NURS 327-437 Psychosis 2024-2025 PDF

NURS 327- 437 Psychosis NURS 437 Week 4 - Psychosis  Optional: While you wait for lecture to begin Reflect: Do any of these poems/quotes resonate with you? How do the arts and creative activities help you connect with mental health? What would you say about mental hea...

NURS 327- 437 Psychosis NURS 437 Week 4 - Psychosis  Optional: While you wait for lecture to begin Reflect: Do any of these poems/quotes resonate with you? How do the arts and creative activities help you connect with mental health? What would you say about mental health if they asked you for your own quote? NOTE: This an optional activity to keep you occupied if you want while you wait for class to start. You do not have to do this if you do not want to.  Objectives 1. Understand the concept of psychosis. 2. Describe the role altered perception plays in mental illness. 3. Compare pharmacologic and non-pharmacologic treatment modalities for psychotic disorders, with a focus on nursing implications. 4. Utilize the nursing process to plan care for patients with psychosis and related disorders. Reminder: Schizophrenia was covered in your pathophysiology-pharmacology course previously Definition Disruptions to a person's thoughts and perceptions that make it difficult for them to recognize what is real and what isn't DSM-5 definition: abnormalities in five different symptomatic domains: - Delusions - Hallucinations - Disorganized thoughts/speech - Disorganized or abnormal behaviour - Negative Symptoms Video Understanding Psychosis 6:41 min  Physiology (Previous Learning from patho-pharm) No one cause - multiple social and biological risk factors Thought to involve dopamine (positive symptoms) Possibly: glutamate, NMDA, and GABA dysregulation Toxin exposure Environmental – social adversity, traumatic life events Genetic links between siblings and parents  Physiology Enlarged ventricles in a twin with schizophrenia Video: Ted Talk: 83,000 Brain Scans (14 min) Risk Factors: Population Low Premorbid IQ in the learning disability range correlates with increased risk Lower individual and community level socio-economic status at time of birth correlates with increased risk Increased risk in urban settings where population density exceeds 1 Million people Increased risk with experiences of racism  Scope What other concepts can you connect to psychosis? Sleep Fatigue Nutrition Self-management Sensory Perception Stress/Coping, etc…  Focus primarily on schizophrenia for exams Psychosis Primary Psychosis Delusional Disorder Brief Psychotic Disorder (less than 1 month) Schizophreniform Disorder (1 to 6 months) Schizophrenia (symptoms longer than 6 months) Schizoaffective Disorder (psychosis with a mood disorder) Catatonia Psychosis Other diagnoses that may manifest psychosis: ○ Bipolar I Disorder ○ Major Depressive Disorder ○ Alcohol Use Disorder ○ Substance Use Disorder Secondary Psychosis – product of underlying medical problem (eg. illness, dementia/delirium, medications, toxins) Schizophrenia (Previous Learning) Diagnostic Criteria: Two or more of the following: ○ Delusions ○ Hallucinations ○ Disorganized speech ○ Disorganized behavior ○ Negative symptoms At least one must be delusions, hallucinations, or disorganized speech Must affect level of functioning, must last at least 6 months Cannot be attributed to another diagnosis with psychotic features, substance use, medication, or other medical condition Schizophrenia Cognitive Symptoms Psychosis Onset  Phases of Psychosis Early: signs may be subtle and not easily identifiable ○ Able to maintain some level of functioning until illness gets worse Acute: Clear symptoms, functioning deteriorates; dependence on family/friends increases ○ Problems with work, school, ADLs, substance use may occur ○ May require hospitalization, high risk of suicide Phases of Psychosis - Recovery Relapse is not guaranteed but is common - subsequent relapses require longer recovery times First Onset Psychosis – 2 year recovery Schizophrenia Overall Recovery Statistics  Consequences of Psychosis Problems with functional ability and self-management Unresolved psychosis is almost always associated with poor outcomes Increase risk to develop dementia Long-term consequences related to pharmacological treatment Critical Thinking (1 min): A parent asks you: is it my fault that my child has schizophrenia? I know there is a genetic link with the illness and there is a history of mental illness in my family. I would feel so guilty if this was the case, I don’t want to be a bad parent. How do you respond, what would you specifically say?  