Psychotic Disorders Flashcards
Schizophrenia - Physiological Factors
Neurotransmitter dysregulation
- Dopamine Hypothesis
- Dopamine and Serotonin Dysregulation (more accepted theory)
Schizophrenia - Onset - Prodromal Symptoms
One year prior to diagnosis Subtle Changes -Behavior -Thinking -Relating to others -Caring for self -Mounting anxiety -Emotional blunting -Loss of interest -Heightened sensitivity to sound -Neglect of personal hygiene -Somatic concerns -Preoccupied with body parts -Sense of body distortion -Self-mutilation -Starving
Schizophrenia communication -
Tangentiality
Digressive or irrelevant manner of speech where central idea is never communicated
Schizophrenia communication -
Circumstantiality
Digression into unnecessary details and inappropriate thoughts before communicating central idea
Impaired communication - Bizarre Speech (8)
- Echolalia-
- Concrete thinking
- Word salad
- Loose associations
- Flight of ideas
- Thought retardation
- Thought blocking
- Neologism - invented words
Schizophrenia - Altered Thought Processes
Delusions (5)
- Persecution
- Paranoia
- Reference
- Referential delusion
- Ideas of reference
- Grandeur
- Somatic
Schizophrenia -
Somatic Delusions
Somatic - Thinking that your body is diseased in some way. i.e. The idea that one’s body is completely infested with parasites (clearly untrue).
Schizophrenia -
Nihilistic Delusions
Nihilistic - Total rejection of values, extreme skepticism or moral and value judgment
Schizophrenia - Negative Symptoms
Alexithymia
Alexithymia - Difficulty naming and describing emotions
Schizophrenia - Negative Symptoms
Asociality
Asociality - Few friends ~ preference for solitary activities
Schizophrenia - Negative Symptoms
Anhedonia
Anhedonia - Inability to experience pleasure
Schizophrenia - Negative Symptoms
Avolition
Avolition - Lack of motivation
Schizophrenia - Negative Symptoms
Apathy
Apathy - You don’t care
Schizophrenia - Negative Symptoms
Affect changes
- Flat = no affect
- Blunted = not overly animated
Schizophrenia - Negative Symptoms
Anergia
Anergia - no energy
Schizophrenia - Negative Symptoms
Ambivalence
Ambivalence - having conflicting ideas, wishes and feelings toward a person, thing or situation.
Schizophrenia - Negative Symptoms
Alogia -
Alogia - Decreased productivity of thought and speech
Catatonia - Clinical picture is dominated by three (or more) of the following symptoms (12)
Stupor - no psychomotor activity
Catalepsy - passive induction of a posture held against gravity
Waxy flexibility - Slight, even resistance to positioning
Mutism - no or very little verbal response
Negativism- oppositional or no response to instructions
Posturing- spontaneous or active maintenance of a posture held against gravity
Mannerisms- Odd, circumstancial caricature of normal actions
Stereotypy- Repetitive, abnormally frequent, non-goal directed movements
Agitation- Not influenced by external stimuli
Grimacing- scowl
Echolalia- Mimicing another’s speech
Echopraxia- Mimicing another’s movement
Schizoaffective Disorder - Period of illness includes
Major mood episode (MDD or Mania)
Concurrent with two or more:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic
- Negative symptoms
A homeless psychotic patient tells you that they were attacked by insects “all over me”. What is the first thing you would do?
Check for bites or any indication of head lice
Nursing Interventions (4)
- Relapse prevention
- Maintain psychosocial functioning
- Provide education
- Improve quality of life
ACT - Assertive Community Treatment
“Kendra’s Law”
Intense case management
-Note: Intense case managemetn should be part of discharge plan for client with multiple psychosocial issues (o.e. homelessness) who have multiple hospitalizations
Community/Outpatient care - Personalized Recovery Oriented Services (8)
- Improve functioning
- Reduce inpatient utilization
- Reduce emergency services
- Reduce contact with criminal justice system
- Increase employment
- Attain higher levels of education
- Secure preferred housing
- Mainstream into the community
Meeting Patient’s Psychological Needs -
Relapse Prevention Education (8)
- Poor nutrition
- Lack of sleep
- Infection
- Hostile environment
- Social isolation
- “Hopeless” attitude
- Poor social skills
- Medication issues
* How will client get meds?
- Order, finance, pick up
Meeting Patient’s Psychological Needs -
Relapse Prevention Education
- Self monitoring
- Recognition of triggers
- Events, time, place, stimuli - Identify HIGH RISK times
Family Needs - Provide Education on the Disease Process
- Need to understand that schizophrenia has many presentation for different clients
- Should NOT compare client’s symptoms to other schizophrenics in the family, relatives, friends, etc.
Strategies for working with Psychotic patients
Re-orient to reality
-“I know that you believe you (hear voices) but I want you to know that I do not hear any voices (except yours).”
