study guide exam 2 Flashcards
how do substances affect the brain
drugs of abuse taken in excess = direct activation of brain reward system involved in the reinforcement of behaviors and production of memories = intense activation of reward system leads to normal activities being neglected
- direct activation of reward pathways
- produces feeling of pleasures…“high”
characteristics of addiction (7)
- heightened memory of substance’s rewarding effects: chasing the dragon “high”
- reinforcement: seeking behavior
- compulsive use: compelled to use substance
- craving: drug of choice
- tolerance: takes more to do less
- dependence: psychological needs for drug
- withdrawal: what patient experiences when stopped taking drug
characteristics of alcohol use ds. (4)
chronic, relapsing brain disease with 4 symptoms:
- craving: needing
- loss of control: of use
- physical dependence: alcohol W/D
- tolerance: doing more for same affect
continuous use reward in changes in brain structure and function in reward or pleasure center…in limbic system
DSM V criteria for alcohol use disorder
problematic use of ETOH with clinically signifiant impairment, manifested by at least 2 of the following within a 12 month period:
- larger amounts over longer period than intended
- persistent desire to cut down or control use
- great deal of time spent in obtaining, using, or recovering from its effect: W/D
- craving/strong desire or urge to use
- failure to fulfill major role obligations
- continued use despite problems caused by use: CPS
- important social, occupational activités given up
- recurrent use in situations that are hazardous
- use is continued despite knowledge of problems
- tolerance
- W/D
mild: 2-3 sx
moderate: 4-5 sx
severe: <6 sx
effects of alcohol
- cancers (liver, esophagus, throat, larynx
- cirrhosis, Brian damage, harm to fetus, pancreatitis, gastritis, esophageal varices
- risks of death d/t accidents, homicides, suicides
prevalence of alcohol use ds.
- common ds.
- 4.6%: 12-17 year olds
- 8.5%: adults age 18 and older
- greater rates in men 12.4%;women 4.9%
- decreases in middle age, greatest among 18-29 year olds
- adults: native Americans and alaskans 12%; whites 9%; hispanics 9%; African Americans 7%; asian Americans/Pacific Islanders 4.5%
development & course of alcohol use DO
- 1st episode of intoxication in mid-teens
- onset: peaks in late teens or early-mid 20s
- W/D occurs after DO is established
- variable course, with periods or remission and relapse
- decision to stop (crisis) follows with weeks of abstinence, then limited periods of controlled or problematic drinking
- once intake resumes, rapid escalation & severe problems will develop once again
- most severe cases represent small proportion of persons with DO
- typical person with DO has more promising prognosis
- adolescents: conduct DO and antisocial behavior often co-occur
- most develop after age 40, 10% later onset
risks and prognostic factors (environmental)
- cultural attitudes towards drinking & intoxication
- availability
- personal experiences w/ alcohol
- stress levels
- heavy peer substance use
- exaggerated positive expectations & experiences with the effects
- suboptimal ways of coping with stress
risk and prognostic factors (genetic & physiological)
- runs in family
- rate 3-4 times higher in close relatives
- rate affected by greater number of affected relatives
- closer genetic relationships to affected person
- higher severity of alcohol related problems in those relatives
- 3-4 times risk in children whose parent had the DO even when adopted and raised by parents without the DO
- gene influence: certain phenotypes are known to identify high risk (preexisting schizophrenia or bipolar, impulsivity, any gene that modulates the dopamine reward system) & low risk (asians: flushed skin)
- impulse issues: any one gene variation likely explains only 1-2% of risks for these DO
red flag indicators
- blood alcohol concentration: can be used to judge tolerance to alcohol (0.08%mg/L Michigan)
- 150mg of ethanol per deciliter (dL): does not show signs of intoxication = some degree of tolerance (0.15% mg/L)
- 200mg/dL: most non tolerant individuals = severe intoxication (0.20%mg/L)
- past hx blackouts; unsuccessful attempts at stopping ETOH
describe alcohol withdrawal delirium (DT’s) (medical emergency, what, peak, CIWA protocol, CIWA score)
- medical emergency; mortality 5-10% rate
- death d/t MI, fat emboli, vascular collapse, electrolyte imbalance, aspiration pneumonia
- peaks 2-3 days after stopping drug, lasts up to 1 week
- CIWA protocol: measures 10 sx. (agitation, anxiety, AV hallucinations, clouding sensorium, headache, N/V, sweats, tactile disturbances. tremors
- score <8-10: minimal to mild W/D
- score 8-15: moderate W/D
- score >15: severe W/D
- categories: rate each from 0-7
what is tolerance
a person no longer responds to the drug in the way the person initially responded
what is with-drawl
set of physiological symptoms that occur when a person stops using a substance
what is co-dependence
a cluster of behaviors originally identified through research involving the families of alcoholic patients
- exhibit overly responsible behavior (doing what others could just as well do for themselves).
