Schizophrenia (1)
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Transcript of Schizophrenia (1)
SchizophreniaSchizophrenia
Definition The schizophrenic disorders are characterized in
general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time.
The most important psychopathological phenomena include thought echo thought insertion or withdrawal thought broadcasting delusional perception and delusions of control influence or passivity hallucinatory voices commenting or discussing the patient in
the third person thought disorders and negative symptoms.
Schizophrenia Schizophrenia occurs with regular frequency
nearly everywhere in the world in 1 % of population and begins mainly in young age (mostly around 16 to 25 years).
Schizophrenia is defined by etymology of the term from the Greek roots skhizein ("to
split") and phrēn, phren- ("mind") Dr. Emile Kraepelin in the 1887 and the illness itself is
generally believed to have accompanied mankind through its history
Swiss psychiatrist, Eugen Bleuler, coined the term, "schizophrenia" in 1911
deterioration in social, occupational, or interpersonal relationships
continuous signs of the disturbance for at least 6 months
History Emil Kraepelin: This illness develops relatively
early in life, and its course is likely deteriorating and chronic; deterioration reminded dementia („Dementia praecox“), but was not followed by any organic changes of the brain, detectable at that time.
Eugen Bleuler: He renamed Kraepelin’s dementia praecox as schizophrenia (1911); he recognized the cognitive impairment in this illness, which he named as a „splitting“ of mind.
Kurt Schneider: He emphasized the role of psychotic symptoms, as hallucinations, delusions and gave them the privilege of „the first rank symptoms” even in the concept of the diagnosis of schizophrenia.
4 A (Bleuler) Bleuler maintained, that for the diagnosis of
schizophrenia are most important the following four fundamental symptoms:
affective blunting disturbance of association (fragmented thinking) autism ambivalence (fragmented emotional response)
These groups of symptoms, are called „four A’ s” and Bleuler thought, that they are „primary” for this diagnosis.
The other known symptoms, hallucinations, delusions, which are appearing in schizophrenia very often also, he used to call as a “secondary symptoms”, because they could be seen in any other psychotic disease, which are caused by quite different factors — from intoxication to infection or other disease entities.
Course of Illness
Course of schizophrenia: continuous without temporary improvement episodic with progressive or stable deficit episodic with complete or incomplete remission
Typical stages of schizophrenia: prodromal phase active phase residual phase
Clinical Picture Diagnostic manuals:
lCD-10 („International Classification of Disease“, WHO) DSM-IV („Diagnostic and Statistical Manual“, APA)
Clinical picture of schizophrenia is according to lCD-10, defined from the point of view of the presence and expression of primary and/or secondary symptoms (at present covered by the terms negative and positive symptoms): the negative symptoms are represented by cognitive
disorders, having its origin probably in the disorders of associations of thoughts, combined with emotional blunting and small or missing production of hallucinations and delusions
the positive symptom are characterized by the presence of hallucinations and delusions
the division is not quite strict and lesser or greater mixture of symptoms from these two groups are possible
Positive and Negative Symptoms
NegativeNegative PositivePositive
AlogiaAlogia HallucinationsHallucinations
Affective flatteningAffective flattening DelusionsDelusions
Avolition-apathyAvolition-apathy Bizarre behaviourBizarre behaviour
Anhedonia-asocialityAnhedonia-asociality Positive formal thought Positive formal thought disorderdisorder
Attentional impairmentAttentional impairment
Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In: Schizophrenia, Hirsch S.R. and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995
The Criteria of DiagnosisFor the diagnosis of schizophrenia is necessary presence of one very clear symptom - from point a) to d) or the presence of the symptoms from at least two groups -
from point e) to h)for one month or more:
a) the hearing of own thoughts, the feelings of thought withdrawal, thought insertion, or thought broadcasting
b) the delusions of control, outside manipulation and influence, or the feelings of passivity, which are connected with the movements of the body or extremities, specific thoughts, acting or feelings, delusional perception
