Download PBL team 12 - Part 1 - Scrubs

Team SCRUBS – PBL team 12
Thursday 11th August
722.724 Focused Experience and Transition into Practice
PBL PART 1
AGNES SMITH
1. Action point: Identify the factors that could be affecting
wound healing for Mrs Smith. For each factor identified,
discuss the underlying patho-physiology.
 Micro vascular disease Diabetes frequently leads to blood
vessel constriction. Various forms of vasculitis (blood vessel
inflammation) frequently cause vessel walls to harden,
thicken, and develop scar tissue, decreasing their diameter
and impeding blood flow. Vascular damage decrease oxygen
supply to the peripheral nerves and quickly lead to serious
damage to or death of nerve tissues, much as a sudden lack of
oxygen to the brain can cause a stroke Poor circulation also
limit the amount of healing nutrients that reach a wound
(NINDS). Several micro vascular abnormalities, including a
reduced response to tissue injury causing under perfusion, the
development
of
dependent
oedema
due
to
a
defective
venoarteriolar
reflex,
and
increased
permeability
of
capillaries, have also been proposed to delay wound healing
(Malik & Rayman, 2007)
 Peripheral Neuropathy slows down the wound healing in a
diabetic ulcer as it causes vessel ischemia. The loss of
protective sensation due to neuropathy and diminished trophic
effect by neuropeptide deficiency have been proposed to lead
to trauma and increased pressure on the foot skin and a
diminished hyperaemic response to tissue injury, respectively
(Malik & Rayman, 2007).
 Hyperglycemia Persistent uncontrolled hyperglycemia interferes
with wound healing, results in endothelial dysfunction, and
increases the risk of sepsis. The exact effect of uncontrolled
hyperglycemia on the process of wound healing and endothelial
dysfunction has not been completely determined (Medscape,
2006).
2. Action point: Your student nurse asks you what the difference
is between Type 1 and Type 2 diabetes. Explain diabetes type 1
& type 2 to your student.
 Type I Diabetes (T1D) is the autoimmune destruction of the
pancreatic beta cells. As pancreatic beta cells are involved
in the production of insulin, a hormone that regulates the
glucose metabolism, its destruction means an absolute lack of
Team SCRUBS – PBL team 12

insulin increasing blood glucose levels and causing the
breakdown of body fats and proteins. The rate of beta cell
destruction depends on the individual and commonly occurs in
young people but can happen at any age. T1D is triggered by
both genetic and environmental factors (Porth, 2007).
Type II Diabetes (T2D) is the occurrence of hyperglycemia or
high blood sugar levels despite the availability of insulin
and accounts for 90-95% people with diabetes, mostly over 40
years of age with some degree of obesity. T2D involves both
genetic factors such as family history and acquired factors
such as lifestyle, physical activity and diet (Porth, 2007).
3. Action point: Considering the underlying patho-physiology,
discuss the reasons why Agnes’s wound may not feel painful and
has moderate-heavy amounts of exudate.
 Distal Symmetric Neuropathy is a complication caused by
diabetes and uncontrolled hyperglycemia which causes nerve
damage to the nerves in the extremities causing its death. It
can cause Agnes not to feel the pain due to impaired pain
sensation and can make her unaware of the constant trauma that
being caused by the ulcer to her feet.
 The heavy amounts of exudates are caused by the inflammatory
phase of the healing process. The inflammatory phase uses the
exudates as a support medium for enzymes, antibodies and the
various cells necessary for wound cleansing. Exudate also
contains a number of growth factors produced by the body which
are critical in the promotion of healing. If the inflammatory
phase is impaired, wound healing may be slowed or halted
(Monash University, N.d).
4. Action point: Access the policy/guideline used by the staff in
your clinical placement for managing a patient who is
experiencing hypoglycaemia. Fully discuss the key aspects of
the policy/ guideline within your team, and ensure you have
the knowledge necessary to respond safely and effectively in a
similar situation.
 Key Points:
Guideline: For the Treatment of Hypoglycaemia

Used by the Counties Manukau District Health Board Staff
for the management of hypoglycaemia. The policy explains
what to do in cases of moderate to severe and life
treatment
hypoglycaemia.
The
policy
also
contains
information about, signs and symptoms, medication and
administration and other important factors that a medical
professionals needs to aware of in such situations.
Team SCRUBS – PBL team 12
CHARLES SMITH
1. Action point: Your student nurses asks… “what about Mr Smith’s
medication?
He’s
NBM
what
do
we
do
about
his
oral
medications?” Review the policy/guidelines used by the staff
in your clinical placement relating to administration of
medications pre-operatively. Considering this, respond to your
student nurse.

