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Schizophrenia
  • 1% of the population
  • multiple presentations
  • cost of treatment greater than all cancer combined
  • early intervention can promote greater recover and reduce cost the the person and community
Schizophrenia
  • evidenced by distorted and bizzare thoughts, perceptions, emotions, movements, and behavior
  • painful to the pt even if they do not show it outwardly
Positive S/S
  • Delusions (thought)
  • Hallucinations (sensory)
  • Grossly disorganized thought, speech, and behavior
  • ambivalence, associated looseness, ideas of reference, flight of ideas, echopraxia
Negative S/S
  • Alogia: absence of speech
  • flat/blunted affect
  • anhedonia
  • apathy
  • lack of volition
  • social withdrawal or discomfort
  • catonia
Schizophrenia and Violence
  • High risk of suicide
  • Aggression: occurs more often when feeling threatened or vulnerable
  • command hallucinations are very dangerous
  • It is important to assess content of hallucinations without reinforcing them
  • Community fear: violence is infrequent, 15x more likely to be assaulted
Paranoid Type Schizophrenia
  • most common
  • persecutory delusions
  • grandoise delusions
  • excessive religiosoty
  • hallucinations
  • hostile and aggressive behavior
Disorganized Type SChizophrenia
  • grossly inappropriate or flat affect
  • incoherent speech
  • loose associations between thoughts and topics
  • disorganized behavior (dress, self care, nutrition)
Catatonic Type Schizophrenia
  • Marked psychomotor disturbance
  • motionlessor excessive motion
  • catatonia is motor immobility
  • waxy flexibility (catalepsy)
  • stupor
  • negativism
  • mutism
  • peculiarities of voluntary movements
  • echolalia
  • echopraxia
Undifferentiated and Residual Type
  • Undifferentiated: mixed
  • Residual: remission? limited symptoms, social withdrawal, flat affect, looseness of association
Schizophrenia: Clinical Course
  • Onset: abrupt or insidious, most have slow, gradual development of S/S
  • worse pronisis for young client with gradual development of symptoms
  • Dx usually with more actively positive symptoms of psychosis
Schizophrenia: Clinical Course cont.
  • Immediate course (two patterns)
  • Ongoing psychosis, never fully recovering
  • Episides of psychotic symptoms alternating with complete recovery (can be highly functioning)
  • log term: intensity of psychosis diminishes with age
Etiology
  • Genetic Factors: twin studies show partial inheritance up to 50%
  • Nero-anatomic factors: less brain tissue, less perfusion and glucose metabolism in frontal lobe, less CSF, enlarged ventricles
  • Neruochemical: excess dopamine, serotonin modulation of dopamine to reduce excess
Etiology cont
  • Three symdromes may relate to neurobiology
  • hallucinations/delusions
  • disorganization of thought and behavior
  • negative symptoms
Cultural Considerations
  • Ideas considered delusional in one culture are possibly commonly accepted by another culture
  • auditory or visual hallucinations are a normal part of the religious experience in some cultures
  • culture-bound syndromes
  • ethnic differences in response to psychotropic meds
Emergency Management
  • Pt is less likely to be compliant with meds if they are prescribed haldol or other antipsychotic for emergency management
  • Better to administer a benzo until sedated
  • Antipsychotics are better for treatment rather than emergency intervention
Psychopharmacology
  • Convential antipsychotics (dopamine antagonists): target positive symptoms, no observable effects on negative symptoms
  • Atypical antipsychotics: dopamine and serotonin antagonists): better modulation of both sets of symptoms, diminsh positive and lessen negative
Maintenance therapy
  • Prolixin and Haldol available as depot injections
  • Effects last 2-4 weeks, eliminate the need for daily PO antipsychotics
Neruologic Side Effects
  • EPS: acute dystonic reactions, akathisia, parkinsonism
  • tardive diskinesia
  • seizures
  • NMS
Non-Neurologic Side Effects
  • Weiht gain, sedation, photosensitivity
  • Anticholinergic symptoms (dry mouth, blurred vision, constipation, urinary retention)
  • Orthostatic hypotension
  • Agranulocytosis (Clozapine)
AIMS (Abnomral Involuntary Movement Scale)
  • Assesses for permanent motor symptoms
  • important to monitor closely to prevent symptoms from developing or worsening
Nursing Assessment of the Schizophrenic Pt
  • History of schizophrenia
  • Hx of suicidal ideation
  • current supprot sytem
  • clients perception of current situation
  • general appearance (dressed for season, odd or bizarre dress, unkempt)
  • Motor behavior (odd, bizarre, catatonia, echopraxia, psychomotor retardation)
  • Speech (word salad, echolalia, latency of resposne)
Assessment cont.
  • Modd/affect (blunted, flat, anhedonia)
  • Thought process and content (thought blocking, broadcasting, withdrawl, or insertion)
  • delusions
  • Hallucinations (sensory, command, cenesthetic)
  • depersonalization
Assessment cont.
  • Intellectual processes: disorded thoughts, but could be intact
  • judgement and insight: usually impaired
  • Roles and relationships: social isolation
  • Physiologic, self care: inattention to hygeine and grooming, failue to recognize snsations, polydipsia)
Analysis and outcome
  • ID appropriate NANDAs for pos and neg symptoms
  • ID short and long term goals
Interventions
  • safety of client and others
  • therapeutic relationship and communication: begin with trust
  • Clinet may not be able to tolerate communicatin at first
  • silence may be helpful, but watch for thought insertion
  • isolation can worsen psychosis
Interventions cont.
  • Delusional thoughts: focus on reality, to not confront or reinforce, help them to learn to talk back to thoughts
  • Hallucinations: assess without reinforcement, determine feeling tone, ID stressors that trigger them, distraction, talk balk to voices
  • manage socially inappropriate behavior
Interventions cont.
  • Client and family education: s/s of relapse, self care, nutrition, social skills, med management, help them to stay connected to family
Older adult considerations
  • psychotic symptms later in life are usually associated with depression or dementia
  • atypical antipsychotic black box warning= DEATH
Mental Health Promotion
  • goal of psych rehab: client recovery
  • accurate ID of those at risk is important
  • early intervention: improved prodromal symptoms, prevention of stagnation or decline, prevention or delay of progression to psychosis
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