HANDOUT # 5 Care Of Clients with Maladaptive Patterns of MIDTERMS

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Schizophrenia Definition: Severe impairment of mental & social functioning with grossly impaired reality testing, sensory perception and with deterioration & regression of psychosocial functioning. A. ASSESSMENT FINDINGS (GENERAL SIGNS): THE FOUR As of SCHIZOPHRENIA ACCORDING TO BLEULER __________________________: jumping to different topics WITHOUT association or relevance __________________________: (Two opposing feelings toward others at the same time) __________________________: (withdrawal from environment and others, neologism, aloofness) __________________________:(Inappropriate or no display of feelings) #1 HALLUCINATION of Schizophrenia is __________________________. DSM V Criteria for Schizophrenia:Characterized by both (-) & (+) symptoms & social / occupational dysfunction for at least SIX (6) months. SIGNS OF SCHIZOPHRENIA: _____________________________________ H I L D D A P I (-) NEGATIVE SIGNS OF SCHIZOPHRENIA: ______________________________________ P P P A A A NURSING DIAGNOSIS FOR SCHIZOPHRENIA: 1. Alteration in Thought Process; 2. Alteration in Content of Thought OTHER NEGATIVE SYMPTOMS: All thEsE signs & symptoms can also be seen in SAM (S______________ A___________ & M________) 1. Neologism _____________________vs. Word Salad _____________________________
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2. Flight of Ideas _____________________________: Commonly seen in MANIC patients, also in Schizophrenia. 3. Verbigeration _________________________________________ vs. Perseveration e.g. 1st stimulus correct response 2nd & following stimulus still responding to the 1st stimuli 4. Circumstantiality _______________________________ Vs. Tangentiality ________________________ 5. Clang association (use of rhymes in sentences) vs. Echolalia/Parroting (Commonly seen in AUTISM) B.PRIORITIZED NURSING DIAGNOSES FOR ALL TYPES OF SCHIZOPHRENIA: 1.Risk for violence: Directed toward self or other PRIORITY 2. Self-care deficit 3.Thought process, altered 4.Sensory/perceptual alterations ( related to illusion,delusion & hallucination) 5.Social isolation NURSING INTERVENTIONS Leave door open -Distance from pt: 1 arms length -stay near door not window -have visibility: stand halfway in & out to be able to call for reinforcement. -calm and firm. ADDITIONALS: THOUGHT PROCESS DISTURBANCE: 1. ______________________________: topics have connection but no thought. I am going to the mall. The mall is in town. The town flies. Flies are here. 2.______________________________: New unrelated topics. 3.______________________________: Pulled by 2 opposing forces. 4. _____________________________: believes he has magical powers. I can turn you into a frog. 5. _____________________________: repeat what is said. Parrots. 6.______________________________: repeats what you do. Repeats what is seen. 7.______________________________: mixes words that dont rhyme. 8.______________________________: uses words that rhyme. Flank, blank, prank. 9.______________________________: invents new words not in the dictionary. Ploopplank, pisnok. 10._____________________________: false belief Grandeur--------------I am a queen/ king/millionaire! Persecution------------THE NBI is out to get me! Ideas of reference-----They talk and write about me! 11.________________________________: pilosopo. What will you wear tomorrow? Clothes 12. ________________________________: ILLUSIONS (with stimuli) Stimuli Visual Auditory
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HANDOUT # 5 Care Of Clients with Maladaptive Patterns of MIDTERMS

