succeed at jobs with stable expectations and a supportive work environment. - However, many clients with schizophrenia have difficulty functioning in the community, and few lead fully independent lives. - This is primarily due to persistent negative symptoms, impaired cognition, or treatment-refractory positive symptoms - Antipsychotic medications play a crucial role in the course of the disease and individual outcomes. - They do not cure the disorder; however, they are crucial to its successful management. - The more effective the client's response and adherence to his or her medication regimen, the better the client's outcome. Longer periods of untreated psychosis lead to poorer long-term outcomes. - Therefore, early detection and aggressive treatment of the first psychotic episode with medication and psychosocial interventions are essential to promote improved outcomes, such as lower relapse rates and improved insight, quality of life, and social functioning

Schizophrenia: Assessment: History:

- The nurse first elicits information about the client's previous history with schizophrenia to establish baseline data. - He or she asks questions about how the client functioned before the crisis developed, such as "How do you usually spend your time?" and "Can you describe what you do each day?" - The nurse assesses the age at onset of schizophrenia, knowing that poorer outcomes are associated with an earlier age at onset. - Learning the client's previous history of hospital admissions and response to hospitalization is also important. - The nurse also assesses the client for previous suicide attempts. - Of all people with schizophrenia, 10% eventually commit suicide. - The nurse might ask, "Have you ever attempted suicide?" or "Have you ever heard voices telling you to hurt yourself?" - Likewise, it is important to elicit information about any history of violence or aggression because a history of aggressive behavior is a strong predictor of future aggression. - The nurse might ask, "What do you do when you are angry, frustrated, upset, or scared?" The nurse assesses whether the client has been using current support systems by asking the client or significant others the following questions: •Has the client kept in contact with family or friends? •Has the client been to scheduled groups or therapy appointments? •Does the client seem to run out of money between paychecks? •Have the client's living arrangements changed recently? - Finally, the nurse assesses the client's perception of his or her current situation—that is, what the client believes to be significant present events or stressors. - The nurse can gather such information by asking, "What do you see as the primary problem now?" or "What do you need help managing now?"

Schizophrenia: Data Analysis:

- The nurse must analyze assessment data for clients with schizophrenia to determine priorities and establish an effective plan of care. - Not all clients have the same problems and needs, nor is it likely that any individual client has all the problems that can accompany schizophrenia. - Levels of family and community support and available services also vary, all of which influence the client's care and outcomes. -The analysis of assessment data generally falls into two main categories: data associated with the positive signs of the disease and data associated with the negative signs. The North American Nursing Diagnosis Association's (NANDA) nursing diagnoses commonly established based on the assessment of psychotic symptoms or positive signs are: •Risk for other-directed violence •Risk for suicide •Disturbed thought processes •Disturbed sensory perception •Disturbed personal identity •Impaired verbal communication The NANDA nursing diagnoses based on the assessment of negative signs and functional abilities include: •Self-care deficits •Social isolation •Deficient diversional activity •Ineffective health maintenance •Ineffective therapeutic regimen management

Schizophrenia: Evaluation:

- The nurse must consider evaluation of the plan of care in the context of each client and family. - Ongoing assessment provides data to determine whether the client's individual outcomes were achieved. - The client's perception of the success of treatment also plays a part in evaluation - Even if all outcomes are achieved, the nurse must ask if the client is comfortable or satisfied with the quality of life. In a global sense, evaluation of the treatment of schizophrenia is based on: •Have the client's psychotic symptoms disappeared? If not, can the client carry out his or her daily life despite the persistence of some psychotic symptoms? •Does the client understand the prescribed medication regimen? Is he or she committed to adherence to the regimen? •Does the client possess the necessary functional abilities for community living? •Are community resources adequate to help the client live successfully in the community? •Is there a sufficient aftercare or crisis plan in place to deal with recurrence of symptoms or difficulties encountered in the community? •Are the client and family adequately knowledgeable about schizophrenia? •Does the client believe he or she has a satisfactory quality of life?

