Schizophrenia and Other Psychotic · PDF fileSchizophrenia and Other Psychotic Disorders...
Transcript of Schizophrenia and Other Psychotic · PDF fileSchizophrenia and Other Psychotic Disorders...
CHAPTER 8
Schizophrenia andOther Psychotic
Disorders
OVERVIEWSchizophreniaThe schizophrenias are severe and persistent neurologicdiseases. These serious disorders affect a person’s:● Perceptions (hallucinations and delusions)● Thinking (delusions, paranoia, disorganized thinking)● Language (associative looseness, poverty of speech)● Emotions (apathy, anhedonia, depression)● Social behavior (aggressive, bizarre behaviors or extreme
social withdrawal)Schizophrenia affects approximately 1% of the popula-
tion, and 95% of individuals who become schizophrenichave the condition throughout their lifetime. Schizophreniais a relapsing psychotic disorder. A psychotic disorder is onein which people have difficulty with differentiating realityfrom fantasy (reality testing).
Major symptoms seen in psychotic disorders are hallu-cinations, delusions, and disorganized thinking. Hallucina-tions and delusions can be very frightening, oftenterrifying for individuals. They also can be very discon-certing initially and even frightening to nurses and otherhealth care individuals. These are the positive symptoms
212
X29168-P0208.qxd 6/24/05 8:42 PM Page 212
of schizophrenia. Nurses can greatly benefit from individ-ual or peer supervision when dealing with these challeng-ing phenomena. Communicating with clients who aredelusional and hallucinatory and have disorganized think-ing is a skill that is learned with guidance and practice.
The negative symptoms of schizophrenia are more sub-tle and are the most damaging to the client’s quality of life.Negative symptoms include feelings of emptiness, amoti-vational states, anhedonia, and apathy.
Cognitive symptoms (poor problem-solving, poor deci-sion-making skills, illogical thinking) also need to be tar-geted when planning care.
The symptoms of schizophrenia usually become appar-ent during adolescence or early adulthood (15 to 25 for men,25 to 35 for women). Paranoid schizophrenia has a lateronset. The schizophrenias are severe, biologically basedmental illnesses. Current theories of schizophrenia involveneuroanatomical and neurochemical abnormalities, whichmight be induced either genetically or environmentally(birth defects, viruses). Although the schizophrenias are notcaused by psychological events, stressful life events cantrigger an exacerbation of the illness. Therefore, psychoed-ucational and family treatment modalities can be crucial inhelping clients in a number of ways. Psychoeducational,family, group, and behavioral approaches, for example, canhelp clients increase their social skills, maximize their abil-ity in self-care and independent living, maintain medicaladherence, and, most important, increase the quality oftheir lives. Client and family education greatly improvesthe management of schizophrenia.
Schizophrenia is not a single disease, but rather a syn-drome that involves cerebral blood flow, neuroelectro-physiology, neuroanatomy, and neurobiochemistry. TheDiagnostic and Statistical Manual of Mental Disorders (4th edi-tion, text revision) (DSM-IV-TR) criteria for the diagnosis ofschizophrenia are listed in Box 8–1.
Box 8–2 identifies five subtypes of schizophrenia.
Other Psychotic Disorders
Schizophreniform DisorderThe essential features of this disorder are exactly those
of schizophrenia except that:
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 213
X29168-P0208.qxd 6/24/05 8:42 PM Page 213
214 PART II Diagnosis and Care Planning
1. Characteristic symptoms: Two (or more) of the following, eachpresent for a significant portion of the time during a 1-monthperiod (or less if successfully treated):● Delusions● Hallucinations● Disorganized speech (e.g., frequent derailment or incoherence)● Grossly disorganized or catatonic behavior● Negative symptoms, (i.e., affective flattening, alogia,or avolition)
Note: Only one Criterion 1 symptom is required if delusions arebizarre or hallucinations consist of a voice keeping up a runningcommentary on the person’s behavior or thoughts, or two ormore voices conversing with each other.2. Social/occupational dysfunction: For a significant portion of the
time since the onset of the disturbance, one or more majorareas of functioning, such as work, interpersonal relations, orself-care, are markedly below the level achieved prior to theonset (or when the onset is in childhood or adolescence, fail-ure to achieve expected level of interpersonal, academic, oroccupational achievement).
3. Duration: Continuous signs of the disturbance persist for atleast 6 months. This 6-month period must include at least 1month of symptoms (or less if successfully treated) that meetCriterion I (i.e., active-phase symptoms) and might includeperiods of prodromal or residual symptoms.
4. Symptoms are not caused by (a) another psychotic disorder;(b) a substance or general medical disorder; or (c) a pervasivedevelopmental disorder, unless prominent delusions or hallu-cinations are also present for at least 1 month.
Box8-1
DSM-IV-TRCriteria for Schizophrenia
Adapted from American Psychiatric Association (2000). Diagnostic andstatistical manual of mental disorders (4th ed., text revision). Washington,DC: American Psychiatric Association, p. 312; reprinted with permission.
● The total duration of the illness is at least 1 month, butless than 6 months.
● Impaired social or occupational functioning during somepart of the illness is not apparent (although it mightoccur).
This disorder might or might not have a good prognosis.
X29168-P0208.qxd 6/24/05 8:42 PM Page 214
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 215
Paranoid
Onset usually in the late 20s to 30s. People who developthis disorder usually function well before the onset of thedisorder (good premorbid functioning). Paranoia (anyintense and strongly defended irrational suspicion) is themain characteristic; the main defense is projection.Hallucinations, delusions, and ideas of reference are dominant.
Disorganized
The most regressed and socially impaired of all the schizo-phrenias. The person has highly disorganized speech andbehavior and inappropriate affect. Bizarre mannerismsinclude grimacing, along with other oddities of behavior.
Catatonia
The essential feature is abnormal motor behavior. Twoextreme motor behaviors are seen in catatonia. Oneextreme is psychomotor agitation, which can lead toexhaustion. The other extreme is psychomotor retardationand withdrawal to the point of stupor. The onset is usuallyacute, and the prognosis is good with medications andswift interventions. Other behaviors might include autism,waxy flexibility, and negativism.
Undifferentiated (Mixed Type)
Clients experience active hallucinations and delusions, butno one clinical picture dominates (e.g., not paranoid, cata-tonic, or disorganized; rather the clinical picture is one of amixture of symptoms).
Residual
A person who is referred to as having residual schizo-phrenia no longer has active symptoms of the disease,such as delusions, hallucinations, or disorganized speechand behaviors. However, there is a persistence of somesymptoms—for example, marked social withdrawal;impairment in role function (wage earner, student, orhomemaker); eccentric behavior or odd beliefs; poor per-sonal hygiene; lack of interest, energy, initiative; and inap-propriate affect.
Box 8-2 Subtypes of Schizophrenia
X29168-P0208.qxd 6/24/05 8:42 PM Page 215
216 PART II Diagnosis and Care Planning
Brief Psychotic DisorderThis is a disorder in which there is a sudden onset of psy-chotic symptoms (delusions, hallucinations, disorganizedspeech) or grossly disorganized or catatonic behavior. Theepisode lasts at least 1 day, but less than 1 month, and thenthe individual returns to his or her premorbid level of func-tioning. Brief psychotic disorders often follow extremelystressful life events.
Schizoaffective DisorderThis disorder is characterized by an uninterrupted periodof illness during which there is a major depressive, manic,or mixed episode, concurrent with symptoms that meetthe criteria for schizophrenia. The symptoms must not bedue to any substance use or abuse or general medicalcondition.
Delusional DisorderThis disorder involves nonbizarre delusions (situationsthat occur in real life, such as being followed, infected,loved at a distance, deceived by a spouse, or having a dis-ease) of at least 1 month’s duration. The person’s ability tofunction is not markedly impaired, nor is the person’sbehavior obviously odd or bizarre. Common types of delu-sions seen in this disorder are delusions of grandeur, per-secution, or jealousy, or somatic or mixed delusions.
