Download Lecture 6 - Home - KSU Faculty Member websites

Lecture 6
Community and Mental Health Nursing-NUR 472
Schizophrenia
Introduction
 The word schizophrenia is derived from
the Greek words skhizo (split) and phren
(mind).
Introduction (cont.)
 More than any other mental illness,
schizophrenia probably causes more




Lengthy hospitalizations
Chaos in family life
Exorbitant costs to people and governments
Fears
Nature of the Disorder
 Schizophrenia:
A serious mental disorder characterized by:
 Disorganized and delusional thinking (Thought
processes)
 Disturbed perceptions/hallucinations
 Inappropriate emotions and actions (affect)
 With schizophrenia, there is a severe
deterioration of social and occupational
functioning
Nature of the Disorder (cont.)
 Premorbid behavior of the client with
schizophrenia can be viewed in four
phases.
First Phase
Schizoid personality
 Indifferent, these people are loners. They do not
enjoy close relationships with others.
Second Phase
Prodromal phase
 These people are socially withdrawn and
show evidence of peculiar behavior
 Neglect of personal hygiene and grooming
 Inappropriate affect
 Disturbances in communication
 Bizarre ideas
Third Phase
Schizophrenia
 In the active phase of the disorder,
psychotic symptoms are prominent
 Delusions
 Hallucinations
 Impairment in work, social
relations, and self-care
Fourth Phase
Residual phase
 Impairment in role
functioning are prominent
Etiological Implications
Schizophrenia is probably caused by a
combination of factors, including





Biological and Heritability predisposition
Biochemical Causes
Physiological factors
Psychosocial stress
Environmental factors
Etiological Implications
 Biological and Heritability predisposition
Genetics plays an important role in the
development of schizophrenia.


10% in those who have immediate family
member.
40% if disease affect in both parents.
 Biochemical Causes
 Dopamine Hypothesis: schizophrenia is
caused by excessive dopamine activity.
Predisposing Factors (cont.)

Physiological influences
Examples of Various physical conditions





Epilepsy
Birth trauma
Head injury
Alcohol abuse
Cerebral tumor
Predisposing Factors (cont.)
 Psychological influences
 Deeply disrupted family.
 Impaired sexual identity or body image.
 Stressful life events.
 Environmental influences
 Viral epidemics: associated with viral diseases
 Prenatal malnutrition
 Low-socioeconomic
Diagnosis
 Schizophrenia is diagnosed based on
talking with the patient, and looking at his
or her behaviour and experiences.
Diagnosis – Examples of Important Tests
 MRI
 Identifies brain changes
 PET (Positron emission tomography) (is a nuclear
medicine imaging)
 Determines brain activity
 EEG
 Reveals electrical activity
 Neurologic examination
 Neuropsychologic tests
Types of Schizophrenia
 Catatonic schizophrenia
 Catatonic stupor: characterized by extreme
psychomotor retardation; patient usually mute
 Catatonic excitement: Extreme psychomotor
agitation; purposeless movements that must be
curtailed to prevent injury to client or others
Types of Schizophrenia
 Disorganized schizophrenia
 Chronic variety with inappropriate affect
 Silliness and incongruous giggling common
 Behavior bizarre; social interaction impaired
Types of Schizophrenia
 Paranoid schizophrenia
 Characterized by delusions of persecution or
grandeur
 Auditory hallucinations
 Client may be argumentative, hostile, and
aggressive
Types of Schizophrenia
 Residual schizophrenia
 Used to diagnose a person who has a history
of at least one episode of schizophrenia with
prominent psychotic symptoms
Types of Schizophrenia
 Schizoaffective disorder
 Schizophrenic symptoms accompanied by a
strong element of symptomatology associated
with mood disorders, either manic or
depressive
Types of Schizophrenia
 Brief psychotic disorder
 Sudden onset of psychotic symptoms
following a severe psychosocial stressor
 Symptoms persist less than 1 month
Types of Schizophrenia
 Schizophreniform disorder
 Same symptoms as schizophrenia.
 The duration of the disorder has been at least
1 month but fewer than 6 months
Types of Schizophrenia
 Undifferentiated schizophrenia
 Bizarre behavior that does not meet the
criteria outlined for the other types of
schizophrenia; delusions and hallucinations
prominent
Nursing Process: Assessment
Content of thought
 Delusions: False personal beliefs
 Religiosity: Excessive demonstration of obsession
with religious ideas and behavior
 Paranoia: Extreme suspiciousness
of others
Nursing Process: Assessment (cont.)
Content of thought (cont.)
 Word salad: Group of words put together
in a random fashion
 Magical thinking: Idea that if one thinks something,
it must be true
 Mutism: Inability or refusal to speak
Nursing Process: Assessment (cont.)
Form of thought
 Associative looseness: Shift of ideas from one
unrelated topic to another
 Neologisms: Made-up words that have meaning only
to the person who invents them
 Perseveration: Persistent repetition of the same word
or idea in response to different questions
Nursing Process: Assessment (cont.)
Perception
 Hallucinations: False sensory perceptions
not associated with real external stimuli
 Illusions: Misperceptions of real external
stimuli
Nursing Process: Assessment (cont.)
 Affect: Emotional tone
 Inappropriate affect: Emotions are
incongruent with circumstances
 Apathy: Lack of interest in environment
 Emotional ambivalence: Coexistence of
opposite emotions toward same object
Nursing Process: Assessment (cont.)
 Sense of Self: The uniqueness and
individuality a person feels
 Echolalia: Repeating words that are heard
 Echopraxia: Repeating movements that are
observed
Nursing Process: Assessment (cont.)
 Impaired interpersonal functioning and
relationship to the external world
 Autism
 Deterioration in appearance: Impaired
personal grooming and self-care activities
Nursing Process: Assessment (cont.)
 Psychomotor behavior (cont.)
 Anergia: Deficiency of energy
 Posturing: Voluntary assumption of
inappropriate or bizarre postures
 Pacing and rocking: Pacing back
and forth and rocking the body
Nursing Process: Assessment (cont.)
 Positive and negative symptoms
 Positive symptoms: Excess or distortion of
normal functions
 Negative symptoms: Deficit or loss of
normal functions
List of Nanda Nursing Diagnosis for Schizophrenia











