Schizophrenia Disorder and Antipsychotic Medications

^Insight reflecting a lack of insight—for example, statements such as "I do not have a problem."

"I do not have a problem."

Clients with schizophrenia: analyze assessment data to determine priorities and establish an effective plan of care. Analysis of assessment data generally falls into two main categories:

(1) data associated with the positive signs (2) data associated with the negative signs.

Cognitive Symptoms of Schizophrenia; Cognitive symptoms are subtle and are often detected only when neuropsychological tests are performed. They include the following:

(1) poor "executive functioning" (the ability to absorb and interpret information and make decisions based on that information), (2) inability to sustain attention, andproblems with "working memory" (the ability to keep recently learned information in mind and use it right away) ***Cognitive impairments often interfere with the patient's ability to lead a normal life and earn a living.

Schizophrenia affects thought processes and content, perception, emotion, behavior, and social functioning; however, the nurse should know it affects each individual differently depending the degree of impairment. Although both clients have the same medical diagnosis, the approach and interventions that each nurse takes would be very different.

(1)the acute or psychotic phase ( 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. (2)the chronic or long-term phase ( 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. ***The nurse would deal with (negative signs of schizophrenia)

(Sensorium and Intellectual Processes) One hallmark symptom of schizophrenic psychosis is hallucinations:

(false sensory perceptions, or perceptual experiences that do not exist in reality).

Delusions

(fixed, false beliefs with no basis in reality) in the psychotic phase of schizophrenia.

KEY POINTS

Schizophrenia is a chronic illness requiring long-term management strategies and coping skills. It is a disease of the brain, a clinical syndrome that involves a person's thoughts, perceptions, emotions, movements, and behaviors. The effects of schizophrenia on the client may be profound, involving all aspects of the client's life: social interactions, emotional health, and ability to work and function in the community. Schizophrenia is conceptualized in terms of positive signs such as delusions, hallucinations, and disordered thought processes as well as negative signs such as social isolation, apathy, anhedonia, and lack of motivation and volition. The clinical picture, prognosis, and outcomes for clients with schizophrenia vary widely. Therefore, it is important that each client is carefully and individually assessed, with appropriate needs and interventions determined. Careful assessment of each client as an individual is essential to planning an effective plan of care. Families of clients with schizophrenia may experience fear, embarrassment, and guilt in response to their family member's illness. Families must be educated about the disorder, the course of the disorder, and how it can be controlled. Failure to comply with treatment and the medication regimen and the use of alcohol and other drugs are associated with poorer outcomes in the treatment of schizophrenia. For clients with psychotic symptoms, key nursing interventions include helping to protect the client's safety and right to privacy and dignity, dealing with socially inappropriate behaviors in a nonjudgmental and matter-of-fact manner, helping present and maintain reality for the client by frequent contact and communication, and ensuring appropriate medication administration. For the client whose condition is stabilized with medication, key nursing interventions include continuing to offer a supportive, nonconfrontational approach, maintaining the therapeutic relationship by establishing trust and trying to clarify the client's feelings and statements when speech and thoughts are disorganized or confused, helping to develop social skills by modeling and practicing, and helping to educate the client and family about schizophrenia and the importance of maintaining a therapeutic regimen and other self-care habits. Self-awareness issues for the nurse working with clients with schizophrenia include dealing with psychotic symptoms, fear for personal safety, and frustration as a result of relapses and repeated hospital admissions.

RELATED DISORDERS

Schizophreniform disorder Catatonia Delusional disorder Brief psychotic disorder Shared psychotic disorder (folie deux) Schizotypal personality disorder

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 work, and neglected hygiene. ***The diagnosis of schizophrenia usually is made when the person begins to display more actively positive symptoms of delusions, hallucinations, and disordered thinking.

Neuroanatomic and Neurochemical Factors of schizophrenia

*(noninvasive imaging techniques such as computed tomography, magnetic resonance imaging, and positron emission tomography) are tools to study the brain structure and have shown: * people with schizophrenia have relatively less brain tissue and cerebrospinal fluid than those who do not have schizophrenia. * enlarged ventricles in the brain and cortical atrophy. * glucose metabolism and oxygen are diminished in the frontal cortical structures of the brain. * decreased brain volume and abnormal brain function in the frontal and temporal areas of persons with schizophrenia. (This 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). *Neurochemical studies have consistently demonstrated alterations in the neurotransmitter systems of the brain in people with schizophrenia. ***THE MOST PROMINENT neurochemical theories involve dopamine and serotonin, suggesting excess dopamine as a cause. This theory was developed based on two observations: (1) drugs that increase activity in the dopaminergic system, such as amphetamine and levodopa, sometimes induce a paranoid psychotic reaction similar to schizophrenia . (2)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. ***Excess of (SEROTONIN ) has been included among the leading neurochemical factors affecting schizophrenia! (Newer atypical antipsychotics, such as clozapine (Clozaril), are both dopamine and serotonin antagonists, and can dramatically reduce psychotic symptoms and ameliorate the negative signs of schizophrenia

