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SCHIZOPHRENIA

Ali C. Robles, RN, MD

INTRODUCTION
Schizophrenia is possibly a group of psychotic

disorders that severely impairs all areas of an individuals functioning. 1 to 1.5% of US population has schizophrenia. However they make up far more than 50% of the county and long-term residents of state mental hospitals. More than 50% are homeless, and in addition may have an addiction problem. The cost of treatment and loss of revenues are estimated in the billions of dollars.

COMORBIDITY
Substance abuse disorders Nicotine dependence Depression

Suicide
Anxiety disorders

Psychosis-induced polydipsia

ETIOLOGY
Neurobiochemical
Dopamine hypothesis Serotonin Glutamate

Neuroanatomical
Structural cerebral abnormalities

Genetic
Several genes on different chromosomes interact with

environment

Nongenetic risk factors


Complications of pregnancy and birth Stress

GENETIC PREDISPOSITION
A single gene has not been identified.

Research is focused on chromosomes 6, 13, 18 & 22. The risk of developing the disorder is as follows: One parent 12-15%+ Both parents 40%+

Identical twins 50%+


(The statistics may vary in different studies)

AREAS OF THE BRAIN AFFECTED

BIOLOGICAL THEORIES Neuroanatomical

Course of Schizophrenia
Recurrent acute exacerbations

of psychosis Increase in residual dysfunction and deterioration with each relapse

Phases in Course of Schizophrenia


1. Acute phase

Positive symptoms and negative symptoms

2. Maintenance phase

Acute symptoms are less severe


Remission of symptoms

3. Stabilization phase

Potential Early Symptoms: Pre-psychotic


Withdrawn from others Depressed

Anxious
Phobias Obsessions and compulsions

Difficulty concentrating
Preoccupation with religion Preoccupation with self

Bleulers 4 As of Schizophrenia
Affect Associative looseness Autism Ambivalence

Signs and Symptoms: Relevant to Treatment

Positive symptoms Negative symptoms Cognitive symptoms Mood symptoms

Dimensions Altered in Individuals with Schizophrenia


Ability to work Interpersonal relationships Self-care abilities Social functioning Quality of life

Positive Symptoms: Alteration in Thinking


Delusions: false, fixed beliefs that cannot be corrected by

reasoning Ideas of reference Persecution Grandiosity Somatic sensations Jealousy Control Thought broadcasting Thought insertion Thought withdrawal Delusion of being controlled Concrete thinking

Positive Symptoms: Alterations in Speech


Associative looseness Neologisms Echolalia Clang association Word salad

Positive Symptoms: Alterations in Perception


Hallucinations: sensory perceptions for which no external stimulus exists
Auditory

Visual
Olfactory Tactile

Personal boundary difficulties

Positive Symptoms: Alterations in Behavior


Extreme motor agitation Stereotyped behaviors

Automatic obedience
Waxy flexibility Stupor Negativism

Negative Symptoms
Affective blunting
Anergia Anhedonia Avolition Poverty of content of speech

Thought blocking
Flat affect/inappropriate affect

Cognitive Symptoms
Inattention, easily distracted
Impaired memory Poor problem-solving skills Poor decision-making skills Illogical thinking Impaired judgment

Depression and Other Mood Symptoms


Dysphoria Suicidal ideation Hopelessness

Types of Schizophrenia
Subtypes Paranoid Catatonic Disorganized Undifferentiated Residual

Peer group supervision

Self-Assessment: Working with Schizophrenic Clients


similar emotions in the nurse

Client's intense emotions produce


Willingness for nurse to discuss feelings and behaviors with

supervisors decreases defensive behaviors

Team approach to decrease staff burnout Periodic reassessments of


Treatment outcomes Client's strengths and weaknesses

Assessment of the Client


Safety of client and others

Medical history and recent medical workup Positive, negative, cognitive, and mood

symptoms Current medications and compliance to treatment Family response/support system

Potential Nursing Diagnoses


Risk for self-directed or other-directed violence
Disturbed sensory perception

Disturbed thought processes


Impaired verbal communication Ineffective coping Compromised or disabled family coping

Outcome Criteria
Acute phase
Client safety and medical stabilization

Maintenance phase
Adherence to medical regimen
Understanding schizophrenia Participation of client and family in psychoeducational activities

Stabilization phase
Target negative symptoms
Anxiety control Relapse prevention

Planning of Appropriate Interventions


Acute phase
Possible hospitalization Ensure client safety Provide symptom stabilization

Maintenance and stabilization phases


Psychosocial education Relapse prevention skills

Interventions: Basic Level


Acute phase Administer antipsychotic medication as prescribed Observe client behavior closely Set limits on inappropriate behavior Do not touch without warning Offer foods that are not easily contaminated Assist with ADL if needed Supportive counseling Milieu management Family psychoeducation

Interventions: Basic Level


Continued
Maintenance and stabilization phases
Health teaching

Health promotion and maintenance

Milieu Therapy
Safety
Potential for physical violence due to hallucinations or

delusions
Priority is least restrictive safety technique

Verbal de-escalation Medications Seclusion or restraints


Activities
Provide support and structure Encourage development of social skills

and friendships

Counseling: Communication Guidelines


Hallucinations
Hearing voices most common Approach client in nonthreatening and nonjudgmental

manner Assess if messages are suicidal or homicidal Initiate safety measures if needed Client anxious, fearful, lonely, brain not processing stimuli accurately Focus on the clients feelings and present reality

Communication Guidelines continued


Delusions
Be open, honest, matter-of-fact, and calm Have client describe delusion

Avoid arguing about content


Focus on feelings Present reasonable doubt

Validate part of delusion that is real

Communication Guidelines continued


Associative looseness Do not pretend that you understand Place difficulty of understanding on yourself Look for reoccurring topics and themes Emphasize what is going on in the client's environment Involve client in simple, reality-based activities Reinforce clear communication of needs, feelings, and thoughts

Client Teaching Coping Techniques for Schizophrenia


Distraction Interaction Activity Social action Physical action

Client and Family Teaching


Learn all you can about the illness. Develop a relapse prevention plan. Avoid alcohol and drugs. Learn ways to address fears and losses. Learn new ways of coping. Comply with treatment. Maintain communication with supportive people. Stay healthy by managing illness, sleep, and diet.