c) hallucinated voices, which are commenting permanently the behavior of the patient or they talk about him between themselves, or the other types of hallucinatory voices, coming from different parts of body
d) permanent delusions of different kind, which are inappropriate and unacceptable in given culture
The Criteria of Diagnosise) the lasting hallucination of every formf) blocks or intrusion of thoughts into the flow of thinking and
resulting incoherence and irrelevance of speach, or neologisms
g) catatonic behaviorh) „the negative symptoms”, for instance the expressed
apathy, poor speech, blunting and inappropriatness of emotional reactions
i) expressed and conspicuous qualitative changes in patient’s behavior, the loss of interests, hobbies, aimlesness, inactivity, the loss of relations to others and social withdrawal
Diagnosis of acute schizophorm disorder (F23.2) – if the conditions for diagnosis of schizophrenia are fulfilled, but lasting less than one month
Diagnosis of schizoaffective disorder (F25) - if the schizophrenic and affective symptoms are developing together at the same time
F20-F29 Schizophrenia, Schizotypal and Delusional Disorders
F20 Schizophrenia F20.0 Paranoid schizophrenia F20.1 Hebephrenic schizophrenia F20.2 Catatonic schizophrenia F20.3 Undifferentiated schizophrenia F20.4 Post-schizophrenic depression F20.5 Residual schizophrenia F20.6 Simple schizophrenia F20.8 Other schizophrenia F20.9 Schizophrenia, unspecified
F20-F29 Schizophrenia, Schizotypal and Delusional Disorders
F21 Schizotypal disorder F22 Persistent delusional disorders F22.0 Delusional disorder F22.8 Other persistent delusional disorders F22.9 Persistent delusional disorder, unspecified F23 Acute and transient psychotic disorders F23.1 Acute polymorphic psychotic disorder with
symptoms of schizophrenia F23.2 Acute schizophrenia-like psychotic disorder F23.3 Other acute predominantly delusional
psychotic disorders F23.8 Other acute and transient psychotic disorders F23.9 Acute and transient psychotic disorder,
unspecified
F20-F29 Schizophrenia, Schizotypal and Delusional Disorders
F24 Induced delusional disorder F25 Schizoaffective disorders F25.0 Schizoaffective disorder, manic type F25.1 Schizoaffective disorder, depressive type F25.2 Schizoaffective disorder, mixed type F25.8 Other schizoaffective disorders F25.9 Schizoaffective disorder, unspecified F28 Other nonorganic psychotic disorders F29 Unspecified nonorganic psychosis
F20.0 Paranoid Schizophrenia Paranoid schizophrenia is characterized
mainly by delusions of persecution, feelings of passive or active control, feelings of intrusion, and often by megalomanic tendencies also. The delusions are not usually systemized too much, without tight logical connections and are often combined with hallucinations of different senses, mostly with hearing voices.
Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.
F20.1 Hebephrenic Schizophrenia Hebephrenic schizophrenia is characterized by
disorganized thinking with blunted and inappropriate emotions. It begins mostly in adolescent age, the behavior is often bizarre. There could appear mannerisms, grimacing, inappropriate laugh and joking, pseudophilosophical brooding and sudden impulsive reactions without external stimulation. There is a tendency to social isolation.
Usually the prognosis is poor because of the rapid development of "negative" symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults.
Denoted also as disorganized schizophrenia
F20.2 Catatonic Schizophrenia Catatonic schizophrenia is characterized
mainly by motoric activity, which might be strongly increased (hypekinesis) or decreased (stupor), or automatic obedience and negativism.
We recognize two forms: productive form — which shows catatonic
excitement, extreme and often aggressive activity. Treatment by neuroleptics or by electroconvulsive therapy.
stuporose form — characterized by general inhibition of patient’s behavior or at least by retardation and slowness, followed often by mutism, negativism, fexibilitas cerea or by stupor. The consciousness is not absent.
F20.3 Undifferentiated Schizophrenia
Psychotic conditions meeting the general diagnostic criteria for schizophrenia but not conforming to any of the subtypes in F20.0-F20.2, or exhibiting the features of more than one of them without a clear predominance of a particular set of diagnostic characteristics.
This subgroup represents also the former diagnosis of atypical schizophrenia.
F20.4 Postschizophrenic Depression A depressive episode, which may be
prolonged, arising in the aftermath of a schizophrenic illness. Some schizophrenic symptoms, either „positive“ or „negative“, must still be present but they no longer dominate the clinical picture.
