Psychiatric / Mental Health NursingNURS 204

Prevalence in U.S. is 1.1%. Average onset is late teens to early twenties, but can be as late as mid-fifties

Affects cognitive, emotional, and behavioral function

30% to 40% relapse rate in the first year

Life expectancy is shortened because of suicide

Language and communication disturbances

Thought disturbances Perception disturbances Affect disturbances Motor behavior disturbances Self-identity disturbances

Progression varies from one client to another◦Exacerbations and remissions◦Chronic but stable◦Progressive deterioration

DSM-IV-TR Diagnosis◦Symptoms present at least 6 months◦Active-phase symptoms present at least 1 month

◦Symptoms are defined as positive and negative

Positive symptoms ◦ Excess or distortion of normal functioning◦ Aberrant response

Negative symptoms◦ Deficit in functioning

Positive Symptoms of Schizophrenia ◦Hallucination:

Auditory, Visual Olfactory, Gustatory, Tactile

◦Delusions: Persecutory, Referential Somatic, Religious, Substitution, Thought Insertion and/or Broadcasting

Nihilistic, Grandiose

◦Disordered speech: Loose Association, Word Salad Clanging, Echolalia, Neologism

◦Disordered behavior: Disorganized walk Touching all objects and surfaces Catatonia

◦Disordered Thinking: Indecisiveness, lack of problem solving skills,

Concreteness, blocking, perservation

Negative Symptoms of Schizophrenia◦Flat affect: lack of emotion◦Apathy: indifference towards people, events, activities and learning.

◦Alogia: Poverty of speech◦Avolition: inability to pursue and persist in goal-directed activities.

◦Anhedonia: inability to experience pleasure.

Paranoid type Disorganized type Catatonic type Undifferentiated type Residual Type

Paranoid Type◦ Delusions

Persecutory and grandiose Somatic or religious

◦ Hallucinations Delusions link with a hallucination

Disorganized type◦ Disorganized speech, behavior, appearance◦ Flat or inappropriate affect◦ Fragmented hallucinations and delusions◦ Most severe form of schizophrenia

Catatonic type◦ Psychomotor retardation and stupor◦ Extreme psychomotor agitation◦ Waxy flexibility◦ Echolalia◦ Mutism ◦ Echopraxia

Undifferentiated type◦Active psychotic state◦Lacks symptoms of other subtypes

Residual type◦At least one episode of schizophrenia◦No prominent positive symptoms◦Negative symptoms present

Schizophreniform disorder Schizoaffective disorder Delusional disorder Brief psychotic disorder Shared Psychotic Disorder (Folie à Deux)

Induced or Secondary Psychosis

Biologic theories Psychological theories Family theories Humanistic-interactional theories

Biologic Theory: Genetic ◦ Only genetic predisposition for developing schizophrenia is inherited

◦ 10% of first-degree relatives◦ 25%-39% of monozygotic twins

Biologic Theory: Brain Structure Abnormality ◦ Differs from those with no symptoms◦ May be genetically based◦ Requires more study

Schizophrenia scans. PET scans of discordant monozygotic twins taken during a test to provoke activity and measure regional cerebral blood flow. (A) Arrows indicate areas of normal blood flow and brain activity in the unaffected twin. (B)

Arrows indicate areas of lower blood flow and brain activity in the twin with schizophrenia. Source: Courtesy of Dr. Karen F. Berman, Clinical Brain

Disorders Branch, National Institute of Mental Health

Biologic Theory: Biochemical Theories◦ Dopamine hypothesis◦ Traditional antipsychotic medications are dopamine blockers

◦ Dopamine blocker alleviate positive symptoms

Psychological theories◦ Information processing

Difficulty controlling the amount and type of information that is processed in the brain.

◦ Attention and arousal Hyper or hypo responsiveness to various situations

Family Theories◦Dysfunctional interaction not supported by research

◦Disordered family communication linked only with genetic predisposition

◦Family emotional tone influences course of schizophrenia

◦Expressed emotions theory (EE)

Humanistic-interactional theories integrate biological and psychosocial theories

Combine influences of:◦Genetic predisposition or biologic vulnerability

◦Environmental stressors◦Social support

Stress–Vulnerability Model ◦ Stressors increase vulnerability◦ Cumulative effect of:

Genetic predisposition Personal stressors Familial factors Environmental factors

Social Pressures ◦ Lack of social support◦ Financial problems◦ Stigma

Psychological pressures ◦ Difficulty with problem-solving◦ Difficulty with interpreting reality◦ Difficulty coping ◦ Problems with self-care ◦ Unstable interpersonal relationships

Assessment◦Premorbid functioning◦Content of thought◦Form of thought◦Perception◦Sense of self◦Delusions and perceptual disturbances◦Hallucinations◦Drug use

