Nursing Week 2: Schizophrenia

Symptoms of Schizophrenia : 

3/8/2010 1 Symptoms of Schizophrenia Positive Symptoms Hallucination, delusions, paranoia, bizarre behavior Negative Symptoms Apathy, avolition, anhedonia, poverty of thought Cognitive Symptoms Impaired memory, executive function, inattention Depressive Symptoms

Etiology Of Mental Illness : 

3/8/2010 2 Etiology Of Mental Illness Heredity/Genetic Factors: 60% in twin studies Dopamine Hypothesis: too much activity Neurodevelopmental Hypothesis: accelerated loss of neuronal connections Stress Models: stress increases dopaminergic transmission Substance Abuse: increased vulnerability after drug use Psychologic Theories: vulnerability to stress

Epidemiology : 

3/8/2010 3 Epidemiology In the United States, schizophrenia affects 1 1.5% of the population and is equal in both men and women. Average age of onset 15 to 25 years for men and 25 to 35 years for women. Childhood-onset affects 1 in 40,000 children compared to 1 in 100 adults. The economic burden of schizophrenia is estimated to be greater than $65 billion dollars. Forty percent of persons with schizophrenia attempt suicide.

Course of Illness : 

3/8/2010 4 Course of Illness Premorbid phase: mild deficits Prodromal phase: symptoms that signal approaching onset of disease Psychotic phase Acute – florid positive symptoms Recovery or maintenance – symptoms less severe Stable - remission

Which of the following statements would the nurse use to describe remission in schizophrenia to a client’s family? : 

3/8/2010 5 Which of the following statements would the nurse use to describe remission in schizophrenia to a client’s family? A. The disease is in the prodromal stage. B. The client no longer has prominent psychotic symptoms. C. The client is free from all signs of illness and is no longer on medication. D. The client is free from all signs of illness whether or not he’s on medication.

Clinical Description : 

3/8/2010 6 Clinical Description Schizophrenia Paranoid – responds well to treatment and with follow up, may not reoccur Catatonic – sudden onset, often complete remission Disorganized, Undifferentiated – outcome poor Residual- varied prognosis Schizophreniform Disorder – 1/3 complete recovery, 2/3 develop schizophrenia Schizoaffective Disorder – lifelong illness but manageable, worsen with stress

Symptoms : 

3/8/2010 7 Symptoms Perceptual: hallucinations, especially command hallucination (clinical alert page 643) Thought: delusions Emotional: blunting Cognitive: inattention Behavioral: possibility of violence Social: lack of social cues

Nursing Assessment : 

3/8/2010 8 Nursing Assessment Complete physical assessment Developmental status Mental status exam: focus on disturbances in Perception Thought Feelings Behavior

A client tells a nurse voices are telling him to do “terrible things.” Which of the following actions is part of initial therapy? : 

3/8/2010 9 A client tells a nurse voices are telling him to do “terrible things.” Which of the following actions is part of initial therapy? A. Find out what the voices are telling him. B. Let him go to his room to decrease his anxiety. C. Begin talking to the client about and unrelated topic. D. Tell the client the voices aren’t real.

Nursing Diagnosis : 

3/8/2010 10 Nursing Diagnosis Risk for suicide Risk for self-directed violence Risk for other-directed violence Disturbed sensory perception Disturbed thought process Risk for deficient fluid volume Risk for imbalanced nutrition Ineffective coping Self-care deficit Impaired social interaction

Which of the following nursing diagnoses is most appropriate for a client with acute schizophrenia? : 

3/8/2010 11 Which of the following nursing diagnoses is most appropriate for a client with acute schizophrenia? A. Social isolation related to impaired ability to trust B Impaired mobility related to fear of hospitalization C. Sleep disturbance related to impaired thinking ability D. Potential for violence directed at others related to perceptual distortions

Outcome Identification : 

