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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 Second Phase Prodromal phase These people are socially withdrawn and show evidence of peculiar behavior Neglect of personal hygiene and grooming Inappropriate affect Disturbances in communication Bizarre ideas Third Phase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