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What does the word schizophrenia mean? What is it not?
- Derived from the greek words Schizo (split) and phren (mind)
- Psychosis is a break from reality
Schizophrenia is not a split personality, caused by childhood trauma, bad parenting or poverty, and is not the result of any actions or personal failure
What are some general treatments for schizophrenia?
- Antipsychotic medications
- Occupational therapy
- Social Skills therapy
What comorbidities are associated with schizophrenia?
- Substance abuse in up to 50% of clients
- Nicotine dependence up to 90%
- Schizo associated with negative outcomes such as incarceration, violence, suicide, and HIV
- Medications cause heart disease, DM
- Anxiety, depression
- High risk of suicide
- Polydipsia (risk of H2O poisoning and F/E imbalances. Fluid restriction necessary)
Describe the chemical and neurological complications associated with schizophrenia
- Extra dopamine in the brain theory (dopamine blockers are effective)
- Gradual deterioration of brain volume, especially frontal cortex (visual/auditory hall)
- Genetic component linked
- Combination of both genetic and non genetic factors
What disturbances occur in schizophrenia?
- Thought processes
What are the four phases of schizophrenia?
- Phase one: Pre-psychotic (schizoid personality)
- -indifferent, cold, aloof, loners
- -Do not enjoy personal relationships
- Phase two: Prodromal phase
- -often occurs before first psychotic break
- -socially withdrawn, behavior is peculiar and eccentric
- -Neglected personal hygiene
- -Disturbances in communication, ideation and perception
- Phase three: Active phase
- -psychotic symptoms are prominent
- -Hallucinations and delusions
- Phase four: residual phase
- -also called the maintenance phase
- -similar to prodromal, near baseline
- -flat affect, role impairment
What factors determine whether someone with schizophrenia will have a favorable prognosis?
- Favorable if:
- -abrupt onset of goof pre-morbid functioning
- -older age of onset
- Less favorable if:
- -slower onset of symptoms 2-3 yrs
- -childhood history of withdrawal, seclusion, eccentric, tense behavior
- -younger onset
What is the DSM-5 criteria for Schizophrenia?
- Two or more of the following, each present during a one month period
- -disorganized speech
- -grossly disorganized or catatonic behavior
- -negative symptoms
What is the general assessment for schizophrenia?
- Positive symptoms
- Negative symptoms
- Cognitive symptoms
- Affective symptoms
What are the 4 fundamental (Bleuler's 4As) signs of schizophrenia?
- Affect (flat)
- Associative Looseness
- Autism (withdrawn into self)
Describe the positive (hard) symptoms of schizophrenia?
- Hallucinations (auditory, visual, tactile, olfactory, gustatory)
- Thoughts of insertion/withdrawal
- Disorganized thoughts
- Flight of ideas
What are the stages of hallucinations? What should be assessed?
- Stage 1: Comforting
- Stage 2: Condemning
- Stage 3: Controlling (Command) * emergency
- Stage 4: Conquering (does what they say)
- Assess for duration, intensity, frequency
- Pattern over time
What client behaviors display that the client is experiencing hallucinations?
- Laughing, speaking to self
- Moving lips without making sounds
- Rapid eye movements
- delayed verbal responses, as if preoccupied
- Inability to follow conversation
- decreased ability to follow verbal commands
How can the nurse communicate with the hallucinating client?
- Ask directly about the hallucinations
- Watch for cues that client is hallucination
- Avoid reacting to hallucinations as if they are real
- Do not negate the client's experience
- Offer your own perceptions
- Focus on reality based diversions
- Be alert to client anxiety
Describe the positive symptoms of waxy flexibility, pressures speech, aggressive/agitated bizarre behavior and bizarre dress/grooming
- Waxy flexibility: limbs remain where they are placed
- Pressured speech: fast, loud speech
- Aggressive, agitated bizarre behavior: labile
- Bizarre dress/grooming: too many layers, inappropriate for weather
What are some common delusions?
- Ideas of reference: misconstruing trivial events/remarks and giving them personal significance
- Persecution: believing one is being singled out for harm by others
- Grandeur: believing one is a powerful, important person
- Somatic: false belief that the body is changing
- Jealousy: false belief that on's significant other is unfaithful
- Thought withdrawal: thoughts have been removed from mind and taken away by another
- Thought insertion: thought of another are being inserted into one's mind
- Thought control: one's mind is being controlled by others
- Religiosity: preoccupation with religious beliefs
- Magical thinking: thoughts/behaviors have control over specific situations or people
How can the nurse communicate with the delusional client?