Schizophrenia: Treatment: Psychopharmacology: First Generation Antipsychotics:

- The primary medical treatment for schizophrenia is psychopharmacology. - In the past, electroconvulsive therapy, insulin shock therapy, and psychosurgery were used, but since the creation of chlorpromazine (Thorazine) in 1952, other treatment modalities have become all but obsolete. - Antipsychotic medications, also known as neuroleptics, are prescribed primarily for their efficacy in decreasing psychotic symptoms. - They do not cure schizophrenia; rather, they are used to manage the symptoms of the disease. - The conventional, or first-generation, antipsychotic medications are dopamine antagonists. - The first-generation antipsychotics target the positive signs of schizophrenia, such as delusions, hallucinations, disturbed thinking, and other psychotic symptoms, but have no observable effect on the negative signs

Schizophrenia: Side Effects:

- The side effects of antipsychotic medications are significant and can range from mild discomfort to permanent movement disorders. - Because many of these side effects are frightening and upsetting to clients, they are frequently cited as the primary reason that clients discontinue or reduce the dosage of their medications. - Serious neurologic side effects include extrapyramidal side effects (EPSs) (acute dystonic reactions, akathisia, and parkinsonism), tardive dyskinesia, seizures, and neuroleptic malignant syndrome (NMS) - Nonneurologic side effects include weight gain, sedation, photosensitivity, and anticholinergic symptoms, such as dry mouth, blurred vision, constipation, urinary retention, and orthostatic hypotension.

Schizoaffective Disorder: Mixture Of Psychotic & Mood Symptoms:

- The symptoms may occur simultaneously or may alternate between psychotic and mood disorder symptoms. - Some studies report that long-term outcomes for the bipolar type of schizoaffective disorder are similar to those for bipolar disorder, while outcomes for the depressed type of schizoaffective disorder are similar to those for schizophrenia. - Treatment for schizoaffective disorder targets both psychotic and mood symptoms. - Often, second-generation antipsychotics are the best first choice for treatment. - Mood stabilizers or an antidepressant may be added if needed

Patient With Schizophrenia Physiologically:

- They have less brain tissue - They have less CSF - They have enlarged brain ventricles - Cortical atrophy - Abnormal function to frontal (negative symptoms) and temporal lobe (positive symptoms) - Excess dopamine/serotonin

Related Disorders: Schizotypal Personality Disorder:

- This involves odd, eccentric behaviors, including transient psychotic symptoms. - Approximately 20% of persons with this personality disorder will eventually be diagnosed with schizophrenia.

Schizophrenia: Extrapyramidal Side Effects: Dystonic Reactions:

- To antipsychotic medications appear early in the course of treatment and are characterized by spasms in discrete muscle groups, such as the neck muscles (torticollis) or eye muscles (oculogyric crisis). - These spasms may also be accompanied by protrusion of the tongue, dysphagia, and laryngeal and pharyngeal spasms that can compromise the client's airway, causing a medical emergency. - Dystonic reactions are extremely frightening and painful for the client. - Acute treatment consists of diphenhydramine (Benadryl) given either intramuscularly or intravenously, or benztropine (Cogentin) given intramuscularly. - Pseudoparkinsonism, or neuroleptic-induced parkinsonism, includes a shuffling gait, masklike facies, muscle stiffness (continuous) or cogwheeling rigidity (ratchet-like movements of joints), drooling, and akinesia (slowness and difficulty initiating movement). - These symptoms usually appear in the first few days after starting or increasing the dosage of an antipsychotic medication. - Akathisia is characterized by restless movement, pacing, inability to remain still, and the client's report of inner restlessness. - Akathisia usually develops when the antipsychotic is started or when the dose is increased -. Clients are typically uncomfortable with these sensations and may stop taking the antipsychotic medication to avoid these side effects. - Beta-blockers such as propranolol have been most effective in treating akathisia, and benzodiazepines have provided some success as well. - The early detection and successful treatment of EPSs is important in promoting the client's compliance with medication. - The nurse is most often the person who observes these symptoms or the person to whom the client reports symptoms. - To provide consistency in assessment among nurses working with the client, a standardized rating scale for EPSs is useful. - The Simpson-Angus scale for EPS is one tool that can be used.

