SCHIZOPHRENIA AND PSYCHOSIS MODULE III RNSG 2213

Transcription

1 SCHIZOPHRENIA AND PSYCHOSIS MODULE III RNSG 2213

2 SCHIZOPHRENIA: OVERVIEW Major Axis I disorder Characterized by disturbances in: Perception Thought processes and reality testing Affect (feelings) Behavior Attention (concentration) Motivation

3 PSYCHOSIS How do we define this term? Inability to evaluate accuracy of one s thoughts and perceptions Incorrect interpretation of external reality Inability to re-evaluate one s thoughts and perceptions, even in the face of evidence that contradicts these. In Schizophrenia, the psychotic person often does not have awareness that he/she is ill

4 OVERVIEW, CONT D Incidence Age of onset is late adolescence 1.1% of population over age 18 Higher rates in inner city populations, lower socioeconomic groups Prenatal probs. correlate with higher rate

5 OVERVIEW, CONT D Prognosis Approx. 25% remain highly functional 50% are minimally functional 25% are in-between with exacerbations/relapses and re-stabilizations (in and out of hosp.)

6 OVERVIEW, CONT D A Chronic Illness Characterized by Phases: Acute phase severe psychotic sx. Stabilizing Phase Stable phase Most pts. alternate between acute and stable phases

7 SCHIZOPHRENIA: : SYMPTOMS Bleuler s (Early 1900 s) 4 A s : Affect disturbances Autism Associative looseness Ambivalence Fragmentation of the Mind

8 CLASSIFICATION OF SYMPTOMS Positive Symptoms Negative Symptoms Cognitive Symptoms

9 Positive Symptoms of Schizophrenia Agitation/aggression Delusions Hallucinations Disordered thinking (AEB disordered speech): circumstantial thinking, loose associations, word salad, neologisms, echolalia

10 Positive Symptoms of Schizophrenia,, cont d Disordered movement: --restlessness, repetitive movements (e.g. echopraxia), --or immobility (catatonia)

11 Matching: Symptoms 1) A blue ape. Makes me scratch. John wore a hair shirt. Are we victims? 2) I am locked in concrete and I have stopped breathing. 3) The CIA has been poisoning my water. 4) Whenever knife take you-a. 5) At HEB, when they play that music, the words are sending messages to me. 6) I love chocolate candy. Candy is my parakeet s name. What s your name? A) Word salad B) Delusion of reference C) Tangentiality D) Neologism E) Loose associations F) Paranoid delusion G) Nihilistic delusion H) Grandiose delusion

12 Grandiose delusion example: I own the Bank of America and my people are going to put up $20 million for my release from here. Neologism example: It tastes screeg because of those nerflexes.

13 Negative Symptoms of Flat affect Schizophrenia Inability to plan or carry out activities Constricted, concrete thinking Poverty of speech (alogia), flat speech Social withdrawal; lack of pleasure in activities (anhedonia) Deep apathy

14 Flat Affects (Flight of the Conchords)

15 Cognitive Symptoms of Schizophrenia Impaired ability to pay attention and to understand Impaired ability to make decisions (ambivalence) Problems in using just-learned information

16 CRITICAL THINKING: Nursing Diagnoses Write one nursing dx. for each symptom or behavior related to schizophrenia 1) Client has command auditory hallucinations that he should kill himself 2) Client does not get dressed or take baths 3) Client believes she can make it snow

17 Suggested Nursing DX: 1) R/F Self-directed Violence r/t sensory perceptual alteration s/t command auditory hallucinations 2) Self-care deficits: grooming and hygiene r/t poor motivation for selfcare s/t schizophrenia 3) Altered thought process s/t grandiose delusion (or delusion of grandeur)

18 Antipsychotic Agents and Symptoms The Typical (older class) of antipsychotics primarily address POSITIVE symptoms Can make negative symptoms Worse The Atypical (newer classes) of antipsychotics address both POSITIVE AND NEGATIVE symptoms

19 A. At least 2: SYMPTOMS: DSM CRITERIA Delusions, Hallucinations, Disorganized speech, Catatonia, Disorganized behavior, Negative symptoms B. Social-occupational dysfunction C. Continuous s/sx. > 6 months D. No schizoaffective diagnosis E. Not caused by substance abuse or medical disorder

20 DSM Criteria: Schizophrenia Subtypes Paranoid persecutory and/or grandiose delusions Disorganized speech & affect & behavior are disturbed Catatonic absent, excessive &/or peculiar movements. Mutism. Undifferentiated does not meet criteria for other subtypes Residual has some disturbed thinking or behavior but does not meet other criteria

21 DSM Criteria: Other Psychotic Disorders Schizophreniform Disorder Has similar symptoms to schizophrenia but for only 1-6 months Schizoaffective Disorder Symptoms of schizophrenia + symptoms of a mood disorder Psychotic Disorder NOS Has Psychotic symptoms but doesn t fit criteria for any of the above

22 Quick Check: What is the most likely DSM IV-TR Diagnosis? Client #1 Elevated mood episodes along with hallucinations and delusions for 2 years Client #2 Is physically immobile at times. Has poverty of speech. Has never worked in adulthood. Client #3 Agitated, reports seeing flashes of color and hearing singing voices x 2 weeks. Client #4 I know 4,000 languages but others are trying to steal these from my mind. As a result, has been living on the streets for many years.

