Nursing Management for Client with Schizophrenia Spectrum Disorder PDF

NURSING MANAGEMENT FOR CLIENT WITH SCHIZOPHRENIA SPECTRUM DISORDER SIRAPORN SILPHIPAT OBJECTIVE  The student will understand nursing management for client with schizophrenia spectrum disorder  The student will identify psychopathology of schizophrenia spectrum disorder  The student will desc...

NURSING MANAGEMENT FOR CLIENT WITH SCHIZOPHRENIA SPECTRUM DISORDER SIRAPORN SILPHIPAT OBJECTIVE  The student will understand nursing management for client with schizophrenia spectrum disorder  The student will identify psychopathology of schizophrenia spectrum disorder  The student will describe nursing intervention schizophrenia spectrum disorder SCHIZOPHRENIA  Schizophrenia is characterized by distortions in thinking, perception, emotions, language, sense of self and behavior.  Common experiences include hallucinations (hearing voices or seeing things that are not there), delusions (false beliefs), abnormal behavior and disorganized speech.(WHO, 2019) KEY FACTS  Worldwide, schizophrenia is associated with considerable disability and may affect educational and occupational performance.  People with schizophrenia require lifelong treatment.  Schizophrenia is treatable. Treatment with medicines and psychosocial support is effective. PREDISPOSING FACTORS  Biological factors (Genetic) - Relatives of individuals with schizophrenia have much higher probability of developing disease.  Biochemical factor(Dopamine Hypothesis) cause by an excess of dopamine-dependent neuronal activity in the brain (other biochemical hypotheses) excess serotonin has been hypothesized to be responsible for positive and negative symptom PREDISPOSING FACTORS  Physiological factors alterations in brain structure (prefrontal cortex abnormality)  Physical condition (brain abscess, cerebrovascular disease, hypo- hyperthyroidism, epilepsy) PREDISPOSING FACTORS  Psychological factors (Family relationship, childhood trauma experience)  Sociocultural factors (lower socioeconomic classes)  Stressful life event that can contribute severity of illness  Cannabis and synthetic cannabinoids ( can induced many schizophrenia like symptom) PHASES OF SCHIZOPHRENIA  There are four phases of schizophrenia as follow  Premorbid (normal functioning)  Prodromal( certain sings and symptoms)  Acute / active(psychotic symptom prominent)  Residual(negative symptoms) PHASE 1 Premorbid Phase:  There is usually a period of normal functioning.  The indicators associated with this phase are shyness, withdrawn personality, poor peer relationships, poor academic, antisocial behavior PHASE 2 Prodomal Phase:  Begins with a change from normal functioning and extends to the start of acute symptoms. This phase can be a few weeks or months, but last about 2-5 years before active phase of disorder begins  Symtoms: poor concentration, anxiety, change in mood, may begin deterioration of role functioning. PHASE 3 Active Schizophrenia:  Psychotic symptoms are prominent :Delusion/hallucinations/disorganized speech (Positive symptoms)  Blunted affect(decrease ability to express emotion), alogia (poverty of speech), avolition (lack of design, drive)  Self care is neglected, social and occupational functioning deteriorates PHASES 4 Residual phase:  Positive symptoms (delusion and hallucination) are often improved but negative symptom may remain and impairment in role functioning are common. POSITIVE AND NEGATIVE SYMPTOMS OF SCHIZOPHRENIA  The symptoms of schizophrenia are usually classified into:  Positive symptoms – any change in behavior or thoughts. (Delusion, Hallucination, disorganized speech).  Negative symptoms – person appear to withdraw from the world around then, take no interest in everyday social interactions, and often appear emotionless and flat. POSITIVE SYMPTOMS Hallucinations (Sensory perception without external stimuli)  Auditory : The person most often hears voices in their head. They might be angry or urgent and demand that they do things. It can sound like one voice or many. They might whisper, murmur, or be angry and demanding.  