Psychosis
What are examples of extrapyramidal side effects?
Akathisia: Feeling restless like you can't sit still.
Akinesia: Absence or impairment in voluntary movement
Dystonia: When your muscles contract involuntarily.
Parkinsonism: Tremors, rigidity, abnormal gait, drooling after administrating antipsychotics.
Oculogyric Crisis: Involuntary rolling back of eyes.
Tardive dyskinesia: Facial movements happen involuntarily
A nurse is assessing a client diagnosed with paranoid schizophrenia for the presence of hallucinations. Which therapeutic communication technique used by the nurse is an example of "making observations"?
1. I notice that you are talking to someone who I do not see.
2. Please tell me what they are telling you.
3. Why do you continually look at the ceiling?
4. I understand that you see someone in the hall, but I do not see anyone.
1. I notice that you are talking to someone who I do not see.
Rationale: The nurse is using the communication technique of making an observation when stating, "I notice that you are talking to someone that I do not see." Making observation involves verbalizing what is observed or perceived. This encourages the client to recognize specific behaviors and make comparisons with the nurse's perceptions.
(Curtis & Tuzo, 2017)
What is the AIMS Scale?
The Abnormal Involuntary Movement Scale is an assessment tool to measure involuntary movements that are associated with tardive dyskinesia.
List 3 family teaching guidelines about psychosis
* Education about what psychosis is
* Symptoms associated with psychosis
* Ways for the family to respond to the behaviors associated with psychosis
* Treatment options and potential side effects
* Resources for family support and education groups
*Monitor for changes in behavior
*When to contact provider
Negative symptoms of Schizophrenia
Lack of emotional expression-blunted affect.
Avolition-lack of motivation, neglecting ADL’s (activities of daily living).
Alogia-decreased verbal communication.
A sociality-decreased interest in relationships and social interaction, withdrawal.
Diminished abstract thinking-difficulty explaining meaning of it's raining cats and dogs.
Example of a typical antipsychotic medication
Haloperidol (Haldol)
Pimozide (Orap)
Thiothixene (Navane)
Fluphenazine
A nurse has received a client's WBC result. Which client was most likely to have his blood work ordered?
1. A client diagnosed with schizophrenia prescribed aripiprazole (Abilify)
2. A client diagnosed with schizophrenia prescribed clozapine (Clozaril)
3. A client diagnosed with schizophrenia prescribed haloperidol (Haldol)
4. A client diagnosed with schizophrenia prescribed risperidone (Risperdal)
2. A client diagnosed with schizophrenia prescribed clozapine (Clozaril)
Rationale: Clozapine can have a serious side effect of agranulocytosis, in which a potentially fatal drop in white blood cells can occur. It is appropriate to monitor white blood cell count on clients receiving this medication.
(Curtis & Tuzo, 2017)
List 3 patient teaching guidelines about psychosis
* Importance of medication (pharmacotherapy) adherence.
* Not to stop taking medication abruptly.
* S/S of antipsychotic medication
* To avoid drugs and alcohol
* Resources for support groups
* When to contact provider
Positive symptoms of Schizophrenia
1. Disturbances in thought content: Delusions, paranoia, magical thinking
2. Disturbances on thought processes manifested in speech: Associative looseness, concrete thinking
3. Disturbances in perception: Hallucinations, illusions
Example of a atypical antipsychotic medication
Aripiprazole (Abilify)
Clozapine (Clozaril)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
The nurse is interacting with a client diagnosed with schizophrenia. List the nurse's interventions in the correct sequence.
1: present and refocus on reality
2: educate the client about the disease process
3: establish a trusting nurse-client relationship
4: encourage compliance with antipsychotic medications.
3: establish a trusting nurse-client relationship
1: present and refocus on reality
4: encourage compliance with antipsychotic medications.
2: educate the client about the disease process
Rationale: The establishment of a trusting nurse-client relationship should be the first because all further interventions will be affected by the trust the client has for nurse.
