Nursing Care of the Patient with Schizophrenia and Other Psychotic Disorders

Denise Coe RN MSN HNC

What is Schizophrenia?
A disorder of the brain Combination of:
Disordered thinking Perceptual disturbances Behavioral abnormalities Affective disruptions Impaired social competency

Etiologies
Uncertain-multiple etiologies: Genetic? Infection? Birth or pregnancy complications? Neuroanatomical theories? A lesion in the limbic system? Dopamine theory?

Risk Factors
Risk is greater if: Single from and industrialized nation lives in a lower socio-economic class lives in a urban center is a product of a difficult labor and delivery

 STRESS- recently experienced stressful events. ( increased cortisol effects on cells in hippocampus).

Risk Factors
Social causationMay be due to more stressful life situations in lower classes, less social support? Downward Drift Theory- as the disease progresses patient has greater difficulty maintaining stable job and relationship.

Risk Factors
Stressful life event Patients report a vulnerability to stress Heightened sensitivity to the environment Less able to screen out sounds, and stimuli.

What is Schizophrenia?
A type of psychosis What is psychosis?
A state in which a person is unable to comprehend reality and has trouble communicating to others.

History of schizophrenia
Emil Kraeplin, a European doctor, first described it in 1896.

History..
In 1911 Dr Eugene Bleuler, from Europe, identified the behaviors typical of people with schizophrenia. He renamed it-schizophrenia- meaning splitting of the mind. The patient is split off from reality, not a split personality.

History.
The four As of Bleuler: Affect- the feelings reflected on our faces, in our expressions, and by our demeanor or behavior.

History
Associations

Autism

History.
Ambivalence experiences strong positive and negative feelings at the same time; hard to make any decisions.

DSM-IV-TR Criteria
A.Characteristic Symptoms: Two or more of the following, each present for a significant portion of the time during a I-month period : Delusions Hallucinations Disorganized speech Grossly disorganized behavior Negative Symptoms

Nature of the Disorder

The person has trouble thinking clearly, knowing what is real, managing feelings, making decisions, and relating to others.

Phases of Onset
Phase 1- The Schizoid personality a person sometimes described as a loner, indifferent to social relationships and having a limited range of emotional experience and expression.

Phases

Phase 2-The Prodromal phase Begin to socially isolate Have difficulty in role functioning Odd behavior Neglect of personal hygiene and grooming Different affect Changes in communication Bizarre ideas Lack of initiative

Phases..
Schizophrenia-active disease See DSM IV TR.

DSM-IV-TR Criteria
A.Characteristic Symptoms: Two or more of the following, each present for a significant portion of the time during a I-month period : Delusions Hallucinations Disorganized speech Grossly disorganized behavior Negative Symptoms

Phases..
Phase4- Residual impairment- often increases between episode A return to full premorbid functioning is not usual

Types of Schizophrenia and Other Psychotic Disorders

Disorganized-Behavior very regressed and primitive. Catatonic-marked abnormalities in motor behavior.
Stupor or excitement Waxy flexibility

Types
Paranoid-characterized mainly by the presence of delusions of persecution or grandeur related to a single theme.

Types
Undifferentiated- Symptoms can not be classified Residual-

Other Psychotic Disorders..

SchizoaffectiveSchizophrenic behaviors with a strong element of symptoms of mood disorder

Other Psychotic Disorders

Brief psychotic disorder-sudden onset of psychosis usually following a severe psychosocial stressor, with full return to normal. Schizophreniform-duration is shorter but same symptoms. Delusional disorder-presence of one or more non bizarre delusions. Behavior not bizarre.

Other Psychotic Disorders

Psychotic disorder that develops due to a general medical condition Substance induced psychotic disorder

Negative and Positive Symptoms

They do not mean good and bad Positive added or excessive behaviors that are not normally seen in mentally well persons Negative-the loss of normal function that is normally seen in mentally well persons The negative symptoms less affected by medications and lead to greater impairment

Characteristics of Schizophrenia
Cognitive
Delusions- false personal beliefs that are inconsistent with the person's intelligence or background. The person holds firm to them despite proof that the thought is false or irrational.

 Types of delusions: Persecution -most common.

Types of Delusions
Delusions- Table 14.3 of text
Grandiose

Jealous Somatic delusions Delusion of reference Delusion of control or influence Nihilistic delusion

Characteristics
Cognitive
Religiosity Disorganized thinking Looseness of associations Concrete thinking Impaired ability to solve problems Memory deficits Magical thinking

Neologisms Clang Associations

Characteristics
Cognitive Word salad Circumstantiality Tangentiality Mutism Preseveration

Perceptual Characteristics
Hallucinations
Auditory-Most common type Usually voices, but can be noises.

Command hallucinations- must assess Visual

 Tactile Gustatory Olfactory

Perceptual Characteristics
Impaired Sensory Filtering

Affective Characteristics
Affect Describes the behavior associated with a persons feeling state or emotional tone. Descriptions of affect include: Inappropriate affect Bland or Flat affect Apathy Anhedonia Overreactive affect

Behavioral Characteristics Social Characteristics

Impaired interpersonal functioning Social isolation-aloof Emotional detachment Poor personal appearance Inadequate social skills

Concomitant Disorders
Dual diagnosis simultaneous substance abuse disorder Both must be treated

Activity
Separate into groups of four. Read the Scenario and define a goal or outcome for the nursing diagnosis. Write the interventions to achieve that goal. Each person write an intervention, something you would do to work toward that goal. Each one will write the intervention and when time is up we will share.

