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A group of psychotic disorders that affect thinking, behavior, emotions, and the ability to perceive reality.
Schizophrenia typ, characterized by suspicion toward others.
SX: hallucinations (E.G. hearing threatening voices) and delusions (E.G. believing oneself president of te US) other-directed violence may occur
Characterized by withdrawl from society and very inappropriate behaviors (E.G. poor hygeine or muttering constantly to oneself). Frequently seen in the homeless population.
SX: Loose associations, bizarre mannerisms, incoherent speech, hallucinations, and delusions may be present but are much less organized than those seen in the client with paranoia.
- Characterized by abnormal motor movements. There are two stages:
- 1. the withdrawn stage
- 2. the excited stage
Withdrawn Stage of Catatonic Schizophrenia
- Stage of catatonic schizophrenia with Sx:
- - Psychomotor retardation (The pt may appear comatose)
- - Waxy flexibility may be present
- - pt often has extreme self-care needs (E.G. tube feeding due to an inability to eat.)
Excited Stage of Catatonic Schizophrenia
- Stage of catatonic schizophrenia with Sx:
- - constant movement, unusual posturing, incoherent speech
- - self-care needs may predominate
- - pt may be a danger to self or others
- Active Sx are nno longer present, but the pt has two or more "residual" sx:
- -Anergia, anhedonia, or avolition, withdrawal from social activities, impaired role function, speech problems (such as alogia), odd behaviors (such as walking in a strange way)
- pt has Sx of schizophrenia but does not meet the criteria for any of the other types.
- -any positive or negative Sx may be present
The pt's disorder meets both the criteria for schizophrenia and onf ot the affective disorders (depression, mania, or mixed disorder)
Brief Psychotic Disorder
The pt has psychotic Sx that last b/w one day and one month
The pt has Sx like those of schizophrenia but the duration is 1-6 months and social/occupational dysfunction may or may not be present
Shared Psychotic Disorder
One person begins to share the delusional beliefs of another person with psychosis. Also called Folie A Deux.
Secondary (Induced) Psychosis
Signs of psychosis are brought on by a medical disorder (such as alzheimer's disease), or by use of chemical substances (such as alcohol abuse)
Positive Sx of Schizophrenia
- -Alterations in speech
- -Bizarre behavior (such as walking backward constantly)
Negative Sx of Schizophrenia
Affect (Negative Sx of Schizophrenia)
Usually blunted (narrow range of normal expression) or flat (facial expression never changes)
Alogia (Sx of Schizophrenia)
Poverty of thought or speech; the pt may sit with a visitor but may only mumble or respond vaguely to questions
Avolition (Sx of Schizophrenia)
Lack of motivation in activities and hygiene (E.G. the pt completes an assigned task, such as making his bed, but is unable to start the next common chore without prompting)
Anhedonia (Sx of Schizophrenia)
Lack of pleasure or joy; the pt is indifferent to things that often make others happy (E.G. looking at beautiful scenery)
Anergia (Sx of Schizophrenia)
Lack of energy
Cognitive Sx of Schizophrenia
- Problems with thinking make it very difficult for the pt to live indpendently.
- -disordered thinking
- -Inability to make decisions
- -poor problem-solving ability
- -difficulty concentrating to perform tasks
- -Memory deficits:
- -Long-term memory
- -Working memory (such as inability to follow directions
- to find an address)
Ideas of Reference
Misconstrues trivial events and attaches personal significance to them. (E.G. believing that others who are discussing the next meal, are talking about them)
Feels singled out for harm by others (E.G. being hunted down by the FBI)
Believes that they are all powerful and important (E.G. the president of the US, or a God)
Believes that his body is changing in an unusual way (E.G. growing a third arm)
Believes that her thoughts are bing heard by others
Believes that others' thoughts are being inserted into their mind
Believes that their thoughts have been removed from their mind by an outside agency
- -Ideas of reference
- -Somatic delusions
- -Being controlled
- -Thought broadcasting
- -Thought insertion
- -Thought Withdrawal
Flight of Ideas
- -Associative Looseness
- -Pt may say sentence after sentence, but each sentence may relate to another topic, and the listener is unable to follow the pt's thoughts
Made up words that only have meaning to the pt (E.G. "I tranged and flittles." )
The pt repeats the words spoken to him
Meaningless rhyming of words, often forceful (such as "O fox, box, and lox.")
