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Mental Health Nursing: Psychotic Disorders

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Title: Mental Health Nursing: Psychotic Disorders


1
Mental Health Nursing Psychotic Disorders
  • By Mary B. Knutson, RN, MS, FCP

2
Psychotic Disorders
  • Health problems including
  • Severe mood disorder
  • Regressive behavior
  • Personality disintegration
  • Reduced level of awareness
  • Great difficulty in functioning adequately
  • Gross impairment in reality testing

3
Behaviors in Schizophrenia
  • Four As
  • Associations (loose)
  • Affect
  • Ambivalence
  • Autistic thinking
  • Additional As
  • Attention defects
  • Disturbances of activity

Schizophrenia relates to split between
cognitive and emotional aspects of the personality
4
Cognition
  • Information processing effected when
    neurotransmissions are delayed, accelerated, or
    blocked
  • People with schizophrenia are sometimes unable to
    produce complex, logical thoughts and express
    coherent sentences
  • Involves memory, attention, form and organization
    of speech (formal thought disorder),
    decision-making, and thought content (delusions)

5
Neurobiological Response Continuum
  • Adaptive responses
  • Logical thought, accurate perceptions, emotions
    consistent with experience, appropriate behavior,
    and social relatedness
  • ? Occasional distorted thought illusions,
    emotional overreaction, odd or unusual behavior,
    withdrawal?
  • Maladaptive responses
  • Thought disorder/delusions, hallucinations,
    inability to experience emotions, disorganized
    behavior, or social isolation ?

6
Delusions
  • Personal belief based on an incorrect inference
    of external reality
  • Paranoid- Suspicious, irrational distrust
  • Grandiose- Greatness or special powers
  • Religious- Favored by a higher being
  • Somatic- Body is diseased or distorted

7
Disordered Thought Content
  • Thought broadcasting- Thoughts being aired to the
    outside world
  • Thought insertion- Thought are being placed into
    mind by outside people
  • Ideas of reference- Incorrect interpretation on
    casual incidents and external events as having
    direct personal references
  • Magical thinking- thinking equates with doing, by
    lack of realistic relationship between cause and
    effect

8
  • Nihilistic- Thoughts of nonexistence or
    hopelessness
  • Obsession- An unwelcome idea, emotion, or impulse
    that repetitively and insistently forces itself
    into consciousness
  • Phobia- Morbid fear associated with extreme
    anxiety

9
Hallucinations
  • Perceptual distortions that occur in maladaptive
    neurobiological responses
  • Can occur in any illness that disrupts brain
    function
  • Perceptual problems are often the first symptoms
    in any brain diseases
  • Can affect any of five senses Sight, sound,
    taste, touch, and smell

10
Sensory Integration
  • Abnormal perceptual behavior can lead to
    deliberate acts of self-harm
  • Pain recognition
  • Stereogenesis-recognition of object by touch
  • Graphesthesia-ability to feel writing on the skin
  • Right/left recognition
  • Perception of faces
  • Often inaccurately assessed with behavioral, not
    perceptual context

11
Environmental Factors
  • Can stimulate visual hallucinations
  • Reflective or glaring objects, like television
    screens, glass in frames, and fluorescent lights
  • Can stimulate auditory hallucinations
  • Excessive noise
  • Sensory deprivation
  • Patients may withdraw from sensory stimuli
  • Often mixed hallucinations/delusions

12
What is Emotion?
  • Mood- Affects the persons world view
  • Affect- Behaviors such as hand or body movements,
    facial expression, and pitch of voice that can be
    observed
  • Broad or restricted affect can be normal
  • Blunted, flat, or inappropriate affect represent
    symptoms of disorder

13
Hypoexpression
  • Alexithymia- Difficulty naming and describing
    emotions
  • Apathy- Lack of feelings, emotions, interests, or
    concern
  • Anhedonia- Inability or decreased ability to
    experience pleasure, joy, intimacy, and closeness
  • Schizoaffective disorder includes major
    depression or bipolar disorder and schizophrenia

14
Maladaptive Movements
  • Catatonia- state of stupor
  • Extrapyramidal side effects of psychotropic
    medications
  • Abnormal eye movements- decreased or rapid
    blinking, difficulty following moving object,
    staring, or avoidance of eye contact
  • Grimacing
  • Apraxia- difficulty carrying out purposeful
    tasks, such as dressing or grooming
  • Echopraxia- Purposeless imitation of movements by
    others
  • Abnormal gait and mannerisms

15
Deteriorating Behavior
  • Person may lack energy and drive
  • Repetitive or obsessive-compulsive behavior may
    be noted
  • Aggression, agitation, and potential for violence
    may be related to chronic illness feeling out of
    control
  • Performance anxiety may be a trigger when
    carrying out formerly simple tasks becomes more
    difficult

16
Effects on Socialization
  • Socialization is the ability to form cooperative
    and interdependent relationships with others
  • Social problems result from psychotic disorders
    directly or indirectly
  • May include socially inappropriate actions
  • Stigma presents major obstacles to developing
    relationships
  • Mark of shame may affect family

17
Patient Example
  • Usually deteriorated appearance
  • Several layers of clothing
  • Refusal to bathe
  • Rocking and hugging oneself
  • Lack of persistence at work or school
  • Lack of energy and drive
  • Repetitive or stereotypical behavior
  • Aggression, agitation, and negativism

18
Predisposing Factors
  • Genetic vulnerability ?
  • Psychosocial stressors ?
  • Environmental stressors?
  • Physiological stressors ?
  • Stress and problems with coping when person
    reaches internal stress tolerance threshold ?
  • Or brain abnormalities causing maladaptive
    neurobiologic responses
  • ? Psychotic Disorders