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Types of schizophrenia
1. DISORGANIZED SCHIZOPHRENIA: sad inside, happy outside inappropriate affect (+)flat affect no affect (-) disorganized manner/speech flight of ideas (+) Hebephrenic- giggling (+) Sx: both (+) and (-). Another word is Hebephrenic. Characterized with inappropriate behavior: Silly crying, laughing, regression, transient hallucinations (Auditory). All behaviors are similar with toddlers since they are anal fixated. Developmental Stage FIXATION: ___________________________ #1 Defense Mechanism:__________________________________________ 2. CATATONIC SCHIZOPHRENIA: ambivalence anal stage (-) No! Negativisim-rebel-anal (-) Waxy flexibility: raise arm of patient. Patients arm remains up for a long time. (-) (-) > (+) With stereotyped position (catatonia) with waxy flexibility, mutism, bizarre mannerism. #1 Defense mechanism:_________________________________ #1 Cardinal Sign of Catatonia ____________________________ (cerea flexibilitas) similar in children with autism Most dangerous/serious type of schizophrenia_________________________________ CATATONIC CHARACTERISTICS: Catatonic stupor markedly slowed movement. Catatonic posturing- bizarre or weird positions Catatonic rigidity cementation/stone-like position Catatonic negativism resistance towards flexion & extension PRIORITIZED NURSING DIAGNOSIS: 1. Fluid & Electrolyte Imbalance 2. Altered Nutrition less than body requirement 3. Self-Care Deficit 3. PARANOID SCHIZOPHRENIA: uses projection. Mistrust, Scared/withdrawn/violent Develop trust: orientation -1:1 interaction -consistent approach -short/frequent interaction -food: sealed container -meds: wrapped in tamper resistant foil
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HANDOUT # 5 Care Of Clients with Maladaptive Patterns of MIDTERMS

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Presenting sign is _____________________________________ ideas of persecution and delusions; sees environment as hostile. And threatening. REMEMBER the 3PS Proxemics( 7 feet away from the patient), Passive Friendliness (#1 attitude therapy: no touching, , no whispering & laughing) , delusion of Persecution (#1 delusion of Paranoid Schizophrenia) , A patient who says, The other staff members are laughing at my back. shows a paranoid delusion of schizophrenia. Schizophrenic says, Someone has placed a transistor in my brain, correct interpretation shows paranoid delusion Statement like, I dont like to eat meat because animal produced foods are Poisonous, shows suspicious paranoid type schizophrenia. Developmental Stage FIXATION: _________________________________________ NURSING CONSIDERATION: 1. Consistency to build trust 2. Food: PACKED OR SEALED foods except canned goods: no metal 3. Social Isolation no group session when schizophrenic Paranoid who is suspicious saying, This place is meant for bugs & prison, In order to encourage trust, the patient should be involved in the plan of care. 4. UNCLASSIFIED OR UNDIFFERENTIATED SCHIZOPHRENIA: Symptoms of more than one type of schizophrenia has delusions & disorganized behavior but DOES NOT meet the critieria for the above sub types alone. The #1 drug of choice is Fluphenazine (Prolixin decanoate) 5. RESIDUAL SCHIZOPHRENIA: no more (+), (-). Social withdrawal No longer exhibits overt symptoms, no more delusions but still has negative symptoms or odd beliefs or unusual perceptions. Undifferentiated type chronic schizophrenia must be referred to a program promoting social skills due to functional loss deficit. Let Us Recall:

Paranoid schizophrenia o Suspiciousness o Hostility o Delusions o Auditory hallucinations Disorganized schizophrenia o Extreme social withdrawal o Disorganized speech or behavior o Flat or inappropriate affect

o o o o o o o

Anxiety and anger Aloofness Persecutory schemes Violence Silliness unrelated to speech Stereotyped behaviors Grimacing mannerisms

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HANDOUT # 5 Care Of Clients with Maladaptive Patterns of MIDTERMS

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Inability to perform activities of daily living Catatonic schizophrenia o Significant psychomotor o Excessive purposeless motor activity disturbances o Echolalia o Immobility o Automatic obedience o Stupor o Stereotyped or repetitive behavior o Waxy flexibility Undifferentiated schizophrenia o Undifferentiated schizophrenia does not meet the criteria for paranoid, disorganized, or catatonic schizophrenia o Delusions and hallucinations o Disorganized speech o Disorganized or catatonic behavior o Flat affect o Social withdrawal Residual schizophrenia o Diagnosed as schizophrenic in the past o Time limited between attacks but may last for many years o The client exhibits considerable social isolation and withdrawal and impaired role functioning
o

