SCHIZOPHRENIA

CLINICAL POWERPOINT BY ABIGAIL

COLLINS
DEFINITION OF
DISEASE

 Distorted and bizarre thoughts,

perceptions, emotions, movements, and
behavior
 Not one illness but a disease process
 Multiple varieties and symptom
grouping
 Huge change in public perception (less
fear and wanting to lock those with
disease away)
 Normal life through medical supervision
and maintaining treatment
PHYSIOLOGY OF DISEASE

Social cause Biologic theories

 Result of  Genetics
dysfunctional  Identical twins have 50% risk of schizophrenia (if one has disease, the other has 50% risk of
relationships development); Fraternal has 15% risk; if one parent has disease child has 15% chance of
in early life development and 35% if both parents have schizophrenia
and  Neurochemical
adolescence  Less brain tissue and cerebrospinal fluid, enlarged ventricles, abnormal function and decreased
 Dysfunctional brain volume in temporal and frontal lobes
 Glucose metabolism and oxygen are diminished in frontal cortex
parenting or
family  Excessive dopamine and serotonin
dynamics  Immunovirological
 Cytokines (chemical messengers) malfunction
 Virus contraction during pregnancy
DIAGNOSIS AND RISK FACTORS

 Late adolescence or early adulthood

 Males: 15-25 years
 Women 25-35 years
 1% of US population (3 million people)
 Onset of symptoms can be abrupt or insidious (most develop s/s slow and gradually)
 Diagnosis is made once they show signs of psychosis (delusions, hallucinations, and disordered thinking)
DSM-5 CRITERIA TO DIAGNOSE WITH SCHIZOPHRENIA
 A. Two or more of the following symptoms, each present for
a significant portion of time during a 1-moth period (or less
if successfully treated). At least one of the presenting
symptoms must be symptom 1, 2, or 3
 1. delusions
 2. hallucinations
 3. disorganized speech
 4. grossly disorganized or catatonic behavior
 5. Negative symptoms (see next slide)
 B. For a significant portion of the time since the onset of the
disturbance, level of functioning in one or more major areas,
such as work, interpersonal relations, or self-care, is
markedly below the level achieved prior to the onset  other required symptoms of schizophrenia, are also
 C. Duration: Continuous signs of the disturbance persist
for at least 6 months. This 6-month period must include at
least 1 month of symptoms (or less if successfully treated)
that meet Criterion A
 D. Schizoaffective disorder and depressive or bipolar
disorder with psychotic features have been ruled out
 E. The disturbance is not attributable to the physiological
effects of a substance
 F. If there is a history of autism spectrum disorder or a
communication disorder of childhood onset, the
additional diagnosis of schizophrenia is made only if
prominent delusions or hallucinations, in addition to the
present for at least 1 month
SIGNS AND SYMPTOMS

Positive or hard Symptoms Negative or Soft Symptoms

 Ambivalence  Alogia

 Associative looseness  Anhedonia

 Delusions  Apathy

 Echopraxia  Asociality

 Flight of Ideas  Blunted affect

 Hallucinations  Catatonia

 Ideas of reference  Flat affect

 Perservation  Avolition or lack of volition

 Bizarre behavior  Inattention

DISEASE OUTCOMES

 Age and onset can predetermine outcomes

 Younger: poor adjustment prediagnosis, prominent negative signs, and greater cognitive impairment than older adults

 Those with a gradual onset (50%) have poor adjustment post diagnosis (both acute and long term) than those who
experience sudden onset
 1/3 to ½ of patients will relapse within 1 year of an acute episode
 Clients tend to follow 1 of 2 paths: ongoing psychosis with no recovery with shifting symptoms and severity
OR episodes of psychotic symptoms that alternate with episodes of recovery and normalcy
 Intensity of psychosis decreases with age
RELATED DISORDERS
 Schizophreniform disorder: acute, reactive psychosis for less than 6 months (diagnosis will change to
schizophrenia is psychosis lasts over 6 months)
 Catatonia: psychomotor disturbance, excessive motor activity or virtual immobility

 Delusional disorder: one or more nonbizarre delusions (delusions are believable) and psychosocial functioning is
not impaired
 Brief psychotic disorder: sudden onset of at least one psychotic symptom that lasts from 1 day to 1 month; can
have nonidentifiable stressor or following childbirth
 Shared psychotic disorder: 2 people share similar delusions (commonly between siblings, parent-child, or partners)

 Schizotypal personality disorder: odd, eccentric behaviors with transient psychotic symptoms; 20% of those with a
personality disorder will eventually be diagnosed with schizophrenia
 Schizoaffective Disorder: the patient exhibits signs of schizophrenia and a mood disorder (bipolar or depression);
s/s of both diseases can occur at the same time or alternate
COMMON
COMORBIDITIES
 Substance abuse is most
common
 Anxiety
 Depression
 Obsessive compulsive disorders
 PTSD
 Personality disorders
 Higher incidences of
developing Type 2 DM,
coronary heart disease and
COPD
  First generation antipsychotics (dopamine antagonists)
 Atypical/second generation (dopamine and serotonin antagonists)
MEDICATIONS  Long-acting injectable antipsychotic agents
 Mood Stabilizers
FIRST GENERATION ANTIPSYCHOTICS