Activity1

 Read the case study and the nursing diagnosis. As a group, discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. Nsg diagnosis-Disturbed sensory perception: auditory hallucinations

Activity 1
Nsg diagnosis-Disturbed sensory perception: auditory hallucinations related to panic anxiety, extreme loneliness, and withdrawal into self evidenced by inappropriate responses, and disordered thoughts.

Activity 2
Read the case study and the nursing diagnosis. As a group, discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. Nsg. Dx.: Social isolation

Activity 2
Nsg. Diagnosis- Social isolation related to inability to trust, panic anxiety, delusional thinking, and regression as evidenced by stating people are trying to poison her.

Activity 3
Read the case study and the nursing diagnosis. As a group, discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. Nsg. Dx. Risk for violence.

Activity 3
Nsg. Dx. Risk for violence: self- directed or other directed related to extreme suspiciousness, panic anxiety,or possibly

command hallucinations as evidenced by believing roommate wanted to kill her and people are trying to harm her.

Activity 4
Read the case study and the nursing diagnosis .As a group, discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. Nsg. Dx.-Impaired verbal communication

Activity 4
Impaired verbal communication related to panic
anxiety, regression, disordered thinking as evidenced by looseness of association.

Activity 5
Read the case study and the nursing diagnosis. As a group discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. Nsg Dx.self care deficit.

Activity 5
Nsg Dx. Self care deficit related to withdrawal, regression, panic anxiety inability to trust as evidenced by inability to do hygiene, grooming and dress.

Psychiatric Rehabilitation
Multidisciplinary and collaborative with the client, family, and community Nurse teaches, coaches, serves as resource Psychological treatments:Focus is always on decreasing anxiety and increasing trust Group-Psycho education R/T meds, relapse prevention, social skills, decrease isolation

Psychiatric Rehabilitation

 Long term.requires from therapist exquisite patience and freedom from the need to prove oneself by effecting change. Psycho education: On medications On the disease process On relapse symptoms On social interaction On expressing emotions On handling frustration

Treatment
Group: inpatient phase of illness represents the most anxiety and social inability.Reduce stimuli. Group supportive, not confrontational. Social skills through role-playing real life situations. Behavior modification- but pts. may have difficulty generalizing to community setting.

Treatment
Family therapy- All illness involves the family, sometimes that may be the people at the halfway house or in the homeless camp. Medications: 1954 Thorazine was the first antipsychotic. Response to meds.-10% do not recover, 30% partial recover needing some assistance, but able to work and care for needs, 30% poor recovery minimally surviving, 30% recover completely.

Treatment
Medications-meds.+ supportive, ongoing therapy.Used both in the acute phase as well as for maintenance Long term use. See handout.
Medications Review side effects: Anticholinergic and movement ( pseudo parkinsonism, akinesia muscle weakness or loss of muscle ability, akathesia, dystonia spasms of the face arms, oculogyric crisis, tardive dyskinesia bizarre facial and

tongue movements, difficulty swallowing. neuroleptic malignant syndrome.

Medications
Non compliance may be an issue may have to use depot Haldol and Prolixin. Comes in pills, liquid concentrate, injectable, and depot injectable for long acting effect Have also begun using mood stabilizers.

Nursing Diagnoses
Altered thought process R/T(delusions,loose associations, concrete thinking) Social Isolation R/T.(withdrawal,lack of social network, anxiety, preoccupation with symptoms) Self esteem disturbance R/T(chronic disease, feeling different from others) Knowledge deficit R/T( not understanding disease, medications)

Nursing Diagnoses
High risk for violence, self or others R/T ( panic level anxiety, command hallucinations, suspiciousness) Self care deficit R/T.amotivation, inabbility to remember Sensory perceptual alterations

Interventions
Active listening
Listen for themes Redirect Social skills training-role play, practice specific skills Model social behavior Self esteem enhancement-self esteem journal, give positive feedback,collage of interests and talk about it

Interventions
Anxiety reduction-Relation techniques, notice and if possible change environmental stimuli, exercise

 Teaching- disease, signs of relapse, plans for relapse identification symptoms, meds, schedule Energy management- ADLS, naps, nutritional meals

Interventions
Self-care assistance- list of hygiene tasks and the steps, times Suicide prevention-assess command hallucinations and teach client what to do Hallucination management-assess, help client describe needs that might be reflected in the content of the hallucination, identify triggers of hallucinations

Interventions
Delusion management-assess, correlate onset of delusion with onset of stress, respond to the underlying feelings Violence prevention encourage to talk rather than act out feelings, identify triggers, give personal space to client who is escalating,verbally set limits on aggressive behavior, avoid touching client who is scared

Interventions
Violence management Assess the congruency of your behaviors Involve family to the level of their ability and client confidentiality Teach family-convey message they are not the cause, teach signs of relapse, medications, how to deal with active symptoms, role play with them, teach about keeping a moderate level of expressed emotion, establish family rules,support groups, and family therapy