Cognition H/I 3 EX 3

delirium

risk: Delirium is always due to underlying physiological causes that are usually multifactorial and involve a dynamic interplay of factors -The key to helping patients avoid the consequences of delirium is recognizing and investigating potential causes as soon as possible. Early recognition and diagnosis are challenging for clinicians due to lack of knowledge about cognitive impairment and its clinical assessment and failure to interpret the signs and symptoms s/s: Delirium is an acute cognitive disturbance and often-reversible condition that is common in hospitalized patients, especially older patients. It is characterized as a syndrome, that is, a constellation of symptoms rather than a disorder. -cardinal symptoms of delirium are an inability to direct, focus, sustain, and shift attention; an abrupt onset with clinical features that fluctuate with periods of lucidity; and disorganized thinking and poor executive functioning. -disorientation (often to time and place, but rarely to person), anxiety, agitation, poor memory, and delusional thinking. -medical emergency that requires immediate attention to prevent irreversible and serious damage -if not treated can cause permanent decline ADPIE: a: mental and neurological status examinations, as well as a physical examination. talk to family and friends, assess meds, toxicity, labs blood/ UA AXO X4, affect, orientation -Illusions are errors in perception of sensory stimuli. A person may mistake folds in the blanket for white rats or the cord of a window blind for a snake. The stimulus is a real object in the environment. However, the individual misinterprets it, and it often becomes the object of the patient's projected fear. -Hallucinations are false sensory stimuli (refer to Chapter 12). Visual hallucinations are common in delirium, although tactile hallucinations may also be present. For example, individuals experiencing delirium may become terrified when they see giant spiders crawling over the bedclothes or feel bugs crawling on or under their bodies. Auditory hallucinations occur more often in other psychiatric disorders such as schizophrenia. A person with delirium becomes disoriented and may try to go home. Alternatively, a person may think that the care facility is home. Wandering, pulling out intravenous lines and indwelling catheters, and falling out of bed are common dangers that require nursing interventions. An individual experiencing delirium has difficulty processing stimuli in the environment, and confusion magnifies the inability to recognize reality. Autonomic signs, such as tachycardia, sweating, flushed face, dilated pupils, and elevated blood pressure, are often present in delirium. The patient's level of consciousness may range from lethargy to stupor or from semi-coma to hypervigilance. In hypervigilance, patients are extraordinarily alert, and their eyes constantly scan the room. Diff sleep and wake meds can cause delerium- poly pharm The individual's moods and physical behaviors may change dramatically within a short period. A person with delirium may display motor restlessness (agitation), or he or she may be "quietly delirious" and appear calm and settled. -Hyperactive agitation -Hypoactive no agitation SAFETY IS PRIORITY -medical equipment ripped out/ seen as danger The overall outcome is that the person experiencing delirium will return to the premorbid level of functioning.

alzheimers cont

meds: Because a deficiency of acetylcholine has been linked to Alzheimer's disease, medications aimed at preventing its breakdown have been developed. -cholinesterase inhibitor, donepezil (Aricept) Other medications are often useful in managing the behavioral symptoms of individuals with dementia, but these need to be used with extreme caution. The rule of thumb for older adults is "start low and go slow." Another is to use the smallest dose for the shortest duration possible and discontinue if they are not effective. -Psychotropic medications may be prescribed. Drug classifications that are used off-label include antidepressants, antipsychotics, antianxiety agents, and anticonvulsants. -aromatherapy

Schizophrenia

prodromal phase during which some milder symptoms of the disorder develop, often months or years before the disorder becomes fully apparent All people diagnosed with schizophrenia have at least one psychotic symptom such as hallucinations, delusions, and/or disorganized speech or thought. The symptoms are severe enough to disrupt normal activities such as school, work, family and social interaction, and self-care; in children and young adults they often delay or halt achievement of age-appropriate milestones. Basic needs such as hygiene, nutrition, and healthcare are often neglected, and socialization and relationships are often disrupted. -Substance use disorders, particularly alcohol and marijuana, occur in nearly half of affected individuals. Substance use is associated with higher rates of treatment nonadherence, relapse, incarceration, homelessness, violence, suicide, and a poorer prognosis -Genetic -Anxiety, depression, and suicide co-occur frequently in schizophrenia. -Physical illnesses are more common among people with schizophrenia than in the general population. -Individuals with psychotic disorders may be at greater risk of poor health maintenance behaviors, poor nutrition, substance use, medication effects, poverty, limited access to healthcare, and reduced ability to recognize or respond to signs of illness. -Polydipsia is compulsive drinking of excess fluids. -Symptoms include confusion, delirium, hallucinations, worsening of existing psychotic symptoms, and ultimately coma. Contributing factors include antipsychotic medication (causes dry mouth), compulsive behavior (present in some with schizophrenia), and neuroendocrine abnormalities -HYPONATREMIA RISK -People with schizophrenia demonstrate differences in brain chemistry, structure, and neurotransmission. Schizophrenia-spectrum disorders are inherited. The first antipsychotic drugs, known as first-generation (typical) antipsychotics, (e.g., haloperidol and chlorpromazine), block the activity of dopamine-2 (D2) receptors in the brain and reduce symptoms such as hallucinations and delusions. Symptom reduction suggested that dopamine plays a significant role in psychosis. Second-generation (atypical) antipsychotics block serotonin (5-hydroxytryptamine 2A, or 5-HT2A) and dopamine, which suggests that serotonin may play a role in schizophrenia as well. It is possible that structural abnormalities cause disruption in communication within the brain. Structural differences may be due to errors in neurodevelopment or errors in the normal pruning of neuronal tissue that happens in late adolescence and early adulthood. Inflammation or neurotoxic effects from factors such as oxidative stress, infection, or autoimmune dysfunction may also alter the brain's structure -brain imaging needed to see this -PET SCANS Infection during pregnancy increases the risk of mental illness in the child. Prenatal infections in the mother also increase the risk of infection in the child after birth, and those infections in the children also can make them more vulnerable to mental illness -Babies in late winter early spring Stress increases cortisol levels, impeding hypothalamic development and causing other changes that may precipitate the illness in vulnerable individuals. Schizophrenia often manifests at times of developmental and family stress such as beginning college or moving away from one's family. Social, psychological, and physical stressors may play a significant role in both the severity and course of the disorder and the person's quality of life. ACES Environmental factors such as toxins, including the solvent tetrachloroethylene (used in dry cleaning, to line water pipes, and sometimes found in drinking water), are also believed to contribute to the development of schizophrenia in vulnerable people -SES/ Living conditions In many cases, schizophrenia does not respond fully to treatments, leaving mild to severe residual symptoms and varying degrees of dysfunction or disability. A minority of individuals requires repeated or lengthy inpatient care or institutionalization.

TIC disorders

1. Provisional tic disorder—Single or multiple motor and or vocal tics for less than 1 year. 2. Persistent motor or vocal tic disorder—Single or multiple motor or vocal tics but not both for more than 1 year. 3. Tourette's disorder—Multiple motor tics and at least one vocal tic for more than 1 year. A familial pattern exists in about 90% of cases. Tourette's disorder often coexists with depression, obsessive-compulsive disorder, and ADHD -treating tics are the first-generation antipsychotics haloperidol (Haldol) and pimozide (Orap) and the second-generation antipsychotic aripiprazole (Abilify). Another second-generation drug, risperidone (Risperdal), does not have FDA approval, but is commonly used for tic disorders. -Clonidine hydrochloride (Catapres), an alpha 2-adrenergic agonist used to treat hypertension, is also prescribed for tics. While less effective and far slower acting than the antipsychotics, it has fewer side effects. -A sort of pacemaker for the brain, deep brain stimulation (DBS) is used when more conservative treatments fail. A fine wire is threaded into affected areas of the brain and connected to a small device implanted under the collarbone that delivers electrical impulses.

Risk factors

Advanced age or Significant risk factors found for women are overall poor health status, dependency, lack of social support, and insomnia. Risk factors specific to men include a history of stroke or diabetes individual: chemical exposure and risk of traumatic injury to the brain, high risk activities, environmental toxins, Congenital/ genetic, physical disability and reduced mobility,Fluid and electrolyte imbalance, systemic or intracranial infection, fever, pain, hypoglycemia, and anoxia can cause delirium that is reversible with treatment of the precipitating cause, stroke, tumors, hematomas ect, resp disease, adverse txt/ meds

