Nursing management of patient with schizophrenia and other psychotic disorder

Schizophrenia

1. Nursing management of patient with schizophrenia, and other psychotic disorder Miss Rupali Subhash Walke Msc Nursing Lecturer Mental Health N ursing Vijaysingh M ohite Patil College of Nursing And Medical Research Institute , Akluj , Solapur

2. INTRODUCTION The word schizophrenia was coined by Swiss Psychatrist Eugen Bleuler in 1908. It is derived from the Greekword skhizo (split) and phren (Mind).In ICD -10, Schizophrenia is classified under the code F2.

3. Definition Schizophrenia is a psychotic condition characterized by a disturbance in thinking, emotions, volitions, and faculties in the presence of clear consciousness, which usually leads to social withdrawal.

4. Schizophrenia is a serious brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others.

5. Epidemiology Schizophrenia occurs equally in males and females. The peak ages of onset are 20-28 years for males and 26-32 years for females. About 1%of general population has the risk of developing the schizophrenia in their life time.

6. Causes

7. Genetics factors Passed on form one generation to another generation i.e. parents to their children Monozygotic twins have more chance of developing schizophrenia than dizygotic twins.

8. Chemical factors Imbalance of certain chemicals in the brain Increased dopamine level Imbalance of dopamine affects – sounds, smell, and sight and can lead to hallucinations and delusion.

9. Brain abnormality Abnormal brain structure and function.

10. Psychological factors Family relationship also important Mother child relationship Dysfunctional family system Double bind communication

11. Environmental factors Viral infection Poor social interaction or highly stressful situation.

12. Theories about schizophrenia

13. Biological psychological socio –cultural Theories Theories Theories Genetic Neurochemical viral contribution and Neuroanatomic infection factors Dopamine serotonin structrual Abnormalities Hypothesis hypothesis Neuroanatomic

14. Biological theories Genetic factors Neuroanatomic Neurochemical factors Immunovirology

15. Genetic factors Families- parents Siblings Offspring’s Consanguineous marriage Twin studies indicates

16. Genetic risk of schizophrenia Identical twin affected – 50% Fraternal twin affected -15% Brother or sister affected -10% One parent affected -15% Both parents affected -35% Second degree relative affective -2-3% General population -1% (no affected relative

17. Neurochemical and Neuroanatomic factors An alteration in neurotransmitter systems Dopamine (DA) Hypothesis : It is belived that increase in dopamine levels. Serotonin hypothesis : excess serotonin

18. Structural abnormalities - neuroanatomic factors Enlarged ventricles Diminished glucose metabolism and oxygen in frontal cortical areas of the brain Abnormal brain function in the frontal and temporal areas of the brain.

19. Viral infection Viruses

20. Psychological theories Stress – increased number of stressful life events Increased Expressed Emotions (EE) hostility, critical comments, emotional over involvement of “significant others” Family theories :-’’ Schizophrenogenic mothers’’ lack of “real parents”, dependency on mother, anxious mother and parental marital

21. Information processing hypothesis Disturbances in attention , inability to maintain a set Inability to assimilate and Psychoanalytical theories According to freud , there are regression to the pre-oral (and Oral )stage of psychosexual development with the use of defence mechanisms of denial, reaction formation and projection.

22. Socio – cultural theories Social influences – poverty, abuse, family problems affect an individual’s mental functioning.

23. Psychopathology

24. Clinical features

25. Positive and Negative symptoms Positive Negative Delusions Affective flattening or blunting Hallucinations Avolition –apathy (lack of initiative) Excitement or agitation Attentiional impairment Hostility or aggressive behavior Anhedonia (inability to experience pleasure) Suspiciousness, ideas of reference Alogia ( lack of speech output) Possible suicidal tendencies Moodinesss Grandiosity Lack of motivation

26. Bleueler’s 4 A’s of Schizophrenia

27. Schneider’s First -rank symptoms of Schizophrenia

28. Common signs & symptoms in schizophrenia Thought and speech disorder Autistic thinking Loosening of association Thought blocking Neologism Poverty of speech Poverty of ideation Echolalia Verbigeration Delusions of various kinds:- delusion of persecution, delusion of grandeur, delusion of reference, delusion of control

29. Disorder of perception Auditory hallucinations Visual hallucinations –Tactile ,gustatory and olfactory are far less common.

