Psych Chapter 24: Schizophrenia
Side effects: Lurasidone (Latuda)
Atypical EPS: 1 Sedation: 3 Anticholinergic: 1 OH: 3 Weight gain: 3
Side effects: Quetiapine (Seroquel)
Atypical EPS: 1 Sedation: 3 Anticholinergic: 1 OH: 3 Weight gain: 4
Side effects: Iloperidone (Fanapt)
Atypical EPS: 1 Sedation: 3 Anticholinergic: 2 OH: 3 Weight gain: 3
Positive symptoms: Word salad
Group of words that are put together randomly and without any logical connection
Side effects: Clozapine (Clozaril)
Atypical: Lots of sedation, anticholinergic, weight gain, OH EPS: 1 Sedation: 5 Anticholinergic: 5 OH: 4 Weight gain: 5
Side effects: Aripprazol (Abilfy)
Atypical: OH EPS: 1 Sedation: 2 Anticholinergic: 1 OH: 3 Weight: 2
Side effects: Asenapine (Saphris)
Atypical: Sedation, OH, weight gain EPS: 1 Sedation: 3 Anticholinergic: 1 OH: 3 Weight gain: 4
Side effects: Olanzapine (Zyprexa)
Atypical: weight gain EPS: 1 Sedation: 3 Anticholinergic: 2 OH: 2 Weight gain: 5
Substance/Medication Induced Psychotic Disorder
Hallucinations and delusions directly attributed to intoxication/withdrawal
Tourettes
Haloperidol, pimozide
Positive symptoms: Paranoia
Individuals have extreme suspiciousness of others and of their actions or perceived intentions
Positive symptoms: Mutism
Individuals inability or refusal to speak
Nursing implications: Reduction of seizure threshold (typical)
CLOZAPINE Closely observe clients with history of seizures
Nursing implications: Agranulocytosis
CLOZAPINE More common with typical Observe for sour throat, fever, malaise
Nursing implications: Urinary retention
Instruc client to report difficulty, monitor intake and output
Delusional disorder: Grandiose
Irrational ideas regarding their own worth, talent, knowledge, power, leads to the assumption of the identity of a diety or religious leader
Delusional disorder: Persecutory
Most common, individual believes they are being persecuted or malevolently treated Plotted against, cheated, spied on, followed, poisoned
Family education
Nature of illness, management of illness, support persons
Disabled family coping
Negelctful care of client in regard to basic human needs or illness treatment, extreme denial or prolonged overconceern regarding illness, depression, hostility, aggression
Antipsychotic drugs
Neuroleptics or major tranquilizers Typical: first generation Atypical: newer novel antipsychotics
Mutism
No or very little verbal response
Interventions: Disturbed sensory perception
Observe for signs of hallucinations, ask "are you hearing the voices again?" Avoid touching before warning client Attitude of acceptance, "What do you hear the voices saying to you?" Help client understant connection between increased anxiety and presence of hallucinations Distract client Voice dismissal
Catatonic disorder
Symptomatology is evidenced from medical history, physical examination, laboratory findings
Side effects: Perphenazine and Thiothixene (Navane) and Trifluoperazine
Typical: EPS EPS: 4 Sedation: 2 Anticholinergic: 2 OH: 2 No weight gain
Side effects: Pimozide (Orap)
Typical: EPS, anti cholinergic EPS: 4 Sedation: 2 Anticholinergic: 3 OH: 2 No weight gain
Side effects: Chloropromazine
Typical: Sedation/anticholinergic EPS: 3 Sedation: 4 Anticholinergic: 3 OH: 4 No weight gain
Side effects: Fluphenazine and Haloperidol (haldol)
Typical: high EPS EPS: 5 Sedation: 2 Anticholinergic:2 OH:2 No weight gain
Side effects: Loxapine and Prochlorperazine
Typical: little EPS EPS: 3 Sedation: 2 Anticholinergic: 2 OH: 2 No weight gain
Side effects: Thioridazine
Typical: sedation, anticholinergic, OH EPS: 2 Sedation: 4 Anticholinergic: 4 OH: 4 No weight gain
Oculogyric Crisis
Uncontrolled rolling back of eyes Part of dystonia EMERGENCY: contact physician, IV benztropine mesylate (Congentin), stay with client, offer reasurance/support
Impaired home maintenance
Unsafe, unclean, disorderly
Positive symptoms: Depersonalization
Unstable self identity of individual that leads to feelings of unreality
Avoid reinforcing hallucination
Use "the voices" in stead of words like "they" "Even though I realize the voices are real to you, I do not hear any voices speaking."