Schizophrenia – Early Intervention MATTERS Early intervention in psychosis decreases the degree of functional impairment. Link: Edmonton Early Psychosis Int ervention Clinic (EEPIC ) British Columbia Example Video (6 min) Learning Objectives Covered Understand the concept of psychosis Nursing Process - Assessment Medical and Psychiatric History Risk factors Personal history: medical and psychiatric Substance use Developmental history Trauma, including perinatal Culture and beliefs Family history Mental Status Assessment Previous coping (non-pharm, pharm) Assessment (con’t) Physical Examination Vital signs Cranial nerve assessment Overall physical health, eg. nutrition, sleep Diagnostic Tests Laboratory tests (CBC, electrolytes, renal, liver) Imaging (CT, MRI, EEG) Assessment: Symptomatic Domains Delusions: False, fixed beliefs that are unlikely to change despite contradictory evidence ○ Grandiose ○ Persecutory/Paranoid ○ Control ○ Somatic ○ Nihilistic ○ Religious ○ Magical thinking Symptomatic Domains (con’t) Hallucinations: Perceptions that occur without an external stimulus ○ Auditory (>50%) ○ Visual ○ Olfactory ○ Gustatory ○ Tactile Assess for command hallucinations  Symptomatic Domains (con’t) Disorganized thoughts: Usually inferred from speech ○ Circumstantial ○ Tangential Disorganized behaviour: ○ Loose associations ○ Flight of ideas ○ Agitation ○ Thought blocking ○ Aggression ○ Catatonia (stupor, waxy flexibility, ○ Perseveration stereotypy) ○ Clang association ○ Echopraxia ○ Echolalia ○ Neologisms ○ Word salad Symptomatic Domains (con’t) Negative symptoms: ○ Alogia ○ Avolition ○ Anhedonia ○ Ambivalence ○ Other: monotony, lack of eye contact, decrease in spontaneous movement, flat affect Assessment: Suicide and Violence Suicide & Self Harm Risk Risk of Violence & Aggression Elopement Risk Abuse risk Risk for poor adherence to treatment  Managing Alterations in Thinking/Perception Assess precipitating factors and triggers for delusions/hallucinations Assess content, gather history on initial admission Note any changes in content over time Determine coping strategies to manage delusions or hallucinations Document behaviors/signs for when client is experiencing Learning Objectives Covered Describe the role altered perception plays in mental illness. Nursing Priorities Disturbed thought process Anxiety (related to delusions or hallucinations) Impaired social interactions Risk for violence Risk for self directed violence Hopelessness Social isolation Safety is often your Ineffective coping first priority Impaired verbal communication Nutrition, sleep, hygiene  Interventions: Nonpharmacological Social Skills Training Psychoeducation - coping skills, cognitive training Support Groups for client/family Individual and Family Therapy Vocational Therapy Cognitive Behavioral Therapy (CBT) - for clients who are stable and have insight Electroconvulsive Therapy (ECT) Interventions: Nonpharmacological (con’t) Establish trust and rapport, provide role clarity Hallucinations: acknowledge the client’s experience and present reality with empathy and validation Example: “I don’t see what you’re seeing but I can understand that you see spiders on the wall and that this is very scary for you.” Control your environment, reduce stimulation Limit interactions if necessary in the short term Interventions: Nonpharmacological (con’t) Move toward use of distraction in reality oriented activities Use grounding techniques Doing a task like a puzzle, drawing, playing a game Listening to music Try teaching the client “thought stopping” or telling the voices to “stop” Create a regular routine - hygiene, sleep, nutrition, ADLs Show positive regard for the client’s experience without arguing or re-affirming their delusions/hallucinations  Additional Strategies for Alterations in Thinking/Perception Examine pharmacological options, use PRNs if needed Encourage support from family/friends, provide patient/family education Maintain a neutral approach, avoid asking too many questions, be careful with use of therapeutic touch Offer choice whenever possible but provide direction/suggestion if the client is struggling due to cognitive issues Goals for Alterations in Thinking/Perception Aim to decrease frequency and intensity of hallucinations/delusions Encourage self-management ranging from staff guidance to independence If possible, work toward helping the patient recognize that hallucinations & delusions are not reality For chronic patients, set boundaries/limits on discussions of delusions and hallucinations Interventions: Nonpharmacological (con’t) Recovery Phase Focus on positive goal-oriented and future oriented activity Model appropriate skills for independence Assist clients to connect with: Community resources Vocational opportunities Support networks, health promotion Finance, housing Safety/crisis planning Interventions: Pharmacological (Previous Learning from patho-pharm) First Generation (Typical) Second Generation (Atypical) Third Generation Management of Side Antipsychotics Antipsychotics Antipsychotics Effects