Mental Health Case Study – Schizophrenia & Psychosis

Most important intervention for Schizophrenia client
• Establish Rapport and Trust
• When clients have cognitive disorders and difficulty processing language, the beginning of trust is more readily established through nonverbal communication
• Secondarily, making adequate social space and approaching the client with calmness and gentle eye contact

Involuntary Commitment?
• (x) Past history of suicide attempts
• (o) Losing 10 lbs in 2 weeks
This criteria for commitment belongs to “unable to provide for own basic needs – excessive weight loss because he is not maintaining adequate nutrition

Involuntary Commitment
• Severely mentally ill
• Those in need of immediate and adequate treatment
• Those who are unable to provide for own basic needs
• Danger to self and/or others

What is the most important part of the admission process?
• Take away dangerous objects
Safety for the client and milieu is the highest prioirity, so the staff should keep any potentially dangerous objects away from the client

Best indicator of the potential for violence
• Past suicide attempts
• History of violence (the best predictor)
• Medication noncompliance
• (x) gender ang age

Reasons for the urine drug screen
• Detection of substances that may have altered the client’s mental status (ex: cause hallucination or delusions)

Urinalysis (소변검사)
• Positive Ketones
Ketones in the urine can suggest malnutrition, fasting or starvation
• Decreased urine pH
Decreased urine pH is associated with urinary tract infection, renal failure, or alkalosis
• Increased urine specific gravity
Increased urine specific gravity is associated with dehydration which could be contributing weight loss

Reasons for Baseline complete blood count (CBC) prior to initiation of the antipsychotic medication
• To monitor for agranulocytosis
A baseline CBC is indicated to allow for monitoring of the development of agranulocytosis, seen in clients taking clozapine (Clozaril)
Agranulocytosis is a POTENTIALLY LIFE-THREATENING side effect that manifests as fatigue, sore throat, and fever

Liver Function Test
• Potential hepatotoxicity
Hepatotoxicity is most often seen in older clients and in clients on multiple medications
• Liver enzymes are measured

Nursing diagnoses for psychosis patient with hallucination and delusions
• Sensory-perceptual alteration related to withdrawal into self
-The priority nursing diagnosis is related to the client’s hallucinations, which impact his functioning and social interaction
• Chronic low self-esteem related to impaired cognition
• Ineffective individual coping related to personal vulnerability
• Knowledge deficit related to medication compliance

Basic interventions for Psychotic patient
• Do not make direct eye contact, rather, take a side-by-side position
• Speak in simple terms and in a slightly louder voice than usual
• Call the client by name
Rationale: Give sensory validation to override the abnormal sensory processes that are occuring in the brain. Direct eye contact may make a paranoid client feel more paranoid. Use non-threatening body language and tone of voice

Additional Interventions?
• Consistency
• Medications
• (x) Isolation – reinforce the psychosis
• (x) Providing ADL – can offer structure for the client, although in the acute phase of treatment the client may not be able to tolerate a lot of stimulus in the environment or a great deal of social interaction

What nursing interventions should be included in care plan early after admission and reinforced until discharge?
• Client safety
• The purpose and side effects of psychotropic medications
• (x) An understanding of psychosis and the causes of it
-Not essential for the client to obtain by discharge. If the client understands the problems that caused the psychosis, he may be able to prevent it from recurring. This process can take months or years
• (x) The importance of attending support groups after discharge
-The client does not necessarily need to attend a support group if he already has an adequate support system in place

Therapeutic Communication Techniques
Therapeutic Communication Techniques

What is the most important benefit psychotic client can receive from attendance at the community meeting?
• Reality orientation
– Meetings that are designed to introduce clients to one another, plan activities for the day, and address client concerns and questions help ground the psychotic client in the present and reality
• (x) Psychosocial skills
-The staff in the community meeting can model psychosocial skill, but this is secondary
• (x) Limits set on behaviors
– Providing structure within the milieu is one way of setting limits on unacceptable behaviors through the use of contracts, tokens, and attendance at individual meetings, but this is secondary

What is a goal of being in this activity group?
• Gain self-acceptance and express feelings
-An activity group promotes self-acceptance, expression of feelings, and a focus on group goals rather than individual issues

What is a goal of being in a psychotherapy group?
• Helps clients gain insight into their behaviors through group processes, and helps them change target behaviors