2. Action point: Your student nurse asks….”He’s so thirsty,
couldn’t we just give him a glass of water”. Respond to your
student nurse, using appropriate medical terminology. Your
decision should be rationalized at a physiological level.

3. Action point: Access the policy / guideline used by the staff
in your clinical placement for administration of opioids (not
all areas will have one). Fully discuss the key aspects of the
policy / guideline within your team, and ensure you have the
knowledge necessary to respond safely and effectively in a
similar situation.

Team SCRUBS – PBL team 12
FRANCESCA SMITH
1. Action point: Outline your immediate actions with rationale.

Pull Francesca aside (introduce yourself), sit her
upright and get her to lean forward slightly, ensure her
arms are supported by her knees/table/chair; be calm and
reassuring and do not leave her.
 Identify if she suffers from a respiratory illness and if
she
uses
anything
to
control
it
(either
asking
her/parents or sport consent form).
 Identify if she has taken anything today and if she has
her blue inhaler with her today.
 Acute asthma episode: person seated and slightly leant, 6
puffs of reliever inhaler (own inhaler, first aid kit
inhaler or borrow one), remember 1 puff at a time with 6
breaths in between. Better delivery and effectiveness of
the drug is through a spacer so if there is one around,
use it. If no improvement, giver another 6 puffs (1 at a
time) – this can be repeated 6 times. If little or no
improvement an ambulance should be called immediately –
simply state that someone is having an acute asthma
episode, keep giving 6 puffs every 6 minutes until the
ambulance arrives.
 A-S-T-H-M-A: Assess Sit, Treat, Help, Monitor, And
All
Okay.
 (Asthma Foundation New Zealand)
2. Action point: Detail the key aspects you would be looking for
in the response from your student nurse.
 Key aspects from a year 1 student nurse: an asthma attack
is a sudden worsening of asthma symptoms caused by the
tightening
of
the
muscles
around
the
airways
–
bronchospasm, when faced with certain triggers. During an
asthma attack, the lining of the airways also becomes
swollen or inflamed and more/thicker mucus is produced.
All these factors (bronchospasm, inflammation, mucus
production) causes’ symptoms of an asthma attack such as
difficulty breathing, wheezing, coughing, shortness of
breath and difficulty performing normal daily activities.
 (Web MD, 2010)
3. Action point: Outline your response to Lisa (and ensure you
include Francesca).
 Relievers are best given through a spacer for adults and
children alike. It makes the drug more effective. Common
side effects are decreases (e.g. oral thrush and
hoarseness).
Team SCRUBS – PBL team 12
1. Shake puffer well, remove cap, place inhaler into the end
of spacer. Prime spacer – 6puffs into compartment.
2. Place mouth piece/face mask on, depress inhaler canister
once.
3. Take 6 normal breathes through mouth piece/ face mask.
4. Repeat steps 2-3 for prescribed puff/dose of inhaler.
5. Rinse mouth out well with water.
6. Cleaning: important to clean it once a month with warm
dish washing water, leave the spacer to air dry and wipe
down the mouthpiece clean before use.
7. Pamphlets are usually available on wards.
 (Asthma SA, 2007)
Team SCRUBS – PBL team 12
TRACEY SMITH
1. Action point: Identify your main concerns about Tracey’s
health related to this information. Outline how you will
respond to Tracey and what education will you offer her.


