suicide/schizophrenia

"A client who is newly diagnosed with schizophrenia tells the nurse, ""The aliens are telling me that I am defective and need to be eliminated."" Which response by the nurse is most appropriate initially?"

"I want you to agree to tell staff when you hear these voices."

onset of schizophrenia

- abrupt or insidiuous - most slow development of symptoms - ongoing psychosis (diminishes w/age) alternates w/relative recovery

suicidal assessment

- sex (men>women) - age (increased in age) - depression

schizophrenia dx criteria

2 or more symptoms for at least 1 month one symptom being over a 6 months period: delusion hallucination disorganized speech neg. symptom grossly disorganized or catatonic

when is the highest risk for suicide

2 years after previous attempt esp. first 3 mths

screening tool for tardive dyskinesia

AIMS (abnormal involuntary movements scale)

The plan of care for an outpatient client with schizophrenia includes risperidone therapy. The nurse prepares to administer this drug based on the understanding of which factor?

Agranulocytosis is less of a risk with risperidone therapy than with clozapine.

A client with schizophrenia is mute, can't perform activities of daily living, and stares out the window for hours. What is the nurse's first priority?

Assist the client with feeding.

A nurse must administer a medication to reverse or prevent Parkinson-type symptoms in a client receiving an antipsychotic. The medication the client will likely receive is:

Benztropine, trihexyphenidyl, or amantadine are ordered for treatment of Parkinson-type symptoms. Diphenhydramine provides rapid relief for dystonia. Propranolol relieves akathisia. Haloperidol can cause Parkinson-type symptoms.

A client with bipolar disorder, manic phase, is yelling at another client. The client's face is flushed and his fists are clenched. Which of the following nursing actions should be taken first?

Direct the client to his room for a time-out.

A client who is newly diagnosed with schizophrenia tells the nurse, The aliens are telling me that I am defective and need to be eliminated. Which response by the nurse is appropriate initially?

I want you to agree to tell staff when you hear these voices.

side effects of antipsychotics SHE WAS ME

S - sedation H - hypotension E - extrapyramidal W - weight gain A - anticholinergic S - sexual dysfunction M - metabolic (glucose tolerance) E - endocrine

SADPERSONS

S - sex A - age D - depression P - previous attempt E - ethanol R - rational thinking S - social support O - organized plan N - no spouse S - sickness

Which effects do most antipsychotic medications exert on the central nervous system (CNS)?

They depress the CNS by blocking the postsynaptic transmission of dopamine, serotonin, and norepinephrine.

mutism

absence of verbal speech

extrapyramidal effect

acute dystonic reaction akathisia parkinsonism

A client receiving haloperidol reports a stiff jaw and difficulty swallowing. The nurse's first action should be to:

administer an as-needed dose of benztropine I.M. as ordered.

what disturbances occur in schizophrenia?

affect mood behavior thought processes

serotonin syndrome

agitation sweating fever tachycardia hypotension rigidity hyperreflexia coma death

extrapyramidal side effects s/s

akathisia = restlessness dystonia = muscle spasms & twitching motions pseudoparkinsonims = mask like face, rigidity, tremors, drooling, shuffling gait, dysphagia

NI for delusions

ask to describe delusion be open & honest in interactions to reduce suspiciousness focus on reality-based topics, rather than delusion encourage expression of feelings, focus on feelings that delusion generates set limits on how long talk about delusions if pt. obsesses do not argue or try to convince that delusion false validate if part of delusion real activities on a one-on-one basis alter routines (allow canned or packaged foods or food from home) recognize accomplishments & provide positive feedback for success

NI for Schizophrenia

assess pt's physical needs set limits on behavior when it interferes w/others maintain safe environment one-on-one interaction & progress to small groups as tolerated spend time w/pt. even if unable to respond monitor for altered thought processes maintain ego boundaries & avoid touching avoid overly warm approach, neutral best (less threatening) keep promises establish daily routines assist pt. to improve grooming & to accept responsibility for personal care sit w/pt. in silence if necessary brief, frequent contact w/pt. tell pt. when u are leaving tell pt. when u do not understand do not go along w/hallucinations or delusions simple concrete activities (puzzles, word games) reorient as necessary help establish what is real stay w/pt. if pt. frightened speak in simple, direct, concise manner reassure pt. that environment is safe remove from group situations if pt is too bizarre, disturbing/danger set realistic goals do not offer choice (initially), gradually assist in making decisions used canned or packaged food provide radio etc. at night for insomnia explain everything that needs to be done set limits for pt. if pt. unable to do so decr. excessive stimuli monitor for suicide risk assist in alternative means to express feelings, (music or art therapy)