Acknowledge feelings
-“I believe you are safe here, but it must be very frightening to believe that the CIA is after you.”
Pharmacologic Intervention - Long acting injections
Given every 4 weeks Check for allergy before administering LAI -Prolixin Decanoate -Haldol Decanoate -Risperdal Consta -Invega Sustenna -Zyprxa Relprevv
Zyprexa Relprevv - Precautions / Implications
- Post injection delirium/sedation syndrome (PDSS)
- Client must stay for 3 hour observation after injection
Zyprexa Relprevv - Symptoms (9)
- Sleepy
- Dizzy
- Disoriented
- Stiff
- Shaky
- Weak
- Increased Blood Pressure
- Seizures
- Unconsciousness
Alternatives to PO Meds
- Orally disintegrating anti-psychotics OR
- Long Acting Injections
*We need to know alternatives to standard PO meds
Orally disintegrating anti-psychotics (3)
- Zyprexa Zydis
- Risperdol-M Tab
- Abilify Discmelt
Long Acting Injectables (5)
- Prolixin Decanoate
- Haldol Decanoate
- Risperdol Consta
- Invega Sustenna
- Zyprxa Relprevv
Patient Education for Antipsychotic Side Effects
- Photosensitivity - Stay out of the sun or wear sunscreen
- EPS - Various movement disorders
- Pregnancy - Risk vs. benefits
- Avoid antacids
- Diet teaching
- Rise slowly - hypotension (orthostatic)
Anti-psychotics Adverse Side Effects -
Agranulocytosis
- May occur with any anti-psychotic
- Most common with CLOZARIL
- May occur at any time during treatment
Anti-psychotics Adverse Side Effects
Agranulocytosis - Symptoms (4)
- Sore throat
- Mouth sores
- Increased temperature
- “Flu Like” symptoms
Anti-psychotics Adverse Side Effects
Agranulocytosis - Nursing interventions (4)
- Check WBCs
- Hold dose of Clozaril
- Notify health care prescriber
- Monitor patient for increased and worsening symptoms
Clozaril Protocol
- Not for patient who dislikes needles! *
Initially - Weekly WBC.CBC for 6 months
After 6 months - WBC/CBC bi -weekly for next 6 months
After first year - Month for the duration of medication
Anti-psychotic Adverse Side Effects
Neuroleptic Malignant Syndrome - AM FM (4)
- Autonomic Instability - Increased BP/P
- Muscle Symptoms - “lead pipe rigidity”
- Fever up to 107
- Mental status changes - confusion to COMA
Extrapyramidal Side Effects -
KNOW
Extrapyramidal Side Effects -
Psuedoparkinsonism
“Pill rolling”
Extrapyramidal Side Effects -
Akathesia
–MOST COMMON SIDE EFFECT–
Extreme restlessness
“Ants in the pants”
Extrapyramidal Side Effects -
Dystonia
“Neck to the side”
- Muscular rigidity
- Stiff or thick tongue
- Difficulty swallowing
- Spasms in face/neck
Extrapyramidal Side Effects -
Tardive Dyskinesia
“Permanent lip smacking”
- abnormal, involuntary skeletal movements
- facial grimacing
- finger movement
- jaw swinging
- repetitive chewing
- tongue thrusting
- *-IRREVERSIBLE**
Extrapyramidal Side Effects -
Bradykinesia
“SLOW movement”
Extrapyramidal Side Effects -
Akinesia
“No movement”
Extrapyramidal Side Effect ASSESSMENT
Observe and measure involuntary movements
- Face
- Trunk
- Extremities
- Abnormal, involuntary skeletal movements
** Extrapyramidal Side Effects ** (4)
- Pseudo parkinsonism
- Pill rolling
- Drooling
- Shuffling gait
Anticholinergics - Indications for use
EPS
Used for
- Dystonias (decrease drooling)
- Pseudo-parkinsonism (less of a shuffle)
- Initiate when symptoms arise
- Use may become unnecessary after several months
- Some potential for abuse
- *-DO NOT USE with TARDIVE DYSKINESIA** -WILL MAKE IT WORSE
Anticholinergics - ABC (3)
Artane (trihexohenidyl)
Benadryl (diphenhydramine)
Cogentin (benzotropine) MOST COMMON
Anticholinergic Side Effects
Can’t See (blurred vision)
Can’t Pee (urinary retention)
Can’t Spit (dry mouth)
Can’t Shit (constipation)
Anticholinergic Syndrome (4)
Increased Temp - Hot as a Hare
Dilated Pupils - Blind as a Stone
Agitation - Made as a Hatter
Hot, dry, flushed skin - Dry as a Bone
Non-Compliance (6)
Find out WHY patient is non-compliant
-Insensitivity to patient’s challenges
Wishes - opposition of idea of taking meds
Complaints - poorly controlled side effects
Ability to buy medications after discharge
Ability to follow up - transportation, insurance
Now Do…
Mood Disorders!
