Nursing Care of the Patient with Schizophrenia

Nursing Care of the Patient with Schizophrenia and Other Psychotic Disorders • Denise Coe RN MSN HNC What is Schizophrenia? • A disorder of the brain • Combination of: Disordered thinking Perceptual disturbances Behavioral abnormalities Affective disruptions Impaired social competency Etiologies • • • • • • • Uncertain-multiple etiologies: Genetic? Infection? Birth or pregnancy complications? Neuroanatomical theories? A lesion in the limbic system? Dopamine theory? Risk Factors • • • • • • Risk is greater if: Single from and industrialized nation lives in a lower socio-economic class lives in a urban center is a product of a difficult labor and delivery • STRESS- recently experienced stressful events. ( increased cortisol effects on cells in hippocampus). Risk Factors • Social causationMay be due to more stressful life situations in lower classes, less social support? Downward Drift Theory- as the disease progresses patient has greater difficulty maintaining stable job and relationship. Risk Factors • • • • Stressful life event Patients report a vulnerability to stress Heightened sensitivity to the environment Less able to screen out sounds, and stimuli. What is Schizophrenia? • A type of psychosis • What is psychosis? A state in which a person is unable to comprehend reality and has trouble communicating to others. History of schizophrenia • Emil Kraeplin, a European doctor, first described it in 1896. History….. • In 1911 Dr Eugene Bleuler, from Europe, identified the behaviors typical of people with schizophrenia. • He renamed it-schizophrenia- meaning “splitting of the mind”. The patient is split off from reality, not a split personality. History…. The four A’s of Bleuler: • Affect- the feelings reflected on our faces, in our expressions, and by our demeanor or behavior. History • Associations • • Autism History…. Ambivalence experiences strong positive and negative feelings at the same time; hard to make any decisions. DSM-IV-TR Criteria A.Characteristic Symptoms: Two or more of the following, each present for a significant portion of the time during a I-month period : • Delusions • Hallucinations • Disorganized speech • Grossly disorganized behavior • Negative Symptoms Nature of the Disorder • The person has trouble thinking clearly, knowing what is real, managing feelings, making decisions, and relating to others. Phases of Onset Phase 1- The Schizoid personality a person sometimes described as a loner, indifferent to social relationships and having a limited range of emotional experience and expression. Phases Phase 2-The Prodromal phase Begin to socially isolate Have difficulty in role functioning Odd behavior Neglect of personal hygiene and grooming Different affect Changes in communication Bizarre ideas Lack of initiative Phases….. • Schizophrenia-active disease See DSM IV TR. DSM-IV-TR Criteria A.Characteristic Symptoms: Two or more of the following, each present for a significant portion of the time during a I-month period : • Delusions • Hallucinations • Disorganized speech • Grossly disorganized behavior • Negative Symptoms Phases….. • Phase4- Residual impairment- often increases between episode • A return to full premorbid functioning is not usual Types of Schizophrenia and Other Psychotic Disorders • Disorganized-Behavior very regressed and primitive. • Catatonic-marked abnormalities in motor behavior. Stupor or excitement Waxy flexibility Types… • Paranoid-characterized mainly by the presence of delusions of persecution or grandeur related to a single theme. Types… • Undifferentiated- Symptoms can not be classified • Residual- Other Psychotic Disorders.. • SchizoaffectiveSchizophrenic behaviors with a strong element of symptoms of mood disorder Other Psychotic Disorders • Brief psychotic disorder-sudden onset of psychosis usually following a severe psychosocial stressor, with full return to normal. • Schizophreniform-duration is shorter but same symptoms. • Delusional disorder-presence of one or more non bizarre delusions. Behavior not bizarre. Other Psychotic Disorders • Psychotic disorder that develops due to a general medical condition • Substance induced psychotic disorder Negative and Positive Symptoms • They do not mean good and bad • Positive –added or excessive behaviors that are not normally seen in mentally well persons • Negative-the loss of normal function that is normally seen in mentally well persons • The negative symptoms less affected by medications and lead to greater impairment Characteristics of Schizophrenia • Cognitive Delusions- false personal beliefs that are inconsistent with the person's intelligence or background. The person holds firm to them despite proof that the thought is false or irrational. • Types of delusions: • Persecution -most common. Types of Delusions • Delusions- Table 14.3 of text Grandiose Jealous Somatic delusions Delusion of reference Delusion of control or influence Nihilistic delusion Characteristics • Cognitive Religiosity Disorganized thinking Looseness of associations Concrete thinking Impaired ability to solve problems Memory deficits “Magical thinking” Neologisms Clang Associations Characteristics • • • • • • Cognitive Word salad Circumstantiality Tangentiality Mutism Preseveration Perceptual Characteristics • Hallucinations Auditory-Most common type Usually voices, but can be noises. Command hallucinations- must assess • Visual • Tactile • Gustatory • Olfactory Perceptual Characteristics • Impaired Sensory Filtering Affective Characteristics • Affect • Describes the behavior associated with a person’s feeling state or emotional tone. • Descriptions of affect include: Inappropriate affect Bland or Flat affect Apathy Anhedonia Overreactive affect Behavioral Characteristics Social Characteristics • • • • • Impaired interpersonal functioning Social isolation-aloof Emotional detachment Poor personal appearance Inadequate social skills Concomitant Disorders • Dual diagnosis simultaneous substance abuse disorder • Both must be treated Activity • Separate into groups of four. Read the Scenario and define a goal or outcome for the nursing diagnosis. Write the interventions to achieve that goal. Each person write an intervention, something you