Exam 2-Care of clients with schizophrenia spectrum another psychotic disorders

Question 1

introduction

Answer 1

-schizophrenia spectrum disorders are among the most severe mental illnesses
-found in all cultures, races, and socioeconomic groups
-heavy stigma for those diagnosed
-different cultural interpretations lead to various attributions for symptoms including possession by demons, punishment for evils done, evidence of being humane
-stigma surrounding the illness leads to difficulties with housing, treatment and rehabilitation for many diagnosed.

Question 2

schizophrenia spectrum disorders

Answer 2

-schizophrenia
-schizoaffective disorder
-brief psychotic disorder
-substance/medication-induction disorder

Question 3

schizophreniform disorder

Answer 3

essential features:
-identical to those of criteria A for schizophrenia=delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms
-EXCEPTION of duration of illness, which can be less than 6 months but with symptoms present for at least 1 month.

Question 4

psychosis

Answer 4

central to understanding schizophrenia spectrum disorders!
-state in which a person experiences hallucinations, delusions, or disorganized thoughts, speech, or behavior
-KEY DIAGNOSTIC FACTOR!

Question 5

prodromal period

Answer 5

stage of early changes, with different types of symptoms. stage of early changes that are a precursor to the disorder.
-may begin in early childhood
-more than half of patients report the following prodromal symptoms:

tension, nervousness, lack of interest in eating, disturbed sleep, difficulty concentrating, decreased enjoyment, loss of interest, restlessness, forgetfulness, depression, social withdrawal, feeling laughed at, more thinking about religion, feeling bad for no reason, feeling too excited, hearing voices, seeing things.

the benefit of discovering the presence of symptoms early, before solidified into a major disorder, is that treatment might be initiated earlier!!!

Question 6

acute illness

Answer 6

symptoms usually occur in late adolescence or early adulthood.
-in men: 18-25
-in women: 25-35
-subtle behaviors progressing to disruptive or bizarre.
-HIGH RISK FOR SUICIDE
-lack of social involvement
-decrease ability to complete basic needs.
-the longer the psychosis remains untreated, the more severe the disorder beocmes.
-as symptoms worsen, patients are less able to care for basic needs, substance use is common, functioning at school or work deteriorates, dependence on family and friends increases (these people will recognize need to pt treatment).
-patient may need to be hospitalized to protect themselves or others!!!
-initial treatment focuses on alleviation of symptoms through beginning therapy with medications, decreasing the risk of suicide through safety measures, normalizing sleep, and reducing substance use.

stabilization is main focus- intense treatment!!

Question 7

recovery

Answer 7

ULTIMATE GOAL!!!
-no medication will cure-medication generally diminishes the symptoms and allows the person to work toward recovery.
-need to follow therapeutic regime, maintain healthy lifestyle, manage stresses of life, develop meaningful interpersonal relationships
-family support and involvement is very important.
-must educate to anticipate and expect relapses and know how to cope with it.
-encourage autonomy with personal and reasonable goal setting, decreasing self-stigma while creating a positive self image, find ways to extract pleasure from life, create and maintain social connections with families and peers.

Question 8

relapses

Answer 8

-major concern of treatment
-MAIN REASON IS FAILURE TO TAKE MEDICATION CONSISTENTLY
-other factors: impairment in cognition and coping skills (leaves patients vulnerable to stressors), limited accessibility of community resources, lack of income support, degree of stigmatization (attacks self-concept of patients), social isolation (level of responsiveness from family and friends when patients need assistance may impact).
-income supports that can buffer day to day stressors of living may be inadequate

Question 9

diagnostic criteria: positive symptoms

Answer 9

excessive or distorted thoughts and perceptions
-hallucinations (1): one or more of senses, usually visual or auditory, without external sensory stimuli. most often a command- command hallucinations range from innocuous to very serious.
-delusions (2): thoughts that are erroneous, fixes, false beliefs that cannot be changed by reasonable argument. types include grandiose, nihilistic, persecutory, and somatic.

Question 10

diagnostic criteria: negative symptoms

Answer 10

lessening or loss of normal functions
-diminished emotional expression
-alogia (diminished used of words)
-avolition
-anhedonia

often not as dramatic as positive symptoms, but can interfere greatly with patient ability to function day to day. patients often laugh, cry, and get angry, less often. they have flat affect, and show little or no emotion.