Alzheimers Cont

Alzheimer's disease (AD) is a chronic, progressive, neurodegenerative brain disease. It is thought that 11% of people age 65 and older, and nearly one third of those over age 85, have AD -The greatest risk factor for AD is age. -Persons with a first-degree relative (parent or sibling) with dementia are more likely to develop the disease. -Cases are referred to as sporadic when there is no familial connection. -Brain health is closely linked to the health of the heart and blood vessels. Brain functioning depends on a good blood supply and nutrients delivered to it by that blood supply. -many factors increase the risk for CVD. These include diabetes, hypertension, obesity, hypercholesterolemia, and smoking -Head trauma is a risk factor for dementia. -Characteristic findings of AD related to changes in the brain's structure and function include (1) amyloid plaques, (2) neurofibrillary tangles, (3) loss of connections between neurons, and (4) neuron death Plaques/ Tangles Eventually AD attacks the cerebral cortex, especially the areas responsible for language and reasoning. Neurofibrillary tangles are abnormal collections of twisted protein threads inside nerve cells. Plaques and neurofibrillary tangles are not unique to patients with AD or dementia. They are also found in the brains of people without cognitive impairment. However, they are more abundant in the brains of those with AD Research suggests AD causes pathologic changes in the brain at least 15 years before the manifestations of AD appear Behavioral manifestations, such as agitation or aggression, result from changes that take place within the brain. These include dysphasia (difficulty comprehending language and oral communication), apraxia (inability to manipulate objects or perform purposeful acts), visual agnosia (inability to recognize objects by sight), and dysgraphia (difficulty communicating by writing). Eventually long-term memories cannot be recalled, and the person may not recognize family members and friends. Later in the disease, the ability to communicate and perform ADLs is lost. Retrogenesis is the process in which the decline in AD mirrors, in reverse order, brain development that occurs from birth.9 Thus it compares the developmental stages of childhood with the deterioration of patients with AD STAGES: Preclinical A long lag exists between pathologic changes in the brain and manifestations of AD. The future goal would be to modify the disease process of AD before it becomes symptomatic. Once plaques and tangles have formed in sufficient quantity, it may be too late to intervene to prevent the disease or its progression. mild cognitive impairment: Mild cognitive impairment (MCI) is the second stage in the AD spectrum. It is a state of cognitive function in which persons have problems with memory, language, or other essential cognitive functions. The problems are severe enough to be noticed by the person having them and by others and can be found on screening tests. -There is little evidence that drugs used in AD, such as cholinesterase inhibitors, affect progression to dementia or improve cognitive test scores in people with MCI -monitoring When all other possible conditions that can cause cognitive impairment have been excluded, a clinical diagnosis of AD can be made. A comprehensive evaluation includes a complete health history, physical examination, neurologic and mental status assessments, and laboratory tests (Table 59.8). A definitive diagnosis of AD requires an examination of brain tissue at autopsy and findings of neurofibrillary tangles and plaques. Neuroimaging techniques allow for detection of changes early in the disease and monitoring of treatment response PET scanning can help distinguish AD from other forms of dementia Guidelines identify 2 biomarker categories: (1) biomarkers showing the level of β-amyloid accumulation in the brain and (2) biomarkers showing that nerve cells in the brain are injured or actually degenerating. Biomarkers include (1) CSF neurochemical markers: β-amyloid and tau proteins, and (2) imaging biomarkers: volumetric MRI and PET. The level of tau in the CSF is an indication of neurodegeneration. Plasma levels of tau or β-amyloid are not of any value in diagnosing AD. At this time there is no cure for AD. Treatment does not stop the deterioration of brain cells -Just txt s/s Cholinesterase inhibitors include donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). Rivastigmine is available as a patch. -Inhibit breakdown of ACH Memantine (Namenda) protects the brain's nerve cells against excess amounts of glutamate, which is released in large amounts by cells damaged by AD. Txt depression Antipsychotic drugs approved for treating psychotic conditions have been used for the management of agitation and aggressive behavior, which occurs in some patients with AD. overall goals are for the patient with AD to (1) maintain functional ability for as long as possible, (2) be in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. Although there is no known definitive way to prevent AD, there are several things that we can do to keep our brain healthy and modify the risk for developing dementia -Early DX Although there is no treatment that reverses AD, ongoing monitoring of both the patient and caregiver is important. Patients with AD move through the stages at variable rates The nursing care needed by the patient with AD changes as the disease progresses, which emphasizes the need for regular assessment and support. The severity of the problems and amount of nursing care needed increase over time. Behavioral problems occur in about 90% of patients with AD. These problems include repetitiveness or asking the same question repeatedly, delusions, hallucinations, agitation, aggression, altered sleeping patterns, wandering, hoarding, and resisting care. Many times, these behaviors are unpredictable and may challenge caregivers. Assess the environment to identify factors that may trigger behavior disruptions. redirection, distraction, and reassurance. A specific type of agitation, termed sundowning, is when the patient becomes more confused and agitated in the late afternoon or evening. -agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity, such as yelling. Nursing interventions that may be helpful include (1) creating a quiet, calm environment; (2) maximizing exposure to daylight by opening blinds and turning on lights during the day; (3) evaluating medications to determine if any could cause sleep problems; (4) limiting naps and caffeine; and (5) consulting with the HCP about drug therapy. The patient with AD is at risk for problems related to personal safety. Potential hazards include falling, ingesting dangerous substances, wandering, injuring others and self with sharp objects, being burned, and being unable to respond to crisis situations. -wandering You need to rely on other clues, such as the patient's behavior. Pain can result in changes in behavior, including increased vocalization, agitation, withdrawal, and changes in function -TXT pain fast Undernutrition is a problem in the moderate and severe stages of AD. Loss of interest in food and decreased ability to self-feed (feeding apraxia) -Dysphagia Nasogastric (NG) feeding may be used for short periods. However, for the long term, the NG tube is uncomfortable and may add to the patient's agitation. A percutaneous endoscopic gastrostomy (PEG) tube is another option Oral care is important- tooth decay- food staying in mouth longer Urinary tract infection and pneumonia are the most common infections in patients with AD. Skin care Incontinence risk Caregiver coping, support, burnout, stress -Support groups

ADPIE Alzheimer's

Alzheimer's disease is commonly characterized by progressive deterioration of cognitive functioning. Initial deterioration may be so subtle and insidious that others may not notice -Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem -Confabulation is not the same as lying. When people are lying, they are aware of making up an answer. Confabulation is unconscious. -Perseveration is the persistent repetition of a word, phrase, or gesture. This repetition continues after the original stimulus is stopped. -Agraphia occurs early in Alzheimer's disease. It is the diminished ability and eventual inability to read or write. -Aphasia is the loss of language ability. Initially, the person has difficulty finding the correct word, then is reduced to a few words, and finally is reduced to babbling or mutism. -Apraxia is the loss of purposeful movement in the absence of motor or sensory impairment. This results in the inability to perform once-familiar and purposeful tasks. -Agnosia is the loss of sensory ability to recognize objects. -Hyperorality refers to the tendency to taste, chew, and put everything in the mouth. -Hypermetamorphosis refers to the urge to touch everything. -Sundowning is the tendency for mood to deteriorate and agitation increase in the later part of the day or at night -Memory impairment -degeneration of neurons disturb executive fxns -Emotions diminish- unresponsive or flat facial affect DX: Depression in the older adult is the disorder frequently confused with disease The attitude of unconditional positive regard is the nurse's single most effective tool in caring for people with dementia. It induces patients to cooperate with care, reduces catastrophic outbreaks, and increases family members' satisfaction with care Patient-centered care is based on an ethical position that personhood in dementia remains and should be honored. The patient-centered approach is focused on forming meaningful relationships with the person who has dementia and also their caregivers -education is key -support groups The overall outcomes for treatment are to promote the person's optimal level of functioning and to delay further regression whenever possible.

Antipsychotic side effects- more specific

Anticholinergic toxicity is a potentially life-threatening medical emergency caused by antipsychotics or other medications with anticholinergic effects including many antiparkinsonian drugs. Older adults and those on multiple anticholinergic drugs are at greatest risk. Symptoms include autonomic nervous system instability and delirium with altered mental status. Mental status changes can include hallucinations and may be mistaken for a worsening of the patient's psychosis, so people whose psychosis is inexplicably worsening should be immediately evaluated for possible anticholinergic toxicity. Neuroleptic malignant syndrome (NMS) occurs in about 0.2% to 1% of patients who have taken first-generation antipsychotics and is characterized by reduced consciousness and responsiveness, increased muscle tone (generalized muscular rigidity), and autonomic dysfunction. Although less likely, NMS can also occur with second-generation antipsychotics. Caused by excessive dopamine receptor blockade, NMS is a life-threatening medical emergency that is fatal in up to 10% of cases. It usually occurs early in therapy but has also occurred 20 years into treatment. Early detection, discontinuation of the antipsychotic, management of fluid balance, temperature reduction, and monitoring for complications such as deep vein thrombosis and rhabdomyolysis (protein in the blood from muscle breakdown, which can cause organ failure) are essential. Agranulocytosis, while most associated with clozapine (Clozaril), is possible with most other antipsychotics as well. Neutropenia can also develop and can be fatal. Monitoring for neutropenia is done as part of the complete blood count through an absolute neutrophil count (ANC). Symptoms of agranulocytosis include signs of infection (e.g., fever, chills, sore throats) or increased susceptibility to infection. Some individuals have lower normal levels of ANC. It is referred to as benign ethnic neutropenia (BEN). Among these people are those from African descent (about 25% to 50%), some Middle Eastern groups, and other non-Caucasians with darker skin. They are not at greater risk for developing agranulocytosis but should have a baseline ANC before starting clozapine. Prolongation of the QT interval may contribute to sudden death of unknown origin that occasionally occurs in individuals with schizophrenia. SGAs quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) can prolong the QT interval. FGAs chlorpromazine (Thorazine), haloperidol (Haldol), and thioridazine (Mellaril) have also been implicated in this cardiac emergency. Electrocardiograms should evaluate all people for existing QT prolongation (which magnifies the risk from medication-related prolongation) before being started on any antipsychotic. Liver impairment may also occur during antipsychotic therapy, particularly with FGAs. SGAs also lead to serum enzyme elevations but rarely with injury or jaundice. Liver impairment usually occurs in the first weeks of therapy. This makes monitoring of liver function values essential. Signs of liver problems include yellowish skin and eyes, abdominal pain, ascites, vomiting, swelling in lower extremities, dark urine, pale or tar-colored stool, and easy bruising. The patient may complain of itchy skin, chronic fatigue, nausea, and a loss of appetite. Disorders co-occurring with schizophrenia should be actively treated. Depression is common in schizophrenia and is typically treated with antidepressants and other interventions (see Chapter 14). Antidepressants and mood-stabilizing agents may be needed for mood symptoms in schizoaffective disorder. Benzodiazepines (e.g., lorazepam [Ativan]) can reduce agitation and anxiety (which can worsen other symptoms and is quite common in schizophrenia) and can help lessen positive and negative symptoms.

