schizophrenia

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“SCHIZOPHRENIA AND ROLE OF NURSE’S” RAJESH KATARIA Lecturer Swift CON

DEFINITION. : 

DEFINITION. Schizophrenia is a type of functional psychosis characterized by disturbances in thought processes, perception, and affect invariably result in severe deterioration of social and occupational functioning.

Epidemiology. : 

Epidemiology. Schizophrenia has total 1% prevalence throughout the world.

PHASES OF SCHIZOPHRENIA : 

PHASES OF SCHIZOPHRENIA Phase I - The schizoid personality Phase II-The prodromal phase. Phase III-Schizophrenia—active phase. Phase IV- Residual phase

PREDISPOSING FACTORS. : 

PREDISPOSING FACTORS. The exact cause of schizophrenia is still unknown Still there are some factors that are considered as risk factors.

Biological theories : 

Biological theories Genetics / Hereditary

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Immunologic factors e.g. Viral exposure in pregnancy. High arousal level from stress , trauma, and drugs e.g. bombardment. Sever disease e.g. encephalitis. Trauma from complication such as obstetrical, head trauma, childhood accidents.

BIO CHEMICAL INFLUENCES. : 

BIO CHEMICAL INFLUENCES. Theories suggests that that schizophrenia may be caused by an excess of Dopamine dependent neuronal activity in the brain. Abnormalities in the neurotransmitters nor epinephrine, serotonin, acetylcholine, and gamma-amino butyric acid and in the neuroregulators such as prostaglandins and endorphins have been suggested.

Physiological Influences : 

Physiological Influences Viral Infection Anatomical Abnormalities Histological Changes. Physical Conditions. Psychological Influences

Diagnostic guidelines : 

Diagnostic guidelines ICD 10 DIAGNOSTIC GUIDELINES The normal requirement for a diagnosis of schizophrenia is that a minimum of one very clear symptom (and usually two or more if less clear cut.) should have been present for most of the time during a period of 1 month or more.

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DSM-IV(TR) There should be at least 6 month period.

ICD- 10 -CATEGORIES OF SCHIZOPHRENIA : 

ICD- 10 -CATEGORIES OF SCHIZOPHRENIA F20.0— Paranoid schizophrenia. F20.1---Hebephrenic schizophrenia. F20.2— Catatonic schizophrenia. F20.3— Undifferentiated schizophrenia. F20.4—Post schizophrenic depression. F20.5---Residual schizophrenia. F20.6— Simple schizophrenia. F20.8—Other schizophrenia. F20.9—Schizophrenia unspecified.

Simple schizophrenia : 

Simple schizophrenia Uncommon disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance.

Paranoid schizophrenia : 

Paranoid schizophrenia This is the commonest type in most parts of the world. The clinical picture is dominated by relatively stable, often paranoid, delusions, accompanied by hallucinations particularly auditory and perceptual disturbances.

Hebephrenic schizophrenia.(disorganized) : 

Hebephrenic schizophrenia.(disorganized) Affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behavior irresponsible and unpredictable, and mannerisms common Prognosis is worst among all types

Catatonic Schizophrenia. : 

Catatonic Schizophrenia. Prominent psychomotor disturbance are essential and dominant features and may alternate between extremes such as hyper- kinesis and stupor, or automatic obedience and negativism.

Undifferentiated schizophrenia. : 

Undifferentiated schizophrenia. Exhibiting the features of more than one of the types without a clear predominance.

Post schizophrenic depression. : 

Post schizophrenic depression. Some schizophrenic symptoms must still be present but no longer dominate the clinical picture. These persisting symptoms may be “positive” or “negative”, though the later are more common.

Residual schizophrenia. : 

Residual schizophrenia. After a adequate treatment there are some sign and symptoms are left in that patient.

Signs and symptoms of schizophrenia. : 

Signs and symptoms of schizophrenia. Primary or fundamental symptoms Secondary symptoms or Accessory symptoms which may or may not be present

PRIMARY OR FUNDAMENTAL SYMPTOMS : 

PRIMARY OR FUNDAMENTAL SYMPTOMS Bleuler’s 4As Association Loosening Autistic thinking Ambivalence Affective Incongruence (Inappropriate Affect ) 5 A, Auditory hallucination

Secondary symptoms : 

Secondary symptoms Disorder of perception Disorder of thought Disorders of activity Disturbance in attention Deteriorated appearance or manner Psychomotor behavior

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Hallucination Delusion Thought broadcasting Irrelevant talking Easily annoyed

Positive and Negative symptoms : 

Positive and Negative symptoms Positive symptoms Hallucination Delusion Disorganized thinking and speech. Disorganized behaviour Negative symptoms Anhedonia Alogia Affective flattening Social isolation

Management of schizophrenia: : 

Management of schizophrenia: Pharmacotherapy Electroconvulsive therapy(ECT) Psychological therapies Psychological rehabilitation

psychopharmacology : 

psychopharmacology ANTIPSYCHOTICS Antiparkinsonian agents Anxiolytic medication Supportive medication.

