Class 7 (psychosis) Flashcards
what is a psychotic disorder
a person living with schizophrenia or another thought disorder may have difficultly distinguishing between what “is” or “isn’t” real
-person may also be withdrawn or unresponsive and may experience difficultly expressing their emotions
-affects perception via hallucinations/delusions
what is schizophrenia
syndrome/groups symptoms
-can be successfully managed once diagnosed
-early tx is better
-most can function independently once tx
-20-50% attempt suicide
-20-30% make a full recovery
schizophrenia co-morbidity
-substance misuse
-depression
-anxiety
-diabetes mellitus
-psychogenic polydypsia
the emotional impact of schizophrenia
-fear comes from stigma, delayed care, minimizes symptoms
-understanding & speak openly with patient
research on schizophrenia
researchers now believe that schizophrenia is actually a group of different illlnesses.
each illness is caused by environmental and social factors, these genes “malfunction” and produce distinct symptoms
risk factors for schizophrenia
-perinatal and obstetrical complications
-increased parental age (50+)
-environment (poverty, lack of services)
-increased immune system activation (inflammation, autoimmune diseases)
-taking mind-altering drugs during teen years & young adultood)
things to consider with schizophrenia that may be risk factors
-age of onset (males; 15-25, females: 25-35)
-ethnic & cultural considerations (decreased reports in asian people)
-genetics(familial tendencies, but still unsure how its “passed on”
-neurobiological (dopamine & limbic system)
signs and symptoms of schizophrenia in kids
visual hallucinations increase common
signs and symptoms of schizophrenia in under 25
increased negative s&s
signs and symptoms of schizophrenia in over 50
increase positive S&S (first 4 of 5 key features)
5 key features of schizophrenia
1.Delusions
2.hallucinations
3.disorganized thinking
4.abnormal motor behaviour
5.negative symptoms (take something away that should be there) i.e. loss of motivation/joy
positive symptoms in schizophrenia
-added to the person, not normally present
-occur earlier & easier to identify=earlier tx
-delusions (ideas of reference, perseuction, grandeur, somatic, jealousy)
-perceptual alterations(hallucinations)
-alterations in speech (loosening og associations, neologism, echolalia, clang association, word salad)
-alterations in behaviour (echopraxia, catatonia)
-disorganized thoughts(thought broadcasting, insetion, withdrawl, delusion of control)
negative symptoms seen in schizophrenia
-taking away from the person (absence of something that should be present)
-apathy
-avolition(decreased motivation)
-anhedonia(decreased pleasure)
-alogia(decerase speech)
-affective flattening
-anergia
paranoid schizophrenia
-included delusions & auditory hallucinations
-normal intellecual functioning & expression of emotion
-anxious, angry, argumentative, aloof
disorganized schizophrenia
-ADL’s disrupted
- alteration in speech & behaviours
-difficult to understand
-flattening of inappropriate emotions
-preoccupied with own thoughts
catatonic schizophrenia
muscle rigidity
residual schizophrenia
-past history of schizophrenia
-no positive s&s
-at least 1 past episode
-between acute & remission
undifferentiated schizophrenia
-both positive and negative S&S
-not enough s&s to diagnose one specific type
-mix of multiple types
pre-psychotic/prodromal phase of schizophrenia
-notices something is wrong
-“warning” signs
-bizarre behaviours
acute phase of schizophrenia
-best if caught early
-psychosis begins
-delusions, distortion of thought
stabilization phase of schizophrenia
-Dx is made, medication is started
-S&S become less acute
-adapting to med side effects
-some social interaction
maintenance phase of schizophrenia
-recovery phase
-monitoring for chnages
-support med adherence
-education for pt & family
-watch for s&s of relapse
things a person living with schizophrenia needs to recover
-knowledgable and caring team
-effective medication
-“talk therapy”
-peer, family, and friend support
-psych & social support programs
-personal relapse prevention plan
questions to ask during inital schizophrenia assessment
-keep it broad & open initially
-assess for hallucinations
-what are you seeing/feeling/experiencing
-substance misuse?
-SI/HI->plan?