3/8/2010 12 Outcome Identification An estimate of the behavioral changes anticipated after interventions The client will Demonstrate absence of suicidal behaviors or violent behaviors towards others Demonstrate reduction in hallucinations and use behavioral techniques to control hallucinations Demonstrate reality-based thinking and behaviors Engage in own hygiene, grooming and ADLs Socialize with peers and participate in groups Participate in discharge planning

Nursing Interventions : 

3/8/2010 13 Nursing Interventions Teach material in small, concrete segments Provide time-outs, low-key interactions Identify events that increase anxiety and promote hallucinations Focus on meaning of delusions, not content Encourage verbalization as a de-escalation technique – “tell me what’s going on” Accompany to group, assist with ADLs Act as a role model for social behaviors Hold onto hope for the client

Which of the following interventions should the nurse plan to use to reduce client focus on delusional thinking? : 

3/8/2010 14 Which of the following interventions should the nurse plan to use to reduce client focus on delusional thinking? Confronting the delusion Focusing on feelings suggested by the delusion Refuting the delusion with logic Exploring the reasons the client has the delusion

A client with schizophrenia tells his primary nurse that he is scheduled to meet the King of Samoa at a special time, making it impossible for the client to leave his room for dinner. Which of the following responses by the nurse is most appropriate? : 

3/8/2010 15 A client with schizophrenia tells his primary nurse that he is scheduled to meet the King of Samoa at a special time, making it impossible for the client to leave his room for dinner. Which of the following responses by the nurse is most appropriate? A. “It’s meal time. Let’s go so you can eat.” B. “The King of Samoa told me to take you to dinner.” C. “Your physician expects you to follow the unit’s schedule.” D. “People who don’t eat on this unit aren’t being cooperative.”

A client asks a nurse if she hears the voice of the nonexistent man speaking to him. Which of the following responses is the best? : 

3/8/2010 16 A client asks a nurse if she hears the voice of the nonexistent man speaking to him. Which of the following responses is the best? A. “No one is in your room except you. B. “Yes, I hear him, but I won’t listen to him.” C. “What has he told you? Is it helpful advice?” D. “No, I don’t hear him, but I know you do. What is he saying?”

A nurse on a psychiatric unit observes a client in the corner of the room moving his lips as if he were talking to himself. Which of the following actions is the most appropriate? : 

3/8/2010 17 A nurse on a psychiatric unit observes a client in the corner of the room moving his lips as if he were talking to himself. Which of the following actions is the most appropriate? A. Ask him why he is talking to himself. B. Leave him alone until he stops talking. C. Tell him it’s not good for him to talk to himself. D. Invite him to join in a card game with the nurse.

Additional Treatment Modalities : 

3/8/2010 18 Additional Treatment Modalities Psychopharmacology Somatic therapy – ECT Milieu therapy Behavior Modification Psychosocial Rehabilitation Interventions Individual, group, occupation & recreational therapies

Antipsychotics : 

3/8/2010 19 Antipsychotics Conventional, typical, 1st generation antipsychotics are high affinity antagonists of dopamine D2 receptors Chloropromazine (Thorazine), Haloperidol (Haldol), Fluphenazine (Prolixin) Effective for positive symptoms High rates extrapyramidal symptoms (EPS), tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS)

Antipsychotics : 

3/8/2010 20 Antipsychotics Atypical or 2nd generation antipsychotics have a lower affinity for D2 receptors and more affinity for serotonin and norepinephrine Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Aripirazole (Abilify) Effective for positive and negative symptoms Lower risk of EPS, TD, and NMS

During a treatment team meeting, the point is made that a client with schizophrenia has recovered from acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin excess will suggest that the client receive: : 

3/8/2010 21 During a treatment team meeting, the point is made that a client with schizophrenia has recovered from acute psychosis but continues to demonstrate apathy, avolition, and blunted affect. The nurse who relates these symptoms to serotonin excess will suggest that the client receive: A. Haloperidol (Haldol) B. Chlorpromazine (Thorazine) C. Olanzapine (Zyprexa) D. Phenelzine (Nardil)