Haloperidol (Haldol) Clozapine (Clozaril) Aripiprazole (Abilify) Benztropine (Cogentin) Fluphenazine (Modecate) Olanzapine (Zyprexa) Cariprazine (Vraylar) Bromocriptine mesylate Thiothixene (Navane) Risperidone (Risperdal) Bexipiprazole (Rexulti) (Parlodel) Trifluoperazine (Stelazine) Quetiapine (Seroquel) Lumateperone (Caplyta) Trihexyphenidyl (Artane) Perphenazine (Trilafon) Paliperidone (Invega) Diphenhydramine Chlorpromazine (Largactil) Ziprasidone (Geodon/Zeldox) (Benadryl) Thioridazine (Mellaril) Asenapine (Saphris) Atropine (via drops) Loxapine (Loxitane) Propanalol Levomepromazine (Nozinan) Clonazepam Zuclopenthixol (Clopixol Dantrolene Accuphase) PO/IM, treat positive symptoms PO/IM, has oral dissolvable PO and IM in longer acting Often prescribed as PRN tablets formulations Extrapyramidal Side Effects (EPS) Treat positive & negative Can cause EPS but to a Check for off-label symptoms, more potent, more lesser degree than 1st and Tardive dyskinesia, usages expensive 2nd gen akathisia, Expensive pseudoparkinsonism, Can cause EPS but to a lesser degree than 1st generation Similar side effects to 2nd dystonia, neuroleptic Can cause weight gain, gen malignant syndrome (NMS) metabolic syndrome, Treat mood disorders and Interventions Acute Typical, atypical , 3rd gen antipsychotics Benzodiazepines PRN use of quick acting injectables Basic needs, ADLs Introduce to therapy, activities Video - Antipsychotic Injection Patient Experience (7 min) Interventions Maintenance Atypical antipsychotics (including long acting depot), 3rd generation Mood stabilizers Antidepressants Electroconvulsive Therapy (ECT) if needed Side Effect Management Build support networks Therapy as needed Strenth focused, promoting independence Extrapyramidal Side Effects (EPS)  EPS: Neuroleptic Malignant Syndrome (NMS) Potentially life threatening – can cause renal, heart, lung failure Stop antipsychotics Initiate IV fluids Dantrolene (muscle relaxant) Bromocriptine (dopamine agonist) Symptom management Critical Thinking: What lab test enzyme would you look for as a result of the muscle breakdown?  Side Effect Screening Tools Are Not on final exams Side Effect Screening Side effect screening tools can be a resource for assessment – see week 3 lab guide for tools Use tools to track baseline and history Advocate to alter medications or adjust medications when possible Look for other medications to help with side effects, eg. PRN medications Some EPS are irreversible Learning Objectives Covered Utilize the nursing process to plan care for patients with psychosis and related disorders. Compare pharmacologic and non-pharmacologic treatment modalities for psychotic disorders, with a focus on nursing implications.  ePoll: https://epoll.srv.ualberta.ca NCLEX Style Questions CODE: XGZ A paranoid client presents with agitation, bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety? A. Ask assessment questions about medication nonadherence B. Observe for escalating behaviors and intervene immediately C. Interpret their attempts at communication D. Ask assessment questions about triggers for bizarre, inappropriate behaviors A client with schizoaffective disorder has been admitted to the inpatient mental health center of the hospital. The client tells the nurse that he hears voices telling him to leave the hospital. Which response from the nurse is best? A. I do not hear anything, but you cannot leave the hospital B. I do not hear anything, but I can see how you may feel worried about being in the hospital right now C. Why don't we go to the game room and see what is happening there today? D. You know that those voices aren't real, don't you?  ePoll: https://epoll.srv.ualberta.ca NCLEX Style Questions CODE: XGZ Which symptom experienced by a client diagnosed with schizophrenia would predict a less positive prognosis? A. Thinking the television is controlling their behavior B. Having little or no interest in work or social activities C. Hearing hostile voices D. Continuously repeating what has been said A client diagnosed with schizophrenia is experiencing anhedonia. Which nursing priority addresses concerns regarding this client’s problem? A. Impaired verbal communication B. Disturbed thought processes C. Disturbed sensory perception D. Risk for suicide Summary and Resources Building trust and rapport is important in managing psychosis Be aware of the holistic implications related to psychosis Look at long term health promotion related to psychosis related to determinants of health Mitigate the barriers that impact recovery from psychosis Supplementary Resources The Voices in My Head - Eleanor Longden - TED 2013 (14:07) Freedom from Schizophrenia: A twin's Quest (15:17) What it is like to have Schizophrenia (1:16) If you like to read, “Hidden Valley Road” by Robert Kolker NCLEX Prep Video: Schizophrenia