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Schizophrenia Chapter 15

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1 Schizophrenia Chapter 15
West Coast University Solomon Tan, MSN/Ed. RN-BC, PHN 2011

2 Eugen Bleuler’s 4 A’s of Schizophrenia
Affect Associative looseness Autism Ambivalence

3 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

4 Comorbidity Substance abuse disorders Anxiety, depression, and suicide
Nicotine dependence Anxiety, depression, and suicide Physical health or illness Polydipsia

5 Etiology Biological factors Neurobiological
Genetics Neurobiological Dopamine theory Other neurochemical hypotheses Brain structure abnormalities

6 Etiology Continued Psychological and environmental factors
Prenatal stressors Psychological stressors Environmental stressors

7 Signs and Symptoms Language and communication disturbances
Thought disturbances Perception disturbances Affect disturbances Motor behavior disturbances Self-identity disturbances

8 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

9 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

10 Assessment During the prepsychotic phase General assessment
Positive symptoms (Excess or distorted) Negative symptoms (Deficit) Cognitive symptoms Affective symptoms

11 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

12 Positive Symptoms Continued
Alterations in speech Neologisms Echolalia Echopraxia Clang associations Word salad Loose Association

13 Positive Symptoms Continued
Alterations in perception Depersonalization Derealization Hallucinations Auditory hallucinations Command hallucinations Visual hallucinations Boundary impairment Negativism Impaired impulse control

14 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.

15 Cognitive Symptoms Difficulty with Attention Memory
Information processing Cognitive flexibility Executive functions

16 Affective Symptoms Assessment for depression crucial
May herald impending relapse Increases substance abuse Increases suicide risk Further impairs functioning

17 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

18 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.”

19 Subtypes of Schizophrenia
Paranoid type Disorganized type Catatonic type Undifferentiated type Residual Type

20 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

21 Specific Interventions for Paranoid and Disorganized Schizophrenia
Communication guidelines Self-care needs Milieu needs

22 Subtypes of Schizophrenia - continued
Catatonic type Psychomotor retardation and stupor Waxy flexibility Mutism Extreme psychomotor agitation Echolalia Echopraxia

23 Specific Interventions for Catatonia
Catatonia – Withdrawn Phase Communication guidelines Self-care needs Milieu needs Catatonia – Excited Phase

24 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

25 Other Psychotic Disorders
Schizophreniform disorder Schizoaffective disorder Delusional disorder Brief psychotic disorder Shared Psychotic Disorder (Folie à Deux) Induced or Secondary Psychosis

26 Assessment Guidelines
1. Any medical problems 2. Abuse of or dependence on alcohol or drugs 3. Risk to self or others Command hallucinations 5. Belief system 6. Suicide risk

27 Assessment Guidelines Continued
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

28 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

29 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

30 Planning Phase I – Acute Phase II – Stabilization
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

31 Implementation Phase 1 – Acute Settings Partial hospitalization
Residential crisis centers Halfway houses Day treatment programs

32 Interventions Acute Phase
Psychiatric, medical, and neurological evaluation Psychopharmacological treatment Support, psychoeducation, and guidance Supervision and limit setting in the milieu

33 Interventions Continued
Stabilization and Maintenance Phase Milieu management Activities and groups Safety Counseling and communication techniques

34 Interventions Continued
Stabilization and Maintenance Phase, continued Hallucinations Delusions Associative looseness Health teaching and health promotion

35 Nursing Implications: Supporting Families
Family needs vary with degree of illness and involvement in client’s care Education Financial support Psychosocial support Advocacy

36 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

37 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

38 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?

39 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?”

40 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.

41 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

42 Negative Effects of Antipsychotics
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

43 All current antipsychotics work on at least one of these neurotransmitters:
Dopamine Serotonin

44 Antipsychotics Typical (Conventional)
Block dopamine receptors at 70% to 80% occupancy to be effective. Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80 Typical = Tardive Dyskinesia (TD) 5.4% vs 0.8% atypicals

45 Pharmacological Interventions
Antipsychotic medications Conventional antipsychotics Typical or first-generation Atypical antipsychotics Second-generation

46 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) Tardive dyskinesia Anticholinergic side effects Lower seizure threshold

47 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)

48 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)

49 Conventional Long-Acting Injectables (Depot Therapy)
Haloperidol Decanoate (Haldol Decanoate) Q4 weeks Fluphenazine Decanoate (Prolixin Decanoate) Q2 Weeks

50 Atypical Antipsychotics
Treat both positive and negative symptoms Fewer extrapyramidal side effects (EPSs) or tardive dyskinesia Reduced affinity for dopamine (D2) receptors Affinity for serotonin receptors D2 antagonist + Serotonin receptor antagonist Disadvantage – tendency to cause significant weight gain