Positive symptoms: Echolalia
Uses words that he or she hears, in attempt to identify with person speaking
Interactions: Atypical antipychotics
Additive hypotensive effects Additive CNS effects Additive anticholinergic effects with resperidone or paliperidone with other drugs with anticholinergic properies Additive effects of QT prolongation Decreased effects of levodopa and dopamine agonists
Predisposing anatomical abnormalities
Ventrical enlargement, cerebellar atrophy, pyramidal cell disorganization in hippocampus
Negative symptoms: Posturing
Voluntary assumption of innapropriate or bizzare postures
Action: Atypical antipsychotics
Weaker dopamine receptor antagonists More potent antagonist for serotonin type 2A receptors Antagonism for cholinergic, histaminic and adrenergic
Family education: Nature of illness
What to expect as illness progresses, symptoms, ways for family to respond to behaviors associated with illness
Interactions: Typical Antipsychotics
Additive hypotensive effects with antihypertensive Additive CNS effects whent taking with CNS depressend Additive anticholinergic effects Additive effects of QT prolongation concurrently with other drugs Haloperidol and carbamazepine = decreased theraputic effect of haloperidol increased carbamazepine
Social isolation
Withdrawal, sad dull affect, need fear dilemma, preoccupation with own thoughts, expression of feelings or rejection or of aloneness imposed by others, uncommunicative, seeks to be alone
Nursing implications: Sedation
Discuss with physician admission of med at bedtime, possible decrease in dosage, order for less sedating drug No driving or operating dangerous equipment
Side affects
Dopamine blockage causes extrapyramidal symptoms, prolactin elevation Cholinergic blockade: anticholinergic side effects Alpha adrenergic Blockage: Dizzy, orthostatic hypertension Histamine blockade: weight gain, sedation
Phases of Schizophrenia
1. Premorbid 2. Prodromal 3. Schizophrenia/Psychotic 4. Residual
Side effects: Risperidone (Risperdal)
Atypical EPS: 1 Sedation: 2 Anticholinergic: 1 OH: 3 Weight gain: 4
Extrapyramidal effects
Acute dyskinesias and dystonic reactions, tardive dyskinesia, Pseudoarkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome, oculogyric crisis
Side effects: Ziprasidone (Geodon)
Atypical EPS: 1 Sedation: 3 Anticholinergic: 1 OH: 2 Weight gain: 2
Risk for violence
Aggressive body language, verbal aggression, catatonic excitemnt, command hallucinations, rage reactions, history of violence, overt and aggressive acts, goal directed destruction of objects in environment, self destructive behavior, active/aggressive suicide acts
Positive symptoms: Delusion of reference
All events within environment are referred by the psychotic person to themselves, "Someone is trying to communicate with me through the TV."
