week 2 Schizophrenia Spectrum
two or more of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated) at least one of these must be 1 2 or 3
1. delusions 2. hallucinations 3. disorganized speech 4. grossly disorganized or catatonic behavior 5. negative symptoms
why would depressive or bipolar disorder be ruled out
1. no major depressive or manic episodes have occurred concurrently with the active-phase symptoms 2. if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness
how long do assessments take fro schizophrenic patients
15-20 minutes
✓A client diagnosed with schizophrenia is thought to be having hallucinations. The most common type of hallucination involves which of the following senses? ❑ a. Auditory. ❑ b. Olfactory. ❑ c. Tactile. ❑ d. Visual.
A
what is the definition of Schizophrenia/ psychosis
A severe mental condition in which there is disorganization of the personality, deterioration in social functioning, and loss of contact with or distortion of reality. There may be evidence of hallucinations and delusional thinking.
When assessing a client with schizophrenia which findings would the nurse most likely note: A. Inappropriate affect B. Delusions C. Bizarre behavior D. Panic attacks E. Hostility F. Phobia's
A. Inappropriate affect- yes B. Delusions- yes C. Bizarre behavior- yes D. Panic attacks- no E. Hostility- yes F. Phobia's- no
Emotional Ambivalence
Ambivalence in the individual with schizophrenia refers to the coexistence of opposite emotions toward the same object, person or situation. These opposing emotions may interfere with the person's ability to make even a simple decision (e.g.; tea or coffee with lunch).
Waxy Flexibility
Associated primarily with catatonia, describes a condition in which the patient allows body parts to be placed in bizarre or uncomfortable positions. Once placed in position, the arm, leg, or head remains in that position for long periods, regardless of how uncomfortable it is for the individual.
In planning the care of a client experiencing paranoid delusions, which of the following is the priority goal? a. Absence of delusions b. Establishing trust c. Participation in all units' activities d. Performing independent activities
B
✓A client is sitting in the corner of the dayroom tilting his head to one side as if he is hearing something, but no one is nearby. The nurse suspects an auditory hallucination. Which would the nurse ask first? ❑a. "Are you seeing someone near you other than me?" ❑b. "What are you hearing right now." ❑c. "What is going on with you right now." ❑d. "Do you want to go to the recreation room?"
B
neuroanatomy vs neurochemistry
Brian structure vs brain activity
The most prominent neurochemical theories involve
Dopamine and serotonin
what increases the risk for Schizophrenia
Environmental risk factors (e.g., exposure to viruses or malnutrition in the womb, problems during birth,) and psychosocial factors increase risk
Identification and imitation
Identification, which occurs on an unconscious level, and imitation which occurs on a conscious level, are ego defense mechanisms used by individuals with schizophrenia and reflect their confusion regarding self-identity. Because they have difficulty knowing where their ego boundaries end and another person's begins, their behavior often takes on the form of that which they see in the other person.
Approximately, 20-70% of patients with schizophrenia have a comorbid substance abuse problem, which is associated with
Increased violence, suicide, non-adherence with recommendations to prevent violence, hostility, crime, poor nutrition, etc.
Social Isolation
Individuals with schizophrenia sometimes focus inward on themselves to the exclusion of the external environment.
how would the nurse respond to a client that says Client: "What did you mean by that remark? People are always making fun of me."
Nurse: "That remark was not meant for you. It was directed toward everyone in the group."
Pacing and Rocking
Pacing back and forth and body rocking usually while sitting. - psychomotor behavior
what are symptoms of paranoid/ persecutory
Persecutory delusions Hallucinations Excessive religiosity Hostile aggressive behavior Suspicious
Deteriorated Appearance
Personal grooming and self-care activities may be neglected. The patient may appear disheveled and will need reminders for personal hygiene.
Regression
Retreat to an earlier level of development. Regression, is a primary defense mechanism of schizophrenia. It provides the basis for many of the behaviors associated with schizophrenia.
Lack of Insight
Some individuals lack awareness of there being any illness or disorder even when symptoms obvious to others.