-how long has this been otg
-have you ADL’s changed
first step of nursing process for schizophrenia (biological interventions)
-history & physical assessment
-bloodwork
-rule out medical or physiological impact
second step of nursing process for schizophrenia (biological interventions)
-monitor/assess ADL’s to determine need for assistance
third step of nursing process for schizophrenia (biological interventions)
-pharmacotherapy: typical antipsychotics
-task description
fourth step of nursing process for schizophrenia (biological interventions)
-ECT if determined to be effective
(not as effective for chronic but good for catatonia or life-threatening situation i.e risk of suicide, food paranoia etc)
typical antipsychotics
first generation antipsychotics
-haloperiodol(halodol)
-perphenazine(trilafon)
–chloropromazine(largactil or thorazaine)
how do typical antipsychotics work
they block dopamine receptors
side effects of typical antipsychotics
-anticholinergic side effects (dry mouth, urinary retention, tachycardia)
-extra pyramidal side effects (4 categories)
-sedation
-increase HR
-decerased BP
-increased prolactin
-agitation
-nausea
-dyspepsia
what are the 4 extrapyramidal side effects
1.dystonic reactions
2.akathesia
3.pseudo-parkinsonism
4.tardive dyskinesia
extrapyramidal side effects: dystonic reactions
abnormal movements:
-torticollis(contraction of neck muscles)
-oculogyric crisis(eyes diviate upwards)
-orolaryngeal pharyngeal hypertonus(difficulty swallowing & protrusion of the tongue)
extrapyramidal side effects: akathesia
significant restlessness
-fidgeting
-pacing
-occurs 2 hours->60 days after drug is started
extrapyramidal side effects: pseudo-parkinsonism
medication induced impaired body movements
-shuffling gait
-tremors
-usually in 1st week of starting med (may give congentin to help but NO KIDS AND NO OLDER ADULTS)
extrapyramidal side effects: tardive dyskinesia
most serious of the 4
-tongue protrusion
-rocking back & forth
-foot taping, jaw movement
can start short term, may not be reversible, usually seen in long term use + high dose
what scale is used to assess for eps?
abnormal involuntary movement scale “AIMS”
atypical antipsychotics
-emerged in 1990s, second generation antipsychotics
-OFTEN FIRST CHOICE d/t improved side effect profile
-can also be used as mood stabilizers
common atypical antipsychotics
-clozapine(clozaril)
-olanzapine(zyprexia)
-risperidone(risperdal)
-quentiapine(seroquel)
-ziprasidone(zeldox)
-aripiprazole(abilify)
side effects common to olanzapine
weight gain, tachycardia, increased risk for diabetes, sedating, bone marrow suppression
what atypical antipsychotics can be prescribed if the pt is prone to weight gain?
ziprasidone (zeldox)
aripiprazole (abilify)
side effects common in risperidone
increased prolactin
enlarged breast
irregular menses
-sexual dysfunction
sedation
hypotension
increased dose=EPS is a concern
side effects common in clozapine
agraunulocytosis
seizures
tachycardia
weight gain
sedating
side effects for atypical antipsychotics
metabolic syndrome
sedation & hypotension common
what is metabolic syndrome?
-significant concern in most atypical antipsychotics
-risk for altered glucose metabolism diabetes (hyperglycemia), dyslipidemia (cholesterol changes), abdominal obesity weight gain
-comorbidity of serious mental illness and metabolic syndrome contributes to the reduced lifespan of those diagnosed with a serious mental illness
what atypical antipsychotics are highest risk for metabolic syndrome
clozapine and olanzapine
what should the nurse be montioring for metabolic syndrome
-get baseline body weight & reassess at visits
-routine blood cultures, weight, blood pressure
what is neuroleptic malignant syndrome (NMS)
life-threatening neurological disorder most often caused by an adverse reaction to antipsychotic medication
-usually occurs when medication is stopped abruptly
-if detected early prognosis is good
what causes NMS
sudden, marked reduction in dopamine activity, either from withdrawl of dopaminergic agents or from blockade of dopamine receptors
seen when meds are stopped abruptly
signs and symptoms of NMS
muscle cramps & tremors
fever over 40
unstable blood pressure
drooling
diaphoresis
renal failure
alterations in mental status (agitation, delirium, coma)
treatment for NMS
discontinue medication, supportive measures, and possibly ECT
generally supportive care: no drug to combat, benzo’s may help
what is anticholinergic crisis
many medications prescribed in the psychiatric setting can produce anticholinergic effects due to sensitivity or over dose
physical symptoms of anticholinergic crisis
blurred vision
hypertension
flushing
dry skin
unstable vital signs
euphoria (overdose results in delirium and extreme agitation)
treatment of anticholinergic crisis due to overdose
gastric lavage
cooling blankets
give benzodiazepines for agitation
reasons for decreased med adherence in pts with psychiatric disorder