Question 11

diagnostic criteria: neurocognitive impairment

Answer 11

-involves memory, vigilance, and executive function
-may be independent of positive and negative symptoms
-often manifested in disorganized symptoms: findings that make it difficult for the person to understand and respond to ordinary sights and sounds of daily living.

Question 12

disorganized thinking symptoms

Answer 12

-echolalia: repetition of another’s words that is parrot-like and inappropriate
-circumstantiality: extremely detailed and lengthy discourse about a topic
-loos associations: absence of the normal connectedness of thoughts, ideas, and topics; sudden shifts without apparent relationship to preceding topics
-tangentiality: the topic of conversation is changed to an entirely different topic that is a logical progression but causes a permanent detour from the original focus.
-flight of ideas: topic of conversation changes repeatedly and rapidly, generally after just one sentence or phrase.
-word salad: stirring together words that are not connected in any way
-neologisms: words that are made up that have no common meaning and are not recognizable
-paranoia:suspiciousness and guardedness that are unrealistic and often accompanied by grandiosity
-stilted language: overly and inappropriately artificial formal language
-referential thinking: belief that neutral stimuli have special meaning to the individual (TV speaking directly to them)
-autistic thinking: restricts thinking to the literal and immediate so that the individual has private rules of logic and reasoning that make no sense to anyone else.
-concrete thinking: lack of abstraction in thinking, inability to understand punch lines, metaphors, and analogies
-verbigeration: purposeless repetition of words or phrases
-metonymic speech: use of words with similar meanings interchangeably
-clang association: repetition of words or phrases that are similar in sound but in no other way (right, light, sight, might)
-pressured speech: speaking as if the words are being forced out.

Question 13

disorganized behavior symptoms

Answer 13

-aggression
-agitation
-catatonia: psychomotor disturbances, like stupor, mutism, posturing, repetitive behavior
-catatonic excitement: hyperactivity characterized by purposeless activity and abnormal movements, like posturing and grimacing
-echopraxia: involuntary imitation of someone elses movements and gestures
-regressed behavior
-stereotypy: repetitive purposeless movements that are idiosyncratic to individual and to some degree outside of the individual’s control.
-hyper-vigilance
-waxy flexibility: posture held in an odd or unusual fixed position for extended periods of time.

Question 14

diagnostic criteria: disruption in sense of self

Answer 14

Self= self-concept, self-consciousness, self-awareness, self-disturbance for those with schizophrenia.

-many symptoms may be attributable to brain deficiencies
-self disturbance: difficulty determining what thoughts and experiences are internal vs external- delusions and hallucinations can be explained by this, as can the person’s failures of insight, self-awareness, and self-monitoring.
-treatment aims to help clients to become active agents in their own care
-treatment that helps develop a sense of self is possible and integral to recovery!!

Question 15

schizophrenia in children

Answer 15

rare before adolescence
-should rule out other disorders before considering in childhood
-potential predictors in adulthood: developmental delays in attainment of speech and motor development, problems in social adjustment, pooer academic and cognitive performance
-adults who had childhood cognitive, social, behavioral, and emotional impairment may be at higher risk of developing schizophrenia.

Question 16

schizophrenia in older adults

Answer 16

if patient had schizophrenia since young adulthood, may be a time of improvement in symptoms, or decrease in relapse fluctuations.
may develop schizophrenia in late life.
-cost of care remains high due to lack of community-based treatment.

Question 17

epidemiology of schizophrenia

Answer 17

-age of onset: usually late adolescence or early adulthood.
-earlier diagnosis and poorer prognosis in men
-racial groups may have varying diagnostic rates, however, not clear whether this is representative correctly or misdiagnoses based on cultural bias of clinician. example- usually over diagnosed in African Americans
-familial differences: first degree biologic relatives of an individual have 10 times estimated greater risk for schizophrenia. other relatives may have increased risk for related disorders.

Question 18

co-morbidities with schizophrenia

Answer 18

patients more susceptible to:
-TB
-HIV
-hep B and C
-osteoporosis
-poor dentition
-impaired lung function
-altered/reduced pain sensitivity
-sexual dysfunction
-obstetric complications
-CV problems
-hyperpigmentation
-obesity (gain weight after medication management)
-DM (type 2)
-metabolic syndrome with HLD
-polydipsia
-thyroid dysfunction
-hyperprolactinemia

early mortality may be from natural or unnatural causes.