Shared Psychotic Disorder (Folie à Deux)A shared psychotic disorder is an occurrence in which oneindividual, who is in a close relationship with anotherwho has a psychotic disorder with a delusion, eventuallycomes to share the delusional beliefs either in total or inpart. Apart from the shared delusion, the person whotakes on the other’s delusional behavior is not otherwiseodd or unusual. Impairment of the person who shares thedelusion is usually much less than the person who has thepsychotic disorder with the delusion. The cult phenome-non is an example, as was demonstrated at Waco andJonestown.
X29168-P0208.qxd 6/24/05 8:42 PM Page 216
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 217
Induced or Secondary PsychosisPsychosis can be induced by substances (drugs of abuse,alcohol, medications, or toxin exposure) or caused by thephysiologic consequences of a general medical condition(delirium, neurologic conditions, metabolic conditions,hepatic or renal diseases, and many more). Medical condi-tions and substances of abuse must always be ruled outbefore a primary diagnosis of a schizophrenia or otherpsychotic disorder can be made.
Phases of SchizophreniaSchizophrenia has been divided into three phases:Phase I—Onset. This phase (acute phase) includes the pro-
dromal symptoms (e.g., acute or chronic anxiety, pho-bias, obsessions, compulsions, dissociative features) aswell as the acute psychotic symptoms of hallucinations,delusions, and/or disorganized thinking.
Phase II—Years following onset. Patterns that character-ize this phase are the ebb and flow of the intensity anddisruption caused by symptoms, which might, in somecases, be followed by complete or relatively completerecovery.
Phase III—Long-term course and outcome. This is thecourse that the severely and persistently mentally illclient follows when the disease becomes chronic. Forsome clients, the intensity of the psychosis might dimin-ish with age; however, the long-term dysfunctionaleffects of the disorder are not as amenable to change.
ASSESSMENT
Presenting Signs and Symptoms1. Positive symptoms
● Delusions● Hallucinations● Disorganized thinking/speech● Disorganized or catatonic behavior
2. Negative symptoms● Flat emotional affect● Sparse productivity of thought (Alogia)● Lack of goal directed activity (Avolition)
X29168-P0208.qxd 6/24/05 8:42 PM Page 217
3. Cognitive symptoms● Memory and attention deficits● Language difficulties● Protiens monitoring personal behavior, establishing
goals maintaining tasks, and so on
Assessment ToolThe Brief Psychiatric Rating Scale (BPRS) (Appendix D-5) isa useful tool for evaluating overall psychiatric functioning.It is particularly helpful in evaluating the degree to whichpsychotic symptoms affect a person’s ability to function.
Assessment Guidelines
Schizophrenias
Assessing Positive Symptoms1. Assess for command hallucinations (e.g., voices telling
the person to harm self or another). If yes:● Do you plan to follow the command?● Do you believe the voices are real?
2. Assess if the client has fragmented, poorly organized,well-organized, systematized, or extensive system ofbeliefs that are not supported by reality (delusions). If yes:● Assess if delusions have to do with someone trying to
harm the client and if the client is planning to retaliateagainst a person or organization.
● Assess if precautions need to be taken.3. Assess for pervasive suspiciousness about everyone and
their actions, for example:● Is on guard, hyperalert, vigilant● Blames others for consequences of own behavior● Is hostile, argumentative, or often threatening, in ver-
balization or behavior
Assessing Negative Symptoms4. Assess for negative symptoms of schizophrenia (see
Table 8-1 for definitions and suggested interventions).5. Assess if client is on medications, what the medications
are, and if treatment is adherent with medications.6. How does the family respond to increased symptoms?
Overprotective? Hostile? Suspicious?7. How do family members and client relate?
218 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 218
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 219
8. Assess support system. Is family well informed aboutthe disease (e.g., schizophrenia)? Does family under-stand the need for medication adherence? Is familyfamiliar with family support groups in the community,or where to go for respite and family support?
NURSING DIAGNOSES WITHINTERVENTIONSPeople with schizophrenia often have multiple needs. Basicto these is safety. Refer to Chapters 16 and 17 for nursingcare plans identifying nursing interventions for suicideintent and violence toward others. Suicide and threat ofviolence to others are basic to nursing interventions for allclients in all settings, not just for people with schizophreniaor the hospitalized person.
Relating to people with schizophrenia can be a chal-lenge, especially in the acute phase; therefore guidelines for
Table 8-1 Negative (Deficit) Symptoms of Schizophrenia
Symptoms Clinical Findings Treatment
Apathy Slow onset The newer atypical Poverty of Interferes with a (novel) antipsychotics speech or person’s life might target some of content of Positive premorbid the negative symptoms.speech history The most used inter-
Poor social Chronic deterioration ventions include:functioning Family history of 1. Skill training
Anhedonia schizophrenia interventions:Social Cerebellar atrophy ● Identify areas
withdrawal and lateral and third of skill deficitventricular enlarge- person is willing ment on computed to work on.tomography ● Prioritize skills scan important to the
Abnormalities on person.neuropsychologic 2. Working with person testing to identify stressors:
Poor response to ● Identify which stres-antipsychotics sors contribute to mal-
adaptive behaviors.3. Work with person on
increasing appropriate coping skills.
X29168-P0208.qxd 6/24/05 8:42 PM Page 219
220 PART II Diagnosis and Care Planning
Impaired Verbal Communication are included. Again,during the acute phase, relating to others is difficult.Guidelines for interacting and gradually adding socialskills are included in Impaired Social Interaction. Workingwith clients who are hallucinating (Disturbed SensoryPerception), delusional (Disturbed Thought Processes),and paranoid (Defensive Coping) can be a great challenge.Therefore, these are included.
Also, importantly, often the families are left to cope withthe exhaustive needs of their family member. InterruptedFamily Processes should always be assessed, and referralsand teaching should be readily available.
Nonadherence to medications or treatment is a huge chal-lenge for mental health professionals. Nursing care plans forNonadherence/Noncompliance are found in Chapter 20.Table 8-2 provides a list of potential nursing diagnoses.
Selected Nursing Diagnoses and NursingCare Plans
IMPAIRED VERBAL COMMUNICATION
Decreased, delayed, or absent ability to receive, process,transmit, or use a system of symbols
Related To (Etiology)▲ Psychologic barriers (e.g., psychosis, lack of stimuli)▲ Side effects of medication▲ Altered perceptions● Biochemical alterations in the brain of certain neuro-
transmitters
As Evidenced By (Assessment Findings/Diagnostic Cues)
▲ Inappropriate verbalization▲ Difficulty expressing thoughts verbally▲ Difficulty in comprehending and maintaining the
usual communication pattern● Poverty of speech
▲ NANDA International accepted; ● In addition to NANDAInternational
X29168-P0208.qxd 6/24/05 8:42 PM Page 220
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 221
Table 8-2 Potential Nursing Diagnoses for Schizophrenia
Symptoms Nursing Diagnoses
Positive SymptomsHallucinations: Disturbed Sensory ● Hears voices (loud noises) Perception: Auditory/Visual
that others do not hear. Risk for Violence: Self-● Hears voices telling them to Directed and Other-
hurt self or others (command Directedhallucinations).
Distorted thinking not based Disturbed Thought Processesin reality, for example: Defensive Coping
● Persecution: thinking others are trying to harm them.
● Jealousy: thinking spouse or lover is being unfaithful, or thinks others are jealous when they are not.
● Grandeur: thinking they have powers they do not possess, or they are someone powerful or famous.
● Reference: believing all events within the environment are directed at or hold special meaning for them.
● Loose association of ideas Impaired Verbal (looseness of association). Communication
● Uses words in a meaningless, Disturbed Thought disconnected manner Processes(word salad).
● Uses words that rhyme in a nonsensical fashion (clang association).