Collaborative Intervention: Client with Delusions

*Be sincere and honest *Avoid vague or evasive remarks. *Be consistent in setting expectations(enforcing rules) *Do not make promises that you cannot keep *Encourage the client to talk with you, but do not pry for information. *Explain procedures, and try to be sure the client understands the procedures before carrying them out. *Give positive feedback for the client's successes. *Initially, do not argue with the client or try to convince the client that the delusions are false or unreal. *Interact with the client on the basis of real things; do not dwell on the delusional material. *Engage the client in one-to-one activities at first, then activities in small groups, and gradually in larger groups. *Recognize and support the client's accomplishments *Show empathy regarding the client's feelings *reassure the client of your presence and acceptance. *Do not be judgmental, belittle, or joke about the client's beliefs. *Never convey to the client that you accept the delusions as reality. *Directly interject doubt regarding delusions as soon as the client seems ready to accept this (e.g., "I find that hard to believe.") *As the client begins to doubt the delusions or is willing to discuss the possibility that they may not be real, talk about his or her perceptions and feelings, and support for expressing feelings and concerns. *Ask the client if he or she can see that the delusions interfere with or cause problems in his or her life. *If the delusions are persistent but the client can acknowledge the consequences of expressing the beliefs, help them to understand the difference between holding a belief and acting on it or sharing it with others.

Nursing diagnoses related to antipsychotic drug therapy:

*Impaired Physical Mobility related to extrapyramidal effects. *Decreased Cardiac Output related to hypotensive effects. *Risk for Injury related to CNS effects and sedation. *Impaired Urinary Elimination related to anticholinergic effects. *Deficient Knowledge regarding drug therapy

Antipsychotics: Patient Teaching

*Provide thorough patient teaching, including drug name, prescribed dosage, measures for avoidance of adverse effects, cautions that it may take weeks to see the desired clinical effects, warning signs that may indicate possible problems, and the need for monitoring and evaluation to enhance patient knowledge about drug therapy and to promote compliance. *** Warn patient that urine may have a pink to reddish-brown color. ***Avoid the use of over-the-counter drugs while you are on this drug. Many of them contain ingredients that could interfere with the effectiveness of your drug.

Advantages of atypical antipsychotic agents are:

*Relief of both positive and negative symptoms. *Decrease in affective findings (depression, anxiety) and suicidal behaviors. *Improvement of neurocognitive defects, such as poor memory. *Fewer or no extrapyramidal symptoms (EPS), including tardive dyskinesia, due to less dopamine blockade. *Fewer anticholinergic effects {EXCEPT: clozapine (Clozaril), which has a high incidence of anticholinergic effects.} *Less relapse

General Appearance, Motor Behavior, and Speech (varies)

*Some appear normal: dressed appropriately, sitting , conversing and exhibiting no strange or unusual postures or gestures; * Others exhibit odd or bizarre behavior: appear disheveled and unkempt with no obvious concern for their hygiene, or they may wear strange or inappropriate clothing for the season. *may be restless and unable to sit still, exhibit agitation and pacing, or appear unmoving (catatonia). *may demonstrate seemingly purposeless gestures (stereotypic behavior) and odd facial expressions such as grimacing. *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. *may exhibit a general slowing of all movements(psychomotor-retardation). *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). *may exhibit an unusual speech pattern. Two typical patterns are : (1) word salad-(jumbled words and phrases that are disconnected or incoherent and make no sense to the listener) (2) echolalla- (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 response- (hesitation before the client responds to questions); may last 30 or 45 seconds and usually indicates the client's difficulty with cognition or thought processes.

Age at "onset" is 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 tend to have both poorer immediate and long-term course than those who experience an acute and sudden onset. *1/3 to 1/2 will relapse within 1 year of an acute episode. (relapses are R/T nonadherence to medication, persistent substance use, caregiver criticism, and negative attitude toward treatment)

Catatonia

*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 :extreme negativism, mutism, peculiar movements, echolalia, or echopraxia. ***Catatonia can occur with schizophrenia, mood disorders, or other psychotic disorders.

Schizophreniform disorder

*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.

Brief psychotic disorder

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

Delusional disorder

*client has one or more nonbizarre delusions (the focus of the delusion is believable.) *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.

The primary medical treatment for schizophrenia is psychopharmacology.

The conventional or first-generation, antipsychotic medications are dopamine antagonists. The atypical or second-generation, antipsychotic medications are both dopamine and serotonin antagonists. ***Because of their associated neurological adverse effects, these medications are also called NEUROLEPTIC agents

Genetic Factors of schizophrenia

*focus on immediate families (i.e., parents, siblings, and offspring) *identical twins have a 50% risk for schizophrenia; that is, if one twin has schizophrenia, the other has a 50% chance of developing it * Fraternal twins have only a 15% risk *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. *BUT genetics CANNOT be the ONLY factor!

Biologic theories of schizophrenia

*genetic factors * neuroanatomic and neurochemical factors (structure and function of the brain) * immunovirology (the body's response to exposure to a virus).

