Nursing 292

Psychiatric Nursing

Schizophrenia and other

Psychotic Disorders

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 Objectives
• Discuss neurobiological processes in
schizophrenia

• Identify positive and negative symptoms of

schizophrenia

• Discuss the clinical course and complications

of schizophrenia

• Develop a nursing care plan for management

of clients with hallucinations, delusions, and
communication problems
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 Objectives
• Understand Pharmacotherapy for Psychosis
– Target symptoms of antipsychotics
– Typical & atypical antipsychotics
– Side-effects & nursing implications
– Antidyskinetic medications
• Discuss AIMS
• Nursing interventions for clients & families
with chronic mental illness

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 Schizophrenia
• Psychotic symptoms for at least 6
months not related to medical condition
or substance use
• Impaired social, academic and
occupational functioning
• Can be single episode, episodic,
continuous, in full or partial remission.

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 Schizophrenia
• Paranoid type – suspicious, may be argumentative,
auditory hallucinations are common

• Disorganized type (hebephrenic) – giggling, bizarre

behavior, impaired socialization and affect

• Catatonic type – extreme psychomotor retardation

(stupor) or purposeless movements (excitement)

• Undifferentiated – bizarre behavior, hallucinations,

delusions

• Residual type – psychotic symptoms, history of 5

schizophrenia
• 0.5-1% prevalence

• Onset most common during late adolescence

• Third most disabling disease along with cardiac

problems and cancer, 10 years loss to normal life
span

• 30% schizophrenics attempt suicide at least 1 X, 10%

die due to suicide

• High costs due to direct care and lost productivity

• Lengthy and frequent hospitalizations

• Family chaos
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 Schizophrenia
• The word schizophrenia is derived
from the Greek words skhizo (split)
and phren (mind) - to describe the
“split mindedness” or separation
among affect, cognition and
emotions

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 Nature of the Disorder
• Schizophrenia disturbs
–Thought processes (delusions)

–Perception (hallucinations)

–Affect (impaired socialization)

–Speech & Behavior (disorganized, bizarre)

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 Nature of the Disorder (cont.)

• Premorbid behavior of the client with

schizophrenia can be viewed in four
phases.

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 First Phase
Schizoid personality
• Indifferent, cold, and aloof, these people
are loners. They do not enjoy close
relationships with others.

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 Second Phase
Prodromal phase
• These people are socially withdrawn and
show evidence of peculiar or eccentric
behavior
• Neglect of personal hygiene and grooming
• Blunted or inappropriate affect
• Disturbances in communication
• Bizarre ideas
• Lack of initiative 11
 Third Phase
Schizophrenia
• In the active phase of the disorder,
psychotic symptoms are prominent
–Delusions
–Hallucinations
–Disorganized speech and behavior
–Impairment in work, social
relations, and self-care

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 Fourth Phase
Residual phase
–Symptoms similar to those of the
prodromal phase

–Flat affect and impairment in role

functioning are prominent

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 Positive and Negative
Symptoms
• Hallucinations • Affective flattening
• Delusions • Anhedonia
• Thought disorders • Avolition
• Disorganized • Attentional problems
speech and • Alogia
behaviors

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 Nursing Assessment
• ABCs of Mental Status
–Appearance & Affect
–Behavior
–Cognitive Functioning
–Speech

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 Thought Content
• Delusions
– False personal beliefs
– Inconsistent with reality
– Not generally accepted by others with
same cultural background
– Content relates to underlying anxiety or
fear

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 Thought Content (cont.)
Types of Delusions (False Beliefs)
– Delusions of Persecution (threatened)
– Delusions of Grandeur (special powers)
– Delusions of Reference (insignificant remarks
have personal meaning – newspaper headlines)
– Delusions of Control (another person controls
thoughts, behavior – thought broadcasting,
thought insertion)
– Somatic Delusions (about bodily function –
disease, pregnancy)
– Nihilistic Delusions (nonexistence of self, world
ending)
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 Thought Content (cont.)
Other types of thought disturbance
– Religious Preoccupation (use religious
ideas to explain behavior)

– Paranoia (suspicious; food poisoned)

– Magical Thinking (thoughts or behavior can

cause or prevent something happening)
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 Thought Content (cont.):
Perceptions
• Hallucinations - False sensory perceptions
– Auditory (most common in schizophrenia)
– Visual
– Tactile
– Olfactory
– Gustatory
– Kinetic
• Illusions – misperceptions of real external
stimuli

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 Disorganized Thoughts
• Change topics - Looseness of association
• Nonsensical speech -Neologisms – new
words
• Concrete thinking – literal interpretations of
environment
• Clang associations – often rhyming
• Word salad – random words without meaning
• Repeat another’s words – Echolalia
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 Disorganized Thoughts