Children/ neurodevelopmental disorders

Barriers:(1) lack of consensus for screening children, (2) lack of coordination among multiple systems, (3) lack of community-based resources and long waiting lists for services, (4) lack of mental health providers, and (5) cost and inadequate reimbursement RISK: Hereditary disorders - (1) lack of consensus for screening children, (2) lack of coordination among multiple systems, (3) lack of community-based resources and long waiting lists for services, (4) lack of mental health providers, and (5) cost and inadequate reimbursement Dramatic changes occur in the brain during childhood and adolescence, including a declining number of synapses (they peak at age 5), changes in the relative volume and activity level in different brain regions, and interactions of hormones -Changes in the brain development Psych: Temperament refers to the usual attitude, mood, or behavior that a child habitually uses to cope with the demands and expectations of the environment. This style is present in infancy, is modified somewhat with maturation, and develops in the context of the social environment. -Traits such as shyness, aggressiveness, and rebelliousness, for example, may increase the risk for substance use problems. External risk factors for using illicit substances include peer or parental substance use and involvement in legal problems such as truancy or vandalism. -Protective factors that shield some children from drug use include self-control, parental monitoring, academic achievement, antidrug-use policies, and strong neighborhood attachment. Resilience is the relationship between a person's inborn strengths and success in handling stressful environmental factors -1. Adaptability to changes in the environment 2. Ability to form nurturing relationships with other adults when the parent is not available 3. Ability to distance self from emotional chaos 4. Social intelligence 5. Good problem-solving skills 6. Ability to perceive a long-term future During childhood, the main context is the family. Parents model behavior and provide the child with a view of the world. If parents are abusive, rejecting, or overly controlling, the child may suffer detrimental effects at the developmental point(s) at which the trauma occurs risk factors include severe marital discord, low socioeconomic status, large families and overcrowding, parental criminality, maternal psychiatric disorders, and foster-care placement. -ACES -Abuse ASSESS: Methods of collecting data include interviewing, screening, testing (neurological, psychological, intelligence), observing, and interacting with the child or adolescent. In addition to the patient, ideally, data will be taken from multiple sources, including parents, teachers, and other caregivers. -Nurses use play activities such as therapeutic games, drawings, and puppets for younger children who have difficulty responding to a direct approach -The main difference is that assessment is adapted to be appropriate for the child's developmental stage, cognitive capabilities, and verbal skills. -The developmental assessment provides information about the child or adolescent's maturational level. These data are then reviewed in relation to the chronological age to identify developmental strengths or deficits. -Nurses need to evaluate behaviors brought on by stress, as well as those of more serious psychopathology, and identify the need for further evaluation or referral. Diff settings for interventions school, inpt, home, outpt, outreach, ect Behavioral interventions reward desired behavior to reduce maladaptive behaviors. Play therapy is a type of intervention that allows children to express feelings such as anxiety, self-doubt, and fear through the natural use of play. Bibliotherapy involves using literature to help the child express feelings in a supportive environment, gain insight into feelings and behavior, and learn new ways to cope with difficult situations. When children listen to or read a story, they unconsciously identify with the characters and experience a catharsis of feelings. -use of art provides a nonverbal means of expressing difficult or confusing emotions -Journaling is a tangible way of recording and viewing emotions and may be a way to begin a dialogue with others -Music can be used to improve physical, psychological, cognitive, behavioral, and social functioning- Engage many senses -Nurses can help family members develop specific goals, identify ways to improve, and work to achieve the goals for the family or subunits within the family -meds -Collab with parents, teachers, health care team -techniques are selected according to the principle of least restrictive intervention. This principle requires that you use more restrictive interventions only after attempting less restrictive interventions that have been unsuccessful to manage the behavior. -Time out -Quiet room -Seclusion and restraint Group therapy Cog-behavioral therapy

Review Meds

Buspirone (BuSpar) is a drug that reduces anxiety without having strong sedative-hypnotic properties. Because this agent does not leave the patient sleepy or sluggish, patients tolerate it better than the benzodiazepines. It is not a CNS depressant and, therefore, does not have as great a danger of interaction with other CNS depressants such as alcohol The monoamine hypothesis of depression suggests that there is a deficiency in one or more of the three neurotransmitters: serotonin, norepinephrine, or dopamine. The theory implies that by increasing these neurotransmitters depression is alleviated. Monoamine oxidase inhibitors (MAOIs) are a class of antidepressant drugs that can have a desired effect in the brain while exerting potentially dangerous effects elsewhere. -Tyramine NONE: meats, cheeses, beer, wine, chocolate, fava beans As the name implies, the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and fluvoxamine (Luvox), block the reuptake of serotonin thereby making more of this neurotransmitter available. However, they each have slightly different effects Serotonin norepinephrine reuptake inhibitors (SNRIs) increase both serotonin and norepinephrine. Venlafaxine (Effexor) acts more like a serotonergic agent at lower therapeutic doses and promotes norepinephrine reuptake blockade at higher doses, leading to the dual SNRI action. Duloxetine (Cymbalta) Tricyclic antidepressants (TCAs) were widely used before the development of SSRIs. They are no longer considered first-line medications since they have more side effects, take longer to reach an optimal therapeutic dose, and are far more lethal in overdose. -amitriptyline, imipramine [Tofranil] lthough lithium (Eskalith, Lithobid) has been used as a mood stabilizer in patients with bipolar (manic-depressive) disorder for many years, we do not understand its mechanism of action. As a positively charged cation, similar in structure to sodium and potassium, lithium may well act by affecting electrical conductivity in neurons. -Sodium -hyponatremia can increase the risk of lithium toxicity because increased renal reabsorption of sodium leads to increased reabsorption of lithium as well. First-generation antipsychotics are also referred to as conventional antipsychotics and typical antipsychotics. An overactivity of the dopamine system in the mesolimbic system may be responsible for at least some of the symptoms of schizophrenia. These drugs are strong antagonists (blocking the action) of the D2 receptors for dopamine Second-generation antipsychotics are also known as atypical antipsychotics. These drugs produce fewer EPS and target both the negative and positive symptoms of schizophrenia (Chapter 12). These newer agents are often chosen as first-line treatments over the first-generation antipsychotics due a more favorable side effect profile. Clozapine (Clozaril) is an antipsychotic drug that is relatively free of the motor side effects of the phenothiazines and other second-generation antipsychotics. Clozapine preferentially blocks the D1 and D2 receptors in the mesolimbic system rather than those in the nigrostriatal area. This allows it to exert an antipsychotic action without leading to difficulties with EPS. However, it can cause a potentially fatal side effect. Clozapine has the potential to suppress bone marrow and induce agranulocytosis. Risperidone (Risperdal) has a low potential for inducing agranulocytosis or convulsions. However, high therapeutic dosages (>6 mg/day) may lead to motor difficulties. As a potent D2 antagonist, it has the highest risk of EPS among the second-generation antipsychotics and may increase prolactin, which may lead to sexual dysfunction. Olanzapine (Zyprexa) is similar to clozapine in chemical structure. It is an antagonist of 5-HT2, D2, H1, alpha-1, and muscarinic receptors. Side effects include sedation, weight gain, hyperglycemia with new-onset type 2 diabetes, and higher risk for metabolic syndrome. Ziprasidone (Geodon) is a serotonin-norepinephrine reuptake inhibitor at multiple receptors: 5-HT2, D2, alpha-1, and H1D. Ziprasidone is contraindicated in patients with a known history of QT interval prolongation, recent acute myocardial infarction, or uncompensated heart failure Paliperidone (Invega) is the major active metabolite of risperidone. It has similar side effects with regard to prolactin elevation. Other than the D2 and 5-HT2A antagonistic properties as an antipsychotic, paliperidone is also an antagonist at alpha-1 receptors and H1 receptors, which explains the side effects of orthostasis and sedation, respectively. Guanfacine and clonidine are centrally acting alpha-2 adrenergic agonists that have traditionally been used for hypertension. The FDA-approved forms for ADHD are used in children ages 6 to 17. Both should be increased slowly and should not be discontinued abruptly. Guanfacine's most common side effects include sleepiness, low blood pressure, nausea, stomach pain, and dizziness. -The FDA has approved three nonstimulants for the treatment of ADHD: atomoxetine (Strattera), guanfacine (Intuniv), and clonidine (Kapvay). Atomoxetine is a norepinephrine reuptake inhibitor approved for use in children 6 years and older. Common side effects include decreased appetite and weight loss, fatigue, and dizziness. It is contraindicated for patients with severe cardiovascular disease due to its potential to increase blood pressure and heart rate. Alzheimer's disease, cholinesterase inhibitors, shows some efficacy in slowing the rate of memory loss and even improving memory. They work by inactivating the enzyme that breaks down acetylcholine, cholinesterase, leading to less destruction of acetylcholine and, therefore, a higher concentration at the synapse. -Glutamate, an abundant excitatory neurotransmitter, plays an important role in memory function. However, too much glutamate can be destructive to neurons.

