Schizophrenia Flashcards
Risk Factors
- age (early)
- gender (the same for male or female)
- family history (10% of developing)
- environmental stressors (problems with interpersonal relationships, work, school, and substance abuse)
Definition
a severe mental condition in which there is disorganization of the personality, deterioration in social functioning, and loss of contact or distortion of reality
-can not be defined as a single illness; syndrome or a disease process with many different varieties and symptoms
Initial Assessment
- current physical status and physical history
- current mental status
- drug history; prescribed and OTC
- safety needs
What does Schizophrenia Cause?
distorted and bizarre thoughts, perceptions, emotions, movements, and behavior
-may be evidence of hallucinations and delusional thinking
Categories of Symptoms
- Positive or hard symptoms (delusions, hallucinations, disorganized thinking, speech, and behavior)
- Negative or soft symptoms (flat affect, lack of volition, social withdrawal or discomfort)
Positive/ Hard Symptoms of Schizophrenia
(In temporal lobe)
- ambivalence
- associative looseness
- delusions
- echopraxia
- flight of ideas
- hallucination
- ideas of reference
- perseveration
- bizarre behavior
Positive/Hard symptom: Ambivalence
holding seemingly contradictory beliefs or feelings about the same person, event, or situation
Positive/ Hard symptoms: Associative Looseness
fragmented or poorly related thoughts and ideas
Positive/ Hard symptoms: Delusions
fixed false beliefs that have no basis in reality
Positive/ Hard symptoms: Echopraxia
imitation of the movements and gestures of another person whom the client is observing
Positive/ Hard symptoms: Flight of Ideas
continuous flow of verbalization in which the person jumps rapidly from one topic to another
Positive/ Hard symptoms: Hallucinations
false sensory perceptions or perceptual experiences that do not exist in reality
Positive/ Hard symptoms: Ideas of reference
false impressions that external events have special meaning for the person
Positive/ Hard symptoms: Perseveration
persistent adherence to a single topic or idea; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic
Positive/ Hard symptoms: Bizarre Behavior
outlandish appearance or clothing; repetitive or stereotyped, seemingly purposeless movements; unusual social or sexual behavior
Negative/ Soft symptoms of Schizophrenia
(in frontal lobe)
- alogia
- apathy
- asociality
- blunted affect
- catatonia
- flat affect
- avolition or lack of volition
- inattention
Negative/ Soft symptoms: Alogia
tendency to speak little or to convey little substance of meaning (poverty of content)
Negative/ Soft symptoms: Anhedonia
feeling no joy or pleasure from life or any activities or relationships
Negative/ Soft symptoms: Apathy
feelings of indifference toward people, acitivites, and events
Negative/ Soft symptoms: Asociality
social withdrawal, few or no relationships, lack of cloeness
Negative/ Soft symptoms: Blunted Affect
restricted range of emotional feeling, tone, or mood
Negative/ Soft symptoms: Catatonia
psychologically induced immobility occasionally marked by periods of agitation or excitement; client seems motionless, as if in a trance
Negative/ Soft symptoms: Flat affect
absence of any facial expression that would indicate emotions or moods
Negative/ Soft symptoms: Avolition or lack of volition
absence of will, ambition, or drive to take action or accomplish tasks
Negative/ Soft symptoms: Inattention
inability to concentrate or focus on a topic or activity, regardless of its importance
Etiology
genetic theories focus on immediate family members (parents, siblings, children)
People with schizophrenia have decreased brain volume and abnormal brain function in what areas of the brain?
frontal and temporal lobes of the brain
Temporal Lobe
involved in memory, sensory input, language, emotion and comprehension
- damage can cause disturbance of auditory, visual sensation, and perception. Also impaired organization, disturbance of language comprehension
- positive signs of schizophrenia
Frontal Lobe
controls important cognitive skills such as emotional expression, problem solving, memory, language, judgment, and sexual behavior
-negative signs of schizophrenia
Neurochemical Theories for Schizophrenia
imbalance of neurotransmitters dopamine and glutamate are found to play a role
- dopamine and serotonin
- excess dopamine as a cause
The most prominent neurochemical theories involve….
