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Psychiatric / Mental Health Nursing NURS 204 Prevalence in U.S. is 1.1%. Average onset is late teens to early twenties, but can be as late as mid-fifties Affects cognitive, emotional, and behavioral function 30% to 40% relapse rate in the first year Life expectancy is shortened because of suicide Language and communication disturbances Thought disturbances Perception disturbances Affect disturbances Motor behavior disturbances Self-identity disturbances Progression varies from one client to another ◦ Exacerbations and remissions ◦ Chronic but stable ◦ Progressive deterioration DSM-IV-TR Diagnosis ◦ Symptoms present at least 6 months ◦ Active-phase symptoms present at least 1 month ◦ Symptoms are defined as positive and negative Positive symptoms ◦ Excess or distortion of normal functioning ◦ Aberrant response Negative symptoms ◦ Deficit in functioning Positive Symptoms of Schizophrenia ◦ Hallucination: Auditory, Visual Olfactory, Gustatory, Tactile ◦ Delusions: Persecutory, Referential Somatic, Religious, Substitution, Thought Insertion and/or Broadcasting Nihilistic, Grandiose ◦ Disordered speech: Loose Association, Word Salad Clanging, Echolalia, Neologism ◦ Disordered behavior: Disorganized walk Touching all objects and surfaces Catatonia ◦ Disordered Thinking: Indecisiveness, lack of problem solving skills, Concreteness, blocking, perservation Negative Symptoms of Schizophrenia ◦ Flat affect: lack of emotion ◦ Apathy: indifference towards people, events, activities and learning. ◦ Alogia: Poverty of speech ◦ Avolition: inability to pursue and persist in goaldirected activities. ◦ Anhedonia: inability to experience pleasure. Paranoid type Disorganized type Catatonic type Undifferentiated type Residual Type Paranoid Type ◦ Delusions Persecutory and grandiose Somatic or religious ◦ Hallucinations Delusions link with a hallucination Disorganized type ◦ ◦ ◦ ◦ Disorganized speech, behavior, appearance Flat or inappropriate affect Fragmented hallucinations and delusions Most severe form of schizophrenia Catatonic type ◦ ◦ ◦ ◦ ◦ ◦ Psychomotor retardation and stupor Extreme psychomotor agitation Waxy flexibility Echolalia Mutism Echopraxia Undifferentiated type Residual type ◦ Active psychotic state ◦ Lacks symptoms of other subtypes ◦ At least one episode of schizophrenia ◦ No prominent positive symptoms ◦ Negative symptoms present Schizophreniform disorder Schizoaffective disorder Delusional disorder Brief psychotic disorder Shared Psychotic Disorder (Folie à Deux) Induced or Secondary Psychosis Biologic theories Psychological theories Family theories Humanistic-interactional theories Biologic Theory: Genetic ◦ Only genetic predisposition for developing schizophrenia is inherited ◦ 10% of first-degree relatives ◦ 25%-39% of monozygotic twins Biologic Theory: Brain Structure Abnormality ◦ Differs from those with no symptoms ◦ May be genetically based ◦ Requires more study Schizophrenia scans. PET scans of discordant monozygotic twins taken during a test to provoke activity and measure regional cerebral blood flow. (A) Arrows indicate areas of normal blood flow and brain activity in the unaffected twin. (B) Arrows indicate areas of lower blood flow and brain activity in the twin with schizophrenia. Source: Courtesy of Dr. Karen F. Berman, Clinical Brain Disorders Branch, National Institute of Mental Health Biologic Theory: Biochemical Theories ◦ Dopamine hypothesis ◦ Traditional antipsychotic medications are dopamine blockers ◦ Dopamine blocker alleviate positive symptoms Psychological theories ◦ Information processing Difficulty controlling the amount and type of information that is processed in the brain. ◦ Attention and arousal Hyper or hypo responsiveness to various situations Family Theories ◦ Dysfunctional interaction not supported by research ◦ Disordered family communication linked only with genetic predisposition ◦ Family emotional tone influences course of schizophrenia ◦ Expressed emotions theory (EE) Humanistic-interactional theories integrate biological and psychosocial theories Combine influences of: ◦ Genetic predisposition or biologic vulnerability ◦ Environmental stressors ◦ Social support Stress–Vulnerability Model ◦ Stressors increase vulnerability ◦ Cumulative effect of: Genetic predisposition Personal stressors Familial factors Environmental factors Social Pressures ◦ Lack of social support ◦ Financial problems ◦ Stigma Psychological pressures ◦ ◦ ◦ ◦ ◦ Difficulty with problem-solving Difficulty with interpreting reality Difficulty coping Problems with self-care Unstable interpersonal relationships Assessment ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Premorbid functioning Content of thought Form of thought Perception