Reading Assignment

Varcarolis (2017)
Pg. 243-271 Chapter 17 – schizophrenia Spectrum
Disorders and Other Psychotic Disorders
Pages 34-43 (Stop at Antidepressant Drugs)
Pg 46-49 Antipsychotic Drugs
Student Learning Outcomes
Patient Centered Care
Compare and contrast positive and negative symptoms of
schizophrenia.
Apply the nursing process to individuals with schizophrenia or
psychosis.
Explain how factors including the client’s culture and spirituality
affect client care.
Safety
Identify the actions and nursing implications of the most
common medications prescribed for managing schizophrenia or
psychosis.
Teach the client and caregiver(s) about how schizophrenia or
psychosis affect home safety. 
Evidence-Based Practice
Discuss evidence-based recommendations to be included in
assessment and care of clients with schizophrenia or psychosis.
Continued………
Quality Improvement
Discuss policies, procedures, and skills related to schizophrenia
or psychosis.
Discuss diagnostic procedures associated with assessment of
schizophrenia or psychosis. 
Informatics
Accurately record and report assessment findings.
Discuss the technology used in the assessment and treatment of
clients with schizophrenia or psychosis.
Medication Cards
chlorpromazine (Thorazine)
clozapine (Clozaril)
olanzapine (Zyprexa)
quetiapine (Seroquel)
risperidone (Risperdal)
Brain Structure and Function
Basal ganglia – regulates movement (drugs that
affect brain function can stimulate or depress
respiration or affect speech patterns
Brainstem/reticular activating system (RAS) –
may interfere with regulation of sleep and
alertness
Cerebellum – hypoactivation affects posture and
equilibrium
Thalamus – reflex movements, body-altering
mechanisms and emotion
Hypothalamus – maintains homeostasis
Neurotransmitters
Dopamine – controls emotional responses and
the brain’s reward and pleasure centers,
stimulate the heart and increase blood to vital
organs
Acetylcholine – balances dopamine
Norepinepherine – regulate mood
Serotonin – regulate mood, arousal, attention,
behavior, and body temperature
Serotonin syndrome – mild (restlessness, shivering
and diarrhea) to severe (muscle rigidity, fever and
seizures)
Histamine – blocking receptor result in sedation
and weight gain
y-Aminobutyric Acid (GABA) – regulation of
anxiety
Glutamine – plays role in memory or learning
Schizophrenia
Targets young people in their teens or early 20s
Disrupts an individual’s ability to perceive reality
accurately, to think clearly, to use language
appropriately, to experience normal emotions,
or to engage in normal social/occupational
experiences
Psychosis – refers to a total inability to recognize
reality
Delusions – believing idea with no basis in fact
Hallucinations – experiencing sensory perceptions
not based in reality
Prevalence and Comorbidity
Poor prognosis
Slow, insidious onset over a period of 2 or 3 years
Early age of onset (18-25 years) and male
Good prognosis
Abrupt onset
Late age of onset (25-35 years) and female
High rate of:
Substance use disorders and tobacco use disorder
Depressive symptoms
Suicide leading cause of death
Obesity
Theory
Most likely results from combination of
inherited genetic and extreme nongenetic
factors
Prenatal risk factors – viral infection, poor nutrition
and exposure to toxins
Hx of perinatal complications (birth complications)
Stress and street drugs
Positive
Positive symptoms
symptoms Mood symptoms


 Hallucinations
Hallucinations
 Depression

 Delusions
Delusions
 Anxiety

 Bizarre
Bizarre behavior
behavior
 Demoralization

 Catatonia
Catatonia
 Dysphoria

 Formal
Formal thought
thought
 Suicidality
disorder
disorder

Negative symptoms
Cognitive
Cognitive symptoms
symptoms
 Apathy

 Impairment
Impairment in in  Lack of motivation
memory;
memory; disruption
disruption  Anhedonia
in
in social
social learning
learning  Blunted or flat affect