30. Disorders of Affect Apathy Emotional blunting Emotional shallowness Anhedonia Inappropriate emotional response

31. Disorders of motor Behavior Increase or decrease in psychomotor activity Mannerisms Grimacing Stereotype Decreased self-care Poor grooming

32. Other features Decreased functioning in work, social relations and self-care, as compared to earlier life Loss of ego boundaries Loss of insight Poor judgment Suicide can occur depression, command hallucinations.

33. Clinical types

34. Paranoid schizophrenia The word ‘paranoid’ means ‘ delusional’ It is most common form of schizophrenia. It has a good prognosis if treated early. It is characterized by the following features

35. Delusion of persecution

36. Delusion of reference

37. Delusion of jealousy

38. Delusion of Grandiosity

39. Hallucinatory voices

40. Other features

41. Hebephrenic schizophrenia It has early and insidious onset. Poor premorbid personality. It is the worst prognoses among all the subtypes. Features Marked thought disorder Incoherence Severe loosening of associations and extreme social impairment Delusions and hallucinations are fragmentary and changeable.

42. Odd behavior – senseless giggling, mirror gazing, grimacing, mannerisms

43. Catatonic schizophrenia Catatonic ( cata –disturbed ) schizophrenia is characterized by marked disturbance of motor behavior . Catatonic stupor Catatonic excitement Catatonia alternating between excitement and stupor

44. Clinical features of excited catatonia Increase in psychomotor activity Increase in speech production Loosening of associations Sometimes excitement becomes very severe and is accompanied by rigidity, hyperthermia and dehydration and can result in death. It is the known as acute lethal catatonia or pernicious catatonia.

45. Clinical features Retarded catatonia ( catatonic Stupor ) Mutism Rigidity Negativism Posturing Stupor Echolalia Echopraxia Waxy flexibility Ambitendancy Automatic obedience

46. Residual schizophrenia Symptoms include emotional blunting , Eccentric behavior, illogical thinking, social withdrawal and loosening of associations.

47. Undifferentiated schizophrenia This category is diagnosed either when features of no subtype are fully present or features of more than one subtype are exhibited.

48. Simple schizophrenia It is characterized by an early and insidious onset, progressive course and presence of characteristics negative symptoms, vague hypochondriac features, wandering tendency, self- absorbed idleness and aimless activity

49. Diagnosis Mental status examination Psychiatric history CT scan and MRI show enlarged ventricals , enlargement of the sulci on the cerebral surface and atrophy of the cerebellum

50. Management Goals To reduce the symptoms To decrease the chances of a relapse, or return of symptoms.

51. Medical management Medication An acute episode of schizophrenia typically responds to treatment with antipsychotic agents, which are the most effective in its treatment. Atypical antipsychotics control wider range of signs and symptoms than conventional agents do and cause few or no adverse motor affects.

52. Conventional antipsychotics Chloropramizine 300-1500mg/day PO 50- 100mg/day IM Fluphenazine decanoate 25-50 mg IM every 1-3 weeks Haloperidol 5-100 mg/day PO—20mg/day IM Trifluoperazine 15-60 mg/day PO 1-5 Mg/day IM

53. Commonely used atypical antipsychotic Clozapine 25-450mg/day PO Risperidone 2-10mg/day PO Olanzapine 10-20mg/day PO Quetipine 150-760mg/day PO Ziprasidone 20-80mg/day PO Aripiprazole 10-15mg/day PO Paliperidone 1.5-12mg/day PO Amisulpride 400-800mg/day PO

54. Electroconvulsive Therapy (ECT) Indication for Catatonic stupor Uncontrolled catatonic excitement Severe side effects with drugs Usually 8-12 ECTs are needed.

