schizo introduction
what is psychosis ?
- a neurocognitive symptom that impairs cognitive capacity leading to deficits or perception, functioning, social relatedness
- mental health conditions, genetics, substance use, trauma, and physical illness or injury are all causing factors
what are the alterations in reality testing ?
- fixed beliefs a person doesn't change even if they are wrong
persecutory - something or someone is going to harm them
referential - ordinary events, objects, or people have special significance or are directed to that person
grandiose - believing they have exceptional fame, abilities, or wealth including believing they are of royalty
what are negative symptoms is schizophrenia defined as ?
the absence of feeling and behaviors that are usually present, resulting in a decreased or loss of function
explain 1st generation antipsychotics
med - Chlorpromazine, Haloperidol
route - PO, short and long acting IM injections
indi - supress positive symptoms
AE - akathisia, pseudoparkinsonism, acute dystonia, tardive dyskinesia, anticholinergic effects, severe dysrhythmias, photosensitivity, neuroleptic malignant syndrome, liver impairment, sedation, weight gain, gynecomastia, galactorrhea, amenorrhea, htn
PE/NC - provide edu on methods to minimize anticholinergic effects, advise to avoid direct sunlight, perform AIMS assessment every 3 months, patients may tolerate a different 1st gen drug, lover dose, or a 2nd gen drug with fewer side effects
prolonged QT interval
- Delay of ventricular repolarization
- May result in tachycardia, fainting, seizures, and even sudden death- Some antipsychotics block potassium channels in the heart, which delays repolarization and prolongs the QT interval on an ECG.
- Baseline ECG before starting high-risk drugs
- Follow-up ECGs if dose changes or patient has risk factors
- Stop the offending drug if QT prolongation is significant
what is schizophrenia ? what are the DSM-5 criteria needed for someone to be diagnosed?
- characterized by increased dysfunction cognitively, emotionally, and behaviorally ; altered cognition, perception, and reality testing
- presents @ 15-25 and child onset and late onset are more rare
DSM-5 : 2 or more of the following for majority of 1 month
- delusions, hallucinations, disorganized speech, gross disorganization or catanoia, negative symptoms, functional impairment of some kind ; also, continuous disturbance for at least 6 months (rule out substance or other disorders first)
what alterations in speech may we see ?
associative looseness - word salad
clang association - words chosen based on sound
neologisms - meaning for the patient only
echolalia - repetition / mimic of anothers words
circumstantiality - wandering speech that eventually gets back on topic
tangentiality - responses that go in multiple directions
psychomotor retardation -lack of motivation, slowed movement, slowed thought process
pressured speech - increased rate and amount of speech
loose association - spontaneously loses focus and shifts topics or ideas that are loosely connected
explain some of the negative symptoms seen in schizophrenia (6 A's)
anhedonia- inablity to feel pleasure or enjoy activities
avolition - lack of motivation to start or complete tasks
asociality - lack of interest in social interactions or relationships
affective blunting - limited or reduced emotional expression
apathy - general lack of concern, interest, or emotion
alogia - poverty of speech ; very little verbal communication
explain 2nd generation antipsychotics
meds - risperidone, quetiapine
route - PO, injections (SA and LA)
indications - pos and neg symptoms
AE - less extrapyramidal se, more metabolic syndrome, side effects tend to be fewer, milder, and better tolerated
PE/NC - similar to 1st gen, focus on metabolic symptoms
explain lier impairment
Impairment usually occurs in the first weeks of therapy
- Jaundice, abdominal pain, ascites, vomiting, lower extremity edema, dark urine, pale or tar-colored stool, easy bruising
what are the risk factors and comorbidities associated with schizophrenia ?
RF : genetics, neurobiological (increased dopamine), poverty, stressful life events, brain structure abnormalities, more in men in urban areas, frequent MJ use increases risk
co-mo : substance abuse disorders, anxiety, depression, SI, physical illness, polydipsia
what are the distortions of thought ?
thought blocking - sudden stop in the middle of thought, cant remember what they were saying
thought insertion - belief someone else is putting thought into their mind
thought deletion - belief someone or something is removing thought from their mind
magical thinking - believing that one's thought or actions can cause events to happen with no logical connection
paranoia - extreme, irrational distrust or suspicion of others
what is affect and what are the different types for negative symptoms of schizophrenia ?
outward expression of a persons internal emotional state
flat - no visible emotion
blunted - very little emotional expression
constricted - limited range of emotions
inappropriate - difficulty understanding, organizing, or responding to information
impaired executive functioning - trouble with planning, decision making, or problem solving
anosognosia - lack of awareness of having an illness or symptoms
anticholinergic toxicity
- excess of anticholinergic activity in the body, usually from medications that block acetylcholine
- can be life threatening, esp in older patients
causes : overdose medications
symptoms : hyperthermia, mydriasis and blurred vision, dry everything, flushed face, delirium, confusion, hallucinations, tachy, urinary retention, constipation, seizures
management - stop the drug
suportive care - hydration, cooling
meds - in severe cases, physostigmine under careful supervision
metabolic syndrome
- Weight gain (especially in the abdomen), dyslipidemia, increased blood glucose, and insulin resistance
- Increases risk of diabetes, certain cancers, hypertension, and cardiovascular disease
what are the phases of schizophrenia ?