What is a goal of being in a psychoeducation group?
• Provides information related to specific mental illnesses

What is a goal of being in a problem-solving group
• Helps the client identify and work to resolve problems related to the client’s treatment plan

Group content vs Group process
• Group content includes what the group members say
• Group process refers to how they communicate their thoughts and feelings
• The client will bring issues and questions to the group, but the nurse should plan and facilitate the content

Teaching to tell the client to discuss symptoms with his nurse
• It is very important to reinforce the client’s medication compliance by recommending that the client discuss any uncontrollable movements of the face or extremities so that the nurse can assess for tardive dyskinesia

As the client is leaving the unit, the caseworker wants to return the medication that the client brought with back to the client
• They need to obtain a prescription from the HCP to return medications
-The HCP must write a prescription for the client to receive medications. Sometimes the client is not allowed to receive any medications that were brought to the hospital, especially if they are different from the discharge medications

Why individuals develop psychosis?
• Psychosis is thought to be caused by the overactivity of a neurotransmitter

Why individuals develop schizophrenia?
(A lot of hypothesis)
• (Best Answer) Schizophrenia is a brain disorder with many predisposing factors. These factors include biological factors related to genetics, neurobiology, neurotransmitters, and neurodevelopment of structural, functional, and chemical brain changes that occur in early years of life and before birth
• Imbalance of the brain neurotransmitters dopamine and serotonin
• Marked decrease in brain volume and abnormal functioning

Symptoms of Schizophrenia
Symptoms of Schizophrenia

Symptom triggers of Schizophrenia
• Symptom triggers are stimuli, or combinations of stimuli, and stressors that precede a new episode of the illness
• Can be related to nutrition, lack of sleep, fatigue, housing difficulties, changes in life events, and feeling overpowered
• Knowing symptom triggers and how to manage them can help prevent relapse
• A client can learn to cope with symptom triggers and prevent relapse and hospitalization

Criteria for Schizophrenia according to DSM-IV
• Characteristics of symptoms
-Disorganized speech (manifestation of disorganised thoughts)
-Grossly disorganized or catatonic(excessive movement) behavior
-Negative Symptoms
• Social-occupational dysfunction: work, interpersonal, and self-care functioning is below the level achieved before onset
• Duration: continuous signs of the disturbance for at least 6 months
• Schizoaffective and mood disorders are not present and are not responsible for signs and symptoms
• Not caused by substance abuse or a general medical disorder

Positive symptoms of Schizophreniaterm
• Hallucinations
• Delusions
• Disorganized speech
• Bizzare behavior

Schizophrenia can be differentiated from psychosis by
Negative Symptoms
• minimal eye contact
• poor grooming and hygiene
• apathy (감정없음)
• blunted affect or flat affect (no facial expression of emotion)
• social inattentiveness (“spaciness”)
• Poverty of content of speech (one-word answers)
• Thought Blocking (stop talking in the middle of a sentence)
• poverty of thought (alogia)
• loss of motivation (avolition)
• Inability experience pleasure or joy (anhedonia)

• Lack of feelings, emotions, interests, or concerns

• A lack of energy or drive

• Inability or decreased ability to experience pleasure, joy, intimacy, and closeness

Hallucination vs Delusions
• A hallucination is an alteration in SENSORY PERCEPTION. Most hallucinations are auditory
• Delusions are fixed, false beliefs that the nurse should avoid trying to logically disprove to the client

Nonverbal Cues for Hallucinations
• Client tilts the head to one side
• Sometimes pause and mumbles

Types of Delusions
• Ideas of Reference (자기빼고 자기얘기하는것 같은 기분)
• Persecution (Secret service is following to kill me)
• Grandeur (I’m a son of God)
• Somatic Delusions (My brain is rotting)
• Jealousy (My girlfriend is cheating on me)

If the nurse is going along with the patient’s delusion
• They may become more delusional and confused, expecially if the patient senses that the nurse is trying to gain his cooperation

How should the nurse respond?
[Responding to the underlying feelings rather than the illogical content]
• (o) “It sounds like you are anxious to leave here”
– Responding to the underlying feelings rather than the illogical content of the delusion will encourage discussion of fears, anxiety, and anger about hospitalization, without assuming the delusion is right or wrong
-The nurse should not attempt to logically explain the delusion
• (x) “Why do you think that someone is out there?”
– Questioning may reinforce the delusion