Presenting reality in a matter-of-fact way helps the client to distinguish what is real from what is not.
Encouraging compliance with with medications helps to decrease symptoms and increases the client's cooperation with psychosocial therapies.
Education about disease comes later on in plan of care. A trusting nurse-client relationship has to be established and client needs to be stabilized because initiating any effective teaching.
(Curtis & Tuzo, 2017)
List 3 coping skills
* Self care
* Find ways to regulate stress- deep breathing, keeping a journal, working out
* Attend support groups
Example of a long-acting injectable
Aripiprazole (Abilify Maintena)
Olanzapine pamoate (Zyprexa Relprevv)
Haloperidol decanoate
Fluphenazine decanoate
Which clinical manifestation would the nurse expect when assessing a client with schizophrenia? Select all that apply. One, some, or all responses may be correct.
a. Paranoid behaviors
b. Recurrent unwanted memories
c. Loose associations
d. Behaviors of avoidance
e. Inappropriate affect
f. Upsetting nightmares
g. Flashbacks
h. Feelings of detachment
a. Paranoid behaviors
c. Loose associations
e. Inappropriate affect
Rationale:
The nurse would expect paranoid behaviors, loose associations, and inappropriate affect. Paranoid behaviors are associated with schizophrenia. Loose association is a characteristic related to the thought disorders in schizophrenia. The affect usually is inappropriate in schizophrenia. Post-traumatic stress disorder (PTSD) is characterized by recurrent and unwanted memories. The individual may behave in a way that helps them avoid discussing, reliving, or remembering an event. Sleep may be disturbed by nightmares of the event for the client with PTSD. Flashbacks, or reliving an event, are associated with PTSD, not with schizophrenia. Feelings of detachment and difficulty maintaining relationships are also clinical manifestations associated with PTSD.
(Curtis & Tuzo, 2017)
List 2 nursing inventions for a patient with schizophrenia
Ensuring safety of patient and others
Decreasing anxiety and establishing trust
Meeting patient's self-care needs
Assisting client to define and test reality
Promoting adaptive family coping
Increase social interactions very gradually
List 3 PRIORITY antipsychotic medication teaching topics
Do not stop taking medication abruptly!
S/S of agranulocytosis- sore throat, fever, malaise. And importance of scheduled lab work. (WBC)
S/S of extrapyramidal symptoms
S/S of tardive dyskinesia
Use sunblock!
Sedation: Avoid hazardous activities, and it is best to take the medication at bedtime.
Orthostatic hypotension: Slowly change positions
Anticholinergic side effects: Use gum, hard candy, ice chips, OTC eye drops, increase fluid intake, and increase dietary fiber
A client has been adherent with olanzapine (Zyprexa) 4mg QHS for the past year. On assessment, the nurse notes that the client has bizarre facial and tongue movements. Which is a priority nursing intervention?
1. With the next dose of olanzapine (Zyprexa), give the ordered PRN dose of benztropine (Cogentin).
2. Notify the physician of the observed side effects, place a hold on the Zyprexa, and request discontinuation of the medication.
3. Ask the physician to increase the dose of Zyprexa to assist with the bizarre behavior.
4. Explain to the client that these side effects are temporary and should subside in 2-3 weeks.
2. Notify the physician of the observed side effects, place a hold on the Zyprexa, and request discontinuation of the medication.
Rationale: Bizarre facial and tongue movements, stiff neck, and difficulty swallowing all are signs of tardive dyskinesia. All receiving antipsychotic medications are at risk. The symptoms are potentially permanent, and the medication should be discontinued as soon as symptoms are noted.
(Curtis & Tuzo, 2017)
List 3 de-escalation techniques
Utilizing verbal communication techniques that are clear and calm
Use non-threatening body language when approaching patients
Approach the patient with respect, being supportive of their issues and problems
Use risk assessment tools for early detection and intervention
Respond to patients expressed problems or conditions
Set clear limits for patient to follow