Psychotic Disorders Flashcards
Psychosis
defined as an abnormal state in which thoughts, feelings and perceptions are altered
Psychosis may be due to…
psychiatric or neurologic disorder or secondary to physiological stressors
Schizophrenia
disease of the brain that causes distorted and bizarre thoughts, perceptions, emotions, movements, and behavior
-syndrome or disease process vs. a single illness
Two major categories of symptoms for Schizophrenia
positive and negative
Positive Schizophrenia Symptoms
- delusions
- hallucinations
- grossly disorganized thinking, speech, and behavior
Negative Schizophrenia Symtpoms
- flatted affect
- social withdrawal
- lack of volition
Symptom rule for Schizophrenia
Two or more of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated).
Of the symptoms, at least 1 of them has to be delusions, hallucinations, or disorganized thoughts.
- delusions
- hallucinations
- disorganized speech
- grossly disorganized or catatonic behavior
- negative symptoms
Adult Schizophrenia patients…
demonstrate a decreased ability to function either at work, in relationships, or in ability to care for themselves
Children Schizophrenia patients….
fail to achieve expected level of performance in tasks related to interpersonal, academic, or occupational functioning
Symptoms of Schizophrenia must be present for…
6 months
Schizoaffective disorder
experience hallucinations, delusions, disorganized thought and disorganized behavior
- they suffer from at least one manic episode or period of major depression
- must experience depressive or manic episodes at least 50 percent of the time throughout the entire course of their illness
- must persist for 2 weeks or more
- often misdiagnosed
Schizophreniform disorder
presents similarly to schizophrenia but symptoms last 1-6 months whereas a full 6 month duration is needed for schizophrenia
Brief psychotic disorder
brief episode of typically positive psychotic behavior and lasts between 1 day and 1 month
catatonia
unusual or lack of body movement
wavy flexibility
will maintain any position in which they are placed
Mood and affect
- variable: flat or blunted to silly and inappropriate
- mood and affect may be incongruent
- anhedonia (lack of pleasure)
- euphoria
Thought context
- WHAT THE CLIENT ACTUALLY SAYS
- the ideas expressed
What is assess under thought content?
- delusions
- suicidal or homicidal ideation
- magical thinking
- poverty of speech or content
Thought Process
aka Form of Thought
- HOW the thoughts are expressed
- assessed through the client’s verbal communication–inferred–speech reflects thoughts
Circumstantiality
speech that takes a circuitous route before reaching its goal
Tangentiality
speech that talks past the point and never reaches the goal of answering the questions
Echolalia
repetition of speech
Clang associations
individual repeatedly uses rhyming words without apparent meaning
Neologisms
uses meaningless words that only have meaning to them
Preservation
uses the same words or phrases over and over
Included in the assessment of perception are…
-hallucinations
Hallucinations
sensory perception in the absence of an actual external stimulus.
they can occur in any sensory system of the body, such as…
- auditory
- visual
- tactile
- olfactory
- gustatory
Command hallucinations
potentially the most dangerous
MUST ASK: “do the voices ever tell you to do thing? if so, do they ever tell you to hurt yourself or someone else?
Judgment
Defined in Taber’s as: the use of available evidence or facts to formulate a rational opinion or to make socially acceptable choices or decisions
Intact judgment
requires the ability to interpret the environment correctly
impaired judgment
may result from faulty perceptions
-this may manifest in an inability to recognize dangers or potential for self neglect
Insight
ability to recognize that something is wrong or that they are suffering from a mental illness
Denial
common with schizophrenia, making the disease particularly difficult to treat
Self Concept
- ego boundaries
- may lack a clear sense of where their own bodies, minds, and influence end and where those of others begin
- can be seen in depersonalization, derealization, and delusions of reference
- may be the source of bizarre behaviors, including some that are socially unacceptable
Roles and Relationships
- difficulties with trust and intimacy
- low self esteem
- combined with problems in thinking, behavior, and self concept this leads to isolation and avoidance of others
- difficulty functioning at even the most basic levels such as being a son, daughter or member of a family
Social Adjustment
interactions with others:
- observe client’s interactions with staff and family
- does client initiate social interactions?
- able to maintain contact?
- take part in recreational and occupational groups?
- active participant in therapy groups?
Developmental
- Regression: Trust vs Mistrust
- Erickson’s first stage
- developmental age/stage may be affected by age of onset
- level of maturity, developmental tasks, and moral development
concrete thinking
inability to think in abstract terms
illusion
distorted perceptions of actual sights, sounds and other stimuli
Occipital lobe
interprets visual stimuli
Temporal lobe
interprets auditory and olfactory stimuli
Therapeutic Relationship
- be patient
- short, frequent contacts
- clear and direct explanations
- personalize the interaction by using client’s name
- do not touch the patient
- maintain body posture that conveys a caring and attentive tone
- be consistent, enhances trust
Communication
be ready for clients who may have little or nothing to say
Respond to the _________ expressed by the client
FEELING
Clarify the meaning of the client’s conversation by….
exploring and clarifying questions, listening for themes, or recurring statements
How can you convey your interest and their value?
just being with the client and accepting them at that level
Interventions for Hallucinations
- look for behavioral clues
- ask what the patient is experiencing
- assess the content of the hallucinations so you can act to protect the client or others
- try and find out what the CLIENT IS FEELING
- focus on the HERE AND NOW (what is on tv, what did the patient eat last)
- sometimes it is useful to engage the client in an activity like cards, music, etc which is a here and now, reality based activity
- control the environment (reduce isolation, reduce excess stimulus and stress)
- ***communicate that you are NOT experiencing the vision or voice, but validate patient experience
- **then provide diversion
- ***I believe that your are hearing the voice of your brother. I do not hear a voice. Let’s go sit outside with the others.