Nursing Diagnoses◦Disturbed thought process◦Disturbed sensory perception◦Social isolation◦Risk for violence◦Self-care deficits◦Altered health maintenance◦Ineffective coping◦Impaired verbal communication◦Excess Fluid Volume◦Decisional Conflict◦Dysfunctional or Interrupted family process

Family needs vary with degree of illness and involvement in client’s care◦ Education◦ Financial support◦ Psychosocial support◦ Advocacy

Schizophrenia is a “family illness.” Family members need to be involved. Educate family about◦Medication◦Illness◦Relapse prevention

Nurse assists family by◦Identifying community agencies/groups for family members

◦Advocating for rights

Promote Safety and a Safe Environment Promote Congruent Emotional Response Promote Social Interaction and Activity Intervene with Hallucinations and Delusions

Preventing Relapse Promoting adherence with medication regimen

Assist with grooming and hygiene Promote Family Understanding and Involvement

Relapse prevention programs provide education and support regarding:– Individual triggers, symptoms of relapse– Managing side effects of medications– Interventions to reduce or eliminate triggers

– Strategies to facilitate early intervention

– Cognitive therapy – Community resources

Side effects of Psychotropic Medications

Level of symptomatology Cognitive, motivational, financial, and cultural issues

Issues with caregivers Insufficient medication teaching Substance abuse

Involve clients in treatment Instruct client about reducing discomfort

Provide peer support Provide reminders and positive feedback

Recognize accomplishments

Identify personal feelings and recognize personal perceptions.

What behaviors do you expect to see? How will you respond to these behaviors?

What is the meaning of the behaviors? What defines “normal” behavior? What are my fears associated with mental illness?

Remember that clients are human beings with a mental disorder and do not choose to be this way.

A primary treatment mode of psychiatric-mental health nursing care

ANA Task Force Guidelines◦Integrate current data from the neurosciences.

◦Demonstrate knowledge of psychopharmacologic principles.

◦Provide safe and effective care of clients taking these medications.

Prior to the 1950s: focus on behavioral interventions and sedatives

Mid-fifties: Introduction of the first antipsychotic medication chlorpromazine (Thorazine)

Since then, many advances have led to the treatment of the client with mental illness in the community.

Psychiatric medications allow for the correction of imbalances of brain chemicals.

The great success of biological psychiatry. This graph illustrates the dramatic decrease in psychiatric inpatient numbers since the inception of

psychopharmacology.

Typical (Conventional)◦ Block dopamine receptors at 70% to 80% occupancy to be effective.

Exptrapyramidal Side Effects (EPSEs) occur at occupancy > 80%

Ongoing research on new medications Ongoing research on new delivery systems◦ Newer depot: Resperidone Consta◦ Orally Disintegrating Tablets: Zyprexa Zydis

Some ethnic groups are slow metabolizers.◦ More side effects◦ Greater risk of toxicity

Some ethnic groups are fast metabolizers.◦ Less effect of the medication

Positive Effects◦Allowed release of clients from inpatient hospital to treatment in the community

◦Manage the symptoms such as delusional thinking, hallucinations, confusion, motor agitation, motor retardation, blunted affect, bizarre behavior, social withdrawal and agitation.

Alleviation of the symptoms, often improving:◦Ability to think logically◦Ability to function in one’s daily life◦Ability to function in relationships

Negative Effects ◦Frightening and life threatening side effects

◦Potential interactions with other medications and substances

◦Possible need to cope with the realization of having a chronic illness

Adherence to prescribed medications by clients in psychiatric services is less than 35%

Reasons for nonadherence:◦ Clients do not know what to expect from medications.

◦ The schedule of doses or routes may be inconvenient.

◦ Friends/relatives may not be supportive.◦ Side effects may be worst than the symptoms.

A careful assessment is needed to decide the right form of the medication:

PO - by mouth (for routine use) Liquid form (concentrate or syrup) Quick-dissolving formulation (sublingual)

PRN injection Depot injection

Atypicals◦ Reduced affinity for dopamine receptors◦ Affinity for serotonin receptors◦ Fewer EPSEs ◦ Reduction in negative symptoms

Side effects◦ ANS, extrapyramidal, other CNS, allergy, blood, skin, eye, endocrine, and weight gain

The five categories of EPSEs are dystonia, drug-induced parkinsonism, akathisia, tardive dyskinesia, and dopamine-acetylcholine imbalance

Occurs usually within 48 hours of initiation of the medication

Involves bizarre and severe muscle contractions

Can be painful and frightening Characterized by odd posturing and strange facial expressions (Torticollis, Opisthotonus, Laryngospasm, Oculogyric Crises)

Usually occurs after 3 or more weeks of treatment

Characterized by:◦ Cogwheel rigidity◦ Tremors at rest◦ Rhythmic oscillations of the extremities◦ Pill rolling movement of the fingers◦ Bradykinesia◦ Postural Changes