Normal Psych

Cerebrum: overall brain Cerebellum: back of brainstem- balance Pons + medulla is brain stem- basic life sustaining things Midbrain: Thalamus (Relay station), hypothalamus (temp) Lobes: Frontal, parietal (sensory), temporal (speech/ auditory), occipital (vision) AGE: The process of cognitive development from infancy throughout childhood has been described by many—perhaps most notable is Piaget.8 According to Piaget, cognitive development is an orderly and sequential process that occurs in four stages: sensorimotor (birth to age 2 years), preoperational (ages 2-7 years), concrete operational (ages 7-11 years), and formal operational (age 11 years and older). -three primary changes occur that influence the developing brain: increase in brain mass, neuronal-synaptic connections, and myelination. The size and weight of the brain and number of neurons decrease with aging. The reduction in and atrophy of neurons results in less efficient neurotransmission and a slowing of neural responses

Learning disorders

Children with specific learning disorders are identified during the school years. A specific learning disorder is diagnosed when a child demonstrates persistent difficulty in reading (dyslexia), mathematics (dyscalculia), and/or written expression (dysgraphia). With any of these problems their performance is well below the expected performance of their peers. Diagnosis of a learning disorder is made through multiple assessments, including formal psychological evaluations. Intellectual disability is characterized by deficits in three areas: • Intellectual functioning. Deficits in reasoning, problem solving, planning, judgment, abstract thinking, and academic ability. • Social functioning. Impaired communication and language, interpreting and acting on social cues, and regulating emotions. • Daily functioning. Practical aspects of daily life are impacted by a deficit in managing age-appropriate activities of daily living, functioning at school or work, and performing self-care. Treatment plans should be individualized and realistic. Although the care plan is developed for the child, family members or caregivers and school personnel should be included in the process.

iMPAIRMENT OF COGNITION

Cognitive impairment refers to deficits in intellectual functioning. categories are used: delirium, neurocognitive disorders (NCDs), cognitive impairment not dementia, focal cognitive disorders, intellectual disabilities, and learning disabilities Delirium: Delirium is a state of disturbed consciousness and altered cognition with a rapid onset occurring over hours or a few days. Neurocognitive disorders (NCDs) refer to a group of disorders better known as dementia. The commonality within these disorders is an acquired and progressive deterioration of all cognitive functions (with little or no disturbance of consciousness or perception), including impairment in memory, judgment, calculation ability, attention span, and abstract thinking. -subtypes include Alzheimer's disease, Parkinson's disease, HIV infection, frontotemporal, Lewy body type, traumatic brain injury, vascular, substance induced, Huntington's disease, prion disease, and other medical conditions. Cog impairment: demonstrate a greater reduction of cognitive function than expected for an individual's age and education, but it does not interfere with functional ability.- high risk for dementia Focal Cog disorders: affect a single area of cognitive function. The area involved may be memory, language, visuospatial ability, or executive function.7 These disorders may be associated with a neurocognitive disorder or may be seen independently Intellectual disability: Intellectual disability refers to limitations of cognitive functioning and below-average intelligence (IQ score <70), in addition to limitations in conceptual skills, social skills, and activities of daily living.15 Intellectual disability differs from neurocognitive disorders in that the cognitive processing never fully develops and the symptoms are identified before age 18 years. Learning Disability: Often identified during childhood, there exists a challenge in taking data signals in and then processing the information received. Learning disorders occur among individuals having average or above-average intelligence, which is an important distinction compared to intellectual disability. Cognitive impairment places an individual at significant risk for a number of adverse physical, psychological, and social outcomes. Individuals with cognitive impairment are at higher risk for injury due to falls (particularly those with dementia) and other injuries within the environment due to the lack of accurate perceptions, risk recognition, and/or lack of capacity for an appropriate response to dangerous situations.

Comm disorders

Communication disorders are a deficit in language skills acquisition that creates impairments in academic achievement, socialization, or self-care. Broadly, we consider speech and language as two separate categories for evaluating communication. -Problems making sounds -Fluency problems -Children may have a receptive language disorder where they experience difficulty understanding or are unable to follow directions. -Children may have an expressive language disorder that results in difficulty in finding the right words and forming clear sentences -In social communication disorder, children have problems using verbal and nonverbal means for interacting socially with others.

strategy working with pt with hallucinations

Compassion Direct eye contact Simple terms Loud clear voice consistency Trust empathy authenticity assertiveness if nurse is frightened so will pt be patient acceptance listening skills observe behavior/ assess duration, intensity, frequency of hallucination ask pt what is happening drugs/ alcohol? impact ADLS? Triggers? Positive S/S: sees something that is not there hallucinations Negative: doesn't see something that is there

Delirium cont

Delirium is a state of confusion that develops over days to hours.1 The patient has decreased ability to direct, focus, sustain, and shift attention and awareness. Deficits in memory, orientation, language, visuospatial ability, or perception may be present. The patient may be hypoactive or hyperactive. Emotional problems include fear, depression, euphoria, or perplexity. Sleep may be disturbed. We do not know the exact cause of delirium. A main contributing factor is impairment of cerebral oxidative metabolism, in which the brain gets less oxygen and has problems using it. -Dec ACH inc DOPAMINE Stress, surgery, and sleep deprivation have been linked to delirium Dementia is the leading risk factor for delirium Parkinsons: ACH UP / EXCITED/ TREMOR DOPAMINE DOWN/ CALM/ STOP TREMOR LEVDOPA Patients with delirium can have a variety of manifestations, ranging from hypoactivity and lethargy to hyperactivity, agitation, and hallucinations. Patients can have mixed delirium, with both hypoactive and hyperactive symptoms. Delirium can develop over the course of hours to days. -The early manifestations often include inability to concentrate, disorganized thinking, irritability, insomnia, loss of appetite, restlessness, and confusion. Later manifestations may include agitation, misperception, misinterpretation, and hallucinations. A key distinction between them is that the patient who has sudden cognitive impairment, disorientation, or clouded sensorium is more likely to have delirium rather than dementia. The Confusion Assessment Method (CAM) is a reliable tool for assessing delirium Once delirium has been diagnosed, explore potential causes. Carefully review the patient's health history and medication record. Laboratory tests include complete blood count, serum electrolytes, blood urea nitrogen, and creatinine levels; ECG; urinalysis; liver and thyroid function tests; and oxygen saturation level. Treatment is important as many cases of delirium are potentially reversible. In caring for the patient with delirium, you are responsible for prevention, early recognition, and treatment. -Other risk factors include sensory impairment, older age, surgery, hospitalization in an intensive care unit (ICU), and untreated pain. Give priority to creating a calm and safe environment. Drug therapy is reserved for patients with severe agitation, especially when it interferes with needed medical treatments. Agitation can put the patient at risk for falls and injury. Dexmedetomidine (Precedex), an α-adrenergic receptor agonist, has been used in ICU settings for sedation. Haloperidol can be given IV, IM, or orally and will produce sedation. Other side effects include hypotension; extrapyramidal side effects, including tardive dyskinesia (involuntary muscle movements of face, trunk, and arms) and athetosis (involuntary writhing movements of the limbs); muscle tone changes; and anticholinergic effects. Short-acting benzodiazepines (e.g., lorazepam [Ativan]) can be used to treat delirium associated with sedative and alcohol withdrawal or in conjunction with antipsychotics to reduce extrapyramidal side effects.

Delirium in children

Delirium is defined as a syndrome characterized by the acute onset of cerebral dysfunction with a change or fluctuation in baseline mental status, inattention, and either disorganized thinking or an altered level of consciousness BRAIN MAPS Bring Oxygen Reduce drugs Atmosphere light, family, schedule, clocks, calendars Infection, immobilization, inflammation New organ Metabolic disturbance- BMP Awake: routine, sleep at night Pain Sedation The pathophysiology of delirium is complex and most likely is due to alterations in neurotransmitter function, reduced cerebral blood flow, increased energy metabolism, and disordered cellular homeostasis.6 The underlying disease process, side effects of treatment, and the foreign critical care environment all contribute to the development of delirium in hospitalized children brain cells cannot preserve a balance of stimulating and inhibiting neurotransmitters The gold standard for identifying delirium is diagnosis by a child and adolescent psychiatrist on the basis of criteria of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Delirium in hospitalized children is characterized as hypoactive, hyperactive, or mixed Hypoactive Hyperactive Mixed Signs Child looks apathetic and seems uninterested Child is irritable despite adequate pain medication and may be thrashing Child fluctuates between a hypoactive and a hyperactive state serial assessments are of great value identifying and modifying factors that contribute to the development of delirium in children, including hypoxia, medications such as anticholinergics and benzodiazepines, metabolic disturbances, pain, and anxiety. The target level of sedation should be the level at which the child is alert and calm, unless existing factors require more sedation, such as when the patient's actions could disrupt the integrity of essential medical devices, such as an endotracheal tube benzodiazepines are a risk factor for delirium This sensory overstimulation, coupled with sleep interruptions, may further exacerbate a delirious child's thought misperceptions, disorientation, and inattention Normal sleep-wake homeostasis is important in immunity, in thermoregulation, and for preventing a catabolic state, all of which are important for recovering from critical illness.8,29,30 Inadequate sleep quality and duration, often experienced by patients in the ICU, are associated with the development of delirium. Having days and nights mixed up Schedules Family involvement 8 In these situations, medications to help manage the signs of delirium may be appropriate to enhance the child's safety and to support brain function Antipsychotics target neurotransmitter dysregulation, and their use does not imply that the child has a psychiatric disorder or that only patients who are psychotic benefit from these medications. Generally, the lowest dose is started and then modified on the basis of the child's response.2 Haloperidol may be beneficial for children who cannot tolerate oral medications and whose agitation has not changed in response to the nonpharmacological interventions previously described Atypical antipsychotics, such as risperidone, olanzapine, quetiapine, and ziprasidone, among others, can be equally useful in the treatment of the physical signs of delirium in children Olanzapine is also available as an oral disintegrating tablet, a form that makes its administration easier in children QTc assessment at baseline and then at least daily, especially when intravenous haloperidol is used for treatment, which should be avoided in patients at high risk for arrhythmia Once delirium has been detected, a multiprofessional approach incorporating evidence-based recommendations for care may improve the morbidity and mortality associated with delirium in children, and ultimately improve outcomes after discharge

