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Schizophrenia Chapter 15. West Coast University Solomon Tan, MSN/Ed. RN-BC, PHN 2011. Eugen Bleuler’s 4 A’s of Schizophrenia . Affect Associative looseness Autism Ambivalence. Epidemiology. Lifetime prevalence of schizophrenia 1% worldwide
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Schizophrenia Chapter 15 West Coast University Solomon Tan, MSN/Ed. RN-BC, PHN 2011
EugenBleuler’s4 A’s of Schizophrenia • Affect • Associative looseness • Autism • Ambivalence
Epidemiology • Lifetime prevalence of schizophrenia 1% worldwide • Average onset is late teens to early twenties, but can be as late as mid-fifties • 30% to 40% relapse rate in the first year • Life expectancy is shortened because of suicide • No difference related to • Race, Social status, Culture
Comorbidity • Substance abuse disorders • Nicotine dependence • Anxiety, depression, and suicide • Physical health or illness • Polydipsia
Etiology • Biological factors • Genetics • Neurobiological • Dopamine theory • Other neurochemical hypotheses • Brain structure abnormalities
EtiologyContinued • Psychological and environmental factors • Prenatal stressors • Psychological stressors • Environmental stressors
Signs and Symptoms • Language and communication disturbances • Thought disturbances • Perception disturbances • Affect disturbances • Motor behavior disturbances • Self-identity disturbances
Features of Schizophrenia • Progression varies from one client to another • Exacerbations and remissions • Chronic but stable • Progressive deterioration • DSM-IV-TR Diagnosis • Symptoms present at least 6 months • Active-phase symptoms present at least 1 month • Symptoms are defined as positive and negative
Phases of Schizophrenia Phase I – Acute • Onset or exacerbation of symptoms Phase II – Stabilization • Symptoms diminishing • Movement towards previous level of functioning Phase III – Maintenance • At or near baseline functioning
Assessment • During the prepsychotic phase • General assessment • Positive symptoms (Excess or distorted) • Negative symptoms (Deficit) • Cognitive symptoms • Affective symptoms
Positive Symptoms • Alterations in thinking • Delusions are false, fixed beliefs • Persecutory, Referential • Somatic, Religious, • Substitution, Thought Insertion and/or Broadcasting • Nihilistic, Grandiose • Concrete thinking is an inability to think abstractly. • Indecisiveness, lack of problem solving skills, • Concreteness, thought blocking, perseveration
Positive SymptomsContinued • Alterations in speech • Neologisms • Echolalia • Echopraxia • Clang associations • Word salad • Loose Association
Positive SymptomsContinued • Alterations in perception • Depersonalization • Derealization • Hallucinations • Auditory hallucinations • Command hallucinations • Visual hallucinations • Boundary impairment • Negativism • Impaired impulse control
Negative Symptoms (5A’s) • Affect • Flat, Blunted, Inappropriate, Bizarre • Apathy • Indifference towards people, events, activities and learning. • Alogia • Poverty of speech • Avolition • Inability to pursue and persist in goal-directed activities. • Anhedonia • Inability to experience pleasure.
Cognitive Symptoms • Difficulty with • Attention • Memory • Information processing • Cognitive flexibility • Executive functions
Affective Symptoms • Assessment for depression crucial • May herald impending relapse • Increases substance abuse • Increases suicide risk • Further impairs functioning
Review Question • A patient with schizophrenia says, “There are worms under my skin eating the hair follicles.” How would you classify this assessment finding? • Positive symptom • Negative symptom • Cognitive symptom • Depressive symptom
Review Question • The nurse is documenting in the multidisciplinary treatment plan. Which assessment data depicts positive symptoms of schizophrenia? • A. “I use to like going to the movies and spending time with my family but rather be alone.” • B. “I don’t want to go to group.” Lack motivation and affect appear Blunted. • C. “I can’t sit still and I feel like I want to jump out of my skin.” • D. “There are cameras in the ceiling and the voices are whispering to me.”
Subtypes of Schizophrenia • Paranoid type • Disorganized type • Catatonic type • Undifferentiated type • Residual Type
Subtypes of Schizophrenia - continued • Paranoid Type • Delusions • Persecutory and grandiose • Somatic or religious • Hallucinations • Delusions link with a hallucination • Disorganized Type • Disorganized speech, behavior, appearance • Flat or inappropriate affect • Fragmented hallucinations and delusions • Most severe form of schizophrenia
Specific Interventions forParanoid and Disorganized Schizophrenia • Communication guidelines • Self-care needs • Milieu needs
Subtypes of Schizophrenia - continued • Catatonic type • Psychomotor retardation and stupor • Waxy flexibility • Mutism • Extreme psychomotor agitation • Echolalia • Echopraxia
Specific Interventions for Catatonia • Catatonia – Withdrawn Phase • Communication guidelines • Self-care needs • Milieu needs • Catatonia – Excited Phase • Communication guidelines • Self-care needs
Subtypes of Schizophrenia - continued • Undifferentiated type • Active psychotic state (Positive & Negative symptoms) • Lacks symptoms of other subtypes • Residual type • Active-phase symptoms no longer present • No prominent positive symptoms • Negative symptoms present
Other Psychotic Disorders • Schizophreniform disorder • Schizoaffective disorder • Delusional disorder • Brief psychotic disorder • Shared Psychotic Disorder (FolieàDeux) • Induced or Secondary Psychosis
Assessment Guidelines 1. Any medical problems 2. Abuse of or dependence onalcohol or drugs 3. Risk to self or others • Command hallucinations 5. Belief system 6. Suicide risk