would do to work toward that goal. Each one will write the intervention and when time is up we will share. Activity1 • Read the case study and the nursing diagnosis. As a group, discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. • Nsg diagnosis-Disturbed sensory perception: auditory hallucinations Activity 1 • Nsg diagnosis-Disturbed sensory perception: auditory hallucinations related to panic anxiety, extreme loneliness, and withdrawal into self evidenced by inappropriate responses, and disordered thoughts. Activity 2 • Read the case study and the nursing diagnosis. As a group, discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. • Nsg. Dx.: Social isolation Activity 2 • Nsg. Diagnosis- Social isolation related to inability to trust, panic anxiety, delusional thinking, and regression as evidenced by stating people are trying to poison her. Activity 3 • Read the case study and the nursing diagnosis. As a group, discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. • Nsg. Dx. Risk for violence. Activity 3 • Nsg. Dx. Risk for violence: self- directed or other directed related to extreme suspiciousness, panic anxiety,or possibly command hallucinations as evidenced by believing roommate wanted to kill her and people are trying to harm her. Activity 4 • Read the case study and the nursing diagnosis .As a group, discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. • Nsg. Dx.-Impaired verbal communication Activity 4 • Impaired verbal communication related to panic anxiety, regression, disordered thinking as evidenced by looseness of association. Activity 5 • Read the case study and the nursing diagnosis. As a group discuss and decide on the nursing goal related to that nursing diagnosis. Write that goal on the paper, and then each person take a turn writing an intervention you would try in order to achieve that goal. When we are through we will discuss the interventions. • Nsg Dx.self care deficit. Activity 5 • Nsg Dx. Self care deficit related to withdrawal, regression, panic anxiety inability to trust as evidenced by inability to do hygiene, grooming and dress. Psychiatric Rehabilitation • Multidisciplinary and collaborative with the client, family, and community • Nurse teaches, coaches, serves as resource • Psychological treatments:Focus is always on decreasing anxiety and increasing trust • Group-Psycho education R/T meds, relapse prevention, social skills, decrease isolation Psychiatric Rehabilitation • Long term….requires from therapist exquisite patience and freedom from the need to prove oneself by effecting change. • Psycho education: • On medications • On the disease process • On relapse symptoms • On social interaction • On expressing emotions • On handling frustration Treatment • Group: inpatient phase of illness represents the most anxiety and social inability.Reduce stimuli. • Group supportive, not confrontational. • Social skills through role-playing real life situations. • Behavior modification- but pts. may have difficulty generalizing to community setting. Treatment • Family therapy- All illness involves the family, sometimes that may be the people at the halfway house or in the homeless camp. • Medications: 1954 Thorazine was the first antipsychotic. Response to meds.-10% do not recover, 30% partial recover needing some assistance, but able to work and care for needs, 30% poor recovery minimally surviving, 30% recover completely. Treatment • Medications-meds.+ supportive, ongoing therapy.Used both in the acute phase as well as for maintenance • Long term use. See handout. Medications • Review side effects: • Anticholinergic and movement ( pseudo parkinsonism, akinesia muscle weakness or loss of muscle ability, akathesia, dystonia spasms of the face arms, oculogyric crisis, tardive dyskinesia bizarre facial and tongue movements, difficulty swallowing. neuroleptic malignant syndrome. Medications • Non compliance may be an issue may have to use depot Haldol and Prolixin. • Comes in pills, liquid concentrate, injectable, and depot injectable for long acting effect • Have also begun using mood stabilizers. Nursing Diagnoses • Altered thought process R/T……(delusions,loose associations, concrete thinking) • Social Isolation R/T…….(withdrawal,lack of social network, anxiety, preoccupation with symptoms) • Self esteem disturbance R/T……(chronic disease, feeling different from others) • Knowledge deficit R/T……( not understanding disease, medications) Nursing Diagnoses • High risk for violence, self or others R/T ( panic level anxiety, command hallucinations, suspiciousness) • Self care deficit R/T….amotivation, inabbility to remember • Sensory perceptual alterations Interventions • Active listening Listen for themes Redirect Social skills training-role play, practice specific skills Model social behavior Self esteem enhancement-self esteem journal, give positive feedback,collage of interests and talk about it Interventions • Anxiety reduction-Relation techniques, notice and if possible change environmental stimuli, exercise • Teaching- disease, signs of relapse, plans for relapse identification symptoms, meds, schedule • Energy management- ADLS, naps, nutritional meals Interventions • Self-care assistance- list of hygiene tasks and the steps, times • Suicide prevention-assess command hallucinations and teach client what to do • Hallucination management-assess, help client describe needs that might be reflected in the content of the hallucination, identify triggers of hallucinations Interventions • Delusion management-assess, correlate onset of delusion with onset of stress, respond to the underlying feelings • Violence prevention encourage to talk rather than act out feelings, identify triggers, give personal space to client who is escalating,verbally set limits on aggressive behavior, avoid touching client who is scared Interventions • • • • Violence management Assess the congruency of your behaviors Involve family to the level of their ability and client confidentiality Teach family-convey message they are not the cause, teach signs of relapse, medications, how to deal with active symptoms, role play with them, teach about keeping a moderate level of expressed emotion, establish family rules,support groups, and family therapy