Nurse must monitor for following side effects
Anticholinergic: dry mouth, blurred vision, constipation, urinary retention Nausea, GI upset Skin rash Sedation Orthostatic hypertension Photosensitivity Hormonal effects Amenorrhea Weight gain ECG changes Reduces seizure threshold Agranulocytosis EPS Tardive dyskinesia
Atypical Antipsychotic Agents
Aripprazol (Abilfy) Asenapine (Saphris) Clozapine (Clozaril) Iloperidone (Fanapt) Lurasidone (Latuda) Olanzapine (Zyprexa) Paliperidone (Invega) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) weight gain
Side effects: Paliperidone (Invega)
Atypical EPS: 1 Sedation: 2 Anticholinergic: 1 OH: 3 Weight gain: 2
Action: Typical antipsychotis
Block postsynaptic dopamine receptors in basal ganglia, hypothalamus, limbid system, brainstem and medulla. Inhibition of dopamine mediated transmission Affinity for cholinergic alpha 2 adrenergic and histamine receptors
Typical Antipsychotic Agents:
Chloropromazine Fluphenazine Haloperidol (Haldol) Loxapine Perphenazine Pimozide (Orap) Prochlorperazine Thioridazine Thiothixene (Navane) Trifluoperazine
Treatment of intractable hiccoughs
Chlorpromazine
Antiemetics
Chlorpromazine, perphenazine, prochlorperazine
Positive symptoms: Clang associations
Choice of words governed by sounds, rhyming
Negative symptoms: Waxy flexibility
Client allows body parts to be placed in uncomfortable positions, will not move it
Negative symptoms: Apathy
Client demonstrates indifference or disinterest in environment
Positive symptoms: Echopraxia
Client who purposelessly imitates movements made by others
Negative symptoms: Impaired social interaction
Cling to others, intrude personal space of others
Negative symptoms: Emotional ambivalence
Coexistence of opposite emotions towards same object, person, situation Challenging to make decisions or fulfill satisfying relationships Simultaneous need for and fear of intimacy
Family education: Management of illness
Connection of exacerbation of symptoms to times of stress, appropriate medication management, side effects, adherence, when to contact PCP, relaxation techniques, social skills training, daily living skill training
Interventions: Disturbed thought process
Convey acceptance of clients need for false belief, indicate you do not share belief Do not argue or deny belief Use reasonable doubt Reinforce and focus on reality, real events, real people Promote trust, avoid physical contact, avoid laughing, whispering, talking quietly where client can see but not hear, canned foods, mouth checks, one to one relationship activities, assertive, mater of fact, genuine
Hormonal Effects
Decreased libido, retrograde ejaculation (into bladder rather then vagina...ouch), gynecomastia Amennorrhea
Negative symptoms: Anergia
Deficiency of energy
Disturbed thought processes
Delusional thinking, inability to concentrate, impaired volition, inability to problem solve, abstract, or conceptualize, extreme suspiciousness of others, inaccurate interpretation of environment
Delusional disorder
Delusions for at least one month No hallucinations No bizarre behavior 1. Erotomanic 2. Grandiose 3. Jealous 4. Persecutory 5. Somatic 6. Mixed
Delusional disorder: Somatic
Delusions of general medical conditions
Delusional disorder: Mixed type
Delusions prominent, no single theme
Delusional disorder: Jealous
Delusions that ones sexual partner is unfaithful, without cause but will search for evidence
Positive symptoms:
Delusions, religiosity, paranoia, magical thinking, associative looseness, neologisms, concrete thinking, clang associations, word salad, circumstantiality, tangentiality, mutism, preservation, hallucinations, illusions, echolalia, echopraxia, identification and imitation, depersonalization
Self care deficit
Difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, toileting
Anticholinergic side effects
Dry mouth, blurred vision, constipation, urinary retention
Positive symptoms: Identification (unconscious) and imitation (conscious)
Ego defense mechanism reflecting confusion with self identity behavior takes form of that which they see in other person
Negative symptoms: Bland or flat Affect
Emotional tone is very week, void of emotional tone
Positive symptoms: Religiosity
Excessive demonstration of or obsession with religious ideas
Nursing implications: Blurred vision
Explain symptom will subside after a few weeks Advise client not to drive car util clears Fall prevention: clear things out of way!