Schizophrenia spectrum disorders- Brief disorder types

Delusional disorder: Delusional disorder is characterized by delusions that have lasted 1 month or longer. The delusions tend to have a general theme that includes grandiose, persecutory, somatic, and referential delusions. These delusions are usually not severe enough to impair occupational or daily functioning. Brief Psychotic dosorder: sudden onset of at least one of the following: delusions, hallucinations, disorganized speech, and disorganized or catatonic (severely decreased motor activity) behavior. The symptoms must last longer than 1 day, but no longer than 1 month with the expectation of a return to normal functioning Schizophreniform disorder: The essential features of this disorder are exactly like those of schizophrenia, except that symptoms last a much shorter period of time (less than 6 months). Also, impaired social or occupational functioning during some part of the illness is not apparent (although it might occur). It is difficult to know the prognosis of a schizophreniform disorder because some individuals return to their previous level of functioning, while others have a more difficulties in moving forward Schizoaffective disorder: disorder is characterized by an uninterrupted period of illness during which there is a major depressive, manic, or mixed episode, concurrent with symptoms that meet the criteria for schizophrenia. The symptoms must not be caused by any substance use or abuse or general medical condition. Substance induced psychotic disorder/ due to another medical condition: -Substances such as drugs, alcohol, medications, or toxin exposure can induce delusions and/or hallucinations. Hallucinations or delusions can also be caused by a general medical condition such as delirium, neurological problems, alterations, hepatic or renal diseases, and many more. Substance use and medical conditions should always be ruled out before a primary diagnosis of schizophrenia

Dementia

Dementia is a broad term used to describe progressive deterioration of cognitive functioning and global impairment of intellect. It is a term that does not refer to specific disease, but rather a collection of symptoms.

Dementia Cont.

Dementia is a disorder characterized by a decline from previous level of function in 1 or more cognitive domains: complex attention, executive function, language, learning and memory, perceptual-motor, and social cognition.1 The cognitive decline interferes with ability to function and perform daily activities. ***does not occur with onset of an acute state of confusion, such as delirium, or the onset of another major mental disorder, such as depression. Treatable causes may initially be reversible. However, with prolonged exposure or disease, irreversible changes may occur. -neurodegenerative conditions that cannot be reversed Vascular, or multiinfarct dementia (VaD), is a loss of cognitive function caused by cardiovascular disease (CVD). -Post stroke Mixed dementia occurs when 2 or more types of dementia are present at the same time. s/s: Manifestations associated with neurologic degeneration usually occur gradually and progress over time. Symptoms of VaD may appear abruptly or progress in a stepwise pattern. diagnosis of dementia is focused on determining the cause Elicit information about (1) problems with judgment; (2) reduced interest in hobbies/activities; (3) repeating questions, stories, or statements; (4) trouble learning how to use a tool or appliance; (5) forgetting the correct month or year; (6) problems handling financial affairs; (7) difficulty remembering appointments; and (8) consistent problems with thinking and/or memory. Med/ Phys HX

Motor disorders

Developmental coordination disorder is based on (1) impairments in motor skill development, (2) coordination below the child's developmental age, and (3) problems interfere with academic achievement or activities of daily living. Symptoms include delayed sitting or walking or difficulty jumping or performing tasks such as tying shoelaces. Stereotypic movement disorder is manifested by repetitive purposeless movements such as hand waving, rocking, head banging, nail biting, and teeth grinding for a period of 4 weeks or more (APA, 2013). This disorder is more common in boys than in girls. Intellectual disability is a risk factor for these repetitive movements with up to 16% of this population affected.

ADPIE SCHIZOPHRENIA

Early assessment plays a key role in improving the prognosis for individuals with schizophrenia. Intervening at this early stage to reduce risk factors such as high levels of stress and substance abuse, coupled with enhancing social and coping skills, can reduce the risk of developing schizophrenia in biologically vulnerable people 1. Positive symptoms: The presence of something that should not be present. Positive symptoms include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or speech. 2. Negative symptoms: The absence of something that should be present. Negative symptoms include the inability to enjoy activities, social discomfort, or lack of goal-directed behavior. 3. Cognitive symptoms: Subtle or obvious impairment in memory, attention, thinking (e.g., disorganized or irrational thoughts), judgment, or problem solving. 4. Affective symptoms: Symptoms involving emotions and their expression The positive symptoms usually appear early. Reality testing is the automatic and unconscious process by which we determine what is and is not real. Delusions are false beliefs held despite a lack evidence to support them. The most common delusions involve persecutory, grandiose, or religious ideas. One of the most common, associative looseness, or looseness of association, results from haphazard and illogical thinking where concentration is poor and individuals loosely associate their thoughts. For example: "I need to get a Band-Aid. My friend was talking about AIDS. Friends talk about French fries but how can you trust the French?" A word salad, the most extreme form of associative looseness, is a jumble of words that is meaningless to the listener (e.g., "throat hoarse strength of policy highlighters on a boat reigning supreme"). Clang association is choosing words based on their sound rather than their meaning and often involves words that rhyme or have a similar beginning sound ("On the track...have a Big Mac" or "Click, clack, clutch, close"). Neologisms are words that have meaning for the patient but a different or nonexistent meaning to others. A person may use a known word differently than others understand it or can create a completely new word that others do not understand (e.g., "His mannerologies are poor"). Echolalia is the pathological repeating of another's words, occurring perhaps because the patient's thought processes are so impaired that he is unable to generate speech of his own. • Circumstantiality: Including unnecessary and often tedious details in conversation but eventually reaching the point. • Tangentiality: Wandering off topic or going off on tangents and never reaching the point. • Cognitive retardation: Generalized slowing of thinking, which is represented by delays in responding to questions or difficulty finishing thoughts. • Pressured speech: Urgent or intense speech; resists allowing comments from others. • Flight of ideas: Moving rapidly from one thought to the next, often making it difficult for others to follow the conversation. • Symbolic speech: Using symbols instead of direct communication. For example, a patient reports "demons are sticking needles in me" when what he means is that he is experiencing a sharp pain (symbolized by "needles"). • Thought blocking: A reduction or stoppage of thought. Interruption of thought by hallucinations can cause this. • Thought insertion: The uncomfortable belief that someone else has inserted thoughts into the brain. • Thought deletion: A belief that thoughts have been taken or are missing. Other positive symptoms manifested in disorders of thought include: • Magical thinking: Believing that thoughts or actions affect others. This is common and usually nonpathological in children (e.g., wearing pajamas inside out to make it snow, or because I was mad at him, he fell down). • Paranoia: An irrational fear, ranging from mild (wary, guarded) to profound (believing irrationally that another person intends to kill you). Fear may result in defensive actions, harming another person before that person can harm the patient The most common perceptual errors are hallucinations. Hallucinations occur when a person perceives a sensory experience for which no external stimulus exists (e.g., hearing a voice when no one is speaking). Types of hallucination include: • Auditory: Hearing voices or sounds- most common • Visual: Seeing people or things • Olfactory: Smelling odors • Gustatory: Experiencing tastes • Tactile: Feeling bodily sensations (e.g., feeling an insect crawling on one's skin) A command hallucination is a particularly disturbing symptom that directs the person to take an action. This type of hallucination must be monitored carefully because they may be dangerous, for example, telling a patient to "jump out the window" or "hit that nurse." Visual hallucinations are the second most common form in schizophrenia. They may involve distortion of visual stimuli or can be formed and realistic images. Seeing individuals and animals are most common. • Illusions: Misperceptions or misinterpretations of a real experience. For example, a man sees a coat on a shadowy coat rack and believes it is a bear. • Depersonalization: A feeling of being unreal or having lost identity. Body parts do not belong or the body has drastically changed (e.g., a patient may see the fingers as being smaller or not theirs). • Derealization: A feeling that the environment has changed (e.g., everything seems bigger or smaller or familiar surroundings seem somehow strange and unfamiliar). • Catatonia: A pronounced increase or decrease in the rate and amount of movement. Excessive motor activity is purposeless and accompanied by echolalia (repeating others' words) and echopraxia (mimicking others' movements). The most common form of catatonia is when the person moves little or not at all. Muscular rigidity, or catalepsy, may be so severe that the limbs remain in whatever position they are placed. Freezing in place may result in problems such as exhaustion, pneumonia, blood clotting, malnutrition, or dehydration. • Waxy flexibility: Maintaining a given posture inappropriately, usually seen in catatonia. For example, when the nurse raises the arm, the patient continues to hold this position in a statue-like manner. • Motor retardation: A pronounced slowing of movement. • Motor agitation: Excited behavior such as running or pacing rapidly, often in response to internal or external stimuli. The agitation can put the patient at risk (e.g., exhaustion, running into traffic) or others at risk (being knocked down). • Stereotyped behaviors: Repetitive behaviors that do not serve a logical purpose. • Echopraxia: The mimicking of movements of another. • Negativism: A tendency to resist or oppose the requests or wishes of others. • Impaired impulse control: A reduced ability to resist one's impulses. Examples include interrupting in the group setting or throwing unwanted food on the floor. It can increase the risk of assault. • Gesturing or posturing: Assuming unusual and illogical expressions (often grimaces) or positions. • Boundary impairment: An impaired ability to sense where one's body or influence ends and another's begins. For example, a patient might stand too close to others or might drink another's beverage, believing that because it is near, it is theirs. Positive symptoms are so attention-getting, they make treatment seem more urgent than negative symptoms. Yet negative symptoms are serious problems for people with schizophrenia because they are the absence of essential human qualities. Treating negative symptoms is more difficult than treating positive symptoms. • Anhedonia (an = without + hedonia = pleasure): A reduced ability or inability to experience pleasure in everyday life. • Avolition (a = without + volition = making a decision): Loss of motivation; difficulty beginning and sustaining goal-directed activities; reduction in motivation or goal-directed behavior. • Asociality: Decreased desire for, or comfort during, social interaction. • Affective blunting: Reduced or constricted affect. • Apathy: A decreased interest in, or attention to, activities or beliefs that would otherwise be interesting or important. • Alogia: Reduction in speech, sometimes called poverty of speech. These symptoms can contribute to poor social functioning and social withdrawal. They can impede a person's ability to initiate and maintain conversations and relationships or succeed in school or work. Apathy and avolition result in deficits in basic activities such as maintaining adequate hygiene, grooming, and other activities of daily living Affect, an additional "A" word, is the external expression of a person's internal emotional state. In schizophrenia, affect may be diminished or not coincide with inner emotions. Some antipsychotics can also cause diminished affect. Affect in schizophrenia can usually be categorized in one of four ways: • Flat: Immobile or blank facial expression • Blunted: Reduced or minimal emotional response • Constricted: Reduced in range or intensity (e.g., shows sadness or anger but no other moods) • Inappropriate: Incongruent with the actual emotional state or situation (e.g., laughing in response to a tragedy) • Bizarre: Odd, illogical, inappropriate, or unfounded; includes grimacing Concrete thinking is an impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner. For example, a nurse might ask what brought the patient to the hospital, and the patient answers "a cab" rather than explaining a suicide attempt. Impaired memory impacts short-term memory and the ability to learn. Repetition and verbal or visual cues may help the patient to learn and recall needed information (e.g., a picture of a toothbrush on the patient's wall as a reminder to brush his or her teeth). Impaired information processing can lead to problems such as delayed responses, misperceptions, or difficulty understanding others. Patients may lose the ability to screen out insignificant stimuli such as background sounds or objects in one's peripheral vision. This can lead to overstimulation. Impaired executive functioning includes difficulty with reasoning, setting priorities, comparing options, placing things in logical order or groups, anticipation and planning, and inhibiting undesirable impulses or actions. Impaired executive functioning interferes with problem solving and can contribute to inappropriateness in social situations. Affective symptoms are those that involve the experience and expression of emotions. They are common and increase patients' suffering. Mood may be unstable, erratic, labile (changing rapidly and easily), or incongruent (not what would be expected for the circumstances). Depression anosognosia (uh-no-sog-NOH-zee-uh), an inability to realize they are ill caused by the illness itself. Anosognosia may result in the patient resisting or stopping treatment, making care challenging and frustrating to staff.