23 ETIOLOGY Multifactorial-no single cause Multiple theories for etiology (see next content)

24 BIOLOGICAL THEORIES 1. The Dopamine Hypothesis: Too much dopamine binds with too many brain receptors and causes positive symptoms Too little dopamine -- negative symptoms

25 BIOLOGICAL THEORIES, cont d 2. Disturbed Ratio of serotonin: dopamine

26 CRITICAL THINKING Based on the preceding hypotheses, what are the principles behind antipsychotic medications? -to treat positive symptoms: -to treat negative symptoms: -to treat altered ratios:

27 BIOLOGICAL THEORY: CHANGES IN BRAIN STRUCTURE AND FUNCTION Alterations found in some Schizophrenics using Diagnostic Imaging PET Scan: glucose metabolism in frontal/temporal lobes; in basal ganglia MRI: Enlargement of ventricles BEAM Scan: Abnormal wave patterns indicting absence of ability to calm the brain Evoked Potential Topography: Illogical thought patterning in frontal lobe

28 PET Scan and Schizophrenia

29 GENETIC THEORY Inherited predisposition to schizophrenia Risk Factors: Two parents with schizophrenia = 35% Identical twins = 50%

30 DEVELOPMENTAL AND ENVIRONMENTAL THEORIES Prenatal infections Parental neglect or rejection Greater % of pts. come from lower socio-economic class

31 Issues in Schizophrenia Family disturbance: a cause or a result? Noncompliance and relapse are common Have poorer ability to cope with stress Increased rates of depression, suicide Increased rate of substance abuse: alcohol, marijuana, nicotine, cocaine Often cannot hold a job

32 Australian aboriginal painting by mental health client INTERVENTIONS/ PSYCHOTHERAPEUTIC MANAGEMENT

33 NURSE-CLIENT RELATIONSHIP Be accepting, consistent and honest Do not argue with or reinforce hallucinations or delusions Reinforce acceptable behaviors Gently encourage withdrawn client Recognize when a client may be suspicious, anxious or fearful, and approach with care Assess for command hallucinations

34 CRITICAL THINKING: Which Nurse is Therapeutic? Non-therapeutic? Client insists he is a negative space alien. Nurse A: Do you live in outer space? Are there other people living there? Nurse B: But I have met your mom. How can you be a space alien? Nurse C: That s interesting. Want to come with me now to see the patient art exhibit? Nurse D: I can see you feel strongly about that.

35 MILIEU MANAGEMENT Set limits on disruptive behavior Assess agitated clients frequently for escalation Assess ability to participate in activities; choose activities at client s level of ability May need 1:1 rather than group activities at first Decrease environmental stimuli prn Supervised meals, hygiene, grooming

36 CRITICAL THINKING: Which Nurse is Therapeutic? Non-therapeutic? A new patient starts pacing back and forth, while saying in a loud voice, Take it back, take it back. Nurse A: Lower your voice, you are disturbing people. Nurse B: Hi, I m Jo the nurse; are you ok? Nurse C: Why are you pacing?

37 CRITICAL THINKING: In what order should the nurse implement? A schizophrenic patient, who hallucinates and is sometimes aggressive, turns off the football game that others are watching. Are you hearing the voices? Right now our activity is watching the football game, so it s not ok to turn it off. Come on outside for some fresh air. I m going to give you some medication right now to help you feel calmer.

38 OTHER INTERVENTIONS Importance of client and family education To address stigma of schizophrenia & To improve functional ability, selfmanagement and prevent relapse

39 Other Interventions, cont d Community Resources and Continuity of Care National Alliance on Mental Illness (NAMI) Outpatient day treatment, home care Self-help, peer support groups (NAMI)

40 PHARMACOTHERAPY Antipsychotic Agents Traditional or Typical Agents: 1 st Generation (beginning 1950 s) Atypical or Second Generation Agents (1990 s) Novel or Third Generation Agents (21 st century)

41 Antipsychotic Agents: Overview of Typical Agents Pharmacologic Effects, in General Sedation (esp. if combined with other CNS depressants) Slowing of motor activity Decrease in hallucinations and delusions Emotional quieting Improved cognitive function; decreased confusion

