Академический Документы
Профессиональный Документы
Культура Документы
Objectives
Define the term schizophrenia Recognize DSM-IV criteria and subtypes Differentiate type I and type II subtypes Describe theories that have contributed to the current understanding of schizophrenia
Schizophrenia
Objectives
Describe objective and subjective symptoms Identify the major drugs used in the treatment of schizophrenia Develop a nursing care plan Evaluate effectiveness of nursing interventions
DSM IV Diagnosis
DSM IV Disorders
Mood Anxiety Somatoform Personality
Psychotic
Cognitive
Eating
Substance Abuse
Schizophrenia
Paranoid
Undifferentiated
Disorganized
Residual
Catatonic
Autism
DSM-IV Criteria
A. At least two of the following:
Plus
DSM-IV Criteria
B. Social / occupational dysfunction C. Duration: continuous signs for 6 months D. Absence of Schizoaffective and mood disorders E. Not caused by substance abuse or a general medical illness
DSM-IV 5 Subtypes
DSM-IV Subtypes
Catatonic Two of the following symptoms are present Motoric immobility, waxy flexibility, or stupor
Purposeless excessive motor activity Extreme negativism or mutism Peculiar or sterotypic of movement Echolalia or echoraxia
DSM-IV Subtypes
Undifferentiated Characteristic symptoms are present but criteria for other subtypes are not met
Residual Characteristic symptoms are no longer present, but there is continuing evidence of negative symptoms or criterion
1952
DSM- I (9) 68 II (11)
1982
Andreason, Crow, Introduce Types I(+) and II(-) 87 DSM III, revised
70 Hebephrenia
96 Paranoia
80 III (5)
94 DSM-IV
97 I, II, Disorganized
Positive Type I
Symptoms reflecting excess or distortion of normal functions.
Negative Type II
Symptoms reflecting diminuation or absence of normal behaviors
Type II
Poor No Chronic Clear Yes Dopamine, CBF VBRs + Varies Good Minimal
Antipsychotic Drug TX
Side Effects Anticholinergic Constipation, dry mouth, blurred vision, urinary retention hesitancy
Due to interference of nerve impulses by acetylcholine and epinephrine
Nursing Interventions
Monitor for these effects
Antipsychotic Drug TX
Side Effects Extrapyramidal Symptoms A resting tremor Mask-like face Decreased blink rate Increased salivation Decreased arm swings Shuffling gait Nursing Interventions 1/3 of patients have EPS Monitor for these effects Administer antiParkinsonian meds Artane Cogentin Symmetrol Lower Med. Dose/potency
Antipsychotic Drug TX
Side Effects Akathisia Characterized by restlessness, pacing, or shifting from one foot to another Usually occurs after weeks of months of treatment Nursing Interventions Distinguish from agitation Ask how the patient feels. I just cant sit still. I feel like jumping out of my skin Administer antiParkinson medication
Antipsychotic Drug TX
Side Effects Dystonic Reactions Characterized by involuntary muscular movements of neck, arms, legs and face. Includes torticollis, oculogyric crisis. Difficulty swallowing Occurs after 1st dose. Nursing Interventions Administer IM antiParkinson medication Terrifying to the patient Reassure pt: explain that this can be fully controlled with antiParkinson medication
Antipsychotic Drug TX
Side Effects Tardive Dyskinesia Characterized by difficulty swallowing, lib smacking, tongue protrusion, puckering, blinking, choreiform movements of limbs and trunk Generally irreversible Associated with the high potency neuroleptics 10-20% who receive antipsychotics >1yr develop this. Nursing Interventions Lower dose, change to less potent antipsychotic, benzodiazepines.
Antipsychotic Drug TX
Side Effects Other Symptoms sedation, orthostatic hypotension, photosensitivity, decreased libido, weight gain, reduction of seizure threshold, amenorrhea, Nursing Interventions Patient Teaching Change position slowly Diet Wear sunscreen and sunglasses Take orthostatic blood pressure
Antipsychotic Drug TX
Side Effects Other Symptoms cholestatic jaundice
(An allergic reaction to chlorpromazine)
agranulocytosis
Antipsychotic Drug TX
Side Effects Neuroleptic Malignant Syndrome Nursing Interventions Monitor for high fever autonomic instability tachychardia muscle rigidity elevated CPK sweating hyperkalemia
to be caused by dopamine blockade in the hypothalamus rate about 20% occur any time.
Report changes in vital sign, rigidity and mental status immediately. Discontinue all Drugs Maintain nutrition, hydration
Reduce temperature using sponge baths, antipyretics Ventilator, renal dialysis Bromocriptine or Dantroline to muscle contraction
Anticholinergic Crisis
Symptoms Red as a Beet Mad as a Hatter Hot as a Stove Dry as a Bone
Motor restlessness Confusion Tachycardia sluggishness Dilated pupils Acute urinary retention Blurred vision Fever and Bowel sounds
Anticholinergic Crisis
Nursing Interventions
Discontinue Neuroleptic
Give the anticholinesterase physostigmine (eserine)
Discharge Planning
Chronic illness with remissions and exacerbations
Patient Teaching
Skills for coping with psychotic symptoms Cognitive reforming regarding the cause of symptoms Gaining control over symptoms
4 Ss Rehabilitation
Safety Symptom
Structure Support
Management
Schizophrenia
Psychotic symptoms of Schizophrenia include altered perceptions auditory hallucinations visual hallucinations, delusions
Schizophrenia
Antipsychotic Drugs have enabled millions of schizophrenics to live in the least restrictive environment Dopamine hypothesis: Excessive dopaminergic activity in cortical areas causes acute positive (Type I) symptoms of schizophrenia.
Schizophrenia
Antipsychotics block access of dopamine to the receptor
Schizophrenia
Traditional Antipsychotics (Neuroleptics) are heavy in side effects Haloperidol (Haldol) Thorazine Fluphenzaine (Prolixin)
Schizophrenia
There are newer generation Antipsychotics available now.
Schizophrenia
New generation antipsychotics are just as effective in reducing symptoms in type I Schizophrenia, and Are more complex (act on more than 1 neurotransmitter) Have little or no extrapyramidal side effects.
Schizophrenia
Clozapine (Clozaril) Especially good for negative symptoms of schizophrenia Patient needs weekly blood tests to detect clozapineinduced agranulocytosis
Schizophrenia
Neurostructural theories Cerebral ventricular enlargement Smaller cerebral and cranial size Hypoplasia of the medial (limpic) temporal structures, especially the hyppocampus
Schizophrenia
Substance abuse is the most common co-morbid psychiatric condition associated with Schizophrenia. The leading cause of death in Schizophrenia is Suicide Medication compliance is one of the most important goals of treatment
It looks like you might be listening to something. Are you hearing voices? Try to describe what you are hearing?
Monitor for command hallucinations that may increase potential for patient to become dangerous.
Schizoaffective Disorder
A hybrid of two disorders schizophrenia and major depression or manic symptoms with substantial loss of occupational and social functioning.
Prognosis is better than that of schizophrenia but significantly less optimistic than the prognosis for mood disorders.
Delusional Disorder
Similar to schizophrenia but with some differences: Delusions have a basis in reality Never fully meet criteria for Schizophrenia Behavior is relatively normal except in relation to delusions Symptoms are directly related to a substance or medical condition
Schizophrenia
THE END
Physician Orders
Haloperidol 2 mg bid Diet, normal Provide supportive therapy
Patient Teaching
How will you determine this patients learning needs related to symptom management? What will the patient need to know about the effects this medication has on symptoms? What will the patient need to know about the side effects of this medication?