Form of medication : 

Form of medication May be in the form of Tablets Injection Liquid

Nursing management : 

Nursing management Nurse play a vital role from admission to till discharge and rehabilitation also. she play role in, Admission. Drug administration. Discharge, and Rehabilitation etc.

ANTIPSYCHOTICS : 

ANTIPSYCHOTICS E.g. Haloperidol(HPL), Trifluoparazine, Chlorpromazine, Risperidone, olanzapine,ziprasidone etc.

Adverse Effects of Antipsychotic Drugs : 

Adverse Effects of Antipsychotic Drugs Extra pyramidal Symptoms (EPS) Neuroleptic-Induced Parkinsonism Acute Dystonia Akathisia Tardive Dyskinesia Neuroleptic Malignant Syndrome(nmss),this is most dangerous and rare symptoms

Parkinsonism : 

Parkinsonism Brady kinesia Drooling Stooped posture Tremors Rigidity Shuffling gait

Acute dystonia : 

Acute dystonia Muscular spam of neck Jaw Tongue Entire body. Oculogyric crisis

Akathisia : 

Akathisia Subjective feeling of muscular discomfort. Agitaion Restlessness Dysphoria

Tardive dyskinesia : 

Tardive dyskinesia Abnormal involuntary movements of head, limb and trunk. Characterized by grimacing, sucking, chewing

Neuroleptic malignant syndrome : 

Neuroleptic malignant syndrome Very dangerous but rare complication of drugs. Characterized by High grade fever. Hypotension or unstable B.P. Seizure. Urinary retention. Dry mouth. In case of NMS immediately stop all the drugs

Nurse’s Responsibility for a Patient Receiving Antipsychotics : 

Nurse’s Responsibility for a Patient Receiving Antipsychotics Instruct the patient to take sips of water frequently to relieve dryness of mouth. A high-fiber diet, increased fluid intake and laxatives Advise the patient to get up from the bed or chair very slowly Administer antiparkinsonian drugs as prescribed Observe the patient regularly for abnormal movements Monitor vital signs. Take all seizure precautions.

ANTIPARKINSONIAN AGENTS : 

ANTIPARKINSONIAN AGENTS Primary used as treatment for medication-induced movement disorders, particularly neuroleptic-induced Parkinsonism, acute dystonia and medication-induced tremor. E.g. Benztropine Bromocriptine Selegiline Trihexyphenidyl

Dosage : 

Dosage 1-2 mg per day orally initially. Maximum dose up to 15 mg/day in divided doses.

Nurse’s Responsibilities : 

Nurse’s Responsibilities Assess parkinsonian and EPS. Medication should be tapered gradually position changes slowly to minimize orthostatic hypotension.(BP measurment) Maintain oral hygiene of the patient. Tell the patient for hot flushing and decrease perspiration.

SODIUM VALPROATE : 

SODIUM VALPROATE

Dosage : 

Dosage The usual dose is 15 mg/kg/day with a maximum of 60 mg/kg/day orally Side effects Nausea, vomiting, diarrhea, sedation, ataxia, dysarthria, tremor, weight gain, loss of hair, thrombocytopenia, platelet dysfunction.

Nurse’s Responsibilities : 

Nurse’s Responsibilities Explain to the patient to take the drug immediately after food to reduce GI irritation. Advise to come for regular follow-up . Periodic examination of blood count, hepatic function and thyroid function. Therapeutic serum level of valproic acid is 50-100 micrograms/ml.

ANXIOLYTICS (ANTI-ANXIETY DRUGS) AND HYPNOSEDATIVES : 

ANXIOLYTICS (ANTI-ANXIETY DRUGS) AND HYPNOSEDATIVES Dosage (mg/day) Alprazolam: 0.5-6 PO Oxazepam: 15-20 PO Lorazepam: 2-6 PO/IV/IM Diazepam: 2-10 PO/IM/slow IV Clonazepam: 0.5-20 PO/IM Chlordiazepoxide: 15-100 PO; 50-100 slow IV Nitrazepam: 5-20 PO.

