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Psychobiological Disorders

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by

Elizabeth Gotay

on 15 September 2013

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Transcript of Psychobiological Disorders

Improvement in symptoms , prevention of acute psychotic symptoms, absence of hallucinations, delusions, anxiety, hostility
Improvement in performance of ADLs
Improvement in ability to socialize with peers
Improvement in sleeping and eating habits
Nursing evaluation
Risperdal
Olanzapine
Quetiapine
Ariprazole
Ziprasidone
Clozapine
Phenelzine
Antipsychotics / Atypical
Advise client to avoid:
OTC
Alcohol
Levodopa
Medication/food interactions
Encourage medication compliance
Explain to client the need to take medication for symptom control, and advise client in identification of adverse side effects.
Compliance
Nursing Care continued
Teaching and modeling self care activities within the mental health facility
Promote self care
Nursing Care continued
Provide for safety if the client is experiencing command hallucinations
Attempt to focus conversations on reality –based subjects
Identify triggers : loud noises, other stimuli
Promote safety
Nursing Care continued
Establish trusting relationship with the client
Encourage development of social skills and friendships
Encourage participation in group work and psychotherapy
Milieu therapy
Nursing Care continued
Video
Video Young Schizophrenic
Video
Symptoms
Hopelessness
Suicidal ideation
Depressive
Characteristics of schizophrenia

Hallucinations
Delusions
Alterations in speech
Bizarre behaviors
Positive symptoms
Most easily identified
Characteristics of schizophrenia
One person begins to share delusional beliefs of another person with psychosis
Example: significant other believes delusions as reality
Shared psychotic disorder
Other psychotic disorders
Symptoms
Has psychotic symptoms that last from one month to several months
Brief psychotic disorder
Other psychotic disorders

Symptoms interfere with interpersonal relationships , self care, ability to work
Schizophrenia
Diagnosis should be made after the age of seven

Attention Deficit hyperactivity with violent tendencies should be ruled out first
Schizophrenia
Genetic factors

Results from non-genetic factors:
Injury at birth
Nutritional
Viral infections
Hormonal imbalances
Schizophrenia


