2007 Schizophrenia

8/14/2019 2007 Schizophrenia

1/53

SCHIZOPHRENIA SCHIZOPHRENIA

Ali C. Robles, RN, MD


2/53

INTRODUCTION

Schizophrenia is possibly a group of psychoticdisorders that severely impairs all areas of anindividuals functioning.1 to 1.5% of US population has schizophrenia.However they make up far more than 50% of the

county and long-term residents of state mentalhospitals.More than 50% are homeless, and in addition mayhave an addiction problem.

The cost of treatment and loss of revenues areestimated in the billions of dollars.


3/53

COMORBIDITY

Substance abuse disorders

Nicotine dependenceDepression

Suicide

Anxiety disordersPsychosis-induced polydipsia


4/53

ETIOLOGY

Neurobiochemical

Dopamine hypothesisSerotoninGlutamate

NeuroanatomicalStructural cerebral abnormalities

GeneticSeveral genes on different chromosomesinteract with environment

Nongenetic risk factorsComplications of pregnancy and birthStress


5/53

GENETIC PREDISPOSITION

A single gene has not been identified.

Research is focused on chromosomes 6, 13, 18 & 22.

The risk of developing the disorder is as follows:

One parent 12-15%+

Both parents 40%+Identical twins 50%+

(The statistics may vary in different studies)


6/53

AREAS OF THE BRAIN AFFECTED


7/53

BIOLOGICAL THEORIESNeuroanatomical


8/53

Course of Schizophrenia

Recurrent acute exacerbations

of psychosisIncrease in residual dysfunctionand deterioration with each relapse


9/53

Phases in Course of

Schizophrenia1. Acute phasePositive symptoms and negativesymptoms

2. Maintenance phaseAcute symptoms are less severe

2. Stabilization phaseRemission of symptoms


10/53

Potential Early Symptoms:

Pre-psychotic

Withdrawn from others

DepressedAnxiousPhobiasObsessions and compulsionsDifficulty concentratingPreoccupation with religionPreoccupation with self


11/53

Bleulers

4 As of Schizophrenia

Affect

Associative loosenessAutismAmbivalence


12/53

Signs and Symptoms: Relevant

to Treatment

Positive symptoms

Negative symptomsCognitive symptomsMood symptoms


13/53

Dimensions Altered in

Individuals withSchizophreniaAbility to work

Interpersonal relationshipsSelf-care abilitiesSocial functioning

Quality of life


14/53


15/53

Positive Symptoms:

Alterations in Speech

Associative loosenessNeologismsEcholalia

Clang associationWord salad


16/53

Positive Symptoms:

Alterations in PerceptionHallucinations: sensory perceptionsfor which no external stimulus exists

AuditoryVisualOlfactory

Tactile

Personal boundary difficulties


17/53

Positive Symptoms:

Alterations in Behavior

Extreme motor agitation

Stereotyped behaviorsAutomatic obedienceWaxy flexibility

StuporNegativism


18/53

Negative Symptoms

Affective blunting

Anergia

AnhedoniaAvolition

Poverty of content of speech

Thought blockingFlat affect/inappropriate affect


19/53


20/53

Depression and

Other Mood SymptomsDysphoria

Suicidal ideation

Hopelessness


21/53

Types of Schizophrenia

SubtypesParanoid

CatatonicDisorganizedUndifferentiated

Residual


22/53

Self-Assessment: Working

with Schizophrenic Clients Peer group supervisionClient's intense emotions produce

similar emotions in the nurseWillingness for nurse to discuss feelings andbehaviors with supervisors decreases defensivebehaviors

Team approach to decrease staff burnout

Periodic reassessments of Treatment outcomes

Client's strengths and weaknesses


23/53

Assessment of the Client

Safety of client and othersMedical history and recent medical

workupPositive, negative, cognitive, andmood symptomsCurrent medications and complianceto treatmentFamily response/support system


24/53

Potential Nursing

DiagnosesRisk for self-directed or other-directedviolenceDisturbed sensory perceptionDisturbed thought processesImpaired verbal communicationIneffective copingCompromised or disabled familycoping


25/53

Outcome Criteria

Acute phaseClient safety and medical stabilization

Maintenance phaseAdherence to medical regimen

Understanding schizophrenia

Participation of client and family in psychoeducational activities

Stabilization phase

Target negative symptomsAnxiety control

Relapse prevention


26/53

Planning of

Appropriate InterventionsAcute phase

Possible hospitalizationEnsure client safetyProvide symptom stabilization

Maintenance and stabilization phases

Psychosocial educationRelapse prevention skills


27/53

Interventions: Basic Level

Acute phaseAdminister antipsychotic medication asprescribed

Observe client behavior closelySet limits on inappropriate behaviorDo not touch without warningOffer foods that are not easily contaminatedAssist with ADL if neededSupportive counselingMilieu managementFamily psychoeducation


28/53

Interventions: Basic LevelContinued

Maintenance and stabilization phases

Health teachingHealth promotion and maintenance


29/53

Milieu TherapySafety

Potential for physical violence due tohallucinations or delusions

Priority is least restrictive safety technique

Verbal de-escalation

Medications

Seclusion or restraints

ActivitiesProvide support and structure

Encourage development of social skillsand friendships


30/53

Counseling: Communication

GuidelinesHallucinationsHearing voices most commonApproach client in nonthreatening and

nonjudgmental mannerAssess if messages are suicidal or homicidalInitiate safety measures if neededClient anxious, fearful, lonely, brain notprocessing stimuli accuratelyFocus on the clients feelings and presentreality