Sense of self Delusions and perceptual disturbances Hallucinations Drug use Nursing Diagnoses ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Disturbed thought process Disturbed sensory perception Social isolation Risk for violence Self-care deficits Altered health maintenance Ineffective coping Impaired verbal communication Excess Fluid Volume Decisional Conflict Dysfunctional or Interrupted family process Family needs vary with degree of illness and involvement in client’s care ◦ ◦ ◦ ◦ Education Financial support Psychosocial support Advocacy Schizophrenia is a “family illness.” Family members need to be involved. Educate family about Nurse assists family by ◦ Medication ◦ Illness ◦ Relapse prevention ◦ Identifying community agencies/groups for family members ◦ Advocating for rights Promote Safety and a Safe Environment Promote Congruent Emotional Response Promote Social Interaction and Activity Intervene with Hallucinations and Delusions Preventing Relapse Promoting adherence with medication regimen Assist with grooming and hygiene Promote Family Understanding and Involvement Relapse prevention programs provide education and support regarding: – Individual triggers, symptoms of relapse – Managing side effects of medications – Interventions to reduce or eliminate triggers – Strategies to facilitate early intervention – Cognitive therapy – Community resources Side effects of Psychotropic Medications Level of symptomatology Cognitive, motivational, financial, and cultural issues Issues with caregivers Insufficient medication teaching Substance abuse Involve clients in treatment Instruct client about reducing discomfort Provide peer support Provide reminders and positive feedback Recognize accomplishments Identify personal feelings and recognize personal perceptions. What behaviors do you expect to see? How will you respond to these behaviors? What is the meaning of the behaviors? What defines “normal” behavior? What are my fears associated with mental illness? Remember that clients are human beings with a mental disorder and do not choose to be this way. A primary treatment mode of psychiatricmental health nursing care ANA Task Force Guidelines ◦ Integrate current data from the neurosciences. ◦ Demonstrate knowledge of psychopharmacologic principles. ◦ Provide safe and effective care of clients taking these medications. Prior to the 1950s: focus on behavioral interventions and sedatives Mid-fifties: Introduction of the first antipsychotic medication chlorpromazine (Thorazine) Since then, many advances have led to the treatment of the client with mental illness in the community. Psychiatric medications allow for the correction of imbalances of brain chemicals. The great success of biological psychiatry. This graph illustrates the dramatic decrease in psychiatric inpatient numbers since the inception of psychopharmacology. Typical (Conventional) ◦ Block dopamine receptors at 70% to 80% occupancy to be effective. Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80% Ongoing research on new medications Ongoing research on new delivery systems ◦ Newer depot: Resperidone Consta ◦ Orally Disintegrating Tablets: Zyprexa Zydis Some ethnic groups are slow metabolizers. ◦ More side effects ◦ Greater risk of toxicity Some ethnic groups are fast metabolizers. ◦ Less effect of the medication Positive Effects Alleviation of the symptoms, often improving: ◦ Allowed release of clients from inpatient hospital to treatment in the community ◦ Manage the symptoms such as delusional thinking, hallucinations, confusion, motor agitation, motor retardation, blunted affect, bizarre behavior, social withdrawal and agitation. ◦ Ability to think logically ◦ Ability to function in one’s daily life ◦ Ability to function in relationships Negative Effects ◦ Frightening and life threatening side effects ◦ Potential interactions with other medications and substances ◦ Possible need to cope with the realization of having a chronic illness Adherence to prescribed medications by clients in psychiatric services is less than 35% Reasons for nonadherence: ◦ ◦ ◦ ◦ Clients do not know what to expect from medications. The schedule of doses or routes may be inconvenient. Friends/relatives may not be supportive. Side effects may be worst than the symptoms. A careful assessment is needed to decide the right form of the medication: PO - by mouth (for routine use) Liquid form (concentrate or syrup) Quick-dissolving formulation (sublingual) PRN injection Depot injection Atypicals ◦ ◦ ◦ ◦ Reduced affinity for dopamine receptors Affinity for serotonin receptors Fewer EPSEs Reduction in negative symptoms Side effects ◦ ANS, extrapyramidal, other CNS, allergy, blood, skin, eye, endocrine, and weight gain The five categories of EPSEs are