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HISTORY:Hipocrates

- Believed that insanity was caused by a morbid state of the liver18th CENTURY

- Disorders of the central nervous system where the cause ofinsanity.

1856 Benedict Morel-was the first who name the psychiatric symptoms ofschizophrenia.

1868 Kahlbaum

-added catatonia in their diagnostic categories to describe patientsimmobilized by psychological factors.

1870 Hecker

-added Hebephrenia (disorganized) in the diagnostic categories todescribe patients with silly, bizarre and regressed behavior.


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1896 , EMIL KREAPELIN (German)

-Organized mentally ill patient by 3 diagnosticgroups that Morel had coined 40 years before.

A. Dementia Praecox

B. Manic Depressive Psychosis

C. Paranoia

- Described schizophrenia as a specific mental illness.

- Greek roots SCHIZO SPLIT and PHRENE MIND

- SPLIT MIND- lack of integration of patients function- there is disharmony between the

patients thinking , feeling & acting.


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EUGENE BLEULER

-ASwiss Psychiatrist

-He was also the first todescribe POSITIVE andNEGATIVE symptoms of

Schizophrenia.


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Kraepelin and Bleuler

-subdivided schizophrenia into 3 Categories based on

prominent symptoms and prognoses.1. Disorganized

2. Catatonic

3. Paranoid

BLEULERS THEORY DIFFERED IN 2 WAYS:

a. Believed that schizophrenia does not always follow acourse of deterioration.

b. nor does it always occur early in life.


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- BLEULER

- Introduced the term schizophrenia & cited symptomsreferred to as BLEULERS 4 As

y AFFECTIVE DISTURBANCE / APATHY

y AUTISTIC THINKING

y AMBIVALENCE

y ASSOCIATIVE LOOSENESS


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AFFECTIVE DISTRBANCE- refers to the persons inability toshow appropriate emotional responses ; inappropriate ,blunted or flattened affect.

AUTISTIC THINKING- is a thought process in which theindividual is unable to relate to others or to theenvironment. Refers to thinking not bound to reality.

AMBIVALENCE- refers to the contradictory or opposingemotions, attitudes, or desires for the same person,thinking or situation ; simultaneous opposite feelings.

ASSOCIATIVE LOOSENESS- is the inability to thinklogically. Ideas expressed have little, if any, connection andshift from one subject to another. Jumbled and illogicalspeech and reasoning.


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1980, (DSM-IV-TR) Diagnostic and StatisticalManual of Mental Disorders, 4th Edition, TextRevision.

List 5 Classifications Originally described by DSM-III

in 1980.y DISORGANIZED

y CATATONIC

y PARANOID

y RESIDUALy UNDIFFERENTIATED


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19th CENTURY

- Show an explosion of information about the body and

mind.- Mental illness was caused by DISEASE of the BRAIN.

- Schizophrenia is biologically based.

- Research in the Genetics of Human Disease (helps to

develop more effective therapies).

1970s

- Studies focus on possible NEUROCHEMICAL CAUSEwhich remains as the primary focus of research andtheory today.


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THEORIES OF CAUSATION:

I.GENETIC PREDISPOSITION THEORY

- Suggests that the risk of inheriting schizophrenia is10% to 20% in those who have one immediate familymember with the disease and approximately 40% if thedse affects both parents or an identical twin.

- Most important studies have centered on TWINS (lowbirth weight; more physiological distress; moresubmissive,tearful, sensitive; impaired motorcoordination).


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- Researchers have recently identified patient groupsconsidered to be at HIGH RISK

y Family history of psychosis

y Schizotypal personality disorder

y Presence of functional decline for atleast 1 month &not longer than 5 years.


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Genetic Risk


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Genetic Association


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II.BIOCHEMICAL AND NEUROSTRUCTURAL THEORY

y DOPAMINE HYPOTHESIS

- Aneurotransmitter located primarily in the brain stem ;generally excitatory ; involved in the control of complexmovement, motivation, cognition and regeneration ofemotional response.

- An excessive amount of the neurotransmitter dopamineallows nerve impulses to bombard the mesolimbicpathways, the part of the brain normally involved inarousal and motivation.Normal cell communication is disrupted resulting in the

development of hallucinations and delusions.