what is substance abuse vs. dependence
substance abuse - can’t control intake of drug usage, feel like you need drug for specific feeling
dependence - physical body/mental dependence on drug
alcohol intoxication vs. withdrawal
alcohol intoxication: blood concentration of 80-100 mg ETOH mg/dL.
- s/sx: slower motor performance, decreased thinking ability, altered mood, and reduced ability to multitask, impaired judgement, exaggerated behavior, euphoria, lower alertness, slurred speech, blackouts, nausea, impaired VS, possibly death
alcohol withdrawal: occurs after reducing or quitting alcohol after heavy and prolonged use.
- s/sx: tremulousness (shakes, jitters), agitation, lack of appetite, N/V, insomnia, impaired cognition
tx. alcohol withdrawal
- benzodiazepines: tapering doses, to prevent seizures
- thiamine: prevents encephalopathy
- magnesium sulfate: reduces seizures
- anticonvulsants: for seizure control
- folic acid (Vitamin B)/multivitamins: correct deficiencies
nursing process: assessment SBIRT (what, refer, considerations, sx, tx)
- screening used standardized tools: non judgmental attitude is key
- may need to refer to addition specialists
- consider family assessments and codependence
- recognize s/sx of intoxication & alcohol withdrawal
- tx: rehab, ongoing support, medications
CNS depressants (OD, tx, W/D)
ETOH, Benzos, Barbs
- OD: cardiovascular & respiratory depression, coma, shock, convulsions, death
- tx: lavage/activated charcoal (takes toxins out), V/S, patent airways, IV fluids
- W/D: abrupt w/d may lead to death, detox with similar drug
CNS stimulants (OD, tx., W/D)
cocaine, amphetamines
- OD: assaultive, grandiose, paranoid, tachycardia, elevated BP, hyperpyrexia, convulsions, coma, death
- tx: antipsychotics PRN (calm pt.), cooling (fever), diazepam (seizures - reduce potential)
- W/D: antidepressants, dopamine agonist, bromocriptine
Opiates (OD, tx., W/D)
fentanyl, IV heroine
- OD: respiratory depression, coma, death
- Tx: narcotic antagonist, naloxone (narcan - emergency, blocks effects of opioids and reverses OD (respiratory depression)
- W/D: methadone taping (old school, prevents physical w/d, careful w/ drug transportation), clonidine-naltrexone detox (adjunct to w/d tx.), buprenorphine substitution (buprenorphine + nalazone = suboxone)
suboxone: cows scale to determine where patient is at in W/D
hallucinogens (intoxication, tx.)
LSD, mescaline, PCP (acid, shrooms)
- intoxication: paranoid ideas, anxiety, synesthesia, depersonalization, hallucinations
- tx: low stimuli, LSD (talk down), monitor VS, hydration
initial and active drug therapy
- maintains abstinence from substances
- demonstrates acceptance for own behavior (serious about tx.)
- continues attendance for treatment & maintains sobriety (AA, NA, CA, group therapy, CBT, etc.)