Phase 2: Prodromal
Extends from premorbid to psychosis Brief or long (weeks or years) Anxiety and sleep disturbances, depressed mood, fatigue Perceptual abnormalities, suspiciousness
Akinesia
Extrapyramidal effect: Muscle weakness, loss or impairment of the power of voluntary movement Symptoms appear 1-5 days after initiation of treatment, more in women, elderly, dehydrated
Akathisia
Extrapyramidal effect: feeling of inner restlessness and a compelling need to be in constant motion, fidgeting More in women, symptoms 50-60 days following start of therapy
Neuroleptic malignant syndrome
Extrapyramidal effect: fever, muscular rigidity, altered mental status, and autonomic dysfunction, BP fluctuations, deterioration of mental status to stupor or coma DISCONTINUE IMMEDIATELY: monitor vital signs, intake and output, LOC Physician may order bromocriptine (Parlodel) or dantrolene (Dantrium)
Dystonic reactions/Dystonia
Extrapyramidal effect: intermittent spasmodic or sustained involuntary contractions of muscles in the face, neck, trunk, pelvis, extremities, and even the larynx More often in men, younger then 25 years EMERGENCY: contact physician, IV benztropine mesylate (Congentin), stay with client, offer reasurance/support
Tardive dyskinesia
Extrapyramidal effect: involuntary movements of the face and jaw, bizarre facial and tongue movements, stiff neck difficulty swallowing Potentially irreversible, drug withdrawn at first sign
Acute dyskinesias
Extrapyramidal effect: involuntary muscle movements
Pseudo parkinsonism
Extrapyramidal effect: tremor, shuffling gait, drooling, rigidity, bradykinesia: slowness of initiation of voluntary movement Symptoms appear 1-5 days after initiation of treatment, more in women, elderly, dehydrated
Positive symptoms: Olfactory hallucination
False perception of smell
Positive symptoms: Gustatory hallucination
False perception of taste, mostly unpleasant
Positive symptoms: Auditory Hallucination
False perceptions of sound Voices, clicks, music, rushing noise Commands, voices Most common
Positive symptoms: Tactile hallucination
False perceptions of touch Formication: sensation something is crawling under skin
Hallucinations
False sensory perceptions not associated with real external stimuli
Positive symptoms: Visual hallucination
False visual perceptions, formed images (physical things: people) or unformed images (flashes of light)
Family education: Support services
Financial assistance, legal assistance, caregiver support groups, respite care, home health care
Nursing implications: Constipation
High fiber foods Encourage increase in physical activity Increase in fluid intake
Contraindications: Atypical antipsychotics
Hypersensitivity Comatose Severely depressed Psychosis related to neurocognitive disorder QT prolongation/cardiac arrhythmias/MI: Ziprasidone, resperidone, paliperidone, asenapine, iloperidone Temp extremes, hypertenstion
Contradictions: Typical Antipsychotics
Hypersensitivity Comatose states or when CNS depression Blood dyscrasias Parkinsons Narrow angle glaucoma LIver/renal/cardiac insufficiency Poorly controlled seizures Psychosis related to neurocognitive disorder Haloperidol, pimozide, thioridazine = causes long QT interval contradicted with other meds that cause this Extreme temperatures
Schizophreniform Disorder
Identical to schizophrenia except duration at least 1 month but less then 6 months
Disturbed sensory perception
Impaired communication ,disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in middle of sentences, tilts heat to side as if to be listening
Negative symptoms: anhedonia
Inability to experience pleasure
Volition
Inability to initiate goal directed activity
Ineffective health maintenance
Inability to take responsibility for meeting basic health practices, history of lack of health seeking behavior, lack of expressed interesed in improving health behaviors, demonstrated lack of knowledge regarding basic health practices
Negative symptoms
Inappropriate affect, bland or flat affect, apathy, emotional ambivalence, deteriorated appearance, impaired social interaction, social isolation, anergia, waxy flexibility, posturing, pacing and rocking, anhedonia, regression
Acute schizophrenia
Increased dopamine
Prenatal exposure to influenza
Increased risk of developing Schizophrenia
Positive symptoms: Delusion of Control/Influence
Individual believes certain objects or persons have control over his/her behavior
Delusional disorder: Erotomanic
Individual believes someone of a higher status is in love with them
Positive symptoms: Circumstantiality
Individual delays in reaching the point of a communication because to tedious to get there, numerous interruptions to keep individual on track of topic being discussed
Positive symptoms: Delusion of Grandeur
Individual exaggerated feelings of importance, power, knowledge or identity
Positive symptoms: Delusion of Persecution
Individual feels threatened, believes others intend to harm or persecute
Positive symptoms: Delusion of Somatic
Individual has false idea about functioning of his or her body
Positive symptoms: Nihilistic delusion
Individual has false idea that themselves, a part of themselves, others or the world is non existent
Positive symptoms:Perseveration
Individual who persistently repeats the same word or idea in response to different questions