 Inability
Inability to
to reason,
reason,  Poverty and speech

 Solve
Solve problems,
problems,

 Focus
Focus attention
attention

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Cultural Considerations
Culture can influence the content and form of
the positive and negative symptoms of
schizophrenia
Assessment
Prodromal phase (1 mo-1 year)
S&S that precede the acute, fully manifested
disease
Social withdrawal and deterioration in function and
depressive mood, perceptual disturbances, magical
thinking, and peculiar behavior  words and phrases may
become indecipherable
Acute phase – periods of positive and negative
symptoms
Stabilization phase – period where symptoms
decrease
Maintenance phase – symptoms are in remission
Key Symptoms of Schizophrenia
(Box 17-2)
Positive symptoms
Psychotic symptoms (ie. delusions & hallucinations)
Negative symptoms
Inability to experience pleasure or joy/bunted affect
Cognitive symptoms
Inability to understand and process information
Mood symptoms
Depression/anxiety/suicidality
Grossly disorganized or catatonic behavior
Extreme abnormal behavior
Characterological symptoms
Isolated/alienated
Positive Symptoms
(florid psychotic symptoms)
Delusions – false fixed beliefs that can not be
corrected by reasoning (persecutory and
grandiose)
Concrete thinking – overemphasis on specific
details and impairment in the ability to use
abstract concepts
Associative looseness – threads to tie one
concept to another are missing; thinking
becomes haphazard, illogical and confused
Neologisms – make up their own words
Echolalia – pathological repeating of another’s
words
Echopraxia – mimicking of movement of
another
Clang association – meaningless rhyming of
words
Word salad – a jumble of words that is
meaningless to the listener and perhaps to the
speaker
Hallucinations – sensory perceptions for which
no external stimulus exists
Command hallucinations – may signal a
psychiatric emergency-“What is the voice telling
you to do?”
Evidence of possible hallucination is turning or
tilting of head; frequent blinking of eyes or
grimacing
Patients who can give an identity to a hallucinated
voice are at a greater risk of compliance
Personal boundary difficulties – lack a sense of
where their bodies end in relationship to where
others begin
Depersonalization – become concerned that body
parts do not belong to them; acute sensation that
the body has drastically changed
Derealization – is the false perception by a person
that the environment has changed
Extreme motor agitation – excited physical
behavior
Stereotyped behaviors – motor patterns that
originally had meaning to the person, but are now
mechanical and lack purpose
Automatic obedience – performance of simple
commands in a robot-like fashion
Waxy flexibility – hold unusual posture for long
periods
Stupor – motionless for long periods
Negativism – does opposite of what they are told
Negative symptoms
During acute psychotic episode, negative
symptoms are difficult to asses because the
positive and more florid symptoms dominate.
Affect – observable behavior that expresses a
person’s emotions
Flat – immobile facial expression
Blunted – minimal emotional response
Inappropriate – emotional response not congruent
with situation
Bizarre – patient unable to relate logically to the
environment
Neurocognitive symptoms
Causes difficulty with attention, memory and
executive functions
Impedes a person’s ability to manage own
health care and or participate fully in relapse
prevention programs
Degree of cognitive deficit = severity of negative
symptoms = degree of disorganized speech,
behavior and affect
Catatonia
Extreme abnormal motor behavior – extreme
motor agitation or retardation
During withdrawn phase – person does not move
or eat
Stereotyped behavior – arranging or rearranging
objects
Extreme negativism and resistance
Echolalia and echopraxia
Paranoia
Intense and strongly defended irrational
suspicion
Projection – is the best common defense
mechanism used by people who are paranoid
Ideas of reference – the patient frequently
misinterprets the messages of others or gives
private meaning to the communication of others
Disorganized
Looseness of associations
Grossly inappropriate affect
Bizarre mannerisms
Incoherent speech-"I am having difficulty
understanding what you are saying.“
Extreme delusions and hallucinations
Fragmented and poorly organized
Assessment
R/O medical or substance-induced psychosis
Verify alcohol or drug use
Assess for command hallucinations
Review patient’s belief system
Assess co-occurring conditions
Verify compliance with medications
Leads to unresponsiveness
Family’s response to s&s
Observe family relationships/interactions
Review support systems
Implementation
Phase I (acute) – focus on crisis intervention, acute
symptom stabilization and safety-maintain a normal
social interaction distance from the patient.
Phase II (stabilization) & III (maintenance) – long-term
care relies on a three-pronged approach: medication,
nursing intervention, and community support
Hallucinations – the nurse initially should try to
understand what voices are saying
Delusions – it is never useful to argue with or try to
“reason” with the patient; clarify misinterpretations
Paranoia – may make offensive and accurate criticisms
of nurse; avoid laughing or whispering near patient
Associative looseness - in behavior =  anxiety
Health Teaching and Health Promotion
Milieu therapy
Provides safety, useful activities, resources for
resolving conflicts and opportunities for learning
social and vocational skills
Safety
Verbal de-escalation and chemical restraints  physical
restraints and seclusion
Program for Assertive Community Treatment
Emphasizes patient’s strengths in adapting to the
community, provides support and assertive
outreach and involves almost every aspect of the
patient’s life
Family Therapy
Emphasizes the value of family participation in
treatment
Cognitive Behavioral Therapy
Improves insight and compliance
Social Skills Training
Improve quality of life and lower anxiety
 Pharmacologic Therapy

Antipsychotic Medications
 Alleviate symptoms of schizophrenia but cannot cure
underlying psychotic processes.
 Psychotic symptoms return with medication

noncompliance.
 Antipsychotic drugs are effective in:
 Acute exacerbations of schizophrenia
 Preventing or mitigating a relapse

32
 Pharmacologic Therapy
(Cont.)
Conventional (first-generation) antipsychotics
 Target positive symptoms
Atypical (second-generation) antipsychotics
 Target positive and negative symptoms
 Atypical agents have fewer side effects.
 Atypical agents treat anxiety, depression, and decrease
suicidal behavior.