Alzheimer's disease

Early: Difficulty with recent memory, impaired learning, apathy, and depression. Moderate to severe: Visual/spatial and language deficits, psychotic features, agitation, and wandering. Late: Gait disturbance, poor judgment, disorientation, confusion, incontinence, and difficulty speaking, swallowing, and walking There is an increased risk for those people with an immediate family member who has or had dementia. There are three known genetic mutations that guarantee that a person will develop Alzheimer's disease, although these account for less than 1% of all cases.- before 65 as early as 30 -Genes at all ages can cause this dx The health of the brain is closely linked to overall heart health, and there is evidence that people with cardiovascular disease are at greater risk of Alzheimer's disease. Brain injury and trauma are associated with a greater risk of developing Alzheimer's disease and other dementias Environment: healthy diet s/s: Severe memory loss is not a normal part of growing older -Although dementia often begins with a worsening of ability to remember new information, it is marked by progressive deterioration in other cognitive functions such as problem-solving and learning new skills and a decline in the ability to perform activities of daily living. A person's declining intellect often leads to emotional changes such as anxiety, mood lability, and depression as well as neurological changes that produce hallucinations and delusions. -The three stages are mild, moderate, and severe. -The loss of intellectual ability is insidious. The person with mild Alzheimer's disease loses energy, drive, and initiative and has difficulty learning new things. - pt can still work until it becomes too demanding -Depression More severe symptoms appear as Alzheimer's disease progresses. The person experiences agnosia, which is the inability to identify familiar objects or people, even a spouse. Apraxia is a common symptom where a person needs repeated instructions and directions to perform the simplest tasks -forgets where toilet is- incontinence

ADPIE

HX/ Phys Exam: general appearance, behavior, assess of cog function Dx testing: imaging, testing, ID impairment, standardized tests Management: Primary prevention: promote healthy lifestyle, genetic counseling, ID high risk behaviors Secondary screening: periodic assessments Tertiary collaborative: Cognition is a consideration in virtually all areas of health care and for all members of the health care team. It is a critical element in communicating with the patient and in the determination of care Promoting adequate rest, sleep, fluid intake, nutrition, elimination, pain control, and comfort are essential elements of care for persons with cognitive impairment. Also of great importance is ensuring an appropriate level of environmental stimulation because excessive stimulation can create agitation and confusion, whereas a lack of stimulation can result in sensory deprivation effects and withdrawal. -Virtually all patients with cognitive impairment benefit from predictable routines, consistent caregivers, simple instructions, eye contact, and the presence of familiar people and objects -Safety is a priority concern for all patients with cognitive impairment. In the management of patients with cognitive impairment, pharmacologic agents primarily treat associated diseases and control behavioral alterations such as sleeplessness, anxiety, agitation, and depression Information should be provided about support groups, respite options, day care, and other community services. Parents of a child born with intellectual disability require a great deal of support, particularly when they learn their child will have lifelong special needs.

ADHD

Individuals with attention-deficit/hyperactivity disorder (ADHD) show an inappropriate degree of inattention, impulsiveness, and hyperactivity. Some children are inattentive, but not hyperactive. In this case the diagnosis is attention-deficit disorder (ADD). -s/s PRESENT AT HOME AND SCHOOL FOR DX -Attention problems and hyperactivity contribute to low frustration tolerance, temper outbursts, labile moods, poor school performance, peer rejection, and low self-esteem. -Peer relationships are strained due to difficulty taking turns, poor social boundaries, intrusive behaviors, and interrupting others. -Inattentive type of ADHD may exhibit high degrees of distractibility and disorganization. They may be unable to complete challenging or tedious tasks, become easily bored, lose things frequently, or require frequent prompts to complete tasks. Children and adolescents with ADHD can be overactive and may display disruptive behaviors that are impulsive, angry, aggressive, and often dangerous. They may have difficulty with maintaining attention in situations that require sustained attention. In addition, their behaviors negatively impact their ability to develop fulfilling peer and family relationships. txt: Therapy, support, stimulant medications -Methylphenidate (Ritalin and others) and the mixed amphetamine salts (Adderall) are the most widely used stimulants because of their relative safety and simplicity of use. -Lowest dose possible is preferred -A nonstimulant selective norepinephrine reuptake inhibitor, atomoxetine (Strattera), is approved for childhood and adult ADHD. Therapeutic responses develop slowly, and it may take up to 6 weeks for full improvement. -Dec appetite, sex drive, Gi issues, weight loss, inc BP, HR, screen liver Two centrally acting alpha-2 adrenergic agonists, clonidine (Kapvay) and guanfacine (Intuniv), are FDA approved for the treatment of ADHD. They may be used alone or in conjunction with other ADHDA medications. Of the two drugs, clonidine carries more side effects -To control aggressive behaviors, pharmacological agents including stimulants, mood stabilizers, alpha-adrenergic agonists, and antipsychotics are used. Stimulants have a dose-dependent effect. Low doses stimulate aggressive behaviors while moderate to high doses suppress aggression. Mood stabilizers such as lithium and anticonvulsants reduce aggressive behavior and are recommended for impulsivity, explosive temper, and mood lability • Access to child specialty care for treatment of depression • Family involvement in the treatment of ADHD • Stimulant medication treatment for ADHD • Antipsychotic treatment for childhood psychoses • Completion of treatment for substance use disorders • Referral to postdetoxification treatment services

Concepts/ Exemplars

Nutrition, Glucose regulation, Gas exchange, perfusion, acid-base balance, development, functional ability, fluid and electrolytes, mobility Delirium, Alzheimer's dx, Lewy Body Dementia, vascular dementia, fetal alcohol syndrome, down syndrome