- attends relapse prevention program
- verbalizes cues that pose increased risk of using
- demonstrates new skills in dealing with troubling feelings (anger, loneliness, cravings, anxiety) - yoga, art
- awareness for need of ongoing treatment
psychotherapy (types, issues, defenses, responses)
- CBT, family, group, individual therapies
- issues: recognizing signals that were cues to drinking & drugs, learn different responses (know triggers)
- denial, rationalization, projection: common defenses
- emotional responses - intense & can create anxiety (coping mechanisms learned)
- responses of family & co-workers addressed (natural support system)
- new coping skills to prevent relapse & ensure prolonged sobriety
outcome criteria for rehab
- free of substance
- acceptance of own behavior
- continuation in therapy; attends relapse prevention program
- aware of cues that stimulate drug abuse
- drug free friends, able to form caring relationships
- aware of addiction
- develops new skills for coping
specific programs for rehab
- AI-ANON, AI-A-Teen
** Alcoholics Anonymous, narcotics anonymous - residential programs
- intensive outpatient programs
- outpatient
- continuing outpatient support groups
psychopharmacology (5 main)
1) naltrexone (revia): blocks opiates receptors, reduce alcohol and opiate preference
2) disulfiram (Antabuse): inhibits impulsive drinking with unpleasant side effects (headache, neck pain, flushing, sweating, resp. directress, n/v) - avoid all substances with ETOH in it
3) methadone hydrochloride (methadone): synthetic opiate, blocks cravings & effects of heroin, HIGHLY ADDICTIVE & produces W/D, used for detox & maintenance - not in itself a treatment option
4) buprenorphine (subutex oral, inj): for active W/D from opiates, also for maintenance
5) naltrexone hydrochloride: heroin, opiates, pathological gambling, detox, maintenance
facts about major depressive DO
- one of most common DO (>13 million/year)
- lifetime risk for MEN (5-12%), women (10-25%)
- r/t: ethnicity, income, education, marital status: single mothers, unemployed, poverty HIGH RISK
- single or recurring episodes
- different from grief & bereavement
- postpartum depression = 10% new moms
- combined children & teens = 6%
- elderly = 3.5 - 16%
- nursing home = 15-20%
- anxiety is COMMON
- leading cause of disability in US
- 1st appears at any age - Peaks 20s
- later life: NO COMMON
- course: variable - some rarely have readmission, others go for few years between episodes
- indigence increases with chronic medical ds.
- can exist with other psych ds.
- recovery begins 3 months to 1 year (sooner the better prognosis)
- worse prognosis if anxiety, psychosis, PD or severe sx.
risk factors of MDD
- temperamental: high levels negative affectivity to stressful life events
- environmental: adverse childhood experiences; stressful life events
- genetic/physiological: first degree family members have increased risk for MDD
- course modifiers: substance use, anxiety, BPD, chronic medical conditions (DM, obesity, CVD = all increase risk of MDD & affect tx. outcomes)
suicide risk of MDD
- risk of suicidal behaviors exists at all times
- common risk factor: past hx. suicide attempts/threats
- most completely suicides are NOT preceded by unsuccessful attempts
- other risks: male, single, living alone, hopelessness, BPD
theories of cause (unlikely, likely, 4 types)
- unlikely: there is one cause
- most likely: interconnection of genetics & life experiences
- four common theories: biologic, psychodynamic, cognitive, learned helplessness
biological theories
- genetic: familial tendencies apparent
- biochemical: dysregulation of neurotransmitters - low serotonin, norepinephrine, dopamine
- decreases in gaba and acetylcholine involved
- hormonal regulation: elevated cortisol
- stressors thought to trigger changes in levels of transmitters in brain
cognitive theory
- psychological predisposition to depression
- early life experiences lead to negative, illogical and irrational thoughts leading to emotions
- process information in negative, illogical, and irrational ways
- negative view of self, the world
- a belief that nothing will change in the future
- help by identifying negative thought patterns, scrutinize negative beliefs, learned to restructure
- balanced, realistic, and appropriate alternatives
learned helplessness - seligman
- anxiety in response to stress then depression
- belief that there is no ability to control outcome
- person is at fault, nothing can be done to change
- relates to social groups: battered women, the aged
GRIEF vs. mdd
- feelings of emptiness and loss
- thoughts of bereaved
- self esteem preserved
- thoughts of wanting to join loved one
- may move to MDD
grief vs. MDD
- persistent depressed mood, plus other sx.