• Circumstantiality – overly detailed

• Tangentiality – unrelated topics; doesn’t
get to the point
• Mutism – inability or refusal to speak
• Perseveration – repeats same idea over
and over

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 Disorganized Behavior
• Repeat actions of others – Epraxia
• Catatonia – decreased reactivity to
surroundings
– Catatonic stupor (immobility, posturing,
waxy flexibility, mutism)
– Excitement (unprovoked, excessive motor
activity)

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 Complications
• Risk of Suicide

• Risk of Chronic Fluid Imbalance –

polydipsia, water intoxication, seizures,
hyponatremia, (heavy smoking
increases risk)

• Medication side-effects
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 Case Study
35 year old man admitted to inpatient
psychiatric unit from ER. Appears
restless and disheveled. History of past
hospitalization for schizophrenia.
Patient reports frightening voices telling
him he is no good and would be better
off dead. Verbally threatened staff in
ER. Has history of suicide attempts in
the past. Mother reports increased
isolation since he stopped medications.

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 Nursing Diagnoses
• Risk for self and other directed violence
• Bathing/hygiene self-care deficit
• Ineffective therapeutic regimen
management
• Social isolation
• Disturbed sensory perception: auditory
hallucinations
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 Other Nursing Diagnoses
• Disturbed thought processes
• Impaired verbal communication
• Disabled family coping
• Ineffective health maintenance

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 Outcomes
• Will not harm self or others
• Will shower and wash clothes
• Will be compliant with medications
• Will exhibit less agitated behavior
• Will decrease hallucinations

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 Nursing Interventions
• Establish trusting relationship
• Monitor symptoms & intervene early
• Facilitate adherence to medications
• Distract client from hallucinations
• Provide safe, structured environment
and reduce stimuli in environment
• Connect symptom improvement to
medication effect

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 Nursing Interventions
• Risk for violence:
– Protect client from harming self or others
– Decrease stimuli
– Remove dangerous objects
– Provide physical outlets
– Medications
– Observation
– Assess for suicidal ideation

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 Nursing Interventions
• Disturbed thought processes (delusions):
– Reassure in safe place (Delusions are based on anxiety &
fear)
– Help identify underlying fear (may reduce delusions)
– Acceptance but do not share belief
– Do not challenge delusional thinking (they are not rational)
– Use “reasonable doubt”
– Talk about real events and people; don’t dwell long time on
irrational thoughts
– Provide reality based activities to help client understand
what is real and what is not
– If suspicious, avoid touch, laughing or talking where client
can see but not hear (reduce sense of being threatened)
– If suspicious, use same staff as much as possible
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 Nursing Interventions
• Disturbed sensory perception (Hallucinations):
– Observe for signs client is hallucinating
– Early interventions can prevent aggression
– Evaluate content of hallucinations (commands)
– Do not touch without warning; allow space
– Accepting, non-judgmental attitude
– Do not reinforce hallucination, say “voices”
– Reassure voices may be frightening, but not real
– Help client learn relationship between anxiety and the
hallucination; explore what precipitates hallucination
– Provide reality based activities to help distract from
hallucinations and reduce anxiety

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 Nursing Interventions
• Impaired verbal communication:
– Seek validation & clarification (“Do you mean...?”)
– Give feedback (“I do not understand what you
mean.”) Helps client see he is not understood and
engages client in improving communication
– Consistent staff assignments to promote trust
– Convey empathy: “Verbalize the implied”; “That
must have been upsetting.”
– Anticipate and meet client’s needs for safety and
comfort until able to communicate effectively
– Orient to reality; call by name

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 Nursing Interventions
• Social Isolation
– Acceptance
– Brief, frequent contacts
– Slow introduction to group activities
– Initially accompany to groups to help client
feel more secure
– Give recognition for interactions with others

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 Evaluation
• Absence of threats to safety of self and
others
• Takes medications as prescribed
• Interacts appropriately with others
• Participates in unit activities and groups
• Begins to modify responses to
hallucinations
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 Client and Family Education
• Nature of illness – what to expect; how
to manage symptoms
• Role of stress and coping skills
• Medication: dose, side-effects, not stop
• Contact info for health care provider
• Social skills training
• Support services
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 Treatment Modalities: Social
• Milieu therapy – group and social
interaction, rules, expectations, relationships,
structure
• Family therapy – education, support, and
conflict resolution
• Assertive Community Treatment (ACT) –
comprehensive community based treatment;
case management model; team approach:
SA treatment, education, mobile crisis,
rehabilitation, work training
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 Etiology
• No single etiological factor
• Genetic link & familial pattern
• Combination genetic & environmental
• Environmental (viruses, stress)
• Neurodevelopmental disorders – early delays
in motor, cognitive, social functioning
• Neurostructural / neurodegenerative factors –
enlarged ventricles, decreased gray matter;
decreased frontal lobe volume
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 Etiology (cont.)
• Biochemical
Factors
• excess dopamine in
limbic system
(Dopamine
Hypothesis)
• Mechanism for positive
symptoms
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 Etiology (cont.)
• Biochemical Factors (cont.)
–Abnormalities in other
neurotransmitters
• Norepinephrine
• Serotonin
• Acetylcholine
• Gamma-aminobutyric acid

