Self-Assessment: Working with Schizophrenic Clients

Peer group supervision Client's intense emotions produce

similar emotions in the nurse Willingness for nurse to discuss feelings and

behaviors with supervisors decreases defensive behaviors

Team approach to decrease staff burnout

Periodic reassessments of Treatment outcomes Client's strengths and weaknesses

Assessment of the Client

Safety of client and others Medical history and recent medical

workup Positive, negative, cognitive, and

mood symptoms Current medications and compliance

to treatment Family response/support system

Potential Nursing Diagnoses Risk for self-directed or other-

directed violence Disturbed sensory perception Disturbed thought processes Impaired verbal communication Ineffective coping Compromised or disabled family

coping

Outcome Criteria

Acute phase Client safety and medical stabilization

Maintenance phase Adherence to medical regimen Understanding schizophrenia Participation of client and family in psychoeducational

activities

Stabilization phase Target negative symptoms Anxiety control Relapse prevention

Planning of Appropriate Interventions

Acute phase Possible hospitalization

Ensure client safety Provide symptom stabilization

Maintenance and stabilization phases Psychosocial education Relapse prevention skills

Interventions: Basic Level

Acute phase Administer antipsychotic medication as

prescribed Observe client behavior closely Set limits on inappropriate behavior Do not touch without warning Offer foods that are not easily

contaminated Assist with ADL if needed Supportive counseling Milieu management Family psychoeducation

Interventions: Basic Level Continued

Maintenance and stabilization phases Health teaching Health promotion and maintenance

Milieu Therapy Safety

Potential for physical violence due to hallucinations or delusions

Priority is least restrictive safety technique Verbal de-escalation Medications Seclusion or restraints

Activities Provide support and structure Encourage development of social skills

and friendships

Counseling: Communication Guidelines Hallucinations

Hearing voices most common Approach client in nonthreatening and

nonjudgmental manner Assess if messages are suicidal or homicidal Initiate safety measures if needed Client anxious, fearful, lonely, brain not

processing stimuli accurately Focus on the client’s feelings and present

reality

Communication Guidelines continued Delusions

Be open, honest, matter-of-fact, and calm

Have client describe delusion Avoid arguing about content Focus on feelings Present reasonable doubt Validate part of delusion that is real

Communication Guidelines continued Associative looseness

Do not pretend that you understand Place difficulty of understanding on yourself Look for reoccurring topics and themes Emphasize what is going on in the client's

environment Involve client in simple, reality-based

activities Reinforce clear communication of needs,

feelings, and thoughts

Client Teaching Coping Techniques for Schizophrenia Distraction Interaction Activity Social action Physical action

Client and Family Teaching

Learn all you can about the illness. Develop a relapse prevention plan. Avoid alcohol and drugs. Learn ways to address fears and losses. Learn new ways of coping. Comply with treatment. Maintain communication with

supportive people. Stay healthy by managing illness,

sleep, and diet.

Treatment Modalities

Individual therapy Social skills training (SST) Cognitive remediation Cognitive adaptation training (CAT) Cognitive behavioral therapy (CBT)

Group therapy Family therapy Psychopharmacology

Psychopharmacology

Antipsychotics Standard/ Typical Atypical

Antiparkinson

PsychopharmacologyTraditional Antipsychotic Dopamine antagonists (D2 receptor

antagonists) Target positive symptoms of schizophrenia Advantage

Less expensive than atypical antipsychotics Disadvantages

Do not treat negative symptoms Extrapyramidal side effects (EPS) Tardive dyskinesia Anticholinergic effects (ACH) Lower seizure threshold

Antipsychotic Medications: Traditional

High potency = low sedation + low ACH + high EPSs Haloperidol (Haldol) Trifluoperazine (Stelazine) Fluphenazine (Prolixin) Thiothixene (Navane)

Medium potency Loxapine (Loxitane) Molindone (Moban) Perphenazine (Trilafon)

Antipsychotic Medications: Traditional continued

Low potency = high sedation + high ACH + low EPSs Chlorpromazine (Thorazine) Thioridazine (Mellaril) Mesoridazine ( Serentil)

Decanoate = Long acting injection Haloperidol decanoate (Haldol D) Fluphenazine decanoate (Prolixin D)

Atypical Antipsychotics (First-Line Antipsychotics)

Serotonin-dopamine antagonists (5-HT2A receptor antagonists)

Advantages Diminishes negative as well as positive symptoms of

schizophrenia Less side effects encourages medication compliance Improves symptoms of depression and anxiety Decreases suicidal behavior

Disadvantages Weight gain Metabolic abnormalities

Antipsychotic Medications: Atypical

Clozapine (Clozaril) Quetiapine (Seroquel) Risperidone (Risperdal Zipreasidone (Geodon) Olanzapine (Zyprexa) Aripiprazole (Abilify)

Side Effects- Atypical

Orthostatic Hypotension Decreased Libido Agranulocytosis

(Clozapine) Weight gain Tachycardia Edema

Side Effects: Anticholinergic Symptoms Dry mouth Urinary retention and hesitancy Constipation Blurred vision Photosensitivity Dry eyes Inhibition of ejaculation or impotence in

men

Side Effects:Extrapyramidal Side Effects

Pseudoparkinson Drooling, lack of facial responsiveness,

shuffling gait, and fine intentional tremors.

Acute DystoniaMuscle spasms of the jaw, tongue, neck or

eyes. Laryngeal spasms possible. Oculogyric crisis, Opisthotonos.

AkathisiaMotor restlessness, pacing, rocking, etc

Side Effects:Extrapyramidal Side Effects

Tardive Dyskinesia

Bizarre facial and tongue movements chewing, tongue from side to side, etc. Involuntary tonic muscular spasms of extremities

Trunk Potentially irreversible

Side Effects:a2 Block: Cardiovasclar

Hypotension Postural hypotension Tachycardia

Side Effects: Rare and Toxic Effects

Agranulocytosis Cholestatic jaundice Neuroleptic malignant syndrome

(NMS) Severe extrapyramidal Hyperpyrexia Autonomic dysfunction

NEUROLEPTIC MALIGNANT SYNDROME RARE, POTENTIALLY FATAL ONSET WITHIN HOURS OR YEARS EPS REACTIONS CPK HYPERTHERMIA 102° AND ABOVE TACHYCARDIA FLUCTUATING B.P. DIAPHORESIS STUPOR AND COMA

AGRANULOCYTOSIS

Potentially fatal disorder Symptoms include:

White blood cells level <2000 mm3 or granulocyte count <1500mm3

Sore throat Low grade fever Malaise Sores in the mouth

NURSING IMPLICATIONS

MONITOR B.P. BEFORE ADMINISTERING MEDS

CHECK CBC, CPK, LIVER FUNCTIONS AND VISION REGULARLY

EVALUATE FOR EFFECTIVENESS AND SIDE EFFECTS

ADMINISTER 1 OR 2 HOURS BEFORE BEDTIME

MIX LIQUIDS WITH 60CC FRUIT JUICE

PATIENT EDUCATION

ANTIPARKINSON AGENTS

COGENTIN ARTANE AKINETON PARLODOL KEMADRIN BENEDRYL

CLIENT AND FAMILY TEACHING

Teach about schizophrenia and available mental health agencies for support at the local and national level (NAMI AND NIMH).

Develop a relapse prevention plan. Teach about medication and treatment

compliance. Teach to avoid alcohol or drugs. Teach to keep in touch with supportive

people. Teach to keep healthy – stay in balance.