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
Reassure her that chlamydia is very common and extremely
treatable
The importance that she gets it treated and finishes her
course of treatment
The importance of informing previous sexual partners
Contraception
The importance of continuing to use contraception until
she finishes her course of treatment
2. Action
point:
Identify
presenting
clinical
signs
for
Chlamydia, gonorrhoea, and Human Papilloma Virus (HPV).
Identify modes of transmission.
Outline best practice
management for each.
S.T.I
Chlamydia
Clinical signs
Women:
 Increase vaginal discharge.
 Frequent urination/pain.
 Pain during sexual
intercourse/or bleeding
afterwards.
 Low abdominal pain.
 Irregular menstrual pain.
Men:
 White discharge from the
penis
 Pain with urinating/ burning
 Pain/swelling in the
testicles
Gonorrhoea
Men:
 Possibly asymptomatic
 Symptoms appear 1-14days
after infected.
 Pain whilst urinating
 White/yellow/green discharge
from penis
 Swollen testicles
Women:
 Often mild symptoms/
asymptomatic/ mistaken for
urinary/vaginal infection
 Pain whilst urinating
 Increased vaginal discharge/
bleeding
** Women are at risk of
developing severe
complications regardless of
Modes of
transmission
 Sexual
intercourse
(oral, genital,
anal) with
infected
partner
 Sharing
infected sex
toys
 Passing through
the birth canal
of a mother
with chlamydia
Best practice
Treatment men &
women:
 Azithromycin 1g
stat
 Or Doxycycline
100mg twice daily
for seven days
 Sustain from sexual
intercourse until
after treatment
 Repeat test 3-6
months after
treatment
 Education
 Partner notified –
assessed and
treated if
necessary
 Sexual
 Treatment as soon as
intercourse
possible
(oral, vaginal,  Follow health care
anal)
provider information
 Ejaculation does  Finish course of
not have to
treatment
occur for the
 Avoid sexual
infection to be
activity until
passed.
course has finished.
 Contact sexual
partners for testing
and treatment
 Follow up test
Team SCRUBS – PBL team 12
presence/severity of
symptoms.
 Asymptomatic
 90% of cases the body clears
virus naturally
 Genital warts
 Throat warts – recurrent
respiratory papillomatosis
 Cervical cancer
 Rare cancers
Human
Papilloma
Virus
 Genital contact  No cure
(vaginal/anal
 Warts treated with
sex)
topical creams/burnt
 Oral sex
off with liquid
nitrogen/surgical
 Very rare:
pregnant women – removal
baby during
 Contacting sexual
delivery (RRP)
partners
 Education – safe sex
 Cervical smears –
3yrly
(AVERTing HIV and AIDS, 2010)
3. Action point: What is contact tracing?
What are the legal
aspects regulating this? What are the ethical issues that may
arise?

What is contact tracing?
o In epidemiology, contact tracing is the identification
and diagnosis of persons who may have come into
contact
with
an
infected
person.
For
sexually
transmitted diseases, this is generally limited to
sexual partners but for highly virulent diseases such
as Ebola and tuberculosis, a thorough contact tracing
would require information regarding casual contacts.

What are the legal issues with this?
o Court cases in both Australia and the UK have
established that the doctor has a duty of care to the
partner/s of their HIV positive patients. You are
advised to counsel your patient to ensure he/she
understands
their
responsibility
in
preventing
transmission of HIV to current or future partners.
Your patient must practice safe sex or inform any
partners who choose to engage in unsafe behaviour of
their HIV status and consequent potential risk of
acquiring HIV infection. You are strongly advised to
thoroughly document the consultation.
o It is important to highlight to patients that the
legal obligations and responsibilities of an HIV
positive person vary between the different states in
Australia and internationally. It is advised to seek
the advice of the leading HIV organization in each
locality to avoid potential prosecution.
What are ethical issues that may arise?
o Some AIDS activists have argued that contact tracing
is counter-productive in that it would lead persons to
avoid seeking medical treatment for fear that it would
breach their right to privacy.

Team SCRUBS – PBL team 12
MELE
1. Action point: Discuss how you will handle this situation and
what your concerns are. Include in this discussion the long
term effects of dental caries with primary dentition.
 Inform them of any other outside agencies that they may
need help with

The importance of brushing their teeth

The
importance
of
reducing
the
amount
foods/drinks that the children are consuming

Not rinsing out tooth paste just spitting

Seeking health care regarding the skin sores

Wash all sheets and blankets and clothes before treatment
and again after
o
of
sugar
Concerns:

Overcrowding in the house hold

State of the children’s teeth and skin

State of the house
2. Action point: Identify other agencies that
contacted and what your referral will cover.
 Housing New Zealand (snug homes)
need
to
be

WINZ (to see if there are any more benefits that they are
allegeable for)

Referral to GP (describing the sores and what treatment
may be needed)

Referral to dentist ( to view child’s teeth)
3. Action point: What is the treatment for impetigo and how do
you minimise spread? Include in the discussion how you
differentiate between impetigo and scabies.
Scabies:

Itchy rash in places such as forearms, around
between fingers, buttocks and under the armpits
waist,
Impetigo:

Scabby sores on exposed parts of the body

Treatment: antibiotics, exclusion
until 24 hours after treatment
from
preschool
etc.

It is spread
infected skin
with
discharge
from
by
direct
contact
Team SCRUBS – PBL team 12
MAX
1. Action point: A prodromal phase often precedes the first
presentation of schizophrenia. Max may have been experiencing
this for the 9 months prior to this presentation. Describe the
prodromal phase and how this impacts on a client’s recovery.
Describe the prodromal phase and how this impacts on a client’s
recovery.