Schizotypal personality disorder

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

Social isolation is prevalent in clients with schizophrenia

*partly as a result of (positive signs) such as: delusions, hallucinations, and loss of ego boundaries. *have problems with trust and intimacy ( interfere with the ability to establish satisfactory relationships). *Low self-esteem, (negative sign) complicates ability to interact with others and the environment. * Lack confidence(result is avoidance of people) *Difficulty filling roles in family, community, work, school (d/t difficulty thinking clearly, remembering, paying attention, and concentrating.) *Lacks motivation

ETIOLOGY schizophrenia: newer scientific studies are finding more evidence to support "neurologic/neurochemical causes" (primary focus of research and theory today)

*results from a type of brain dysfunction * theories are supported by the effects of antipsychotic medications( help to control psychotic symptoms), and neuroimaging tools (computed tomography, showing that the brain of people with schizophrenia differs in structure and function from the brain of control subjects). * However, some therapists still believe(like scientists in the early 1/2 of the century)that schizophrenia results from dysfunctional parenting or family dynamics.

Long-Term Course - the intensity of psychosis tends to diminish with age; Clients regains

*some degree of social and occupational functioning. *The disease becomes less disruptive to the person's life and easier to manage. *(rarely can the client overcome the effects of many years of dysfunction) * may live independently or in a structured family-type setting and may succeed at jobs with stable expectations and a supportive work environment. (when illness is medically supervised and whose treatment is maintained) *many though, have difficulty functioning in the community, and few lead fully independent lives D/T (persistent negative symptoms:impaired cognition, or treatment-refractory positive symptoms.)

Immunovirologic Factors of schizophrenia

*theories that exposure to a virus or the body's immune response to a virus could alter the brain physiology of people with schizophrenia. * cytokines ( signals the brain to produce behavioral and neurochemical changes needed in the face of physical or psychological stress to maintain homeostasis), therefore, may have a role in the development of major psychiatric disorders such as schizophrenia * infections ( influenza) in pregnant women as a possible origin for schizophrenia. *children born in crowded areas in cold weather, conditions that are hospitable to respiratory ailments

Shared psychotic disorder (folie 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; like siblings, parent and child, or husband and wife.) * The more submissive or suggestible person may rapidly improve if separated from the dominant person.

Abstract thinking can be dangerous in schizophrenia.

- may not understand what is being said and misinterpret instructions. (ex).nurse says, "It is always important to take all your medications." The client may misinterpret and take the entire supply of medication at one time.

Lack of judgment is so severe in schizophrenia.

-clients cannot meet their needs for safety and protection and place themselves in harm's way. (ex). failing to wear warm clothing in cold weather, failing to seek medical care even when desperately ill, or failing to recognize needs for sleep or food.

Antipsychotics: (thioridazine, mesoridazine, ziprasidone) are associated with prolongation of the QTc interval, which could lead to:

-serious or even fatal cardiac arrhythmias. *** Patients receiving these drugs should have a baseline and periodic electrocardiogram (ECG

Immediate Course - the years immediately after the onset of psychotic symptoms, two typical clinical patterns emerge:

1. Client experiences ongoing psychosis and never fully recovers, although symptoms may shift in severity over time. 2. Client experiences episodes of psychotic symptoms that alternate with episodes of relatively complete recovery from the psychosis.

DSM-5 DIAGNOSTIC CRITERIA: Schizophrenia

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorgranized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional or avolition) B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences). D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).

A nurse is completing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms? (Select all that apply.) A. Auditory hallucination B. Lack of motivation C. Use of clang associations D. Delusion of persecution E. Constantly waving arms F. Flat affect

Answer: A, C, D, and E

A nurse is caring for a client who has schizoaffective disorder. Which of the following statements indicates the client is experiencing depersonalization? A . "I am a superhero and am immortal." B. "I am no one, and everyone is me." C. "I feel monsters pinching me all over." D. "I know that you are stealing my thoughts."

Answer: B

A nurse is speaking with a client who has schizophrenia when he suddenly seems to stop focusing on the nurse's questions and begins looking at the ceiling and talking to himself. Which of the following actions should the nurse take? A. Stop the interview at this point, and resume later when the client is better able to concentrate. B. Ask the client, "Are you seeing something on the ceiling?" C. Tell the client, "You seem to be looking at something on the ceiling. I see something there, too." D. Continue the interview without comment on the client's behavior

Answer: B

The nurse is caring for a client with schizophrenia who is taking haloperidol (Haldol). The client complains of restlessness, cannot sit still, and has muscle stiffness. Of the following PRN medications, which would the nurse administer? A. Haloperidol (Haldol), 5 mg PO B. Benztropine (Cogentin), 2 mg PO C. Propranolol (Inderal), 20 mg PO D. Trazodone, 50 mg PO

Answer: B

A nurse is caring for a client on an acute mental health unit. The client reports hearing voices that are telling her to "kill your doctor." Which of the following is the priority action for the nurse to take? A. Use therapeutic communication to discuss the hallucination with the client. B. Initiate one-to-one observation of the client. C. Focus the client on reality. D. Notify the provider of the client's statement.

Answer: B * A client who is experiencing a command hallucination is at risk for injury to self or others. * safety is the priority, and initiating one-to-one observation is the priority action

Which of the following statements would indicate that 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."