- Excessive dopamine activity in cortical areas causes acutepositive symptoms (hallucinations, delusions, thoughtdisorders)


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This hypothesis was developed based on

TWO OBSERVATIONS:

1st: Drug that increase activity in the dopaminergicsystem, such as AMPHETAMINE & LEVODOPAsometimes induce a paranoid psychotic reaction

similar to schizophrenia.

2nd: Drugs blocking post synaptic dopamine receptorsreduce psychotic symptoms; in fact, THE GREATER

THE ABILITY OF THE DRUG TO BLOCK DOPAMINEPECEPTOR, THE MORE EFFECTIVE IT IS INDECREASING SYMPTOMS OF SCHIZOPHRENIA.


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Type

Dopamine

Norepinephrine

(noradrenaline)

Epinephrine (adrenaline)

Serotonin

Histamin

Acetylcholine

Neuropeptides

Glutamate

Gamma-aminobutyricacid (GABA)

MAJOR TRANSMITTERS

y Excitatory

y

Excitatory

y Excitatory

y Inhibitory

y Neuromodulator

y

Excitatory or inhibitory

y Neuromodulator

y Excitatory

y Inhibitory

y Controls complexmovements,motivation, cognition;regulates emotionalresponse

y Causes changes in attention, learning

and memory,sleep and wakefulness,mood

y Controls fight-or-flight response

y Controls food intake, sleep andwakefulness, temperature regulation,

pain control, sexualbehaviors,regulationof emotions

y Controls alertness, gastric secretions,cardiac stimulation,peripheral allergicresponses

y Controls sleep and wakefulness cycle;signals muscles to become alert

y Enhance, prolong, inhibit, or limit theeffects of principal neurotransmitters

y Results in neurotoxicity if levels aretoo high

y Modulates other neurotransmitters


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GABA GAMAAMINO

BUTYRICACID

An Amino Acid

Major inhibitory

neurotransmitter in the

brain

Found to modulate other

neurotransmitter ratherthan to provide a direct

stimulus.

GLUTAMATE- Is considered to be the

most prevalent excitatoryneurotransmitter in thebrain

- Dysfunction of glutamatereceptors, which are likelypresent on every cell in thebrain, maybe the cause ofmany neurologic andpsychiatric disorders.


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GABA and glutamateregulate action potentialtraffic. GABA, an inhibitory

neurotransmitter, stopsaction potentials. Glutamate,an excitatoryneurotransmitter, startsaction potentials or keepsthem going.

Since GABAis inhibitory andglutamate is excitatory,both neurotransmitterswork together to controlmany processes, including

the brain's overall level ofexcitation. Many of thedrugs of abuse affect eitherglutamate or GABAor bothto exert tranquilizing orstimulating effects on the

brain


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Computed

tomography (CT)

Magnetic resonance

imaging (MRI)

Positron emission

tomography

(PET)

Single photon

emission computed

tomography (SPECT)

BRAIN IMAGINGTECHNOLOGYIMAGINGMETHOD

Serial x-rays of brain

Radio waves from brain

detectedfrom magnet

Radioactive tracer injectedinto blood stream and

monitored as clientperforms activities

Same as PET

y Structural image

y Structural image

y Functional

y Functional


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Gross neuroanatomical abnormalities in

schizophreniay (lateral and 3rd) and

decreased brain volume isthe most replicated finding.

y Ventricular enlargement isfound in affected twins ofmonozygotic pairsdiscordant for schizophrenia.

yThis enlargement appears tobe stable when patients arefollowed up prospectively.

Unaffected twin Schizophrenic twin


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PET


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Limitations of Brain Imaging Techniques

Although imaging techniques such as PET and SPECT have helped bring abouttremendous advances in the study of brain diseases, they have some

limitations:

y The use of radioactive substances in PETand SPECT limits the number of times a person can undergo these

tests. There is the risk that the client will have an allergicreaction to the substances.

y Some clients may find receiving intravenous doses of radioactivematerial frightening or unacceptable.

y Imaging equipment is expensive to purchase and maintain, soavailability can be limited.

y APET camera costs about $2.5 million; ay

SPECT camera costs about $500,000.y Some persons cannot tolerate these procedures because of fear

or claustrophobia.y Researchers are finding that many of the changes in disorders

such as schizophrenia are at the molecular and chemical levels


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III.ORGANIC OR PATHOPHYSIOLOGIC THEORY

- Offer hope that schizophrenia is a functional deficitoccuring in the brain, caused by stressors as:

yViral infection

y Toxins

y Trauma

y Abnormal substances

- Also proposed that schizophrenia maybe a metabolicdisorder.