Ineffective role performance
Powerlessness
Risk for injury
Risk for other-directed violence
Risk for self-directed violence
Social isolation
Imbalanced nutrition: Less than body requirements
Impaired home maintenance
Impaired social interaction
Impaired verbal communication
Ineffective coping
List of Nanda Nursing Diagnosis for Schizophrenia











Disturbed personal identity
Disturbed sensory perception (auditory, visual)
Disturbed sleep pattern
Disturbed thought processes
Dressing or grooming self-care deficit
Fear
Anxiety
Bathing or hygiene self-care deficit
Disabled family coping
Disturbed body image
Disturbed personal identity
Planning
 The client
 Demonstrates an ability to relate to others
satisfactorily
 Recognizes distortions of reality
 Has not harmed self or others
 Perceives self realistically
 Demonstrates ability to perceive the
environment correctly
Planning (cont.)
 The client (cont.)
 Maintains anxiety at a manageable level
 Demonstrates ability to trust others
 Uses appropriate verbal communication in
interactions with others
 Performs self-care activities independently
Implementation
 Nursing interventions for the client with
schizophrenia are aimed at:






Decreasing anxiety and establishing trust
Assisting client to define and test reality
Encouraging interaction with others
Ensuring safety of client and others
Meeting client’s self-care needs
Promoting adaptive family coping
Implementation -Client/Family Education
 Nature of illness
 What to expect as illness progresses
 Symptoms associated with illness
 Management of illness
 Connection of exacerbation of symptoms to
times of stress
 Appropriate medication management
Implementation -Client/Family Education (cont.)
 Management of illness (cont.)






Side effects of medications
Importance of not stopping medications
When to contact healthcare provider
Relaxation techniques
Social skills training
Daily living skills training
Evaluation
 Evaluation questions
 Has client established trust with at least one staff
member?
 Is anxiety level maintained at a manageable level?
 Is delusional thinking still prevalent?
 Is client able to interrupt escalating anxiety with
adaptive coping mechanisms?
 Is client easily agitated?
 Is client able to interact with others ppropriately?
Treatment Modalities
 Schizophrenia requires treatment that is
comprehensive and presented in a
multidisciplinary effort.
 Psychological treatments
 Individual psychotherapy: Long-term
therapeutic approach difficult because of
client’s impairment in interpersonal
functioning
Treatment Modalities (cont.)
 Psychological treatments (cont.)
 Group therapy: Some success if
participating over long-term course of the
illness; less successful in short-term
treatment
 Behavior therapy
 Occupational therapy
Treatment Modalities (cont.)
 Psychological treatments (cont.)
 Social skills training: Use of role play to
teach client appropriate eye contact,
interpersonal skills, posture, and so on, aimed
at improving relationship development
 Electroconvulsive therapy
Treatment Modalities (cont.)
 Social treatment
 Milieu therapy: Best if used in conjunction
with psychopharmacology
 Family therapy: Aimed at helping family
members cope with long-term effects of
illness
Treatment Modalities (cont.)
 Psychopharmacology
 Antipsychotics: Used to decrease agitation
and psychotic symptoms
 Antiparkinsonian agents
 Others:
 Reserpine
 Lithium carbonate
 Carbamazepine
 Diazepam
 Propranolol
Treatment Modalities (cont.)
 Side effects for Antipsychotics (e. x:)




Nausea; GI upset; weight gain
Sedation
Decreased libido
Gynecomastia; amenorrhea
 The client should
 Not stop taking the drug abruptly
 Not consume other medications (including
over-the-counter drugs) without the
physician’s knowledge