42 TYPICAL or Traditional ANTIPSYCHOTIC AGENTS High Potency e.g. haloperidol (Haldol), fluphenazine (Prolixin) Moderate Potency e.g. loxapine (Loxitane), perphenazine (Trilafon) Low Potency e.g. chlorpromazine (Thorazine), thioridazine (Mellaril)

43 Typical/Traditional Antipsychotics, cont d Action = Block Dopamine D2 Receptors Most effective for Positive (+) symptoms

44 Atypical (2 nd Generation) Agents clozapine (Clozaril) (prototype) Action of this drug: blocks multiple dopamine receptors quetiapine (Seroquel) risperidone (Risperdal) olanzapine (Zyprexa) ziprasidone (Geodon) paliperidone (Invega)

45 Newest Atypical Agents iloperidone (Fanapt) Asenaphine (Saphris)

46 Atypical (2 nd generation) Agents, cont d Action: Block (antagonists) or enhance (agonists) multiple dopamine, serotonin and/or norepinephrine receptors. Useful for both positive and negative symptoms

47 Novel (3 rd Generation) Agents aripiprazole (Abilify) Action: Partial dopamine antagonist Balances dopamine (both increases and decreases it in different brain areas)

48 Antipsychotics: Side Effects Main Side Effects: Extra-Pyramidal (EPSEs)- abnormally increased or decreased motor activity, muscle spasms, twisting, tremors Akinesia Akathisia Pseudo-Parkinsonism Dystonias Tardive Dyskinesia Acute dystonic reaction

49 Tardive Dyskinesia

50 EPSEs To assess for tardive dyskinesia, administer AIMS (Abnormal Involuntary Movement Scale)

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52 Antipsychotics: Side Effects, cont d Anticholinergic Effects-dry mouth, orthostatic hypotension, urinary retention, blurred vision Usually resolve over time

53 Other Side Effects Other Side Effects Cardiac: Arhythmias (QT interval lengthened) Blood: Leukopenia, anemias, agranulocytosis (clozapine/clozaril) Endocrine and Metabolic: Weight gain Altered glucose metabolism Diabetes type II Elevated prolactin levels Sexual: Impaired libido, performance

54 A Dangerous Side Effect Neuroleptic Malignant Syndrome (NMS) Potentially lethal Associated with use of high-potency agents e.g. haloperidol/haldol Onset: within a week after starting meds. Symptoms: muscular rigidity, tremors, autonomic hyperactivity e.g. high body temperature, altered consciousness

55 Nursing Interventions R/T Antipsychotic Meds. Medication education (You cannot teach too often) Side effect issues contribute to poor adherence/compliance: E.g. hypotension, CNS depression, photosensitivity, thermoregulation problems

56 Education/Safety Issues: What will you teach the client about...? Hypotension Sedation Photosensitivity Problems with thermoregulation Weight gain

57 Nursing Interventions R/T Pharmacotherapy --Option for client with poor adherence: Long acting ( depot ) form, give IM q 1week - 4 wks

58 Nursing Interventions r/t Pharmacotherapy Oral solution Disintegrating oral tablet

59 EMERGENCY MEDS Common choice: IM cocktail of sedating antipsychotic + antihistamine and benzodiazepine Goals: reduce agitation rapid sedation

60 CRITICAL THINKING: Antipsychotic Therapy A 65 year-old client will start on an antipsychotic agent for delusions secondary to severe depression. Choose the 3 highest priority diagnostic tests that will be performed. A) CBC with diff. D) EEG B) Chest x-ray E) BUN/Creatinine C) EKG F) Electrolytes

61 PHARMACOTHERAPY FOR EXTRAPYRAMIDAL SEs: Antiparkinson Agents benztropine (Cogentin) trihexyphenidyl (Artane) biperiden (Akineton) diphenhydramine (Benadryl) amantadine (Symmetrel)

62 Antiparkinson Agents, cont d Action: Restore balance of dopamine with acetylcholine (ACh) Reduce motor and muscle dysfunctions caused by this imbalance But: They also may cause anticholinergic SEs and mental confusion

63 CRITICAL THINKING Which client(s) is(are) candidate(s) for benztropine/cogentin? A) is unable to void urine B) reports onset of difficulty swallowing and stiff muscles C) is pacing in response to hearing voices D) has had tardive dyskinesia symptoms for several years

64 CRITICAL THINKING: Anti-Parkinson/Anticholinergic Agents On the mental health unit, a client who was recently prescribed an antiparkinson agent for EPSEs reports very dry mouth and constipation. What will the nurse do? (Choose all that apply) A) Call the dr. to discuss changing dose of the med. B) Encourage use of hard candies and increase in fluid intake C) Hold the medication D) Inform the client that these effects may decrease in a few weeks.