Psychotic disorder that affects thinking , behavior , emotions and the ability to perceive reality
The student will understand the purpose and use of anti psychotic medication
The student will describe the adverse effects of psychotropic medications
The student will identify safety practices associated with care of a schizophrenic client.
Objectives
The student will identify the characteristics of schizophrenia.
The student will describe the differences between positive and negative symptoms in schizophrenia.
The student will identify different types of schizophrenia.
The student will identify alterations in behavior.
The student will develop and implement appropriate nursing interventions for schizophrenia.
The student will identify the psychotropics used in schizophrenia.
Objectives
Elizabeth Gotay, MSN/INF, RN
Psychobiologic Disorders
Townsend, M. (2088). Essentials of psychiatric mental health nursing : Concepts of care in evidence -based practice . Philadelphia , Pennsylvania : F.A.Davis.
Institute of Medicine. Health professions education: A bridge to quality. Washington DC: National Academies Press; 2003.
Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D., Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55(3)122-131.
References
Respect and encourage individual expression of patient values, preferences and expressed needs
Value the patient's expertise with own health and symptoms
Seek learning opportunities with patients who represent all aspects of human diversity
Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds
Willingly support patient-centered care for individuals and groups whose values differ from own
QSEN KSA
Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values
Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care
Communicate patient values, preferences and expressed needs to other members of health care team
Provide patient-centered care with sensitivity and respect for the diversity of human experience
Value seeing health care situations "through patients' eyes“
QSEN KSA
Knowledge Skills Attitudes Integrate understanding of multiple dimensions of patient centered care:
patient/family/community preferences, values
coordination and integration of care
information, communication, and education
physical comfort and emotional support
involvement of family and friends
transition and continuity
QSEN KSA
Patient-centered Care
Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs.
QSEN KSA
Administer Orally or IM
Depot injections are given every 2 weeks
Low dosage are given initially and gradually increased
Use oral disintegrating tablets to avoid attempt to cheek or pockets tablets
Nursing Administration
Avoid use in clients on clozapine
Avoid alcohol, hazardous activities
Counteracts the effect of antipsychotics
Avoid use with Ziprasidone
Monitor medication effectiveness
Immunosuppressive medications further suppress the immune function
CNS suppression
Levodopa
Tricyclic antidepressants , cordarone, biaxin, prolong qt intervals
Barbiturates and dilantin stimulate hepatic metabolism
Food interactions
Use cautiously in cardiac disease, cerebrovascular disease, seizures, diabetes mellitus
Pregnancy
Dementia related psychosis
Alcohol
Contraindications
Nursing Interventions
S & Sx
Extrapyramdial symptoms : tremors
Adverse side effects
Nursing Interventions
S & Sx
Agitation
Dizziness
Sedation
Sleep disruption
Adverse side effects
Nursing Intervention
S & Sx
Anticholinergic effects:
Urinary hesitancy, retention, dry mouth
Adverse side effects
Nursing intervetions
S & Sx
Orthostatic hypotension
Adverse side effects
Nursing Interventions
S & Sx
Hypercholesterolemia
Adverse side effects
Nursing interventions
S&Sx
New onset diabetes
Adverse side effects
Side effects
Side effects
Become very familiar with the list of foods and medicines you must avoid while you are taking Phenelzine.
Phenelzine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.
Nardil
Worsening side effects
Side effects
Allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Nardil
Therapeutic Uses
Purpose
Phenelzine is a monoamine oxidase inhibitor (MAOI) that works by increasing the levels of certain chemicals in the brain.
Phenelzine is used to treat symptoms of depression that may include feelings of sadness, fear, anxiety, or worry about physical health (hypochondria).
Nardil
Assess between EPS or worsening of psychotic disorder
Advise client that medication are not addictive
Advise client to take medications as ordered
Medications are to be taken for rest of their lives
Side effects must be reported asap.
Consider intramuscular route, administer every 2to 4 weeks, begin with twice daily dosing, reduced to daily and give at bedtime to decrease drowsiness during the day and promote sleep
Nursing Administration
Nursing Interventions
Dysrhythmias
Associated with conventional antipsychotics
Adverse side effects
Nursing Intervention
Agranulocytosis
Fever
Sore throat
Adverse side effects
Nursing intervention
Sexual dysfunction
Common in both males and females
Adverse side effects
Nursing interventions
Neurogenic effects
Gynecomastia
Galactorrhea
Menstrual irregularities
Adverse side effects
Nursing Interventions
Sedation
Client may experience weakness, sense of exhaustion, sleepiness
Adverse side effects
Nursing intervention
Orthostatic hypotension
Blood pressure and heart rate changes
Adverse side effects
Nursing Interventions
Anticholinergic effects
Dry mouth
Blurred vision
Photophobia
Urinary hesitancy or retention
Constipation
Tachycardia
Adverse side effects
Nursing Interventions
Neuroleptic malignant syndrome
Sudden high fever
Blood pressure fluctuations
Dysrhythmias
Muscle rigidity
Changes in level of consciousness
Coma
Adverse side effects
Nursing Interventions
Late Extrapyramidal side effects
Tardive Dyskinesia :
Involuntary movement of the face and tongue such as lip smacking
Involuntary movement of the legs, arms, trunk
Adverse side effects
Nursing interventions
Akathasia
Inability to stand or sit still
Continual pacing and agitation
Adverse side effects
Nursing Interventions
Parkinsonism
Bradykinesia
Rigidity
Shuffling gait
Drooling
Tremors
Adverse side effects
Nursing Interventions
Acute Dystonia
Severe spasm of the neck, tongue, face, and back
This is a crisis situation requiring immediate treatment
Adverse side effects
Norepinephrine causes vasoconstriction, increased heart rate, blood pressure, and modulates sugar levels
Histamine
Modulates the internal clock
Makes you awake and alert
Antihistamine cause drowsiness
Modulates gastric acid, bone marrow, white cell production
Smooth muscle relaxation
Receptors
Atypical
Conventional anti psychotics
Used to control positive symptoms
Used in clients who are using them successfully and tolerate the side effects
For clients who are aggressive or violent
Medications
Goals: suppression of acute episodes
Prevention reoccurrence of acute symptoms
Maintenance of highest level of functioning
Nsg Dx, Actions, Outcomes
S & Sx
Social withdrawal
Expresses fear of failure
Concept care plan
Nsg Dx, Actions, Outcomes
S& SX
Delusional thinking
Concept care plan
Relate elements of symptom management , encourage symptom management techniques such as music, attending activities, walking, talking to a trusted friend or relative when hallucinations are bothersome
Relate wellness
Nursing Care continued
Be genuine and empathetic in all dealings with client

