Transcript Mental Health Nursing: Anxiety Disorders

Mental Health Nursing: Psychotic
Disorders
By Mary B. Knutson, RN, MS, FCP
Psychotic Disorders
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Health problems including
 Severe mood disorder
 Regressive behavior
 Personality disintegration
 Reduced level of
awareness
 Great difficulty in
functioning adequately
 Gross impairment in
reality testing
Behaviors in Schizophrenia
Four A’s
 Associations (loose)
 Affect
 Ambivalence
 Autistic thinking
 Additional A’s
Schizophrenia relates to
“split” between
 Attention defects
cognitive and emotional
 Disturbances of
aspects of the
activity
personality

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)
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Neurobiological Response Continuum
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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 
Delusions
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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
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
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 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
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
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Sensory Integration
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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
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Often inaccurately assessed with
behavioral, not perceptual context
Environmental Factors
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Can stimulate visual hallucinations
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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
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What is Emotion?
Mood- Affects the person’s 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
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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
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Maladaptive Movements
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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
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
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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
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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
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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
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Alleviating Factors
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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
Medical Diagnosis
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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
Examples: Nursing Diagnosis
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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
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
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Nursing Care
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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
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Treatment
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Physical care and monitoring in safe,
supportive environment
Manage delusions- calm, empathic nonverbal communication, and gentle eye
contact
 Manage hallucinations- listen and
observe, with goal to increase pt’s
awareness (learn difference between the
world of psychosis and the world of
others)
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Psychopharmacology
Phenothiazines and derivatives
provide some sx relief for 80% of
patients
 Caffeine and nicotine consumption
can affect the action of psychotropic
medication
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Typical Anti-Psychotic Drugs
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Phenothiazines
Chlorpromazine (Thorazine)
 Thioridazine (Mellaril), or Mesoridazine
(Serentil)
 Fluphenazine (Prolixin)- can be injection
lasting 2-4 weeks
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Haloperidol (Haldol)
Side effects can range from uncomfortable, treatable ones to
painful and disabling extrapyramidal symptoms to lifethreatening emergency like neuroleptic malignant syndrome
Atypical Antipsychotic Drugs
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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
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
 Parkinson’s syndrome- cogwheel
rigidity, fine tremor, akinesia
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Tardive Dyskinesia
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Involuntary movements
Tongue protrusion
 Lip smacking, chewing
 Grimacing, blinking
 Choreiform movements of limbs and
trunk
 Foot tapping
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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
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Anticholinergic Effects
Constipation
 Dry mouth
 Blurred vision
 Orthostatic hypotension
 Tachycardia
 Urinary retention
 Nasal congestion
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General Pharmacological Principles
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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
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
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Interventions
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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
Evaluation
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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
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Nursing Evaluation
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Was nursing care adequate, effective,
appropriate, efficient, and flexible?
References
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Stuart, G. &
Sundeen, S. (1995).
Principles & practice
of psychiatric
nursing (5th Ed.). St.
Louis: Mosby