● Repeats words that are heard (echolalia).
● Does not speak (mutism).● The person delays getting
to the point of communica-tion because of unnecessary and tedious details (circumstantiality).
● Concrete thinking: The in-ability to abstract; uses literal translations concerning aspects of the environment.
Continued
X29168-P0208.qxd 6/24/05 8:42 PM Page 221
222 PART II Diagnosis and Care Planning
Table 8-2 Potential Nursing Diagnoses forSchizophrenia—cont’d
Symptoms Nursing Diagnoses
Negative SymptomsUncommunicative, withdrawn, Social Isolationno eye contact.
Preoccupation with own Impaired Social Interactionthoughts.
Expression of feelings of Risk for Lonelinessrejection or of aloneness (lies in bed all day; positions back to door).
Talks about self as “bad” Chronic Low Self-Esteemor “no good.”
Feels guilty because of “bad Risk for Self-Directed thoughts”; extremely sensitive Violenceto real or perceived slights.
Lack of energy (anergia). Ineffective CopingLack of motivation (avolition); Self-Care Deficit unable to initiate tasks (social (bathing/hygiene, contact, grooming, and other dressing/grooming)aspects of daily living). Constipation
OtherFamilies and significant others Compromised Familybecome confused, over- Copingwhelmed, lack knowledge of Disabled Family Copingdisease or treatment, feel Impaired Parentingpowerless in coping with Caregiver Role Strainclient at home
Nonadherence to medications Deficient Knowledgeand treatment: Client stops Nonadherence taking medication (often (Noncompliance)because of side effects), stopsgoing to therapy groups.
● Disturbances in cognitive associations (e.g., loosenessof association, perseveration, neologisms)
● Inability to distinguish internally stimulated thoughtsfrom actual environmental events or commonly sharedknowledge
● In addition to NANDA International
X29168-P0208.qxd 6/24/05 8:42 PM Page 222
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 223
Outcome Criteria● Communicates thoughts and feelings in a coherent,
goal-directed manner (to client’s best ability)● Demonstrates reality-based thought processes in ver-
bal communication (to client’s best ability)
Long-Term GoalsClient will:● Be able to speak in a manner that can be understood by
others with the aid of medication and attentive listeningby discharge
● Learn two diversionary tactics that work for him/her tolower anxiety, thus enhancing ability to think clearly andspeak more logically by (date)
Short-Term GoalsClient will:● Spend three 5-minute periods with nurse sharing obser-
vations in the environment within 4 days● Spend time with one or two other people in structured
activity involving neutral topics by (date)
Interventions and RationalesIntervention Rationale1. Assess if incoherence 1. Establishing a baseline
in speech is chronic facilitates the establish-or if it is more sudden, ment of realistic goals, as in an exacerbation the cornerstone for of symptoms. planning effective care.
2. Identify how long 2. Therapeutic levels of client has been on anti- an antipsychotic helps psychotic medication. clear thinking and
diminishes looseness of association (LOA).
3. Plan short, frequent 3. Short periods are less periods with client stressful, and periodic throughout the day. meetings give client a
chance to develop familiarity and safety.
● In addition to NANDA International
X29168-P0208.qxd 6/24/05 8:42 PM Page 223
Intervention Rationale4. Use simple words, 4. Client might have diffi-
and keep directions culty processing even simple. simple sentences.
5. Keep voice low and 5. High pitched/loud tone speak slowly. of voice can raise anxiety
levels; slow speaking aids understanding.
6. Look for themes in 6. Often client’s choice what is said, even of words is symbolic of though spoken words feelings.appear incoherent (e.g., anxiety, fear, sadness).
7. When you do not 7. Pretending to under-understand a client, stand (when you do not) let him/her know you limits your credibility in are having difficulty the eyes of your client understanding (e.g., and lessens the potential “I want to understand for trust.what you are saying, but I am having difficulty.”)
8. Use therapeutic techni- 8. Even if the words are ques to try to under- hard to understand, try stand client’s concerns getting to the feelings (e.g., “Are you behind them.saying . . .?” “You mentioned demons many times. Are you feeling frightened?”).
9. Focus on and direct 9. Helps draw focus away client’s attention to from delusions and concrete things in the focus on reality-based environment. things.
10. Keep environment 10. Keeps anxiety from quiet and as free of escalating and increa-stimuli as possible. sing confusion and
hallucinations/delusions.11. Use simple, concrete, 11. Minimizes misunder-
and literal explana- standing and/or tions. incorporating those
misunderstandings into delusional systems.
224 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 224
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 225
Intervention Rationale12. When client is ready, 12. Helping client to use
introduce tactics that tactics to lower anxiety can lower anxiety can help enhance and minimize voices functional speech.and “worrying” thoughts. Teach client to do the following:● Take time out.● Read aloud to self.● Seek out staff,
family, or other supportive person.
● Listen to music.● Learn to replace irra-
tional thoughts with rational statements.
● Learn to replace “bad” thoughts with constructive thoughts.
● Perform deep breathing exercises.
IMPAIRED SOCIAL INTERACTION
The state in which an individual participates in an insufficientor excessive quantity or ineffective quality of social exchange
Related To (Etiology)▲ Impaired thought processes (hallucinations or delu-
sions)▲ Self-concept disturbance (might feel “bad” about self
or “no-good”)▲ Difficulty with communication (e.g., associative
looseness)● Inappropriate or inadequate emotional responses● Feeling threatened in social situations● Exaggerated response to stimuli● Difficulty with concentration
▲ NANDA International accepted; ● In addition to NANDAInternational
X29168-P0208.qxd 6/24/05 8:42 PM Page 225
226 PART II Diagnosis and Care Planning
As Evidenced By (Assessment Findings/Diagnostic Cues)
▲ Verbalized or observed discomfort in social situations▲ Observed use of unsuccessful social interactions
behaviors▲ Dysfunctional interaction with peers● Spends time alone by self● Inappropriate or inadequate emotional response● Does not make eye contact, or initiate or respond to
social advances of others● Appears agitated or anxious when others come too
close or try to engage him in an activity
Outcome Criteria● Improves social interaction with family, friends, and
neighbors● Engages in social interactions in goal directed manner● Uses appropriate social skills in interactions
Long-Term GoalsClient will:● Engage in one or two activities with minimal encourage-
ment from nurse or family members by (date)● Use appropriate skills to initiate and maintain an interac-
tion by (date)● State that he or she is comfortable in at least three struc-
tured activities that are goal directed by (date)● Demonstrate interest to start coping skills training when
ready for learning
Short-Term GoalsClient will:● Engage in one activity with nurse by the end of the day● Attend one structured group activity within 1 week● Maintain an interaction with another client while doing
an activity (drawing, playing cards, cooking a meal)
▲ NANDA International accepted; ● In addition to NANDAInternational
Au: M.S.not clear
X29168-P0208.qxd 6/24/05 8:42 PM Page 226
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 227
Interventions and RationalesIntervention Rationale1. Assess if medication 1. Many of the positive
has reached symptoms (paranoia, therapeutic levels. delusions, and halluci-
nations) will subside with medications, which will facilitate interac-tions.
2. Ensure that the goals 2. Avoids pressure on set are realistic, client, and sense of whether in the hospi- failure on part of nurse/tal or community. family. This sense of
failure can lead to mutual withdrawal.
3. Keep client in an 3. Client might respond environment as free to noises and crowding of stimuli (loud noises, with agitation, anxiety, high traffic areas) and increased inability as possible. to concentrate on
outside events.4. Avoid touching the 4. Touch by a “stranger”
client. can be misinterpreted as a sexual or threaten-ing gesture. This is particularly true for a paranoid client.
5. If client is unable 5. An interested presence to respond verbally can provide a sense of or in a coherent being worthwhile.manner, spend fre-quent, short periods with client.
6. Structure times each 6. Helps client to develop day to include a sense of safety in a planned times for nonthreatening environ-brief interactions ment.and activities with the client on a one-on-one basis.