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IV. ENVRONMENTAL OR CULTURAL THEORY

- Faulty reaction to environment, being unable to

respond selectively to numerous social stimuli.

COMMON STRESSORS:

y Biological (medical illness)

y

Psychosocial (loss of relationship)y Sociocultural (homelessness)

y Emotional (persistent criticism)

- Theorist also believed that persons who come from loweconomic areas or single- parent, home in depressedarea, are not expose to situations in w/c they canachieve or become successful in life, are at risk fordeveloping schizophrenia.


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V. PERINATAL THEORY

- Exist if the developing fetus or newborn is deprived ofoxygen during pregnancy.

- If the mother suffers from malnutrition or starvationduring the 1st trimester of pregnancy.

- In the 34th or 35thweek of gestation-the critical pointin fetal life where brain develops- development ofschizophrenia may occur..

- Schizophrenia can be linked to influenza, minormalformation developing during early gestation andcomplications of pregnancy particularly during laborand delivery.


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VI. DEVELOPMENTAL THEORIES

Adolf Meyer and Sigmund Freud- Believed that the seeds of mental health and illness are

sown in childhood.

- Freud- focused on mental process- focused on fantacy

- Meyer- focused on real life events

- Erikson- 8 stages model of human development- saw

Trust vs. Mistrust as crucial to later interpersonal

relationship.


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yFAMILY THEORIES

yVULNERABILITY- STRESS MODEL

Common Stressors:

1. Biological

2. Psychosocial

3. Sociocultural

4. Emotional


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BATESON (1973,1979)

- Introduced the double bind theory is a no-winexperience, one in which there is no correct choice.

SPECIAL ISSUES RELATED TO

SCHIZOPHRENIA Family of Schizophrenics

Depression & Suicide

Relapse

Stress SubstanceAbuse

Work

Psychosis-Induced Polydipsia


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Clinical Symptoms and

Diagnostic Characteristic:PHASES OF SCHIZOPHRENIA:

I. Pre-morbid phase no clinical symptoms ofschizophrenia are expressed

II. Prodromal phase

may arise a year before the first hospitalization.

- gradual subtle change of behavior, decline from hisprevious level of functioning, neglect personalhygiene & grooming.

- may withdraw from friends, hobbies & interests.


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III.Active Phase

- commonly triggered by a stressful event

- functional deficit worsen- patient has acute psychotic symptoms such as

hallucinations, delusions, incoherence or catatonic

behavior.

IV. Residual Phase

- follows active phase, during which time the client

has experienced repeated episodes & relapses for anumber of years.

- rarely marked by full remission & return to pre

illness level of functioning.


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- Symptoms resembles those of the prodromal phase

- Blunted affect & impaired role functioning possiblymore pronounced

- Persistent of some psychotic sx such as hallucinationsbut without strong affect.


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DSM IV- TR CRITERIA FOR

SCHIZOPHRENIAA. CHARACTERISTIC SYMPTOMS

(at least 2 of the ff.)

- Delusion

- Hallucination

- Disorganized speech

- Grossly disorganized or catatonic behavior

- Negative symptoms


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B. SOCIAL/ OCCUPATIONAL DYSFUNCTION

- work, interpersonal and self care functioning is below thelevel achieved prior to onset.

C. DURATION

- continuous signs of the disturbance for at least 6 months

D. SCHIZOAFFECTIVE AND MOOD DISORDERS are

NOT present and are not responsible for the s/sx.

E. NOT CAUSED bysubstance abuse or a generalmedical disorder


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COURSE OF THE DISEASE(eg.)

y 6 months of prodromal sx & 1 week sx in activephase .

y No prodromal sx with 6 months of sx in activephase.

y No prodromal sx, 1week of sx in active phase & 6

months of residual sx.