Schizophrenia: Diagnosis:

- Two or more positive symptoms must be present for at one month: •Delusions •Hallucinations •Disorganized speech - Loose associations: (Ideas and topics don't connect) - Neologism: (Made up words that make sense to them - Ideas of reference: (Stimuli has special meaning to the person) •Disorganized Behavior - Aggression - Agitation - Catatonic - Waxy flexibility •Negative symptoms - The disturbance must persist for 6 months - Level of function below previous function prior to the onset of symptoms - Coupled with one month of one of the above

Side Effects Of Antipsychotics:

- Weight gain - Sedation - Anticholinergic Effects - Photosensitivity - Orthostatic hypotension - EPS

Cultural Differences: Bouffe Delirante:

- West Africa & Haiti

Exhibiting Psychosis:

- When exhibiting psychosis, clients may fail to notice they're hungry/thirsty - Constipation is common

Schizophrenia Etiology:

- Whether schizophrenia is an organic disease with underlying physical brain pathology has been an important question for researchers and clinicians for as long as they have studied the illness. - In the first half of the 20th century, studies focused on trying to find a particular pathologic structure associated with the disease, largely through autopsy. - Such a site was not discovered. In the 1950s and 1960s, the emphasis shifted to examination of psychological and social causes. - Interpersonal theorists suggested that schizophrenia resulted from dysfunctional relationships in early life and adolescence. - None of the interpersonal theories has been proved, and newer scientific studies are finding more evidence to support neurologic/neurochemical causes. - However, some therapists still believe that schizophrenia results from dysfunctional parenting or family dynamics. - For parents or family members of persons diagnosed with schizophrenia, such beliefs cause agony over what they did "wrong" or what they could have done to help prevent it. - Newer scientific studies began to demonstrate that schizophrenia results from a type of brain dysfunction. - In the 1970s, studies began to focus on possible neurochemical causes, which remain the primary focus of research and theory today. - These neurochemical/neurologic theories are supported by the effects of antipsychotic medications, which help control psychotic symptoms, and neuroimaging tools such as computed tomography, which have shown that the brains of people with schizophrenia differ in structure and function from those of control subjects.

Schizophrenia: Positive (Hard) Symptoms:

- Which include delusions, hallucinations, and grossly disorganized thinking, speech, and behavior

Schizophrenia: Negative (Soft) Symptoms:

- Which include flat affect, lack of volition, and social withdrawal or discomfort. - Medication may control the positive symptoms, but frequently, the negative symptoms persist after positive symptoms have abated. - The persistence of these negative symptoms over time presents a major barrier to recovery and improved functioning in the client's daily life.

Schizophrenia: Biological Theories: Neuroanatomic and Neurochemical Factors:

- With the development of noninvasive imaging techniques, such as computed tomography, magnetic resonance imaging, and positron emission tomography, in the past 25 years, scientists have been able to study the brain structure (neuroanatomy) and activity (neurochemistry) of people with schizophrenia. - Findings have demonstrated that people with schizophrenia have relatively less brain tissue and cerebrospinal fluid than those who do not have schizophrenia; this could represent a failure in the development or a subsequent loss of tissue. - Computed tomography scans have shown enlarged ventricles in the brain and cortical atrophy. - Positron emission tomography studies suggest that glucose metabolism and oxygen are diminished in the frontal cortical structures of the brain. - The research consistently shows decreased brain volume and abnormal brain function in the frontal and temporal areas of persons with schizophrenia. - This pathology correlates with the positive signs of schizophrenia (temporal lobe), such as psychosis, and the negative signs of schizophrenia (frontal lobe), such as lack of volition or motivation and anhedonia. - It is unknown whether these changes in the frontal and temporal lobes are the result of a failure of these areas to develop properly or whether a virus, trauma, or immune response has damaged them. - Intrauterine influences, such as poor nutrition, tobacco, alcohol, and other drugs, and stress are also being studied as possible causes of the brain pathology found in people with schizophrenia - Neurochemical studies have consistently demonstrated alterations in the neurotransmitter systems of the brain in people with schizophrenia. - The neuronal networks that transmit information by electrical signals from a nerve cell through its axon and across synapses to postsynaptic receptors on other nerve cells seem to malfunction. - The transmission of the signal across the synapse requires a complex series of biochemical events. - Studies have implicated the actions of dopamine, serotonin, norepinephrine, acetylcholine, glutamate, and several neuromodulary peptides. - Currently, the most prominent neurochemical theories involve dopamine and serotonin. - One prominent theory suggests excess dopamine as a cause. This theory was developed on the basis of two observations: - First, drugs that increase activity in the dopaminergic system, such as amphetamine and levodopa, sometimes induce a paranoid psychotic reaction similar to schizophrenia. - Second, drugs blocking postsynaptic dopamine receptors reduce psychotic symptoms; in fact, the greater the ability of the drug to block dopamine receptors, the more effective it is in decreasing symptoms of schizophrenia.. - More recently, serotonin has been included among the leading neurochemical factors affecting schizophrenia. - The theory regarding serotonin suggests that serotonin modulates and helps to control excess dopamine. - Some believe that excess serotonin itself contributes to the development of schizophrenia. - Newer atypical antipsychotics, such as clozapine (Clozaril), are both dopamine and serotonin antagonists. - Drug studies have shown that clozapine can dramatically reduce psychotic symptoms and ameliorate the negative signs of schizophrenia

Stilted Language:

- Word fluff

Self-Awareness Issues:

- Working with clients with schizophrenia can present many challenges for the nurse. - Clients have many experiences that are difficult for the nurse to relate to, such as delusions and hallucinations. - Suspicious or paranoid behavior on the client's part may make the nurse feel as though he or she is not trustworthy or that his or her integrity is being questioned. - The nurse must recognize this type of behavior as part of the illness and not interpret or respond to it as a personal affront. - Taking the client's statements or behavior as a personal accusation only causes the nurse to respond defensively, which is counterproductive to the establishment of a therapeutic relationship. - The nurse may also be genuinely frightened or threatened if the client's behavior is hostile or aggressive. - The nurse must acknowledge these feelings and take measures to ensure his or her safety. - This may involve talking to the client in an open area rather than in a more isolated location or having an additional staff person present rather than being alone with the client. - If the nurse pretends to be unafraid, the client may sense the fear anyway and feel less secure, leading to a greater potential for the client to lose personal control. - As with many chronic illnesses, the nurse may become frustrated if the client does not follow the medication regimen, fails to keep needed appointments, or experiences repeated relapses. - The nurse may feel as though a great deal of hard work has been wasted or that the situation is futile or hopeless. - Schizophrenia is a chronic illness, and clients may suffer numerous relapses and hospital admissions. - The nurse must not take responsibility for the success or failure of treatment efforts or view the client's status as a personal success or failure. - Nurses should look to their colleagues for helpful support and discussion of these self-awareness issues.

Which of the following is a neurologic side effect of antipsychotic therapy? A. Blurred vision B. Agranulocytosis C. Sedation D. Tardive dyskinesia

D. Tardive dyskinesia - Rationale: Tardive dyskinesia is a neurologic side effect of antipsychotic therapy. o Blurred vision, sedation, and agranulocytosis are nonneurologic side effects.

Is the following statement true or false? The nurse should confront the client's delusions.

False - Rationale: When a client is experiencing delusions, the nurse should focus on the reality and not confront or reinforce the client's delusions.

2. The nurse is planning discharge teaching for a client taking clozapine (Clozaril). Which teaching is essential to include? a.Caution the client not to be outdoors in the sunshine without protective clothing. b.Remind the client to go to the lab to have blood drawn for a white blood cell count. c.Instruct the client about dietary restrictions. d.Give the client a chart to record the daily pulse rate.

b.Remind the client to go to the lab to have blood drawn for a white blood cell count.