X29168-P0208.qxd 6/24/05 8:42 PM Page 227
228 PART II Diagnosis and Care Planning
Intervention Rationale7. If client is delusional/ 7. Even simple activities
hallucinating or is help draw client away having trouble con- from delusional thinking centrating at this onto reality in the time, provide very environment.simple concrete acti-vities with client (e.g., looking at a picture book with nurse, drawing, painting).
8. Structure activities 8. Client can lose interest that work at the in activities that are too client’s pace and ambitious, which can ability. increase a sense of
failure.9. Try to incorporate 9. Increases likelihood
the strengths and of client’s participation interests the client and enjoyment.had when not as impaired into the activities planned.
10. If client is very 10. Client is free to choose paranoid, solitary his level of interaction; or one-on-one acti- however, the concentra-vities that require can help minimizeconcentration are distressing paranoid appropriate. thoughts or voice
(e.g., chess).11. If client is very 11. Learns to feel safe with
withdrawn, one-on- one person, then one activities with a gradually might partici-“safe” person initially pate in a structured should be planned. group activity.
12. As client progresses, 12. Gradually the client provide the client learns to feel safe and with graded activities competent with according to level of increased social tolerance e.g., demands.(1) simple games with one “safe” person; (2) slowly add a third person into “safe”
X29168-P0208.qxd 6/24/05 8:42 PM Page 228
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 229
Intervention Rationaleactivities; (3) introduce simple group acti-vities; and then (4) groups in which clients participate more.
13. Eventually engage 13. Client continues to feel other clients and safe and competent in significant others in a graduated hierarchy social interactions of interactions.and activities with the client (card games, ping-pong, sing-a-longs, group outings, etc) at client’s level.
14. Identify with client 14. Increased anxiety can symptoms he expe- intensify agitation, riences when he/she aggressiveness, and begins to feel anxious suspiciousness.around others.
15. Teach client to remove 15. Teaches client skills in himself briefly when dealing with anxiety feeling agitated and and increasing a sense work on some anxiety- of control.relief exercises (e.g., deep breathing, thought stopping).
16. Provide opportunities 16. Social skills training for the client to learn helps client adapt and adaptive social skills function at a higher level in a nonthreatening in society, and increases environment. Initial clients quality of life. social skills training These simple skills could include basic might take time for a social behaviors (e.g., client with schizo-maintain good eye phrenia, but can increase contact, appropriate self confidence as well distance, calm as more positive demeanor, moderate responses from others.voice tone).
X29168-P0208.qxd 6/24/05 8:42 PM Page 229
Intervention Rationale17. As client progresses, 17. Increases client’s ability
Coping Skills Training to derive social support should be available to and decrease loneliness. him/her (nurse, staff, Clients will not give up or others). Basically substances of abuse the process is: unless they have alter-a. Define the skill to native means to facili-
be learned. tate socialization and b. Model the skill. feel they belong.c. Rehearse skills in
a safe environment, then in the community.
d. Give corrective feedback on the implementation of skills.
18. Useful coping skills 18. These are fundamental that client will need skills for dealing with include conversa- the world, which every-tional and asser- one uses daily with tiveness skills. more or less skill.
19. Remember to give 19. Recognition and appre-acknowledgment ciation go a long way and recognition for to sustaining and increa-positive steps client sing a specific behavior.takes in increasing social skills and appropriate interac-tions with others.
HallucinationsPresenting Signs and Symptoms● Clients state they hear voices.● Client denies hearing voices, but observer notes
client(‘s):●● Eyes following something in motion that observer can-
not see●● Staring at one place in room●● Head turning to side as if listening
230 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 230
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 231
●● Mumbling to self or conversing when no one else ispresent
●● Inappropriate facial expressions, eye blinking● If hallucinations are from other causes (e.g., drugs, alco-
hol, delirium), the underlying cause needs to be treatedas soon as possible using accepted medical and nursingprotocols.
Assessment Guidelines
Hallucinations1. Assess for command hallucinations (e.g., voices telling
the person to harm self or another).2. Assess when hallucinations seem to occur the most (e.g.,
times of stress, at night).
Selected Nursing Diagnoses and Nursing Care Plans
DISTURBED SENSORY PERCEPTION:AUDITORY/VISUAL
Change in the amount or patterning of incoming stimuliaccompanied by a diminished, exaggerated, distorted, orimpaired response to such stimuli
Related To (Etiology)▲ Altered sensory reception: transmission or integra-
tion▲ Biochemical imbalance▲ Chemical alterations (e.g., drugs, electrolyte imbal-
ances)▲ Altered sensory perception▲ Psychologic stress● Neurologic/biochemical changes
▲ NANDA International accepted; ● In addition to NANDAInternational
X29168-P0208.qxd 6/24/05 8:42 PM Page 231
232 PART II Diagnosis and Care Planning
As Evidenced By (Assessment Findings/Diagnostic Cues)
▲ Disorientation to time/place/person▲ Auditory distortions▲ Hallucinations● Tilting the head as if listening to someone● Frequent blinking of the eyes and grimacing● Mumbling to self, talking or laughing to self▲ Altered communication pattern▲ Change in problem-solving pattern▲ Reported or measured change in sensory acuity▲ Inappropriate responses
Outcome Criteria● Maintains social relationships● Maintains role performance● States that the voices are no longer threatening, nor do
they interfere with his or her life■ Learns ways to refrain from responding to hallucina-
tions
Long-Term GoalsClient will:● Demonstrate techniques that help distract him or her
from the voices by (date)● Monitor intensity of anxiety
Short-Term GoalsClient will:● State, using a scale from 1 to 10, that “the voices” are less
frequent and threatening when aided by medication andnursing intervention by (date)
● State three symptoms they recognize when their stresslevels are high by (date)
▲ NANDA International accepted; ● In addition to NANDAInternational
■ Adapted from NOC Objective Distortive Thought Self-Control
X29168-P0208.qxd 6/24/05 8:42 PM Page 232
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 233
● Identify two stressful events that trigger hallucinationsby (date)
● Demonstrate one stress reduction technique by (date)● Identify two personal interventions that decrease or
lower the intensity or frequency of hallucinations (e.g.,listening to music, wearing headphones, reading outloud, jogging, socializing) by (date)
Interventions and RationalesIntervention Rationale1. If voices are telling 1. People often obey
the client to harm hallucinatory commands self or others, take to kill self or others. necessary environ- Early assessment and mental precautions. intervention might save a. Notify others and lives.
police, physician, and administration according to unit protocol.
b. If in the hospital, use unit protocols for suicidal or threats of violenceif client plans to act on commands.
c. If in the community, evaluate need for hospitalization.
Clearly document what client says and, if he/she is a threat to others, document who was contacted and notified (use agency protocol as a guide).
2. Decrease environ- 2. Decrease potential for mental stimuli when anxiety that might possible (low noise, trigger hallucinations. minimal activity). Helps calm client.
X29168-P0208.qxd 6/24/05 8:42 PM Page 233
Intervention Rationale3. Accept the fact that 3. Validating that your
the voices are real reality does not include to the client, but voices can help client explain that you do cast “doubt” on the not hear the voices. validity of his or her Refer to the voices voices.as “your voices” or “voices that you hear.”
4. Stay with clients 4. Clients can sometimes when they are starting learn to push voices to hallucinate, and aside when given direct them to tell the repeated instruction, “voices they hear” to especially within the go away. Repeat often framework of a trusting in a matter-of-fact relationship.manner.
5. Keep to simple, basic, 5. Client’s thinking might reality-based topics be confused and disor-of conversation. Help ganized; this inter-client to focus on one vention helps client focusidea at a time. and comprehend
reality-based issues.6. Explore how the 6. Exploring the hallucina-
hallucinations are tion and sharing the experienced by experience can help give the client. the person a sense of
power that he or she might be able to manage the hallucinatory voices.
