Maggie Motyka, MS, RNC Fall 2012

Delusions Hallucinations Disorganized speech Disorganized or catatonic behavior Psychotic symptoms more pronounced and disruptive than in other psychotic disorders

Schizophrenia occurs in
1 in 100 adults 1 in 40,000 children

Age of onset 17 to 25 years most common With schizophrenia, there is a severe deterioration of social and occupational functioning.

Substance abuse disorders Nicotine dependence Depression

Suicide

Anxiety disorders Psychosis-induced polydipsia

A return to full premorbid function is not common

Factors associated with a positive prognosis include Good premorbid adjustment Later age at onset; Being female Abrupt onset precipitated by a stressful event Associated mood disturbance Minimal residual symptoms Brief duration of active-phase symptoms Absence of structural brain abnormalities No family history of schizophrenia
5

Affect Associative looseness Autism Ambivalence Plus a 5th

Automatic Obedience

Neurobiochemical
Dopamine hypothesis Serotonin Glutamate

Neuroanatomical

Structural cerebral abnormalities

Genetic

Several genes on different chromosomes interact with environment

Nongenetic risk factors

Complications of pregnancy and birth Stress

8

 Thought

content
Firmly Fixed False Personal Beliefs

Delusions:

Religiosity: Excessive demonstration of obsession

with religious ideas and behavior

Paranoia: Extreme suspiciousness of others

Magical thinking: Idea that if one thinks
something, it must be true
9

Word salad: Group of words put together in a

random fashion

Associative looseness: Shift of ideas from

one unrelated topic to another

Neologisms: Made-up words that have

the environment

meaning only to the person who invents them

Concrete thinking: Literal interpretations of

Clang associations: Choice of words is

governed by sound (often rhyming)

10

Circumstantiality: Delay in reaching the point of a communication because of unnecessary and tedious details Tangentiality: Inability to get to the point of communication due to introduction of many new topics Mutism: Inability or refusal to speak Perseveration: Persistent repetition of the same word or idea in response to different questions

11

Hallucinations: False sensory perceptions not associated with real external stimuli
Auditory, Visual, Tactile, Olfactory, Gustatory

Illusions: Misperceptions of real external stimuli

Such as?? Caused by ??

12

Sense of Self: The uniqueness and individuality a

person feels

Echolalia: Repeating words that are heard Echopraxia: Repeating movements that are
observed

Identification and imitation: Taking on the

form of behavior one observes in another

Depersonalization: Feeling of unreality

13

Affect: the feeling state or emotional tone

Inappropriate affect: emotions are incongruent with the circumstances Bland or flat: weak emotional tone Apathy: disinterest in the environment

Avolition: Impairment in ability to initiate goal-directed activity

Emotional ambivalence: Coexistence of opposite emotions toward same object, person, or situation
14

Impaired interpersonal functioning and relationship to the external world

Autism:

Deterioration in appearance:
Impaired personal grooming and self-care activities

The focus inward on a fantasy world while distorting or excluding the external environment

15

Psychomotor behavior
Anergia: Deficiency of energy Waxy flexibility: Passive yielding of all Posturing: Voluntary assumption
and rocking the body
movable parts of the body to any effort made at placing them in certain positions of inappropriate or bizarre postures

Pacing and rocking: Pacing back and forth

16

Associated features:
Anhedonia: Inability to experience pleasure Regression: Retreat to an earlier level of
development

17

Inattention, easily distracted Impaired memory Poor problem-solving skills Poor decision-making skills Illogical thinking Impaired judgment

18

Dysphoria Suicidal ideation Hopelessness

19

Recurrent acute exacerbations of psychosis Increase in residual dysfunction and deterioration with each relapse

20

Phase I Premorbid behavior Normal functioning Shy and withdrawn Poor peer relationships Doing poorly in school Antisocial behavior

21

Prodromal phase Phase II

Lasts from a few weeks to a few years Deterioration in role functioning and social withdrawal Substantial functional impairment Sleep disturbance, anxiety, irritability Depressed mood, poor concentration, fatigue Perceptual abnormalities, ideas of reference, and suspiciousness herald onset of psychosis

22

Withdrawn from others

Depressed
Anxious Phobias

Obsessions and compulsions

Difficulty concentrating Preoccupation with religion Preoccupation with self
23

Schizophrenia Phase III In the active phase of the disorder, psychotic symptoms are prominent