Prodromal Phase – earliest manifestation of a
disorder which often develops in early adolescence:
-
Sleep/appetite disturbance
-
Marked unusual behaviour
-
Feeling different to others (blunted or incongruent)
-
Speech difficult to follow
-
Marked pre occupation with unusual ideas
-
Ideas of reference things having special meaning
-
Persistent feeling of unreality
-
Changes in a way things appear, sound or smell

Prodromal features in Schizophrenia are vague and not
specific. Although when the illness becomes severe it can be
diagnosed and prodromal features can be identified.
psychotic
2. Action point: Educating clients and their families about the
nature and process of the mental health act is an important
role for the mental health nurse. Outline for Max’s parents,
the criteria for a person to be under the Mental Health Act
and give the family an overview of how antipsychotic
/anxiolytic medications are used in the management of
psychosis.
Max’s parents also ask you about the interview
taking place in the other room. Describe your response.
 Educating clients and their families about the nature and
process of the mental health act is an important role for the
mental health nurse.
 The Mental Health (Compulsory Assessment and Treatment) Act
1992 defines the circumstances in which a person may be
required to undergo compulsory psychiatric assessment and
treatment. The Act aims to ensure that both vulnerable
individuals and the public are protected from harm with its
rights of patients and proposed patients and aims to protect
those rights.
Team SCRUBS – PBL team 12
Under this act, the clients are entitled to:
• To have their culture respected
• To have an interpreter present
• To be supported by whanau or friends
• To have visitors and access to a phone
• The company of others
• Not to be video or audio taped
• Access to a District Inspector
• Full information on your status
• Receive appropriate health care
• To be informed of benefits of treatment
• To be informed of possible side effects
• To seek a second independent opinion
• To have access to legal advice
• To have a Judicial Review
The Summary of the Procedure for Assessment and Treatment under the
Mental Health Act 1992:
• Section
• Section
• Section
• Section
• Section
• Section
• Section
8A
Application for assessment
8B
Medical certificate
9
Notice to attend an assessment
10
Certificate of preliminary assessment
11
Further assessment and treatment (5 days)
13 (2 weeks)
15 (4 weeks)
Community Treatment Orders
• Section 29
Can last up to 6 months
Can be extended or made indefinite
Can be converted to an inpatient order
Must attend for treatment
Inpatient Orders
• Section 30
Provides for compulsory treatment
Lasts for up to six months
Can be extended or made indefinite
Can be converted to a community treatment order
• Section 31
Provides for conditional leave
Revoked if conditions not adhered to
Outline for Max’s parents, the criteria for a person to be under the
Mental Health Act and give the family an overview of how
antipsychotic /anxiolytic medications are used in the management of
psychosis

Mental Disorder

Intermittent disorder
– Repeated or prolonged episodes of illness
Team SCRUBS – PBL team 12
- Severe consequences during phases of illness;
such as severe violence to self or others
- Early loss of insight during an episodes of
illness, with a pattern of failing to be able
to take the necessary steps to halt the
development of illness
- Changeable insight =
consistent decision
inability
to
maintain
o
Degree of disorder – seriously diminishes the capacity of look
after himself or herself i.e. failure to comply with meds
(i.e. insulin); self-neglect such as inattention to cooking
and high risk fire; a person in a manic state who overspends
to such an extent that he or she finds himself or herself
bankrupt when symptoms of mania are no longer present
o
Poses a serious danger to the health or safety of that person
or others
o
Threshold for application for compulsory treatment
o
Abnormal state of mind
o
Disorders of volition and cognition (Volition: depression
stupor; catatonic excitement/withdrawal;passisivity;lack of
motivation)
o
Head injury resulting to disturbance in behaviour
o
Personality disorder
o
Substance abuse

Antipsychotics – previously referred to as major tranquilizers
or neuroleptics are effective for the treatment of a variety
of psychotic symptoms. All available antipsychotics antagonize
dopamine (d2) receptors in vitro.
Max’s parents also ask you about the interview taking place in the
other room. Describe your response.