7. Help the client to 7. Hallucinations might identify the needs reflect needs for:that might underlie a. Powerthe hallucination. b. Self-esteemWhat other ways can c. Angerthese needs be met? d. Sexuality
234 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 234
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 235
Intervention Rationale8. Help client to identify 8. Helps both nurse and
times that the halluci- client identify situations nations are most and times that might be prevalent and most anxiety producing frightening. and threatening to client.
9. Engage client in simple 9. Redirecting client’s physical activities or energies to acceptable tasks that channel activities can decrease energy (writing, draw- the possibility of acting ing, crafts, noncompeti- on hallucinations and tive sports, treadmill, help distract from voices.walking on track, exercise bike).
10. Work with the client 10. If clients’ stress triggers to find which activities hallucinatory activity, help reduce anxiety they might be more and distract the client motivated to find ways from hallucinatory to remove themselves material. Practice new from a stressful environ-skills with client. ment or try distraction
techniques.11. Be alert for signs 11. Might herald halluci-
of increasing fear, natory activity, which cananxiety, or agitation. be very frightening to
client, and client might act upon command hallucinations (harm self or others).
12. Intervene with 12. Intervene before anxiety one-on-one, seclusion, begins to escalate. or PRN medication If client is already out (as ordered) when of control, use chemical appropriate. or physical restraints
following unit protocols.
DelusionsPresenting Signs and Symptoms● The client has fragmented, poorly organized, well-organ-
ized, systematized, or extensive system of beliefs that arenot supported by reality.
● The content of the delusions can be grandiose, persecu-tory, jealous, somatic, or based on guilt.
X29168-P0208.qxd 6/24/05 8:42 PM Page 235
236 PART II Diagnosis and Care Planning
Assessment Guidelines
Delusions1. Assess if delusions have to do with someone trying to
harm the client, or if the client is planning to retaliateagainst a person or organization.a. If client is a threat to self or others, notify person and
authorities.b. Confer with physician and administration if precau-
tions need to be taken.2. Assess when delusional thinking is the most point (e.g.,
when under stress, in the presence of certain situationsor people, at night).
Selected Nursing Diagnoses and Nursing Care Plans
DISTURBED THOUGHT PROCESSES
Disruption in cognitive operations and activities
Related To (Etiology)● Biochemical/neurologic imbalances● Panic levels of anxiety● Overwhelming stressful life events● Chemical alterations (e.g., drugs, electrolyte imbal-
ances)
As Evidenced By(Assessment Findings/Diagnostic Cues)
▲ Inaccurate interpretation of environment▲ Memory deficit/problems▲ Egocentricity▲ Inappropriate non-reality-based thinking● Delusions
▲ NANDA International accepted; ● In addition to NANDAInternational
X29168-P0208.qxd 6/24/05 8:42 PM Page 236
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 237
Outcome Criteria● Refrains from acting on delusional thinking● Demonstrates satisfying relationships with real people.● Delusions no longer threaten or interfere with his or her
ability to function in family, social, and work situations.■ Perceive environment effectively
Long-Term GoalsClient will:● Demonstrate two effective coping skills that minimize
delusional thoughts by (date)
Short-Term GoalsClient will:● State that the “thoughts” are less intense and less fre-
quent with aid of medications and nursing interventionsby (date)
● Talk about concrete happenings in the environment with-out talking about delusions for 5 minutes by (date)
● Begin to recognize that his or her frightening (suspicious)“thinking” occurs most often at times of stress and whenhe or she is anxious
Interventions and RationalesIntervention Rationale1. Utilize safety measures 1. During acute phase,
to protect clients or client’s delusional others, if clients believe thinking might dictate they need to protect to them that they might themselves against a have to hurt others or specific person. self in order to be safe. Precautions are needed. External controls might
be needed.2. Attempt to understand 2. Important clues to
the significance of these underlying fears and beliefs to the client at issues can be found in the time of their the client’s seemingly presentation. illogical fantasies.
■ NOC objective Distance Thought Self-Control
X29168-P0208.qxd 6/24/05 8:42 PM Page 237
Intervention Rationale3. Be aware that client’s 3. Identifying the client’s
delusions represent experience allows the the way that he or nurse to understand the she experiences reality. client’s feelings.
4. Identify feelings related 4. When people believe to delusions. For that they are understood, example: anxiety might lessen.a. If client believes some-
one is going to harm him/her, client is experiencing fear.
b. If client believes some-one or something is controlling his/her thoughts, client is experiencing helplessness.
5. Do not argue with the 5. Arguing will only client’s beliefs or try increase client’s defen-to correct false beliefs sive position, thereby using facts. reinforcing false beliefs.
This will result in the client feeling even more isolated and misunder-stood.
6. Do not touch the client; 6. A psychotic person use gestures carefully. might misinterpret touch
as either aggressive or sexual in nature and mightinterpret gestures as aggressive moves. People who are psychotic need a lot of personal space.
7. Interact with clients on 7. When thinking is focusedthe basis of things in the on reality-based environment. Try to activities, the client is distract client from their free of delusional delusions by engaging thinking during that in reality-based activities time. Helps focus (cards, simple board attention externally.games, simple arts and crafts projects, cooking with another person, etc.).
238 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 238
Intervention Rationale8. Teach client coping 8. When client is ready,
skills that minimize teach strategies client “worrying” thoughts. can do alone.Coping skills include:● Talking to a trusted
friend● Phoning a helpline● Singing● Going to a gym● Thought-stopping
techniques9. Encourage healthy habits 9. All are vital to help
to optimize functioning: keep client in remission.● Maintain regular
sleep pattern.● Reduce alcohol and
drug intake.● Maintain self-care.● Maintain medication
regimen.
ParanoiaPresenting Signs and Symptoms● Pervasive suspiciousness about one or more persons and
their actions● On guard, hyperalert, vigilant● Blames others for consequences of own behavior● Hostile, argumentative, often threatening verbalizations
or behavior● Poor interpersonal relationships● Has delusions of influence, persecution, and grandiosity● Often refuses medications because “nothing is wrong
with me”● Might refuse food if believes it is poisoned
Assessment Guidelines
Paranoia1. Assess for suicidal or homicidal behaviors.2. Assess for potential for violence.3. Assess need for hospitalization.
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 239
X29168-P0208.qxd 6/24/05 8:42 PM Page 239
240 PART II Diagnosis and Care Planning
Selected Nursing Diagnoses and Nursing Care Plans
DEFENSIVE COPING
Repeated projection of falsely positive self-evaluation basedon a self-protective pattern that defends against underlyingperceived threats to positive self-regard
Related To (Etiology)● Perceived threat to self● Suspicions of the motives of others● Perceived lack of self-efficacy/vulnerability
As Evidenced By (Assessment Findings/Diagnostic Cues)
▲ Projection of blame/responsibility▲ Grandiosity▲ Denial of obvious problems▲ Rationalization of failures▲ Superior attitude toward others▲ Hostile laughter or ridicule of others▲ Difficulty in reality testing of perceptions▲ Difficulty establishing/maintaining relationships● Hostility, aggression, or homicidal ideation● Fearful● False beliefs about the intentions of others
Outcome Criteria● Interacts with others appropriately● Maintains medical compliance● Demonstrates decreased suspicious behaviors interact-
ing with others■ Avoids
▲ NANDA International accepted; ● In addition to NANDAInternational
■ NOC outcome for Impulse Self-Control
Au: M.S.not clear
X29168-P0208.qxd 6/24/05 8:42 PM Page 240
Long-Term GoalsClient will:● Acknowledge that medications help lower suspiciousness● State that he/she feels safe and more in control in inter-
actions with environment/family/work/social gather-ings by (date)
● Be able to apply a variety of stress/anxiety-reducingtechniques on own by (date)
Short-Term GoalsClient will:● Remain safe with the aid of medication and nursing
interventions (either interpersonal, chemical, or seclu-sion), as will others in the client’s environment
● Focus on reality-based activity with the aid of medica-tion/nursing intervention by (date)
● Demonstrate two newly learned constructive ways todeal with stress and feelings of powerlessness by (date)
● Demonstrate the ability to remove himself or herselffrom situations when anxiety begins to increase with theaid of medications and nursing interventions by (date)
● Identify one action that helps client feel more in controlof his or her life
Interventions and RationalesIntervention Rationale1. Use a nonjudgmental, 1. There is less chance
respectful, and neutral for a suspicious client approach with the to misconstrue intent or client. meaning if content is
neutral and approach is respectful and nonjudgmental.