Words, jumbled together with little meaning or significance to the listener (E.G. "Hip hooray, the flip is cast and wide-sprinting in the forest." )
Excessive maintnance of position
Motionless for long periods of time, coma-like
Doing the opposite of what is requested
Purposeful imitation of movements made by others
Global Assessment of Functioning (GAF)
Helps to determine a client's ability to perform ADLs and function independently
Nursing Care of pt With Schizophrenia
- -Milieu therapy
- -Therapeutic communication
- -Establish a trusting relationship with pt
- -Encourage the development of social skills and friendships
- -Encourage participation in group work and psychotherapy
- -Promote self care
- -Encourage medication compliance
- -Provide teaching regarding medications
Adaptive use of Defense Mechanisms
Helps people to achieve their goals in acceptable ways
Maladaptive use of Defense Mechanisms
When they interfere with functionins, relationships, and orientation to reality
- -Reaction Formation
- - Somatization
- -Acting-out behaviors
- -Passive aggression
Dealing with anxiety by reaching out to others
(Ex: A nurse who lost a family member in a fire becomes a volunteer fire fighter)
Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression.
Ex: A person who has feelings of hstility toward his work supervisor sublimates those feelings by working out vigorously at the gym during his lunch period.
Voluntarily denying unpleasant thoughts and feelings
Ex: A person who has lost his job states he will worry about paying his bills next week.
Putting unacceptable iseas, thoughts, and emotions out of conscios awareness
Ex: a Person who has a fear os dentist's drill continually "forgets" his dental appointments
Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation.
Ex: A person who is angry about losing his job destroys his child's favorite toy.
Overcompnsating or demonstrating the opposite behavior of whati s felt
Ex: A person who dislikes her sister's daughter offers to babysit so that her siste can go out of town.
Developing a physical symptom in place of anxiety
Ex: A school-age child develops abdominal pain to avoid going to school, where he is being bullied.
Performing an act to make up for prior behavior
Ex: An adolescent completes his chores without being prompted after having an argument with his parent.
Creating reasonable and acceptable explanations for unacceptable behavior.
Ex: A young adult explains he had to drive home froma party after drinking alcohol because he had to feed his dog.
Indirectly behaving aggressively but appearing to be compliant
Ex: A person's coworker agrees to take one of her assignmets but then does not meet the deadline
Managing emotional conflicts through actions, rather than sel-reflection.
Ex: A preschool child is told to share her toys, so she throws the toys across the room.
Temporarily blocking memories and perceptions from consciousness.
Ex: An adolescent witnesses a shooting and is unable to rcall and detaila af the event.
Expressing negative thoughts of self or others
Ex: A person who is passed up for a promotion states that the job is better than the one he currently has.
Ecpressing extremely positive thoughts of self or others
Ex: A school-aged boy boasts about his older brother and his accomplishments.
Demonstrating an inability to reconcile negative and positive attributes of self or others
Ex: A client tells a nurse that she is the only one who cares about her, yet the following day, the same client refuses to talk to the nurse.
Blaming others for unacceptable thoughts and feelings
Ex: A young adult blames his substance abuse on his parents' refusal to buy him a new car.
Pretending the truth is not reality to manage the anxiety of ackowledging what is real.
Ex: A parent who is informed that his son was killed in combat tells everyone he is coming home for the holidays.
A healthy life force that is necessary for survival, normal anxiety motivates people to take action.
Acute (state) Anxiety
This level of anxiety is precipitated by an imminnt loss or change that threatens one's sense of security. (such as a sudden death of a loved one)
Chronic (trait) Anxiety
This level of anxiety is one that usually develops over time, often starting in childhood. The adult who experiences chronis anxiety may display that anxiety in physical symptoms, suchas fatigue and frequent headaches.
- -Occurs in the normal experience of everyday living
- -Increases one's ability to perceive reality
- -There is an identifiable cause
- -Other characteristics include: a vague feeling of mild discomfort, impatience, and apprehension.
- -Occurs when mild anxiety escalates
- -Slightly reduces perception and processing of information occurs, and selective inattention may occur
- -Ability to think clearly is hampered, but learning and problem solving may still occur
- -Other characteristics include concentration difficulties, tiredness, pacing, and increced HR and RR
- -The client with this type of anxiety usually benefits from the direction of others
- -Perceptual field is greatly reduced with distorted perceptions
- -Learning and problem solving do not occur
- -Other characteristics include confusion, feelings of impending doom, and aimless activity
- -The client with severe anxiety usually is not abl to take direction from others
- -Characerized bymarkedly disturbed behavior
- -The clint is not able to process what is occuring in the environment and may loose touch with reality
- -The client experiences extreme fright and horror
- -Other characteristics may include dysfunction in speech, inability to sleep, delusions, and hallucinations
Nursing Interventions for Mild to Moderate Anxiety
- -Use active listening to demonstrate willingness to help, and use specific communication techniques (Open-ended questions, giving broad opening, exploring, and seking clarification)
- -Provide a calm presence, recognizing the client's distress
- -Evaluate past coping mechanisms
- -Explore alternatives to problem situations
- -Encourage participation in activities, such as exercise that may temporarily relieve feelings of inner tension
Nursing Interventions for the Client With Severe to Panic Levels of Anxiety
- -Provide an environment that meets the physical and safety needs of the client. Remain with the client.