Interventions Assess the clients physical needs Set limits on the clients behaviors when it interferes with others and becomes disruptive Maintain a safe environment Initiate one-on-one interaction and progress to small groups as tolerated o Although, reintegrating the client into the milieu as soon as possible is essential Spend time with the client even if client is unable to respond Monitor for altered thought processes Maintain ego boundaries and avoid touching the client o Touching others without warning or invitation o Intruding in others living spaces o Talking to or caressing inanimate objects o Undressing, masturbating, or urinating in public Avoid an overly-warm approach; a neutral approach is less threatening Do not make promises to the client that cannot be kept Establish daily routines Assist the client to improve grooming and to accept responsibility for self-care Sit with the client in silence if necessary Provide short, brief and frequent contact with the client Tell the client when you are leaving Do not go along with the clients delusions or hallucinations Provide simple concrete activities such as puzzles or word games Reorient the client as necessary Help the client establish what is real and unreal Stay with the client if he is frightened
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HANDOUT # 5 Care Of Clients with Maladaptive Patterns of MIDTERMS

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Speak to the client in a simple direct and concise manner Reassure the client that the environment is safe Set realistic goals Initially do not offer choices to the client, and gradually assist the client in making own decisions Use canned or packaged food, especially with the paranoid schizophrenic client Provide a radio or tape player at night for insomnia Explain to the client everything that is being done Set limits on the client behavior if the client is unable to do so Decrease excessive stimuli in the environment Monitor for suicide risk Assist the client to use alternative means to express feelings through must or art therapy or writing.

Nursing interventions for the client experiencing delusions Be open and honest in interactions to reduce suspiciousness Focus the conversation on reality based topics rather than the delusion Encourage the client to express feelings and focus on the feelings that the delusions generate Do not dispute with the client or try to convince the client that the delusions are false Validate if part of the delusion is real Recognize accomplishments and provide positive feedback for successes Nursing interventions for the client experiencing hallucinations Monitor for hallucination cues o See blue box on page 296 Intervene with one on one contact Decrease stimuli or move the client to another area Avoid conveying to the client that others are also experiencing the hallucination Respond verbally to anything real the client talks about Avoid touching the client Encourage the client to express feelings Accept and do not judge or joke about the clients behavior Provide easy activities and a structured environment with routine activities of daily living Monitor for signs or increasing fear, anxiety, or agitation Provide seclusion if necessary Administer medications as prescribed Language and communication disturbances Clang association: Repetition of words or phrases that are similar in sound but in no other way. Echolalia: Repetition of words or phrases heard from another person Mutism: Absence of verbal speech Neologism: A new word devised that has a special meaning to the client Word salad: Form of speech in which words or phrases are connected meaninglessly Latency of response: hesitation before the client responds to questions. This latency or hesitation may last 30-45 seconds and usually indicates the clients difficulty with cognition or thought processes. Thought broadcasting: believe that others can hear their thoughts Thought withdrawal: believe others are taking their thoughts
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HANDOUT # 5 Care Of Clients with Maladaptive Patterns of MIDTERMS

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Thought insertion: others are placing thoughts in their mind against their will