2. Be honest and consis- 2. Suspicious people are tentwith client quick to discern dis-regarding expecta- honesty. Honesty and tions and enforcing consistency provide an rules. atmosphere in which
trust can grow.
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 241
X29168-P0208.qxd 6/24/05 8:42 PM Page 241
Intervention Rationale3. Use clear and simple 3. Minimize the opportu-
language when nity for miscommunica-communicating with tion and misconstruing a suspicious client. the meaning of the
message.4. Explain to client what 4. Prepares the client
you are going to do beforehand and mini-before you do it. mizes misinterpreting
your intent as hostile or aggressive.
5. Be aware of client’s 5. Suspicious clients will tendency to have ideas automatically think that of reference; do not they are the target do things in front of the interaction and of client that can be interpret it in a negative misinterpreted: manner (e.g., you are a. Laughing laughing at them, b. Whispering whispering about them, c. Talking quietly etc.).
when client can see but not hear what is being said
6. Diffuse angry and 6. When staff become hostile verbal attacks defensive, anger with a nondefensive escalates for both client stand. and staff. A nondefen-
sive and nonjudgmental attitude provides an atmosphere in which feelings can be explored more easily.
7. Assess and observe 7. Intervene before client client regularly for loses control.signs of increasing anxiety and hostility.
8. Provide verbal/ 8. Often verbal limits are physical limits when effective in helping a client’s hostile client gain self-control.behavior escalates: We won’t allow you to hurt anyone here. If you can’t control yourself, we will help you.
242 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 242
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 243
Intervention Rationale9. Set limits in a clear, 9. Calm and neutral
matter-of-fact way, approach may diffuse using a calm tone. escalation of anger. Threatening John is not Offer an alternative to acceptable. Let’s talk verbal abuse by finding About appropriate appropriate ways ways to deal with To deal with feelings.your feelings.
10. Maintain low level 10. Noisy environments of stimuli and might be perceived as enhance a nonthrea- threatening.tening environment (avoid groups).
11. Initially, provide 11. If a client is suspicious solitary, noncompe- of others, solitary titive activities that activities are the best. take some concentra- Concentrating on tion. Later a game environmental stimuli with one or more minimizes paranoid clients that takes rumination.concentration (e.g., chess, checkers, thoughtful card games such as bridge or rummy).
Providing Support to Family/Others
INTERRUPTED FAMILY PROCESSES
Change in family relationships and/or functioning
Related To (Etiology)▲ Shift in health status of a family member▲ Situational crisis or transition▲ Family role shift▲ Developmental crisis or transition● Mental or physical disorder of family member
▲ NANDA International accepted; ● In addition to NANDAInternational
X29168-P0208.qxd 6/24/05 8:42 PM Page 243
244 PART II Diagnosis and Care Planning
As Evidenced By(Assessment Findings/Diagnostic Cues)
▲ Changes in participation in decision making▲ Changes in mutual support▲ Changes in stress reduction behavior▲ Changes in communication patterns▲ Changes in participation in problem solving▲ Changes in expression of conflict in family● Inability to meet needs of family and significant oth-
ers (physical, emotional, spiritual)● Knowledge deficit regarding the disease and what is
happening with ill family member (might believeclient is more capable than they are)
● Knowledge deficit regarding community and health-care support
Outcome CriteriaFamily members/significant others will:● State they have received needed support from commu-
nity and agency resources that offer support, education,coping skills training, and/or social network develop-ment (psychoeducational approach)
● Demonstrate problem-solving skills for handling tensionsand misunderstanding within the family environment
● Recount in some detail the early signs and symptoms ofrelapse in their ill family member, and know whom tocontact
Long-Term GoalsFamily members/significant others will:● Know of at least two contact people when they suspect
potential relapse by (date)● Discuss the disease (schizophrenia) knowledgeably by
(date):●● Understand the need for medical adherence●● Support the ill family member in maintaining opti-
mum health
▲ NANDA International accepted; ● In addition to NANDAInternational
X29168-P0208.qxd 6/24/05 8:42 PM Page 244
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 245
●● Know about community resources (e.g., help with self-care activities, private respite)
● Have access to family/multiple family support groupsand psychoeducational training by (date)
Short-Term GoalsFamily members/significant others will:● Meet with nurse/physician/social worker the first day
of hospitalization and begin to learn about this neuro-logic/biochemical disease, treatment, and communityresources
● Attend at least one family support group (single family,multiple family) within 4 days from onset of acuteepisode
● Problem-solve, with the nurse, two concrete situationswithin the family that all would like to change
● State what the medications can do for their ill member,the side effects and toxic effects of the drugs, and theneed for adherence to medication at least 2 to 3 daysbefore discharge
● Be included in the discharge planning along with client● State and have written information identifying the signs
of potential relapse and whom to contact before dis-charge
● Name and have complete list of community supports forill family member and supports for all members of thefamily at least 2 days before discharge
Interventions and RationalesIntervention Rationale1. Identify family’s ability 1. Family’s needs must
to cope (e.g., experience be addressed to stabilizeof loss, caregiver family unit.burden, needed supports).
2. Provide opportunity 2. Nurses and staff can for family to discuss best intervene when feelings related to ill they understand the family member and family’s experience identify their and needs.immediate concerns.
X29168-P0208.qxd 6/24/05 8:42 PM Page 245
Intervention Rationale3. Assess the family 3. Family might have
members’ current level misconceptions and of knowledge about misinformation about the disease and schizophrenia and medications used to treatment, or no treat the disease. knowledge at all.
Teach at client’s and family’s level of understanding and readiness to learn.
4. Provide information 4. Meet family members’ on disease and needs for information.treatment strategies at family’s level of knowledge.
5. Inform the client and 5. Understanding of the family in clear, simple disease and the treat-terms about psycho- ment of the disease pharmacologic therapy: encourages greater dosage, the need to family support and take medication as client adherence.prescribed, side effects, and toxic effect. Written information should be given to client and family members as well. Refer to the client and family teaching guide-lines in Chapter 21 under Antipsychotic Medication.
6. Provide information 6. Schizophrenia is an on family and client over-whelming disease community resources for both the client and for client and family the family. Groups, after discharge: support support groups, and groups, organizations, psychoeducational day hospitals, psycho- centers can help:educational programs, respite centers, etc. See list of associations and Internet sites at end of chapter.
246 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 246
Intervention Rationalea. Develop family
skillsb. Access resourcesc. Access supportd. Access caringe. Minimize isolationf. Improve quality
of life for all family members
7. Teach family and 7. Rapid recognition client the warning of early warning symp-symptoms of poten- toms can help ward off tial relapse. potential relapse when
immediate medical attention is sought.
MEDICAL TREATMENT
PsychopharmacologyAntipsychotic medications are indicated for nearly all psy-chotic episodes of schizophrenia. To delay medication ther-apy too long can put the client at risk for suicide or otherdangerous behaviors.
Medications used to treat schizophrenia are calledantipsychotic medications. Two groups of antipsychoticdrugs exist: standard (traditional/conventional) and thenewer atypical (or novel) medications. Many physiciansurge the use of the atypical medications initially becauseof their better side effect profile and the fact that theatypical medications target the negative symptoms (apa-thy, lack of motivation) and anhedonia (lack of pleasurein life), thereby increasing the quality of life for clients.