19
Alleviating Factors
  • Family resources such as parental understanding,
    and providing support.
  • Coping resources to manage fear and anxiety can
    be learned
  • Regression
  • Projection
  • Withdrawal
  • Denial- gradually gather internal and external
    resources to adapt to stressors gradually

20
Medical Diagnosis
  • Schizophrenia- Paranoid, Disorganized, or
    Catatonic type
  • Schizophreniform disorder (1-6 mo.) with good
    social and work function
  • Schizoaffective disorder
  • Delusional disorder- non-bizarre delusions with
    functioning unaffected
  • Brief psychotic disorder (1-30 days)
  • Shared psychotic disorder- delusions of people in
    close relationship are similar

21
Examples Nursing Diagnosis
  • Impaired verbal communication r/t formal thought
    disorder as e/b loose associations
  • Sensory/perceptual alteration (auditory) r/t
    physiological brain dysfunction e/b verbal
    reports of hearing voices
  • Social isolation r/t inadequate social skills e/b
    inappropriate sexual advances toward members of
    both sexes
  • Altered thought processes r/t physiological brain
    dysfunction e/b stated belief that staff members
    are really actors who were hired by parents to
    watch him

22
Treatment
  • Stabilize health
  • Maintain wellness
  • Recognize early signs of relapse
  • Facilitate habilitation
  • Goal To live, learn, and work at a maximum
    possible level of success as defined by the
    individual
  • Time to achieve goal varies- may be several
    months to several years

23
Nursing Care
  • Assess subjective and objective responses in
    order to develop individualized care plan
  • Recognize behavior challenges
  • Assist to maintain appropriate level of
    responsibility to own behavior
  • Work on other complicating issues, such as
    substance abuse
  • Facilitate integration into family and community

24
Treatment
  • Physical care and monitoring in safe, supportive
    environment
  • Manage delusions- calm, empathic non-verbal
    communication, and gentle eye contact
  • Manage hallucinations- listen and observe, with
    goal to increase pts awareness (learn difference
    between the world of psychosis and the world of
    others)

25
Psychopharmacology
  • Phenothiazines and derivatives provide some sx
    relief for 80 of patients
  • Caffeine and nicotine consumption can affect the
    action of psychotropic medication

26
Typical Anti-Psychotic Drugs
  • Phenothiazines
  • Chlorpromazine (Thorazine)
  • Thioridazine (Mellaril), or Mesoridazine
    (Serentil)
  • Fluphenazine (Prolixin)- can be injection lasting
    2-4 weeks
  • Haloperidol (Haldol)

Side effects can range from uncomfortable,
treatable ones to painful and disabling
extrapyramidal symptoms to life-threatening
emergency like neuroleptic malignant syndrome
27
Atypical Antipsychotic Drugs
  • Clozapine (Clozaril)
  • Resiperidone (Risperdal)
  • Olanazapine (Zyprexa)
  • Quetiapine (Seroquel)
  • Ziprasidone (Geodon)
  • Aripiprazole (Ablify)

Extrapyrimidal syndrome (EPS) or tardive
dyskinesia (TD) is rare Usually improve mood and
cognitive impairment May cause sedation, wt gain,
metabolic disturbances, risk of diabetes The
biggest disadvantage is their high expense
28
Extrapyramidal Symptoms
  • Acute dystonic reactions- Sudden muscle spasms in
    neck, back, or eyes that may be painful and
    frightening
  • Akathisia- Pacing, inner restlessness, leg aches
    relieved by movement
  • Parkinsons syndrome- cogwheel rigidity, fine
    tremor, akinesia

29
Tardive Dyskinesia
  • Involuntary movements
  • Tongue protrusion
  • Lip smacking, chewing
  • Grimacing, blinking
  • Choreiform movements of limbs and trunk
  • Foot tapping

30
Other Potential Side Effects
  • Neuroleptic Syndrome- Fever, tachycardia,
    sweating, muscle rigidity, tremor, incontinence,
    stupor, leukocytosis, renal failure
  • Agranulocytosis- Fever, malaise, ulcerative sore
    throat, leukopenia
  • Seizures
  • Photosensitivity

31
Anticholinergic Effects
  • Constipation
  • Dry mouth
  • Blurred vision
  • Orthostatic hypotension
  • Tachycardia
  • Urinary retention
  • Nasal congestion

32
General Pharmacological Principles
  • Dosages vary- Must be adjusted
  • May start feeling sedating effects in 1-3 days
  • Full benefit of typical antipsychotics may take 4
    or more weeks
  • Atypical drugs may begin to work in a week, but
    take several months to reach maximum effect
  • Slowly taper off meds to prevent dyskinetic
    reactions, rebound side effects, and relapse

33
Social Aspects of Treatment
  • Assess social skills and plan activities and
    education plan for enhancing social skills
  • Family involvement
  • Group therapy
  • Mental health education involving both patient
    and family
  • Discharge planning to include supervision and
    support groups

34
Interventions
  • Teach health management, hygiene, health care,
    nutrition, sleep/rest pattern
  • Educate regarding diagnosis and tx options
  • Assist with medication management
  • Develop acceptable tx plan
  • Teach relapse planning and prevention
  • Identify symptom triggers
  • Assist with avoidance of substance abuse, sensory
    overload, and isolation

35
Evaluation
  • Patient Outcome/Goal
  • Relapse can not always be prevented because these
    are serious, long-term illnesses
  • Patient will be satisfied with his/her level of
    functioning and ability to communicate either
    improvement or impending relapse
  • Nursing Evaluation
  • Was nursing care adequate, effective,
    appropriate, efficient, and flexible?

36
References
  • Stuart, G. Sundeen, S. (1995). Principles
    practice of psychiatric nursing (5th Ed.). St.
    Louis Mosby
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