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8/8/2019 Schizophrenia Fall

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Schizophrenia&

Other Psychotic Disorders

Chapter 20

Melinda Hermanns,MSN, RN, BC


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Schizophrenia

Neurological disease thataffects a persons perception,

thinking, language, emotion,and social behavior.

Occupies approximately 50% ofall hospital beds and 35-50% ofthe homeless population


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Schizophrenia

Lifetime Prevalence: 1% worldwide

Typical Age ofOnset: late teens

and early 20s.

Men and women equal


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Theories

Cause unknown most likely aresult of inherited geneticfactors and non-geneticfactors


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Theories (contd)

Neuroanatomical Studies -structural brain abnormalities:

Cerebral ventriclesCortical atrophy

Atrophy of frontal lobe

PET ScanMRI


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Non-genetic Risk Factors

Birth and Pregnancy

Complications

Stress-Related Theories


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Bleulers 4 As

Affect

Associative Looseness

Autism

Ambivalence


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Prodromal /Early Symptoms

Symptoms one month to one yearbefore psychotic break

Person feels something strange orweird is happening to them

Misinterprets things in theenvironment

Feelings of rejection, lack of self-respect, loneliness,hopelessness,isolation, withdrawal, and inability

to trust others.


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DSM-IV-TRDiagnosis

Schizophrenia Must exhibit two or more of the

following, each present for at least a 1-

month period:delusions

hallucinations

disorganized speechgrossly disorganized

negative symptoms (flat affect)


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Assessing Symptoms

Symptoms may be classified as

Positive attention getter symptoms i.e.hallucinations, delusions, bizarre behavior,

disorganized speech Negative crippling symptoms i.e. apathy,

lack of motivation, anhedonia

Cognitive - i.e. difficulty with attention,

memory, and problem solving Disorganized i.e. disorganized speech,inappropriate affect


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Alterations in Thinking

Delusions

Ideas of Reference

Persecution

Grandiosity

Bodily Functions

Jealousy

Control


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Symptoms

thoughtbroadcasting

thoughtinsertion

thought

withdrawalbeing

controlled

LooseAssociation

Neologisms Concrete

Thinking

Echolalia ClangAssociation

Word Salad

Review

Table 22-6,

page 643


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Alterations in Perceiving

Hallucinations - auditory, visual, olfactory,gustatory, and tactile

90% of schizophrenics experiencehallucinations - auditory most common

Difference between Illusions andHallucinations

Depersonalization and Derealization (loss ofego boundaries)

Bizarre BehaviorBe familiar with the terms in Table 22-4,

page 636


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Negative Symptoms

Develop over time

May not be detected (masked by positive

symptomsNegative symptoms include: poverty of

speech content, thought blocking, anergia,

anhedonia, affective blunting, and lack ofavolition.


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Associated Symptoms

Depression and Suicide

Water Intoxication

Substance Abuse

Violent Behavior


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Nursing Diagnosis

Multifaceted approach

Table 20 5: Potential Nursing Diagnoses


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Outcome Criteria

Phase I: Acute Phase - crisis

intervention

Phase II: Maintenance

Phase III: Stable


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Planning

Hospitalization

Identify long-term care needs

Identify and provide proper referrals For patient and family follow-up

Living arrangements, economic resources, socialsupports, family relationships, vulnerability to stress

Referral to community agencies Example:Andrews Center MHMR (learn about illness,medications, and relapse prevention skills)


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Intervention

Treatment Focus at Different Phases of

Schizophrenia Table 20 -7, p. 540

SAFETY First - Verbal Deescalation, followed by

Chemical Restraints (antipsychotics), then

as last resorts: Physical Restraints, andSeclusion may be indicated.