Examples Using these Meds

 Chlorpromazine (Thorazine)  Side Effects

 Higher risk of neurological side effects
 Haloperidol (Haldol)  Tardive dyskinesia

 Extrapyramidal side effects

 Trifluoperazine (Stelazine)
 Insomnia, restlessness, anxiety, agitation, headaches

 Thioridazine (Mellaril)  Agranulocytosis, respiratory depression, laryngospasms

 Labs
 Perphenazine (Trilafon)
 Therapeutic levels, WBC, LFT
 Fluphenazine (Prolixin)  Patient Education

 Thiothixene (Navane)  NO ALCOHOL!!

 Do not drive until drug effects are known

 Loxapine (Loxitane)  Increase fluids

 S/S of EPS
 SECOND GENERATION ANTIPSYCHOTICS

Examples Using these Meds

 Side Effects
 Olanzapine (Zyprexa)
 Higher risk of metabolic side effects

 Clozapine (Clozaril)  Hyperglycemia, weight gain, dyslipidemia, hypotension, tachycardia

 Headache, agitation, insomnia, nervousness, hostility/aggression, somnolence, dizziness

 Paliperidone (Invega)  EPS, tardive dyskinesia (lower incidences

 Risperidone (Risperdal)  Labs

 BP, HR, QTC interval (especially in Geodon),BMI, HbA1c, blood sugar, lipid
 Quetiapine (Seroquel) panel/cholesterol, LFT

 Ziprasidone (Geodon)  Patient Education

 NO ALCOHOL!

 Do not drive until effects are known

 Medication reactions

 s/s of hyperglycemia

 Increase fluids, avoid situations where you can become easily dehydration
 LONG ACTING INJECTABLE ANTIPSYCHOTICS

Examples Why Use Injections Over Oral?

 Fluphenazine (Prolixin)  Supervised medication

 Haloperidol (Haldol) compliance
 Patients will not or cannot keep
 Risperidone (Risperdal
up with a daily regimen
Consta)
 Medications last from 2-4 weeks
 Paliperidone (Zyprexa
 Fluphenazine: 7-28 days
Relprevv)
 Haloperidol: 4 weeks
 Aripiprazole (Abilify
Maintena)
MOOD STABILIZERS

Examples Using these Meds

 Lithium  Side Effects
 Itching, rash, excessive thirst, frequent urination, tremors, N/V, slurred speech, irregular
 Valproic acid (Valproate) heartrate, blackouts

 Divalproex Sodium (Depakote)  Labs

 Depakote: Hepatotoxic (ALT/AST), pregnancy, WBC, platelets, Therapeutic range (50-
 Carbamazepine (Carbatrol, Epitol, Equetro, 125)
Tegretol)  Lithium: Renal toxic: Creatinine, BUN, Sodium levels., therapeutic levels (0.6-1.2)

 Valproic acid: Therapeutic levels (50-100)

 Lamotrigine (Lamictal)
 Patient Education
 Lithium: s/s toxicity (N/V/D, blurred vision, tinnitus, ataxia, slurred speech), increase
sodium
 Depakote: safe sex (pregnancy risk), s/s of infection and hemorrhage, s/s liver failure

 Lamictal: s/s of Steven-Johnson syndrome

EXTRAPYRAMIDAL SIDE EFFECTS

What are they? Treatment

 Reversible movement disorders (if caught soon
enough) caused by prolonged use of antipsychotics
 Dystonic reactions
 Spasms of muscle groups (usually neck or face)
accompanied by protrusion of tongue, dysphagia, and
throat spasms
 Dystonic: Benadryl (IM/IV) or benztropine
(Cogentin) IM
 Parkinsonism: dopaminergic and Benadryl
 Benztropine (Cogentin), trihexyphenidyl (Artane),
amantadine (Symmetrel),

 Parkinsonism  Akathisia: Beta-Blockers and benzodiazepines

 Shuffling gait, masklike facial expression, muscle
stiffness, drooling akinesia, hand tremors
 Akathisia
 Restless movement, paving, inability to remain still
LAB VALUES TO
RULE OUT OTHER
CAUSES
 Hematocrit
 Hemoglobin
 White blood cells
 Red blood cells
 TSH
 T4
 Glucose
 If patient is also abusing
alcohol/drugs: ALT/AST,
ammonia
OTHER
TREATMENTS
AND THERAPIES
 Individual: counseling,
personal therapy, social
skills therapy, vocational
shelters employment
rehabilitation therapies
 Group: interactive and social