Treatment Modalities
Individual therapy

Social skills training (SST) Cognitive remediation Cognitive adaptation training (CAT) Cognitive behavioral therapy (CBT)

Group therapy Family therapy Psychopharmacology

Psychopharmacology
Antipsychotics
Standard/ Typical Atypical

Antiparkinson

Psychopharmacology Traditional Antipsychotic


Dopamine antagonists (D2 receptor antagonists)
Target positive symptoms of schizophrenia Advantage
Less expensive than atypical antipsychotics

Disadvantages
Do not treat negative symptoms Extrapyramidal side effects (EPS) Tardive dyskinesia Anticholinergic effects (ACH) Lower seizure threshold

Antipsychotic Medications: Traditional


High potency = low sedation + low ACH + high EPSs
Haloperidol (Haldol) Trifluoperazine (Stelazine) Fluphenazine (Prolixin) Thiothixene (Navane)

Medium potency
Loxapine (Loxitane)
Molindone (Moban) Perphenazine (Trilafon)

Antipsychotic Medications:
Traditional continued
Low potency = high sedation + high ACH + low EPSs
Chlorpromazine (Thorazine) Thioridazine (Mellaril) Mesoridazine ( Serentil)

Decanoate = Long acting injection


Haloperidol decanoate (Haldol D) Fluphenazine decanoate (Prolixin D)

Atypical Antipsychotics (First-Line Antipsychotics)


Serotonin-dopamine antagonists
(5-HT2A receptor antagonists)

Advantages
Diminishes negative as well as positive symptoms of schizophrenia
Less side effects encourages medication compliance Improves symptoms of depression and anxiety Decreases suicidal behavior

Disadvantages
Weight gain Metabolic abnormalities

Antipsychotic Medications: Atypical


Clozapine (Clozaril) Quetiapine (Seroquel)

Risperidone (Risperdal
Zipreasidone (Geodon) Olanzapine (Zyprexa) Aripiprazole (Abilify)

Side Effects- Atypical


Orthostatic Hypotension Decreased Libido Agranulocytosis (Clozapine) Weight gain Tachycardia Edema

Side Effects: Anticholinergic Symptoms


Dry mouth
Urinary retention and hesitancy Constipation

Blurred vision
Photosensitivity Dry eyes Inhibition of ejaculation or impotence in men

Side Effects: Extrapyramidal Side Effects


Pseudoparkinson
Drooling, lack of facial responsiveness, shuffling gait,

and fine intentional tremors.

Acute Dystonia
Muscle spasms of the jaw, tongue, neck or eyes.

Laryngeal spasms possible. Oculogyric crisis, Opisthotonos.

Akathisia
Motor restlessness, pacing, rocking, etc

Side Effects: Extrapyramidal Side Effects


Tardive Dyskinesia
Bizarre facial and tongue movements

chewing, tongue from side to side, etc. Involuntary tonic muscular spasms of extremities Trunk Potentially irreversible

Side Effects: a2 Block: Cardiovasclar

Hypotension Postural hypotension Tachycardia

Side Effects: Rare and Toxic Effects


Agranulocytosis Cholestatic jaundice

Neuroleptic malignant syndrome (NMS)

Severe extrapyramidal

Hyperpyrexia
Autonomic dysfunction

NEUROLEPTIC MALIGNANT SYNDROME


RARE, POTENTIALLY FATAL ONSET WITHIN HOURS OR YEARS EPS REACTIONS CPK HYPERTHERMIA 102 AND ABOVE TACHYCARDIA FLUCTUATING B.P. DIAPHORESIS STUPOR AND COMA

AGRANULOCYTOSIS
Potentially fatal disorder Symptoms include:
White blood cells level <2000 mm3 or granulocyte

count <1500mm3 Sore throat Low grade fever Malaise Sores in the mouth

NURSING IMPLICATIONS
MONITOR B.P. BEFORE ADMINISTERING MEDS CHECK CBC, CPK, LIVER FUNCTIONS AND VISION REGULARLY EVALUATE FOR EFFECTIVENESS AND SIDE EFFECTS ADMINISTER 1 OR 2 HOURS BEFORE BEDTIME MIX LIQUIDS WITH 60CC FRUIT JUICE PATIENT EDUCATION

ANTIPARKINSON AGENTS

COGENTIN ARTANE AKINETON PARLODOL KEMADRIN BENEDRYL

CLIENT AND FAMILY TEACHING


Teach about schizophrenia and available mental

health agencies for support at the local and national level (NAMI AND NIMH). Develop a relapse prevention plan. Teach about medication and treatment compliance. Teach to avoid alcohol or drugs. Teach to keep in touch with supportive people. Teach to keep healthy stay in balance.

Thank You

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