Privacy Act 1993
3. Action point: Describe what needs to be undertaken for
holistic assessment of Max in a first assessment interview.

a
Psychiatric Assessment
The purpose of the psychiatric assessment is to develop an
understanding of the person presenting for help. It involves
Team SCRUBS – PBL team 12
taking a basic psychiatric history and a mental status
assessment.
The
following
information
is
required
in
conducting a comprehensive psychiatric assessment:
1.
Identifying Information
 Includes; name, age, sex, present address, telephone
number, languages spoken, general practitioner,
marital status, occupation and next of kin.
2. Reason for Referral
 This should include;
 Who has asked for the client to be seen and why
 The nature of the problem
 Events that led to this presentation
 Any recent suicide attempts
 Any recent episodes of self-harm
3. Presenting Problem and/or precipitating factors
 Information needed include;
 Specific symptoms that are present and their duration
 Time relationships between the onset or exacerbation
of
symptoms
and
the
presence
of
social
stressors/physical illness
 Any disturbance in mood, appetite, sexual drive or
sleep
 Any treatments given by other doctors or specialists
for this problem
 The individual response to treatment
4. Mental Health/Medical/Drug History
 Information
required
includes
the
number
of
admissions to mental health inpatient units, number
of episodes of self-harm, attempted suicide or
occasions of assault, and an indication of any mental
health treatments received. This information is
usually obtained from the client, previous clinical
notes, a letter from the doctor, or history provided
by relatives or friends.
5. Psychosocial/Relationship History
 This outlines circumstances that are significant for
understanding current issues, and covers many aspects
of the individual’s life, such as relationships,
family background, work or school history and,
possibility, developmental stages.
6. Determining Risk Factors
 Several risk factors need to be assessed for each
client;
 Harm to others, harm to self, suicide, absconding,
vulnerability to exploitation or abuse (sexual)
 Vulnerability to exploitation or abuse (violence)
7. Assessment of Strengths
 The focus on strengths of individuals and their
opportunities
rather
than
pathology
creates
opportunity for growth. The strengths identified in
this conceptual framework include the individual’s
Team SCRUBS – PBL team 12
interests, aspirations, skills, competencies and
talents.
8. Mental State Examination (BATOMI)
 A semi- structured interview used mainly as a
screening
tool
to
assess
a
person’s
current
neurological and psychological status along several
components. The exam involves observations as well
as an interview.

It involves;
o Appearance and Behaviour
o Speech, Mood and Affect
o Form of Thought
o Thought Content
o Perception
o Sensorium and Cognition
9. Physical Assessment
 Involves past and present health status, physical
functions
(elimination,
activity
and
exercise,
sleep, appetite and nutrition, hydration, selfcare), Laboratory results
20. Spiritual Assessment
 It is important because it provides a deeper
understanding of the client, their social setting
and the possible origins of the problem.
21. Cultural Assessment
 Mental health nurses need to engage the client and
the family so that appropriate care should be given.
In New Zealand, the principle of Cultural Safety is
applied to provide quality care that is also
culturally sensitive to the patients.
22. Triage Assessment
 Refers to the decision-making process that occurs
when
alternatives
for
acute
care
are
being
considered
Team SCRUBS – PBL team 12
ADAM SMITH
1. Action point: What information are you going to pass on to
Agnes?
 Schizophrenia is a chronic, severe, and disabling brain
disorder that has affected people throughout history.

People with the disorder may hear voices other people
don't hear. They may believe other people are reading
their minds, controlling their thoughts, or plotting to
harm them. This can terrify people with the illness and
make them withdrawn or extremely agitated.

People with schizophrenia may not make sense when they
talk. They may sit for hours without moving or talking.
Sometimes people with schizophrenia seem perfectly fine
until they talk about what they are really thinking.