dopamine and serotonin
-excess dopamine as a cause or excess serotonin
Clozapine
- dopamine and serotonin antagonists
- dramatically reduce psychotic symptoms and ameliorate the negative signs of schizophrenia
- atypical antipsychotic
Cultural Considerations
ideas that are considered delusional in one culture, may be commonly acceptable by other cultures
- auditory or visual hallucinations, such as seeing the virgin Mary or hearing gods voice may be a normal part of religious experience in some cultures
- assessment of affect requires sensitivity to differences in eye contact, body language, and acceptable emotional expression
- ethnicity; genetic makeup; metabolized meds more slowly
Psychopharmacology
- anti-psychotic medications also known as neuroleptics, are prescribed for their efficacy to decrease psychotic symptoms
- do not cure, rather they manage symptoms of the disease
- Convention/ First Generation–> Dopamine antagonists
- Atypical/ Second Generation–> Dopamine and Serotonin Antagonists
Conventional/ First Generation Anti-psychotics
- dopamine antagonists
- targets the positive signs of schizophrenia such as delusions, hallucinations, disturbed thinking, and other psychotic symptoms
- have no observable effect on the negative signs
Atypical/ Second Generation Anti-psychotics
- both dopamine and serotonin antagonists
- diminish positive symptoms and lessen the negative sings of lack of volition and motivation, social withdrawal, and anhedonia
- used as a first-line treatment because of fewer side effect than with conventional anti-psychotic meds
Examples of Atypical/ Second Generation Anti-psychotics
Dopamine and Serotonin Antagonists
- Clozapine (Clozaril)
- Olanzapine (Zyprexa)
- Aripiprazole
- Quetiapine (Seroquel)
- Risperidone (Risperdal)
- Ziprasidone (Geodon)
Examples of Conventional/ First Generation Anti-psychotics
Dopamine Antagonist
- Fluphenazine (Prolixin)
- Haloperidol (Haldol)
- Thiothixene (Navane)
- Chlorpromazine (Thorazine)
Side Effects of Anti-Psychotic Medications
- dystonic reactions
- tardive dyskinesia
- neuroleptic malignant syndrome
- akathisia
- EPSs or neuroleptic-induced parkinsonism
- seizures
- sedation
- photosensitivity
- weight gain
- dry mouth
- blurred vision
- constipation
- urinary retention
- orthostatic hypotension
Drugs to treat extrapyramidal side effects
- Benztropine
- Diphenhydramine
- Amantadine
- Biperiden
Side effect of Anti-Psychotics: Dystonic Reactions
spasms in discrete muscle groups such as neck (torticollis) or eye muscle (oculogyric crisis)
-accompanied by protrusion of the tongue, dysphagia and laryngeal and pharyngeal spasms that compromise the clients airway, causing a medical emergency
Treatment: diphenhydramine (Benadryl) given IM or IV, or Benztropine given IM
-it is a extrapyramidal side effect
Nursing Interventions for Dystonic Reactions
- administer medications as ordered (diphenhydramine)
- assess for effectiveness
- reassure client if he/she is frightened
Side Effect of Anti-psychotics: Tardive Dyskinesia
characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of limbs and feet
- irreversible once appears but decreasing or discontinuing the medication can arrest the progression
- Clozapine recommended for clients who have experienced this while taking conventional anti-psychotics
Nursing Intervention for Tardive Dyskinesia
assess with tool such as AIMS
-report occurrence of score increase to physician
Abnormal Involuntary Movement Scale (AIMS)
to screen symptoms of movement disorders
ex: tardive dyskinesia
Fatal Side Effect of Clozapine (Atypical Anti-psychotic)
agranulocytosis
6 anti-psychotics are available for long-acting injections (depot injections) for Maintenance Therapy
- Fluphenazine (conventional)
- Haloperidol (conventional)
- Risperidone (atypical)
- Olanzapine (atypical)
- Aripiprazole (atypical)
- Paliperidone
Anti-psychotic side effect: Neuroleptic Malignant Syndrome
muscle rigidity, high fever, increased muscle enzymes and leukocytes
Nursing Interventions for Neuroleptic Malignant Syndrome
- treated by stopping medication
- ability to tolerate other anti-psychotic meds after NMS varies, but seems possible
- stop all anti-psychotic meds
- notify physician immediately
Clinical Presentation Symptoms
- delusions
- form of thought
- perception (hallucinations)
Application of the Nursing Process: Assessment
schizophrenia affects thought processes and content, perception, emotion, behavior, and social functioning
-affects each individual differently
General Appearance
may vary
- appear normal exhibiting no strange or unusual postures or gestures
- others exhibit odd or bizarre behavior; appear disheveled and unkempt with no obvious concern for their hygiene, or may wear strange or inappropriate clothing
ex: heavy wool coat in hot weather
Motor Behavior
may be odd
- restless, unable to sit still, exhibiting agitation and pacing or appear unmoving (catatonia)
- demonstrate purposeless gestures and odd facial expression such as grimacing
- echopraxia
- rambling speech
- psychomotor retardation (sowing of all movements)
Catatonic/ Catatonia Subtype
- waxy flexibility
- stupor
- motor immobility
- peculiarities of voluntary movement
- maintain any position in which they are placed, even if the position is awkward or uncomfortable
Mood and Affect
- flat affect (no facial expression)
- blunted affect (few observable facial expressions)
- “mask-like”
- described as silly, characterized by giddy laughter for no reason
- exhibit inappropriate expressions or emotions incongruent with context of situation
- anhedonia
- conversely, feeling all-knowing, all-powerful, not concerned with circumstance of situation
Unusual Speech Patterns
- Clang associations
- Neologisms
- Verbigeration
- Echolalia
- Stilted language
- Perseveration
- Word Salad
Unusual Speech Patterns: Clang Associations
ideas that are related to one another based on sound or rhyming rather than meaning
-ex: “I will take a pill if I go up the hill but not if my name is Jill, I don’t want to kill”
Unusual Speech Pattern: Neologisms
words invented by the client
-ex: “I’m afraid of grittiz. If there are any grittiz here, I will have to leave.”
