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NSG211 Test #2 - TEST 2 NOTES
Health Care Concepts II (NSG 211)
Germanna Community College
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Test 2: Halter, Chapter 11, 12, 23 Lilley, Chapter 16
Week 5:
Watch Psychosis Content Video Links (1-3) Exemplars: Schizophrenia
Schizophrenia Spectrum and Other Psychological
Disorders
Powerpoint: NSG 211 1st Generation Antipsychotics Dopamine Receptor Antagonists (DRA) Adasuve Fluphenazine Haldol decanoate Haloperidol Loxapine, Loxapine inhaled 2nd Generation Antipsychotics Serotonin-Dopamine Antagonists Asenapine Clozapine Iloperidone Lumateperone Lurasidone Olanzapine Paliperidone Quetiapine 3rd Generation Antipsychotics Partial Dopamine D 2 Agonists Aripiprazole Cariprazine Brexpiprazole Lumateperone Anticholinergics Benztropine Diphenhydramine Introduction
● Schizophrenia: devastating brain disease affecting thinking, language, emotions, social behavior, and reality perception ● Psychotic disorder: refers to experiencing such phenomena as delusions, hallucinations, disorganized speech or behavior ● Considered a severe mental illness (SMI) ○ Chronic condition; treatable but not curable ● Prevalence ○ Lifetime prevalence worldwide is 1% ○ No differences in regard to race, social status, culture, gender, or environment Schizophrenia Spectrum Disorders ❖ Share features with schizophrenia ➢ Characterized by psychosis ■ Altered cognition ■ Altered perception, and/or ■ Impaired ability to determine what is or is not real Phases of Schizophrenia ➢ Prodromal ○ Onset; early symptoms preceding diagnosis; social withdrawal, deterioration in function, perceptual disturbances, magical thinking, and peculiar behavior. Hyper-religiosity common ➢ Acute ○ Exacerbation of symptoms ➢ Stabilization ○ Symptoms diminishing ○ Movement toward previous level of functioning ➢ Maintenance or residual ○ New baseline is established Risk Factors ➔ Biological factors ◆ Genetics: twin and adoptive studies validate ◆ Multiple genes believed to be involved ➔ Neurobiological ◆ Glutamate, dopamine, and serotonin ◆ Acetylcholine ➔ Brain structure abnormalities ➔ Prenatal stressors ➔ Environmental factors
● Echolalia ○ Pathological repetition of another’s words ● Other Abnormal Speech Patterns ○ Circumstantiality ○ Tangentiality ○ Cognitive retardation ○ Pressured speech ○ Flights of ideas ○ Symbolic speech ■ Concrete thinking- inability to think abstractly ● Alterations in behavior ○ Catatonia ○ Motor retardation ○ Motor agitation ○ Stereotyped behaviors ○ Waxy flexibility ○ Echopraxia ○ Negativism ○ Impaired impulse control ○ Gesturing or posturing ○ Boundary impairment ● Disorders or Distortion of Thought ○ Thought blocking ○ Thought insertion ○ Thought deletion ○ Magical thinking ○ Paranoia ● Negative ○ The absence of essential human qualities ■ Anhedonia ● Lack of feeling pleasure in anything in life ■ Avolition ■ Asociality ■ Affective blunting ■ Apathy ■ Alogia ○ Changes in affect ■ Flat affect: no emotion displayed ■ Inappropriate affect: emotional response incongruent to situation ■ Blunted affect: minimal emotional response ■ Bizarre affect: grimacing, giggling, mumbling
○ Poor social functioning ■ Clingling and intruding on the personal space of others ■ Exhibiting behaviors that are not culturally and socially acceptable ■ Social isolation: a focus inward on the self to the exclusion of the external environment ○ Poverty of thought ● Cognitive ○ Concrete thinking ○ Impaired memory ○ Impaired information processing ○ Impaired executive functioning ○ Anosognosia ● Affective ○ Assessment for depression is crucial ■ May herald impending relapse ■ Increases substance abuse ■ Increases suicide risk ■ Further impairs functioning Nursing Diagnoses/Concerns ❖ Positive symptoms ➢ Disturbed sensory perception ➢ Risk for self-directed violence ■ Risk for other-directed violence ● Related to ◆ Extreme suspiciousness