Answer: C

The family of a client with schizophrenia asks the nurse about the difference between conventional and atypical antipsychotic medications. The nurse's answer is based on which of the following? 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. typical antipsychotics are dopamine and serotonin antagonists; conventional antipsychotics are only dopamine

Answer: D

^A client diagnosed with schizophrenia gained 50 lb (22.7 kg) in 6 months while taking olanzapine. After a prescription change from olanzapine to ziprasidone, the client tells the nurse, "I do not want to take this ziprasidone either. I cannot gain any more weight." Which response by the nurse is most appropriate for this client? a) "Abnormal movements are not as common with zipradisone." b) "We can give it to you as an injection rather than in capsule form." c) "You can take it just before bedtime, so you will not need a snack." d) "Ziprasidone causes less weight gain than the other atypical antipsychotics."

Answer: D

^When conducting a mental status examination with a newly admitted client who has a diagnosis of paranoid schizophrenia, the client states, "I am being followed; it is not safe. They are monitoring my every move." In which area of the mental status examination should the nurse document this information? a) insight b) judgment c) quality of speech d) thought content

Answer: D Rationale: Presence of delusions is described in the area of thought content in the mental status examination.

Which of the following are considered to be positive signs of schizophrenia? SELECT ALL THAT APPLY A. Anhedonia B. Delusions C. Hallucinations D. Disorganized thinking E. Illusions F. Social withdrawal

Answers: B, C, D

Third-Generation Antipsychotic (called dopamine system stabilizer)

Aripiprazole (Abilify) ***Antimanic Drug

Types of hallucinations

Auditory hallucinations, 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. Command Hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Visual hallucinations 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. 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. 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. Gustatory hallucinations 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. Cenesthetic hallucinations 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. 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.

^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.

antipsychotic agents may also cause:

Bone Marrow Suppression ***Monitor CBC If s/s present discontinue the drug

Antipsychotic-alcohol combinations result in an increased risk of ____ ____.

CNS Depression

^ The client is less verbal, less active, less responsive to directions, severely anxious, and more stuporous. The client is exhibiting sympyoms of becoming ______.

Catatonic

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.) *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. *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 occur.

First-generation (conventional) antipsychotic medications are used mainly to control positive symptoms of psychotic disorders and are reserved for clients who are:

Using them successfully and can tolerate the adverse effects. Violent or particularly aggressive

^A client with a diagnosis of schizophrenia is admitted to the psychiatric hospital in a catatonic state. During the physical examination, the client's arm remains outstretched after the nurse obtains his pulse and blood pressure readings, and the nurse must reposition his arm. This client is exhibiting:

Waxy flexibility - the ability to assume and maintain awkward or uncomfortable positions for long periods, is characteristic of catatonic schizophrenia.

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. Ex: "I will take a pill if I go up the hill but not if my name is Jill, I don't want to kill." Neologisms are words invented by the client. Ex: "I'm afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?" Verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. Ex: "I want to go home, go home, go home, go home." Echolalia is the client's imitation or repetition of what the nurse says. Exe: Nurse: "Can you tell me how you're feeling?" Client: "Can you tell me how you're feeling, how you're feeling?" Stilted language is use of words or phrases that are flowery, excessive, and pompous. Ex: "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?" 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. Ex: 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." Word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. Ex: "Corn, potatoes, jump up, play games, grass, cupboard."

Atypical or Second-Generation Antipsychotics *** The second-generation antipsychotics not only diminish positive symptoms but also, for many clients, lessen the negative signs of lack of volition and motivation, social withdrawal, and anhedonia.

Clozapine (Clozaril) "PROTOTYPE" Fazaclo (clozapine) Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Paliperidone (Invega) Paliperidone (Invega) Iloperidone (Fanapt) Asenapine (Saphris) Lurasidone (Latuda) most common SUFFIX (done)

^Clozapine can cause life-threatening neutropenia or granulocytopenia.

a WBC count should be performed weekly. ***sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells.

^Phenothiazines differ from central nervous system (CNS) depressants in their sedative effects by producing:

a calming effect from which the client is easily aroused.

^Neolgisms are words that

a person invents.

During episodes of psychosis, clients are commonly disoriented to time and sometimes place. The most extreme form of disorientation is _____.

Depersonalization (client feels detached from her or his behavior)

Nursing Diagnosis: Client with Delusions

Disturbed Thought Processes: Disruption in cognitive operations and activities

Conventional/First-Generation Antipsychotics anticholinergic effects

Dry mouth Blurred vision Photophobia Urinary hesitancy or retention Constipation Tachycardia

Schizophrenia usually is diagnosed in late _____ or early _____. Rarely does it manifest in _____.

adolescence, adulthood, childhood

Common neurological effect of antipsychotic drugs are:

Dystonia-spasms of the tongue, neck, back and legs. {Spasms may cause unnatural positioning of the neck, abnormal eye movements, excessive salivation.) Akathisia-continuous restlessness, inability to sit still. (Constant moving, foot tapping, hand movements) Pseudoparkinsonism-muscle tremors, cogwheel rigidity, drooling, shuffling gait, slow movements. Tardive dyskinesia-abnormal muscle movements. (lip smacking, tongue darting, chewing movements, slow and aimless arm and leg movements.)

^Propranolol relieves _____.

akathisia

antipsychotic-anticholinergic combinations lead to increased _____ _____.

anticholinergic effects. ***dose adjustments are necessary

Treatment for schizoaffective disorder targets both psychotic and mood symptoms. Second-generation _____ are the best first choice for treatment. Mood stabilizers or an _____ may be added if needed.

antipsychotics, antidepressant

The nurse first elicits information about the client's previous history with schizophrenia to establish baseline data

ask 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?"