55. Psychological Therapies

56. Psychosurgery Lobotomy used to severe certain nerve pathways in the brain

57. Nursing Management Nursing assessment History collection –family members , other familiar member , old records Observe behavior pattern, posturing psychomotor, disturbance, appearance hygiene Identify the type of disturbance the patient is experiencing. Ask the patient about feelings while thought alterations are evident. Note the effect and emotional tone of the patient and whether they are appropriate in relation to the thought or present situation. Assess for theme and content of delusional thinking.

58. Assess speech patterns associated with the delusional thinking. Assess speech patterns associated with the delusions. Assess for ability to perform self-care activity, i.e. sleep pattern and interaction with other patients

59. Nursing Diagnosis 1. Disturbed thought process, related to inability to trust, panic anxiety, possible hereditary or biochemical factors evidenced by delusional thinking, extreme suspiciousness of others. Objective :- The patient will Eliminate pattern of delusional thinking Demonstrate trust in others Demonstrates improved reality orientation

60. 2.Ineffective health maintence related to inability to trust, extreme Suspiciousness evidenced by poor diet intake, inadequate food and fluid intake, difficulty in falling asleep Objective :- The patient will Maintain adequate nutrition , hydration and elimination Maintain adequate sleep and rest Take medication as administerd

61. 3.Self –care deficit related to withdrawal, regression, panic anxiety, cognitive impairment , inability to trust, evidenced by difficulty in carrying out tasks associated with hygiene, dressing, grooming, eating, sleeping and toileting. Objective :- The patient will Demonstrate increased interest in self-care. Complete daily activities with minimum assistance. Demonstrate adequate personal hygiene skills.

62. 4. potential for violence, self-directed or at others, related to command hallucinations evidenced by physical violence, destruction of objects in the environment or self- desructive behavior. Objective :- The patient will Not injure others or destroy property or self Verbalize feelings of anger or frustration Express decreased feelings of agitation fear or anxiety.

63. 5.Risk for self-inflicted or life-threatening injury related to command hallucinations evidenced by suicidal ideas, plans or attempts. Objective :- The patient will not harm self

64. 6.Disturbed sensory- perception ( auditory/visual)related to panic anxiety, possible hereditary or biochemical factors evidenced by inappropriate responses, distordered thought sequencing, poor concentration, disorientation, withdrawal behavior.

65. 7. Impaired verbal communication related to panic anxiety ,disordered, unrealistic thinking, evidenced by loosening of associations, echolalia, verbalizations that reflect concrete thinking, and poor eye contact. Objective :- The patient will be abele to communicate appropriately and comprehensibly by the time of discharge.

66. 8. ineffective family coping related to highly ambivalent family relationships, impaired , family communication, evidenced by neglectful care of the patient , extreme denial or prolonged over-concern regarding his illness. Objective: Family will identify more adaptive coping strategies for dealing with patient’s illness and treatment regimen.

67. Home care Never contradict to the patient about hallucinatory voices and ideas. Being non –judgmental to the client. Frequently make him aware regarding reality to keep him in touch with reality. Provide assistance in maintaining personal hygiene of the client Try to keep the client associated with different conditions. Provide emotional support whenever required by the client. Assess the side effects. Be simple, direct and concise when speaking to the client. Protect the client from harming himself or herself or others. Be sincere and honest when communicating with the client .

68. Rehabilitation Focus – strengthening self-care and promoting and promoting and improving quality of through relapse prevention. Rehabilitation Half-way homes Long-term homes Day hospitals

69. Conclusion Schizophrenia it is a psychotic disorder marked by severely impaired thinking , emotions and behaviors. Schizophrenic patients are unable to filter sensory stimuli and may have enhanced perception of sounds, colors and other features of their environment.

70. References R. Sreevani , A Guide to Mental Health and Psychiatric N ursing, 4 th edition, J ypee publisher, 2016. Ram K umar Gupta, A Text Book of Mental Health and Psychiatric Nursing, 2011