Unusual Speech Pattern: Verbigeration
is the stereotyped repetition of words of phrases that may not have meaning to the listener
ex: “I want to go home, go home, go home, go home”
Unusual Speech Pattern: Echolalia
clients imitation or repetition of what the nurse says
-ex: NURSE: “can you tell me how you’re feeling?”
CLIENT: “can you tell me how you’re feeling, how you’re feeling?”
Unusual Speech Pattern: Stilted Language
use of words or phrases that are flowery, excessive, and pompous
ex: “would you be so kind, as representative of Florence Nightingale, as to do me the honor of providing just a wee bit of refreshment, perhaps in the form of some clear spring water?”
Unusual Speech Pattern: Perseveration
persistent adherence to a single idea or topic and verbal repetition of a sentence, phrase, or word, even when another person attempts to change the topic
ex: NURSE: “how have you been sleeping lately?”
CLIENT: “I think people have been following me”
NURSE: “where do you live?”
CLIENT: “at my place people have been following me.”
NURSE: “what do you like to do in your free time?”
CLIENT: “nothing because people are following me”
Unusual Speech Pattern: Word Salad
combination of jumbled words and phrases that are disconnected and incoherent and make no sense to the listener
ex: “corn, potatoes, jumps up, play games, grass, cupboard”
Thought Processes and Content
- thought disorder; primary feature of disease
- thought process disordered, and continuity of thought and information processing is disrupted
- thought broadcasting
- thought blocking
- thought withdrawal
- thought insertion
- tangential thinking
- poverty of content (alogia)
Thought Blocking
client may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute
Thought broadcasting
may state that they believe others can hear their thoughts
Thought withdrawal
believe others are taking their thoughts
Thought insertion
believe that others are placing thoughts in their mind against their will
Tangential Thinking
veering onto unrelated topics and never answering the original question
-gives unnecessary details or strays from the topic but eventually provides the requested information
Poverty of Content (Alogia)
lack of any real meaning or substance in what the client says
-speak little
-ex: NURSE: “how have you been sleeping lately?”