Assess whether the client has been using current support systems.

ask 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?

Assess the client for previous suicide attempt. (10% of all people with schizophrenia eventually commit suicide)

ask, "Have you ever attempted suicide?" or "Have you ever heard voices telling you to hurt yourself?"

Assess history of violence or aggression. (HX of aggressive behavior is a strong predictor of future) aggression.

ask, "What do you do when you are angry, frustrated, upset, or scared?"

Assesses the client's perception of his or her current situation.

ask, "What do you see as the primary problem now?" or "What do you need help managing now?"

^ An Idea of reference

assumes that the remarks and behavior of others apply to oneself.

Side Effects of Antipsychotic Medications and Nursing Interventions:

Dystonic reactions:(Administer medications as ordered; assess for effectiveness; reassure client if he or she is frightened.) Tardive dyskinesia:(Assess using tool such as AIMS; report occurrence or score increase to physician.) Neuroleptic malignant syndrome: (Stop all antipsychotic medications; notify physician immediately.) Akathisia :(Administer medications as ordered; assess for effectiveness.) EPSs or neuroleptic-induced parkinsonism:(Administer medications as ordered; assess for effectiveness.) Seizures :(Stop medication; notify physician; protect client from injury during seizure; provide reassurance and privacy for client after seizure.) Sedation :(Caution about activities requiring client to be fully alert, such as driving a car.) Photosensitivity:(Caution client to avoid sun exposure; advise client when in the sun to wear protective clothing and sun-blocking lotion.) Weight gain:( Encourage balanced diet with controlled portions and regular exercise; focus on minimizing gain. Anticholinergic symptoms ) Dry mouth:( Use ice chips or hard candy for relief. Blurred vision Assess side effect, which should improve with time; report to physician if no improvement.) Constipation:(Increase fluid and dietary fiber intake; client may need a stool softener if unrelieved.) Urinary retention:(Instruct client to report any frequency or burning with urination; report to physician if no improvement over time.) Orthostatic hypotension: (Instruct client to rise slowly from sitting or lying position; wait to ambulate until no longer dizzy or light-headed.)

_____ _____and_____ _____ of the first psychotic episode with medication and psychosocial interventions were associated with improved outcomes such as lower relapse rates and improved insight, quality of life, and social functioning.

Early detection, aggressive treatment

Herbal and Alternative Therapies: Patients with schizophrenia should be advised to avoid the use of ____ _____.

Evening Primrose ****D/T increased symptoms and central nervous system hyperexcitability.

BEST PRACTICE: STRATEGIES FOR ADHERENCE PROBLEMS

First-line interventions to improve adherence in persons with serious mental illness include symptom/side effect monitoring, services to handle logistic problems, environmental support such as Assertive Community treatment of cognitive adaptive training, and adjusting dosage or switching medications for persistent side effects. Second-line interventions include switching to a long-acting antipsychotic when lack of insight, substance use, persistent symptoms, lack of routines, or lack of family/social support interfere with adherence; patient psychoeducation; CBT; and family-focused therapy. The next step is systematic identification of factors interfering with adherence for each patient with serious mental illness so that the most appropriate, effective interventions can be implemented.

Mood and Affect (wide variances)

Flat affect (no facial expression) or Blunted affect (few observable facial expressions). * typical facial expression often is described as mask-like. *affect may be described as silly, characterized by giddy laughter for no apparent reason. *may exhibit an inappropriate expression or emotions incongruent(ranges from mild or subtle to grossly inappropriate)with the context of the situation. (ex. 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). *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.

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. ex. say, "Please explain that to me" or "Tell me what you're thinking about that."

Antipsychotics with _____ may lead to an increase in the effect of both drug

beta-blockers ***this combination should be avoided

negative or soft symptoms/signs:

Flat affect, lack of volition, and social withdrawal or discomfort. Alogia: Tendency to speak very little or to convey little substance of meaning (poverty of content) Anhedonia: Feeling no joy or pleasure from life or any activities or relationships Apathy: Feelings of indifference toward people, activities, and events Asociality: social withdrawal, few or no relationships, lack of closeness Blunted affect: Restricted range of emotional feeling, tone, or mood Catatonia: Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance Flat affect: Absence of any facial expression that would indicate emotions or mood Avolition or lack of volition: Absence of will, ambition, or drive to take action or accomplish tasks Inattention: Inability to concentrate or focus on a topic or activity, regardless of its importance

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)

Groups that focus on topics of concern such as medication management, use of community supports, and family concerns also have been beneficial to clients with schizophrenia, improving their social competence with social skill training, into a more effective functioning in the community.

^Differentiate delusions and hallucinations

Hallucinations are visual, auditory, gustatory, tactile, or olfactory perceptions that have no basis in reality. Delusions are false beliefs, rather than perceptions, that the client accepts as real.

Evaluation of the treatment of schizophrenia is based on the following:

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 that he or she has a satisfactory quality of life?