6. The client who hesitates 30 seconds before responding to any question is described as having a.blunted affect. b.latency of response. c.paranoid delusions. d.poverty of speech.

b.latency of response.

4. Which of the following statements would indicate family teaching about schizophrenia had been effective? a."If our son takes his medication properly, he won't have another psychotic episode." b."I guess we'll have to face the fact that our daughter will eventually be institutionalized." c."It's a relief to find out that we did not cause our son's schizophrenia." d."It is a shame our daughter will never be able to have children."

c."It's a relief to find out that we did not cause our son's schizophrenia."

1. The family of a client with schizophrenia asks the nurse about the difference between conventional and atypical antipsychotic medications. The nurse's best answer may include which information? a.Atypical antipsychotics are newer medications but act in the same ways as conventional antipsychotics. b.Conventional antipsychotics are dopamine antagonists; atypical antipsychotics inhibit the reuptake of serotonin. c.Conventional antipsychotics have serious side effects; atypical antipsychotics have virtually no side effects. d.Atypical antipsychotics are dopamine and serotonin antagonists; conventional antipsychotics are only dopamine antagonists.

d.Atypical antipsychotics are dopamine and serotonin antagonists; conventional antipsychotics are only dopamine antagonists.

3. The nurse is caring for a client who has been taking fluphenazine (Prolixin) for 2 days. The client suddenly cries out, his neck twists to one side, and his eyes appear to roll back in the sockets. The nurse finds the following PRN medications ordered for the client. Which one should the nurse administer? a.Benztropine (Cogentin), 2 mg PO, bid, PRN b.Fluphenazine (Prolixin), 2 mg PO, tid, PRN c.Haloperidol (Haldol), 5 mg IM, PRN extreme agitation d.Diphenhydramine (Benadryl), 25 mg IM, PRN

d.Diphenhydramine (Benadryl), 25 mg IM, PRN

7. The overall goal of psychiatric rehabilitation is for the client to gain a.control of symptoms. b.freedom from hospitalization. c.management of anxiety. d.recovery from the illness.

d.recovery from the illness.

Client & Family Education For Management Of Antipsychotic Medications:

•Drink sugar-free fluids and eat sugar-free hard candy to ease the anticholinergic effects of dry mouth. •Avoid calorie-laden beverages and candy because they promote dental caries, contribute to weight gain, and do little to relieve dry mouth. •Constipation can be prevented or relieved by increasing intake of water and bulk-forming foods in the diet and by exercising. •Stool softeners are permissible, but laxatives should be avoided. •Use sunscreen to prevent burning. Avoid long periods of time in the sun, and wear protective clothing. Photosensitivity can cause you to burn easily. •Rising slowly from a lying or sitting position prevents falls from orthostatic hypotension or dizziness due to a drop in blood pressure. Wait until any dizziness has subsided before you walk. •Monitor the amount of sleepiness or drowsiness you experience. Avoid driving a car or performing other potentially dangerous activities until your response time and reflexes seem normal. •If you forget a dose of antipsychotic medication, take it if the dose is only 3 to 4 hours late. If the missed dose is more than 4 hours late or the next dose is due, omit the forgotten dose. •If you have difficulty remembering your medication, use a chart to record doses when taken, or use a pillbox labeled with dosage times and/or days of the week to help you remember when to take medication.