51 Atypical Antipsychotics Continued
Clozapine (Clozaril) (6.25 – 900 mg/d) Side effects: 5% risk of seizures, agranulocytosis, weight gain, hypersalivation, anticholinergic Olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv) (5 – 20 mg/d) Side effects: Weight gain, diabetes, sedation, bankruptcy 20mg/day = $925/month Paliperidone (Invega) (3 – 12 mg/d) Quetiapine (Seroquel) (150 – 600 mg/d) Side effects: sedation, weight gain, restless leg syndrome Risperidone (Risperdal, Risperdal M-Tab) (2 – 6 mg/d) (Increase Prolactin)

52 Atypical Antipsychotics Continued
Ziprasidone (Geodon) ( 40 – 160 mg/d) Side effects: QTc prolongation, minimal sedation Administer with food for improve efficacy Aripiprazole (Abilify) (15 – 30 mg/d) Side effects: akathisia, insomnia/sedation, maybe less weight gain Asenapine (Saphris) (5 – 10 mg/d) Sublingual Iloperidone (Fanapt) (12 – 24mg/d) Lurasidone HCL (Latuda) (40 – 80 mg/d)

53 Long-Acting Injectables Depot Therapy
Risperidone Consta (Risperdal Consta) Q2 Weeks Paliperidone Sustenna (Invega Sustena) Q 4 weeks Zyprexa Relprevv (Q2 or Q4 weeks depending on the dose) Monitor for 3 hours after injection

54 Anti-Parkinson Medications
Trihexyphenidyl (Artane) Benztropine (Cogentin) Diphenhydramine (Benadryl) Amantadine (Symmetrel)

55 Antiadrenergic Effect: Orthostatic Hypotension
Take the client’s blood pressure in a supine position and then in a standing position. Caution clients to rise slowly from a supine position.

56 Extrapyramidal Side Effects Interventions
Acute dystonia anticholinergics Akathisia anticholinergics but not always responsive Pseudoparkinsonism Tardive dyskinesia – Abnormal Involuntary Movement Scale (AIMS)

57 Dystonia Occurs usually within 48 hours of initiation of the medication Involves bizarre and severe muscle contractions Can be painful and frightening Characterized by odd posturing and strange facial expressions: Torticollis Opisthotonus Laryngospasm Oculogyric

58 Torticollis

59 Opisthotonus

60 Oculogyric Crises

61 Laryngospasm

62 Drug-induced Parkinsonism
Usually occurs after 3 or more weeks of treatment Characterized by: Cogwheel rigidity Tremors at rest Rhythmic oscillations of the extremities Pill rolling movement of the fingers Bradykinesia Postural Changes

63 Akathisia Usually occurs after 3 or more weeks of treatment
Subjectively experienced as desire or need to move Described as feeling like jumping out of the skin Mild: a vague feeling of apprehension or irritability Severe: an inability to sit still, resulting in rocking, running, or agitated dancing

64 Tardive Dyskinesia Usually occurs late in the course of long-term treatment Characterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping) Often irreversible Prophylactic use of vitamin E and Omega-3 FFA Avoid typical antipsychotics Abnormal Involuntary Movement Scale

65 Autonomic Nervous System Effects: Anticholinergic Side Effects
Dry mouth Blurred vision Constipation Urinary retention Tachycardia

66 Interventions for Anticholenergic Side Effects
Ice chips, hard candy Eye drops Fiber diet, exercise Increase fluid intake Catheterization

67 Potentially Dangerous Responses to Antipsychotics
Neuroleptic malignant syndrome (NMS) Typically occurs in the first 2 weeks of treatment or when the dose is increased Hold the medication, notify the physician, and begin supportive treatments. Symptoms: muscle rigidity, tachycardia, hyperpyrexia, altered consciousness, tremors and diaphoresis

68 Neuroleptic malignant syndrome (NMS)
Risk Factors Dehydration Agitation or catatonia Increase dose of neuroleptic Withdrawal from anti-parkinson medication Long acting or depot medication Pharmacologic treatment Antipyretics Muscle relaxant Dopamine receptor agonist

69 Potentially Dangerous Responses to Antipsychotics
Agranulocytosis Early symptoms: beginning signs of infection White blood cells are routinely monitored in clients taking clozapine (Clozaril).

70 Other Central Nervous System Effects
Sedation Lowering of the seizure threshold: Observe clients with seizures disorders carefully when treatment is initiated.

71 Cardiac Effects Some antipychotics may contribute to prolongation of the QTc interval and lead to arrhythmias. An EKG can identify those at risk.

72 Blood, skin and eye effect
Agranulocytosis Blurred Vision Skin photosensitivity Retinitis pigmentosa

73 Endocrine Effects Hyperprolactinemia may cause:
Oligomenorrhea or amenorrhea in women Galactorrhea in women and rarely in men Osteoporosis if prolonged Impotence in males may occur. Diabetes Monitor blood glucose levels.

74 Weight Gain Monitor weight Teach about diet and exercise
Weight gain may contribute to physical as well as psychosocial stressors

75 Adjuncts to Antipsychotic Drug Therapy
Antidepressants Antimanic agents

76 Advanced Practice Interventions
Psychotherapy Cognitive-behavioral therapy (CBT) Group therapy Medication Social skills training Cognitive remediation Family therapy

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