33
Conventional (First-Generation)
Antipsychotics
Target positive symptoms:
Low Potency
High Potency  chlorpromazine
trifluoperazine
(generic only) (thorazine)
thiothixene (Navane)
 thioridazine (Mellaril)
fluphenazine (Prolixin) Medium Potency
haloperidol (Haldol)  loxapine (Loxitane)
pimozide (Orap)  molidone (Moban)

perphenazine (Trilafon)

34
Atypical (Second-Generation)
Antipsychotics
Target positive or negative symptoms
 aripiprazole (Abilify)
 clozapine (Clozaril)

 olanzapine (Zyprexa)

 paliperidone (Invega)

 quetiapine (Seroquel)
 risperidone (Risperdal)
 ziprasidone (Geodon)

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Atypical (Second-Generation)
Antipsychotics (Cont.)
Disadvantages
Metabolic syndrome
 Weight gain, dyslipidemia, altered glucose
 Risk of diabetes, hypertension, atherosclerosis, and increase
in heart disease
Is more expensive than conventional
antipsychotics

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Pharmacological Therapies
Antipsychotic agents usually take effect 2 to 4 weeks after regimen is started.
First-generation agents/
conventional antipsychotics
(formerly called neuroleptics)
Target positive symptoms
(hallucinations and delusions)
Large number of side effects;
extrapyramidal symptoms (EPS)
of akathisia (restlessness),
dystonia (muscle cramps of
head/neck)-Haldol,
parkinsonism and tardive
dyskinesia (tongue and lip
smacking to muscular spams);-
should be reported to HCP!
anticholinergic effects,
orthostasis and low seizure
threshold
Second-generation agents/
atypical antipsychotics
Example Latuda(lurasidone
HCL)
Also diminish negative symptoms
Fewer side effects; higher risk for
metabolic syndrome (weight
gain, diabetes and dyslipidemia);
more cardiovascular events and
premature deaths
Clozapine produces
agranulocytosis (increase risk for
infection can be fatal) and
increases risk of seizures
Weight management strategies
should be discussed
Neuroleptic malignant syndrome
Characterized by  LOC, greatly  muscle tone
and autonomic dysfunction, including
hyperpyrexia, labile hypertension, tachycardia,
tachypnea, diaphoresis and drooling
Treatment = early detection, D/C antipsychotic
agent, management of fluid balance, reduction
of temperature and monitoring complications
Adjuncts to Therapy
Antidepressants
Added when meeting criteria for major depression
cause severe distress, including suicidal thoughts or
when depression is disabling
Benzodiazepines
Have been used in past (recent study concludes
they are associated with increased morbidity)
Audience Response Questions:
1. The nurse at the mental health clinic plans a series of
psychoeducational groups for persons with
schizophrenia. Which topic would take priority?

A. How to complete an application for employment.

B. The importance of correctly taking your medication.
C. How to dress when attending community events.
D. How to give and receive compliments.
 
B
During the acute phase of the illness, the overall
goal is patient safety and medical stabilization.
Therefore if the patient is at risk for violence to
self or others, initial outcome criteria should
address safety issues. Medication adherence is
a vital outcome for all phases of recovery.
2. The nurse sits with a client with a new onset
disorganized schizophrenia. The client starts to
laugh uncontrollably, although the nurse has not
said anything funny. Select the nurse’s best
response.

A. “Why are you laughing?”

B. “Please share the joke with me.”
C. “I don’t think I said anything funny.”
D. “You’re laughing. Tell me what’s happening.”
D
Disorganized components of schizophrenia represent the most
regressed and socially impaired of all individuals with
schizophrenia. A person who presents with these symptoms of
schizophrenia may have marked looseness of association,
grossly inappropriate affect, bizarre mannerisms, and
incoherence of speech, and may display extreme social
withdrawal and severe cognitive impairment. Although
delusions and hallucinations are present, they are fragmented
and poorly organized. Behavior may be considered odd, and
giggling or grimacing in response to internal stimuli is common.
Avoid the use of why questions, and ask the patient to what is
happening.
3. The nurse is caring for a client with schizophrenia who
says, “The voices are bothering me. They yell and tell me
I’m bad. I have got to get away from them.” Select the
nurse’s most helpful reply.

A. “Do you hear the voices often?”

B. “Do you have a plan for getting away from the
voices?”
C. “I’ll stay with you. Focus on what we are talking
about, not the voices.”
D. “Forget the voices, and ask some other clients to
play cards with you.”
C
Keep the patients focused on simple, basic,
reality-based topics. Help patients focus on
one idea at a time. Hallucinating patients are
confused and disoriented; help patients focus
on people and happenings in reality.
4. The nurse is caring for a client who has received several
doses of low-potency antipsychotic medication. The client
stands, sways, and then grasps the table for support and
sits down again. What are the nurse’s best actions?
(Select all that apply.)

A. Distract the client with activity.

B. Ask the client, “Do you feel dizzy?”
C. Assess the client’s sitting and standing BPs.
D. Continue observing the client from a distance.
E. Administer a PRN dose of diphenhydramine
(Benadryl).
 B&C
Pg. 268 Table 17-10
Orthostatic hypotension (drop in blood pressure
on standing; may lead to falls and injury).