-substance abuse, depression, DM, obesity

Question 19

biologic theories of schizophrenia

Answer 19

-neuroanatomic findings: larger lateral and third ventricles, total brain volume smaller (VBR larger in those with schizophrenia)
-genetic associations: identified in numerous areas of the brain, some tying to neuropathways related to cognitive deficits- important for future treatment!
-neurodevelopment: pathologic processes caused by genetic and environmental factors beginning before the brain reaches its adult state. in utero during first or second trimester, with genes involved in cell migration, proliferation, axonal outgrowth, and myelination may be affected by neurologic insults (like viral infections). early insults may lead to dysfunction of specific networks becoming obvious at adolescence during normal loss of some plasticity and synapse development.
-neurotransmitters, pathways, receptors: dopamine hypothesis- resonated that hyperactivity in the mesolimbic tract at the D2 receptor site in striatal area may be responsible for positive symptoms. low levels of dopamine in prefrontal cortex are thought to underly cognitive dysfunction in schizophrenia.
-dopamine dysregulation
-receptors roles
-gut microbiota

Question 20

family response to schizophrenia

Answer 20

-usually experience disbelief, shock, fear, concern family member
-may attribute to illicit drugs or extraordinary stress or fatigue
-respond with fear, confusion, anxiety
-may deny severity and chronicity of illness
-may feel overwhelmed, angry, and depressed
-may be fearful of behaviors and respond to patient anger and hostility with fear, confusion, and anxiety
-parents may become caregivers as the person transitions into adulthood, thus facing challenges accessing health care and resources

Question 21

teamwork for working toward recovery

Answer 21

team members: generalist nurse, advanced practice psych nurse, psychiatry, psychology, social work, OT and recreational therapy, pastoral counseling
-med management
-recovery-oriented strategies
-psychosocial interventions
-complementary and alternative therapies

Question 22

ACT team: assertive community treatment

Answer 22

ACT= assertive community treatment
-team directed programs helping people with severe mental illness
-for people with schizophrenia in their late teens to older ages who have a hard time functioning in their own community
-various professionals work as a team instead of being outside consultants
-help with community and family matters

Question 23

safety issues with schizophrenia

Answer 23

-SI/HI assessment: ALWAYS WHEN PATIENT IS EXPERIENCING PSYCHOTIC EPISODE
-potential aggressive actions toward staff and other patients when admitted to inpatient unit
-substance use: substance related disorders common
-must determine if displaying negative symptoms, side effects of antipsychotic meds, or actual depression and demoralization as a result of this illness.

Question 24

EBP nursing care and schizophrenia

Answer 24

-recovery is LONG TERM JOURNEY
-may need hospitalization for stabilization and meds adjustment
-nurse and patient collaborate in developing recovery-oriented strategies during periods of relative stability

Question 25

mental status and appearance

Answer 25

-mood and affect: affective lability, ambivalence, apathy -speech: thought content and other mental processes are expressed in speech. may include obvious obsessions or delusions, loose associations, or flight of ideas -thought process assessment: determine if any hallucinations, delusions, disorganized communication, or cognitive impairments are present. -hallucinations: auditory most common -delusions: do not change even though strong evidence contradicts the belief. must consider culture when evaluating delusions. delusional beliefs are those not sanctioned or held by cultural or religious subgroup. -disorganized communication: watch for abrupt shifts in focus of conversation. impaired verbal fluency commonly present -cognitive impairments: memory and orientation (orientation x4 may remain intact unless particularly preoccupied with delusions and hallucinations; memory or ability to recall newly learned information may be particularly diminished, impacting short and long term memory, and the ability to engage in abstract thinking may be impaired- POOR HISTORIAN) , insight and judgment: insight is recognizing delusions/hallucinations are mental disorder s/sx, judgment is ability to decide or act about situation) -behavioral responses -self concept -stress and coping patterns -social network -functional status -support systems

Question 26

quality of life

Answer 26

-often have poorer quality of life -assess how improvements can be made -simple changes can greatly improve patient: arrange different roommate, improve access to social activities, meet transportation needs.