- negative thoughts about self, self critical, pessimistic, rumination
- worthlessness & self loathing are common
- focus on ending life due to pain of depression
what are the 5 stages of loss
1) denial
2) anger
3) bargaining
4) depression
5) acceptance
comparison between MAJOR DEPRESSION & dysthymia
- substantial pain & suffering
- occupational, social & psychological affects
- delusional or psychotic sx.
- 60% recurrence
comparison between major depression & DYSTHYMIA
- early, Late and insidious onset
- chronic depressive sx.
- sx. for at least 2 years
- hard to distinguish from “usual” pattern
- hospitalization rare
- at risk for major depression
- often seen in childhood teens
DSM 5 criteria for MDD
- change in previous functions; sx. causes distress
- 5 or more of following for 2 week period
- depressed mood most of the day
- anhedonia, anergia
- wt. loss due to anorexia
- insomnia/hypersomnia
- feelings of hopeless, helpless, despair, guilt
- decreased concentration
- recurrent thoughts of death or suicidal ideation
- SIG E CAPS
- vegetative: bowel, appetite, sleep, sex
nursing diagnosis for MDD
- risk for violence: self directed
- ineffective coping
- hopelessness
- powerlessness
- chronic low self esteem
- impaired social interaction
- social isolation
interventions for acute MDD
acute phase: 6-12 weeks
- if suicidal: hospitalization
- pharmacology
- psychotherapy
- ECT
interventions for continuation MDD
continuation phase: 4-9 months
- need to continue with medications, perhaps for life
- psychotherapy
interventions for maintenance MDD
maintenance phase (1 or more years)
- continuation of full dose antidepressants to prevent relapse
Electroconvulsive therapy (ECT)
- induced grand Mal seizure -> alters activity if NTs (theory)
- used for: drug resistant patients with MDD, MDD with psychotic features, bipolar manic, schizophrenia, schizoaffective disorder
- 2-3 treatments/week for approximately 12 treatments
- can be highly effective
- side effects: confusion, disorientation early with memory deficits short term
- may need maintenance treatments & medications
antidepressants 1st line of meds
serotonin reuptake inhibitors (SSRI’s)
SSRI medications
- fluoxetine (prozac)
- paroxetine (Paxil)
- sertraline (zoloft)
- citalopram (celexa)
- fluvoxamine (Luvox)
- escitalopram (lexapro)
SNRI’s medications
- venlafaxine (efferxor)
- duloxetine (Cymbalta)
- pristique
NDRI (norepi Dopamine re-uptake inhibitors) medications
- bupropion (Wellbutrin)
tricyclics medications
- amitriptyline (Elavil)
- desipramine (norpramin)
- doxepin (sinequan)
- imipramine (tofranil)
- nortryptiline (Pamelor)
MAOI’s medications
- phenelzine (nardil)
- tranylcypromine (parnate)
side effects of SSRIs
- fewer than TCA’s, low lethality risk, less sedating
- agitation, anxiety, sleep disturbance, sexual dysfunction, dry mouth, weight gain (WARNING: if agitation occurs early)
side effects of NDRI antidepressants
- fewer than TCA’s relatively safe
- nausea, dizziness, headache, sedation, weight gain
side effects of tricyclics
- anticholinergics, cardiovascular arrhythmias, adverse reactions to other drugs (CAUTION: with elderly)
side effects of MAOI’s
- toxic: hypertensive crisis (CAUTION with etc meds)
- avoid tyramine containing foods
- waiting period between changing classes of medications
possible toxic effects of SSRI’s
- central serotonin syndrome: rare but life threatening
- over activation of serotonin receptors…wait 5 weeks if changing from SSRI to MAOI
- s/sx: abdominal pain, diarrhea, increased BP, confusion, muscle spasms, irritability, increased motor activity
- if severe: high fever, shock, DEATH
patient & family teaching SSRI’s
- inform of side effects
- 2-4 weeks to begin to address symptoms
- do not stop drug abruptly…contact MD
- avoid alcohol
- if drowsy, avoid driving
- inform RN of MD if agitation or anxiety occurs
what is serotonin syndrome
- rare and life threatening event associated with SSRI’s
- over-activation of the central serotonin receptors caused by either too high a dose or interaction with other drugs
- sx: abdominal pain, diarrhea, sweating, fever, tachycardia, elevated blood pressure, altered mental status (delirium), myoclonus (muscle spasms), increased motor activity, irritability, hostility, and mood change
- severe manifestation: hyperpyrexia (excessively high fever), cardiovascular shock, or death
describe Bipolar I
- classic
- most severe/mania with depression
- alternating episodes of mania & depression
- chronic mood disorder throughout life with normal periods between episodes (some pt. have more long lasting sx.)
