Chapter 22 Schizophrenia

The nurse observes a client with schizophrenia sitting alone, laughing occasionally, and turning his head as if listening to another person. The nurse assesses this behavior to indicate that the client is experiencing auditory hallucinations and says ...

"Are you hearing something?"

A nurse is assessing a client diagnosed with schizophrenia. When documenting the findings, which would the nurse identify as a positive symptom? Select all that apply.

Delusions Hallucinations

risk factors of schizophrenia

Early neurologic problems, stressful life events, and nonhereditary genetic factors Genetic factors related to cognitive and brain function and brain structure Environmental factors include migrant status, having an older father, Toxoplasma gondii antibodies, prenatal famine, lifetime cannabis use, obstetric complications

Some research has suggested that schizophreniform disorder may be an early manifestation of which other mental health condition?

Schizophrenia

A client with command auditory hallucinations and a history of aggressive outbursts is observed pacing and grimacing while in the day room. Which should be the nurse's priority?

Support the client in returning to the client's room

Research related to the development of schizophrenia has shown what?

The disorder is thought to arise from the interaction of a biological predisposition and environmental stressors.

NURSING ASSESSMENT

The nursing assessment should include the biologic, psychological, and social aspects because schizophrenia affects all aspects of the person's life. Not only are symptoms assessed, but strengths are also important in the assessment process.

Extrapyramidal Side Effects

parkinsonism: Resting tremor, rigidity, bradykinesia or akinesia, masklike face, shuffling gait, decreased arm swing dystonia reactions - starts: oculogyric crisis - advance to: torticollos/retrocollis (Tx: Benedryl, Cogentin) akathisia: Obvious motor restlessness evidenced by pacing, rocking - Tx antivan, anti-parkinson meds tardive dyskinesia: Abnormal dyskinetic movements of the face, mouth, and jaw - no Tx; things to distract

what is the ultimate goal for treatment for schizophrenia?

recovery! (can be lifelong) - following a therapeutic regime, maintaining a healthy lifestyle, managing the stresses of life, and developing meaningful interpersonal relationships are important parts of the recovery

A client begins to exhibit hallucinations and delusions along with disorganized speech after forgetting to take antipsychotic medication. The nurse suspects that the client is at which point in the clinical course of the disorder?

relapse

therapeutic relationship

remain calm - short time interactions - allow time to calm down - do not overstimulate them - power struggle = avoid arguments

Clozapine side effects

stop smoking - weight gain - Agranulocytosis - interactions with other antidepressants

A client is diagnosed with schizoaffective disorder. The interdisciplinary plan of care includes key family members. The nurse understands that a major reason for doing so involves which of the following?

strengthening the clients recovery

negative symptoms of schizophrenia

the absence of appropriate behaviors (expressionless faces, rigid bodies) diminished emotional expression and avolition (lack of interest or motivation

psychosocial interventions

therapeutic interactions enhancing cognitive functioning using behavioral interventions

Paliperidone (Invega) side effects

weight gain, sedation, and musculoskeletal pain (not as important to remember)

Positive symptoms seen in schizophrenia are believed to be a result of which type of neurological dysfunction?

increased amount of dopamine

When describing the difference between schizoaffective disorder (SAD) and schizophrenia, the nurse would address which as associated with SAD?

increased mood responses

age of onset of schizophrenia

late teens to early 20s

Using Behavioral Interventions

list of things 'to do' or complete - Reinforcement of positive behaviors (getting up on time, completing hygiene, going to treatment activities) can easily be included in a treatment plan

A client diagnosed with schizoaffective disorder exhibits the symptoms of a psychosis in addition to which of the following?

mood disorder

late adolescence in schizophrenia

more anger and agitation, harming themselves - monitor for suicide risks

relapses

no inevitable - With each relapse, a longer period of time is needed to recover - Combining medications, particularly long-acting injectable agents greatly diminishes the severity and frequency of relapses - One major reason for relapse is failure to take medication consistently

A nurse is reviewing a journal article about the etiology of schizophrenia.The nurse would expect to find information about the dysfunction of which neurotransmitter? Select all that apply.

Dopamine Glutamine Serotonin Gamma-aminobutyric acid (GABA)

suicide assessment

A suicide assessment always should be completed when a person is experiencing a psychotic episode - especially with hallucinations and delusions

The nurse is providing teaching to a client diagnosed with schizoaffective disorder. The nurse should explain to the client that which is true about this disorder?

It is a mix of psychotic and mood symptoms.