These depressive states are associated with an increased risk of suicide.
F20.5 Residual Schizophrenia A chronic stage in the development of
schizophrenia with clear succession from the initial stage with one or more episodes characterized by general criteria of schizophrenia to the late stage with long-lasting negative symptoms and deterioration (not necessarily irreversible).
F20.6 Simple Schizophrenia
Simple schizophrenia is characterized by early and slowly developing initial stage with growing social isolation, withdrawal, small activity, passivity, avolition and dependence on the others.
The patients are indifferent, without any initiative and volition. There is not expressed the presence of hallucinations and delusions.
F21 Schizotypal disorder According to lCD-10 this disorder is
characterized by eccentric behavior and by deviations of thinking and affectivity, which are similar to that occurring in schizophrenia, but without psychotic features and expressed symptoms of schizophrenia of any type.
F22 Persistent Delusional Disorders Includes a variety of disorders in which
long-standing delusions constitute the only, or the most conspicuous, clinical characteristic and which cannot be classified as organic, schizophrenic or affective.
Their origin is probably heterogeneous, but it seems, that there is some relation to schizophrenia.
F22.0 Delusional Disorder A disorder characterized by the
development of one delusion or of the group of similar related delusions, which are persisting unusually long, very often for the whole life.
Other psychopathological symptoms — hallucinations, intrusion of thoughts etc. are not present and are excluding this diagnosis.
It begins usually in the middle age.
F23 Acute and Transient Psychotic Disorders The criteria should be the following features:
acute beginning (to two weeks) presence of typical symptoms (quickly changing
“polymorphic symptoms”) presence of typical schizophrenic symptoms.
Complete recovery usually occurs within a few months, often within a few weeks or even days.
The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.
F24 Induced Delusional Disorder A delusional disorder shared by two or more
people with close emotional links. Only one of the people suffers from a genuine psychotic disorder; the delusions are induced in the other(s) and usually disappear when the people are separated.
The psychotic disorder of the dominant member of this dyad is mainly, but not necessarily, of schizophrenic type. The original delusions of dominant member and his partner are usually chronic, either persecutory or megalomanic.
F25 Schizoaffective Disorders Episodic disorders in which both affective and
schizophrenic symptoms are prominent (during the same episode of the illness or at least during few days) but which do not justify a diagnosis of either schizophrenia or depressive or manic episodes.
Patients suffering from periodic schizoaffective disorders, especially with manic symptoms, have usually good prognosis with full remissions without any remaining defects.
They are divided in different subgroups: F25.0 Schizoaffective disorder, manic type F25.1 Schizoaffective disorder, depressive type F25.2 Schizoaffective disorder, mixed type F25.8 Other schizoaffective disorders F25.9 Schizoaffective disorder, unspecified
Genetics of Schizophrenia
Many psychiatric disorders are multifactorial (caused by the interaction of external and genetic factors) and from the genetic point of view very often polygenically determined.
Relative risk for schizophrenia is around: 1% for normal population 5.6% for parents 10.1% for siblings 12.8% for children
Etiology of Schizophrenia
The etiology and pathogenesis of schizophrenia is not known
It is accepted, that schizophrenia is „the group of schizophrenias“ which origin is multifactorial: internal factors – genetic, inborn, biochemical external factors – trauma, infection of CNS, stress
Etiology of Schizophrenia - Dopamine Hypothesis
The most influential and plausible are the hypotheses, based on the supposed disorder of neurotransmission in the brain, derived mainly from
1. the effects of antipsychotic drugs that have in common the ability to inhibit the dopaminergic system by blocking action of dopamine in the brain
2. dopamine-releasing drugs (amphetamine, mescaline, diethyl amide of lysergic acid - LSD) that can induce state closely resembling paranoid schizophrenia
Classical dopamine hypothesis of schizophrenia: Psychotic symptoms are related to dopaminergic hyperactivity in the brain. Hyperactivity of dopaminergic systems during schizophrenia is result of increased sensitivity and density of dopamine D2 receptors in the different parts of the brain.
Etiology of Schizophrenia - Contemporary Models Dopamine hypothesis revisited: various
neurotransmitter systems probably takes place in the etiology of schizophrenia (norepinephric, serotonergic, glutamatergic, some peptidergic systems); based on effects of atypical antipsychotics especially.