- -Provide a quiet environment with minimal stimulation
- -Use medications and restraint, but only after less restrictive interventions have failed to decrease anxiety to safer levels
- -Encourage gross motor activities, such as walking and other forms of exercise
- - Set limits by using firm, short, and simple statements. Repetition may be necessary
- -Direct the client to acknowledge realiy and focus on what is present in the environment
- Creates an environment that is supportive, therapeutic and safe.
- The goal is that while the client is in therapeutic environment, he will learn the tools necessary to cope adaptively, interact more effectively and approprately, and strengthen relationship skills. Hopefully the client will use those tools in all other aspects of life.
Therapeutic Nurse-Client Relationship
- -Consistently focus on th client's ideas, experiences, and feelings
- -Identify and explore the client's needs and problems
- -Discuss problem-solving alternatives with the client
- -Help to develop the client's strengths and new coping skills
- -Encourage positive behavior change in the client
- -Assist the client to develop a sense of autonomy and slf-reliance
- -Portray genuineness, empathy, and a positive regard toward the client
Phases of a Therapeutic Relationship
- 1. Orientation
- 2. Working
- 3. Termination
Orientation Phase of Therapeutic Relationships (Nurse)
- -Introduce self to client and state purpose
- -Set the contract: meeting time, place, frequency, duration, and date of termination
- -Discuss confidentiality
- -Build trust by establishing expectations and boundaries
- -Set goals with the client
- -Explore the client's ideas, issues, and needs
- -Explore te meaning of testing behaviors
- -Enforce limits on testing or other inappropriare behaviors
Orientation Phase of Therapeutic Relationships (Client)
- -Meet with the nurse
- -Agree to the contract
- -Understand the limits of confidentiality
- -Understand the expectations and limits of the relationship
- -Participate in setting goals
- -Begin to exlpore own thoughts, experiences, and feelings
- -Explore the meaning of own behaviors
Working Phase of Therapeutic Relationships (Nurse)
- -Maintain relationship according to the contract
- -Perform ongoing assessment to plan and evaluat therapeutic measures
- -Facilitate the client's expression of needs and issues
- -Encourage the client to problem solve
- -Promote the client's self-esteem
- -Foster positive behavioral change
- -Explore and deal with resistance and other defense mechanisms
- -Recgnize transference and goals, and revise plans as necessary
- -Support the client's adaptive alternatives and use of new coping skills
- -Remind the client about the date o termination
Working Phase of Therapeutic Relationships (Client)
- -Explore problematic areas of life
- -Reconsider usual coping behaviors
- -Examine own worldview and self-concept
- -Describe major coflicts and varios defenses
- -Experience intense feelings, and learn to copw with anxiety reactions
- -Test new behaviors
- -Begin to develop awareness of transference situations
- -Try alternative aolutions
Termination Phase of Therapeutic Relationships (Nurse)
- -Provide opportunity for the client to discuss thoughts and feelings about termination and loss
- -Dscuss the client's previous experiences with separation and loss
- -Elicit the client's feelings about the terapeutic work in the nurse-client relationship
- -Summerize goals and acheivements
- -Review mmories of work in the sessions
- -Express own feelings about sessions to validate the experience with the client
- -Discuss ways for the client to incorporate new healthy behaviors into life
- -Maintain limits of final termination
Termination Phase of Therapeutic Relationships (Client)
- -Discuss thoughts and feelings about termination
- -Examine previous eparation and loxx experiences
- -Explore the meaning of the therapeutic relationship
- -Review goals and achievements
- - Discuss plans to continue new behaviors
- -Express any feelings of loss related to termination
- -Make plans for the future
- -Accept termiation as final
Boundaries of a Therapeutic Relationship
Boundaries must be establishe in order to maintain a safe and professional nurse-client relationship. Blurred boudaries occur if the relationship begins to meet the needs of the nurse rather than those of the client, or if the relationship becomes social rather than therapeutic.
Occurs when the client views a member of the health care team as having characteristics of nother person who has been significant to the client's personal life.
Ex: A client may see a nurse as being like his mother, and thus may demonstrate some of the same behaviors with the hurse as he demonstrated with his mother
Occurs when a health care team mmber displaces characteristics of people in her past onto a client.
Ex: A nurse may feel defensive and angry with a client for no apparent reason if t client reminds her of a friend who often elicited those feelings.