describe Bipolar II
- hypomania with profound depression
describe cyclothymic disorder
hypomania with mild to moderate depression for at least 2 years
describe DSM-V criteria
- mania: persistently & abnormally elevated expansive or irritable mood (1 week)
- with 3 or more: inflated self esteem or grandiosity, decreased need for sleep, pressured speech & talkativeness, flights of ideas, racing thoughts, dis-tractability, increase in goal directed activity, excessive risk taking or extravagent behaviors
- euphoric mania: initially “wonderful” turns to loss of control
- dysphoric mania: AKA mixed state or agitated depression/irritable, angry, suicidal, hyper sexual, grandiosity, panic, pressured speech
etiology bipolar DO
- genetic: strong heritability (more than environment), strongest & most consistent risk factors
- similar chromosome irregularities as schizophrenia on 13 & 15 (similar psychotic sx. in both)
- complex interrelationship of NTs (norepi, dopamine, serotonin)
- receptor site insensitivity
- structural and functional brain changes found in prefrontal and temporal love areas
- psychological impact: severe stressful event with predisposition
- environment: high proportion among upper socioeconomic classes, higher education, more creative individuals, professionals, reason unclear, research in progress
HYPOMANIA vs. mania
- change in functioning from normal
- disturbance in mood noticed by others
- social/occupational impairments ABSENT
- hospitalization NOT needed
hypomania vs. MANIA
- severe enough to affect occupational, social, or other relationships
- hospitalization NEEDED
- sx. not due to substances, etc.
- sx: tangetiality, flight of ideas, grandiosity, clang association, hyperactivity
nursing diagnosis for BPD
- risk for injury
- risk for other or self directed violence
- ineffective coping
- disturbed thought processes
- impaired verbal communication
-self care deficiet - disturbed sleep pattern
- imbalanced nutrition
acute phase BDP interventions
- hospitalization to medically stabilize and for a structured and safe milieu PRN meds
- lower physical activity, redirect energy increase food & keep hydrated, establish sleep, protect patient population, seclusion protocol
- admission to first few days, not coherent, unstable, labile, cannot learn or comprehend)
continuation phase BDP intervention
- med compliance
- prevent relapse
- education
- support
- problem solving
- psychotherapy
- patient is coherent and can problem solve, learn
maintenance phase BDP interventions
- prevent relapse
- periodic evals
- support family, work, and social life
- ongoing
- discharged to home - prevent relapse)
1st choice mood stabilizers
- lithium carbonate
lithium carbonate
- effective in bipolar I acute and maintenance phase in 80% clients (effective, NOT CURE)
- indefinite use for maintenance (vg for elation, grandiosity, flight of ideas, irritability, anxiety)
- therapeutic: 7-10 days (routine blood levels)
- therapeutic blood levels: 0.4 - 1.3 mEq/L
- early signs of toxicity: <1.5 mEq/L
- advanced toxicity: 1.5-2.0 mEq/L
- severe: 2.0-2.5 mEq/L
- death: >2.5 mEq/Lc
common side effects of lithium carbonate
kidney failure
hypothyroidism
pt/family teaching lithium carbonate
- diet
- hydration
- monitor blood levels
- some side effects subside with time (p. 241)
anti-epileptic drugs
- effective for mood disorders, impulsive/aggressive behavior, controlling mania, rapid cycling, mood swings, impulsivity, mania & depression
- valproate (depakote), carbamazepine (tegretol), lamotrigine (lamictal)
- can be used with or without lithium
valproate (depakote)
- good for lithium non responder, mania, rapid cycling, prevention
carbamazepine (tegretol)
- treatment resistant patients
- blood levels for first 8 weeks -> increase liver enzymes
lamotrigine (lamictal)
- 1st line tx. for acute & maintenance
- watch for RASH (LIFE THREATENING)
antipsychotics/anxiolytics
- atypical (second gen) antipsychotics in acute phase to sedate and rest, and manage agitation, insomnia, mood, violence, etc.