◆ The existence of prominent, non-bizarre delusions lasting one month or longer ◆ Includes grandiose, persecutory, somatic, and referential themes ◆ Are not severe enough to impair functioning ➔ Brief Psychotic Disorder ◆ Sudden onset of symptoms ◆ May or may not be preceded by a severe psychosocial stressor ◆ Lasts less than 1 month ◆ Return to full premorbid level of functioning ➔ Schizophreniform Disorder ◆ Symptoms ● Exactly like those of schizophrenia, except that symptoms have thus far lasted less than 6 months ◆ Impaired social or occupational functioning may not be apparent ◆ May or may not return to previous level of functioning ➔ Schizoaffective Disorder ◆ Major depressive, manic, or mixed episode, concurrent with symptoms that meet the criteria for schizophrenia ◆ Not caused by any substance use or general medical condition ➔ Substance-Induced Psychotic Disorder ◆ The presence of prominent hallucinations and delusions that are judged to be directly attributable to substance intoxication or withdrawal ➔ Psychotic Disorder Associated with Another Medical Condition ◆ Prominent hallucinations and delusions are directly attributable to a general medical condition ➔ The Catatonic Features Specifier ◆ Catatonic features may be associated with other psychotic disorders ◆ Symptoms of catatonic disorder include ● Stupor and muscle rigidity or excessive, purposeless motor activity ● Waxy flexibility, negativism, echolalia, echopraxia ➔ Catatonic Disorder Associated with Another Medical Condition ◆ This diagnosis is made when the catatonic symptoms are directly attributable to the physiological consequences of a general medical condition Schizophrenia ★ Schizophrenia affects 1% of the population ★ Characterized by psychosis ○ Altered cognition, perception, and reality testing ★ 75%: develop gradually, presenting at 15-25 years of age ★ Child- onset and late-onset are more rare
DSM-V Criteria: Highlights ● Two or more of the following for a significant portion of time in 1 month: ○ Delusions ○ Hallucinations ○ Disorganized speech ○ Gross disorganization or catatonia ○ Negative symptoms (diminished emotional expression or avolition) ○ Functional impairment of some kind ● Continuous disturbance for at least 6 months ● Ruled out: substances or other disorders Epidemiology ❖ Childhood- onset schizophrenia: 1 in 40,000 children ❖ No difference related to ➢ Race ➢ Culture ❖ More frequently diagnosed: ➢ Among males ➢ In urban areas Comorbidity ➢ Substance abuse disorders: approximately 40%-50% of people with schizophrenia ○ Nicotine dependence: 75%-85% ➢ Anxiety, depression, and suicide ○ Depressive disorders and anxiety disorders are common ○ Suicide 20 times more prevalent than general population (10% commit suicide) ➢ Physical illness ➢ Polydipsia ○ Are common Assessment Guidelines ➔ Any medical problems ➔ Medical problems that mimic psychosis ➔ Drug or alcohol use disorders ➔ Mental status examination ➔ Include cognitive assessment (e., reality testing) ➔ Assess for hallucinations ➔ Assess for delusions
● Phase I- acute ○ Best strategies to ensure patient safety and provide symptom stabilization ● Phase II- stabilization ● Phase III- maintenance ○ Provide patient and family education ○ Relapse prevention skills are vital ● Nursing interventions for the client with schizophrenia or other psychotic disorder are aimed at ○ Decreasing anxiety and establishing trust ○ Assisting client to define and test reality ○ Encouraging interaction with others ○ Ensuring safety of client and others ○ Meeting client’s self-care needs ○ Promoting adaptive family coping Implementation ❖ Acute Phase ➢ Psychiatric, medical, and neurological evaluation ➢ Psychopharmacological treatment ➢ Support, psychoeducation, and guidance ➢ Supervision and limit setting in the milieu ➢ Monitor fluid intake ➢ Working with aggression ■ Regularly assess for risk and take safety measures ❖ Stabilization and maintenance phases ➢ Medication administration/adherence ➢ Relationships with trusted care providers ➢ Community-based therapeutic services ➢ Teamwork and safety ➢ Activities and groups ❖ Counseling and communication techniques ➢ Hallucinations ➢ Delusions ➢ Associative looseness ➢ Health teaching and health promotion Evaluation ➢ Reevaluate progress regularly and adjust treatment when needed ➢ Even after symptoms improve outwardly, inside the patient is still recovering ➢ Set small goals; recovery can take months ➢ Active, ongoing communication and caring is essential