The symptoms of schizophrenia
categories: positive symptoms,
cognitive symptoms
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
fall into three broad
negative symptoms, and
Positive symptoms
Positive symptoms are psychotic behaviours not seen in
healthy people. People with positive symptoms often "lose
touch" with reality. These symptoms can come and go.
Sometimes they are severe and at other times hardly
noticeable, depending on whether the individual is
receiving treatment. They include the following:
Hallucinations are things a person sees, hears, smells,
or feels that no one else can see, hear, smell, or feel.
"Voices" are the most common type of hallucination in
schizophrenia. Many people with the disorder hear voices.
The voices may talk to the person about his or her
behaviour, orders the person to do things, or warn the
person of danger. Sometimes the voices talk to each
other. People with schizophrenia may hear voices for a
long time before family and friends notice the problem.
Other types of hallucinations include seeing people or
objects that are not there, smelling odours that no one
else detects, and feeling things like invisible fingers
touching their bodies when no one is near.
Delusions are false beliefs that are not part of the
person's culture and do not change. The person believes
delusions even after other people prove that the beliefs
are not true or logical. People with schizophrenia can
have delusions that seem bizarre, such as believing that
neighbours can control their behaviour with magnetic
waves. They may also believe that people on television
are directing special messages to them, or that radio
stations are broadcasting their thoughts aloud to others.
Sometimes they believe they are someone else, such as a
famous
historical
figure.
They
may
have
paranoid
delusions and believe that others are trying to harm
Team SCRUBS – PBL team 12
them, such as by cheating, harassing, poisoning, spying
on, or plotting against them or the people they care
about.
These
beliefs
are
called
"delusions
of
persecution."
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Thought disorders are unusual or dysfunctional ways of
thinking. One form of thought disorder is called
"disorganized thinking." This is when a person has
trouble organizing his or her thoughts or connecting them
logically. They may talk in a garbled way that is hard to
understand. Another form is called "thought blocking."
This is when a person stops speaking abruptly in the
middle of a thought. When asked why he or she stopped
talking, the person may say that it felt as if the
thought had been taken out of his or her head. Finally, a
person with a thought disorder might make up meaningless
words, or "neologisms."
Movement disorders may appear as agitated body movements.
A person with a movement disorder may repeat certain
motions over and over. In the other extreme, a person may
become catatonic. Catatonia is a state in which a person
does not move and does not respond to others. Catatonia
is rare today, but it was more common when treatment for
schizophrenia was not available."Voices" are the most
common type of hallucination in schizophrenia.
Negative symptoms
Negative symptoms are associated with disruptions to
normal emotions and behaviours. These symptoms are harder
to recognize as part of the disorder and can be mistaken
for depression or other conditions. These symptoms
include the following:
Flat affect
(a person's face does not move or he or she talks in a
dull or monotonous voice)
Lack of pleasure in everyday life
Lack of ability to begin and sustain planned activities
Speaking little, even when forced to interact.
People with negative symptoms need help with everyday
tasks. They often neglect basic personal hygiene. This
may make them seem lazy or unwilling to help themselves,
but
the
problems
are
symptoms
caused
by
the
schizophrenia.
Cognitive symptoms
Cognitive symptoms are subtle. Like negative symptoms,
cognitive symptoms may be difficult to recognize as part
of the disorder. Often, they are detected only when other
tests are performed. Cognitive symptoms include the
following:
Poor "executive functioning" (the ability to understand
information and use it to make decisions)
Trouble focusing or paying attention
Problems with "working memory" (the ability to use
information immediately after learning it).
Team SCRUBS – PBL team 12
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How is schizophrenia treated?
Because the causes of schizophrenia are still unknown,
treatments focus on eliminating the symptoms of the
disease. Treatments include antipsychotic medications and
various psychosocial treatments.
Antipsychotic medications
Clozapine (Clozaril) is an effective medication that
treats psychotic symptoms, hallucinations, and breaks
with reality. But clozapine can sometimes cause a serious
problem called agranulocytosis, which is a loss of the
white blood cells that help a person fight infection.
People who take clozapine must get their white blood cell
counts checked every week or two. This problem and the
cost of blood tests make treatment with clozapine
difficult for many people. But clozapine is potentially
helpful for people who do not respond to other
antipsychotic medications.
Other atypical antipsychotics were also developed. None
cause agranulocytosis. Examples include:
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega).
When a doctor says it is okay to stop taking a
medication, it should be gradually tapered off, never
stopped suddenly.
What are the side effects?
Some people have side effects when they start taking
these medications. Most side effects go away after a few
days and often can be managed successfully. People who
are taking antipsychotics should not drive until they
adjust to their new medication. Side effects of many
antipsychotics include:
Drowsiness
Dizziness when changing positions
Blurred vision
Rapid heartbeat
Sensitivity to the sun
Skin rashes
Menstrual problems for women.
Atypical antipsychotic medications can cause major weight
gain and changes in a person's metabolism. This may
increase a person's risk of getting diabetes and high
cholesterol. A person's weight, glucose levels, and lipid
levels should be monitored regularly by a doctor while
taking an atypical antipsychotic medication.
Team SCRUBS – PBL team 12
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Typical antipsychotic medications can cause side effects
related to physical movement, such as:
Rigidity
Persistent muscle spasms
Tremors
Restlessness.
Long-term use of typical antipsychotic medications may
lead to a condition called tardive dyskinesia (TD). TD
causes muscle movements a person can't control. The
movements commonly happen around the mouth. TD can range
from mild to severe, and in some people the problem
cannot be cured. Sometimes people with TD recover
partially or fully after they stop taking the medication.
TD happens to fewer people who take the atypical
antipsychotics, but some people may still get TD. People
who think that they might have TD should check with their
doctor before stopping their medication.
How are antipsychotics taken and how do people respond to them?
 Antipsychotics are usually in pill or liquid form. Some
anti-psychotics are shots that are given once or twice a
month.
 Symptoms of schizophrenia, such as feeling agitated and
having hallucinations, usually go away within days.
Symptoms like delusions usually go away within a few
weeks. After about six weeks, many people will see a lot
of improvement.
 However,
people
respond
in
different
ways
to
antipsychotic medications, and no one can tell beforehand
how a person will respond. Sometimes a person needs to
try several medications before finding the right one.
Doctors and patients can work together to find the best
medication or medication combination, as well as the
right dose.
 Some people may have a relapse -- their symptoms come
back or get worse. Usually, relapses happen when people
stop taking their medication, or when they only take it
sometimes. Some people stop taking the medication because
they feel better or they may feel they don't need it
anymore. But no one should stop taking an antipsychotic
medication without talking to his or her doctor. When a
doctor says it is okay to stop taking a medication, it
should be gradually tapered off, never stopped suddenly

