NUR 414A Schizophrenia
what are the losses in the life of a person with schizophrenia
-2/3 never marry -few friends or social contacts -20% homeless at any time, 40% incarcerated -<15% hold competitive employment -pervasive isolation, hopelessness, stigma
what teaching is important with antipsychotics
-all antipsychotics carry a black box warning about the use in older adults with dementia where an increased risk for death is seen -increased risk for suicidal thinking in children-young adults -potential risk for extrapyramidal s/s and withdrawal s/s in newborns whose mothers were treated with antipsychotics -do not abruptly stop due to risk of withdrawal psychosis
objective behavioral disorders in schizophrenia
-alterations in personal relationships (withdrawal, hostility, inadequate communication) -alterations of activity (psychomotor agitation, catatonic rigidity, echopraxia)
subjective behavioral disorders in schizophrenia
-altered perception -alterations of thought -altered consciousness -alterations of affect
common stressors in schizophrenia
-biological (medical illness) -psychosocial (loss of relationship) -sociocultural (homelessness) -emotional (persistent criticism)
risk factors for suicide
-depression r/t schizophrenia -hopelessness r/t schizophrenia -unemployment -comorbid substance abuse
types of delusions
-erotomanic -somatic -grandiose -religious -nihilistic -delusions of reference -delusions of influence -paranoid -cotard -folie a deux -capgras
comorbidities of schizophrenia
-hypertension -diabetes -cardiovascular disease -metabolic syndrome -accelerated aging
what are some pre-natal and peri-natal events associated with schizophrenia
-maternal influenza -birth during late winter or early spring -obstetric complications -prenatal exposure to lead -maternal starvation -perinatal exposure to cats
how do you assess a pt with schizophrenia
-mental status exam -ask about environment -thoughts about religion, biological, social -therapeutic communication -early detection and treatment: lessens severity and improves prognosis
how do you manage an aggressive pt
-remain calm -acknowledge their grievances -deescalation techniques -keep hands in front of you
what is anticholinergic toxicity
-some antipsychotics have anticholinergic effects -s/s: dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils NOT reactive to light, blurred vision, decreased sweating, increased HR -central side effects: impaired concentration, confusion, attention deficit, memory impairment -tx: ECG, benzodiazepines, catheter, cooling, fluids, ABG, metabolic panel, coagulation, tox screen -*ANTIDOTE: PHYSOSTIGMINE * keep atropine on hand in case HR, BP, and RR decrease too much!
key objectives for treating patients with schizophrenia
-work with the family -treat depression -minimize stressful interactions -treat substance abuse -avoid lengthy, intense verbal interactions
The mental health nurse notes that a client diagnosed with schizophrenia is exhibiting flat affect. Which situation supports this documentation? 1.During the entire family visit, the client presented with an expressionless, blank look. 2.The client demonstrated minimal response to the news that his discharge had been postponed. 3.The client grimaced during the entire therapy session that focused on finding one's personal joy. 4.During grief therapy, the client was observed laughing while another client described the death of a parent.
1
The nurse is planning relapse prevention information for a client diagnosed with schizophrenia. The nurse understands that it is important to ensure which primary intervention? 1.Including the client's support system in the teaching 2.Facilitating weekly maintenance therapy for the client 3.Having the client restate discharge goals and strategies 4.Stressing the importance of client compliance with the medication plan
1
Which situation will present the most prominent problem when attempting to manage the outpatient care of a client diagnosed with schizophrenia? 1.The client's noncompliance with medication therapy 2.The community's opposition to outpatient mental health clinics 3.The associated increased risk that the client may become homeless 4.The family's negative reaction to transferring the client to community-based care
1
how long can psychotic s/s occur before a psychotic break
1 month-1 year
The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? 1.When told that a beloved pet has died, the client responds, "OK." 2.The client giggled while describing being physically abused as a child. 3.The client's facial expressions are unchanged during the entire admission process. 4.When staff members attempt to engage the client in conversation, the client only mumbles.
2
dx criteria
2 or more of the following present for 1 month, with at least 1 psychotic symptom (1,2,3) 1. delusions 2. hallucinations 3. disorganized speech 4. grossly disorganized behavior 5. negative s/s (avolition, diminished emotional expression)
The nurse is preparing a client with schizophrenia a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1."My medications will help my anxious feelings." 2."I'll go to support group and talk about what I am feeling." 3."When I have command hallucinations, I'll call a friend for help." 4."I need to get enough sleep and eat well to help prevent feeling anxious."
3
A hospitalized client is receiving clozapine for the treatment of a schizophrenic disorder. The nurse determines that the client may be having an adverse reaction to the medication if abnormalities are noted on which laboratory study? 1.Platelet count 2.Cholesterol level 3.Blood urea nitrogen 4.White blood cell count
4
The nurse is administering risperidone to a client with schizophrenia who is scheduled to be discharged. Before discharge, which instruction should the nurse provide to the client? 1.Get adequate sunlight. 2.Continue driving as usual. 3.Avoid foods rich in potassium. 4.Get up slowly when changing positions.