Apathy
The individual with schizophrenia often demonstrates an indifference to or disinterest in the environment. The bland or flat affect is a manifestation of the emotional apathy. lack of interest, enthusiasm, or concern.
Depersonalization
The unstable self-identity of an individual with schizophrenia may lead to feelings of un reality (e.g., feeling that one's extremities have changed in size; or a sense of seeing oneself from a distance)
Posturing
This symptom is manifested by voluntary assumption of inappropriate or bizarre postures unnatural to gravity. - psychomotor behavior
what are symptoms of catatonic/ catatonia
Waxy Flexibility Stupor Motor immobility Mutism Peculiarities of voluntary movement
flat affect
absence of any facial expressions that would indicate emtions or mood
abolition or lack of volition
absence of will, ambition, or drive to take action to accomplish tasks
▪Patients with schizophrenia are found to do what more often than the regular population?
abuse alcohol and/or drugs - Abusing substances can reduce the effectiveness of treatment. attempt suicide - about 10% succeed
what are negative symptoms
affect ❑ Inappropriate affect, blunted or flat affect, unable to experience pleasure or express emotion (anhedonia) ❑ Inability to carry out goal-directed behavior (avolition)
what are risk factors
age and gender
when the client is experiencing more command hallucinations/ delusions, there is an increased potential for
aggressive behavior (think medication)
The goal of acute-phase treatment, usually lasting for 4-8 weeks, is to
alleviate the most severe psychotic symptoms.
The nurse caring for a client diagnosed with schizophrenia administers what classification of drugs to treat hallucinations/delusions_________?
antipsychotics
❑Patients with immediate family members diagnosed as schizophrenic are how likely to get the disorder
approximately a 10% of developing the disorder.
✓A schizophrenic patient who has been taking a typical antipsychotic for 5 years is exhibiting involuntary movements of the tongue and mouth. The nurse interprets these findings as: ❑a. Hyperpyrexia ❑b. Tardive dyskinesia ❑c. Akathisia ❑d. Parkinsonism
b
Findings have demonstrated that people with schizophrenia have relatively less ______ and ______ than those who do not have schizophrenia; this could represent a failure in the development or a subsequent loss of tissue.
brain tissue and cerebral spinal fluid
You are assessing a patient who has been on a typical antipsychotic for 1 week. The patient reports feeling restless, agitation, and the inability to sit still. You suspect the patient is experiencing: a. Dystonia b. Dyskinesia c. Akathisia d. Neuroletpic Malignant Syndrome
c
Observe for increased motor activity and/or erratic response to staff and other clients. The client may be experiencing an increase in
command hallucinations/delusions
flight of ideas
continuous flow of verbalization in which the person jumps rapidly from one topic to another
▪with catatonic patients attempts at consistent communication are
critical-presence helps even when they are not speaking!
the research consistently shows that people with schizophrenia have
decreased brain volume and abnormal brain function in the frontal and temporal areas of persons with schizophrenia
stress increases anxiety which then increases
delusions/hallucinations
Schizophrenia is generally considered a chronic condition, which needs long-term management. What are some nursing interventions that may decrease relapse potential?
educate the family of the signs of relapses deconoates (long term- drugs at the clinic they can go and get every 7 months ) medications
what are positive symptoms
extreme or exaggerated behaviors - delusions
ideas of reference
false impressions that external events hav special meaning for the person
Delusions
false personal beliefs that are inconsistent with the person's intelligence or cultural background. The individual continues to have the belief in spite of obvious proof that it is false or irrational. (somatic, ideas of reference, thought broadcasting, thought insertion, and thought withdrawal, delusions of reference, delusions of control, nihilistic delusions - inappropriate to over-reactive affect -ex if someone dies in the fam they may laugh
hallucinations
false sensory perceptions or perceptual experiences that do not really exist
anhedonia
feeling no joy or pleasure from life or any activities or relationships
apathy
feeling no joy or pleasure from life or any activities or relationships
delusions
fixed false beliefs that have no basis in reality
associative looseness
fragmented or poorly related thoughts or ideas
positron emission tomography studies suggest that
glucose metabolism and oxygen are diminished in the frontal cortical structures of the brain
As you begin your shift as the charge nurse in an acute care psychiatric unit, you are informed in report of a new admission. The client has a psychiatric diagnosis of schizophrenia, paranoid type. What types of symptoms might you anticipate?