Visual :The person might see lights, objects, people.  Olfactory :This can include good and bad smells and tastes. Someone might believe they’re being poisoned and refuse to eat.  Tactile:This creates a feeling of things moving on your body, like hands or insects. POSITIVE SYMPTOMS  Delusion (Beliefs that seem real, but are not / false belief) -Persecutory :Belief that one is going to be harmed by other -Somatic: These center on the body. Belief that one have a terrible illness or bizarre health problem like worms under the skin or damage from cosmic rays -Grandiose : Belief that they have exceptional greatness -Erotomanic: Belief that someone, usually of a higher status, is in love with him or her( Famous persons often the subjects)  POSITIVE SYMPTOMS  Disorganized thinking or Disorganized speech (Manifest in speech) -Loose association: The topic are not connected -Tangentiality: veering away from the topic discussion( answers are unrelated to the questions) -Circumstantial thinking: talking in circles, adding unnecessary details and never getting to the point POSITIVE SYMPTOMS -Incoherence ("word salad"): no discernible connection between words or a group of words that are put random together, without any logical connection. Become increasingly difficult to understand. Ex. I need a sandwich, but the chair is wet, and I want to fly, do you see the fish? POSITIVE SYMPTOMS  Abnormal motor behavior - Hyperactivity: abnormally or extreme active - Hypervigilance: the state of being highly or abnormally alert to potential danger or threat - Agitation: a state of anxiety or nervous excitement - Catatonia: a psychomotor disorder that involves the connect between mental &movement (sitting or standing in same position for hours) and impaired communication CATATONIA  Stupor(immobility): a lack of responsiveness to the environment  Waxy flexibility: temporary resistance to being moved, similar to a wax doll  Mutism: not speaking  Stereotyped: repetitive purposeless movement or behaviors  Echolalia: repeating sounds others make  Echopraxia: repeating movements of others CATATONIA NEGATIVE SYMPTOMS ❑ Alogia – decrease verbal communication  Avolition- having no drive to do anything (Neglect of activities of daily living)  Anhedonia (reduced ability to experience pleasure/loss of pleasure or interest)  Apathy (lack of social engagement)  Lack of emotion expression- blunted affect NEGATIVE SYMPTOMS  Negative symptoms can severely affect a person's ability to function socially, and personally.  They may lead to difficulty maintaining relationships, holding down a job, or participating in typical life activities.  DSM-V-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA  A. Two (or more) of the following symptoms present for one month, at least one of these must be (1), (2), or (3): 1.Delusion 2. Hallucination 3. Disorganized speech illogical speech, loose associations. 4. Grossly disorganized or catatonic behavior unpredictable movements/lack of movement or response). 5. Negative symptoms  B. Decline in social and/or occupational functioning since the onset of illness  C. Continuous signs of illness for at least six months with at least one month of active symptoms meeting criteria A DSM-V-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA  D. Schizoaffective disorder and depressive and bipolar disorder with psychotic features have been excluded  E. The disturbance is not due to substance abuse or medical condition SCHIZOPHRENIA SPECTRUM  Schizophreniform disorder  Brief psychotic disorder  Schizoaffective disorder  Delusional disorder  DSM-V-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIFORM DISORDER  A. Two (or more) of the following symptoms present for one month, at least one of these must be (1), (2), or (3): 1.Delusion 2. Hallucination 3. Disorganized speech illogical speech, loose associations. 4. Grossly disorganized or catatonic behavior unpredictable movements/lack of movement or response). 