Outcomes/ intervention during phases

Outcomes should be consistent with the recovery model (refer to Chapter 32), which stresses hope, living a full and productive life, and eventual recovery rather than focusing on controlling symptoms and adapting to disability. Phase 1: Acute: For the acute phase of schizophrenia, the overall goal is patient safety and stabilization. Phase 2: Stabilization: Outcome criteria during phase II focus on patient understanding of the illness and treatment, achieving an optimal medication and psychosocial treatment regimen, and controlling and/or coping with symptoms and side effects- Negative S/S Phase 3: Maintenence: Outcome criteria during phase II focus on patient understanding of the illness and treatment, achieving an optimal medication and psychosocial treatment regimen, and controlling and/or coping with symptoms and side effects PLANNING: Acute: Hospitalization is indicated if the patient is considered a danger to self or others (e.g., refuses to eat or is too disorganized to function safely in the community). It may also be needed to clarify and confirm the diagnosis. ENSURE SAFTEY -Work with agitation and aggression Stabilization: Planning during the stabilization and maintenance phases focuses on providing patient and family education, support, and skills training. Planning incorporates interpersonal, functional, coping, healthcare, shelter, educational and vocational strengths and needs, and addresses how and where these needs can best be met within the community. Maintenance: Relapse prevention 1. Medication 2. Treatment adherence 3. Relationships with trusted care providers and support people 4. Community-based therapeutic services In general, during the acute phase of schizophrenia, 24-hour support is required to prevent harm to self or others GEAR CARE TOWARD STRENGTHS Therapy, support groups, therapeutic communication, brign them back down to earth, reality testing Associative looseness is a reflection of idiosyncratic and disorganized thinking. Increased anxiety or overstimulation worsens cognitive disorganization.- Speak concisely, clearly, and concretely -Do not pretend with pt EDUCATION AND SAFETY ARE KEY HERE 1. First-generation antipsychotics (FGAs)—traditional dopamine (D2 receptor) antagonists, also known as typical antipsychotics or neuroleptics (e.g., haloperidol [Haldol]). 2. Second-generation antipsychotics (SGAs)—serotonin (5-HT2A receptor) and dopamine (D2 receptor) antagonists (e.g., clozapine [Clozaril]); other drugs are antagonist in areas of high dopamine activity, but agonists in areas of low dopamine activity (e.g., aripiprazole [Abilify]). -The FGAs primarily affect positive symptoms (e.g., hallucinations and delusions) but have little effect on negative symptoms. Second-generation antipsychotics treat positive symptoms and can also help negative symptoms (e.g., asociality, blunted affect) though improvement in negative and cognitive symptoms is usually less. Second-generation drugs are generally an improvement on earlier drugs while reducing the overall burden of side effects. Antipsychotics are not addictive. However, they should be discontinued gradually to minimize a discontinuation syndrome that can include dizziness, nausea, tremors, insomnia, electric shock-like pains, and anxiety. -Take 2-6 weeks to work Some are available in long-acting injectable (LAI) formulations that only need to be administered every 2 to 4 weeks and in one case, every 3 months. Some require special administration protocols First-generation antipsychotics are dopamine (D2) antagonists in both limbic and motor centers. Blockage of D2 receptors in motor areas causes extrapyramidal side effects (EPS) including: 1. Acute dystonia—Sudden, sustained contraction of one or several muscle groups, usually of the head and neck. Acute dystonias can be frightening and painful, but unless they involve muscles affecting the airway, which is rare, they are not dangerous. However, they cause significant anxiety and should be treated promptly. 2. Akathisia—A motor restlessness that causes pacing, repetitive movements, or an inability to stay still or remain in one place. It can be severe and distressing to patients. It can be mistaken for anxiety or agitation. Sometimes more of the drug that caused the akathisia is mistakenly given, which makes the side effect worse. A tardive form can persist despite treatment. 3. Pseudoparkinsonism—A temporary group of symptoms that looks like Parkinson's disease: tremor, reduced accessory movements (e.g., arms swinging when walking), gait impairment, reduced facial expressiveness (mask facies), and slowing of motor behavior (bradykinesia). Oral antiparkinsonian drugs are also useful. However, these drugs have their own side effects because most are anticholinergic. Tardive dyskinesia is a persistent EPS side effect involving involuntary rhythmic movements. The first-generation antipsychotics cause anticholinergic (ACh) side effects by blocking muscarinic cholinergic receptors. Anticholinergic side effects include urinary retention, dilated pupils, constipation, reduced visual accommodation (blurred near vision), tachycardia, dry mucous membranes, reduced peristalsis (rarely, leading to paralytic ileus and risk of bowel obstruction), and cognitive impairment. ACH TOXICITY Other side effects of FGAs include sedation, orthostatic (postural) hypotension, lowered seizure threshold (leading to seizures), photosensitivity, cataracts or other visual changes (with chlorpromazine [Thorazine] and thioridazine [Mellaril]), and increased release of prolactin (hyperprolactinemia), which can result in sexual dysfunction (impotence, anorgasmia, impaired ejaculation), galactorrhea (flow of fluid from the breasts), amenorrhea, and gynecomastia. -Weight gain SGAs include drugs such as clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). They antagonize D2 receptors as do FGAs but also bind to serotonin receptors as well. -sedation, sexual dysfunction, seizures, and increased mortality in elderly individuals with dementia. However, most SGAs are less likely to cause tardive dyskinesia or significant EPS -Clozaril can also cause myocarditis and life-threatening bowel emergencies. Agranulocytosis Symptoms include reduced neutrophil counts and increased frequency and severity of infections. Any symptoms suggesting infection (e.g., sore throat, fever, malaise, body aches) should be carefully evaluated Neuroleptic malignant syndrome (NMS) Rare but dangerous. Severe muscle rigidity, dysphasia, flexor-extensor posturing, reduced or absent speech and movement, decreased responsiveness. Hyperpyrexia is the main feature: temperature over 103°F Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence Delirium, stupor, coma Metabolic syndrome Weight gain, dyslipidemia (abnormal lipid levels), increased insulin resistance, leading to increased risk of cardiovascular disease, diabetes, and other serious medical conditions All SGAs carry a risk of metabolic syndrome, which includes weight gain (especially in the abdominal area), dyslipidemia, increased blood glucose, and insulin resistance. This metabolic syndrome is a significant concern and increases the risk of diabetes, certain cancers, hypertension, and cardiovascular disease, making its prevention an important role for nurses

Psychosis Variations/ etiology

Psychosis can manifest from varied etiologies and can be categorized as either primary or secondary in origin. Primary psychosis has a 349psychiatric etiology, as can be seen in schizophrenia, schizoaffective disorder, and, in some instances, other psychiatric illnesses. Secondary psychosis has an organic etiology, as can be seen in acute substance intoxication, delirium, or dementia. Primary and secondary forms of psychosis are not mutually exclusive; not only do they coexist but also in some instances they potentiate the other PRIMARY: Schizophrenia Spectrum and Other Psychotic Disorders classification, psychosis is the principal symptom(s) of interest. Clinical disorders in this category include delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, and catatonia.4 As a primary etiology of psychosis, the schizophrenia spectrum and other psychotic disorders reflect greater potential for long-term disability due to their genomic and neurodevelopmental etiology Disorders such as bipolar I disorder and major depressive disorder have the potential to manifest psychosis.4 More than half of those diagnosed with bipolar disorder will experience psychosis at some time in their life.9 Psychosis associated with bipolar disorder is commonly an acute presentation that has potential to subside but is associated with poor outcomes.10 Among the depressive disorders, psychosis is exclusively associated with the most severe expressions of clinical depression and occurs in 14-20% of those who are clinically depressed.11 Psychotic episodes that manifest in the context of a depressive disorder are more commonly acute in presentation and typically have high rates of recovery with treatment. Psychotic symptoms are not explicitly seen within the personality disorders. However, personality disorders can be comorbid with a number of conditions that have the potential to manifest psychosis SECONDARY: Toxic psychosis is the product of an underlying and untreated medical issue. Delirium is an example of toxic psychosis. Psychosis associated with delirium is typically rapid in onset and defined by a hallmark sign of dramatic fluctuations in mental status. Dementia is one of many neurocognitive disorders that have potential to manifest psychosis. Dementia can be the product of multiple etiologies, including Alzheimer's, Lewy bodies, vascular, HIV, prion, Parkinson's, traumatic brain injury, and Huntington's disease Numerous medical conditions can, given the right circumstances, manifest symptoms of psychosis. Patients can manifest psychosis secondary to endocrinopathies (e.g., adrenal or thyroid disorders), metabolic disorders (e.g., porphyria and Wilson's disease), nutritional and vitamin deficiencies (e.g., vitamin A, D, and B12, magnesium, and zinc deficiency), central nervous system disorders (e.g., cerebral vascular accident, epilepsy, and hydrocephalus), degenerative disorders (e.g., Friedriech's ataxia), autoimmune disorders (e.g., multiple sclerosis and paraneoplastic syndrome), infections (e.g., encephalitis, neurosyphilis, Lyme disease, and sarcoidosis), space-occupying lesions (e.g., congenital vascular malformations and tuberous sclerosis), and chromosomal abnormalities (e.g., Klienfelter's and fragile X syndrome) Psychosis can also be a product of numerous toxins, drugs, and medications. This form of psychotic expression is typically most challenging to causally identify. When recognized, this secondary source of psychosis will commonly be classified as a Substance-/Medication-Induced Psychotic Disorder.4 Toxins known to potentially induce psychosis include but are not limited to carbon monoxide, organophosphates, and heavy metals such as arsenic, magnesium, mercury, and thallium. -Likewise, certain prescribed medications also demonstrate an elevated risk for psychosis as a side effect, including sedative-hypnotic agents, amphetamines, anticholinergic agents, antiseizure agents, corticosteroids, and mefloquine.