CLIENT: “well, I guess, I don’t know, hard to tell”
Delusions
fixed, false beliefs with o basis in reality
- part of psychotic phase of illness
- common characteristic is the direct, immediate, and total certainty with which the client holds these beliefs
- he/she acts according to delusions
Types of Delusions
- Persecutory/ Paranoid
- Referential
Persecutory/ Paranoid Delusions
involve the clients beliefs that “others” are planning to harm him or her or are spying, following, ridiculing, or belittling the client in some way
- sometimes client cannot define who the “others” are
- Ex: Clients may think that food has been poisoned or that rooms are bugged with listening devices
- “persecutor” is government, FBI, or another powerful organization
- specific individuals or family members can be the “prosecutor”
Referential Delusions
or ideas of reference, involve the clients belief that television, broadcasts, music, or newspaper articles have special meaning to him/ her
Sensorium and Intellectual Processes
- hallmark symptom of schizophrenic psychosis is hallucinations
- disoriented to time, sometimes to place
- depersonalization
- poor intellectual functioning
- difficulty with abstract thinking (legitimate)
Hallucinations
false sensory perceptions, or perceptual experiences that do not exist in reality
- can involve 5 sense and bodily sensations
- distinguished from illusions
- perceives these as real but later in illness recognizes them as hallucinations
Example of hallucinations
Auditory Hallucinations
>command
Auditory Hallucinations
most common
- involve hearing sounds, most often voices, talking to or about the client
- may be one or multiple voices; a familiar or unfamiliar persons voice may be speaking
Command Hallucinations
type of auditory hallucination
-voices demanding the client to take action often to harm the self or others and are considered dangerous
Depersonalization
client feels detached from his or her behavior
-although the client can state his/ her name correctly, he/she feels as if their body belongs to someone else or that their spirit is detached from the body
Self-Concept
- deterioration of the concept of self
- “loss of ego boundaries”
- may believe they are fused with another person or object, may not recognize body parts as their own, or may fail to know whether they are male or female
Loss of Ego Boundaries
describes lack of clear sense of their own body, mind, and influence end and where those aspects of other animate and inanimate objects begin
Roles and Relationships
- social isolation
- low self-esteem
- lack confidence
- feel strange or different from others
- experience great frustration with fulfillment of roles
- success in school or work can be compromised because of difficulty thinking clearly, remembering, paying attention, and concentrating
- frightens and embarrasses family
Physiological and Self-care Considerations
- self-care deficits
- inattention to hygiene and grooming
- occupied in delusions or hallucinations; fail to perform basic activities of daily living
- fail to recognize sensations of hunger or thirst; malnourishment, constipation
- unable to sit down long enough to eat, needs finger foods high in protein and nutrients
- develop polydipsia
- sleep problems; insomnia
Polydipsia
excessive water intake
- leads to water intoxication
- serum sodium levels to become too low, leading to seizures
Nursing Diagnoses for Positive Signs
- risk for other-directed violence
- risk for suicide
- disturbed thought process
- disturbed sensory perception
- disturbed personal identity
- impaired verbal communication
Nursing Diagnosis for Negative Symptoms
- self-care deficit
- social isolation
- deficient diversional activity
- ineffective health management
- ineffective therapeutic regimen management
Atypical Anti-psychotic Drugs
used as a first line treatment because of fewer side effects than with conventional or typical anti-psychotics
- Aripiprazole (Abilify)
- Clozapine (Clozaril)
- Olanzapine (Zyprexa)
- Risperidone (Risperdal)
- Quetiapine (Seroquel)
- Ziprasidone (Geodon)
Nursing Interventions
- promoting safety of patient and others
- establishing a therapeutic relationship via trust
- using therapeutic communication (clarifying feelings and statements when speech and thoughts are disorganized or confused)
- implementing interventions for delusional thoughts
Nursing Interventions for Delusions
- do not openly confront the delusion or argue with client
- establish and maintain reality for the client– listen to what the patient is saying
- use distracting techniques; work with staff one to one, then small group
- teach positive self talk, positive thinking, and to ignore delusions
Interventions for Hallucinations
- help present and maintain reality by frequent contact and communication
- elicit description of hallucination to protect client and others. Understanding hallucination helps know how to calm or reassure patient– listen to what the patient is saying
- engage in reality based activities; card playing, occupational therapy, or listening to music
Coping with Socially Inappropriate Behavior
- redirect patient away from problem situations–taking the patient to a quiet area away from public
- in a nonjudgmental and matter- of- fact manner, give factual statements
- attempt to re-integrate patient into treatment milieu as soon as possible; 1:1, 1:2, small group
- don’t make patient feel punished or shunned for their behavior
- teach social skills through education, role-playing and practice
Auditory Hallucination Intervention: Dismissal Intervention
telling the voices to go away
- teaching to talk back to the voices forcefully may help manage auditory hallucinations
- done in private
Medication Management
- drink sugar-free liquids
- sugar free hard candy to ease anti-cholinergic effect of dry mouth
- avoid calorie-laden beverages and candy; promote dental caries, weight gain, do little to reduce dry mouth
- constipation; increase water and bulk-forming foods in diet; avoid laxatives
- photosensitivity; sunscreen, avoid long hours in the sun
- orthostatic hypotension; rise slowly
- monitor sleepiness and drowsiness; sedation
Medication Adherence Rating Scale
provides a clear picture bout the clients difficulties with medication adherence
- questionnaire with 10 yes-or no questions clients can answer easily
- guide staff in identifying strategies to improve compliance if used on a regular basis