-lack of insight into medications
-thinking meds are not needed
-medication side effects
-insufficient knowledge about tx
-cultural shame
promote through education & collaborative care
nursing process: psychological interventions
-MSE
-nursing management
-education
-safety
-support
-psychotherapy (CBT, DBT)
what may cause a first episode of psychosis (FEP)
-use of psychoactive substances
-stress
- significant lifestyle changes
-emotional attitudes and beliefs of family members
nursing process: social interventions
therapeutic milieu
group activities
safety for self and others
community supports for psychiatric disorder clients
-peer support groups
-educational workshops
-advocacy
-create a meaningful life in community
-connecting with people/services
schizoaffective disorder
-S&S typical of both schizophrenia and a mood disorder (MDD or mania)
-positive symptoms: hallucination, delusion, disorganized speech, acatonia
-negative symptoms: affective flattening, alogia, avolition
-appear to have more insight into their illness vs true schizophrenia
what is delusional disorder
-presence of non-bizzare delusions (not outside the realm of possibility)
-delusions are not due to the efects of medications, drugs, or medical conditions
-denies psychiatric bases for problems
-could exhibit odd/bizzare behaviour
erotomanic delusional disorder ex:
belief that a famous person is in love with you
grandiose delusional disorder ex:
belief they are the most important/intellegent
jealous delusional disorder ex:
belief that a partner is cheating
somatic delusional disorder ex:
hypochondriac but really believe it
mixed delusional disorder
characteristics of several types
unspecified delusional disorder
other type of delusion; most common persecutory delusions
schizophreniform disorder
-similar to schizophrenia but shorter lasting (min; 1 month, max: 6 months. if continued=schizophrenia Dx)
-S&S of schizophrenia are present (hallucinations, disorganized speech, catatonic behaviour, negative symptoms)
-may/ may not be impaired social or occupational functioning
-not a result os schizoaffective disorder or a mood disorder
-ensure it’s not d/t a physical issue or substance use
brief psychotic disorder
emotional turmoil
confusion
may also experience hallucinations/deusions/bizarre behaviour
comes on suddenly (min 1 day max <1 month) with MIN 1 positive symptom
after tx goes back to baseline
psychotic disorders due to drugs and alcohol
need blood work to Dx
psychosis due to consuming drugs or alcohol
psychosis or catatonia d/t another medical or mental illness
i.e. hypothyroidism, cva, head injury
commonalities with cluster A personality disorders
most have had a depressive episode
30-50% have concurrent depression
schizotypal personality disorder
-pattern of social and interperosnal deficits
-discomfort with and reduced capacity for close relationships
-cognitive or perceptual distortions(ideas of reference, belief events have a true meaning to them)
-eccentric behaviour
-communication may be affected:speech is clear but very vague/no context, rambling, delusions (loss of ability to express/experience full range of emotions)
-increased prevelance in first degree relatives with schizophrenia(genetic) but criteria for schizophrenia will not be met
-may lack social supports d/t issues with expression/relationships (lack of trust/suspicious)
-need assistance with social integration
treatment for schizotypal personality disorder
psychotherapy
social integration
meds for concurrent dx
paranoid personality disorder
-pervasive distrust and suspiciousness of others at an inappropriate level, will never believe their suspicons are wrong
-psychotic episodes can occur
-difficult to facilitate their making contact with the health care team for fear of being labeled=delayed tx
-increased prevalence in families with history of schizophrenia (genetic)
-creates challenges for establishing therapeutic relationship d/t mistrust
-may lack support systems: impacts outcomes
-medications (atypical antipsychotics) may be helpful
-increasingly common in men
-distinct lack of humour, very serious
-will be on edge/alert
schizoid personality disorder
-difficulty expressing emotion
-detachment form social relationship
-can become delusional/develop schizophrenia
-lack of social supports & lack of interest in developing
-difficult to establish therapeutic relationship (slow steps)
-self absorbed, introverted, shy, socially withdrawn, “loner”
-lack of nurturing/empathy in childhood
-seek out jobs when they work alone i.e. night shift, computers
assessments for type a personality disorders
-semi-structured interview: goes beyond self-reported s&s, “how do others” questions d/t lack of insight
-history: genetic & environmental
-nurses self assessment to remove stigma and bias
assessment tools for type a personality disorder
Minnesota multiphasic personality inventory (MMPI)
-25-45 mins to complete
-10 clinical scales
-dx isnt dependent on this one tool