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Other Influences (Etiology cont.)
• Psychological Factors – deficient ego
development, anxiety, ineffective
coping, regression
• Environmental Factors
– Poverty/poor social conditions
– Stress
– Families with high expressed emotion
(EE)
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 Etiology (cont.)
• Conclusion: Theoretical Integration
–Schizophrenia is most likely a
biologically based disease, the onset
of which is influenced by factors in the
internal or external environment.

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 Other Psychotic Disorders
• Schizophreniform disorder – symptoms
< 6 mos; may not have significant
impaired functioning

• Schizoaffective disorder – symptoms of

schizophrenia and also major
depressive or bipolar symptoms

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Other Psychotic Disorders (cont.)

• Brief psychotic disorder – sudden onset following a

stressor; symptoms >1 day and <1 month; returns to pre-morbid
functioning

• Shared psychotic disorder - client with close, dependent

relationship with someone with psychotic disorder (folie á deux)

• Psychotic disorder due to medical condition (see text)

• Substance-induced psychotic disorder

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Other Psychotic Disorders (cont.)

• Delusional disorder - The existence of

prominent, non-bizarre delusions
– Erotomanic type
– Grandiose type
– Jealous type
– Somatic type
– Persecutory type

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 Basic facts about psychotropic
medications

• They work by altering or balancing brain

chemistry – affect neurotransmitters and
neurotransmitter receptor sites
• They do not cure mental illness, but
work by getting and keeping symptoms
in control.

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 The nurse’s role in
psychopharmacology
• Assessment, including personal and family
responsiveness to medications, and attitude
towards medications
• Educating patients and family members
• Medication administration
• Monitoring of desired and side effects
• Connect positive effects to medication
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 Antipsychotic Medications
Typical Atypical
Chlorpromazine (Thorazine) Risperidone (Risperdal)
Thioridazine (Mellaril) Olanzapine (Zyprexa)
Fluphenazine (Prolixin) Quetiapine (Seroquel)
Perphenazine (Trilafon) Ziprasidone (Geodon)
Trifluoperzine (Stelazine)
Clozapine (Clozaril)
Thiothixene (Navane)
Aripiprazole (Abilify)
Haloperidol (Haldol)

Depot—Long acting preparations

Fluphenazine decanoate (Prolixin)
Haloperidol decanoate (Haldol)
Risperidone microspheres (Risperdal Consta) 47
 Drug Action
• Typical antipsychotics primary action is
to block dopamine receptors (D2)

• Atypical antipsychotics block several

neurotransmitters: primarily serotonin
(serotonin receptor, 5HT2-3) and
dopamine (D1, D3, D2)

• Dopamine system stabilizer (Abilify)

acts as dopamine agonist or antagonist
in different areas of brain
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 Target symptoms controlled by
antipsychotics
• Agitation
• Apathy* • Paranoia
• Delusions • Racing thoughts
• Emotional withdrawal* • Rage
• Feelings of unreality • Severe impulsiveness
• Hallucinations • Social discomfort or
• Ideas of reference isolation*
• Lack of motivation* • Terror
• Lack of pleasure* • Unclear thoughts
• Lack of spontaneity* • Uncontrollable hostility
• Overreactive senses • Uncontrollable negativism

* Negative symptoms

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 Common Side Effects
• EPS • Hypergylcemia
• Orthostatic Hypotension (Atypicals)
• Sedation • Hypercholesterolimia
• Weight Gain • Hypertriglycerides
• Temperature • Diabetes mellitus
Dysregulation • Agranulocytosis
• Neuroleptic Malignant (Clozaril)
Syndrome • Myocarditis (with
• Photosensitivity Clozaril)
• Seizures (Typicals, • Prolonged QT (Invega,
Clozaril) Geodon)
• Increased salivation
(Abilify, Clozaril)

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 Anticholinergic side effects
• Constipation
• Blurred vision
• Urinary retention or hesitancy
• Nasal congestion
• Dry mouth
Clozaril has strong potential for anticholinergic side
effects
Water, sugar-free candy, alcohol-free, moisturizing
mouth wash, fiber, increased fluids

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 Abnormal Glucose Metabolism

• Associated with atypical antipsychotics

• Before treatment assess for risk of
diabetes
• Monitor FBS & lipid levels regularly