Client/Family Teaching with 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 Selfcare and proper nutrition Teaching social skills through education, role modeling, and practice Seeking assistance to avoid or manage stressful situations Counseling and education family/significant others about the biologic causes and clinical course of schizophrenia and the need for ongoing support Importance of maintain contact with community and participating in supportive organizations and care

Culteral considerations: When assessing for symptoms of schizophrenia. Nurse should consider: Ideas that are considered delusional in one culture, such as

Ideas that are considered delusional in one culture, such 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.

Expected Outcomes: Client with Delusions

Immediate; The client will: *Be free of injury throughout hospitalization *Demonstrate decreased anxiety level within 24 to 48 hours *Respond to reality-based interactions initiated by others, for example, verbally interact with staff for 5 to 10 minutes within 24 to 48 hours Stabilization;The client will: *Interact on reality-based topics such as daily activities or local events *Sustain attention and concentration to complete tasks or activities

A fearful or agitated client has the potential to harm self 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 such as: administering medication; moving the client to a quiet, less stimulating environment; and, in extreme situations, temporarily using seclusion or restraints.

Clients with schizophrenia may have significant self-care deficit

Inattention to hygiene and grooming needs is common ***especially during psychotic episode *may fail to recognize sensations such as hunger or thirst, and food or fluid intake may be inadequate *Occasionally, clients develop polydipsia (excessive water intake), which leads to water intoxication. ***Serum sodium levels can become dangerously low, leading to seizures. * Polydipsia usually is seen in clients who have had severe and persistent mental illness for many years as well as long-term therapy with antipsychotic medications; caused by the behavioral state itself or may be precipitated by the use of antidepressant or antipsychotic medication *Sleep problems are common( hallucinations may stimulate clients, resulting in insomnia) * 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( bank account/paying bills, buying food/preparing meals, and using public transportation )

Prototype: Chlorpromazine(Thorazine) { low potency} Conventional/First-Generation Antipsychotics

Indications: Management of manifestations of psychotic disorders, relief of preoperative restlessness, adjunctive treatment of tetanus, acute intermittent porphyria, severe behavioral problems in children, and control of hiccups, nausea, and vomiting. Actions: Blocks postsynaptic dopamine receptors in the brain, depresses those parts of the brain involved in wakefulness and emesis, anticholinergic, antihistaminic, alpha-adrenergic blockin. Adverse Effects: Drowsiness, insomnia, vertigo, extrapyramidal symptoms, orthostatic hypotension, photophobia, blurred vision, dry mouth, nausea, vomiting, anorexia, urinary retention, photosensitivity.

Prototype Clozapine (Clozaril) Atypical/Second-GenerationAntipsychotic

Indications: Management of severely ill patients with schizophrenia who are unresponsive to standard drugs; reduces of risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder (Schizophrenia spectrum disorders). Actions: Blocks dopamine and serotonin receptors, depresses the reticular activating system, anticholinergic, antihistaminic, alpha-adrenergic blocking. Adverse Effects: Drowsiness, sedation, seizures, dizziness, syncope, headache, tachycardia, nausea, vomiting, fever, neuroleptic malignant syndrome.

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. ( more likely to obtain accurate assessments when the client's thought processes are clearer)

ELDER CONSIDERATIONS: schizophrenia

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. 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

^The nurse is facilitating a group of clients with schizophrenia when one client says, "I like to drive my car, bar, tar, far." This client is exhibiting:

clang association -Linking words together based on their sounds rather than their meaning

^ A Delusion of persecution

client's believes that "others" are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. (ex.)The client thinks he is being followed by foreign agents who are after secret papers in his briefcase.

KEY POINTS

Mental disorders are thought-process disorders that may be caused by some inherent dysfunction within the brain. A psychosis is a thought disorder, and schizophrenia is the most common psychosis in which delusions and hallucinations are hallmarks. Antipsychotic drugs are generally dopamine-receptor blockers that are effective in helping people to organize thought patterns and to respond appropriately to stimuli. Antipsychotics can cause hypotension, anticholinergic effects, sedation, and extrapyramidal effects, including parkinsonism, ataxia, and tremors.

Evaluation related to antipsychotic drug therapy:

Monitor patient response to the drug (decrease in signs and symptoms of psychotic disorder). Monitor for adverse effects (sedation, anticholinergic effects, hypotension, extrapyramidal effects, bone marrow suppression). Evaluate the effectiveness of the teaching plan (patient can give the drug name and dosage, possible adverse effects to watch for, specific measures to prevent adverse effects, and warning signs to report). Monitor the effectiveness of comfort measures and compliance with the regimen.

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.

^Dystonia is characterized by cramps and rigidity of the tongue, face, neck, and back muscles. Akathisia causes restlessness, anxiety, and jitteriness.:

cramps and rigidity of the tongue, face, neck, and back muscles.

Antipsychotic medications do not _____ the disorder; however, they are crucial to its successful _____.

cure, management

Antipsychotic drugs are the primary treatment for psychotic disorders such as schizophrenia, but they produce a host of side effects that also may require pharmacologic intervention.

Neurologic side effects, which can be treated with anticholinergic medications, are called EPS and include acute dystonia, akathisia, and pseudoparkinsonism. Some of the more serious neurologic side effects include TD (permanent involuntary movements) and NMS, which can be fatal.