- ex: olanzapine (zyprexa), ziporasidone (geodon), aripiprazole (abilify)
- anxiolytics: lorazepam (Ativan) -> manage agitation seen in acute phase
health teaching for BDP
- awareness of illness, signs, relapse
- need for medication compliance for life
- alcohol, other drugs of abuse
- sleep hygiene
- psychosocial strategies: work, interpersonal issues
- support network for patients and families
what is borderline personality disorder
- personality traits are inflexible & maladaptive, pervasive pattern of abnormality exists
- cause significant functional impairment or subjective distress
- limited ability to achieve trust, autonomy, independence, and meaningful relationships
- may not affect all areas of life
- patients with PD seek treatment with crisis or trauma
what is antisocial personality disorder
a pattern of disregard for, and violation of, the rights of others
- commonly referred to as sociopath
- antagonistic behaviors such as being deceitful and manipulative for personal gain
what are the 4 common characteristics of borderline personality and antisocial personality disorder
pervasive patterns exists
- inflexible and maladaptive response to stress
- disability in working and loving
- ability to evoke interpersonal conflict
- capacity to “get under the skin” of others
what is the splitting major defense mechanism
- the inability to view both positive and negative aspects of others as a whole
what are nursing diagnosis for borderline PD
- ineffective coping
- anxiety
- self mutilation
- risk for other-directed violence
- impaired parenting
- social isolation
- disturbed thought process
- hopelessness, helplessness, risk for suicide
nursing diagnosis for antisocial personality disorder
- risk for other0directed violence, defensive coping, impaired social interactions, ineffective health maintenance
what is the limit setting for borderline personality and antisocial personality disorder
1) limits: clear, consistent, enforceable
2) team: aware of limits, need for consistency (primary nurse)
- communicate expectations to client
- be realistic (which behaviors to limit)
- clear consequences of exceeding limits
- follow through with consequences in non-punitive manner
- assist client to limit own behavior
- assess insight and motivation to change
- avoid power struggles
what is superficial cutting
self destructive behavior
interventions for impulsive behaviors
- identify antecedent needs and feelings
- discuss current/previous impulsive acts
- explore impact on self and others
- refer or teach needed coping skills
- discuss alternatives to impulsive behavior
- role play new skills
- provide feedback
- support new skills
- identify strengths and effective communication
what are the specific interventions of borderline personality disorder
- set clear, realistic goals
- be aware of manipulative behaviors
- clear, consistent boundaries/limits
- behavioral problems: review therapeutic goals and tx. boundaries
- avoid rejecting, rescuing
- assess for suicidal, self mutilating behaviors
- assess for “splitting” esp. in relation to staff (select primary nurse, adhere strictly to care plan, be aware of “all good, all bad” phenomena)
- meds PRN, antidepressants, antipsychotics
specific interventions for antisocial BPD
- set clear, realistic limits on specific behaviors
- all limits adhered to by all staff
- document objective physical signs of manipulation or aggression
- provide clear boundaries, consequences
- guard against letting client make you feel guilty
- guard against bing manipulated
what is the epidemiology of schizophrenia
- devastating disease of the brain; multifactorial cause likely involving chronic or recurring psychosis, with each relapse there is increased dysfunction
- affects thinking, language, emotions, social behaviors, and ability to perceive reality
- age of onset: late teens, mid 30s (1st episode), early 20s (males poorer prognosis with negative/cognitive ds), females (mood sx.)