2nd Generation

Risperidone (Risperdal) Clozapine (Clozaril) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega)

Abilify side effects

akathisia, anxiety, insomnia, constipations (not as important to remember)

homicidal ideations

assess for any homicidal thoughts when assessing for suicide risks/thoughts

One evening, a client with schizophrenia leaves the client's room and begins marching in the hall. When approached by the nurse, the client says, "God says I'm supposed to guard the area." Which response would be best?

"I understand you hear a voice. You and I are the only ones in the hall, and I don't hear a voice."

The nurse is working with a client who has schizophrenia, disorganized type. It is time for the client to get up and eat breakfast. Which statement by the nurse would be most effective in helping the client prepare for breakfast?

"It is time to put your clothes on now"

The nurse is teaching a client with schizoaffective disorders (SAD) about the client's prescribed medication therapy. The nurse determines that additional education is needed when the client states what?

"One day, I won't have to worry about taking any medication."

The nurse enters the room of a client with schizophrenia the day after the client has been admitted to an inpatient setting and says, "I would like to spend some time talking with you." The client stares straight ahead and remains silent. Which would be the best response by the nurse?

"You don't need to talk right now. I'll just sit here for a few minutes."

stabilization

- Treatment is intense during this period as medication regimens are established and patients and their families begin to adjust to the idea of a family member having a long-term severe mental illness. - knowing the SE of the meds - Socialization with others begins to increase, so that rehabilitation begins.

Ziprasidone side effects

- give with food - hypersensitivity

acute illness

- symptoms of acute illness usually occur in late adolescence or early adulthood - episodes of staying up all night for several nights, incoherent conversations, or aggressive acts against oneself or others - As symptoms worsen, patients are less and less able to care for their basic needs (e.g., eating, sleeping, bathing). Substance use is common. - the acute phase, individuals afflicted by schizophrenia are at high risk for suicide (pt may be hospitalized)

diagnostic findings of Schizophrenia

1 month of symptoms - negative and positive last at LEAST 6 months

ages that men usually get diagnosed with Schizophrenia

18-25 - 'imaginary friends'

ages that women usually get diagnosed with Schizophrenia

25-35

A client diagnosed with schizophreniform disorder must have symptoms present for at least 1 month but with a duration of less than:

6 months

A nurse teaching a client about prescribed antipsychotic medication informs the client to contact a health care provider immediately if the client notices:

A dramatic change in temperature.

A nurse monitoring client medication needs to recognize side effects quickly and intervene promptly for which reason?

Alleviate the side effects and help client maintain adherence

Which of the following would the nurse identify as a negative symptom associated with schizophrenia?

Anhedonia

Which would a nurse expect to administer to a client with schizophrenia who is experiencing a dystonic reaction?

Benztropine (or benadryl)

A psychiatric-mental health nurse is assessing a client with schizophrenia. Which finding would the nurse document as reflecting disorganized thinking? Select all that apply.

Clang associations Neologisms Circumstantiality

wellness challenges

Coping effectively with daily stresses when also dealing with positive and negative symptoms - Strategies: Relaxation, meditation, deep breathing, and mindfulness Seeking pleasant environments that support well-being - Strategies: Seek comfortable living arrangements and explore community resources Satisfying current and future financial situations - Strategies: Seek financial counseling and refer to social services Satisfying and enriching work - Strategies: Explore meaningful activities and occupational opportunities system Expanding a sense of purpose and meaning in life - Strategies: Focus on goals, values and beliefs, and read inspiring stories or essays

managing and treatment complications

DRESS: life threatening hypersensitivity - Drug Reaction Eosinophilia Systemic Symptoms Neuroleptic Malignant Syndrome: muscle rigidity; Tx is anti-pyretics/cool blankets Agranulocytosis: low WBC, mouth sores; Tx is anti-virals/biotics Cholinergic Rebound: abruptly stopping those meds; severe N/V, excessive sweating, changes thought process: NIGHTMARES Anticholinergic Crisis/ Anticholinergic Delirium: overdose of the med

Schizophrenia

Disorder of thoughts, perception & behavior - Psychotic symptoms that last for at least 6 mo

A client diagnosed with schizoaffective disorder and severe depression is being treated with antipsychotic medications. The client tells the nurse about difficulty with self-care activities. With which intervention should the nurse respond?

Establish a routine and set goals.

Mental Health Nursing Interventions

Establishing Mental Health and Wellness Goals Self Care - Daily schedule - Wellness Challenges Activity and exercise: maintain a healthy lifestyle but also to counteract the side effects of psychiatric medications that cause weight gain (from meds) Acute psychosis: During episodes of acute psychosis, patients are sometimes unable to focus on eating. - encourage finger foods - if overweight, think of healthier options

Which type of antipsychotic medication is most likely to produce extrapyramidal effects?