Psychosocial treatments
Psychosocial
treatments
can
help
people
with
schizophrenia that is already stabilized on antipsychotic
medication. Psychosocial treatments help these patients
deal with the everyday challenges of the illness, such as
difficulty with communication, self-care, work, and
forming and keeping relationships. Learning and using
coping mechanisms to address these problems allow people
with schizophrenia to socialize and attend school and
work.
Team SCRUBS – PBL team 12
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Patients who receive regular psychosocial treatment also
are more likely to keep taking their medication, and they
are less likely to have relapses or be hospitalized. A
therapist can help patients better understand and adjust
to living with schizophrenia. The therapist can provide
education about the disorder, common symptoms or problems
patients may experience, and the importance of staying on
medications.

Illness management skills. People with schizophrenia can
take an active role in managing their own illness. Once
patients learn basic facts about schizophrenia and its
treatment, they can make informed decisions about their
care. If they know how to watch for the early warning
signs of relapse and make a plan to respond, patients can
learn to prevent relapses. Patients can also use coping
skills to deal with persistent symptoms.

Integrated treatment for co-occurring substance abuse.
Substance abuse is the most common co-occurring disorder
in people with schizophrenia. But ordinary substance
abuse treatment programs usually do not address this
population's special needs. When schizophrenia treatment
programs and drug treatment programs are used together,
patients get better results.

Rehabilitation. Rehabilitation emphasizes social and
vocational training to help people with schizophrenia
function
better
in
their
communities.
Because
schizophrenia usually develops in people during the
critical career-forming years of life (ages 18 to 35),
and because the disease makes normal thinking and
functioning difficult, most patients do not receive
training in the skills needed for a job.
Rehabilitation programs can include job counselling and
training, money management counselling, help in learning
to use public transportation, and opportunities to
practice communication skills. Rehabilitation programs
work well when they include both job training and
specific therapy designed to improve cognitive or
thinking skills. Programs like this help patients hold
jobs, remember important details, and improve their
functioning.

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Family education. People with schizophrenia are often
discharged from the hospital into the care of their
families. So it is important that family members know as
much as possible about the disease. With the help of a
therapist, family members can learn coping strategies and
problem-solving skills. In this way the family can help
make sure their loved one sticks with treatment and stays
on his or her medication. Families should learn where to
find outpatient and family services.