- slow insidious onset of sx
- affects <1% of population, 40-50% have substance abuse
- 10% recover, 55% chronic sx, 35% intermittent course
- suicide -> leading cause of death, depression common
theory of causes
- combination of inherited genetic factors & extreme nongenetic factors affecting genes or direct injury to brain
- origins: conception & “something more”
- pregnancy & birth complications: hypoxia
- disease: brain chemistry and activity
- increase: dopamine, decreased serotonin, increased norepi, decreased gaba, all play a part
- neurotransmitters & neural circuits are disrupted
- atrophy of frontal lobe, cortex, cerebellum
- enlargement of lateral cerebral ventricles = less grey matter, differences in white matter connectivity
- overall decrease in brain volume
- genetic contribution = increased in relatives
what are prodrome symptoms
- sx. from 1 month to 1 year before 1st psychotic break
- clear deterioration in functioning
- withdrawal, loneliness, depression in adolescents
- plans for future vague, unrealistic
- acute or chronic anxiety
- pulling away from family, friends, school, activities
DSM 5 diagnostic criteria
2 or more during 1 month period:
- delusions, hallucinations, disorganized speech & behavior, negative symptoms
- social/occupational dysfunction (1 or more areas are below premorbid functioning)
- duration: continuous signs atleast 6 months
- all other mental, physical, developmental diseases have been ruled out
paranoid schizophrenia
- delusions
- hallucinations
- no disorganization
- later onset
- higher functioning
positive symptoms of schizophrenia
- hallucinations
- delusions
- bizarre behavior (clothing, appearance, social, sexual, aggressive-agitated, repetitive)
- formal thought disorder (derailment, tangentiality, incoherence, illogicality, circumstantiality, pressure of speech, distractible speech)
- more florid symptoms and respond to meds
negative symptoms of schizophrenia (6)
- anhedonia (w/o pleasure): a reduced ability or inability to experience pleasure in everyday life
- avolition (w/o making decision): loss of motivation; difficulty beginning and sustaining goal directed activities; reduction in motional or goal directed behavior
- asociality: decreased desire for, or comfort during, social interaction
- affective blunting: reduced or constricted affect (flat, inappropriate, bizarre)
- apathy: decreased interest in, or attention to, activities or beliefs that would otherwise be interesting or important
- alogia: reduction in speech (aka: poverty of speech)
slides:
- affective blunting: flat, inappropriate, bizarre
- anergia: lack of energy
- anhedonia: lack of pleasure
- avolition: apathy
- alogia: poverty of ideas/content of speech, thought blocking
- can be more debilitating and hard to treat with meds
hallucinations (types)
- auditory: hearing voices that do not exist, voices are projections of own inner thoughts
- visual: seeing a person or object that does not exist in the environment
- tactile: feeling strange sensations when no external stimulus exists
- olfactory: smelling odors not actually present in the environment
- gustatory: tasting sensations that have no stimulus
delusions (types, firm/fixed beliefs)
- ideas of reference: misconstructing trivial events/remarks and giving them personal significance
- persecution: believing one is being singled out for harm by others
- grandeur: believing one is a powerful, important personage
- somatic: false belief that the body is changing
- jealousy: false belief that one’s significant other is unfaithful
cognitive symptoms of schizophrenia
- affect 40-60% of people with the disorder
- one of the major disabilities
- difficulty with attention, memory, executive functions (decision making, problem solving)
- disorganized speech & behavior & inappropriate affect stems from this
slides:
- inattention, easily distracted
- impaired memory
- poor problem solving skills
- poor decision making skills
- illogical thinking
- impaired judgement
common nursing diagnosis
- altered (disturbed) thought process
- disturbed sensory perception
- risk for harm to self and others
- impaired verbal communication
- social isolation
- risk for loneliness
- self care deficit
- compromised family coping
what is altered disturbed through process
conversation is derailed by unnecessary and tedious details (circumstantiality)
acute phase schizophrenia
- crisis intervention: safety & med stabilization, looking for decrease in intensity & frequency of sx.
- may need hospitalization, structure & support, meds, limit setting, directive communication, evaluation, short day then DCed to community
maintenance phase schizophrenia
- pt./family psychoeducation
- self effect management
- cognitive & social skills enhancement
- ID signs of relapse
- attends to self care
- social & work functioning
communication for hallucinating client
- ask directly about hallucinations
- watch for cues that client is hallucinating
- avoid reacting to hallucinations as if they are real
- do not neglect client experience: respond to feelings
- offer your own perceptions
- focus on reality based diversion
- be alert to client anxiety
communication for delusional client
- be open, honest, reliable
- be matter-of-fact and calm
- ask client to describe delusions
- avoid arguing but interject doubt
- focus on feelings the delusions generate
- once delusion is described, do not dwell on it; set firm limits on time you will devout to them
- observe events that trigger delusions; discuss w/ pt.