types of hallucinations

auditory (hearing voices) gustatory (taste) olfactory (smell) tactile (feel) visual (see)

childhood onset

before age 12 = severe form

meds to prevent extra pyramidal effects

benadryl cogentin

pseudoparkinsonism

benztropine

negative symptoms

blunted affect poverty of thought (alogia) loss of motivation (avolition) inability to experience pleasure or joy (anhedonia)

types of schizophrenia

catatonic disorganized paranoid residual undifferentiated

schizophrenia motor activity

catatonic posturing (holding bizarre postures catatonic excitement (moving excitedly, w/ no enviro stimuli) total immobilization inability to respond to commands waxy flexibility repetitive/stereotype movements incr. motor activity (agitation, pacing, inability to sleep, loss of appetite/weight) inability to initiate activity (anergia)

indicators of suicide ideation

change in school work performance incr. accidents choosing method for suicide = lethality degree of effort specificity accessibility of weapon ease of rescue sudden interest in life insurance

schizophrenia maintenance therapy

decanoate Haldol & Proloxin (fluphenazine) lasts 2-4 weeks, no need for daily meds

overcompliance

deny responsibility by following instructions to the letter

dystonia

diphenhydramine benztropine

undifferentiated schizophrenia

does not meet any of the other criteria delusions & hallucinations disorganized speech disorganized or catatonic behavior flat affect social withdrawal

circumstantiality

doesn't get to the point,

residual schizophrenia

dx of schizophrenia in the past time ltd. between attacks, but may last for many years considerable social isolation & withdrawal, impaired role functioning

depressive & other mood symptoms in schizophrenia

dysphoria suicidal hopelessness

depressive & other mood symptoms in schizophrenia

dysphoria suicidal hopelessness

antipsychotics side effects

extrapyramidal effects tardive dyskinesia seizures neuroleptic malignent syndrome weight gain, sedation, photosensitivity anticholinergic orthostatic hypotension agranulocytosis

disorganized schizophrenia

extreme social withdrawal disorganized speech or behavior flat or inappropriate affect silliness unrelated to speech stereotyped behaviors grimacing mannerisms inability to perform activities of daily living

neuroleptic syndrome s/s

fever (101-103) respiratory distress tachycardia seizures diaphoresis HTN or hypotension pallor tiredness severe muscle rigidity loss of bladder control stop meds, txt symptoms

confabulation

fills in memory gap with detailed fantasies, to maintain selfesteem

how quickly do illusions & hallucinations diminish with txt?

first few days of txt delusions/hallucinations not as intense but these symptoms only rest takes 6-8 wks to respond

flight of ideas

flow of speech, jumps from topic to topic, not connection between

suicide pathophysiology/etiology

genetic impulsivity serotonin dysfunction post traumatic brain injury

etiology schizophrenia

genetic (partially inherited) neuroanatomic or neurochem. factors (less brain tissue, cerebrospinal fluid, excess of dopamine & serotonin immunovirologic factors (viral exposure, cytokinesis)

pharmacology & schizophrenia

goal: reduce psychotic symptoms antipsychotics (dopamine agonists) - targets positive symptoms atypical antipsychotics (dopamine/serotonin antagonists) - diminish positive symptoms& lessen negative symptoms

what is schizophrenia?

group of mental disorders * psychotic features * disordered thought processes * disrupted interpersonal relationships

psychotic features

hallucinations delusions

positive symptoms of schizophrenia

hallucinations delusions disorganized speech (LOA) bizarre behavior

looseness of association

haphazard, illogical, confused thinking, interrupted connections in thought

A nurse knows that a physician has ordered the liquid form of the drug chlorpromazine  rather than the tablet form because the liquid:

has a more predictable onset of action. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.