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CHARACTERISTIC DIMENSIONS OF SCHIZOPHRENIA

Andreasen and Crow (1982) Classified schizophrenia into POSITIVE (TYPE I) and

NEGATIVE (TYPE II)

Positive: type I - Negative: type II

Prognosis: good - poor

Onset: acute - chronic

Sensorium: dreamlike - clearIntellectual impairment: none - yes

Response to tx: good - typical: varies atypical: good

Effect of levodopa : increased - minimal

Hyperdopaminergic process - Non dopaminergicprocess/ Hypodopaminergic, Decreased CBF

No structural changes - Structural changes

(increased ventricular brain

ratios; decreased cerebral

blood flow).


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OBJECTIVE AND SUBJECTIVE BEHAVIORAL

DISORDERS IN SCHIZOPHRENIA

A. Objective signs:y Alteration in personal relationship

Decrease attention to appearance and social ameneties

Inadequate or inappropriate communication

Hostility

Withdrawal

yAlteration of activity

Psychomotor agitation

Catatonic rigidity

echopraxia


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B. Subjective symptoms:

y Altered perception hallucination, illusions,

paranoid thinking

y Alteration of thought- flight ofideas,retardation,blocking, autism, ambivalence,loose association, delusion, poverty of speech, ideaof reference, mutism

y Altered Consciousness confusion, incoherentspeech, clouding, sense of going crazy

y Alteration of Affect inappropriate , blunted,flattened, or labile, apathy, ambivalence,overreaction, anhedonia


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POSITIVE (type I)- these are the most easily identifiedsymptoms.

- believedto be causedby too much dopamine,normalbrainstructure andabsence ofintellectualdeficits.

A. AMBIVALENCE- Holding seemingly contradictory beliefs orfeeling about the same person, event or situation.

B. ECHOPRAXIA- imitation of the movement & gestures ofanother person whom that the client is observing.

C. IDEAS OF REFERENCE- false impressions that external eventshave special meaning to the person.

D.FLIGHT OF IDEAS- continous flow of verbalization in whichthe person jumps rapidly from one topic to another.


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E. ALTERATION IN SPEECH

1. ASSOCIATIVE LOOSENESS- fragmented or poorly related

thoughts and ideas

2. NEOLOGISM-words invented by the client.

3. ECHOLALIA- clients imitation or repetition of what thenurse says.

4. CLANG ASSOCIATION- ideas related to one another basedon sound or rhyming rather than meaning.


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5. WORD SALAD-jumbled words and phrases that aredisconnected or incoherent and makes no sense to thelistener.

6. VERBIGERATION- is the stereo type repetition ofwords or phrases that may or may not have meaning tothe listener.

7. STILTED LANGUAGE- use of words or phrases thatare flowery, excessive and pompous.

8. PERSEVERATION- persistent adherence to a singleidea or topic and verbal repetition of a sentence,phrase or word, even when another person attempts tochange the topic.


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F. ALTERATION IN PERCEPTIONLACKOFEGO BOUNDERIES

y describes the clients lack of a clear sense of where his or her ownbody, mind, andinfluenceendandwhere those aspects of otheranimate andinanimate objects begin

1. DEPERSONALIZATION- most extreme form ofdisorientation.

-Although the client can state her or his name correctly,

Clients feel detached from his/her behavior

Feels her body belongs to someone else or that her /hisspirit is detached from the body.

2. DEREALIZATION-environmental objects becomesmaller or larger or seen unfamiliar.

y Clients may believe that they are fused with anotherperson or object, may not recognize body parts astheir own, or may fail to know whether they are maleor female.


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y3. HALLUCINATION- false sensoryperceptions, or perceptual experiencesthat do not exist in reality

- can involve 5 senses and bodilysensations.

- they can be threatening and frighteningfor the client.

- initially the client perceiveshallucinations as real, but later in theillness he or she may recognize them ashallucinations.

y Hallucinations are distinguished fromillusions,which are misperceptions ofactual environmental stimuli.

-


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HALLUCINATION

A. Auditory- most common type, involvehearing sound, most often voices, talkingto or about the client.

- There may be one or multiple voices, a

familiar or unfamiliar persons voice maybe speaking.

COMMAND HALLUCINATIONS- are

voices demanding that the client takeaction, often to harm self or others, andare considered dangerous.