Usually occurs after 3 or more weeks of treatment

Subjectively experienced as desire or need to move

Described as feeling like jumping out of the skin

Mild: a vague feeling of apprehension or irritability

Severe: an inability to sit still, resulting in rocking, running, or agitated dancing

Usually occurs late in the course of long-term treatment

Characterized by abnormal involuntary movements (lip smacking, tongue protrusion, foot tapping)

Often irreversible

Inability to wear dentures Impaired respirations Weight loss Impaired gait Impaired posture

A rare side effect Characterized by hallucinations, dry mouth, blurred vision, decreased absorption of antipsychotics, decreased gastric motility, tachycardia, and urinary retention

Dry mouth Blurred vision Constipation Urinary retention Tachycardia

Sedation Lowering of the seizure threshold:◦ Observe clients with seizures disorders carefully when treatment is initiated.

Some antipychotics may contribute to prolongation of the QTc interval and lead to arrhythmias.◦ An EKG can identify those at risk.

Agranulocytosis Skin photosensitivity Retinitis pigmentosa

Early symptoms: beginning signs of infection

White blood cells are routinely monitored in clients taking clozapine (Clozaril).

Hyperprolactinemia may cause:◦ Oligomenorrhea or amenorrhea in women◦ Galactorrhea in women and rarely in men◦ Osteoporosis if prolonged

Impotence in males may occur. Diabetes◦ Monitor blood glucose levels.

Monitor weight Teach about diet and exercise Weight gain may contribute to physical as well as psychosocial stressors

Typically occurs in the first 2 weeks of treatment or when the dose is increased

Hold the medication, notify the physician, and begin supportive treatments.

Symptoms: muscle rigidity, tachycardia, hyperpyrexia, altered consciousness, tremors and diaphoresis

Risk Factors◦ Dehydration◦ Agitation or catatonia◦ Increase dose of neuroleptic◦ Withdrawal from anti-parkinson medication◦ Long acting or depot medication

Pharmacologic treatment◦ Antipyretics◦ Muscle relaxant◦ Dopamine receptor agonist

A primary nursing role is to teach patients about the major side effects of psychotropic medications and how to manage them.

Nurses must monitor for side effects and intervene when necessary.

Dsytonia and drug-induced parkinsonism are treated by anticholinergics.

Akathisia may be treated with anticholinergics but is not always responsive.

Tardive dyskinesia treatment is preventive through careful and routine assessment.

Take the client’s blood pressure in a supine position and then in a standing position.

Caution clients to rise slowly from a supine position.

Anticholenergic Side Effects:◦ Ice chips, hard candy◦ Eye drops◦ Fiber diet, exercise◦ Increase fluid intake◦ Catheterization

Typical Agents◦ Low Potency

Chlorpromazine (Thorazine) (25 – 800 mg/d) Thioridazine (Mellaril) (150 – 800 mg/d) Mesoridazine (Serentil) (100 – 400 mg /d)

◦ Side Effects: Sedation, Anticholernergic, Hypotention, EPSEs (less vs high potency)

Typical Agents◦ High Potency

Haloperidol (Haldol) (1 – 30 mg/d) Fluphenazine (Prolixin) (0.5 – 40 mg/d) Thiothixene (Navane) (2 – 30 mg/d) Trifluoperazine (Stelazine) (1 – 40 mg/d) Perhenazine (Trilafon) (8-60 mg/d) Loxapine (Loxitane) (20 – 250 mg/d) Molindone (Moban) (50 – 225 mg/d) Pimozide (Orap) 0.5 – 9 mg/d)

Side Effects Sedation, Anticholenergic SE (less vs low potency)

EPSEs

Atypical Agents◦ Clozapine (Clozaril) (6.25 – 900 mg/d)

Side effects: seizures, agranulocytosis, weight gain, hypersalivation, anticholinergic

◦ Olanzapine (Zyprexa, Zyprexa Zydis) (5 – 20 mg/d)

◦ Paliperidone (Invega) (3 – 12 mg/d)◦ Quetiapine (Seroquel) (150 – 600 mg/d)◦ Risperidone (Risperdal, Risperdal M-Tab) (2 – 6 mg/d)

◦ Ziprasidone (Geodon) ( 40 – 160 mg/d)◦ Aripiprazole (Abilify) (15 – 30 mg/d)◦ Asenapine (Saphris) (5 – 10 mg/d) Sublingual◦ Iloperidone (Fanapt) (12 – 24mg/d)

Typical Agents◦ Haloperidol Decanoate (Haldol Decanoate)

Q4 weeks◦ Fluphenazine Decanoate (Prolixin Decanoate) Q2 Weeks

Atypical Agents◦ Risperidone Consta (Risperdal Consta)

Q2 Weeks◦ Paliperidone Sustenna (Invega Sustena)

Q4 weeks

Trihexyphenidyl (Artane) Benztropine (Cogentin) Diphenhydramine (Benadryl) Amantadine (Symmetrel)