 Cognitive behavioral therapy

and compliance therapy
 Electroconvulsive therapy
 5 NURSING DIAGNOSES
 Impaired social interaction
 Goals: 1. pt. will attend group and interact 2. pt. will engage
in social interaction without or with minimal encouragement
 Interventions: 1. ease client into going to common area 2.
medication if patient is having delusions/hallucinations 3.
encourage pt. to remove themselves from situation if
becoming agitated or overly anxious (with teaching of
coping techniques for both)
 Disturbed sensory perception (auditory or visual)
 Goals: 1. pt. will rate how loud voices are before and after
medication 2. pt. will state events that trigger hallucinations
 Interventions: 1. reorient to reality once then distract 2.
explore how hallucination are experienced by pt. 3. stay with
patient when experiences hallucinations or delusions
 Disturbed thought process
 Goals: 1. pt. will verbally recognize that thoughts are delusional 2. pt. will
improve attention span and concentration
 Interventions: 1. ID feelings related to delusion 2. explain all procedures
before carrying them out 3. do not argue beliefs
 Defensive coping
 Goals: 1. pt. will maintain medical compliance 2. pt. will demonstrate healthy
coping mechanisms
 Interventions: 1.use neutral language and be nonjudgmental 2. set limits in a
clear manner with calm tone 3. be honest and consistent
 Interrupted family process
 Goals: 1. family will state they have received needed to support from
community (education/social work) 2. family will attend at least one support
group after acute episode
 Interventions: 1. encourage phone calls to family once stable 2. assessment of
family’s current knowledge level about disease process 3. ID family coping
skills and roles
RESEARCH ARTICLE ONE
 Impact of a Simulation on Nursing Students’ Attitudes Toward
Schizophrenia
 The simulation features auditory hallucinations and a standardized
patient interaction
 Measured empathy, attitude, and fear of interaction

 This experienced lowered negative perceptions but did not change the
empathy the students had to patients with this mental disease
 Concludes that attitudes may improve further with more opportunities
for interaction
 Link: https://www.nursingsimulation.org/article/S1876-
1399(14)00218-7/fulltext
RESEARCH ARTICLE TWO
 Nursing Interventions in Schizophrenia; The Importance of Therapeutic Relationship
 When in acute phase, patient is not reliable historian so nurse must build relationship with
family and significant people to obtain accurate history as well as previous medical files
 “The therapeutic relationship is defined as being an interaction between two people, in
this case, the nurse-patient, in which the collaboration between both contributes to a
curative climate, promoting growth and/or prevention of the disease”
 Before beginning a relationship, nurse must know themselves and all about disease
process(must eliminate any stigma they have about disease)
 Obstacles to the therapeutic relationship includes: the patient not seeing a need for help,
scared family, patient having difficulty expressing need for help, patient not participating
to build therapeutic relationship, patient not accepting all aspects of their disease
 To nurture relationship nurse must constantly monitor patient mood, family mood, and
their own feelings on the situation
 Base of relationship begins with caring for patient basic needs consistently, being honest,
and truthful to yourself and the patient
 A positive therapeutic relationship results in a positive outcome with nursing care
 Link: https://www.researchgate.net/profile/Lara-Guedes-De-
Pinho/publication/319967306_Nursing_Care_Open_Access_Journal_Nursing_Interventions_in_Schizophrenia_The_Importance_of_Therape
utic_Relationship/links/59c4024d0f7e9b07cbb9d5de/Nursing-Care-Open-Access-Journal-Nursing-Interventions-in-Schizophrenia-The-
Importance-of-Therapeutic-Relationship.pdf
 RESEARCH ARTICLE THREE

 Burden on Family Caregivers Caring for Patients with Schizophrenia and Its Related Factors
 Family caregiver is most important role to patient but may experience feelings of being
burdened and burnout after long-term care of patient
 Burden is defined as a “negative impact of caring for the impaired person experienced by
caregiver on their activity (objective burden) or feeling (subjective burden) that involves
emotional, physical health, social life, and financial status”
 Factors include caregivers age, gender, education level, income, health status, and coping
 Patient factors were included (age, s/s, and degree of disability) and so were
environmental factors (access to mental health services and community/social support)
 Most caregivers have or are currently experiencing burden
 Reported poorer mental health themselves, more physician visits, and social/activity
limitations
 Link: https://ejournal.undip.ac.id/index.php/medianers/article/viewFile/745/604
REFERENCES

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC415906
1/
 https://www.racgp.org.au/afp/2015/november/comorbidit
ies-and-risk-factors-among-patients-with-schizophrenia/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC265930
6/
 https://www.ncbi.nlm.nih.gov/books/NBK519704/table/c
h3.t22/
 https://www.psychiatry.org/newsroom/news-releases/ect-
effective-for-treatment-of-schizophrenia
 https://psychopharmacologyinstitute.com/publication/firs
t-vs-second-generation-antipsychotics-2082
 https://www.nimh.nih.gov/health/topics/mental-health-m
edications/index.shtml
 http://www.robholland.com/Nursing/Drug_Guide/
 https://nurseslabs.com/schizophrenia-nursing-care-plans/