Associated with clozapine and olanzepine

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 Blood Dyscrasias
• Agranulocytosis can occur in clients on
clozapine (Clozaril)
– Baseline WBC & absolute neutrophil count
(ANC) and weekly X 6 months
– Continued monitoring every 2 weeks
– Monitor monthly after 1 year
– Observe for signs of infection (fever, sore
throat)
– Stop medication immediately
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 Other side-effects of antipsychotics

• Sexual side effects: delay in orgasm, reduced

sex drive, amenorrhea
• Orthostatic hypotension: monitor BP seated
and standing; fliuds, falls risk, change
position slowly (clozaril, thorazine, mellaril)
• Photosensitivity
• Hypersalivation – drooling (Clozaril)
• QT prolongation (Mellaril, Geodon, Invega)
• Weight gain
• Sedation
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 Extrapyramidal (Muscular) Side
Effects
• Dystonic Reaction – involuntary muscle
reactions mostly involving neck and face;
sudden onset often in initial days of treatment
– Torticolis
– Oculogyric crisis (eyes roll up, lateral gaze)
– Tongue protrudes
– Involuntary smile
Treat with IV Valium, Banadryl; 100%
curable
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 Extrapyramidal (Muscular)
Side Effects (cont.)
• Akasthisia—motor restlessness (legs),
can’t stop moving, anxious, very
uncomfortable. Untreated can lead to
suicide.
Treat with anticholinergic med, valium,
propanolol. Preventable and reversible.

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 Extrapyramidal (Muscular)
Side Effects (cont.)
• Parkinsonism—drug induced, mimics Parkinson’s.
Develops gradually often early in treatment (days to
months). Client often not bothered or aware.
– Akinesia: weakness, fatigue, lack of movement, slow
movements, facial masking, decreased blinking, drooling
(decreased swallowing)
– shuffling gait
– tremors
– Rigidity, cogwheeling
– Stooped posture

Treat by decreasing or changing antipsychotic med; low dose,

short-term anticholinergic (careful in elderly)

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 Extrapyramidal (Muscular) Side
Effects (cont.)
• Tardive Dyskinesia: late onset, often irreversible
– Random, involuntary movements of arms, legs
– Dystonia – neck twisting
– Finger rubbing or jerking
– Twitching or over-activity of the tongue
– Exaggerated blinking
– Puckering or chewing movements of the mouth
– Tic-like movements of the face

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Antidyskinetic Medications—used to treat
muscular side effects of antipsychotics

• Benztropine (Cogentin)
• Biperiden (Akineton)
• Orphenadrine (Norflex)
• Diphenhydramine (Benadryl)
• Procyclidine (Kemadrin)
• Trihexyphenidyl (Artane)
• Amantadine (Symmetrel)
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 AIMS
• Abnormal involuntary movement scale

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 Neuroleptic Malignant
Syndrome
• Elevated CPK
• Elevated Temperature
• Autonomic instability—Hypertension
• Tachycardia
• Diaphoresis
• Muscle rigidity— “Lead Pipe Rigidity”
• Stop medication and Treat Symptoms
• Deteriorating mental status
Can be fatal. Stop antipsychotic med immediately.

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 Chronic Illness
• Chronic illness, mental and physical,
includes all diseases or disorders that
remain with the individual for the rest of
the client’s lifetime once the condition
has been diagnosed.

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 Chronic Mental Illness

• All psychiatric disorders have the

potential to persist and become chronic
with the following having the most
potential to do so:
– Schizophrenia
– Major depressive disorder
– Bipolar disorder
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 Management & Treatment
• The nursing plan needs to be individualized, realistic,
integrated with other members of the psychiatric
team

• Actively involve family members and the client in

planning

• Provide counseling for grief and loss for the family

and the individual

• Individual, group, and family psychotherapy can

benefit the client and significant others 64
 Management & Treatment
• Stress management
• Empowerment
• Crisis intervention
• Psychiatric rehabilitation
• Psychoeducation
• Basic cognitive and academic skills training
• Social skills training
• Vocational training
• Interpersonal skills building
• Behavior modification
• Medication management.
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 Psychiatric Rehabilitation
• Relearning skills and competencies needed
for successful interpersonal, social, and
vocational functioning
– Psychoeducation
– Medication management
– Academic skills
– Social skills
– Stress Management
– Behavior modification
– Vocational training
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 Psychoeducation
• Psychoeducation involves teaching clients,
their families and significant others about:
– the disease or condition (i.e. the specific chronic
mental illness)
– types of psychotherapy
– medication management
– complementary therapies
– compliance with different treatment modalities
– rehabilitation
– signs of relapse
– community resources
– coping skills
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 Recovery Model
• Consumers have primary control over
decisions about their own care
• Based on concepts of strength &
empowerment
• Control and choice in treatment leads to
increased control & initiative in their
lives

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