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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.