Concepts and examples

Pt education Ethics Collaboration Communication Health care law Health policy schizophrenia MDD- severe with psychotic features Delirium Major Neruo-cog Disorder Substance med induced psychotic disorder

ASD

autism spectrum disorder is a complex neurobiological and developmental disability that typically appears during a child's first 3 years of life. Autism spectrum disorder affects the normal development of social interaction and communication skills. It ranges in severity from mild to moderate to severe. Symptoms associated with autism spectrum disorder include deficits in social relatedness, which are manifested in disturbances in developing and maintaining relationships. Other behaviors include stereotypical repetitive speech, obsessive focus on specific objects, overadherence to routines or rituals, hyperreactivity or hyporeactivity to sensory input, and extreme resistance to change. -EARLY INTERVENTION EARLY DX Often, symptoms are first noticed when the infant fails to be interested in others or to be socially responsive through eye contact and facial expressions. Some children show improvement during development, but puberty can be a turning point toward either improvement or deterioration The child with autism spectrum disorder has severe impairments in social interactions and communication skills, often accompanied by stereotypical behavior, interests, and activities. At least half of those diagnosed with autism spectrum disorder will have some intellectual disability (IQ <85), which will impact their academic performance as well. Children with autism spectrum disorder should be referred to early intervention programs once communication and behavioral symptoms are identified, typically in the second or third year of life. -Treatment plans include behavior management with a reward system, teaching parents to provide structure, rewards, consistency in rules, and expectations at home to shape and modify behavior and foster the development of socially appropriate skills. Children with autism spectrum disorder may receive physical, occupational, and speech therapy as part of the plan of care. -Focus on strengths Pharmacological agents target specific symptoms and may be used to improve relatedness and decrease anxiety, compulsive behaviors, or agitation. The second-generation antipsychotics risperidone (Risperdal) and aripiprazole (Abilify) have FDA approval for treating children 5 and 6 years of age and older, respectively. -SSRIS- mood/ anxiety -Stimulants • Level 1 requires support • Level 2 requires substantial support • Level 3 requires very substantial support

cognition

cognition is defined as the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses -Six domains of cognitive function include perceptual motor function, language, learning and memory, social cognition, complex attention, and executive function.4 Three related terms—perception, memory, and executive function Scope: At the most basic level, cognition may be described as intact or impaired. Intact cognition means that an individual exhibits cognitive behaviors that are considered to be within the range of normal for age and culture. Impaired cognition signifies an observable or measurable disturbance in one or more of the cognitive processes resulting from an abnormality within the brain or a factor interfering with normal brain function Cognitive impairment, Basic Cognitive functioning, Higher order cognitive functioning -All have ranges never al or nothing

Psychosis

currently defines psychosis as abnormalities in five different symptomatic domains: delusions, hallucinations, disorganized thought, disorganized or abnormal motor behavior, and negative symptoms. A psychobiological definition of psychosis would implicate dysregulation of dopamine transport systems between the limbic system and prefrontal cortex. "person's mental capacity, affective response, and capacity to recognize reality, communicate, and relate to others is impaired." psychosis is defined as a syndrome of neurocognitive symptoms that impairs cognitive capacity leading to deficits of perception, functioning, and social relatedness SCOPE: continuum ranging from absence of psychosis to severe psychosis -Absence of Psychosis -Mild -Moderate -Severe -Psychosis can be acute in onset and relatively short in duration, as can be seen with a delirium or substance-induced psychotic episode. Under no circumstances should the symptoms associated with psychosis be considered "normal" or acceptable. Regardless of etiology, the duration of untreated psychosis is associated with poor outcomes

Health disparities for adults with IDD

intellectual or developmental disability, also called IDD little training on how to interact with these pt populations let dx overshadow pt current condition -make excuses like oh this is apart of your dx Not able to access/ qualify for resources/ do not even know resources that are out there caregiver burnout Commonly visit ED...not well taken care of delays in diagnosis and/or treatment and failure to comply with legislation that protects people with ID Barriers to accessing care for people with ID include difficulty communicating with health practitioners [13], coping in an unfamiliar environment, and receiving a lower quality of care [16]. Thus, it is not surprising that research has shown people with ID and their caregivers report negative experiences in hospitals patient needs are not always communicated or met, staff are discriminatory, and staff lack knowledge and skills in caring for patients with ID This finding highlights the time and resource constraints ED nurses face [15], limiting their ability to address the gaps identified in this study -ED systems and policies should critically examine how accessible care can be embedded in ED culture so that it is not seen as an additional competing work demand -Nurses are the first point of contact for patients entering the ED, however, less than thirty percent of nurses in our study reported an awareness of strategies to identify whether a patient has ID EDUCATION AND TRAINING IS NEEDED educational areas to target for ED nurses could include: recognizing that a patient has ID, common care issues, community resources, and further strategies in adapting care. Currently no formal education on ID is required of health professionals, including ED nurses. Given the health disparities that exist for people with ID [36], it is important that nurses are supported to gain the necessary skills, knowledge and comfort to provide quality care for this population

s/s Psychosis

• Delusions: Fixed beliefs that are not amenable to change in light of conflicting evidence • Hallucinations: Perception-like experiences that occur without an external stimulus • Disorganized thinking: Most commonly inferred from speech, defined by derailment, loose associations, tangentially, and incoherence • Disorganized/abnormal motor behavior: Markedly abnormal behavior ranging from agitation to catatonia that is commonly situationally incongruent • Negative symptoms: Alogia, affective blunting, asociality, anhedonia, and avolition Untreated psychosis has the potential to cause dementia; thus a determination of consequences follows the trajectory of both the etiology and symptoms. Much like how a compromised nuclear power plant is unable to control its core reactor temperature, the consequence of unregulated neural circuits is the release of inflammatory markers that further degrades the circuit.15 Consequently, early and decisive treatment of psychosis is critical. RISKS: Schulz et al. identified that children with a premorbid IQ in the learning disability range demonstrate a statistically significant risk for schizophrenia Individual risk factors for psychosis exist within four potentially interrelated domains of temperament, environment, genetics, and physiology. -Sleep issues Thorough assessment, PHYS/ HX, and DX TESTING DX TESTS: Although there currently are no diagnostic tests that definitively rule in or out psychosis, a number of tests are available that can aid the nurse in differentiating between the primary and secondary etiologies of psychosis. Laboratory studies such as a complete blood count, chemistry panel (Chem18), thyroid function test, rapid plasma reagin, dexamethasone suppression test, HIV test, heavy metals panel, urinalysis, urine drug screen, urine culture and sensitivity, computerized tomography, and magnetic resonance imaging can rule out a number of potential organic etiologies If the nature of the psychosis is secondary, the health care team must treat the underlying cause of the psychosis while simultaneously managing the symptoms of psychosis. In instances in which psychosis does not have a secondary cause, a number of treatment options are available to manage psychosis. screening: including the Brief Psychiatric Rating Scale (BRPS),28 the Positive and Negative Syndrome Scale (PANSS),29 the Minnesota Multiphasic Personality Inventory-2 (MMPI-2),30 and the DSM-V's Level I Cross-Cutting Symptoms Measure. -early intervention within the prodromal phase (the period in which subtle symptoms of psychosis begin to rise to the level of clinical significance) is associated with the best possible outcome. -The clinical management of psychosis is subdivided into four classifications of pharmacologic (Box 36-3), nonpharmacologic, lifestyle modification, and community integration. MEDS: Most first-generation antipsychotics are no longer considered first-tier choices for the treatment of psychosis; however, they are still seen in community-based and forensic settings throughout the country. -However, they are known for significant side effects including anticholinergic side effects, high-risk extrapyramidal side effects (EPS), and sedation that has historically led to medication adherence problems. Second-generation antipsychotic agents (see Box 36-3) also target positive symptoms of psychosis with their D2 antagonism; in addition, they target negative symptoms with their 5-HT2a antagonism and (for certain agents) 5-HT1a agonism. -Although the second-generation antipsychotics are considered first-line choices for the treatment of psychosis and have a lower risk for EPS, they have a marked increased risk for metabolic disorders such as dyslipidemia, diabetes, and weight gain if used for long periods of time Anticholinergic agents (see Box 36-3) are used to treat EPS resulting from antipsychotic medication use. EPS can occur because of excessive D2 binding within the nigrostriatal pathway -EPS are considered medical emergencies (e.g., acute pharyngeal dystonia) and potentially permanent (e.g., tardive dyskinesia), anticholinergic agents can be delivered both orally and intramuscularly to target EPS. NONPHARM: SOCIAL SKILL TRAINING FAMILY FOCUSED THERAPY COG-BEHAVIORAL THERAPY COG ENHANCEMENT ECT LIFESTYLE MODIFICATION HEALTH MONITOR CASE MANAGEMENT VOCATIONAL THERAPY

Phases of Schizophrenia

• Prodromal—Mild changes in thinking, reality testing, and mood, insufficient to meet the diagnostic criteria for schizophrenia. Symptoms appear a month to more than a year before the first full-blown episode of the illness.- DETERIORATION • Acute—Later symptoms vary, from few and mild to many and disabling. Symptoms such as hallucinations, delusions, apathy, social withdrawal, diminished affect, anhedonia, disorganized behavior, impaired judgment, and cognitive regression result in functional impairment. As symptoms worsen the person has difficulty coping -Hospitalization • Stabilization—Symptoms are stabilizing and diminishing, and there is movement toward a previous level of functioning (baseline). Care in an outpatient mental health center or partial hospitalization program (which includes many of the services offered in inpatient mental health units, but without an overnight stay in the hospital • Maintenance or Residual—The condition has stabilized and a new baseline is established. Positive symptoms (which will be described later) are usually absent or significantly diminished, but negative and cognitive symptoms continue to be a concern. Ideally, recovery with few or no residual symptoms will occur, and the patient is again able to live independently or with family.