Ability to perform ADL
Empathetic care


Assess discharge needs
Nursing Care continued
Extreme agitation, pacing , rocking
Stereotyped mechanical (sweeping the floor)
Automatic obedience(robot behavior)
Waxy Flexibility
Abnormal behavior patterns
Alterations in behavior
Depersonalization –nonspecific feeling the person has lost their identity, self is different or not real
Derealization perception that environment has changed
Personal boundary difficulties
Alteration in physical perception
Auditory : hearing voices or sounds
Visual seeing imagery people or things
Olfactory smelling odors
Gustatory experiencing tastes
Tactile feeling bodily sensations
Hallucinations
Sensory perceptions that do not have any apparent external stimulus
Alteration in perception
Repeats words spoken to them


Meaningless rhyming words , often forceful , such as , OX , fox, box, and lox.
Echolalia



Clang association
Alterations in speech
Associative loose thoughts
The client repeats sentences, each sentence relates to another topic

Made up words that have meaning only to the client
Flight of ideas





Neologisms
Alterations in speech
Is obsessed by religious beliefs
Religiosity

Joan of Arc
Alterations in thoughts
Believes thoughts are heard by others

Believes others thought are being inserted into their minds

Believes thoughts have been removed by outside forces, agency
Thought broadcasting


Thought insertion


Thought withdrawal
Alterations in thoughts
May feel spouse is sexually involved with another individual

Believes a force outside there environment is controlling them
Jealousy



Being controlled
Alterations in thoughts
Feels single out for harm by others

Believes they are all powerful


Believes body is changing in an unusual way
Persecution


Grandeur


Somatic delusions
Alterations in thoughts
Misconstrues trivial events
Attaches personal significance
Ex. believes others discussing the next meal are talking about them
Ideas of reference
Characteristics of schizophrenia
Symptoms
Disordered thinking
Inability to make decisions
Poor problem solving ability
Difficulty concentrating in performing tasks
Memory deficits: long term
Working memory such as inability to follow directions
Cognitive symptoms
Problems with thinking
Makes it difficult for client to live independently
Characteristics of schizophrenia
Affect is flat, narrow range of expression
Alogia poverty of thought or speech , mumbling
Avolition lack of motivation
Anhedonia lack of feeling pleasure
Anergia lack of energy
Negative symptoms
More difficult to identify and treat
Characteristics of schizophrenia
Symptoms
Schizophrenic symptoms that last from 1 to 6months
Social and occupational dysfunction may or may not be present
Schizophreniform
Other psychotic disorders
Symptoms
Any positive or negative symptoms may be present
Undifferentiated
Has symptoms of schizophrenia but does not meet criteria for the other types
Types of schizophrenia
Symptoms
Anergia
Anhedonia
Avolition
Withdrawal from social activities
Impaired role function
Speech problems(alogia)
Odd behaviors
Residual
Active symptoms are no longer present but remains with residuals
Types of schizophrenia
Symptoms
Withdrawn stage:
Psychomotor retardation
Client has extreme self care needs



Excited stage:
Constant movement, unusual posturing , incoherent speech
Client may be a danger to self and others
Catatonia
Abnormal movements
Two stages:
Withdrawn stage

Excited stage
Types of schizophrenia
Symptoms :
Loose associations
Bizarre mannerisms
Incoherent speech
Hallucinations, delusions are much less organized as compared to the paranoid
Disorganized schizophrenia:
Characterized by withdrawal from society
Inappropriate behaviors
Poor hygiene
Muttering constantly
Frequently seen in homeless population
Types of schizophrenia :
Symptoms:
hallucinations
auditory
threatening voices
delusions
other directed violence
Paranoid :
Characterized by suspicion towards others
Types of schizophrenia
Typical age of onset teens, early twenties
Has occurred in children, and late adulthood
Schizophrenia
Discuss potential and actual impact of national patient safety resources, initiatives and regulations
Use national patient safety resources for own professional development and to focus attention on safety in care settings
Value relationship between national safety campaigns and implementation in local practices and practice settings
Nursing Care and Safety Practices
QSEN Safety Competencies
Low risk for EPS
High risk for diabetes, weight gain, dyslipidemia, orthostatic hypotension,sedation,anticholinergic effects, cataracts, headache , anxiety, insomnia, gastrointestinal upset
ECT changes, QT prolongation
Risk for fatal agranulocytosis
Zyprexa