5. Negative symptoms DSM-V-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIFORM DISORDER  B. An episode of disorder at least 1 month but less than 6 months  C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been excluded  D.The disturbance is not due to substance abuse or medical condition DSM-V-TR DIAGNOSTIC CRITERIA FOR BRIEF PSYCHOTIC DISORDER  A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3): 1.Delusion 2. Hallucination 3. Disorganized speech (illogical speech, loose associations.) 4. Grossly disorganized or catatonic behavior (unpredictable movements/lack of movement or response). DSM-V-TR DIAGNOSTIC CRITERIA FOR BRIEF PSYCHOTIC DISORDER  B. Duration of an episode of the disturbances at least 1 day but less than 1 month.  C. The disturbance is not explained by major depressive of bipolar disorder or schizophrenia and is not due to substance abuse or medical condition. TIP  Schizophrenia -Psychotic symptoms > 6 months  Schizophreniform disorder -Psychotic symptoms lasting between 1-6 months ▪ Brief psychotic disorder -Psychotic symptoms lasting < 1 month DSM-V-TR DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE DISORDER  A. Major Mood Episode (Depressive or Manic) concurrent with criterion A. of schizophrenia( Psychotic symptoms)  B. During the course of the illness, the individual must have delusions or hallucinations for at least 2 weeks in the absence of a major mood episode.(Depressive or Manic)  C. The disturbance is not due to substance abuse or medical condition DSM-V-TR DIAGNOSTIC CRITERIA FOR SCHIZOAFFECTIVE DISORDER There are two type of schizoaffective: -Schizoaffective disorder , Bipolar Type: Include manic episodes -Schizoaffective disorder, Depressive Type: Involves only depressive episodes. TIP  Schizoaffective disorder - Symptoms criteria A of schizophrenia + additional experience of a major mood episode (depressive or manic) DSM-V-TR DIAGNOSTIC CRITERIA FOR DELUSIONAL DISORDER  A. The presence of one or more delusions with a duration of 1 month or longer  B. Criterion A for Schizophrenia is not met (the presence of significant hallucinations, disorganized speech.)  C. Functioning is not markedly impaired (often function fairly well in other areas of life)  D. The disturbance is not due to substance abuse or medical condition DSM-V-TR DIAGNOSTIC CRITERIA FOR DELUSIONAL DISORDER The DSM-5 also identifies specific subtypes of delusional disorder based on the nature of the delusions:  Erotomanic Type: The person believes that another person, often someone of higher social status, is in love with them.  Grandiose Type: The person has an exaggerated sense of their own importance, power, knowledge, or identity.  Jealous Type: The person believes their partner is unfaithful, despite no evidence to support this belief. DSM-V-TR DIAGNOSTIC CRITERIA FOR DELUSIONAL DISORDER  Persecutory Type: The person believes they are being targeted or persecuted by others.  Somatic Type: The person believes they have a physical defect or medical condition despite evidence to the contrary.  Mixed Type: The person has more than one type of delusional belief  Unspecified Type: The delusions do not clearly fit into any of the above types. CARE PLAN FOR PATIENT WITH SCHIZOPHRENIA SPECTRUM  Here are six (7) nursing diagnosis that can use for nursing care plan (NCP):  Impaired Verbal Communication related to altered perceptions, disorganized thinking or auditory hallucinations.  Impaired Social Interaction related to social withdrawal, difficulty with communication, difficulty with concentration, impaired thought processes (delusions or hallucinations), fear of others  Disturbed Sensory Perception: Auditory/Visual related to altered sensory reception, chemical alterations, neurologic/biochemical changes. CARE PLAN FOR PATIENT WITH SCHIZOPHRENIA SPECTRUM  Disturbed Thought Process related to chemical alterations, possibility of a hereditary factor, panic level of anxiety.  Self care deficit related to social withdrawal , regression, panic, anxiety, perceptual or cognitive impairment  Risk for violence : self directed or other directed related to delusion, hallucination, disturbed thought process.  