4
The nurse is caring for a client diagnosed with schizophrenia who states, "I decided not to take my medication because I realize that it really can't help me. Only I can help me." Which question asked by the nurse has the best therapeutic value? 1."Why do you think this is a wise decision?" 2."I don't understand. Only you can help you?" 3."You've decided not to take your medication. Is that right?" 4."Do you recall what it was like before you started your medication?"
4
The nurse is preparing a client with schizophrenia with a history of command hallucinations for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggests to the nurse that the client has a need for additional information? 1."My medications will help my anxious feelings." 2."I'll go to support group and talk about what I am feeling." 3."I need to get enough sleep and eat well to help prevent feeling anxious." 4."When I have command hallucinations, I'll call a friend and ask him what I should do."
4
what is neuroleptic malignant syndrome
a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. -s/s: very high fever (102-104 F), irregular pulse, tachycardia, tachypnea, muscle rigidity, altered mental status, autonomic nervous system dysfunction resulting in high or low BP, profuse sweating -tx: STOP antipsychotics, IV fluids, benzodiazepines
what is a milieu
a pts environment
what are the positive symptoms of schizophrenia
abnormal thoughts agitation bizarre behavior delusions excitement grandiosity hallucinations hostility illusions insomnia
what is the course of schizophrenia
acute phase stabilizing phase stable phase
how does the age of onset differ b/w men and women
age of onset occurs 4-6 years earlier in men
what are the 3 inescapable facts about schizophrenia
age of onset-late adolescence or early adulthood role of stress-onset and relapse efficacy of dopamine antagonists
what must happen prior to schizophrenia dx
all other possibilities ruled out
what are the negative symptoms of schizophrenia
alogia anergia asocial behavior attention deficits poor grooming and hygiene poor rapport poverty of speech blunted affect
what are third generation antipsychotics
aripiprazole - the only one. listed in the text as "2nd gen" but online declares it is 3rd gen.
what are the early warning signs of acute episodes of schizophrenia
bizarre behaviors, deterioration of hygiene and social relationships, shift in basic personality, inability to concentrate or cope
what is akathisia
distressing motor restlessness
example of delusions of influence
i can control her with my thoughts
what are extrapyramidal side effects
involuntary motor s/s
who has the more severe course of schizophrenia, men or women?
men
what does effective care of schizophrenia look like
nurse-pt relationship: focus on behavior, consistency, reorient to reality medications: antipsychotics, observe for side effects milieu: decrease stimulation, safety, staff consistency, monitor TV watching
what is the priority of the acute phase of schizophrenia
patient safety, manage s/s
what are guidelines for communicating with a pt experiencing delusions
pay attention to the emotions of the person discuss the way you see the delusion (orient to reality)
example of cotard delusions
persistent feelings of non-existence
example of erotomanic delusions
pt believes sandra bullock is in love with him
Example of nihilistic delusions
pt believes they are dead
what is a typical sign of illness
pt does not recognize the s/s of the illness
example of somantic delusions
pt insists they have cancer in their stomach after medical tests confirm otherwise
describe stable phase of schizophrenia
pt is still experiencing hallucinations/delusions nearing baseline, can be productive member of society
describe stabilizing phase of schizophrenia
pt it getting better can go back to more of a baseline functioning and supervised group home
example of grandiose delusions
pt states they are the president
what is dystonia
rigidity, painful muscle spasms
what is pseudoparkinsonism
s/s such as akathisia (distressing motor restlessness) and acute dystonia (painful muscle spasms)
what is tardive dyskinesia
serious drug adverse effect characterized by abnormal and distressing involuntary body movements and muscle tension that is associated with the use of antipsychotic meds involuntary contractions of oral and facial muscles and choreoathetosis
what is agranulocytosis
severe and dangerous leukopenia (low WBC) caused by antipsychotics found in blood and urine tests tx- STOP antipsychotic
what is associative looseness
severe disoriented thinking, aka "derailment" jumbled and illogical speech and reasoning
describe acute phase of schizophrenia
severe psychotic s/s, disruptive -hallucination -delusion -apathy -withdrawal -lost ability to be functional
example of folie a deux delusions
sharing of a delusional belief between two or more people
example of capgras delusions
someone/someplace/something is an imposter
how do you help pts who are experiencing hallucinations
talk with the pt about their experiences involve pt in distracting activites - watching Tv, listening to music, playing game
what pt and family teaching is needed for schizophrenia
teach stressors that can result in acute episode medications and their side effects consistency is key and reorient reality modify environment to decrease stimulation for safety protect self esteem
what are command hallucinations
tell the pt to do something, they can be innocent commands or can cause harm to self or others
what is a "psychotic break"
the full manifestation of the illness; deterioration from previous functioning
example of delusions of reference
the tv is talking about me. the guests on oprah are making fun of me
example of paranoid delusions
they all think that i am a homosexual
example of religious delusions
woman attempts to kill children b/c she believes the devil wants her to do so
who has more positive s/s: men or women
women