Most important short-term outcome for schizophrenia clients?
• Interacting without expressing delusional thoughts
-As the client gains insight into the symptoms, the client can differentiate experiences with delusions from those that are reality

Most therapeutic group for Schizophrenia patient
• Structured Medication Group
-Clients with schizophrenia have CONCRETE THINKING PROCESS and will respond best to structured activities
-Groups that support medication education are important to promote medication compliance

Concrete thinking
• Inability to abstract so that clients interpret the literal meaning of words

Why not other groups?
• Group about personal issues
-A group about personal issues will be less sturctured, so the client may have poor attention and difficulty staying focused on a single task or accurately testing reality
• Group about self-esteem
-Self-esteem is more abstract and less concrete so the client may have difficulty focusing attention

Short-acting anxiolytic
• Antianxiety medications [Benzodiazepines such as lorazepam, clonazepam, or diazepam) are most effective for anxiety-related symptoms to produce calming and sedation
• When used in conjunction with an atypical antipsychotic medication [Olanzapine], benzodiazepines, especially IM, can augment the efficacy of the antipsychotic medication thus quickly alleviating acute agitaion of a client

• effective for treating mood disorders
• They also provide a secondary benefit for treating co-occurring depressive and anxiety disorders

Mood-stablizing medication for Mania
• Mood-stablizing medications are effective for eliminating the symptoms of mania and for stablizing mood to prevent cycling between depression and mania

Anti-psychotic medications
for Delusions and Hallucinations
[ Fluphenazine Decanoate (Prolixin)]
• Antipsychotic medications are useful to manage symptoms related to cognitive impairment such as delusions and/or hallucinations, as well as behaviors related to agitation and aggression
• Prolixin is a long-acting medication that is administered as an injection in muscle (IM) every 7~28 days to promote compliance with the medication regimen
• Prolixin can cause extrapyramidal side effects
• Prolixin is contraindicated with liver, renal, cardiac insufficiency

Side effects of Fluphenazine Decanoate (Prolixin)
[ High extrapyramidal effects & Low anticholinergic effects]
• Prolixin is a traditional antipsychotic
• Traditional antipsychotics generally have hight extrapyramidal effects and low anticholinergic effects

Haldol and Dystonia
• Dystonia is acute, tonic muscle spasms
• Often of the tongue, jaw, eyes, and neck but sometimes of the whole body
• Sometimes occur during the first few days of antipsychotic administration

Side effects of Atypical Psychotics
• Clozapine (Clozaril) and Zyprexa (Olanzapine)
• Weight gain is common
• Anticholinergic side effects such as dry mouth, blurred vision, urinary hesitancy and constipation are commonly experienced with atypical antipsychotics

Atypical antipsychotic medication
(2nd Generation Drugs)
• Olanzapine (zyprexa)
• Clozapine (Clozaril) – AGRANULOCYTOSIS!!!!
• Ziprasidone (Geodon)

Clozapine (Clozaril)
• An atypical antipsychotic
• Agranulocytosis, fever, and elevated BP
• Weight gain occurs with Clozaril
• Used for clients with schizophrenia who have not responded to other antipsychotics
– When a client has failed to respond to antipsychotic medications or long-acting antipsychotics, clozapine (Clozaril) may be initiated
– Potentially serious side effect of agranulocytosis requires that WBC counts be done weekly or every 2 weeks

Olanzapine (Zyprexa)
• Atypical antipsychotics
• Weight gain occurs with Zyprexa
• Steady state is generally reached in 1 week

Advantages of Olanzapine (Zyprexa)
• Calming but not sedating
• Rapid onset
• Olazepine (Zyprexa) injection is effective in the treatment of acutely agitated psychotic clients and there is sustained efficacy when the client is switched to oral maintenance treatment

Antipsychotic Drugs
•Drugs used to treat serious mental illness
-Behavioral problems or psychotic disorders
•Have been known as Tranquilizer or Neuroleptics (신경이완제)
•Simultaneous use of these drugs with alcohol or other CNS depressants can be fatal
•Obtain baseline Vital Signs, including postural BP
•Always assess for injury to self and others
•Check the pt’s mouth to make sure oral doses are swallowed
•Advise patients to change positions slowly to avoid postural hypotension and possible injury
• Increased caffeine and nicotine can affect the action of psychotropic medications and increase the metabolism of the medications