Side Effects : 

Side Effects Nausea, vomiting, weakness, vertigo, blurring of vision, body aches, epigastric pain, diarrhea, impotence, sedation, increased reaction time, ataxia, dry mouth, retrograde amnesia, impairment of driving skills, dependence and withdrawal symptoms

Nurse’s Responsibility in the Administration of Benzodiazepines : 

Nurse’s Responsibility in the Administration of Benzodiazepines Advise to take with food. Advise to take timely. Do not take over the counter medicine. Explain possible side effect to patient. Instruct to not to take alcohol. Maintain oral hygiene . Do not mix other drugs with that one drugs. In case of IM, give deep intramuscular site. Avoid driving and other hazardous activity

Electroconvulsive therapy(ECT) : 

Electroconvulsive therapy(ECT)

Psychosocial therapy : 

Psychosocial therapy

Responsibility while dealing with disease problem : 

Responsibility while dealing with disease problem Non compliance to management Explain the management to patient shortly or as you required. Develop therapeutic relationship with the patient. Develop trust with the patient. Listen any complain of patient carefully. Don’t ignore anything that related to drugs.

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Set the diet according to the drugs. Give medicine regularly Check the blood level regularly to maintain adequate drug level.

Impaired perception : 

Impaired perception Assess the level of orientation. Allow the patient to talk about hallucination. Avoid reinforcing the hallucination. Avoid saying that you are wrong. Support the patient in initial stage by saying that you are just thinking but the reality is just opposite. Remove all the injurious thing. Diversion of activity.

Impaired sleep : 

Impaired sleep Asses the pattern of sleep. Provide calm and quite environment. Isolate the disturbing patient. Provide a glass of warm milk before sleep. Provide a warm bath before sleep. Maintain a daily routine of sleeping and awakening. Put off the light in around at 100 clock every day. Provide comfort measure as pillow ,back rub. Give p.r.n as prescribed.

Altered Bowel and Bladder activity : 

Altered Bowel and Bladder activity Assess the type of alteration of b/b. In case of constipation encourage high fiber diet Increase fluid intake Food Intake should be frequently. Take the choice of food to patient. Serve the food in attractive manner. Encourage patient to take proper sleep or rest. Encourage for light exercise or walking jogging. If the patient not taking food than explain politely that food is compulsory for recovery.

Altered thought process : 

Altered thought process Assess the level of thought process. Convey acceptance of the patient’s need for false belief but that you do not share. Do not argue . Do not force. Do not say you are wrong. Use same language in front of patient. Avoid physical contact in form of touch. Avoid laughing ,whispering there. Avoid competitive activities. Reinforce focus on reality.

Altered physical activity : 

Altered physical activity Assess the level of activity pattern of patient. Give high calories diet. Remove all things near to bed. Maintain calm and quite environment. Avoid argument with the patient. Give the medicine timely to maintain drug level. Avoid talking excessively. Give some simple task to do the patient. Encourage for light rest in day as well as night.

Anxiety. : 

Anxiety. Asses the level of anxiety. Maintain therapeutic relationship. Explain everything before doing . Hold the hand of patient if patient threatened (if required). Explain queries of patient clearly. Don’t ignore patient . Stay with patient. Use same language in front of patient. Ask patient to explain his/her anxiety more and more. Give tranquilizer as prescribed. Provide safe environment. Use relaxation technique if possible.

Impaired orientation. : 

Impaired orientation. Assess the level of perception. Provide a safe environment. Ask the patient to express impaired perception. Help the patient to get oriented. Focus on reality.

Altered nutrition : 

Altered nutrition Assess the level of nutrition. Provide calories according to activity. Find out patient like and dis like. Provide 6-8 glass water (if not contraindicated). Maintain accurate record of intake and out put. Supplement diet with vitamin and mineral. Walk or sit with the patient. Serve food attractively. Instruct to relatives to take food with patient if suspiciousness is there.

Impaired socialization. : 

Impaired socialization. Maintain therapeutic relationship with patient. Encourage patient to talk with other people or patient. Encourage to play with other patient. Offer patient for group activity. Give a positive reinforcement for participation.

Other nursing problem : 

Other nursing problem Impaired communication Violent behaviour withdrawn behaviour. Self care deficit. Impaired family coping.

Rehabilitation : 

Rehabilitation

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Thank you