Although the symptoms of schizophrenia are always severe, the long-term course does not always involve progressive deterioration. The clinical course varies among clients;

Onset Immediate Course Long-Term Course

positive or hard symptoms/signs:

delusions, hallucinations, and grossly disorganized thinking, speech, and behavior. Ambivalence: Holding seemingly contradictory beliefs or feelings about the same person, event, or situation Associative looseness: Fragmented or poorly related thoughts and ideas Delusions: Fixed false beliefs that have no basis in reality Echopraxia: Imitation of the movements and gestures of another person whom the client is observing Flight of ideas: Continuous flow of verbalization in which the person jumps rapidly from one topic to another Hallucinations: False sensory perceptions or perceptual experiences that do not exist in reality Ideas of reference: False impressions that external events have special meaning for the person Perseveration: Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic Bizarre behavior: Outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior

Obesity is common in clients with schizophrenia, further increasing the risk for type 2 _____ _____ and _____.

diabetes mellitus , cardiovascular disease

All of the atypical antipsychotics include warnings that there is a risk for the development of _____ _____ and _____ _____.

diabetes mellitus, weight gain ***Client should be monitored regularly for the signs and symptoms of diabetes mellitus.

^One of the causes of schizophrenia involves an overstimulation of:

dopamine.

Anticholinergic effects of antipsychotics are:

dry mouth, nasal congestion, flushing, constipation, urinary retention, impotence, glaucoma, blurred vision, and photophobia.

^Diphenhydramine provides rapid relief for _____.

dystonia

^Benztropine is an anticholinergic medication administered to reduce the_____adverse effects of chlorpromazine and other antipsychotic medications.

extrapyramidal - This drug exerts its effect by: blocking cholinergic activity in the central nervous system (CNS).

*One of the advantages of the antipsychotic medication APO-risperidone is:

has a lower incidence of extrapyramidal effects than the typical antipsychotics

Cardiovascular (CV) effects of antipsychotics are:

hypotension, orthostatic hypotension, cardiac arrhythmias, congestive heart failure, and pulmonary edema.

^ A Delusion of grandeur

involves an exaggerated idea of one's importance or identity.

Assess the age at onset of schizophrenia

knowing that poorer outcomes are associated with an earlier age at onset.

Respiratory effects of antipsychotic drugs are:

laryngospasm, dyspnea, and bronchospasm

LABS monitored (antipsychotic drug therapy)

liver and renal function tests, blood glucose levels, thyroid function tests, electrocardiogram if appropriate, and complete blood count (CBC).

A nurse is aware that antipsychotic medications may cause:

lower seizure threshold.

The persistence of these negative symptoms over time presents a

major barrier to recovery and improved functioning in the client's daily life.

^Echopraxia refers to

meaningless imitation of others' motions.

^A first-generation antipsychotic agent such as haloperidol (Haldol) can cause:

muscle spasms in the neck, face, tongue, back, and legs as well as torticollis (twisted neck position). (ex.)holding head to one side and C/O neck and jaw spasms. ^^^By treating psychosis, haloperidol, decreases agitation. ^^^ haloperidol can cause Parkinson-type symptoms.

Family education and therapy are known to diminish the _____ of schizophrenia and reduce the _____ rate.

negative effects, relapse

^A client who takes neuroleptic medication for treatment of chronic schizophrenia is admitted to the psychiatric unit. Nursing assessment reveals rigidity, fever, hypertension, and diaphoresis. Which life-threatening reaction do these findings suggest?

neuroleptic malignant syndrome

^Echolalia is the involuntary

parrot like repetition of words spoken by others

^Judgment reflecting a lack of judgment—for example:

poor choices such as buying a gun for self-protection.

The symptoms of schizophrenia are divided into two major categories:

positive or hard symptoms/signs and negative or soft symptoms/signs

Medication may control the _____ symptoms, but frequently the _____ symptoms persist after positive symptoms have abated

positive, negative

Risperidone(Risperdal) is an atypical antipsychotic used to treat :

positive, negative, and affective symptoms of schizophrenia. *has a lower risk of extrapyramidal side effects than typical antipsychotics * has a lower risk of anticholinergic adverse effects than typical antipsychotics ***should NOT be used for clients who have dementia.

^ Schizophrenia is best described as a disorder characterized by:

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

Patients should not take thioridazine or ziprasidone with any other drug that is associated with;

prolongation of the QTc interval.

^Loose associations are

rapid shifts among unrelated ideas.

^ An Idea of influence

refers to the belief that people or objects have control over one's behavior.

The more effective the client's _____and _____ to his or her medication regimen, the better the client's outcome.

response, adherence

^ Akathisia causes:

restlessness, anxiety, and jitteriness.

Schizoaffective disorder signs and symptoms include those of both _____ and a _____such as depression or bipolar disorder.

schizophrenia, mood disorder ***Can occur simultaneously or may alternate between psychotic and mood disorder symptoms.

The most common CNS effects of antipsychotics are:

sedation, weakness, tremor, drowsiness, extrapyramidal side effects, pseudoparkinsonism, dystonia, akathisia, tardive dyskinesia, and potentially irreversible neuroleptic malignant syndrome. ****Provide safety measures

Schizoaffective disorder is diagnosed when the client is

severely ill and has a mixture of psychotic and mood symptoms.