Question 27

strength assessment

Answer 27

-identify personal and family strengths -FAMILY SUPPORT CRITICAL -intellectual ability and coping with stress- may be areas of strength -since usually diagnosed at younger age, person may be physically fit with little evidence of chronic illness, strengths will emerge as assessment is completed

Question 28

prioritization of nursing care

Answer 28

SAFETY, STABILIZATION, TREATMENT ENGAGEMENT -variety of nursing care needs emerge at different times: SAFETY IS FOCUS DURING PSYCHOSIS EPISODES -sleep is severe problem -depression may be priority at later time -hygiene may be issue -motivation may become issue -ALWAYS PRIORITIZE SEVERITY OF CURRENT RESPONSES -nursing: short, time limited interactions, consistency, keep promises, recovery-oriented model, must develop trust, calm and caring presence.

Question 29

mental health nursing interventions

Answer 29

-self care -activity, exercise, nutrition: may be necessary to counteract SE of psych meds that may cause weight gain- HOWEVER, this may be a reason pts stop taking medications. -thermoregulation interventions -fluid balance: observe for polydipsia, incontinence (may lead to low serum sodium levels and water intoxication, a medical emergency) -primary care coordination -medications: antipsychotics

Question 30

antipsychotics

Answer 30

treatment of choice for patients with psychosis. used due to general effect of blocking dopamine transmission, leading to a decrease in psychotic symptoms. -medications must be individualized. -first gen: haloperidol, chlorpromazine -second gen: risperidone, olanzapine, quetiapine, paliperidone, ziprasidone, ariprazole, iloperidone, lurasidone (more likely to have metabolic side effects) 2nd gen: effective in treating positive and negative symptoms, blocking D2 and serotonin transmission signals. also target serotonin and glutamate, believed to contribute to antipsychotic effectiveness.

Question 31

typical/first generation antipsychotics

Answer 31

D2 receptor antagonist -role: motor control, motivation, arousal, cognition, reward, sexual gratification, nausea -focus: positive symptoms, hallucinations, delusions -side effect: impacts voluntary and involuntary movement examples: chlorpromazine, haloperidol

Question 32

atypical antipsychotics

Answer 32

-1-2 weeks to effect a change in symptoms, usually trial of 6-12 weeks before a change -ziprasidone and lurasidone given with FOOD- ensures proper metabolism of the drug -clozapine used when no other second-generation agent is effective. adherence to prescribed medication regime best approach to prevent relapse!! -may discontinue if: neuroleptic malignancy syndrome, agranulocytosis, drug reaction with eosinophilia and systemic symptoms, tardive dyskinesia.

Question 33

extrapyramidal side effects

Answer 33

-parkinsonism (shuffles, stooped posture, bradykinesia, rigidity, pill-rolling), anticholinergic effects -dystonic reactions -akathisia -usually happens after years of being on same medication and usually first gen: tardive dyskinesia (protrusion and rolling tongue, smacking lips, chewing, involuntary movements), tardive dystonia (facial grimacing, upward eye movement, laryngeal spasms, muscle spasms), tardive akathisia (restless, trouble standing still, pacing, feet in constant motion) -orthostatic hypotension -sedation -hyperprolactinemia -weight gain -new onset diabetes -cardiac arrhythmias -agranulocytosis

Question 34

complications: neuroleptic malignant syndrome

Answer 34

life threatening condition that can develop in reaction to antipsychotic medications. primary symptoms are MENTAL STATUS CHANGES, SEVERE MUSCLE RIGIDITY, AND AUTONOMIC CHANGES (elevated temp- 101 and 103), tachycardia, BP lability) -mental status changes and severe muscle rigidity usually occur within first week of initial of antipsychotic therapy, and can include two or more: HTN, tachy, tachypnea, prominent diaphoresis, incontinence, mutism, leukocytosis, lab evidence of muscle injury) -can be fatal

Question 35

nursing aspects for NMS

Answer 35

-recognizing symptoms early -withholding any antipsychotic or other dopamine antagonist medications -initiate supportive nursing care -be alert for NMS signs in high risk patients (those who are agitated, physically exhausted, or dehydrated, or who have existing medical or neurological illness).