Cognitive behavioural therapy. Cognitive behavioural
therapy (CBT) is a type of psychotherapy that focuses on
Team SCRUBS – PBL team 12
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thinking and behaviour. CBT helps patients with symptoms
that do not go away even when they take medication. The
therapist teaches people with schizophrenia how to test
the reality of their thoughts and perceptions, how to
"not listen" to their voices, and how to manage their
symptoms overall. CBT can help reduce the severity of
symptoms and reduce the risk of relapse.
Self-help groups. Self-help groups for people with
schizophrenia and their families are becoming more
common. Professional therapists usually are not involved,
but group members support and comfort each other. People
in self-help groups know that others are facing the same
problems, which can help everyone feel less isolated. The
networking that takes place in self-help groups can also
prompt families to work together to advocate for research
and more hospital and community treatment programs. Also,
groups may be able to draw public attention to the
discrimination many people with mental illnesses face.
Short term in the inpatient setting
Principles of treatment for the first episode
Medication
 Proper treatment of the first psychotic episode is of the
utmost importance. Inadequate management at this stage
may foster the development of secondary
 Consequences which can snowball and lead to a substantial
deterioration in long-term outcome. For instance, lack of
insight (i.e. unawareness of illness) is
 A frequently encountered problem in schizophrenia. If the
degree of insight is low after the first episode, it can
lead to reduced compliance to treatment, which
 In turn can increase the relapse rate and worsen the
long-term outcome. Likewise, residual psychotic symptoms
after
the
first
episode
may
affect
social
and
occupational functioning of patients and indirectly
predispose them to stressful experiences (eg relationship
or occupational problems). Difficulties like these
 Lead to relapses and a poor long-term outcome. Hence, the
thorough and vigorous treatment of the first episode is
very important.
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Maintenance therapy
One further issue is the length of maintenance therapy
needed after a single episode of illness. Existing data
suggests that a number of patients may not suffer a
second episode even without maintenance treatment.44
Unfortunately, it is not yet possible to identify those
who will relapse and those who will not.28 As yet, data
from double-blind controlled studies that specifically
address the optimal length of maintenance therapy are not
available.28,45 It appears, however, that continuing
medication after the first episode seems to reduce the
relapse
rate
in
the
subsequent
12
months
from
approximately 70% to approximately 40%.46
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Management of depressive symptoms and suicide risk
Depression is common in first-episode schizophrenic
patients, with prospective studies reporting rates of
identifiable depressive syndrome of around 50% of
First episode patients. The actual rate of depressive
symptoms detected varied considerably between individual
studies (from 20% to 80%), depending on
The rating instruments used. In most cases, depressive
symptoms are worse at the time of the acute episode and
tend to subside as the psychosis comes under
Control. If depressive symptoms persist, antidepressant
therapy should be commenced. The risk of suicide
occurring is substantially increased in first-episode
schizophrenia, especially among male patients.
Psychosocial intervention
Apart
from
medication,
psychosocial
rehabilitation
efforts are particularly important for managing negative
symptoms. Negative symptoms can be substantially
Present in the first episode. Vigorous rehabilitation
directed at these symptoms is particularly important in
minimising secondary disabilities. Competence in social
skills is also important in sustaining a social support
network and is a crucial element in long-term management.
A further disability is the presence of
Substantial neurocognitive deficits. By giving adequate
medication treatment, some of these deficits may improve
with time, but the improvement takes
Longer than does the improvement in symptoms. The
efficacy of cognitive remediation programmes in reducing
neurocognitive deficits is still not established.
In general, it is known that a high level of expressed
emotion among carers of schizophrenics is predictive of
more frequent relapses. Family behavioural therapy may be
effective in modifying the amount of expressed motion and
the lower relapse rate in selected patients.
Team SCRUBS – PBL team 12
Bibliography
Asthma Foundation New Zealand. (n.d.). Asthma Emergency. Retrieved
August 1, 2011, from Asthma Foundation NZ:
http://www.asthmafoundation.org.nz/asthma_emergency.php
Asthma SA. (2007). Spacer Technique. Retrieved August 1, 2011, from
Asthma SA:
http://asthmasa.org.au/sendfile.php/id/208e9fce2937125b0c89fc1
c24944dd6/name/Spacer%20Technique
AVERTing HIV and AIDS. (2010). Common STD's. Retrieved August 1,
2011, from Sexually Transmitted Diseases:
http://www.avert.org/std.htm
Web MD. (2010). Asthma-Attack. Retrieved August 1, 2011, from Web
MD: http://www.webmd.com/asthma/guide/asthma-attack
Elder, R., Evans, K. & Nizette, D. (2009). Psychiatric and mental
health nursing (2nd ed.). Sydney:
Mosby.
Johannessen, J. O. (2001). Early recognition and intervention: The
key to success in the treatment of schizophrenia?. Dis Manage
Health Outcomes, 9(6), 317-327.
Malik, R., & Rayman, G. (2007). Neurovascular Factors in Wound
Healing in the Foot Skin of Type 2 Diabetic Subjects. P a t h o
p h y s i o l o g y / C o m p l i c a t i o n s , 30.
Medscape. (2006). Diabetic Foot Disease: Etiology of DFD. Retrieved
07 27, 2011, from Medscape:
http://www.medscape.com/viewarticle/545974_3
Monash University. (N.d). WOUND CARE MODULE. Melbourne: Monash
University.
NINDS. (n.d.). Peripheral Neuropathy Fact Sheet. Retrieved 08 3,
2011, from NINDS:
http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_p
eripheralneuropathy.htm
Porth, C. (2007). Essentials of Pathophysiology. Philadelphia:
Lippincott Williams & Wilkins .