Contemporary models of schizophrenia conceptualize it as a neurocognitive disorder, with the various signs and symptoms reflecting the downstream effects of a more fundamental cognitive deficit: the symptoms of schizophrenia arise from “cognitive
dysmetria” (Nancy C. Andreasen) concept of schizophrenia as a neurodevelopmental disorder
(Daniel R. Weinberger)
Etiology of Schizophrenia - Neurodevelopmental Model
Neurodevelopmental model supposes in schizophrenia the presence of “silent lesion” in the brain, mostly in the parts, important for the development of integration (frontal, parietal and temporal), which is caused by different factors (genetic, inborn, infection, trauma...) during very early development of the brain in prenatal or early postnatal period of life.
It does not interfere too much with the basic brain functioning in early years, but expresses itself in the time, when the subject is stressed by demands of growing needs for integration, during formative years in adolescence and young adulthood.
Treatment of Schizophrenia The acute psychotic schizophrenic patients will
respond usually to antipsychotic medication. According to current consensus we use in the first
line therapy the newer atypical antipsychotics, because their use is not complicated by appearance of extrapyramidal side-effects, or these are much lower than with classical antipsychotics.
conventional antipsychotics(classical neuroleptics)
chlorpromazine, chlorprotixene, clopenthixole, levopromazine, periciazine, thioridazine
droperidole, flupentixol, fluphenazine, fluspirilene, haloperidol, melperone, oxyprothepine, penfluridol, perphenazine, pimozide, prochlorperazine, trifluoperazine
atypical antipsychotics
amisulpiride, clozapine, olanzapine, quetiapine, risperidone, sertindole, sulpiride
Neuroleptics are drugs that modify psychotic symptoms, including
symptoms of bipolar disorder, schizophrenia, delusional disorder and psychotic depression.
There are two classes of neuroleptic drugs. Typical antipsychotics were discovered and first used in the 1950s, Atypical antipsychotics were developed and used in the 1970s.
Atypical neuroleptic drugs generally are regarded as more effective and less likely to cause side effects than typical neuroleptic drugs.
Tardive dyskinesia is a type of repetitive movement the patient cannot control
Side Effects: EPS Extrapyramidal syndrome is a condition that causes
involuntary muscle movements or spasms that usually occur in the face and neck. It occurs when the release and re-uptake of the neurotransmitter dopamine is not regulated correctly.
Muscle movement problems that may accompany extrapyramidal syndrome include constantly
smacking the lips moving the tongue, blinking, neck twitches and finger spasms.
Neuroleptics
Generic name Brand names
Chlorprothixene Truxal
LevomepromazineLevium, Levomepromazine Neuraxph., Neurocil
PerazinePerazin Neuraxph., Taxilan
Promethazine
Atosil, Closin, Promethazin Neuraxph., Proneurin, Prothazin
Prothipendyl Dominal
SulpirideDogmatil, Dogmatyl, Sulpirid
ThioridazineMelleril, Thioridazin Neuraxph.Generic name Brand names
Zuclopenthixol Cisordinol, Clopixol
Mild Strength[edit]Medium Strength
Mild Strength
iMedium Strength
Strong Strength
Generic name Brand names
Perfenazine Trilafon
Generic name Brand names
BenperidolBenperidol Neuraxph., Glianimon
Bromperidol Impromen
Fluphenazine
decanoate
Anatensol, Dapotum D, Deconoat, Fludecate, Modecate, Prolixin Decanoate, Sinqualone
enanthate
Dapotum Injektion, Flunanthate, Moditen Enanthate Injection, Sinqualone Enantat
hydrochloride
Dapotum, Permitil, Prolixin, Lyogen, Moditen, Omca, Sediten, Selecten, Sevinol, Siqualone, Trancin
FluspirilenFluspi, Fluspirilen Beta, Imap
Haloperidol Haldol, SerenasePimozide Orap
[Very Strong Strength
Aty
pic
al N
eu
role
pti
cs
Generic name Brand names
Amisulpride Solian
Aripiprazole Abilify
Asenapine Saphris
Benztropine Cogentin
BuspironeAnsial, Ansiced, Anxiron, Axoren, Bespar, Buspar, Buspimen, Buspinol, Buspisal, Narol
Chlorpromazine Largactil, Thorazine
Clozapine Clozaril, Fazaclo, Leponex
Flupenthixol Depixol, Fluanxol
Iloperidone Fanapt
Melperone Eunerpan, Melneurin
Olanzapine Zyprexa
Paliperidone Invega, Invega Sustenna
Penfluridol Semap
