Schizophrenia

DSM-V criteria

2 or more symptoms present for at least 1 month

• delusions

• hallucinations

• disorganized speech

• Negative symptoms (diminished emotional expression or flat affect)

Brief Psychotic Dx

• psychosis lasting < 30 days

Schizophreniform Dx

• psychosis lasting 1-6 months

Delusional Dx

• presence of 1 or more delusions

• presents later in life

• NO FUNCTIONAL IMPAIRMENT

Schizoaffective Dx

• schizophrenia s/s PLUS mood disorder s/s present at the same time

• more SEVERE FORM of schizophrenia

Substance induced psychotic Dx

psychotic s/s attributed to substance use

could be related to withdrawal from substance

Phases of schizophrenia

3

Prodromal

• change in mood or behavior, tend to withdraw

Active

• (+) positive s/s

  • hallucinations, delusions, disorganized thinking, bizarre thoughts

Residual

• positive s/s resolve

• residing s/s persist and affect the state of the pt

Positive s/s

• Elevated Dopamine levels

• presence of something that should NOT be there

• classified by alterations in reality- hallucinations & delusions

Negative s/s

• Low dopamine levels

• absence of something that should be there

• classified by absence in cognition, perception-lack of affect, lack of energy, apathetic

Hallucinations may cause ___ auditory instructions to act in a certain way

Command

Illusions are ___ of correct sensory input

misinterpretation

Delusions are a __ belief not supported by reality

• Grandeur

• somatic

• persecutory

• religious

false/fixed

Thought blocking

abrupt uncousious loss of thought

Though insertion

feeling that their own thoughts are not their own

Thought deletion

feeling that someone has TAKEN their thoughts

Loose associations

flight of ideas

word salad

Clang association are words chosen based on__

sound, similar sounding words

echolalia

echo echo echo

repetition of another’s words

Cirumstantiality

tangeniality

derailment

pressured speech

• eventually answers question by round about path

• gets off topic & does NOT come back

• abruptly changes topic without warning

• INC rate, tone, feels rushed to speak

Catatonia is the __ of movement

absence

Waxy flexibility

body retains position to which they are moved

frozen

Avolition is the loss of __

motivation

alogia is the poverty of ___

speech

Flat

blunted

inappropriate

bizarre

[Affects]

blank facial expression

reduced or minimal emotional response

incongruent w actual emotional state

Concrete thinking causes the pt to take things in a __ manner

literal

absence of abstract thinking

Nursing considerations for care

• keep promises

• do not reinforce or challenge hallucinations or delusions

• validate their perceptions but reinforce reality

• ORIENT pt to time, place, person

• do NOT touch w/out warning

• reinforce (+) behavior

Avoid __ activities for pt

competitive

Begin with ___ interactions

1×1

Milieu management of disruptive pt

• set limits

• DECREASE stimulation

  • reduce aggrivation

• observe for escalating behaviors [verbal & non-verbal]

• minimize potential weapons

• be judicious w concequences

• invoke consequences when violations occur

• provide for pt safety when restraints are needed

Management of withdrawn pt’s

• arrange nonthreatening activities

• arrange furniture around a table

• provide psychosocial rehab

• assist w decision-making

managing halluncinations

• use distraction

• teach socially appropriate behaviors

• discourage talking about hallucinations

• monitor command hallucinations [ask ab them directly]

Anosognosia is the inability for pt to realize they are__

often combined with ___ making accepting help difficult

ill

paranoia

what aspects are included in the assessment guidelines

• presence of medical problems

• medical problems that mimic psychosis

• drug or alc use

• MSE

• Risk assessment

What is the priority problems for these pt?

Positive s/s

• disturbed sensory perception may cause risk for self-directed or other directed violence

• impairs verbal communication

negative s/s

• social isolation

• c. low self-esteem

What med is used during the acute phase of dx

What should be monitered?

• Dopamine ANTAGONIST

  • risperidone

  • clozapine

risk for injury

monitor fluid intke

First gen antipsychotics [dopamine antagonists]

• Haloperidol

• fluphenazine

• perphenazine

• chlorpromazine

and ASE

• best for positive s/s

• EPS

• tardive dyskinesias

• anticholinergic effects

  • cant shit, spit

• weight gain, sexual dysfunction

What cues would indicate Extrapyrymidal s/s?

• tremor

• muscle rigidity

• acute dystonia [sustained muscle contraction]

• drooling

• unsteady gait

• oculogyric crisis

  • involuntary upward movement of the eyes

EPS reverse

• lower dose of med

• change antipsychotic med

• Admin anticholinergic

  • Amantadine [DA]

  • Benztropine [Cogentin]

  • antihistamine [Benadryl]

Tardive dyskinesia

persistent EPS

due to prolonged treatment

side effects seen in oral/facial muscles

often persists after med has been discontinued

Tx

• STOP med, taper off, administer Valbenazine [Ingrezza]

Atypical meds

• Pine ending

• First line

• fewer EPS

• More selective for (+) s/s

• -PINE ending

  • clozapine

  • risperidone

  • olanzapine

  • quetiapine

  • ziprasidone

s/e

• weight gain

• sedation

• dizziness

• metabolic syndrome

Neuroleptic malignant syndrome

• Medical emergency

• severe muscle rigidity

• dysphagia

• dec responsiveness

• hyperpyrexia [temp over 103]

• HTN

• delirium

• coma

Agranulocytosis

• low WBC, risk for infection

• PINES!

Anticholinergic effects

• constipation

• dry mouth

• blurred vision

• memory impairment

• confusion

• dizziness

• urinary retention

• nasal congestion

s/s of toxicity→ anticholingerics

• hyperthermia

• delerium

• unstable VS

• change in mental status