Assessment GuidelinesContinued 7. Ability to ensure self-safety • Co-occurring disorders 9. Medications 10. Presence and severity of positive and negative symptoms 11. Patient’s insight into illness 12. Family’s knowledge of patient’s illness and symptoms
Potential Nursing Diagnoses • Positive symptoms • Risk for violence • Disturbed sensory perception • Risk for self-directed or other-directed violence • Disturbed thought processes • Negative symptoms • Social isolation • Chronic low self-esteem • Altered health maintenance • Ineffective coping • Impaired verbal communication
Outcomes Identification • Phase I - Acute Patient safety and medical stabilization • Phase II - Stabilization • Adhere to treatment • Stabilize medications • Control or cope with symptoms • Phase III - Maintenance • Maintain achievement • Prevent relapse • Achieve independence, satisfactory quality of life
Planning • Phase I – Acute • Best strategies to ensure patient safety and provide symptom stabilization • Phase II – Stabilization • Phase III – Maintenance • Provide patient and family education • Relapse prevention skills are vital
Implementation • Phase 1 – Acute Settings • Partial hospitalization • Residential crisis centers • Halfway houses • Day treatment programs
Interventions • Acute Phase • Psychiatric, medical, and neurological evaluation • Psychopharmacological treatment • Support, psychoeducation, and guidance • Supervision and limit setting in the milieu
InterventionsContinued • Stabilization and Maintenance Phase • Milieu management • Activities and groups • Safety • Counseling and communication techniques
InterventionsContinued • Stabilization and Maintenance Phase, continued • Hallucinations • Delusions • Associative looseness • Health teaching and health promotion
Nursing Implications:Supporting Families • Family needs vary with degree of illness and involvement in client’s care • Education • Financial support • Psychosocial support • Advocacy
Nursing Implications:Supporting Families - continued • Schizophrenia is a “family illness.” • Family members need to be involved. • Educate family about • Medication • Illness • Relapse prevention • Nurse assists family by • Identifying community agencies/groups for family members • Advocating for rights
General Nursing Intervention • Promote Safety and a Safe Environment • Promote Congruent Emotional Response • Promote Social Interaction and Activity • Intervene with Hallucinations and Delusions • Preventing Relapse • Promoting adherence with medication regimen • Assist with grooming and hygiene • Promote Family Understanding and Involvement
Review Question • The client informs you that the CIA monitoring his every move to find evidence that he killed someone. Which response by the nurse is therapeutic for the client?
Review Answers • A. "I will make sure that the security guard will monitor your room.” • B. "Don't worry you are safe here, the CIA can't enter the hospital.” • C. "You seem fearful for your safety, but you are safe here.” • D. "Why do you think the CIA is following you, who did you kill?”
Psychopharmacology • Prior to the 1950s: focus on behavioral interventions and sedatives • Mid-fifties: Introduction of the first antipsychotic medication chlorpromazine (Thorazine) • Psychiatric medications allow for the improve imbalances of neurotransmitters. • Goal is to treat quickly so disease does not progress. • Clients may initially be resistant to medications.
Goals of Antipsychotics • Positive Effects • Allowed release of clients from inpatient hospital to treatment in the community • Manage the symptoms such as delusional thinking, hallucinations, confusion, motor agitation, motor retardation, blunted affect, bizarre behavior, social withdrawal and agitation. • Alleviation of the symptoms, often improving: • Ability to think logically • Ability to function in one’s daily life • Ability to function in relationships
Negative Effects of Antipsychotics • Negative Effects • Frightening and life threatening side effects • Potential interactions with other medications and substances • Possible need to cope with the realization of having a chronic illness
All current antipsychotics work on at least one of these neurotransmitters: • Dopamine • Serotonin
Antipsychotics • Typical (Conventional) • Block dopamine receptors at 70% to 80% occupancy to be effective. • Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80 • Typical = TardiveDyskinesia (TD) • 5.4% vs 0.8% atypicals
Pharmacological Interventions • Antipsychotic medications • Conventional antipsychotics • Typical or first-generation • Atypical antipsychotics • Second-generation
Conventional Antipsychotics • 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 (EPSs) • Tardivedyskinesia • Anticholinergic side effects • Lower seizure threshold
Conventional Antipsychotics • Typical Agents • Low Potency • Chlorpromazine (Thorazine) (25 – 800 mg/d) • Thioridazine (Mellaril) (150 – 800 mg/d) • Mesoridazine (Serentil) (100 – 400 mg /d) • Side Effects: • Sedation, Anticholernergic, Hypotention, • EPSEs (less vs high potency)
Conventional Antipsychotics • High Potency • Haloperidol (Haldol) (1 – 30 mg/d) • Fluphenazine (Prolixin) (0.5 – 40 mg/d) • Thiothixene (Navane) (2 – 30 mg/d) • Trifluoperazine (Stelazine) (1 – 40 mg/d) • Perhenazine (Trilafon) (8-60 mg/d) • Loxapine (Loxitane) (20 – 250 mg/d) • Molindone (Moban) (50 – 225 mg/d) • Pimozide (Orap) 0.5 – 9 mg/d) • Side Effects • Sedation, Anticholenergic SE (less vs low potency) • EPSEs (high vs low potency)
Conventional Long-Acting Injectables (Depot Therapy) • Haloperidol Decanoate (HaldolDecanoate) • Q4 weeks • FluphenazineDecanoate (ProlixinDecanoate) • Q2 Weeks
Atypical Antipsychotics • Treat both positive and negative symptoms • Fewer extrapyramidalside effects (EPSs) or tardivedyskinesia • Reduced affinity for dopamine (D2) receptors • Affinity for serotonin receptors • D2 antagonist + Serotonin receptor antagonist • Disadvantage – tendency to cause significant weight gain