Treatment Modalities ➢ Psychological treatments ○ Individual psychotherapy: difficult because of client's impairment in interpersonal functioning ○ Group therapy: some success if long-term; less successful in acute, short- term treatment ○ Behavior therapy: chief drawback-inability to generalize to community setting after discharged from treatment ○ Social skills training: use of role play to teach appropriate eye contact, interpersonal skills, voice intonation, posture, ect.; aimed at improving relationship development ○ Milieu therapy: best if used in conjunction with psychopharmacology ○ Family therapy: aimed at helping family members cope with long-term effects of the illness ➢ The Recovery Model ○ A concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her full potential ○ Research provides support for recovery as an obtainable objective for individuals with schizophrenia ○ Focus is on the individual’s level of functioning in areas of relationships, work, independent living, and other kinds of life functioning ○ There is no defined end point. Recovery is viewed as a process that continues throughout the individual’s life and involves collaboration between client and clinician Treatment for Schizophrenia ➔ Antipsychotic medications ◆ Used to alleviate symptoms, not curative ◆ When patients discontinue medication, psychotic symptoms/relapse occurs ● Each relapse leads to longer recovery time and possibility that patient will become unresponsive to medications ◆ Types of antipsychotic medications ● Conventional/traditional (first-generation) ● Atypical (second generation) ◆ Adjuncts to Antipsychotic Drug Therapy ● Antidepressants ● Antimanic agents
■ May improve positive and negative symptoms and cognitive function ● Little risk of EPS or tardive dyskinesia ★ Injectable antipsychotics ○ Short-acting ○ Long-acting ■ First-generation: haloperidol, fluphenazine, decanoate ■ Second-generation: olanzapine, pamoate, paliperidone, palmitate Dangerous Responses to Antipsychotics ● Anticholinergic toxicity ○ Reduced or absent peristalsis (can lead to bowel obstruction); urinary retention; mydriasis; hyperpyrexia without diaphoresis (hot dry skin); delirium with tachycardia, unstable vital signs, agitation, disorientation, hallucinations, reduced responsiveness; worsening of psychotic symptoms; seizure; repetitive motor movements ● Neuroleptic Malignant Syndrome (NMS) ○ Severe muscle rigidity, dysphasia ○ Flexor- extensor posturing ○ Reduced or absent speech and movement ○ Decreased responsiveness ○ Hyperpyrexia: temperature over 103°F ○ Autonomic dysfunction: hypertension, tachycardia, diaphoresis, incontinence ○ Delirium, stupor, coma ○ Bromocriptine and dantrolene can relieve muscle rigidity and reduce the fever ● Severe neutropenia/agranulocytosis (remember clozapine for this particularly) ○ Reduced neutrophil counts and increased frequency and severity of infections ○ Any symptoms suggesting infection (e., sore throat, fever, malaise, body aches) should be carefully evaluated ● Prolongation of the QT interval ○ Delay of ventricular repolarization. May result in tachycardia, fainting, seizures, and even sudden death ● Liver impairment ○ Impairment usually occurs in the first weeks of therapy ○ Jaundice, abdominal pain, ascites, vomiting, lower extremity edema, dark urine, pale or tar-colored stool, easy bruising
