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NSG211 Test #2- updated version
Health Care Concepts II (NSG 211)
Germanna Community College
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NSG 211Preview text
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 Only target + symptoms of schizophrenia Linked with anticholinergic effects and extrapyramidal side effects (TD) Dopamine Receptor Antagonists (DRA) Adasuve Fluphenazine Haldol decanoate Haloperidol Loxapine, Loxapine inhaled Chlorpromazine 2nd Generation Antipsychotics Treat + and - symptoms of schizophrenia and mood issues Little EPS and TD Linked with Metabolic Syndrome Serotonin-Dopamine Antagonists Asenapine Aripiprazole Clozapine- agranulocytosis (killer side effect) Iloperidone Lumateperone Lurasidone Olanzapine Paliperidone Quetiapine Risperidone 3rd Generation Partial Dopamine D 2 Aripiprazole Cariprazine
Antipsychotics Agonists 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 ○ Requires hospitalization ➢ Stabilization ○ Symptoms diminishing ○ Movement toward previous level of functioning ➢ Maintenance or residual ○ New baseline is established Risk Factors
○ Derealization ■ Alterations in speech ● Associative looseness ○ Word salad- most extreme form; jumble of words meaningless to a listener ● Clang association ○ Words chosen based on sound ● Neologisms ○ Meaning for the patient only ● 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 ○ More of a depression quality ■ Anhedonia ● Lack of feeling pleasure in anything in life
■ Avolition ● The inability to initiate or engage in goal-directed behavior ■ Asociality ● Lack of motivation to engage in social interaction ■ Affective blunting ● A decrease in facial expression ■ Apathy ● Lack of interest, enthusiasm, or concern ■ Alogia ● Poverty of thought ○ 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
○ Lowering the patient's anxiety ○ Decreasing defensive patterns ○ Encouraging participation in therapeutic and social events ○ Raising feelings of self-worth ○ Increasing medication compliance ➢ Dealing with hallucinations and delusions ○ Approach in non threatening and non judgemental manner ○ Identify feelings patient is experiencing ○ Clarify reality ○ Avoid arguing/attempt to reason ○ Distract patient’s attention from hallucination/delusional belief ➢ Dealing with the patient who is paranoid ○ Be honest and consistent ○ Avoid talking, laughing, whispering ➢ Dealing with associative looseness ○ Do not pretend to understand ○ Tell patient you are having difficulty understanding ○ Look for recurring topics or themes ○ Emphasize what is going on in the “here and now” Types of Schizophrenia and Other Psychotic Disorders ➔ Delusional Disorder ◆ 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
★ Phase II- stabilization ○ Help patient understand illness and treatment ○ Stabilize medications ○ Control or cop with symptoms ★ Phase III- maintenance ○ Maintain achievement ○ Prevent relapse ○ Achieve independence, satisfactory quality of life Nursing Diagnoses ● Hallucinations/delusions ● Risk for violence ● Distorted thinking/impaired abstract thinking ● Impaired communication ● Anosognosia ● Negative self-image ● Risk for loneliness ● Powerlessness ● Risk for suicide ● Impaired health maintenance Planning/Interventions ● 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
■ Remember the opposite effect with dopamine is Parkinson’s Disease ■ Treat positive and negative symptoms plus cognitive and affective, decrease depression and anxiety and suicidal behavior ■ Minimal to no EPS or tardive dyskinesia ■ Disadvantage- tendency to cause significant weight gain; risk of metabolic syndrome ● Weight gain, dyslipidemia, altered glucose ● Risk of diabetes, hypertension, atherosclerotic and increase in heart disease ■ More expensive than traditional ■ Agranulocytosis (especially clozapine) ■ Atypical (second-generation) antipsychotics ● Target positive or negative symptoms ○ Aripiprazole (Abilify) ○ Clozapine (Clozaril) ○ Olanzapine (Zyprexa) ○ Paliperidone (Invega) ○ Quetiapine (Seroquel) ○ Risperidone (Risperdal) ○ Aiprasidone (Geodon) ○ Third-generation (Atypical) ■ Really a subset of the SGAs ■ Aripiprazole (Abilify), brexpiprazole (Rexulti), and cariprazine (Vraylar) ■ Dopamine system stabilizers ■ 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 (everything dries up) ○ 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; seizures; 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 ■ Change in LOC ○ 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 ○ Great risk of infection, to where the infection kills the patient ● Prolongation of the QT interval ○ Delay of ventricular repolarization. May result in tachycardia, fainting, seizures, and even sudden death ○ EKG’s ● 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 (IM) or diphenhydramine (IV)) ➢ Akathisia: motor restlessness causing inability to stay sill or remain in one place ➢ Pseudoparkinsonism: temporary group of symptoms that resemble Parkinson’s Disease
◆ Home health care Program of Assertive Community Treatment (PACT) ★ Program of case management, team approach in providing comprehensive, community-based psychiatric treatment, rehabilitation, and support ★ Services include: ○ Substance abuse treatment ○ Psychoeducational programs ○ Family support/education ○ Mobile crisis intervention ○ Attention to healthcare needs ★ Services are provided by a multidisciplinary team of ○ Psychiatrists ○ Nurses ○ Social workers ○ Vocational rehabilitation therapists ○ Substance abuse counselors ★ Services available 24 hours a day, 365 days a year ★ Services provided wherever required ○ Person’s home ○ Neighborhood ○ Local restaurants ○ Stores ○ Parks Psychological Therapies ● Individual and group therapy ● Psychoeducaiton ● Medication prescription and monitoring ● Basic health assessment ● Cognitive remediation or enhancement ● Family therapy ● Support groups
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
● Alcohol and CNS depressants can result in additive CNS depression and even death ● More likely to occur in patients with renal or hepatic compromise ○ Miscellaneous drug: buspirone (BuSpar) ■ Non Sedating and non-habit forming ■ May have drug interaction with selective serotonin reuptake inhibitors (SSRIs) (serotonin syndrome) ■ Do not administer with MAOIs ■ Unknown mechanism of action ■ Administered on a scheduled basis ■ Adverse effects: paradoxical anxiety ■ Blurred vision ■ Headache ■ Nausea Mood-Stabilizing Drugs ● Lithium carbonate and lithium citrate ● Other drugs may be used in combination with lithium ○ Benzodiazepines ○ Antipsychotic drugs ○ Antiepileptic drugs ○ Dopamine receptor agonists ● Lithium ○ Drug of choice for the treatment of mania ■ It is thought to potentiate serotonergic neurotransmission ■ Narrow therapeutic range: acute mania– lithium serum level of 1 to 1 mEq/L; maintenance serum levels should range between 0. and 1 mEq/L ■ Level exceeding 1 to 2 mEq/L begin to produce toxicity, including gastrointestinal (GI) discomfort, tremor, confusion, somnolence, seizures, and possibly death ■ Keeping the sodium level in the normal range (135 to 145 mEq/L) helps to maintain therapeutic lithium levels ○ 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
NSG211 Test #2- updated version
Course: Health Care Concepts II (NSG 211)
University: Germanna Community College
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