Types of Antipsychotic Drugs
• Traditional, conventional drugs (First-generation)
• Atypical antipsychotics (New-generation)
-Better adverse effect profiles

Traditional vs Conventional Antipsychotic Drugs
• As compared with atypical (new-generation) drugs, traditional antipsychotics have high extrapyramidal effects and low anticholinergic effects

Traditional Antipsychotics [Haldol]
• Traditional Antipsychotic Drugs
• Haldol is the prototype traditional antipsychotic
• Traditional antipsychotics block escessive dopamine, an excitatory neurotransmitter, so that symptoms related to psychosis are reduced (do not affect NE, Serotonin)
• Potent medication that causes numerous EPS but few anticholinergic side effects

Antipsychotics: Mechanism of Action
• Block dopamine receptors in the brain
– Areas associated with emotion, cognitive function, motor function (limbic system, basal ganglia)
•Dopamine levels in the CNS are decreased
•Result: tranquilizing effect in psychotic patients

Antipsychotics: Adverse effects
•Photosensitivity (dermatologic)
•Leukopenia (백혈구 감소증)
•Agranulocytosis ( 과립구 감소증 – 백혈구의 이상 감소로 인해 발병되는 혈액병)
•NMS (Neuroleptic Malignant Syndrome)
•EPS (Extrapyramidal Symptoms)
•TD (Tardive Dyskinesia)

Common side effects of psychotropic medications
• Orthostatic hypotension
-A blood pressure reading should be taken while he is both sitting and standing to determine if a positional change, referred to as orthostatic hypotension, is associated with a change in the blood pressure readings
-The nurse should educate the client about rising slowly and cautiously
• Photosensitivity

NMS (Neuroleptic malignant syndrome)
•Potentially life threatening
•Hight fever, unstable BP, myglobinemia

TD (tardive dyskinesia) 지발성(늦게 발생하는) 안면마비
•Involuntary contractions of oral and facial muscles
•Choreoathetosis (wavelike movements of extremities)
•Occurs with continuous long-term antipsychotic therapy
• Screening for tardive dyskinesia should be done after 90 days exposure to an antipsychotic and every 6 months thereafter

EPS (Extrapyramidal Symptoms)
•Drug induced movement disorders that include acute and tardive symptoms
•Involuntary muscle symptoms similar to those of Parkinson’s disease
•Akathisa(motor restlessness-가만못앉기)
•Acute dystonia (painful muscle spasms)
•Treated with benztropine (Cogentin) and trihexyphenidyl (Artane)

Mood stablizer drugs
• Lithium
• Carbamazepine (tegretol)
• Valproic acid (Depakote)

•Narrow therapeutic range
-Maintenance serum level: 0.6~1.2 mEq/L
-measure blood levels 8-12 hours after last dose.
•Contraindications: dehydration, known sodium imbalance, and major renal or cardiovascular disease.
•Long term use may cause hypothyroidism.
•Most serious side effect is CARDIAC DYSRHYTHMIA

Side effects of Traditional Antipsychotics & Nursing interventions
Side effects of Traditional Antipsychotics & Nursing interventions

Haldol & Extrapyramidal Side Effects (EPS)
• EPS during the administration of HALDOL (haloperidol) have been reported frequently, often during the first few days of treatment.
• Can be categorized generally as Parkinson-like symptoms, akathisia, or dystonia (including opisthotonos and oculogyric crisis).
• While all can occur at relatively low doses, they occur more frequently and with greater severity at higher doses.
• The symptoms may be controlled with dose reductions or administration of antiparkinson drugs such as benztropine mesylate USP or trihexyphenidyl hydrochloride USP.
• It should be noted that persistent EPS have been reported; the drug may have to be discontinued in such cases.
• EPS is associated Basal Ganglia in Brain

Administration Haldol with Benztropine (Cogentin) IM
• To reduce severity of extrapyramidal effects
The addition of benztropine (cogentin) will reduce the likelihood of severe extrapyramidal symptoms that occur more often with prototype antipsychotic medications such as haloperiodl (Haldol)