***This is an important intervention: use cautiously if patient in crisis
Impaired reality testing
- help patient check environment for source of sound
- help patient assess responses of others (if they are not frightened, perhaps what patient saw or heard was not real)
- help patient identify persons they trust
**use these interventions once patient is more stable
Interventions for Delusional Thoughts
- avoid playing along or participating in the client’s delusions
- avoid openly confronting the delusions
- distraction from delusional thinking with playing board games, listening to music, walking
How to avoid openly confronting the delusions
- present and maintain reality such as “I’ve seen no evidence of that”
- use statements that cast doubt such as “It doesn’t seem that way to me”
Interventions for Disorganized Thinking
- Communication
- Assess need for assistance with self care
- Always create trust, conduct psychosocial assessment each shift
Communication techniques for disorganized thinkers
- attempt to decode speech you do not understand
- anticipate patient’s needs
- use short, concrete explanations (1-6 words)
Physiologic and Self-Care Considerations
- ADL’s: Lack of interest in grooming and basic hygiene
- Performing basic ADLs may be difficult
- They may not recognize or attend to hunger or thirst, and may become dehydrated and undernourished
- paranoia may keep them from eating
Sleep issues
paranoid thoughts, hallucinations
-sleep cycle disruptions due to late night activity and daytime sleeping
basic living skills
paying bills, cooking, grocery shopping, etc may be lacking
To apply the concept of cognition
-recognize situations in which a patient’s thought processes contribute to increased risk of self harm
use nursing process to minimize risk of harm or neglect and promote progress on goals
-identify interventions that allow patients to maintain dignity
Collaborative Care goals: Acute stage
- protect safety of patient and others
- stabilize with antipsychotics
- develop therapeutic relationship with patient (provides foundation for more in depth assessment)
- monitor/encourage continued progress as degree of psychosis clears
Culture of Safety
- staff practice nonviolent crisis intervention
- use personal safety plans with patients
- coordinated response teams
- APNA position statement on seclusion and restraint
APNA position statement on reduction of seclusion and restraints shows some evidence that all of the following are helpful:
- maintain presence on the unit and notice early changes in patient and milieu
- assess the patient and intervene early with less restrictive measures
- changing aspects of the unit to promote a culture of structure, calmness, negotiation and collaboration rather than control
Psychotropic Drugs do what…
- reduce distorted thinking (delusions)
- reduce distorted perceptions (hallucinations)
- reduce anxiety to manageable levels
- reduce violent/bizarre behaviors
Nursing Diagnoses for patients exhibiting POSITIVE symptoms
- risk for injury
- acute confusion
- impaired memory
- personal identity disturbance
- impaired verbal communication
- dysfunctional family processes/altered family coping
Nursing Diagnoses for patients exhibiting NEGATIVE symptoms
- self neglect
- impaired social isolation
- diversional activity deficit
- ineffective health maintenance
- ineffective management of therapeutic regimen
- self care deficit
Active Intervention is required when…
A. When the client is in an acute stage of psychosis.
B. When the client is in emotional or physical pain.
C. When the client is a danger to him/her self or others.
D. When the client is destructive to the environment.
Intervening with Socially Inappropriate Behaviors
-loss of ego boundaries can lead clients into inappropriate expression of feelings and behaviors:
- touching others
- intruding into the living space or personal space of others
- taking to inanimate objects
- inappropriate statements
**protect client from retaliation
Inappropriate Behaviors
- redirect or interrupt the unacceptable behavior to reduce intrusion on others
- engage client in activity
- offer some time out (client’s room or quiet area)
- use a non-judgmental and matter of fact manner, use factual statement without scolding
- provide explanation to other clients without violating confidentiality
Outcome Identification: Client Goals during the acute or inpatient phase
- free from injury to self or others
- establish contact with reality
- increase social interaction
- express thoughts/feelings appropriately
- participate in therapeutic activities
Suicide Risk Stats
Schizophrenics: 50x higher
40 percent of patients attempt suicide once, 10 percent die
Collaborative Discharge Planning
-nurse and patient will collab with:
all tx team members
physician, pharmacy, social worker, family and outpatient case manager to coordinate availability and continued adherence to medications
followup care
physician, social worker, family, and outpatient case manager and outpatient provider
The nurse can help the client understand…
- nature of the illness
- medication
- learn social skills through education, role modeling and practice
- self care, ADLs, proper nutrition
Family and significant other teaching
- refer to NAMI
- identify community resources
- create a crisis response plan
Patient and family teaching
- identify behaviors that may signal a potential relapse
- understand importance of maintaining support systems
Community Resources
- case management
- ACT (Assertive Community Treatment)
Relapse Prevention
- teach risk factors for relapse
- drug or alcohol use
- new diagnosis
- stress
- teach warning signs for relapse (hearing voices)
- feeling suspicious
- staying away from friends
- losing interest
To prevent relapse encourage patient to…
- take meds
- keep all doctor and therapy appointments
- recognize warning signs
- attend any weekly support group or family education
- get to a doctor ASAP
Role of the Family (inpatient)
- involve family in patient’s care, esp ADL’s
- involve family in unit activities when possible
- involve family in decision making concerning patient’s treatment
- often family need to have power of attorney, esp health care
- refer to appropriate agencies
Role of the Family (inpatient)
- involve family in patient’s care, esp ADL’s
- involve family in unit activities when possible
- involve family in decision making concerning patient’s treatment
- often family need to have power of attorney, esp health care
- refer to appropriate agencies
Difference between positive and negative symptoms
Positive: additional psychotic behaviors not commonly obsereved in adult patients that can cause them to lose touch with reality
Negative: more difficult to notice, can be confused with depression