Negative symptoms: Inappropriate Affect
Individuals emotional tone incongruent with circumstances (laugh with death of mother)
Negative symptoms: Social isolation
Individuals focus inward on themselves to the point of exclusion of the external environment
Positive symptoms: Concrete thinking
Literal interpretations of environment, regression to earlier level of cognitive development, abstract thinking very difficult
Impared verbal communication
Loose association of ideas, neologisms, word salad, clang associations, echolalia, verbalizations that reflect concrete thinking, poor eye contact, difficulty expressing thoughts verbally, inappropriate verbalization
Echopraxia
Mimicking anothers movement
Echolalia
Mimicking anothers speech
Positive symptoms: Illusions
Misperceptions or misinterpretations of real external stimuli
Mannerism
Odd, circumstatial caricature of normal actions
Selected agents used in treatment of bipolar mania
Onlanzapine, aripirazole, chlorpromazine, quetiapine, risperidone, asenapine, ziprasidone
Negativism
Opposition or no response to instructions or external stimuli
Catalepsy
Passive induction of a posture help against against gravity
Positive symptoms: Neologisms
Person invents new words, meaningless to others but have symbolic meaning to self
Positive symptoms: Tangentiality
Person never gets to point of communication, unrelated topics introduced
Negative symptoms: Deteriorated appearance
Personal grooming self care neglected, disheveled and untidy, need to be reminded
Treatment
Pharmacotherapy, psychosocial care, social skills training, family therapy
Agranulocytosis
Potentially fatal disorder, WBC count drops,
ECG changes
Prolongation of QT interval Ziprasidone, thioridazine, pimosize, haloperidol, paliperidone, iloperidone, asenapine, clozapine
Nursing implications: Hormonal effects
Provide explanation of effects, reassurance of reversibility, alternative med from physician
Negative symptoms
Reflect a diminution or loss of normal functions, inert/unmotivated
Stereotypy
Repetitive, abnormal frequent, non goal directed movements
Nursing implications: Skin rash
Report appearance to physician, avoid spilling any liquid concentrate on skin
Negative symptoms: Regression
Retreat to an earlier level of development, primary defense mechanism, attempt to reduce anxiety Basis for many behaviors associated with schizo
Nursing implications: Orthostatic hypotension
Rise slowly from lying or sitting position Monitor BP lying and standing each shift, document significant changes
Schizoaffective disorder
Schizophrenic behaviors with strong element of symptomatology associated with mood disorders (depression or mania) Presence of hallucinations/delusions that occur for at least 2 weeks in absence of major mood episode
Psychosis
Severe mental condition, disorganization of personality, social functioning decreased, loss of contact/distortion of reality, hallucinations/delusional thinking
Waxy flexibility
Slight/resistance to positioning by examiner
Negative symptoms: pacing and rocking
Slow, rhythmic, backward and forward swaying ot the trunk from the hips
Phase 1: Premorbid
Social withdrawal, irritability, shy/withdrawn, poorly in school, antisocial, enjoy solitary activity
Schizophrenia
Split mind Genetic predisposition, biochemical dysfunction, psychosocial stress NO ONE TREATMENT
Posturing
Spontaneous and active maintenance of a posture against gravity
Catatonia Specifier
Stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, sterotpy, agitation, grimacing, echolalia, echopraxia
Brief Psychotic Disorder
Sudden onset, may/may not be preceded by severe psychosocial stressor Symptoms at least a day, less then a month Turmoil, overwhelmed, impaired reality, incoherent speech, hallucinations, delusions, bizzare behavior, disorientation, catatonic features
Nursing implications: dry mouth
Sugarless candy, bum, ice, sips of water Ensure client practices strict oral hygein
Nursing implications: Photosensitivity
Sunblock lotion, protective clothing, sunglasses when outdoors
Nursing implications: Nausea
Tablets or capsules administered with food to minimize GI upset Concentrated diluted Administered with fruit juice (mixed immediately before administration
Positive symptoms: Associative Looseness
Thinking characterized by speech in which ideas shift from one unrelated subject to another Individual unaware topics are unconnected Could be incoherent
Downward Drift
Those with schizophrenia drift down social class ladder because of difficulty functioning
Indications for Antipsychotics
Treatment of schizophrenia and other psychotic disorders
Phase 3: Schizophrenia
Two or more of following for at least 1 month 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Disorganized/catatonic behavior 5. Negative symptoms (decrease emotional expression)
Delusions
false personal beliefs that are inconsistent with persons intelligence or cultural background, continues to have belief in spite of obvious proof that it is false positive symptom
Stupor
no psychomotor activity, not actively related to environment
Positive symptoms: Magical thinking
person believes his or her thoughts or behaviors have control over specific situations or people
Positive symptoms
reflect an alteration or distortion of normal mental functions