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B. Olfactory- involves smell or odors. They may be a specificscent , such as urine or feces, or more general such as rottenor rancid odor.

C. Tactile- refers to sensations such as electricity runningthrough the body or bugs crawling on the skin.

- Found most often in clients undergoing alcoholwithdrawal.

D. Visual- involve seeing images that do not exist at all, suchas seeing a frightening monster instead of the nurse.

- 2nd most common type of hallucinations.


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E. Gustatory involve a taste lingering in the mouth orthe sense that food tastes like something else.

- The tastes maybe metallic or bitter or may berepresented as a specific taste.

F. Cenesthetic- involve the clients report that he/she

feels bodily functions are usually undetectable.

G. Kinesthetic- occur when the client is motionless butreports the sensation of bodily movement.

- Occasionally the body movement is something unusualsuch as floating above the ground.


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Intervention for hallucinationsEngage client in realitybasedactivities such as cardplaying,

occupationaltherapy, orlistening to music.

Help present andmaintain realityby frequent contact andcommunication with client

Nurse:Idont hear any voices; what are you hearing?(presenting reality/seeking clarification).

Elicit description of hallucination to protect client andothers thenursesunderstanding of hallucination help him or her know how to calm or

reassure the client.

Idont see anything, but you must be frightened.Youare safe here in the hospital (presentingreality/translating into feelings).


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G. ALTERATION IN THINKING

1. DELUSIONS- a false belief held and maintained astrue, even with evidence to the contrary.

- no basis in reality

- because the client believes the delusion, he or she will

therefore act accordingly.

TYPESOFDELUSION:

A. PERSECUTORY/PARANOID- involve the clients beliefthat others are planning to harm the client or are spying,following, rediculating or belittling the client in someway.Sometimes the client cannot define who these others are.


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B. GRANDIOSE arecharacterized by the clientsclaim to association withfamous people or celebreties,or the clients belief that he orshe is famous or capable ofgreat feats.

C. RELIGIOUS- often centeredaround the 2nd coming ofChrist or another significantreligious figure or prophet.

- These religious delusions

appear suddenly as part ofclients psychosis and are notpart of his or her religiousfaith or that of others.


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D. SOMATIC- are generally vague and unrealistic beliefsabout the clients health or bodily functions. Factual

information or diagnostic testing does not changethese beliefs.

E. REFERENTIAL- involve the clients belief that

televisions broadcast music, or newspaper articleshave special meaning for him or her.

F. NIHILISTIC DELUSION

G. DELUSION OF INFLUENCE


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INTERVENTION FOR DELUSION

y Do not openly confront the delusions or argue with theclient.

y Establish and maintain reality for the client

y Use distracting technique

y

Teach client positive self talk, positive thinking andignore delusional beliefs.


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2. THOUGHT BLOCKING

- client may stop talking inthe middle of the sentence

and remain silent forseveral seconds to oneminute.

3. THOUGHT

BROADCASTING- Believe that others can

hear their thoughts

4. THOUGHTWITHDRAWAL

- Believe that others aretaking their thoughts


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5. THOUGHT INSERTION

- Believe that others are placing thoughts in their mindagainst their will.

6. TANGENTIAL THINKING

-veering onto unrelated topics and never answering the

original question.

7. CIRCUMSTANTIALITY

-evidenced if the client gives unnecessary details or staysfrom the topic but eventually provides the requestedinformation.


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3. AVOLITION- lack of motivation inactivities and hygiene.

- Absence of will, ambition or drive totake action or accomplish tasks.

4. ANHEDONIA- inability to findpleasure in life, the client isindifferent to things that often makeothers happy.

5. ANERGIA- lack of energy, chronicfatigue.


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6. APATHY- feeling of indifferencetowards people, activities andevents.

7. CATATONIA- psychologicallyinduced immobility occasionallymarked by periods of agitation orexcitement. The client seems to be

motionless, as if in a trance.