First-generation antipsychotic drugs

biologic and psychological theories of Schizophrenia

Genetic: altered dopamine transmission Neurobiological: changes to brain (usually find out after they die) Non-genetic: birth complications

A client on the unit suddenly cries out in fear. The nurse notices that the client's head is twisted to one side, the client's back is arched, and the client's eyes have rolled back in the sockets. The client has recently begun drug therapy with haloperidol. Based on this assessment, which would be the first action of the nurse?

Give a PRN dose of benztropine IM

During a client interview, a client states that "God has sent me a special message. I'm the only one who can carry out his plan." The nurse interprets this statement as suggesting which type of delusion?

Grandiose

1st generation antipsychotics

Haloperidol (Haldol) Loxapine (Loxitane) Thiothixene (Navane)

Haldol side effects

Hyperprolactinemia

Enhancing Cognitive Functioning

If the ability to focus or maintain attention is an issue, patients can be encouraged to select activities that improve attention, such as computer games. For memory problems, patients can be encouraged to make lists and to write down important information.

A client diagnosed with delusional disorder is experiencing persecutory delusions involving the belief that someone is putting poison in his food. When developing the client's plan of care, which nursing diagnosis would be most likely?

Imbalanced Nutrition, Less than Body Requirements

Catatonia as seen in clients with schizophrenia is unique in the existence of which feature?

Immobility like being in a trance

When preparing a class presentation about schizophrenia, what would the nurse most likely include?

Improvement in symptoms can occur as a client with a history of schizophrenia reaches older adulthood.

Nursing Responsibilities for Administering Medications

Initial Acute Phase of Schizophrenia Stabilization Adherence best approach to prevent relapse Long-Term Injectable: more compliance Lifetime- Rarely Discontinued

Which is the central focus of persecutory delusions?

Injustice that must be remedied by legal action

A client with delusional disorder is hospitalized. When reviewing the client's medical record, the nurse identifies which reason as most likely for the hospitalization?

Legal violation

A psychiatric-mental health nurse is conducting a teaching session for family members of clients with schizophrenia. When describing relapse, which factor would the nurse address as a major cause?

Medication noncompliance

A nurse is reading a journal article about schizophrenia spectrum disorders and theories related to their etiology. Part of the article describes events occurring in utero in which genes involved with cell migration, cell proliferation, axonal outgrowth, and myelination may be affected by neurologic insults such as viral infections. The nurse identifies this as which hypothesis?

Neurodevelopmental

preventing drug-drug interactions

Nicotine Grapefruit Juice Other Antidepressants Non-adherence leads to relapse - also alcohol/substance use

All are included in the plan of care for a client with schizophrenia. Which nursing intervention should the nurse perform first when caring for this client?

Observe for signs of fear or agitation.

The client was conversing with the nurse when noticeable changes occurred with the client. Which is a term used to describe the occurrence of the eye rolling back in a locked position, which occurs with acute dystonia?

Oculogyric crisis

managing side effects 1

Orthostatic Hypotension: by teaching them to rise slowly and by monitoring blood pressure before giving the medication; prevent falls Hyperprolactinemia: When dopamine is blocked in the tuberoinfundibular tract, it can no longer repress prolactin; Gynecomastia Sedation: for older pts assess for fall risks; for younger consider changing medications Weight gain: I&O's; antipsychotic agents; Diet teaching and monitoring may have some effect; educate on healthy foods and exercise New onset DM: should be assessed in patients taking antipsychotic drugs; should be monitored for signs of DM; Fasting blood glucose tests are common (3 P's!!!) Cardiac arrhythmias: monitor vital signs; Prolongation of the QTc interval; T-tach/V-fib

When developing the plan of care for a client diagnosed with delusional disorder, the nurse would anticipate treatment in which setting?

Outpatient

Which type of delusion refers to a situation whereby a person or someone close to person is being malevolently treated in some way?

Persecutory type

fluid balance - teaching self monitoring skills

Polydipsia: increased thirst, constantly drinking... risks: watch SODIUM levels Monitor weight I& 0 Urine specific gravity

When planning the discharge for a client who has schizophrenia, the nurse anticipates barriers to the client's ability to adhere to the medication regimen. Which characteristics improves the likelihood that the client will follow the prescribed medication regimen? Select all that apply.