Client & Family Education For Schizophrenia:

•How to manage illness and symptoms •Recognizing early signs of relapse •Developing a plan to address relapse signs •Importance of maintaining prescribed medication regimen and regular follow-up •Avoiding alcohol and other drugs •Self-care and proper nutrition •Teaching social skills through education, role modeling, and practice •Seeking assistance to avoid or manage stressful situations •Counseling and educating family/significant others about the biologic causes and clinical course of schizophrenia and the need for ongoing support •Importance of maintaining contact with the community and participating in supportive organizations and care

Early Signs Of Relapse:

•Impaired cause-and-effect reasoning •Impaired information processing •Poor nutrition •Lack of sleep •Lack of exercise •Fatigue •Poor social skills, social isolation, loneliness •Interpersonal difficulties •Lack of control, irritability •Mood swings •Ineffective medication management •Low self-concept •Looks and acts different •Hopeless feelings •Loss of motivation •Anxiety and worry •Disinhibition •Increased negativity •Neglecting appearance •Forgetfulness

Schizophrenia: Treatment:

•Medications due not cure •Possible of medication is to treat the symptoms/management of symptoms •Adherence and compliance are important to successful management - Non-compliance is an issue with schizophrenia •First generation Antipsychotics effective with positive symptoms •Haloperidol •Chlorpromazine •Perphenazine •Second generation effective for both positive and negative symptoms •Clozapine •Risperidone •Olanzapine •Quetiapine •Ziprasidone (Geodon) •Paliperidone (Invega) •Long-acting injections for maintenance therapy •Fluphenazine •Risperidone (Risperdal consta) •Paliperidone (Invega sustenna) - Medications are slowly absorbed overtime - Effects last 2-4 weeks - Increase adherence/compliance - 7 to 28 for fluphenazine - 4 weeks haloperidol - Remember patients should be on oral medication before receiving injectable meds of antipsychotics

Points To Consider When Working With Clients With Schizophrenia:

•Remember that although these clients often suffer numerous relapses and return for repeated hospital stays, they do return to living and functioning in the community. Focusing on the amount of time the client is outside the hospital setting may help decrease the frustration that can result when working with clients with a chronic illness. •Visualize the client not at his or her worst, but as he or she gets better and symptoms become less severe. •Remember that the client's remarks are not directed at you personally but are a byproduct of the disordered and confused thinking that schizophrenia causes. •Discuss these issues with a more experienced nurse for suggestions on how to deal with your feelings and actions toward these clients. You are not expected to have all the answers.

Other Related Disorders:

•Schizophreniform disorder - Psychosis for less than 6 months •Brief Psychotic Disorder - Sudden onset of positive symptoms - Symptoms present for one day but less than 1 month/return to pre-psychotic state •Delusion disorder - Delusions are present for 1 month or longer - Typically no hallucination •Schizoaffective - Manic or depressive state - Delusions or hallucination are present for 2 or more weeks outside of mood episodes

Side Effects Of Treatment:

•Weight gain, sedation, photosensitivity and anticholinergic symptoms •EPS •Acute dystonic reactions - Muscle spasms - Torticollis - Oculogyric crisis - Can be frightening or painful for the client - Treated with Benadryl or Cogentin (IM) •Akathisia - Restlessness (inner restlessness) - Propranolol has been successful in treating restlessness •Pseudoparkinsonism - Shuffling gait, masklike face, drooling - Symptoms are reversible and appear at the start of medication or increase of dose •Tardive Dyskinesia - Irreversible - Decrease dose or discontinuation decrease progression - Clozapine (atypical-second generation) - Lip smacking, chewing, grimacing, blinking, restless/fidgeting •AIMS (abnormal involuntary movement scale) tool to assess - Completed every 3-6 months - Symptoms rated on scale 0-4 - Early recognition is important to prevent progression - Appears late in treatment • Seizures - Rare •Neuroleptic Malignant syndrome - Stop medications - Muscle rigidity - High fever -Increased muscle enzymes (CPK-creatine phosphokinase) - Indicate muscle damage •Agranulocytosis - Clozapine - Discontinue medication if labs indicate present - Need WBC prior to and periodically while on medication - 18-24 weeks after starting treatment - Fever, malaise, sore throat, leukopenia - Only dispense 7 to 14 days because a WBC is required for refill - 3,500 cells •Group therapy is an opportunity provides social contact - Medication management • Community support - Cognitive Enhancement therapy- practice and develop social skills