- Be open, honest, reliable
- Be matter-of-fact and calm
- Ask client to describe delusion
- Avoid arguing, but interject doubt
- Focus on feelings the delusions generate
- Once delusion is described, do not dwell on it
- Observe events that trigger delusions
- validate any true part of the delusion
What are some different kinds of disorganized speech?
- Incoherence: inability to understand ideas, shifting from one unrelated topic to another
- Clang Association: choice of words r/t to rhyming sounds
- Loose Association: ideas shift from one unrelated topic to another
- Tangential: never get to the point of the story
- Circumstantial: point of story is reached through many unnecessary details
- Concrete thinking: literal interpretations (its raining cats and dogs)
- Echolalia: repeating another's words
- Word Salad: mixture of meaningless words
- Neologisms: words having meaning only for the client
- Mutism: inability/refusal to speak
- Perseveration: repeating same word/idea in response to different questions
What is grossly disorganized or catatonic behavior?
- Lack of any goal directed behavior
- Negative behavior: clients doing the opposite of what is suggested or NOT doing what is suggested (such as getting out of bed)
- Catatonia: extreme psychomotor agitation or retardation
- Catatonic stupor: extreme motor retardation, mutism
- Catatonic posturing: waxy flexibility and passive bizarre posturing
What are some negative (soft) symptoms of schizophrenia?
- Affect and cognition is effected
- Anhedonia: lack of pleasure
- Anergia: lack of energy
- Apathy: indifference
- Alogia: poverty of speech (1 word answers)
- Avolition: lack of motivation
- Thought blocking: stop talk in middle of sentence
- Flat affect, bizarre affect, inappropriate affect
- Social isolation
- Poor grooming/hygiene
- Decreased spontaneity and gestures
What are the affective symptoms of schizophrenia (mood disorders)?
- Assessment for DEPRESSION is crucial
- May herald impending relapse
- Increase in substance abuse
- Increase in suicide risk
- Further impairs functioning
What are the crucial assessments for a client with schizophrenia?
- Any medical problems
- Abuse of or dependence on alcohol or substances
- Risk to self or others
- Command hallucinations
What is schizoaffective disorder?
- Positive symptoms of schizophrenia and meets the criteria for major affective (mood) disorder
- Often schiz with depression
What is brief psychotic disorder?
- Sudden onset of psychotic symptoms following a severe psychosocial stressor
- Symptoms last <1mo
- Individual returns to full premorbid functioning
- More common in borderline and BPD clients
What is delusional disorder?
- Prominent non-bizarre delusions
- Erotomanic: believe someone of higher status is in love with them
- Grandeur: irrational ideas about your own worth, power
- Jealousy: irrational idea that one's partner is unfaithful
- Persecution: most common
- Somatic: irrational belief they have some physical defect, disorder, disease
What is shared psychotic disorder?
- A delusional system develops in a second person as a result of close relationships with a psychotic, delusional person
- Also called "folie a deux" and is considered a cult phenomenon
What are some medical conditions that can cause psychosis and needs to be ruled out when considering schizophrenia?
- Thyroid imbalance
- Lupus (LSE)
- Toxic Fumes
- Carbon Monoxide
What are the priority nursing diagnosis for someone with schizophrenia?
- Risk for violence to self or others
- Alteration in sensory perception
- Altered thought process
- Impaired verbal communication
- Self-care deficit
- Social isolation
- Ineffective family coping
What interventions can be done for a client with a risk for violence?
- Maintain Safe environment
- Decrease stimuli
- Increase monitoring of client
- ASSESS FOR PRESENCE OF COMMAND HALLUCINATIONS
- Provide distraction activities
- Ask, don't ignore behaviors
- Never go alone but have one leader
- Directly ask about agitation
- Remain calm, non threatening, but firm
- Use clear, simple statements
- Cite specific behaviors
What kind of nurse relationship is beneficial for a client with schizophrenia?
- Primary nursing, trust v mistrust
- Unconditional positive regard, provide praise
- Mutually agreed upon contract
- Brief, frequent contacts (5-10 min, several times a shift)
- Gradually increase length of sessions
What nursing considerations should be taken if a client is experiencing hallucinations?
