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Thursday, October 4, 2012

Psychiatric Nursing: Schizophrenia


Schizophrenia

Overview
  1. Characterized by disordered thinking, delusions, hallucinations, depersonalization (feeling of being strange, not oneself), impaired reality testing (psychosis), and impaired interpersonal relationships.
  2. Regression to the earliest stages of development is often noted (e.g., incontinence, mutism)
  3. Onset is usually in adolescence/early adulthood (15-35 years of age).
  4. Client may be seriously impaired and unable to perform ADL.
  5. Etiology is not known; theories include
1.       Genetic: 1% of population
2.       Biochemical: neurotransmitter of dysfunction i.e. dopamine, serotonin
3.       Interaction of predisposing risk and environmental stress.
  1. Prior to onset (premorbid) client may have been suspicious, eccentric, or withdrawn.

Classifications
  1. Disorganized: Incoherent; delusions are not organized; social withdrawal; affect blunted, silly, or inappropriate
  2. Catatonic: psychomotor disturbances
1.       Strupor: mute, little reaction or movement
2.       Excitement: purposeless, excited motor activity
3.       posturing: voluntary, inappropriate, bizarre postures
  1. Paranoid: delusions and hallucinations of persecution/grandeur
  2. Undifferentiated: disorganized behaviors, delusions, and hallucinations

Assessment:
  1. Four A’s
1.       Affect: flat, blunted
2.       Associative looseness: verbalizations are disorganized
3.       Ambivalence: cannot choose between conflicting emotions
4.       Autistic thinking: thoughts on self, extreme withdrawal, unable to relate to outside world
  1. Any changes in thoughts, speech, affect
  2. Ability to perform self-care activities, nutritional deficits
  3. Suicide potential
  4. Aggression
  5. Regression
  6. Impaired communication
Analysis
Nursing diagnosis for clients with schizophrenic disorders may include:
  1. anxiety
  2. impaired verbal communication
  3. ineffective individual/family coping
  4. high risk for injury
  5. altered nutrition
  6. powerlessness
  7. self-care deficit
  8. self-esteem disturbance
  9. sensory-perceptual alteration
  10. sleep pattern disturbance
  11. social isolation
  12. high risk for violence
Planning and Implementation
Goals
                Client will:
    1. develop a trusting/therapeutic relationship with nurse
    2. be oriented, able to test reality
    3. be protected from injury
    4. be able to recognize impending loss of control
    5. adhere to medication regimen
    6. participate in activities
    7. increase ability to care for self
Interventions
    1. offer self in development of therapeutic relationship
    2. use silence
    3. set time for interaction with client
    4. encourage reality orientation but understand that delusions/hallucinations are real to client.
    5. Assist with feeding/dressing as necessary
    6. Check on client frequently; remove potentially harmful objects
    7. Contract with client to tell you when anxiety is becoming so high that loss of control is possible
    8. Administer antipsychotic medications as ordered; observe for effects
1.       reduction of hallucinations, delusions, agitation
2.       postural hypotension
a.       obtain baseline BP and monitor sitting/standing
b.       client must lie prone for 1hour following injection
c.        teach client to sit up or stand up slowly
d.       elevate client’s leg while seated
e.       withhold drug if systolic pressure drops more than 20-30mmhg from previous    
         reading
3.       photosensitivity
a.       add use of sunscreen
b.       avoid exposure to sunlight
4.       agranulocytosis
a.       instruct client to report sore throat or fever
b.       institute reverse isolation if necessary
5.       elimination
a.       measure I&O
b.       check bladder distention
c.        keep bowel record
6.       Sedation
a.       avoid use of heavy machinery
b.       do not drive
7.       Extrapyramidal symptoms
a.       Dysthonic reactions
                                        i.      Sudden contractions of face, tongue, extraoccular muscles
                                   ii.      Administer antiparkinson agents prn (e.g., benztropine (cogentin) 1-8mg or dipenhydramine (benadryl) 10-50mg), which can be given PO or IM for faster relief; trihexyphendil (artane) 3-15mg PO only, can also be used prn).
                                   iii.      Remain with client; this is a frightening experience and usually occurs when medication is started
b.       Parkinson syndrome
                                       i.      Occurs within 1-3 weeks
                                       ii.      Tremors, rigid, posture, masklike facial appearance
                                       iii.      Administer antiparkinson agents prn
c.        Akathisia
                                         i.      Motor restlessness
                                         ii.      Need to keep moving
                                         iii.      Administer antiparkinson agents
                                        iv.      Do not mistake this for agitation; do not increase antipsychotic  medication
                                        v.      Reduce medications to see if symptoms decrease
                                        vi.      Determine if movement is under voluntary control
d.       Tardive dyskinesia
                                        i.      Irreversible involuntary movements of tongue, face, extremities
                                        ii.      May occur after prolonged use of antipsychotics
e.        Neuroleptic malignant syndrome
                                         i.      Occurs days/weeks after initiation of treatment in 1% of clients
                             ii.      Elevated VS, rigidity, and confusion followed by incontinence, mutism, opisthotonos, retrocollis, renal failure, coma, and death
                                     iii.      Discontinue medication, notify physician, monitor VS, electrolyte balance, I&O
                                    iv.      Elderly clients should receive doses reduced by one-half  to one-third of recommended level
8.       encourage participation in milieu, group, art, and occupational therapies when client able to tolerate them.
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