More Responses to Antipsychotics ❖ Extrapyramidal Side Effects (EFSs) (more likely associated with traditional/first generation antipsychotics) ➢ Acute dystonia: sudden, sustained contraction, can be dangerous if involves neck/airway (benztropine or diphenhydramine) ➢ Akathisia: motor restlessness causing inability to stay sill or remain in one place ➢ Pseudoparkinsonism: temporary group of symptoms that resemble Parkinson’s Disease ➢ Tardive dyskinesia: involuntary rhythmic movements, often include tongue movements, lip smacking with uncontrollable biting, chewing, or sucking movements ❖ Metabolic Syndrome ➢ Weight gain (especially in the abdomen), dyslipidemia, increased blood glucose, and insulin resistance ➢ Increases risk of diabetes, certain cancers, hypertension, and cardiovascular disease ➢ More likely associated with atypical antipsychotics Adjuncts to Antipsychotic Drug Therapy ➢ Antidepressants are administered for severe depression ➢ Lithium and other mood stabilizers reduce aggressive behavior ➢ Benzodiazepine augmentation improved positive and negative symptoms ➢ Clonazepam decreases anxiety, agitation, and possibly psychosis Client/Family Education ➔ The client should: ◆ Not stop taking the drug abruptly ◆ Use sunscreens and wear protective clothing ◆ Weekly then monthly blood work (if receiving clozapine therapy) ◆ Be aware of possible risks of taking antipsychotics during pregnancy ◆ Not drink alcohol ◆ Not consume other medications (including over-the-counter drugs) without the physician’s knowledge ➔ Nature of Illness ◆ What to expect as illness progresses ◆ Symptoms associated with illness ◆ Ways for family to respond to behaviors ➔ Management of the Illness ◆ Connection of exacerbation of symptoms to stress ◆ When to contact healthcare provider
Concept: Psychotherapeutic Drugs
Powerpoint: Chapter 16: Lilly Psychotherapeutic Drugs ● Used in the treatment of emotional and mental disorders ○ Ability to cope with emotions can range from occasional depression or anxiety to constant emotional distress ○ When emotions significantly affect an individual’s ability to carry out normal daily functions, treatment with a psychotherapeutic drug is a possible option ● Three main emotional and mental disorders ○ Anxiety ■ Unpleasant state of mind characterized by a sense of dread and fear ■ May be based on actual anticipated experiences or past experiences ■ May be exaggerated responses to imaginary negative situations ○ Affective disorders ○ Psychoses ● Types of psychotherapeutic drugs ○ Anxiolytic drugs ○ Mood-stabilizing drugs ○ Antidepressant drugs ○ Antipsychotic drugs Anxiety Disorders ❖ Six major anxiety disorders (persistent anxiety) ➢ Obsessive- compulsive disorder (OCD) ➢ Posttraumatic stress disorder (PTSD) ➢ Generalized anxiety disorder (GAD) ➢ Panic disorder ➢ Social phobia (social anxiety disorder) ➢ Simple phobia Affective Disorders (Mood Disorders) ➢ Changes in mood that range from mania (abnormally pronounced emotions) to depression (abnormally reduced emotions) ➢ Some patients may exhibit both mania and depression: bipolar disorder (BPD)
Psychosis ➔ Severe emotional disorder that impairs the mental function of the affected individual to the point that the individual cannot participate in activities of daily living ➔ Hallmark: loss of contact with reality ➔ Examples ◆ Schizophrenia ◆ Depressive and drug-induced psychoses Anxiolytic Drugs ★ Reduce anxiety by reducing overactivity in central nervous system (CNS) ○ Benzodiazepines ■ Depress activity in the brainstem and limbic system ■ Alprazolam (Xanax) ● Most commonly used as an anxiolytic ● Indicated for GAD, short-term relief of anxiety symptoms, panic disorder, and anxiety associated with depression ● Adverse effects: confusion, ataxia, headache, and others ● Interactions: alcohol, oral contraceptives, and others ■ Diazepam (Valium) ● Indications: relief of anxiety, management of alcohol withdrawal, reversal of status epilepticus, preoperative sedation, and