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TYPES OF

SCHIZOPHRENIA Disorganized Paranoid Catatonic

Undifferentiated ResidualRelated Psychotic Disorders:Schizoaffective Disorder

Schizophreniform disorderDelusional disorderBrief Psychotic disorder


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PARANOID TYPEy Persistent delusions/persecutory naturey

Dominant: Persistent Delusion ofPersecution, Grandiose delusion,occasional Religious delusion- Auditory hallucinations-single orassociated theme

y Guarded, suspicious, hostile, angry,possibly violent

y Pervasive anxietyy Intensive, reserved, controlled social

interactionsy Onset- later in lifey No Negative symptoms- no

disorganized speech, disorganizedbehavior, catatonia or inappropriateaffect.

y More responsive to treatmenty Prognosis: goody Defense mechanism: projection


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y INTERVENTION

o Approach him in a calm & unhurried manner

o Be honest and dependable, build trust

o If he tells you to leave- do leave, but make sure toreturn soon

o Set limits firmly but without anger

o If patient has auditory hallucinations, explore thecontent of hallucination.

o If patient expresses suicidal thoughts or say he hears avoice/s telling him to harm himself-INSTITUTE

SUICIDAL PRECAUTION, document his behavior.o If he expresses homicidal thoughts, INSTITUTE

HOMICIDAL PREC. , document the patientscomment & names of those notified.


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DISORGANIZED TYPEy Grossly inappropriate/flat affect

y Primitive / uninhibited behavior poor hygiene, muttering constantly toself/incoherence, frequently seen inhomeless population, silly behavior

y Unusual mannerisms-giggle/cry outloud or outburst of laughter/distort

facial expressionsy Hypochondriasis (multiple physical

complaints)y Socially inept/withdrawn, poor social

skills, inappropriate emotionalresponses

Onset early- pre-psychotic period-marked adjustment problemsHallucinations/delusions more

fragmented


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Prognosis: Poor

Defense Mechanism: Regression

INTERVENTION

y Assist with activities of daily living

y Encourage activity

y

Present reality


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CATATONICTYPECharacterized by abnormal motor

movements.2 STAGES

1.WITHDRAWN STAGE:o Psychomotor retardation, client may

appear comatose.

o Waxy f lexibility or stupor

o Echolalia and/ or echopraxia

o Client often has extreme self-care needssuch as for tube feeding due to inability toeat.

EXCITED STAGE


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2.EXCITED STAGE

o Peculiar voluntary movement:unusual posturing, stereotyped

movements, prominentmannerisms, prominent grimaces

o Excessive purposeless motor

activity (agitation)

o Senseless or incoherent shouting ortalking

o Self-care needs may predominate

o Client may be a danger to self and

others


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INTERVENTION

y

Remember that, despite the appearance, the patient isacutely aware of his environment ; assume the patient canhear- speak to him directly and dont talk about him inhis presence

y Tell him directly, specifically, and concisely what needs tobe done- Dont give him choice. (eg.) its time to go for a

walk. Lets go.y Spend time with the patient even if hes mute and

unresponsive to provide reassurance and support.y Remember- if hes in a bizarre posture, he may be at risk

for pressure ulcers or decreased circulation (provide

ROM exercises, ambulate every 2hrs.)y Stay alert for violent outburst; if these occur, get help

promptly to intervene safely for yourself, patient andothers.


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UNDIFFERENTIATED TYPE

(MIXEDTY

PE)y Client has symptom for schizophrenia, but does not meetcriteria for any of the other types.(no one clinical presentation dominates eg. Paranoiddisorganized, catatonic )

y Any positive or negative symptoms may be present- hasactive phase symptoms (does have hallucinations,delusions, and bizarre behaviors).

y Eccentricy Psychotic features are extreme:

Fragmented delusionsVague hallucinationsBizarre disorganized behaviorDisorientation, incoherence


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RESIDUAL TYPEy positive symptoms are no longer present (delusions,

hallucinations, disorganized speech and behaviors )y However, the client has two or more residual symptoms

some Negative symptoms such as:

Marked social isolation or withdrawal.