Quetiapine Seroquel
Risperidone Belivon, Risperdal, Risperdal Consta
Sertindole Serdolect, Serlect
Thiothixene Navane
TrifluoperazineEskazinyl, Eskazine, Jatroneural, Modalina, Stelazine, Terfluzine, Trifluoperaz, Triftazin
Ziprasidone Geodon, Zeldox
Zotepine Nipolept
Carbamazepine, Valproic acid sometimes used
Nursing Management The nurse may assess a client with a known
history of schizophrenia or a client with a unknown to the mental health care system. Assessment begins with an interview and focuses on establishing the client's signs and symptoms, degree of impairment in the thought process, risk for self injury or violence towards others, and available support systems. The nurse may wish to interview the client with a family member or a friend to obtain all information regarding family history, previous episodes of psychotic symptoms, onset of symptoms, and thoughts of suicide or violent behaviour
Assessment:
1. Assessing mood and cognitive state: The nurse is alert for the signs and symptoms such as : Absence of expression of feelings Language content that is difficult to follow Pronounced paucity of speech and thoughts Preoccupation with odd ideas Ideas of reference Expression of feelings of unreality Evidence of hallucinations such as comments that the way
they things appear, sound, or smell is different. The nurse can also inquire about recent stressors, which can
precipitate a psychotic episode in the client with a thought disorder, and signs and symptoms of impending relapse. These signs include disturbed sleep cycle, significant mood changes( mostly depression), decreased appetite, and somatic complaints such as headache, malaise, and constipation. Relapse eads to client withdrawal, resistance, and preoccupation with psychotic symptoms.
2. Assessing potential for violence:The nurse assess the potential for violence by
inquiring about the following: History of violent or suicidal behavior Extreme social isolation Feeling of persecution or being controlled by
others. Auditory hallucinations that tells the client to
commit violent acts. Concomitant substance use. Medication noncompliance Feelings of anger, suspiciousness, or hostility.
3. Assessing social support: Availability and responsiveness of a social support
network and the client's role in the family and community are important factors in nursing assessment
4. Assessing knowledge The nurse assess the client's and families
knowledge of schizophrenia, its treatment, and the potential for relapse. Adherence to medication regimens and other therapeutic schedules is bolstered when cients and families understand the biologic basis of the illness, signs of recovery and relapse, and their role in treatment.
NURSING DIAGNOSIS:
1. Disurbed thought process related to biochemical imbalances, as evidenced by hypervigilence, distractibility, por concentration, disordered thought sequencing, inappropriate responses, and thinking not based in reality.
2. Disturbed sensory perception( auditory/visual) related to biochemical imbalances, as evidencd by auditory or visual hallucinations.
3. Risk for other- directed or self directed violence related to delusional thoughts and hallucinatory commands, history of childhood abuse, or panic,as evidencedby overt aggressive acts, threatening stances, pacing, or suicidal ideation or plan.
4. Social isolation related to alterations in mental status and an ability to engage in satisfying personal relationships, as evidenced by sad, flat affect, absence of supportive significant others, withdrawal, uncommunicativeness and inability to meet the expectations of others.
5. Noncompliance with medication regimen related to health beliefs and lack of motivation, as evidenced by failure to adhere to medication schedule.
6. Ineffective coping related to disturbed thought process as evidenced by inability to meet basic needs.
7. Interrupted family process related to shift in health status of a family member and situational crisis, as evidenced by changes in the family's goals, plans, and activities and changes in family pattern and rituals.
8. Risk for ineffective family management of therapeutic regimen related to knowledge deficit and complexity of client,s healthcare needs.