Atypical (Novel) Antipsychotic MedicationsDuring the early 1990s, new types of antipsychotics beganappearing on the market, and they are currently used as first-line medications. (Clozapine [Clozaril] is the excep-tion because of its tendency to cause agranulocytosis and itshigh incidence for seizures.) These drugs not only target theacute and disturbing symptoms seen in acute active episodesof schizophrenia (hallucinations, delusions, associative
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 247
X29168-P0208.qxd 6/24/05 8:42 PM Page 247
looseness, paranoia), called positive symptoms, but alsotarget the negative symptoms, which allows improvementin the quality of life for clients (increased motivation,improved judgment, increased energy, ability to experiencepleasure and ↑ cognitive Function). These drugs also havea very low extrapyramidal symptom (EPS) profile and, ingeneral, have a more favorable side-effect profile.Pros● Target negative and positive symptoms● Lower risk of EPS● Lower SE profile, ↑ compliance● May improve symptoms of:
● Anxiety● Depression● ↓ Suicidal behavior
Cons● ↑ Weight gain● Metabolic abnormalities (glucose dysregulation, hyperc-
holesterolemia)● Are more expensive
Table 8-3 provides a list of atypical antipsychotics, theirdosages, and the side effects.
Standard MedicationsThe standard antipsychotic drugs target the more flagrantsymptoms of schizophrenia (hallucinations, delusions, sus-piciousness, associative looseness). These drugs can:● Reduce disruptive and violent behavior● Increase activity, speech, and sociability in withdrawn
clients● Improve self-care● Improve sleep patterns● Reduce the disturbing quality of hallucinations and delu-
sions● Improve thought processes● Decrease resistance to supportive therapy● Reduce rate of relapse● Decrease intensity of paranoid reactions
Antipsychotic agents are usually effective 3 to 6 weeksafter the regimen is started.
Side Effects There are some troubling side effects of thesedrugs that can at times limit medical adherence. Some of
248 PART II Diagnosis and Care Planning
<AU: ok asset? Ms.Unclear
>
X29168-P0208.qxd 6/24/05 8:42 PM Page 248
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 249
Tabl
e 8-
3A
nti
psy
cho
tic
Med
icat
ion
s Aty
pic
al A
nti
psy
cho
tic
Ag
ents
Do
se R
ang
e D
rug
(mg
/day
)EP
SA
CH
OH
SED
Spec
ial C
on
sid
erat
ion
s
Clo
zapi
ne
300–
900
No
Hig
hH
igh
Hig
hU
sed
in tr
eatm
ent-
refr
acto
ry c
lient
s—(C
loza
ril)
non
–fir
st-l
ine
P.O
. OD
T:
0.8%
–0.1
% in
cide
nce
of a
gran
uloc
ytos
is—
FAZ
AC
LO
wee
kly
WBC
Hig
h se
izur
e ra
teR
ispe
rid
one
2–16
Low
Ver
y M
odL
owW
eigh
t gai
n si
gnif
ican
t(R
ispe
rdal
)lo
wD
oses
>6
mg
mig
ht s
ee T
DP.
O. (
Con
sta)
: (L
AI)
(C
onst
a: L
AI)
Ola
nzap
ine
2.5–
20L
owL
owM
odL
owW
eigh
t gai
n si
gnif
ican
t(Z
ypre
xa)
Onc
e-d
aily
dos
e (l
ong
half
-lif
e)O
DT:
Zyd
isIn
tera
ctio
n w
ith
SSR
Is m
ight
occ
ur
P.O
. By
mou
thI.M
. Inj
ecta
ble
L.A
.I. L
ong-
acti
ng in
ject
able
O.D
.T. O
rally
dis
inte
grat
ing
tabl
ets
Con
tinu
ed
X29168-P0208.qxd 6/24/05 8:42 PM Page 249
250 PART II Diagnosis and Care Planning
Tabl
e 8-
3A
nti
psy
cho
tic
Med
icat
ion
s—co
nt’
d
Aty
pic
al A
nti
psy
cho
tic
Ag
ents
Do
se R
ang
e D
rug
(mg
/day
)EP
SA
CH
OH
SED
Spec
ial C
on
sid
erat
ion
s
Que
tiap
ine
150–
750
Low
Low
-Non
eM
odL
owR
isk
of T
D a
nd N
MS
very
low
(Ser
oque
l)Z
ipra
sid
one
40–1
60L
owM
ild-M
odM
ildL
owE
CG
cha
nges
-QT
pro
long
atio
n; n
ot to
(G
eod
on)
-Non
ebe
use
d w
ith
othe
r d
rugs
kno
wn
to p
rolo
ng Q
T in
terv
alP.
O/
IME
ffec
tive
wit
h th
e d
epre
ssiv
e sy
mpt
oms
of s
chiz
ophr
enia
Low
pro
pens
ity
for
wei
ght g
ain
Ari
pipr
azol
e 10
–30
Low
Low
Low
Low
-Te
ach
abou
t and
che
ck f
or a
kath
isia
; (A
bilif
y)-N
one
-Mild
repo
rted
in s
ome
child
ren
F.O
/IM
TD
and
sed
atio
n d
ose
rela
ted
NM
S ra
reL
ittl
e or
no
wei
ght g
ain
or in
crea
se
in g
luco
se, H
DL
, LD
L, o
r tr
igly
ceri
des
Firs
t of
a ne
w c
lass
of
atyp
ical
an
tips
ycho
tics
X29168-P0208.qxd 6/24/05 8:42 PM Page 250
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 251
Tabl
e 8-
3A
nti
psy
cho
tic
Med
icat
ion
s
Stan
dard
(Tr
adit
iona
l) A
ntip
sych
otic
Med
icat
ions
Ro
utes
of
Acu
te
Mai
nte
nan
ce
Dru
gA
dm
inis
trat
ion
(mg
/day
)*(m
g/d
ay)*
Spec
ial C
on
sid
erat
ion
s
Hal
oper
idol
PO
, IM
5–50
2–20
Has
low
sed
ativ
e pr
oper
ties
; is
used
in
(Hal
dol
)la
rge
dos
es f
or a
ssau
ltiv
e at
ient
s,
thus
avo
idin
g th
e se
vere
sid
e ef
fect
of
hyp
oten
sion
App
ropr
iate
for
the
eld
erly
for
the
sam
e re
ason
as
abov
e; le
ssen
s th
e ch
ance
of
falls
fr
om d
izzi
ness
or
hypo
tens
ion
Hig
h in
cid
ence
of
extr
apyr
amid
al s
ide
effe
cts
Trif
luop
eraz
ine
PO, I
M10
–60
5–30
Low
sed
atio
n—go
od f
or w
ithd
raw
n or
(S
tela
zine
)pa
rano
id s
ympt
oms
Hig
h in
cid
ence
of
EPS
NM
S m
ight
occ
urFl
uphe
nazi
ne (
Prol
ixin
)PO
, IM
, SC
2.5–
202–
20A
mon
g th
e le
ast s
edat
ive
Thi
othi
xene
(N
avan
e)PO
, IM
6–30
5–40
Hig
h in
cid
ence
of
akat
hisi
aL
oxap
ine
(Lox
itan
e)PO
, IM
60–1
0020
–200
Poss
ibly
ass
ocia
ted
wit
h w
eigh
t red
ucti
onM
olin
don
e (M
oban
)PO
50–1
0020
–200
Poss
ibly
ass
ocia
ted
wit
h w
eigh
t red
ucti
onPe
rphe
nazi
ne (
Trila
fon)
PO, I
M, I
V12
–32
8–64
Can
hel
p co
ntro
l sev
ere
vom
itin
gC
hlor
prom
azin
e PO
, IM
, R20
0-16
0020
0-10
00In
crea
ses
sens
itiv
ity
to s
un (
as w
ith
othe
r (T
hora
zine
)ph
enot
hiaz
ines
)
Con
tinu
ed
X29168-P0208.qxd 6/24/05 8:42 PM Page 251
252 PART II Diagnosis and Care Planning
Tabl
e 8-
3A
nti
psy
cho
tic
Med
icat
ion
s—co
nt’
d
Stan
dard
(Tr
adit
iona
l) A
ntip
sych
otic
Med
icat
ions
Ro
utes
of
Acu
te
Mai
nte
nan
ce
Dru
gA
dm
inis
trat
ion
(mg
/day
)*(m
g/d
ay)*
Spec
ial C
on
sid
erat
ion
s
Hig
hest
sed
atio
n an
d h
ypot
ensi
on e
ffec
ts;
leas
t pot
ent
Can
cau
se ir
reve
rsib
le r
etin
itis
pig
men
tosi
s at
800
mg/
day
Chl
orpr
othi
xene
PO
, IM
50-6
0075
-600
Wei
ght g
ain
com
mon
(Tar
acta
n)T
hior
idaz
ine
(Mel
lari
l)PO
200-
600
200-
600
Not
rec
omm
end
ed a
s fi
rst-
lin
e an
tip
sych
otic
Dos
e-re
late
d s
ever
e E
CG
cha
nges
; mig
ht
caus
e su
dd
en d
eath
Mes
orid
azin
e (S
eren
til)
PO, I
M75
-300
100-
400
Am
ong
the
mos
t sed
ativ
e; s
ever
e na
usea
an
d v
omit
ing
mig
ht o
ccur
in a
dul
tsA
u: M
S. n
otcl
ear?