hallucination agitation delusion suspicious paranoid
ambivalence
holding seemingly contradictory beliefs to feelings about the same person, event, or situation
echopraxia
imitation of the movements and gestures of another person whom the client is observing
Genetic theories focus on
immediate family members (parents, siblings, children)
Social skills training are aimed at
improving the way patients with schizophrenia interact with others and family
inattention
inability to concentrate or focus on a topic or activity, regardless of its importance
Ahnedonia
inability to experience pleasure. This is a particularly distressing symptom that compels some individuals to attempt suicide.
Impaired volition has to do with the inability to initiate goal-directed activity. In the individual with schizophrenia, this may take the form of
inadequate interest, motivation, or ability to choose a logical course of action in a given situation. Example: may stay at home for long periods of time without seeking people or medical help.
Environmental stressors are found to be associated with the development of schizophrenia, including problems with
interpersonal relationships, difficulties at school/work, and substance abuse.
Anergia
is a deficiency of energy. The individual with schizophrenia may lack sufficient energy to carry out activities of daily living or to interact with others.
why are these segments timed
it can increase their anxiety they are going from topic to topic so you won't get a lot of information from them
what is Schizophrenia an imbalance between
neurotransmitter dopamine and glutamate (and possibly others) are found to play a role in schizophrenia Temporal lobe and frontal cortical structures
bizarre behavior
outlandish appearance of clothing, receptive or stereotyped, seemingly purposeless movements, unusual social or sexual behavior
what are two subtypes of schizophrenia
paranoid/ persecutory catatonic/ catatonia
perseveration
persistent adherence to a single idea or topic, verbal repetition of a sentence, word, or phrase, resting attempts to change the topic
thought blocking and definitions speech may be slowed
pg 274-5
the treatment goals are to
prevent relapse and to improve patients level of functioning
catatonia
psychologically induced immobility occasionally marked by periods of agitation or excitement, the client seems motionless, as if in a trance
blunted affect
restricted range of emotional feelings, tone, or mood
What are considered nursing priorities when a client is experiencing psychosis?
safety
What are the priorities of care?
safety
Why is it important initially to seek information from the client (if possible) regarding the content of the delusions or hallucinations?
safety
what can catatonia occur with
schizophrenia, mood disorders, or other psychotic disorders
Inpatient treatment is necessary for patients with
serious suicidal or homicidal ideation and plan, whose behavior can unintentionally be harmful to self or others, who are incapable of providing self-care, or who are at risk for behavior that may lead to long-term negative consequences.
sociality
social withdrawal, few or no relationships, lack of closeness
Impaired Social Interaction
some patients with acute schizophrenia clinging to others and intrude on personal space
positive symptoms correspond to the negative symptoms correspond to
tempotal lobe frontal lobe
alogia
tendency to speak very little or to convey little substance of meaning (poverty of content)
Do not argue with a client about delusions or hallucinations. Logic does not work; it only increases how should you be?
the client's anxiety Be matter-of-fact and divert delusions and hallucinations to reality.
When evaluating client behaviors, consider
the medications the client is receiving. Exhibited behaviors may be manifestations of schizophrenia or a medication reaction.
Sense of self describes
the uniqueness and individuality a person feels.
Because of extremely week ego boundaries, the individual with schizophrenia lacks
this feeling of uniqueness and experiences a great deal of confusion regarding his or her identity.