Diagnoses Nursing Care Plans For Schizophrenia
Anxiety Bathing or hygiene self-care
deficit Disabled family coping Disturbed body image Disturbed personal identity Disturbed sensory
perception (auditory, visual, kinesthetic)
Disturbed sleep pattern Disturbed thought processes Dressing or grooming self-
care deficit Fear Hopelessness
Imbalanced nutrition: Less than body requirements
Impaired home maintenance Impaired social interaction Impaired verbal
communication Ineffective coping Ineffective role performance Powerlessness Risk for injury Risk for other-directed
violence Risk for self-directed
violence Social isolation
Disturbed Thought Processes Convey acceptance of client's need for false
belief but that you do not share the belief Do not argue or deny the belief Reinforce and focus on reality If client is suspicious Consistent staff Honest, keep all promises
Disturbed Sensory Perception Auditory/Visual
Observe for signs of hallucinations Avoid touching client without warning Do not reinforce the hallucination - let the
client know that you do not share the perception - "Even though I know the voices are real to you, I do not hear them"
Help client understand connection between anxiety and hallucinations
Try to distract
Social Isolation Convey accepting attitude by making brief,
frequent contacts. Show unconditional positive regard
Offer to be with client during group activities that he/she finds frightening
Give recognition and positive reinforcement for client voluntary interactions with others
Self Care Deficit Provide assistance as appropriate Encourage independence - positive
reinforcement concrete communications
Impaired verbal communication Seek validation and clarification Consistent staff Verbalizing the implied Orient to reality
Key outcomes Nursing Care Plans For Schizophrenia
The patient will consider an alternative interpretation of a situation without becoming unduly hostile or anxious.
The patient will perform bathing and hygiene activities to the fullest extent possible.
The patient's family will demonstrate adaptive coping behaviors.
The patient will verbalize positive feelings about self.
The patient will identify internal and external factors that trigger delusional episodes.
The patient will maintain maximum functioning within the limits of his auditory, visual, or kinesthetic impairment.
The patient will resume appropriate rest and activity patterns.
The patient will identify and perform activities that decrease delusions.
The patient will perform dressing and grooming activities to the fullest extent possible.
The patient will express fears and concerns. The patient and his family will participate in care
and prescribed therapies. The patient will remain free from signs of
malnutrition. The patient will develop effective coping behaviors. The patient will maintain usual roles and
responsibilities to the fullest extent possible. The patient will recognize symptoms and comply
with medication regimen. The patient will demonstrate effective social
interaction skills in both one-on-one and group settings.
The patient will express his needs. The patient will gradually join in self-care and the
decision-making process. The patient will remain free from injury. The patient won't harm others. The patient won't harm self or others. The patient will maintain family and peer
relationships.
Interventions Nursing Care Plans For Schizophrenia
Assess the patient's ability to carry out the activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn't eating. If he thinks that his food is poisoned, allow him to fix his own food when possible, or offer him foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container.
Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to your facility's policy to ensure the patient's safety and that of others.
Adopt an accepting and consistent approach with the patient. Don't avoid or overwhelm him. Keep in mind that short, repeated contacts are best until trust has been established.
Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself.
Reward positive behavior to help the patient improve his level of functioning.
Engage the patient in reality-oriented activities that involve human contact: inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide reality-based explanations for distorted body images or hypochondriacal complaints. Clarify private language, autistic inventions, or neologisms, explaining to the patient that what he says isn't understood by others. If necessary, set limits on inappropriate behavior.
If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they're command hallucinations that place the patient or others at risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing about the hallucinations; if possible, change the subject.
Don't tease or joke with the patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who's told, That procedure will be done on the floor, may become frightened, thinking he is being told to lie down on the floor.
Don't touch the patient without telling him first exactly what you're going to do. For example, clearly explain to him, I'm going to put this cuff on your arm so I can take your blood pressure. If necessary, postpone procedures that require physical contact with facility personnel until the patient is less suspicious or agitated.
Remember, institutionalization may produce new symptoms and handicaps in the patient that aren't part of his diagnosed illness, so evaluate symptoms carefully.
Mobilize community resources to provide a support system for the patient and reduce his vulnerability to stress. Ongoing support is essential to his mastery of social skills.
Encourage compliance with the medication regimen to prevent relapse. Also monitor the patient carefully for adverse effects of drug therapy, including drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome. Make sure you document and report such effects promptly.
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