Schizophrenia and Nursing Care Plan

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– Gross splitting of mental functions and loosing connection between these functions.

Epidemiology:

– incidence (about 1% male = female)

– 50% of male admitted < 25

– 30% of female admitted <25

– peak age of onset 15-25 in males.

– Peak onset 25-35 in females .

– Rare <10ys >50ys

– Seasonality: more in winter

– Suicide : 10 – 15 %

– Substance abuse : (cigarette – alcohol –marijuana – cocaine )

– From DSMIV

Schizophrenia:

Two or more of the following symptoms for at least one month

a) delusions.

b) hallucinations.

c) disorganized speech(incoherence or derailment).

d) grossly disorganized or catatonic behavior.

e) negative symptoms (affective flattening, alogia ,or avolition.)

– significant social/occupational dysfunction since the disorder began.

positive and negative symptoms

a) positive symptoms

– formal thought disorder(derailment-tangential-incoherent-irrelevant answers-illogical)

– bizarre behavior(in clothing –appearance- social and sexual behavior-agitated or aggressive –repetitive or stereotyped behavior )

– delusions

– hallucinations.

b) negative symptoms.

– alogia(poverty of speech or contents-blocking-increased latency)

– flattening of affect (poor facial expression –decreased spontaneous movements and expressions-poor eye contact )

– avolition (impaired hygiene-anergia-lack of persistence at work or school)

– anhedonia (decreased interests –impaired intimacy-few relationships)

– impaired attention (social inattentiveness- or during testing)

Etiology:

1) genetic : 1st degree relatives (one parent 13% – two parents 46% )

– Monozygotic twins 50%

– mode of inheritance unclear

2) Neurochemistry and neuroanatomy:

– low blood flow.

– Low metabolism in brain cells specially in frontal cortex(PET)

– Electrical activity shows hypo function.

– Hypersensitivity of dopamine receptors.

– Widening of ventricles.

– Faulty metabolism .

3) psychosocial factors

History :

1) emil kraepelin ( named it dementia praecox comes in early life with downhill course due to organic pathology , comes with hallucinations , delusions, affecting thought, speech, with poor insight and judgment, and reduced attention to outside world.).

2) bleuler : it is splitting in mind with 4 fundamental and 3 accessory behavior

– fundamental: associative disturbance , autism, ambivalence , affective flattening.

Accessory : delusions , hallucinations , catatonic posturing.

3) Freud : schizophrenia is reaction to frightening unbearable idea.

4) Sullivan: it is originated from impaired interpersonal relations to parents , or a significant people

.

5) Schneider’s: schizophrenia is syndrome characterized by(3 hallucinations audible thoughts, second person voice, third person voice, 3 thoughts insertion, withdrawal ,broadcasting, 3 made feelings , impulses ,passivity , and delusional perception.

Schizophrenia subtypes:

a) paranoid

– client preoccupied by one or more delusions or auditory hallucinations, no disorganized speech or catatonic behavior, no flat or inappropriate affect.

b) disorganized

– disorganized speech or behavior , flat or inappropriate affect .

– not having criteria for catatonic type.

c) catatonic

– motor immobility , excess motor activity not influenced by external stimuli.

– Peculiarities of involuntary movement, echolalia or echopraxia.

d) undifferentiated

– that does not meet the criteria of the above groups.

e) residual

– no florid psychotic symptoms or present in attenuated form , with one or more negative symptoms .

Delusional disorder

Diagnostic criteria:

1- None bizarre delusions involving situation that could occur in real life such as being followed , poisoned ,infected having a disease , loved at distance , deceived , or got a message from Allah , of at least one month duration .

2- has never met a criteria a of schizophrenia for more than few hours.

3- apart from impact of delusions or its ramifications , functions are not markedly impaired , and behavior is not obviously odd or bizarre.

Types:

– Erotomanic: delusions that another person usually higher status is in love with the individual.

– Grandiose : delusions of inflated worth, power, knowledge, identity , or special relationship with diety or famous person.

– Jealous and infidelity : delusions that ones sexual partner is unfaithful.

– Persecutory: delusions that one usually close to him is being malevolently treated in some way .

– Somatic : delusions that one has some physical defect .

– Mixed : has more than one character of the above types but none of them predominates.

– Unspecified.

Nursing role in management of schizophrenia:

(a) assessment :collecting all medical , psychiatric, social ,and financial ,information’s and needs to include them in overall coordinated plan.

(b) planning :overall plan includes management, crisis intervention, service providers , to ensure continuity of care.

(c) linking : helps the patients and families to get access to services required for comprehensive care

(d) therapeutic care :

1) education teaching patient about his illness , how to manage stress, importance of treatment and side effects.

2) focusing on problem solving.

3) setting reasonable expectations.

4) expressing emotions.

5) crisis intervention.

6) managing dependence .

7) illness self management.

8) good selection for recreational activities e.g. art ,dance or music

(e)evaluation efficacy of procedures. and outcome.

Antipsychotics

A- Typical antipsychotics:

– e.g. Serenace (Haloperidol ), Largactil (Chlorpromazine ).

– Side effects: sedation, dry mouth, urine retention, constipation and EPS

 

EPS
Extra pyramidal

– Dystonias: muscle spasm.

– Akathesia: Motor restlessness.

– Drug induced parkinsonism: tremors, rigidity and akinesia.

– Tardive dyskinesia: late- appearing and irreversible movements.

Neuroleptic malignant syndrome

A- Fatal Side effect.

– Muscle rigidity.

– Tremors.

– Inability to talk.

– Altered level of consciousness.

– Hyperthermia.

– Autonomic dysfunction .

– Leukocytosis.

B- Atypical antipsychotic:

– O- lanzepine ( weight gain, DM, dyslipidemia)

– Respiredal ( EPS, hyperprolactenemia)

– Quetiapine ( weight gain )

– Clozapin ( weight gain, sedation, AGRANULOCYTOSIS, DM, orthostatic hypotension)

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