Short-term memory intact Receives monthly disability checks States location of pharmacy nearest the client's residence

A nurse is assessing a client who is reporting the sensation of "bugs crawling under the skin" and intense itching and burning. The client states, "I know bugs have invaded my body." There is no evidence to support the client's report. The nurse interprets this as which type of delusion?

Somatic

prodromal period of schizophrenia

Stage of early changes that are precursor to the disorder - Tension, nervousness, lack of interest in eating, difficulty concentrating, disturbed sleep, decreased enjoyment, loss of interest, hearing voices

comorbidity of schizophrenia

Substance abuse*** disorders Nicotine dependence Anxiety, depression, and suicide*** Physical health or illness Polydipsia usually die up to 20 years earlier than most people

A client comes to the clinic for an evaluation. During the interview, the client states that the client feels insects crawling all over the skin on the client's arms and legs. The nurse interprets this as which type of sensorium or processing deficit?

Tactile hallucination

A client with severe and persistent mental illness has been taking antipsychotic medication for 20 years. The nurse observes during a therapy session that the client's behavior includes repetitive movements of the mouth and tongue, facial grimacing, and rocking back and forth. The nurse recognizes these behaviors as indicative of what?

Tardive dyskinesia

signs and symptoms of schizophrenia

Thoughts- Delusions Perception- Hallucinations Behaviors- Disorganized Thoughts Affective Symptoms Personal Boundary Difficulties ^^ all positive symptoms

A client is diagnosed with a delusional disorder. While providing care to the client, the nurse assesses the client's delusions. Which would be least appropriate for the nurse to do?

Try to change the client's delusional belief

therapeutic interactions

Validation of what they are seeing/feeling - "are you seeing things?" no power struggle make them feel safe

Assessment of genetic predisposition supports asking a client who is exhibiting symptoms of a delusional disorder what?

Whether any family members have been diagnosed with schizophrenia

A client with schizoaffective disorder is receiving multiple psychiatric medications. The nurse would ensure obtaining a baseline electrocardiogram if the client is prescribed which medication?

Ziprasidone

disorganized behavior

agitation: inability to sit still or attend to others, accompanied by heightened emotions and tension echopraxia: involuntary imitation of another person's movements and gestures hypervigilance: sustained attention to external stimuli as if expecting something important or frightening to happen waxy flexibility: posture held in an odd or unusual fixed position for extended periods of time

disorganized thinking

clang association: repeats words that SOUND alike (rhyming) concrete thinking: lack of abstraction in thinking; inability to understand punch lines, metaphors, and analogies loose associations: absence of the normal connectedness of thoughts, ideas, and topics; sudden shifts without apparent relationship to preceding topics Echolalia: repetition of another's words that is parrot-like and inappropriate (repeat things that YOU say) word salad: stringing together words that are not connected in any way (no meaning to it, just talking!!)

when do people with schizophrenia become an issue?

danger to self/society not recognize their not normal thoughts can not take care of themselves refuse treatment - leads to escalation and the force of treatment

Which increases the risk for neuroleptic malignant syndrome (NMS)?

dehydration

when do people with schizophrenia need treatment

denial leads to the need for treatment

A nurse working in a nonpsychiatric setting is more likely to provide care to an individual with which undiagnosed psychiatric illness?

depression

Delusional disorders are primarily characterized by which of the following? Select all that apply.

distrust paranoia jealousy

Risperidone side effects

drowsiness; tardive dyskinesia; dizziness; constipation; hypersensitivity; NMS; hyperglycemia; dysphagia; priapism

continuum of care

emergency care: crisis; danger to self; hypothermia/overheated inpatient - focused care: stabilization community care: outside resources; therapy

A nurse is working with a client that has been diagnosed with delusional thoughts. Which is an initial short-term outcome appropriate for this client?

engage in reality oriented conversation

Anticholinergic Crisis/ Anticholinergic Delirium side effects

fever dry throat burning throat delirium: changes thought process Tx: stop meds!!!! (3 days symptoms will improve)

Eosinophilia

fever with rash, swollen glands Tx: corticosteroids

what do you do if pt is having a cholinergic rebound?

get back on meds, slowly taper and will make symptoms slowly go away

During an admission assessment, a client with schizoaffective disorder states that the client hears the voice of God in the client's head and the voice is telling the client that the client is worthless. What would the nurse document this symptom as?

hallucinations

A client has been prescribed clozapine for treatment of schizophrenia. The client must be taught to monitor which blood concentrations weekly while taking this drug?

white blood cells - agranulocytosis

thermoregulation interventions

winter - they may seem to be oblivious to cold weather - wearing shorts in the cold - homeless summer - they may dress for winter