Peer group supervision

Self-Assessment: Working with Schizophrenic Clients

similar emotions in the nurse

Client's intense emotions produce

Willingness for nurse to discuss feelings and behaviors with

supervisors decreases defensive behaviors

Team approach to decrease staff burnout Periodic reassessments of

Treatment outcomes Client's strengths and weaknesses

Assessment of the Client

Safety of client and others

Medical history and recent medical workup Positive, negative, cognitive, and mood

symptoms Current medications and compliance to treatment Family response/support system

Potential Nursing Diagnoses

Risk for self-directed or other-directed violence
Disturbed sensory perception

Disturbed thought processes

Impaired verbal communication Ineffective coping Compromised or disabled family coping

Outcome Criteria
Acute phase
Client safety and medical stabilization

Maintenance phase
Adherence to medical regimen
Understanding schizophrenia Participation of client and family in psychoeducational activities

Stabilization phase
Target negative symptoms
Anxiety control Relapse prevention

Planning of Appropriate Interventions

Acute phase
Possible hospitalization Ensure client safety Provide symptom stabilization

Maintenance and stabilization phases

Psychosocial education Relapse prevention skills

Interventions: Basic Level

Acute phase Administer antipsychotic medication as prescribed Observe client behavior closely Set limits on inappropriate behavior Do not touch without warning Offer foods that are not easily contaminated Assist with ADL if needed Supportive counseling Milieu management Family psychoeducation

Interventions: Basic Level

Continued
Maintenance and stabilization phases
Health teaching

Health promotion and maintenance

Milieu Therapy
Safety
Potential for physical violence due to hallucinations or

delusions
Priority is least restrictive safety technique

Verbal de-escalation Medications Seclusion or restraints

Activities
Provide support and structure Encourage development of social skills

and friendships

Counseling: Communication Guidelines

Hallucinations
Hearing voices most common Approach client in nonthreatening and nonjudgmental

manner Assess if messages are suicidal or homicidal Initiate safety measures if needed Client anxious, fearful, lonely, brain not processing stimuli accurately Focus on the clients feelings and present reality

Communication Guidelines continued

Delusions
Be open, honest, matter-of-fact, and calm Have client describe delusion

Avoid arguing about content

Focus on feelings Present reasonable doubt

Validate part of delusion that is real

Communication Guidelines continued

Associative looseness Do not pretend that you understand Place difficulty of understanding on yourself Look for reoccurring topics and themes Emphasize what is going on in the client's environment Involve client in simple, reality-based activities Reinforce clear communication of needs, feelings, and thoughts

Client Teaching Coping Techniques for Schizophrenia

Distraction Interaction Activity Social action Physical action

Client and Family Teaching

Learn all you can about the illness. Develop a relapse prevention plan. Avoid alcohol and drugs. Learn ways to address fears and losses. Learn new ways of coping. Comply with treatment. Maintain communication with supportive people. Stay healthy by managing illness, sleep, and diet.

Treatment Modalities
Individual therapy

Social skills training (SST) Cognitive remediation Cognitive adaptation training (CAT) Cognitive behavioral therapy (CBT)

Group therapy Family therapy Psychopharmacology

Psychopharmacology
Antipsychotics
Standard/ Typical Atypical

Antiparkinson

Psychopharmacology Traditional Antipsychotic

Dopamine antagonists (D2 receptor antagonists)
Target positive symptoms of schizophrenia Advantage
Less expensive than atypical antipsychotics

Disadvantages
Do not treat negative symptoms Extrapyramidal side effects (EPS) Tardive dyskinesia Anticholinergic effects (ACH) Lower seizure threshold

Antipsychotic Medications: Traditional

High potency = low sedation + low ACH + high EPSs
Haloperidol (Haldol) Trifluoperazine (Stelazine) Fluphenazine (Prolixin) Thiothixene (Navane)

Medium potency
Loxapine (Loxitane)
Molindone (Moban) Perphenazine (Trilafon)

Antipsychotic Medications:
Traditional continued
Low potency = high sedation + high ACH + low EPSs
Chlorpromazine (Thorazine) Thioridazine (Mellaril) Mesoridazine ( Serentil)

Decanoate = Long acting injection

Haloperidol decanoate (Haldol D) Fluphenazine decanoate (Prolixin D)

Atypical Antipsychotics (First-Line Antipsychotics)

Serotonin-dopamine antagonists
(5-HT2A receptor antagonists)

Advantages
Diminishes negative as well as positive symptoms of schizophrenia
Less side effects encourages medication compliance Improves symptoms of depression and anxiety Decreases suicidal behavior

Disadvantages
Weight gain Metabolic abnormalities

Antipsychotic Medications: Atypical

Clozapine (Clozaril) Quetiapine (Seroquel)

Risperidone (Risperdal
Zipreasidone (Geodon) Olanzapine (Zyprexa) Aripiprazole (Abilify)

Side Effects- Atypical

Orthostatic Hypotension Decreased Libido Agranulocytosis (Clozapine) Weight gain Tachycardia Edema

Side Effects: Anticholinergic Symptoms

Dry mouth
Urinary retention and hesitancy Constipation

Blurred vision
Photosensitivity Dry eyes Inhibition of ejaculation or impotence in men

Side Effects: Extrapyramidal Side Effects

Pseudoparkinson
Drooling, lack of facial responsiveness, shuffling gait,

and fine intentional tremors.

Acute Dystonia
Muscle spasms of the jaw, tongue, neck or eyes.

Laryngeal spasms possible. Oculogyric crisis, Opisthotonos.

Akathisia
Motor restlessness, pacing, rocking, etc

Side Effects: Extrapyramidal Side Effects

Tardive Dyskinesia
Bizarre facial and tongue movements

chewing, tongue from side to side, etc. Involuntary tonic muscular spasms of extremities Trunk Potentially irreversible

Side Effects: a2 Block: Cardiovasclar

Hypotension Postural hypotension Tachycardia

Side Effects: Rare and Toxic Effects

Agranulocytosis Cholestatic jaundice

Neuroleptic malignant syndrome (NMS)

Severe extrapyramidal

Hyperpyrexia
Autonomic dysfunction

NEUROLEPTIC MALIGNANT SYNDROME

RARE, POTENTIALLY FATAL ONSET WITHIN HOURS OR YEARS EPS REACTIONS CPK HYPERTHERMIA 102 AND ABOVE TACHYCARDIA FLUCTUATING B.P. DIAPHORESIS STUPOR AND COMA

AGRANULOCYTOSIS
Potentially fatal disorder Symptoms include:
White blood cells level <2000 mm3 or granulocyte

count <1500mm3 Sore throat Low grade fever Malaise Sores in the mouth

NURSING IMPLICATIONS
MONITOR B.P. BEFORE ADMINISTERING MEDS CHECK CBC, CPK, LIVER FUNCTIONS AND VISION REGULARLY EVALUATE FOR EFFECTIVENESS AND SIDE EFFECTS ADMINISTER 1 OR 2 HOURS BEFORE BEDTIME MIX LIQUIDS WITH 60CC FRUIT JUICE PATIENT EDUCATION

ANTIPARKINSON AGENTS

COGENTIN ARTANE AKINETON PARLODOL KEMADRIN BENEDRYL

CLIENT AND FAMILY TEACHING

Teach about schizophrenia and available mental

health agencies for support at the local and national level (NAMI AND NIMH). Develop a relapse prevention plan. Teach about medication and treatment compliance. Teach to avoid alcohol or drugs. Teach to keep in touch with supportive people. Teach to keep healthy stay in balance.