Abnormal motor behaviors _____________________________: Displaying motor restlessness and muscular quivering; the client is unable to sit or lie quietly _____________________________: Repeating the movements of another person _____________________________: having ones arms or legs placed in a certain position and holding that same position for hours _____________________________: Impairment of the power of voluntary movements D. PRINCIPLES OF CARE 1. Maintenance of safety: Protect from altered thought processes. Respond to feelings, and not to delusions; Do not argue; Validate reality; remove from areas of tension Suspiciousness & paranoid patient is threatening to the staff, the action of an RN that shows a need for further teaching is when she goes to the room of a pt. who yells, Everyone, out of here, Appropriate action of RN to a Schizophrenic who yells loudly, talks t o wall and saying Dont talk to me, bastard. includes walking towards the pt & ask him who he is talking to. 2. Meeting of physical needs: May have to be fed / bathed initially 3. Establishment and maintenance of therapeutic relationship: Engage in individual therapy; Promote trust; Encourage expression by verbalizing the observed; Offer presence-Tolerate long silences 4. Implementation of appropriate family, group, social or diversional therapies Patients with schizophrenia need activities that do not require interaction, so solitary activities are preferred over team activities. Admission assessment of a Schizophrenic client reveals auditory hallucination, and drinking more than 6 L of water daily for past weeks, priority focus should be hyponatremia. Desired efficacy of treatment in schizophrenic patient who is mute & immobilized includes standing up when RN enters the room.
READING ASSIGNMENT: PSYCHOPHARMACOLOGY AND SCHIZOPHRENIA ANTIPSYCHOTICS Another word: Neuroleptic / Major Tranquilizers USES: Schizophrenia, acute mania, depression and organic conditions; Non-psychiatric cases: Nausea and vomiting, pre-anesthesia, intractable hiccups. Antipsychotics can only decrease the positive symptoms of schizophrenia, but not the negative symptom such as ambivalence. Action: delusion, hallucinations, looseness of association to decrease levels of dopamine in the substantia nigra

I. Phenothiazine Code: AZINE

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_________________________________________________________________________________________________ Fluphenazine (Prolixin)* Acetophenazine (Tindal) Pherphenazine (Trilafon) Promazine (Sparine) Chlorpromazine (Thorazine)* ALERT: #1 that causes photosensitivity/photophobia; Side effects: Causes also red orange urine In liquid form is usually put in a chaser Mesoridazine (Serentil) Thioridazine (Mellaril)* ceiling dose/day: 800 mg Adverse Effect: retinitis pigmentosa Prochlorperazine (Compazine)* #1 commonly used anti emetic Compazine causes anticholinergic side effects Trifluoperazine (Stelazine) II. Butyrophenones Code : PERIDOL Haloperidol (Haldol, Serenase)* ALERT: #1 drug used for extreme violent behaviour Instruct patient taking Haldol to wear sunscreen Droperidol (Inapsine) III. Thioxanthenes Code: THIXENE Chlorprothixene (Taractan Thiothixene (Navane) IV. Atypical Antipsychotics Code: DONE / ZAPINE or APINE Olanzapine (Zyprexia) Clozapine (Clozaril) ALERT: #1 that causes Agranulocytosis & Blood Dyscrascia I will need to monitor my blood level to continue my medication. shows a correct understanding of a patient while taking Clozaril. Loxapine (Loxitane) Risperidone (Risperidone) #1 drug for Korsakoffs psychosis Molindone (Moban) Aripiprazole (Abilify) newest antipsychotic drug SIX COMMON ANTICHOLINERGIC SIDE EFFECTS OF ANTIPSYCHOTICS (Anticholinergic effects are drug actions of antipsychotic drugs because they BLOCK MUSCARINIC CHOLINERGIC RECEPTORS) CODE: BUCO PanDan anticholinergic S/Es
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1. Blurring of Vision - sympathetic reaction (dont operate machinery); Mydriatic pupil dilate: sympa : IOP dont use in glaucoma 2. Urinary Retention (Post Partum, Autonomic Dysreflexia, paraplegia) Nursing Interventions: 1. Provide Privacy give bed pan 2. Sounds of dripping water faucet 3. Intermittent cold & warm compress 3. Constipation Nursing Interventions: 1. Prevent constipation fiber (residue) AG or roughage, prune/pineapple/papaya juice/ fruits 2. exercise 4. Orthostatic Hypotension/Postural Hypotension - take BP in supine, Fowlers & standing position. Difference of BP 15-20 mm Hg below S/Sx: Ppallor, dizziness Nursing consideration: Slowly change position Told patient to dangle feet first before standing 5. Pan Photosensitivity (photophobia) Nursing Intervention: 1. Use sun glasses, sun block, long sleeves or/and umbrella Patients taking antipsychotic should be instructed to wear wide brimmed hat when going outside 6. Dan Dry mouth/ Xerostomia Prioritized Nursing Intervention: Give (1) ice chips, (2) chewing gum, (3) sips of water ACUTE/COMMON SIDE-EFFECTS FOR PROLONGED USED OF ANTIPSYCOTICS Extrapyramidal Symptoms (EPS) Common Signs & Symptoms: Definition of EPS: Reversible side effect (except TARDIVE DYSKINESIA), which is a result of neurological dysfunction of the Extrapyramidal System. Patients taking with prolonged antipsychotic medications should always be assessed for symptoms of extrapyramidal symptoms. 1. Akathisia another word: Motor restlessness 1-6 wks Signs of motor restless: Foot tapping, finger fidgeting, cant sit down for more than 15 minutes and pacing back & forth. Patient is unable to remain still Drug of Choice: CODE: CBA #1 Cogentin (Benztropine Mesylate) #2 Benadryl (Diphenhydramine Hcl)
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HANDOUT # 5 Care Of Clients with Maladaptive Patterns of MIDTERMS