Ineffective health maintenance related to lack of knowledge about disease process, medications, and treatment adherence. CARE PLAN FOR PATIENT WITH SCHIZOPHRENIA SPECTRUM  Disturbed Sensory Perception: Auditory/Visual - Observe for sign of hallucinations (laughing or talking to self) - An attitude of acceptance will encourage the patient to share the content of hallucination with the nurse. - Providing a calm and supportive environment. - Try to distract the patient from hallucination (e.g., card games, simple arts and crafts projects etc.).  CARE PLAN FOR PATIENT WITH SCHIZOPHRENIA SPECTRUM  Disturbed Thought Process - Observing for signs of delusions, hallucinations, or disorganized speech. - Recognizes the client’s delusions as the client’s perception of the environment.(understand the feelings he or she is experiencing) - Do not touch the client, use gestures carefully (clients might misinterpret touch as either aggressive or sexual in nature ) - Provide reality orientation techniques such as clear, simple explanations and orienting the patient to time, place, and situation. - Try to distract client from their delusions by engaging in reality-based activities (e.g., card games, simple arts and crafts projects etc.)  CARE PLAN FOR PATIENT WITH SCHIZOPHRENIA SPECTRUM  Impaired Social Interaction - Encourage social interaction by providing opportunities for the patient to engage with others in structured settings (e.g., group therapy) - Identify with client symptoms he experiences when he or she begins to feel anxious around others. - Offer to be with patient during group activities. - Give recognition and positive reinforcement for patient’s voluntary interactions with others. CARE PLAN FOR PATIENT WITH SCHIZOPHRENIA SPECTRUM  Risk for violence : self directed or other directed - Monitor for changes in mood or behavior. - Offer empathetic response to patient feeling. - Maintain low level of stimuli in patient environment ( low lighting, few people, low noise level) - Ensure a safe environment by remove all dangerous objects from patient’s environment - Monitor for signs of agitation (if necessary, provide physical restraints) CARE PLAN FOR PATIENT WITH SCHIZOPHRENIA SPECTRUM  Impaired Verbal Communication - Observe the patient's speech for signs of speech disorganization - Keep voice in a low manner and speak slowly, use simple, clear language - Keep environment calm, quiet and as free of stimuli as possible (loud noises, television, or excessive activity ) -Seek validation and clarification by stating “Is it that you mean….? “Would you please explain to me again…..” “Can you tell me more about how you’re feeling today?” CARE PLAN FOR PATIENT WITH SCHIZOPHRENIA SPECTRUM  Ineffective health maintenance - Educate the patient and family about schizophrenia, its symptoms, and treatment options, emphasizing the importance of medication adherence. - Collaborate with the healthcare team (involve social workers, psychiatrists, and psychologists in the patient’s care for a multidisciplinary approach) - Encourage family involvement in the treatment process. - Monitor for medication side effects and address any patient concerns (may have regarding the medication’s impact on their daily life) TREATMENT FOR SCHIZOPHRENIA  Psychological treatment  Social treatment  Pharmacological treatment  Hospitalization  TREATMENT FOR SCHIZOPHRENIA  Psychological treatment -Individual psychotherapy: which can help the person better understand their illness, and learn coping and problem-solving skills -Group therapy: patients are able to share experiences and learn that others feel the same way and have had the same experiences. (Reducing social isolation)  Social treatment -Social skills training: focuses on improving communication and social interactions. -Family therapy: helpful for family members to understand what are they going through, how they can manage their feelings, and what they can do to help. TREATMENT FOR SCHIZOPHRENIA  Hospitalization: the best option for people: with severe symptoms, who might harm themselves or others, who can’t take care of themselves at home PSYCHOPHARMACOLOGICAL TREATMENT  Typical (First-Generation or conventional Antipsychotic Drugs).  