31/53

Communication Guidelinescontinued

DelusionsBe open, honest, matter-of-fact, andcalmHave client describe delusionAvoid arguing about contentFocus on feelings

Present reasonable doubtValidate part of delusion that is real


32/53

Communication Guidelinescontinued

Associative loosenessDo not pretend that you understandPlace difficulty of understanding on yourself

Look for reoccurring topics and themesEmphasize what is going on in the client'senvironmentInvolve client in simple, reality-based activitiesReinforce clear communication of needs, feelings,and thoughts


33/53

Client TeachingCoping Techniques forSchizophrenia

Distraction

InteractionActivitySocial action

Physical action


34/53

Client and Family Teaching

Learn all you can about the illness.Develop a relapse prevention plan.Avoid alcohol and drugs.

Learn ways to address fears and losses.Learn new ways of coping.Comply with treatment.Maintain communication with supportivepeople.Stay healthy by managing illness, sleep, anddiet.


35/53

Treatment Modalities

Individual therapySocial skills training (SST)Cognitive remediationCognitive adaptation training (CAT)Cognitive behavioral therapy (CBT)

Group therapy

Family therapyPsychopharmacology


36/53

Psychopharmacology

AntipsychoticsStandard/ TypicalAtypical

Antiparkinson


37/53

PsychopharmacologyTraditional Antipsychotic

Dopamine antagonists (D 2 receptor antagonists)

Target positive symptoms of schizophreniaAdvantage

Less expensive than atypical antipsychoticsDisadvantages

Do not treat negative symptomsExtrapyramidal side effects (EPS)

Tardive dyskinesiaAnticholinergic effects (ACH)Lower seizure threshold


38/53

Antipsychotic Medications:Traditional

High potency = low sedation + low ACH + highEPSs

Haloperidol (Haldol) Trifluoperazine (Stelazine)

Fluphenazine (Prolixin)

Thiothixene (Navane)

Medium potencyLoxapine (Loxitane)

Molindone (Moban)

Perphenazine (Trilafon)


39/53

Antipsychotic Medications:Traditional continued

Low potency = high sedation + highACH + low EPSs

Chlorpromazine (Thorazine) Thioridazine (Mellaril)Mesoridazine ( Serentil)

Decanoate = Long acting injection

Haloperidol decanoate (Haldol D)Fluphenazine decanoate (Prolixin D)


40/53

Atypical Antipsychotics(First-Line Antipsychotics)

Serotonin-dopamine antagonists (5-HT 2A receptor antagonists)

AdvantagesDiminishes negative as well as positive symptoms of schizophrenia

Less side effects encourages medication compliance

Improves symptoms of depression and anxiety

Decreases suicidal behavior

DisadvantagesWeight gain

Metabolic abnormalities


41/53

Antipsychotic Medications:Atypical

Clozapine (Clozaril)

Quetiapine (Seroquel)Risperidone (RisperdalZipreasidone (Geodon)

Olanzapine (Zyprexa)Aripiprazole (Abilify)


42/53

Side Effects- Atypical

Orthostatic HypotensionDecreased Libido

Agranulocytosis (Clozapine)Weight gainTachycardia

Edema


43/53

Side Effects:

Anticholinergic SymptomsDry mouthUrinary retention and hesitancyConstipationBlurred visionPhotosensitivityDry eyesInhibition of ejaculation or impotence inmen


44/53

Side Effects:Extrapyramidal Side Effects

PseudoparkinsonDrooling, lack of facial responsiveness,

shuffling gait, and fine intentional tremors.

Acute DystoniaMuscle spasms of the jaw, tongue, neck oreyes. Laryngeal spasms possible. Oculogyriccrisis, Opisthotonos.

AkathisiaMotor restlessness, pacing, rocking, etc


45/53

Side Effects:Extrapyramidal Side Effects

Tardive Dyskinesia

Bizarre facial and tongue movementschewing, tongue from side to side, etc.Involuntary tonic muscular spasms of

extremitiesTrunk

Potentially irreversible


46/53


47/53


48/53

NEUROLEPTIC MALIGNANTSYNDROME

RARE, POTENTIALLY FATALONSET WITHIN HOURS OR YEARSEPS REACTIONS

CPK HYPERTHERMIA 102 AND ABOVETACHYCARDIA

FLUCTUATING B.P.DIAPHORESISSTUPOR AND COMA


49/53

AGRANULOCYTOSIS

Potentially fatal disorderSymptoms include:

White blood cells level


50/53

NURSING IMPLICATIONS

MONITOR B.P. BEFOREADMINISTERING MEDSCHECK CBC, CPK, LIVER FUNCTIONS

AND VISION REGULARLY EVALUATE FOR EFFECTIVENESS ANDSIDE EFFECTSADMINISTER 1 OR 2 HOURS BEFORE

BEDTIMEMIX LIQUIDS WITH 60CC FRUIT JUICEPATIENT EDUCATION


51/53


52/53

CLIENT AND FAMILY TEACHING

Teach about schizophrenia and available mentalhealth agencies for support at the local andnational level (NAMI AND NIMH).Develop a relapse prevention plan.

Teach about medication and treatmentcompliance.

Teach to avoid alcohol or drugs. Teach to keep in touch with supportive people. Teach to keep healthy stay in balance.


53/53

Thank

You!

Documents

2007 Schizophrenia