The nurse informs clients taking antipsychotic medication about the types of _____ _____ that may occur and encourages clients to report such problems to the physician instead of _____ the medication.

side effects , discontinuing

The antipsychotics are widely distributed in the tissues and are often stored there, being released for up to ____ months after the drug is stopped.

six

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.)

Second-generation (atypical) antipsychotic agents are the current medications of choice for clients receiving initial treatment and treating breakthrough episodes in clients on conventional medication therapy because:

they are more effective with fewer adverse effects.

(Thought Process and Content) Schizophrenia often is 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. -assess thought content by evaluating what the client actually says. ex. clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute (thought blocking) ex clients. may state that they believe others can hear their thoughts (thought broadcasting), others are taking their thoughts (thought withdrawal), or others are placing thoughts in their mind against their will (thought insertion). Clients also may exhibit tangential thinking, (veering onto unrelated topics and never answering the original question)

^Tardive dyskinesia causes involuntary movements of the

tongue, mouth, and muscles of the face, arms, and legs.

phenothiazines (chlorpromazine, fluphenazine, prochlorperazine, promethazine, and thioridazine)

turn the urine pink to reddish-brown as a result of their excretion.

Schizophrenia is a syndrome or disease process with many different:

varieties and symptoms: bizarre thoughts, perceptions, emotions, movements, and behavior.

Types of Delusions:

Persecutory/paranoid delusions involve the client's belief that "others" are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. 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. Religious delusions often center around the second coming of Christ or another significant religious figure or prophet. 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. 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. 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. 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.

Conventional or First-Generation Antipsychotics: ***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.

Phenothiazines: Chlorpromazine (Thorazine) " PROTOYPE" Perphenazine (Trilafon) Fluphenazine (Prolixin) Thioridazine (Mellaril) Mesoridazine (Serentil) Trifluoperazine (Stelazine) Thioxanthene: Thiothixene (Navane) Butyrophenones: Haloperidol (Haldol) Droperidol (Inapsine) Dibenzazepine: Loxapine (Loxitane) Dihydroindolone: Molindone (Moban) Most common suffix (zine)

^A paranoid client is having a delusion. While the client is having a delusion, the nurse should:

Present reality when the client asks about the delusion. -The nurse should tell the client that he or she does not hear the voice, see the image, or experience whatever other manifestation of the delusion that the client is experiencing.

Nursing Interventions for Clients with Schizophrenia

Promoting safety of client and others and right to privacy and dignity Establishing therapeutic relationship by establishing trust Using therapeutic communication (clarifying feelings and statements when speech and thoughts are disorganized or confused) Interventions for delusions: Do not openly confront the delusion or argue with the client. Establish and maintain reality for the client. Use distracting techniques. Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs. Interventions for hallucinations: Help present and maintain reality by frequent contact and communication with client. Elicit description of hallucination to protect the client and others. The nurse's understanding of the hallucination helps him or her know how to calm or reassure the client. Engage client in reality-based activities such as card playing, occupational therapy, or listening to music. Coping with socially inappropriate behaviors: Redirect the client away from problem situations. Deal with inappropriate behaviors in a nonjudgmental and matter-of-fact manner; give factual statements; do not scold. Reassure others that the client's inappropriate behaviors or comments are not his or her fault(without violating client confidentiality). Try to reintegrate the client into the treatment milieu as soon as possible. Do not make the client feel punished or shunned for inappropriate behaviors. Teach social skills through education, role modeling, and practice. Client and family teaching Establishing community support systems and care

HEALTHY PEOPLE 2020 MENTAL HEALTH OBJECTIVES

Reduce the suicide rate Reduce suicide attempts by adolescents Reduce the proportion of adolescents who engage in disordered eating behaviors in an attempt to control their weight Reduce the proportion of persons who experience major depressive episode Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral Increase the proportion of juvenile residential facilities that screen admissions for mental health problems Increase the proportion of persons with serious mental illness (SMI) who are employed Increase the proportion of adults with mental health disorders who receive treatment Increase the proportions of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders Increase depression screening by primary care providers Increase the number of homeless adults with mental health problems who receive mental health services

Nursing diagnoses of psychotic symptoms or positive signs

Risk for Other-Directed Violence Risk for Suicide Disturbed Thought Processes Disturbed Sensory Perception Disturbed Personal Identity Impaired Verbal Communication

^A nurse is planning care for a client with a diagnosis of schizophrenia who has been admitted to the psychiatric unit. Which nursing diagnosis should receive the highest priority? a) Risk for other-directed violence b) Imbalanced nutrition: Less than body requirements c) Compromised family coping d) Impaired verbal communication

Risk for other-directed violence Answer: A Rationale: characteristics as suspiciousness, anxiety, and hallucinations put the client with schizophrenia at risk for violence toward himself or others. Imbalanced nutrition: Less than body requirements, Compromised family coping, and Impaired verbal communication are also appropriate nursing diagnoses but should be addressed after the( safety )of the client and those around him has been established.

Nursing diagnoses of negative signs and functional abilities

SCulturakelf-Care Deficits Social Isolation Deficient Divisional Activity Ineffective Health Maintenance Ineffective Therapeutic Regimen Management