Question 36

anticholinergic medication effects and abuse

Answer 36

-some patients find the effects pleasurable -toxic dosages may experience mild delirium with disorientation and hallucination -lesser doses may cause patients to experience greater sociability and euphoria

Question 37

complications: anticholinergic crisis

Answer 37

AKA anticholinergic delirium- may resemble schizophrenia -potentially life-threatening emergency: overdose or sensitivity to drugs with anticholinergic properties -s/sx: hot as a hare, blind as a bat, mad as a hatter, dry as a bone -self limited, usually 3 days after drug is discontinued -treatment: discontinuation of medication, physostigmine, gastric lavage, charcoal, catharsis for intentional overdoses

Question 38

psychosocial interventions

Answer 38

nursing interventions: should be guided by three general patient outcomes: 1-decrease frequency and intensity of hallucinations and delusions 2-recognize hallucinations and delusions are symptoms of a brain disorder 3-develop strategies to manage the recurrence of hallucinations or delusions -enhance cognitive functioning -use behavioral interventions

Question 39

psycho-education

Answer 39

-teaching strategies, teach about symptoms: what they are, who to talk to about them -teach how to cope with stress -social skills training -family education

Question 40

promoting patient safety

Answer 40

-monitor for potential aggression -administer medication as ordered -reduce environmental stimulation -use individualized approach -convene support groups -implement milieu therapy

Question 41

developing recovery-oriented rehabilitation strategies

Answer 41

-promote recovery: adjustment, coping, reappraisal, responding to the illness, social support, close relationships, and belonging -negative impact on recovery: negative interactions and isolation, internal barriers, uncertainty and hopelessness

Question 42

evaluation and treatment outcomes

Answer 42

-continuum of care: emergency care, in-patient focused care, community care -successful treatment and management with significant improvement or recovery -continuity of care as a major goal of recovery -mental health promotion with a positive support system for stressful periods

Question 43

SAD= schizoaffective disorder

Answer 43

mental health condition combining symptoms of schizophrenia and mood disorder. changes how people think, feel, and act characterized by periods of intense symptom exacerbation alternating with periods of adequate psychosocial functioning. at times marked by psychosis, other times by mood disturbance, when psychosis and mood disturbance occur at the same time. -most associated with late teens to early 30s, more common in women than men -s/sx: hallucinations or delusions, disorganized thinking, depressed mood, manic behavior -more likely to exhibit persistent psychosis than are patients with a mood disorder -long term outcome is generally better than that of schizophrenia but worse than that of mood disorder -patients are at risk for suicide -risk factors for suicide increase with the use of alcohol or substances, cigarette smoking, previous suicide attempts, and hospitalizations -lack of social contact may also be a factor for suicidal behavior

Question 44

treatment for SAD

Answer 44

-antipsychotics -antidepressants -mood stabilizers: treat underlying conditions related to disorder like bipolar, mood swings, manic episodes BBW: extrapyramidal effects with use of first gen antipsychotics and high risk of death in elderly patients with dementia.

Question 45

delusional disorder

Answer 45

logical, stable, well-systematized delusions that occur in the absence of other psychiatric disorders -delusions: situations that could occur in real life and are plausible in the context of the person's ethnic and cultural background or clearly impossible

Question 46

schizophreniform

Answer 46

identical features to those of schizophrenia, with the exception of the duration of the illness, WHICH CAN BE LESS THAN 6 MONTHS. -symptoms must be present for at least 1 month to be classified -about 1/3 of patients recover, with 2/3 developing schizophrenia

Question 47

brief psychotic disorder

Answer 47

a disorder on the spectrum of schizophrenia. length of the episode is at least 1 day but less than 1 month -onset is sudden and includes at least one of the positive symptoms (delusions and hallucinations) of schizophrenia -person generally experiences emotional turmoil or overwhelming confusion and rapid, intense shifts of affect. -high risk for suicide -s/sx: delusion, inappropriate behavior, hallucinations, paranoia, blunt behavior and flat affect, schizophasia/word salad -episodes only occur once, and if another episode occurs, the patient will get a diagnosis of schizophrenia -RECOVERY IS ULTIMATE GOAL

Question 48

treatment for brief psychotic disorders

Answer 48

-haloperidol (first gen) -risperidone (second gen) -chlorpromazine (first gen) -ANTIPSYCHOTICS that are used to treat schizophrenia are often prescribed