_________________________________________________________________________________________________ #3 Akineton (Biperiden Hcl) 2.Dystonia #1 cardinal Sign: Oculogyric crisis = involuntary rolling of eyeballs, neck shoulder, jaw and throat spasm (dysphagia) 2-5 days Drug of Choice:CODE: CBA #1 Cogentin (Benztropine Mesylate) #2 Benadryl (Diphenhydramine Hcl) #3 Akineton (Biperiden Hcl) 3. Pseudoparkinsonism - another word: Drug-induced Parkinsonism #1 sign: Pill--rolling tremors. Other signs: Mask-like face, flat affect, shuffling gait or festinating gait, cogwheel rigidity. DRUG OF CHOICE: #1 Artane (trihexyphenydyl) #2 Amantadine ( Symmetrel) can also be used in Chicken pox, also an ANTI VIRAL 4. Tardive Dyskinesia Starts with T: TONGUE (tongue rolling & tongue protrusion) lip smacking, tongue rolling, protrusion of the tongue, vermicular or vermiform tongue rolling irreversible. This is an EMERGENCY!!! Symptoms of tardive dyskinesia include fly catchers mouth, tongue thrusting, facial grimacing, puckering of cheeks, and drooling of saliva.administer Artane, Benadryl, Cogentin, Antiparkinsonian drug 5.Akinesia absence of kinetic movements ANTI- EPS MEDICATIONS CODE: PACABBA - Usually they are anticholinergic & antiparkinsonian drugs Procyclidine (kemadryl, kemadrin) Artane ( trihexyphenydyl) Cogentin (Benztropine mesylate) Akineton (biperiden Hcl) Bromocriptine (Parlodel) Benadryl (Diphenhydramine) Amantadine (Symmetrel) ADVERSE EFFECT OF ANTIPSYCHOTIC DRUGS: Neuroleptic Malignant Syndrome RARE, LIFE-THREATENING : (EXTREME EMERGENCY): #1 Cardinal Sign is High fever, tremors, tachycardia, tachypnea, sweating, hyperkalemia, stupor, incontinence, renal failure, muscle rigidity ALERT: (Discontinue all drugs STAT; ventilation; hydration; nutrition; renal dialysis; hydrotherapeutic measures).

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[Type here] Elevated blood pressure and diaphoresis are indicative of Neuroleptic malignant syndrome, which is a medical emergency. ANTIDOTE: Dantrolene (Dantrium) or Bromocriptine (ParlodeL))

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