Seroquel


Abilify

Ziprasidone

Clozapine
Atypical Antipsychotic Agents
Nursing interventions
S & Sx
Weight gain
Adverse side effects

Therapeutic Uses
Pharmaceutical effect
Blocks serotonin, dopamine, norepinephrine,
acetylcholine, histamine
Purpose
Glaucoma
Paralytic ileus
Prostrate enlargement
Heart disorders
Liver and kidneys disease
Seizure disorders
Coma
Severe depression
Parkinson's disease
Prolactin dependent cancer of the breast
Severe hypotension
Contraindications Precautions
Nursing Interventions
Skin effects
Photosensitivity can cause severe sunburn
Contact dermatitis
Adverse side effects
Nursing Interventions
Seizures
Highest risk associated with clients who have existing disorder
Adverse side effects
Therapeutic uses
Purpose
Blocks dopamine , acetylcholine, histamine, norepinephrine receptors in the brain.
Medications Prototype : Thorazine
Acetylcholine deficiency affects memory, remembering names, faces, lists, slowed thinking. Making mistakes. Socially withdraws. Rarely feels passion.
Feels despair and lacks joy.
Lost ability to be creative, imaginative.
Caused by genetic or acquired factors.
Can be raised effectively using nutrient based therapies or medications
Dopamine receptors control motor activity
Reward and reinforcement is one of the primary functions
When stimulated with recreational drugs it causes euphoria, has effect on memory.
Dysfunctional receptors have effect on social phobias, ADHD,schizophrenia, Parkinson, Neuroleptic malignant syndrome, genetic hypertension.
Receptors
Nsg Dx, Actions , Outcomes
S & Sx
Offensive body odor
Soiled clothing
Unkempt appearance
Concept care plan
Nsg Dx, Actions, Outcomes
S & Sx
Verbalizes hearing voices
Listening pose
Concept care plan
Provides structure, safe environment , to decrease anxiety and distract the client from constant thinking of hallucinations
Promote therapeutic communication lowering anxiety, decrease defensive patterns and encourage participation in milieu therapy
Milieu therapy used 24hours in mental health facilities
Nursing Care
Helps to determine a clients ability to perform activities of daily living and to function independently
Scales provides numerical values that identifies the severity of the negative symptoms

Assesses extrapyramdial side effects: Gait, arm dropping, shoulder shaking, elbow and wrist rigidity.
The Global Assessment of Functioning GAF scale


Scale for Assessment of Negative Symptoms


Simpson Neurological Rating Scale
Standardized Screening tools
Words jumbled together with little meaning to the client
Word salad
Alterations in speech
Symptoms
Signs of psychosis are brought on by medical disorder such as Alzheimer's , chemical substances, alcohol abuse.
Secondary induced psychosis
Other psychotic disorders
Symptoms:
Meets criteria for schizophrenic disorder and affective disorders such as depression, mania or mixed disorders
Schizoaffective disorder
Other psychotic disorders
What is schizophrenia?
Video
Worsening side effects
Side effects
Stop using phenelzine and call your doctor at once if you have any of these serious side effects:
sudden and severe headache, rapid heartbeat, stiffness in your neck, nausea, vomiting, cold sweat, sweating, vision problems, sensitivity to light;
chest pain, fast or slow heart rate;
swelling, rapid weight gain;
agitation, unusual thoughts or behavior; or
feeling light-headed, fainting.
Nardil
Ask client about hallucinations, do not argue or disagree with clients view of the situation
Do not argue with clients delusions, focus on clients feelings and offer reasonable explanations
Use appropriate communication to address hallucinations and delusions
Nursing Care continued
Psychotic disorder that affects thinking , behavior , emotions and the ability to perceive reality
Identify family or significant person of influence who is capable assisting in the care of the patient.
Assist with milieu therapy, activities of daily living,social interaction, medication compliance.
Assist with followup and continual care.
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