Benztropine (Cogentin) IM
• Anticholinergic medication
• Antiparkinsonian agent
• Used to relieve drug-induced extrapyramidal symptoms
• Help prevent the extrapyramidal side effects of the Prolixin
• Intramuscular (IM) adminitration of benztropine (Cogentin) provides immediate relief from the dystonic reaction the client is currently experiencing. The oral medication is used to alleviate future dystonic reaction

Serious side effects of anticholinergic medications like benztropine (Cogentin)
• Urinary retention
• Tachycardia
• Blurred vision or eye pain
• Confusion and hallucinations
• Uncontrollable movements of the client’s eyes, lips, tongue, face, and limbs
• (x) dry mouth and constipation

Assessment for discharge of Schizophrenia client
• Talk to client for at least 20 min
-The nurse should be able to talk to the client without observing the presence of delusional thoughts
• (x) Observe client for signs of talking to himself
-A client who talks to self may be experiencing auditory hallucination

What will be the most important group activity to promote wellness in the community?
• Explore symptom management
-Symptom management exploration is an important activity for clients with schizophrenia so that relapse can be prevented. Clients often continue to experience symptoms such as hallucination while living in the community
• (x) Practice social skills
-This is secondary
• (x) Identify community coping resources
-This is secondary

Nursing interventions to Prevent Relapse
• Identify symptoms that signal relapse
• Identify symptom triggers
• Select symptom management techniques
• Identify coping strategies for symptom triggers
• Identify support system for future relapse
• Document action plan in writing and file with key support people
• Facilitate integration into family and community

After identifying symptoms trigger relapse?
• Identify current ways to manage symptoms
-After the client has identified problem symptoms, the client should then identify current symptom management techniques and specific support systems and discuss other ways to manage symptoms
• Then, talk about specific support systems
• Then, discuss other ways to manage symptoms
• Then, develop a new symptom management plan

Which strategy is best for clients who hear voices?
• Avoid certain situations
-Avoiding situations that increase symptoms can be helpful to minimize symptoms.
– Other general strategies include distraction, help seeking, or attempts to feel better such as taking shower or performing relaxation excercises

Most common cause of relapse in the client with schizophrenia
• Medications
– Relapse is likely to occur whether the client is taking medication or not
• Lack of community support and health practice are also associated
• BUT, relapse still can happen even if the client is taking medication as prescribed

Ask directly
• “Do you think about hurting anyone now?”
-The nurse should directly ask the client about thoughts of harm

• Confabulation occurs often with clients who have demenia
• Confabulation occurs when a client fills in memory gaps
• Confabulation involves filling in memory gaps with situations or event that cannot be remembered

Thought disorder vs. Mood disorder
• Characteristics of THOUGHT DISORDER include disorganized speech which is manifestation of disorganized thougths
• Characteristics of MOOD DISORDER include blunted affect, irritability, preoccupation with guilty feelings

Akathisia (정좌불능)
• An extrapyramidal side effect
• Often occur with medication HALDOL

Flight of ideas
• Rapid, overproductive, and disorganized speech
• Rapidly shifts from one topic to another with fragmented ideas

Word Salad
• A series of words that seem totally unrelated

Most important Assessment to release client against medical advice (AMA)
• Potential danger to self or others

• An abnormal condition that is often manifested by motor restlessness, such as the inability to sit still or feeling the need to pace

Tardive Dyskinesia (계속 얼굴 움직이면서 표정 만들기)
• A neurological movement disorder charaterized by involuntary muscle contractions
• Symptoms may include sticking out the tongue, puckering (잔주름이 잡히다, 얼굴이 일그러지다, 입술이 오므라지다) of the mouth or lips, lip smacking, puffing of the cheeks, and chewing movements
• Tardive dyskinesia may be a side effect of certain antipsychotic medications, but only after a period of long-term use

Dystonia (한쪽으로 기울어져서 굳어보임)

[To relieve dystonia – Benztropine (Cogentin) or Diphenhydraine (Benadryl)]

• A neurological movement disorder characterized by involuntary muscle contractions, particularly of the face, tongue, neck, and jaw
• To immediately relieve a dystonic action, the nurse should provide relief with diphenhydramine (Benadryl) IM or benztropine (Cogentin) IM [*IM rather than PO]

• Manifestations of Parkinsonism include a shuffling gait, drooling, tremors, and muscle rigidity

Adverse effects of Receptor blockage
Adverse effects of Receptor blockage