Delusions Hallucinations Impairment in work, social relations, and self-care

24

Residual phase Phase IV

Symptoms similar to those of the prodromal phase Flat affect and impairment in role functioning are prominent

25

Positive symptoms Negative symptoms Cognitive symptoms Mood symptoms

26

Ability to work Interpersonal relationships Self-care abilities Social functioning Quality of life

27

Peer group supervision

Client's intense emotions produce similar emotions in the nurse Willingness for nurse to discuss feelings and behaviors with supervisors decreases defensive behaviors

Team approach to decrease staff burnout Periodic reassessments of

Treatment outcomes
Client's strengths and weaknesses
28

Safety of client and others Medical history and recent medical workup Positive, negative, cognitive, and mood symptoms Current medications and compliance to treatment Family response/support system

29

Risk for self-directed or other-directed violence Disturbed sensory perception Disturbed thought processes Impaired verbal communication Ineffective coping Compromised or disabled family coping

30

Acute phase
Client safety and medical stabilization

Maintenance phase
Adherence to medical regimen Understanding schizophrenia Participation of client and family in psychoeducational activities

Stabilization phase
Target negative symptoms Anxiety control Relapse prevention
31

Acute phase
Possible hospitalization
Ensure client safety Provide symptom stabilization

Maintenance and stabilization phases

Psychosocial education Relapse prevention skills

32

Acute phase
Psychobiological intervention Counseling Milieu management Family psychoeducation

Maintenance and stabilization phases

Health teaching Health promotion and maintenance

33

Safety
Potential for physical violence due to hallucinations or delusions Priority is least restrictive safety technique
Verbal de-escalation Medications Seclusion or restraints

Activities
Provide support and structure Encourage development of social skills and friendships
34

Hallucinations

Hearing voices most common Approach client in nonthreatening and nonjudgmental manner Assess if messages are suicidal or homicidal Initiate safety measures if needed Client anxious, fearful, lonely, brain not processing stimuli accurately

Delusions

Be open, honest, matter-of-fact, and calm Have client describe delusion Avoid arguing about content Interject doubt Validate part of delusion that is real
35

Associative looseness
Do not pretend that you understand Place difficulty of understanding on yourself Look for reoccurring topics and themes Emphasize what is going on in the client's environment Involve client in simple, reality-based activities Reinforce clear communication of needs, feelings, and thoughts

36

Distraction Interaction Activity Social action Physical action

37

Learn all you can about the illness. Develop a relapse prevention plan. Avoid alcohol and drugs. Learn ways to address fears and losses. Learn new ways of coping. Comply with treatment. Maintain communication with supportive people. Stay healthy by managing illness, sleep, and diet.

38

Antipsychotic medications Neuroleptics Major Tranquilizers

Traditional or conventional Atypical or novel

39

Indications:

Action:

Treatment of acute and chronic psychoses; selected agents are also used in the treatment of bipolar mania, as antiemetics, in the treatment of intractable hiccoughs, and for control of tics and vocal utterances in Tourettes disorder

Unknown; thought to block postsynaptic dopamine receptors in the basal ganglia, hypothalamus, limbic system, brainstem, and medulla. Newer antipsychotics may block action on receptors specific to dopamine, serotonin, and other neurotransmitters.
40

 Contraindicated:

In hypersensitivity; CNS depression; when blood dyscrasias exist; in clients with Parkinsons disease or narrow-angle glaucoma; those with liver, renal, or cardiac insufficiency; or poorly controlled seizure disorders

Caution

with elderly, debilitated, or diabetic clients or those with respiratory insufficiency, prostatic hypertrophy, or intestinal obstruction

41

 Additive hypotension with antihypertensive agents Additive CNS effects with CNS depressants Additive anticholinergic effects with similar agents Reduced effectiveness of oral anticoagulants Severe hypotension with epinephrine or dopamine Additive QT prolongation with other drugs that prolong QT interval Pimozide is contraindicated with CYP3A inhibitors Thioridazine is contraindicated with CYP2D6 inhibitors Concomitant use results in haloperidol and carbamazepine
42

 Additive hypotension with antihypertensive agents Additive CNS effects with CNS depressants Additive anticholinergic effects with similar agents Additive QT prolongation with other drugs that prolong QT interval Decreased effects of levodopa and dopamine Increased effects with CYP3A4 and CYP1A2 inhibitors Decreased effects with CYP1A2 inducers Additive hypotension with other drugs that cause this side effect
43

44

Dopamine antagonists (D2 receptor antagonists) Target positive symptoms of schizophrenia Advantage