as an adjunct for the relief of skeletal muscle spasms ● Avoid in patients with hepatic dysfunction ● Adverse effects: headache, confusion, slurred speech, and others ● Interactions: alcohol, oral contraceptives, and others ■ Lorazepam (Ativan) ● Intermediate-acting benzodiazepine ● Can be given by IV push; useful in the treatment of an acutely agitated patient ● Continuous infusion for agitated patients who are undergoing mechanical ventilation ● Used to treat or prevent alcohol withdrawal ■ Adverse effects: ● Are an overexpression of their therapeutic effects ● Decreased CNS activity, sedation ● Hypotension ● Drowsiness, loss of coordination, dizziness, headaches ● Nausea, vomiting, dry mouth, constipation
○ Adverse effects ■ Most serious adverse effect is cardiac dysrhythmia ■ Other effects: drowsiness, slurred speech, epilepsy-type seizures, choreoathetotic movements (involuntary wavelike movements of the extremities), ataxia (generalized disturbance of muscular coordination), and hypotension ■ Long-term treatment may cause hypothyroidism Antidepressants ❖ Tricyclic antidepressants ➢ Have largely been replaced by SSRIs as first-line antidepressant drugs ➢ Considered second line ■ For patients who fail with SSRIs or other newer generation antidepressants ■ As adjunct therapy with newer generation antidepressants ➢ Amitriptyline (Envail) ■ Oldest and most widely used of all the TCAs ■ Original indication was depression ■ Commonly used to treat insomnia and neuropathic pain ■ Contraindications: known drug allergy, pregnancy, and recent myocardial infarction ■ Adverse effects: dry mouth, constipation, blurred vision, urinary retention, and dysrhythmias ➢ Mechanisms of action ■ Block reuptake of neurotransmitters, causing accumulation at the nerve endings ■ It is thought that increasing concentrations of neurotransmitters will correct the abnormally low levels that lead to depression ➢ Indications ■ Depression ■ Childhood enuresis (imipramine) ■ OCDs (clomipramine) ■ Adjunctive analgesics for chronic pain conditions, such as trigeminal neuralgia ➢ Adverse effects ■ Sedation ■ Impotence ■ Orthostatic hypotension ■ Others ■ Older patients
● Dizziness, postural hypotension, constipation, delayed micturition, edema, muscle tremors ➢ Overdose ■ Lethal: 70%-80% die before reaching the hospital ■ CNS and cardiovascular systems are mainly affected ■ Death results from seizures or dysrhythmias ■ No specific antidote ● Decrease drug absorption with activated charcoal ● Speed elimination by alkalinizing urine ● Manage seizures and dysrhythmias ● Provide basic life support ❖ Monoamine oxidase inhibitors (MAOIs) ➢ Nonselective: isocarboxazid, phenelzine, and tranylcypromine ➢ Selective: selegiline ➢ Rarely used for depression ➢ Used for Parkinson’s disease ➢ Disadvantage: potential to cause hypertensive crisis when taken with tyramine ➢ MAOIs and Tyramine ■ Ingestion of foods or drinks with tyramine leads to hypertensive crisis, which may lead to cerebral hemorrhage, stroke, coma, or death ■ Avoid foods that contain tyramine! ● Aged, mature cheeses (cheddar, blue, Swiss) ● Smoked, pickled, or aged meats, fish, poultry (herring, sausage, corned beef, salami, pepperoni, paté ● Yeast extracts ● Red wines (Chianti, burgundy, sherry, vermouth) ● Italian broad beans (fava beans) ❖ Second-generation antidepressants ➢ SSRIs ➢ Serotonin-norepinephrine reuptake inhibitors ➢ Vortioxetine (Brintelix) ➢ Fewer adverse effects than TCAs and MAOIs ➢ Very few drug-drug or drug-food interactions ➢ Still take about 4-6 weeks to reach maximum clinical effectiveness ➢ Now considered first-line drugs for depression ➢ Mechanisms of action: inhibition of serotonin reuptake and possible effects on norepinephrine and dopamine reuptake ➢ Indications: ■ Depression
NSG211 Test #2 - TEST 2 NOTES
Course: Health Care Concepts II (NSG 211)
University: Germanna Community College
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