The medications block a brain chemical “dopamine” and effectively control the hallucinations, delusions, and confusion  Cheaper than second-generation antipsychotics ASSOCIATED SIDE EFFECT (FIRST-GENERATION ANTIPSYCHOTICS )  These first-generation antipsychotics have frequent and potentially significant neurological side effects, including the possibility of developing a movement disorder extrapyramidal symptom (EPS) and galactorrhea  Anticholinergic effect: Tachycardia, tremor, insomnia, postural hypotension TYPICAL (FIRST-GENERATION OR CONVENTIONAL)  Haloperidol (Haldol)  Pimozide (Orap)  Chlorpromazine (Thorazine)  Thioridazine (Mellaril)  Fluphenazine (Proxlixin)  Thiothixene (Navane)  Loxapine (Loxitane)  Trifluoperazine (Stelazine)  Perphenazine (Trilafon) PSYCHOPHARMACOLOGICAL TREATMENT  Atypical ( second generation, the newer antipsychotic drugs)  They’re newer than the first-generation drugs.  These medications might work on both serotonin and dopamine receptors.  Lower risk of serious side effects than first-generation antipsychotics. ASSOCIATED SIDE EFFECT (SECOND GENERATION ANTIPSYCHOTIC DRUGS)  Weight gain, nausea/vomiting, low potential for ejaculation difficulty, sexual dysfunction, low potential for EPS  Anticholinergic effect: Tachycardia, tremor, insomnia, postural hypotension ATYPICAL ANTIPSYCHOTIC AGENTS (SECOND GENERATION, NOVEL)  Aripiprazole (Abilify)  Lurasidone (Latuda)  Asenapine (Saphris)  Olanzapine (Zyprexa)  Brexpiprazole (Rexulti)  Paliperidone (Invega)  Cariprazine (Vraylar)  Pimavanserin (Nuplazid)  Clozapine (Clozaril)  Quetiapine (Seroquel)  Iloperidone (Fanapt)  Risperidone (Risperdal)  Lumateperone tosylate (Caplyta)  Ziprasidone (Geodon) SIDE EFFECT OF ANTIPSYCHOTIC AGENT  From the blockage of dopamine can result in :Extrapyramidal symptoms  Stimulate the production of prolactin(galactorrhea)  Galactorrhea is the spontaneous flow of milk from the breast that unrelated to breastfeeding or childbirth. EXTRAPYRAMIDAL SYMPTOMS (EPS)  Are drug induced movement disorder that most commonly seen in patient taking antipsychotics or dopamine blocking agents.  These EPS symptoms are interfered with daily life and negative impact social communication.  Potential to cause EPS ( First generation > Second generation) EXTRAPYRAMIDAL SYMPTOMS (EPS) ANTIPARKINSONIAN AGENTS  Antiparkinsonian agents used to treat extrapyramidal side effects of antipsychotic drug ANTIPARKINSONIAN AGENTS Common side effect  Dry mouth, Blurred vision, constipation, urinary retention, tachycardia, nausea /GI upset, cognitive impairment, drowsiness NURSING CARE FOR A PATIENT EXPERIENCING EXTRAPYRAMIDAL SYMPTOMS (EPS)  Monitor & Assess EPS Symptoms  Report the development of EPS symptoms to the physician immediately.  Provide medications as ordered by the physician to relieve EPS symptoms (e.g., benztropine, trihexyphenidyl).  Monitor the patient for any side effects from antiparkinsonian agents. (such as dry mouth, blurred vision, constipation, urinary retention)  Provide emotional support for the patient as EPS can cause anxiety and frustration about physical symptoms. Explain the symptoms are related to their medication and that they can be treated.  Teach the patient and their family about the signs and symptoms of EPS and the importance of reporting any new symptoms promptly. REFERENCES  Morgan, I.K., & Townsend, M.C. (2020). Essentials of psychiatric mental health nursing: (8th ed.). Philadelphia: F.A. Davis.  American Psychiatric Association. (2013). Diagnotic and statistical manual of mental disorder (5 th ed.). Washington: American Psychiatric Publishing.  Boyd, M. A. (2016). Psychiatric nursing: Contemporary practice (5th ed.). Philadelphia: Wolters Kluwer Health / Lippincott Williams & Wilkins.  Evans, K., Nizette, D., & O’Brien, A. (2017). Psychiatric mental health nursing (4th ed.). New South Wales: Elsevier.  Morgan, I.K., & Townsend, M.C. (2017). Essentials of psychiatric mental health nursing: Concepts of care in evidence-based practice (7th ed.). Philadelphia: F.A. Davis.