A nurse knows that a physician has ordered the liquid form of the drug chlorpromazine rather than the tablet form because the liquid:

has a more predictable onset of action. A liquid phenothiazine preparation will produce effects in 2 to 4 hours. The onset with tablets is unpredictable.

perceptual distortions in schizophrenia

illusions hallucinations

abnormal thought processes

impaired reality testing fragmentation of thoughts thought blocking loose association echolalia distorted perception of the environment neologisms magical thinking inability to conceptualize meaning in words or thoughts inability to organize facts logically delusions associated with thought processes or content

cognitive symptoms in schizophrenia

inattention, easily distracted impaired memory poor problem-solving skills poor decision-making skills illogical thinking impaired judgment

psychosocial txt in schizophrenia

individual/group therapy social skills training (cognitive adaptation training, cognitive enhancement therapy CET) family therapy family education

tardive dyskinesia

involuntary movement of mouth (tongue writhing, tongue protrusion, teeth grinding, lip smacking), face & exremities can occur 6 mths after start of txt

types of delusions in schizophrenia

loss of reference (everything happening related to self) delusions of persecution delusions of grandeur somatic delusions (body is changing or responding unusually)

neologism

makes up words that have meaning for them, part of a delusional system

adolescent onset

may be triggered by a stressor

illusion

misinterpretation or misperception of reality

schizophrenia emotional characteristics

mistrust view of world as threatening & unsafe affect blunted, flat, inappropriate feelings of ambivalence, helplessness, anger, guilt, depression

A client diagnosed with schizoaffective disorder is suffering from schizophrenia with elements of which other disorder?

mood disorder

older adult onset

most have had disorder since use

neologism

newly devised word that has special meaning only to pt.

hallucination

no basis in reality (with five senses)

waxy flexibility

once placed into position holding the same position for hours

Schizophrenia is best described as a disorder characterized by

preoccupation with persecutory delusions, anxiety, anger, and potential for violence.

clinical predictor of suicide

previous attempts

akathisia txt

propranolol benzodiazepines

catatonic schizophrenia

psychomotor disturbance immobility stupor waxy flexibility excessive purposeless motor activity echolalia automatic obedience stereotyped or repetitive behavior

elders & schizophrenia

psychotic symptoms usually due to depression or dementia variety of outcomes for elderly

verbigeration

purposeless repetition of words or phrases

Diphenhydramine .

rapid relief for dystonia.

language & communication disturbance in schizophrenia

related to disorders in thought processes inability to organize language difficulty in communicating clearly inappropriate responses to situation single word or phrase may represent the whole meaning development of private language

language & communication disturbance in schizophrenia

related to disorders in thought processes inability to organize language difficulty in communicating clearly inappropriate responses to situation single word or phrase may represent the whole meaning development of private language

Propranolol

relieves akathisia

echolalia

repeating speech of another person

echopraxia

repeating the movements of another person

echolalia

repetition of words & sounds heard from other person

clang association

repetition of words or phrases that are similar in sound

compulsive rituals schizophrenia

repetitive actions to resolve conflict feelings

NI for hallucination

safety 1st intervene w/ one-on-one contact ask directly about hallucinations avoid conveying that others experience hallucinations too avoid reacting to hallucinations as if they were real decrease stimuli or move client to another area accept behavior do not joke or judge provide easy activities & structured environment w/routine activities of daily living do not negate pt's experience focus on reality-based topics attempt to engage attention through concrete activities respond verbally to anything real pt. talk about avoid touching pt monitor for signs of increasing anxiety or agitation (hallucination may be increasing) administer meds

disorders related to schizophrenia

schizophreniform disorder catatonia delusional disorder brief psychotic disorder shared psychotic disorder schizotypical personality disorder

pressured speech

speaking as if the words are being forced out quickly

thought blocking

sudden cessation of thought in middle of sentence, unable to continue train of though, new thoughts come up unrelated to the topic

paranoid schizophrenia

suspiciousness hostility delusions auditory hallucinations anxiety & anger aloofness persecutory themes violence

When discharging a client after treatment for a dystonic reaction, an emergency department nurse must ensure that the client understands

the client must take benztropine as ordered to prevent a return of symptoms. (anticholinergic)

antipsychotics used in schizophrenia

thorazine prolixin haldol clozapine risperdal seroquel olanzepine

Benztropine

treatment of Parkinson-type symptoms

physical characteristics schizophrenia

unkempt body image distortion preoccupied w/somatic complaints neglect hygiene, eating, sleeping, elimination

lithium toxicity s/s

vomiting diarrhea decreased coordination muscle weakness/twitching drowsiness hold meds/notify HCP

word salad

words or phrases are connected meaninglessly