prodromal : onset of manifestations, mild changes, disruption of sleep, loss of concentration, increased anxiety and suspicions, isolation. they may have mild hallucinations or delusions
acute/active : more regular severe/noticeable episodes of hallucinations or delusions, mood manifestations can occur and speech/behavior are disorganized, this is usually when others begin to notice and ECOs are implemented
stabilization : s/s diminished, movement towards previous level of functioning
maintenance or risidual : similar to prodromal phase, manifestations include less severe hallucinations/delusions, perception can still be altered, neg manifestations are common including social difficulties and lack of attention
explain the alterations in perception associated with positive schizophrenia symptoms ?
hallucinations - auditory, visual, olfactory, gustatory, tactile, and command
illusions - misinterpretation, something is actually there but perceives it incorrectly
depersonalization - beliefs that they are separated from self, "out of body"
derealization - feeling that the surroundings are not real
what are the affective symptoms noted with negative symptoms of schiz
changes or disturbances in mood or emotional expression
- symptoms show how the person feels or expresses emotions and how the illness affects the person's emotions
- assessment for depression is crucial
NMS
- Rare but life-threatening reaction to antipsychotic (neuroleptic) medications, usually high-potency or high-dose ones, though it can occur with any dopamine-blocking drug.
causes : typical antipsychotics, atypical antipsychotics, and sometimes antiemetics that block dopamine
s/s = "FEVER" fever, encephalopathy, VS instability, elevated enzymes, rigidity ; diaphoresis, drooling, tremors, and sometimes AKI
onset : usually develops within days to weeks of starting or increasing dose and can occur with any route
management : immediate discontinuation
supportive care : hydration, cooling, monitor VS and electrolytes
meds in severe cases : dantrolene, amantadine
key difference ? NMS has severe “lead-pipe” rigidity, very high fever, and develops over days, whereas serotonin syndrome develops quickly and usually has hyperreflexia and clonus.
extrapyramidal side effects
Acute dystonia: Sudden, sustained contraction
Akathisia: Motor restlessness causing inability to stay still or remain in one place
Pseudoparkinsonism: Temporary group of symptoms that resemble Parkinson’s disease
what are the phases of outcome identification in the nursing process ?
phase 1 - acute : patient safety and medical stabilization
phase 2 - stabilization : help pt understand illness and treatment, stabilize meds, and control or cope with symptoms
phase 3 - maintenance : maintain achievement, prevent relapse, achieve independence, satisfactory quality of life
what are the alterations in motor behavior ?
catatonia - decrease in reactivity to external stimuli, resulting in either lack of movement and severe rigidity or hyperactive unrestrictive movement
psychomotor retardation - lack of motivation, slowed thought process
motor agitation - excessive, purposeless physical activity thats often driven by inner tension
stereotyped behaviors - repeated, non-purposeful movements or actions that are the same each time
waxy flexibility - the person keeps their body in whatever position someone else places it in even if uncomfortable
negativism - doing the opposite of that is asked or refusing to cooperate w/out reason
impaired impulse control
gesturing or posturing - assuming unusual or rigid body positions or movements that are often held for long periods
boundary impairment - difficulty understanding where one's body or personal space ends and another begins
what kids of medications will we use with schizophrenia ?
antipsychotic medications
severe neutropenia
- drug most common is clozapine
onset : usually within the 1st 6-18 weeks of Tx
symptoms : fever, sore throat, mouth ulcers, signs of infection
- pts need a regular CBC (weekly for 1st 6 months, then q2weeks for next 6 months, then monthly after 12 months)
management - immenndiate discontinue, hospitalization if needed with infection
- may need antibiotics for infection
TIP : Clozapine is the classic antipsychotic associated with agranulocytosis, so always remember “Clozapine = CBC monitoring & risk for neutropenia.”
explain tardive dyskinesia in further detail including movements, onset, cause, management, and why its important to know
- involuntary rhythmic movements, resulting from long term use of certain antipsychotics
movements : Grimacing, tongue protrusion, lip smacking, puckering, rapid eye blinking, or finger/limb movements
onset : Usually develops after months or years of antipsychotic use, but sometimes can appear after a shorter period
cause : Dopamine receptor sensitivity changes in the brain caused by chronic antipsychotic exposure
management : sometimes reversible if meds are stopped/switched, often chronic and newer meds help reduce symptoms
important : usually late-onset and often persistent even after stopping the drug