Less expensive than atypical antipsychotics

Disadvantages
Do not treat negative symptoms Extrapyramidal side effects (EPS) Tardive dyskinesia Anticholinergic effects (ACH) Lower seizure threshold
45

High potency = low sedation + low ACH + high EPSs

Haloperidol (Haldol)

Trifluoperazine (Stelazine)
Fluphenazine (Prolixin) Thiothixene (Navane)

Medium potency
Loxapine (Loxitane) Molindone (Moban)

Perphenazine (Trilafon)
46

Low potency = high sedation + high ACH + low EPSs

Chlorpromazine (Thorazine) Thioridazine (Mellaril) Mesoridazine ( Serentil)

Decanoate = Long acting

Haloperidol decanoate (Haldol) Fluphenazine decanoate (Prolixin)

47

Serotonin-dopamine antagonists
(5-HT2A receptor antagonists)

Advantages
Diminishes negative as well as positive symptoms of schizophrenia Less side effects encourages medication compliance Improves symptoms of depression and anxiety Decreases suicidal behavior

Disadvantages
Weight gain Metabolic abnormalities
48

Clozapine (Clozaril) Quetiapine (Seroquel) Risperidone (Risperdal Zipreasidone (Geodon) Olanzapine (Zyprexa) Aripiprazole (Abilify)

49

Dry mouth Urinary retention and hesitancy Constipation Blurred vision Photosensitivity Dry eyes Inhibition of ejaculation or impotence in men

50

Hypotension Postural hypotension Tachycardia

51

Pseudoparkinsonism Acute dystonic reactions

Opisthotonos Oculogyric crisis

Akathisia Tardive dyskinesia (AIMS test)

Choreic Athetoid

Facial Limbs Trunk

52

53

Indications:
treatment of parkinsonism of various causes, including degenerative, toxic, infective, neoplastic, or drug induced

Action:

works to restore the natural balance of acetylcholine and dopamine in the CNS

54

 Contraindicated

in known hypersensitivity; angle-closure glaucoma; pyloric, duodenal, or bladder neck obstructions; prostatic hypertrophy; or myasthenia gravis

Caution

with hepatic, renal, or cardiac insufficiency; elderly and debilitated clients; those with a tendency toward urinary retention; those exposed to high environmental temperatures

55

 Additive anticholinergic effects with other drugs that possess these properties Concurrent use with haloperidol or Phenothiazines may result in decreased effect of the antipsychotic and increased incidence of anticholinergic side effects.
Additive CNS effects with CNS depressants

56

Agranulocytosis Cholestatic jaundice Neuroleptic malignant syndrome (NMS)

Severe extrapyramidal Hyperpyrexia Autonomic dysfunction

57

Disorders caused by changes in the brain marked by disturbances in:

Orientation Memory Intellect Judgment Affect

58

59

Acute onset Disturbances in consciousness Disturbed thinking, memory, attention, and perception Disorientation and confusion that fluctuates by minute, hour, and day Always caused by an underlying condition
Treatment priority: Identify cause, then intervene so that permanent damage to neurons does not result
60

Temporary Transient

Cognitive and perceptual disturbances Physical needs

Safety
Physical Bacteriological Biophysical

Mood and behavior

61

Risk for injury Deficient fluid volume Acute confusion Disturbed thought processes Fear Disturbed sleep pattern Impaired verbal communication Impaired social interaction

62

A cognitive disorder with these signs and symptoms:

Insidious onset Deterioration of
Memory Judgment Ability to think abstractly Orientation

May be progressive and irreversible

63

Pathological
Cerebral atrophy Neuritic plaques Neurofibrillary tangles

Genetic
Chromosome 19 Apolipoprotein E gene

Nongenetic Neurochemical
Acetyltransferase Estrogen

64

65

Stage 1 (mild): forgetfulness

Stage 2 (moderate): confusion

Stage 3 (moderate to severe): ambulatory dementia

Stage 4 (late): end stage

66

Confabulation: unconscious attempt to maintain self-esteem Perseveration: repetition of phrase or behaviors Aphasia: loss of language ability Apraxia: loss of purposeful movement in the absence of motor or sensory impairment Agnosia: loss of sensory ability to recognize objects

67

Risk for injury Impaired verbal communication Impaired memory Ineffective coping Caregiver role strain Anticipatory grieving

68

For cognitive impairment

Physostigmine (Antilirium) Tacrine (Cogex) Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Razadyne) Memantine (Namenda)

69