- validate any true part of the decision
ways of coping with voices and worry thoughts
- distracting: listening to music, reading aloud, counting backwards, describing an object in detail, watching TV, exercising, cleaning house, bath, singing, play a instrument
- interacting: telling voices to go away, agreeing to listen only at certain times, talking to friend, family, phoning a helpline, going to a drop in center
- physical: taking extra medication-call MD, breathing exercised, relaxation exercises
additional nursing interventions
- brief interactions, several times a day
- monitor safety ADLs
- encourage socialization, even is only 1:1
- reorient to reality
- support
- monitor symptoms and medicate as necessary
- psychoeducation when ready
1 generation antipsychotic drug therapy
- less expensive than 2nd generation
- are D2 receptor antagonists in both limbic and motor centers
- motor = EPS -> add antiparkinsonian drugs, anticholinergics -> in the 1950’s (moderate EPS: “benchmark” drug)
1st generation antipsychotic drug therapy examples
- chlorpromazine (thorazine): 1st antipsychotic (1950s), moderate EPS (“benchmark” drug)
- haloperidol (haldol): high EPS, used w/ aggressive pts. w/o hTN, good for elderly
- fluphenazine (prolixin): among the least sedative, high EPS
- thiothixene (Navane): high EPS, high incidence of akathisia
- haldol decanoate: IM given Q3-4 weeks
- prolixin decanoate: IM given Q2-4 weeks
2nd generation antipsychotic drug therapy
- emerged in 1990’s
- often 1st line: Low EPS side effects, wt. gain, glucose, cholesterol increase (metabolic syndrome)
- risk for: DM, HTN (works on +/- sx.)
2nd generation antipsychotic drug therapy examples
- clozapine (clozaril): used in refractory patients - weekly, WBC, agranulocytosis 0.8-0.1%
- risperidone (risperdol): wt. gain, can be given IM
- olanzapine (zyprexa): wt gain., Qday dosing, may interact with SSRI’s
- Quietiapine (Seroquel): risk of TD & NMS low
- Ziprasidone (geodon): ECG changes OQ prolonged, good with depressive symptoms, low wt. gain, IM
antipsychotic side effects: anticholinergic sx.
- dry mouth
- urinary hesitancy/retention
- constipation
- blurred vision
- photosensitivity
- dry eyes
- ejaculatory inhibition
antipsychotic side effects: extrapyramidal effects + tx.
- pseudoparkinsonism: artane, cogentin
- acute dystonic reaction: Benadryl (ocluogyric crisis, opisthotonus, laryngeal dystonia)
- Akathisia: D’C drug, benzes
- tardive dyskinesia: no treatment
antipsychotic side effects: 2nd generation
- metabolic syndrome: glucose dysregulation
- increased cholesterol
- wt. gain 20-35% of body weight
- risk for: DM, HTN, atherosclerosis
- Emergency! -> Neuroleptic Malignant Syndrome
caused by sudden reduction in dopamine activity
- severe muscle rigidity, fever, HTN, tachycardia, diaphoresis, tachypnea, confusion
- occurs in 1% of those on antipsychotics
- tx: hold meds, supportive care, monitor fluids & lyres, ICU, bromocriptine
schizoaffective disorder
- sx. of schizo & mood disorder, somewhat controversial, DSM IV in ‘87
- uninterrupted period of illness with major mood disorder (MDD or mania) with criteria A of schizophrenia
- delusions or hallucinations <2 weeks, during lifetime
- sx. of mood disorder present throughout illness
- specific bipolar or depressed types
- treat with antipsychotics, mood stabilizers, antidepressants
community mental health
- characteristics
- treatment outcomes
- interventions
- settings
- assertive community treatment (ACT)
chronic mental illness
- extends from acute to long term
- marked by persistent impairment of functioning
- deinstitutionalized to community mental health
- erodes basic coping, quality of life, contact with others, employment, self image
noncompliance
- control
- reluctance to give up behavior (smoking, drugs)
- secondary gains from sick role
- effects of the illness on the brain
- negative family influences
- inability to understand
- side effects of medications