- Observe for s/s of hallucinating
- Avoid touching the client without asking
- Encourage client to share content of hallucinations with you
- Actively listen for theme or tone and respond to it
- Do not reinforce or discredit the hallucinations (present reality)
What nursing interventions can be done for a client experiencing paranoid delusions?
- Promote trust- use primary nursing
- Slowly and gradually increase involvement in group activities as client can tolerate
- Avoid being obvious in monitoring client
- Avoid laughing, whispering, joking within earshot of client
- Provide pre-packaged, unopened food if necessary
What are the first generation anti-psychotics for schizophrenia?
- Dopamine Antagonists (D2 receptor antagonists)
- Chlorpromazine (Thorazine)
- Fluphenazine (Prolixin)
- Thiothixene (narvane)
- Haloperidol (Haldol)
- Target the positive symptoms of schizophrenia
- Less expensive than the second gen
- EPS, TD, Weight gain, sexual dysfunction, endocrine disturbances, and anticholinergic side effects
What are the second generation anti-psychotics for schizophrenia?
- Treat both positive and negative symptoms with minimal to no EPS and TD
- Disadvantage is that they tend to cause significant weight gain
- Risperidone (risperidol)
- Quetiapine (seroquel)
- Olanzapine (Zyprexa)
- Clozapine (clozaril)
- Ziprasidone (Geodon)
- Paliperidone (Invega)
What are the third generation anti-psychotics for schizophrenia?
- Aripiprazole (Abilify)
- Dopamine system stabilizer
- Improves positive and negative symptoms and cognitive function
- -little risk of EPS or tardive dyskinesia
What are EPS?
- Extrapyramidal Symptoms
- Pseudoparkinsonism: tremors, shuffling gait, drooling, rigidity (often occur in women, elderly, dehydrated). Symptoms within 1-5 days of treatment
- Akinesia: muscular weakness
- Akathisia: continuous restlessness, fidgeting
- Acute Dystonic Reactions: involuntary muscular movements (spasms) of the face, arms, legs and neck (occurs suddenly, frightening, painful)
- Treatment: IV/IM Cogentin, have resp support available
Describe tardive dyskinesia
- Irreversible involuntary movements due to long use of anti-psychotic medications, decreasing or stopping abruptly after long term use
- Irreversible, must be detected early (no treatment at present)
- Tongue protrusion, lip smacking, chewing, blinking, grimacing, foot tapping
What is NMS? What are the appropriate interventions?
- Rare, potentially fatal dysregulation of the thermoregulation system-Parkinsonian muscle rigidity (severe)
- -Hyperpyrexia up to 107
- -Tachycardia and tachypnea
- -labile BP
- -rapid LOC deterioration
- -elevated CPK
- -Onset within hours of therapy and progression over 24-72hrs
- -more common in dehydrated individuals
- -D/C antipsychotic immeadiately
- -monitor VS, LOC, I/O
- -Physician may order Bromocriptine (parlodel) to reverse effects
- -Supportive care
Describe anti-psychotics and agranulocytosis
- WBC levels can drop fatally low (<3,000mm3 or <1500mm3 granulocyte count)
- High incidence associated with Clozaril, occurring within the first 3 months
- Abrupt onset of fever (always take temp), malaise, ulcerative sore throat (always report a sore throat), leukopenia
- Interventions include antibiotics and reverse isolation
How is cigarette smoking related to schizophrenia?
- Schizophrenia clients smoke at the double the rate of the general population (up to 88% of clients)
- Offer a nicotine patch
- All drug trials are done on smoking clients
What is syndrome X?
- DM II
- Abd obesity
- Insulin resistance
How is diabetes related to schizophrenia?
- Higher risk of developing DM II r/t high risk of obesity
- Clozapine and Olanzapine are agents most commonly associated with DM
- Risperidone not associated with signif risk of DM
What are some teaching guidelines for clients and families facing schizophrenia?
- Learn all you can about the illness
- Develop a relapse prevention plan- recognize symptoms that signal relapse
- Take advantage of psycho-educational tools
- Comply with treatment
- Avoid alcohol/drugs
- Keep in touch with supportive people
- Stay physically healthy
- Join a support group to deal with stigma