what is the basis for all these interactions
trust
Atypical antipsychotic drugs are suggested to be used as a first-line treatment because of fewer side effects than with conventional or typical antipsychotic medications: most common:
▪ Olanzapine (Zyprexa) ▪ Clozapine (Clozaril) ▪ Aripiprazole (Abilify) ▪ Risperidone (Risperdal) ▪ Quetiapine (Seroquel) ▪ Ziprasidone (Geodon)
what are some acute nursing interventions/ treatments
▪Promoting Safety of patient and others ▪Establishing a therapeutic relationship via trust ▪Using therapeutic communication ▪Implementing Interventions for Delusional Thoughts ▪Implementing Interventions for Hallucinations ▪Coping with Socially Inappropriate Behavior ▪Patient & Family Teaching ▪Establishing community support systems and care
Nursing Intervention with Hallucinations
✓Help present and maintain reality by frequent contact and communication with client ✓Elicit description of hallucination to protect client and others. The nurse's understanding of the hallucination helps him or her know how to calm or reassure the patient-Listen to what the patient is saying! ✓Engage the patient in reality-based activities such as card playing, occupational therapy, or listening to music
the major needs of schizophrenic clients, think SDS
✓S tructure- because they tend to have too little in their lives ✓D iversion- to distract them from troubling thoughts ✓S tress reduction- to minimize the severity of the disorder
Nursing Interventions with delusions
✓do not openly confront the delusion or argue with the client ✓Establish and maintain reality for the client-Listen to what the patient is saying! ✓Use distracting techniques-work with staff 1:1 then small group ✓Teach the client positive self-talk, positive thinking, and to ignore delusions
It is important to monitor and manage side effects of antipsychotic medications which are
❑ Extrapyramidal symptoms ❑ Neuroleptic Malignant syndrome ❑ Agranulocytosis ❑ Postural hypotension
➢The nurse needs to do ongoing assessment when a client is on the antipsychotic haloperidol (Haldol) because of which significant side effects? Select all that apply: ❑1.Diarrhea ❑2.Constipation ❑3.Orthostatic hypotension ❑4.Akathesia ❑5.Elevated blood pressure ❑6.Urinary frequency
❑1.Diarrhea- no ❑2.Constipation- yes ❑3.Orthostatic hypotension-yes ❑4.Akathesia-yes ❑5.Elevated blood pressure-no ❑6.Urinary frequency-no (urinary retention)
what should you do with socially inappropriate behavior
❑Redirect patient away from problem situations-taking the patient to a quiet area away from the public ❑Deal with inappropriate behaviors in a non-judgmental and matter-of-fact manner; give factual statements ❑Attempt to reintegrate the patient into the treatment milieu as soon as possible 1: 1, 1:2 the small group ❑Do not make the patient feel punished or shunned for inappropriate behaviors ❑Teach social skills through education, role modeling, and practice
clinical presentation of this illness
❑form of thought (Associative Looseness, Neologisms- you don't know what they are saying, can you draw it or point to it, Concrete thinking, clang association, word salad, circumstantiality, tangentiality, mutism, perservation) ❑Perception (Hallucinations are false sensory perceptions not associated with real external stimuli, may involve all five senses. ❑Auditory (most common) may issue commands of violence, visual, tactile, gustatory, olfactory command hallucinations- thought telling them to do something seeing images that do not exists at all, they are the 2nd most common types of hallucinations
what are some medial/ legal pitfalls
❖Misdiagnosis ❖Mental Health providers should inform patients being treated with conventional antipsychotic medications about the risk of Tardive Dyskinesia which could be a permanent condition affecting an already stressed life
what is included in the initial assessment
➢Current physical status and physical history ➢Current mental status ➢Drug history including prescribed and over-the-counter drugs ➢Safety needs
what are some outcomes
➢Meet developmental tasks ➢Receive, interpret & express messages appropriately ➢Use coping strategies in a functional adaptive manner ➢Eat adequate amounts of different food groups ➢Not injure self or others ➢Participate in prescribed therapeutic interventions ➢Establish contact with reality (via treatment) ➢Express thoughts and feelings in a safe and socially acceptable environment
what is included in the diagnostic work up
➢Physical and mental status examination ➢Hepatic functioning ➢Metabolic panel ➢Alcohol and drug screening ➢Pregnancy test for female patients at childbearing age ➢Complete neurological examination
what are some differential diagnosis
➢Psychotic disorder due to a general medical condition, delirium, dementia ➢Substance-induced psychotic disorder ➢Bi-polar disorder with psychotic features (this is a brain disfunction that last for a very long time)