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Communication Skills

Table 20 8, p. 541

What to do if:

The patient is hallucinating The patient is experiencing delusions


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Schizoaffective Disorder

Mixture of Schizophrenic and Affectivesymptoms

I.e. alterations in mood as well as disturbancesin thought

Thought by some to be a severe form ofBipolar (Varcarolis, 1998)

Treatment: Lithium used with antipsychotictherapy for treatment of manic symptoms


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Psychopharmacology

Typical (Traditional) Antipsychotics

target the positive symptoms

Older drugs Watch for signs of EPS

Atypical (Novel) Antipsychotics

diminish the positive and negative

symptoms


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Typical Antipsychotic

Medications Thorazine

Mellaril

Stelazine

Trilafon

Serentil

Prolixin

Navane

Haldol

(Haloperidol

and Haloperidoldeconate)

Loxapine

Moban

KNOW SIDE EFFECTS


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Side Effects of Antipsychotics

Anticholinergic Symptoms

Extrapyramidal Symptoms (EPS)

1. Pseudoparkinsonism2. Acute dystonic reactions

-Opisthotonos

-Oculogyric Crisis

3. Akathisia

4. Tardive Dyskinesia


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Atypical Antipsychotics

Advantage over typical: alleviate bothpositive and negative symptoms(improvement of quality of life)

Clozapine (Clozaril) - agranulocytosisand seizures

LOWER SIDE EFFECTS:

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiapine (Seroquel)

Ziprasidone (Geodon)


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Adjuncts to Antipsychotic Therapy

Antidepressants

Antimanic Agents

Benzodiazepines

ECT


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Sub-types of Schizophrenia

Paranoid Type

Disorganized Type

Catatonic Type


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Subtype: Paranoid

Any intense and strongly defendedirrational suspicion

Most common symptoms -hallucination and delusions

Defense Mechanism - Projection


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Subtype: Disorganized Type

Most regressed and sociallyimpaired

Symptoms - loose association,inappropriate affect, bizarremannerisms, incoherent speech

and withdrawn Onset?

Prognosis


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Subtype: Catatonia

Abnormal motor behavior

Be familiar with other symptoms

Prognosis?

Physical Needs are a Priority


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Nursing Interventions for

Schizophrenic Subtypes Be familiar with the following in each of

the subtypes:

Communication Guidelines

Self-Care Needs

Milieu Needs


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FOR SCHIZOPHRENIA &

SCHIZOPHRENIA SUB-TYPES


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Patient and Family Health Teaching

Educate patient and family about illness

Assist patient in improving his or her ability to

solve problems related to environmental stress Teach the patient coping strategies

Assist family and patient to identify sources for

ongoing support

TABLE 20 10, p. 544


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Case Management

DISCHARGE PLANNING

Partial Hospitalization

Halfway Houses

Day Treatment Programs Group Therapy

Supervised Activities Individual Counseling

Specialized Training and Rehabilitation


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Therapy

Individual

Supportive

Group

Family

Counseling

Psychoeducational


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Evaluation

Realistic Goals

Reassess patients problems

Active involvement in patients progress


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Neologism

Definition: Words a personmakes up that have meaning

only for that person, it is oftenpart of a delusional system.

Example: I am afraid to go to

the hospital because the norksare looking for me.

Back


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Echolalia

Definition - mimicking or imitating

the speech of another person.

Example: The nurse says to thepatient, Tell me your name. The

patient responds, Tell me your

name, tell me your name.Back


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Word Salad

Definition: Mixture of wordsand phrases that have no

meaning. Example: I am fineapple

pieno salefurniture

storetake it slowcellardoor Back


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Concrete Thinking

What brought you here to thehospital?

The cab People in glass houses shouldnt

through stones.

Dont throw stones or the windowswill break.

ANSWERS ARE LITERAL

Back


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BE FAMILIAR WITH:

thought broadcasting - the

belief that ones thoughts can

be heard by others

Back


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Thought Insertion

thought insertion - the belief

that thoughts from other people

are being inserted into onesmind

BACK


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BE FAMILIAR WITH:

thought withdrawal - the belief

that thoughts have been

removed from ones mind by anoutside agency.

Back


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Delusions of Being Controlled

Delusions of being controlled

belief that ones body or mind is

controlled by an outside agency

BACK


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Common Side Effects

Anti-cholinergic

Sedation

Orthostatic Hypotension

Lowered Seizure Threshold

Extrapyramidal Side Effects (EPS) Less Common NMS


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PET ScanDiscordant Monozygotic

Twins

Frontal

LobeFrontal

Lobe

BACK


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BACK

Magnetic Resonance Imaging

(MRI)

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