X29168-P0208.qxd 6/24/05 8:42 PM Page 252
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 253
Dec
ano
ate:
Lo
ng
-Act
ing
Hal
oper
idol
a-I
M
050
-300
Giv
en d
eep
mus
cle
z-tr
ack
IM(H
ald
ol)
LA
IG
ive
ever
y 3-
4 w
eek
sFl
uphe
nazi
ne
012
.5-5
0G
iven
dee
p m
uscl
e z-
trac
k IM
dec
a-IM
LA
I (P
rolix
in)
Giv
e ev
ery
2-4
wee
ks
Dru
g d
osag
es f
rom
Ful
ler
and
Saj
atov
ic,
2000
, L
iebe
rman
and
Tas
man
, 20
00,
and
Ken
ned
y 20
00;
adap
ted
fro
m V
arca
rolis
, E
.Fo
unda
tion
s of
psy
chia
tric
men
tal h
ealt
h nu
rsin
g(5
th e
d.).
Phi
lad
elph
ia: W
B S
aund
ers,
pp.
?*D
osag
es v
ary
wit
h in
div
idua
l res
pons
es to
ant
ipsy
chot
ic a
gent
use
d.
AC
H, A
ntic
holin
ergi
c si
de
effe
cts
(e.g
., d
ry m
outh
, blu
rred
vis
ion,
uri
nary
rete
ntio
n, c
onst
ipat
ion,
agi
tati
on);
EC
G, e
lect
roca
rdio
grap
h;E
PS,
ext
rapy
ram
idal
sid
e ef
fect
s; H
DL,
hig
h-d
ensi
ty l
ipop
rote
in; I
M, i
ntra
mus
cula
r; I
V, i
ntra
veno
us; L
DL,
low
-den
sity
lip
opro
tein
;O
H, o
rtho
stat
ic h
ypot
ensi
on; N
MS,
neu
role
ptic
mal
igna
nt s
ynd
rom
e; P
O, o
ral;
R, r
ecta
l; SC
, sub
cuta
neou
s; I
M-i
ntra
mus
cula
r L
.A.I
.-L
ong
acti
ng i
njec
tion
O.D
.T.-O
rally
dis
inte
grat
ing
tabl
ets.
SE
D,
sed
atio
n; S
SRI,
sele
ctiv
e se
roto
nin
reup
take
inh
ibit
or;
TD
, ta
rdiv
ed
yski
nesi
a; W
BC
, whi
te b
lood
cel
l cou
nt
X29168-P0208.qxd 6/24/05 8:42 PM Page 253
these side effects can be managed with other medications.EPS, cardiac side effects, and toxic effects of these drugs arediscussed further in Chapter 21.
One of the most disturbing side effects to clients are theEPS; medication is used to treat the EPS caused by thesestandard antipsychotics. Refer to Chapter 21 for a clientand family medication teaching plan.
PSYCHOSOCIAL APPROACHESTreatment of Comorbid ConditionsThere are many treatment approaches that can help clientswith schizophrenia better adjust to their environment andincrease their quality of life when used in conjunction withmedications. Some of the psychotherapeutic approachesthat seem to be useful for many people with these disor-ders are discussed here. However, treatment should notonly be aimed at the symptoms of schizophrenia but alsoneed to target some of the comorbid conditions that a clientmight exhibit. Some of the more common comorbid condi-tions in people with schizophrenia include:● Substance use problems● Depressive symptoms or disorders● Risk for suicide● Violent behaviors
If a comorbid condition is identified, it must be treated,if overall adherence to a second treatment approach is fol-lowed and/or successful.
Specific Psychosocial Treatments
Individual TherapyThere is evidence that supportive therapy that includes prob-lem-solving techniques and social skills training helpsreduce relapse and enhance social and occupational func-tioning when added to medication treatment for schizo-phrenic individuals who are treated in an outpatientenvironment. Cognitive behavioral therapy (CBT), cogni-tive rehabilitation, and social skills training (SST) are par-ticularly helpful in people with chronic schizophrenia whohave cognitive impairments.
254 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 254
Family InterventionFamilies with a schizophrenic member endure considerablehardships while coping with the psychotic and residualsymptoms of schizophrenia. Often families are the sole care-takers of their schizophrenic member and need education,guidance, and support as well as training to help them man-age (APA, 2000b). A Psychoeducational family approachprovides support, education, coping skills training, andsocial network expansion and has been proven very suc-cessful with both decreasing family stress and increasingclient adherence to treatment. Families can be helped by:● Understanding the disease and the role of medications● Setting realistic goals for their schizophrenic member● Developing problem-solving skills for handling tensions
and misunderstanding within the family environment● Identifying early signs of relapse● Having knowledge of where they can go for guidance
and support within the community and nationally
Group TherapyThe goals of group therapy for individual members are toincrease problem-solving ability, to enable realistic goalplanning, to facilitate social interactions, and to managemedication side effects (Kanas, 1996). Groups can helpclients develop interpersonal skills, resolution of familyproblems, utilization of community supports as well asincrease medication compliance by learning to deal withtroubling side effects.
NURSE, CLIENT, and FAMILYRESOURCES
ASSOCIATIONSNational Alliance for the Mentally III (NAMI)Colonial Place Three2107 Wilson Boulevard, Suite 300Arlington, VA 22201-3042(800) 950-NAMI (check this one out!)http://www.nami.org
CHAPTER 8 Schizophrenia and Other Psychotic Disorders 255
X29168-P0208.qxd 6/24/05 8:42 PM Page 255
Schizophrenics Anonymous403 Seymour Avenue, Suite 202Lansing, MI 48933(517) 485-7168;(800) 482-9534 (consumer line) (check this
one out!)
Recovery, Inc.802 North Dearborn StreetChicago, II, 60610(312) 337-5661
INTERNET SITESDoctors Guide to the Internethttp://www.pslgroup.com/schizophr.htmMany articles; good site for schizophrenia information
Internet Mental Healthhttp://www.mentalhealth.comVast amount of information/booklets/articles and general
information
National Alliance for Research on Schizophrenia andDepression
http://www.narsad.org
Schizophrenia.comhttp://www.schizophrenia.com
256 PART II Diagnosis and Care Planning
X29168-P0208.qxd 6/24/05 8:42 PM Page 256