dystonia, druginduced parkinsonism, akathisia, tardive dyskinesia, and dopamine-acetylcholine imbalance Occurs usually within 48 hours of initiation of the medication Involves bizarre and severe muscle contractions Can be painful and frightening Characterized by odd posturing and strange facial expressions (Torticollis, Opisthotonus, Laryngospasm, Oculogyric Crises) Usually occurs after 3 or more weeks of treatment Characterized by: ◦ ◦ ◦ ◦ ◦ ◦ Cogwheel rigidity Tremors at rest Rhythmic oscillations of the extremities Pill rolling movement of the fingers Bradykinesia Postural Changes Usually occurs after 3 or more weeks of treatment Subjectively experienced as desire or need to move Described as feeling like jumping out of the skin Mild: a vague feeling of apprehension or irritability Severe: an inability to sit still, resulting in rocking, running, or agitated dancing Usually occurs late in the course of long-term treatment Characterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping) Often irreversible Inability to wear dentures Impaired respirations Weight loss Impaired gait Impaired posture A rare side effect Characterized by hallucinations, dry mouth, blurred vision, decreased absorption of antipsychotics, decreased gastric motility, tachycardia, and urinary retention Dry mouth Blurred vision Constipation Urinary retention Tachycardia Sedation Lowering of the seizure threshold: ◦ Observe clients with seizures disorders carefully when treatment is initiated. Some antipychotics may contribute to prolongation of the QTc interval and lead to arrhythmias. ◦ An EKG can identify those at risk. Agranulocytosis Skin photosensitivity Retinitis pigmentosa Early symptoms: beginning signs of infection White blood cells are routinely monitored in clients taking clozapine (Clozaril). Hyperprolactinemia may cause: ◦ Oligomenorrhea or amenorrhea in women ◦ Galactorrhea in women and rarely in men ◦ Osteoporosis if prolonged Impotence in males may occur. Diabetes ◦ Monitor blood glucose levels. Monitor weight Teach about diet and exercise Weight gain may contribute to physical as well as psychosocial stressors Typically occurs in the first 2 weeks of treatment or when the dose is increased Hold the medication, notify the physician, and begin supportive treatments. Symptoms: muscle rigidity, tachycardia, hyperpyrexia, altered consciousness, tremors and diaphoresis Risk Factors ◦ ◦ ◦ ◦ ◦ Dehydration Agitation or catatonia Increase dose of neuroleptic Withdrawal from anti-parkinson medication Long acting or depot medication Pharmacologic treatment ◦ Antipyretics ◦ Muscle relaxant ◦ Dopamine receptor agonist A primary nursing role is to teach patients about the major side effects of psychotropic medications and how to manage them. Nurses must monitor for side effects and intervene when necessary. Dsytonia and drug-induced parkinsonism are treated by anticholinergics. Akathisia may be treated with anticholinergics but is not always responsive. Tardive dyskinesia treatment is preventive through careful and routine assessment. Take the client’s blood pressure in a supine position and then in a standing position. Caution clients to rise slowly from a supine position. Anticholenergic Side Effects: ◦ ◦ ◦ ◦ ◦ Ice chips, hard candy Eye drops Fiber diet, exercise Increase fluid intake Catheterization Typical Agents ◦ Low Potency Chlorpromazine (Thorazine) (25 – 800 mg/d) Thioridazine (Mellaril) (150 – 800 mg/d) Mesoridazine (Serentil) (100 – 400 mg /d) ◦ Side Effects: Sedation, Anticholernergic, Hypotention, EPSEs (less vs high potency) Typical Agents ◦ High Potency Haloperidol (Haldol) (1 – 30 mg/d) Fluphenazine (Prolixin) (0.5 – 40 mg/d) Thiothixene (Navane) (2 – 30 mg/d) Trifluoperazine (Stelazine) (1 – 40 mg/d) Perhenazine (Trilafon) (8-60 mg/d) Loxapine (Loxitane) (20 – 250 mg/d) Molindone (Moban) (50 – 225 mg/d) Pimozide (Orap) 0.5 – 9 mg/d) Side Effects Sedation, Anticholenergic SE (less vs low potency) EPSEs Atypical Agents ◦ Clozapine (Clozaril) (6.25 – 900 mg/d) Side effects: seizures, agranulocytosis, weight gain, hypersalivation, anticholinergic ◦ ◦ ◦ ◦ Olanzapine (Zyprexa, Zyprexa Zydis) (5 – 20 mg/d) Paliperidone (Invega) (3 – 12 mg/d) Quetiapine (Seroquel) (150 – 600 mg/d) Risperidone (Risperdal, Risperdal M-Tab) (2 – 6 mg/d) ◦ ◦ ◦ ◦ Ziprasidone (Geodon) ( 40 – 160 mg/d) Aripiprazole (Abilify) (15 – 30 mg/d) Asenapine (Saphris) (5 – 10 mg/d) Sublingual Iloperidone (Fanapt) (12 – 24mg/d) Typical Agents ◦ Haloperidol Decanoate (Haldol Decanoate) Q4 weeks ◦ Fluphenazine Decanoate (Prolixin Decanoate) Q2 Weeks Atypical Agents ◦ Risperidone Consta (Risperdal Consta) Q2 Weeks ◦ Paliperidone Sustenna (Invega Sustena) Q4 weeks Trihexyphenidyl (Artane) Benztropine (Cogentin) Diphenhydramine (Benadryl) Amantadine (Symmetrel)