Impaired role function (wage earner, student, homemaker)

Anergia, anhedonia or avolition

Alogia (speech problem)

Odd behavior such as walking in a strange way

Impaired personal hygiene

Lack of initiative, interest or energy

Blunted or inappropriate affect


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Schizophrenia

S & Sx S & Sx S & Sx S & Sx


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Delusional thinking verbalizes hearing voices social withdrawal offensive body odor

suspiciousness Listening pose Expresses fear of failure Soiled clothing

Nsg Dx Nsg Dx Nsg Dx Nsg Dx

Disturbed thought Disturbed sensory Low Self careprocess perception esteem deficit

Nursing actions Nursing actions Nursing actions Nursing Actions

* Don't whisper to * Observe for signs of * Spend time with client * Encourage indepen

others in client's hallucinations and develop trust * dence in ADLs,but

presence *Cautious with touch * Attend groups with client intervene as needed

* Serve food family style Use the voices instead at first, to offer support * Offer recognition and

* Mouth checks for meds of they when asking * Encourage simple positive reinforcement* Cautious with touch for content of methods of achievement for independent

* Use same staff hallucinations * Teach effective com accomplishments

* Meet client needs and * Use distraction to bring munication techniques

keep promises to client back to reality * Encourage verbalization

* promote trust of fears

Medical RX:

Risperidone

2 mg bid

Outcomes: Outcomes: Outcomes: Outcomes:

* Demonstrates Discusses Attends groups Performs ADLs

ability to trust content of willingly and independently

* Differentiates hallucinations without being * Maintains

between with nurse accompanied personal hygiene

Delusional * Hallucinations by nurse at an acceptable

thinking and are eliminated * nteracts level

Reality appropriately

with others

Nursing Diagnosis


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Nursing Diagnosis

(Actual or Potential)y Communication, Impaired verbal

y Disturbed personal Identity

y Coping, Ineffective Individual

y Family Process, alteredy Sensory/ perceptual alterations

y Thought processes, altered

yViolence, risk for: self/other directed

y Altered nutrition < body requirements

y Self care deficit (bathing/hygiene/grooming/

bathing/feeding/toileting)


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y RISK FACTORS FORRELAPSE

y ENVIRONMENTAL RISKFACTORS

y Financial difficultiesy Housing difficulties

y Stressful changes in lifeevents

y Poor occupational skills,inability to keep a job

y Lack oftransportation/resources

y Poor social skills, socialisolation, loneliness

y Interpersonal difficulties

HEALTH RISK FACTORS

y Impaired cause-and-effectreasoning

y Impaired informationprocessing

y Poor nutrition

y Lack of sleep

y Lack of exercise

y Fatigue

y Intolerable side effects ofmedication


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BEHAVIOR AND EMOTIONALRISK FACTORS

y Lack of control, aggressive orviolent behavior

y Mood swings

y Poor medication and symptommanagement

y Low self-concept

y Looks and acts different

y Hopeless feelingsy Loss of motivation


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Nursing Interventions/Rationales

Involve client/family in treatment process (avoidsmisunderstandings;resistancefrom client/family/orfinancial/environmentalconstraints)

Establish a therapeutic relationship with client first (theclient must first feelhe can trust thenurse-assists withsafety andsecurity)

Institute measures to maintain/regain physical health(the clients safety andphysicalhealth are priority!)


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y Use clear/concrete statements vs. generalizations(they mayexacerbate misperceptions orhallucinations)

y Determine stressors that may trigger sensory-perceptual disturbances (hallucinations maybeexacerbatedbyexternal/environmentalstressors)


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Disruptive Behaviory Set limit

y decrease environmental stimuli

y intervention before acting out

y close observation

y safety environment - minimize potential weapons

y making contract with the client

y

using restraints


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Withdrawn Patientsy encourage participation seating

y A

rrange non threatening activitiesy provide remotivation and resocialization group

experience

y reinforce appropriate grooming and hygiene

y provide psychosocial rehabilitation - social skilltraining, ...

COPINGWITH SOCIALLY INAPPROPRIATE


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COPINGWITH SOCIALLY INAPPROPRIATE

BEHAVIOR:y

Redirect client away from problem situations.y Deal with inappropriate behaviors in a non

judgemental and matter-of-fact mannner

y Give factual statements; do not scold.

y

Reassure clients inappropriate behaviors or commentare not his or her fault (without violating clientsconfidentiality)

y Try to reintegrate the client into tx millieu as soon aspossible.

y Do not make the client feel punished or shunned forinappropriate behavior.

y Teach social skills through education, role modellingand practice.

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