Neuroleptic

Antipsychotic Medication

affect

outward expression of the client's emotional state

akathesia

intense need to move about; characterized by restless movement, pacing, inability to remain still, and client's report of inner restlessness

alogia

a lack of any real meaning or substance in what the client says

ambivalence

a state in which a person concommitantly experiences conflicting feelings

anhedonia

having no pleasure or joy in life; losing any sense of pleasure from activities formerly enjoyed

Asperger's Syndrome

a pervasive developmental disorder similar to autistic d/o characterized by severe impairment of social interactions & by restricted interests & behaviors

autism

a mental d/o characterized by extreme withdrawl & abnormal absorption in fantasy accompanied by delusion, hallucination, & inability to communicate

autistic behavior

impaired social interaction, impaired communication & remarkably restricted repertoire of activities and interests

delusion

a fixed, false belief not based in reality

echolalia

repetition or imitation of what some else says; echoing what is heard

echopraxia

imitation of the movements and gestures of someone an individual is observing

extrapyramidal side effects

reversible movement d/o induced by antipsychotic or neuroleptic medications

flight of ideas

excessive amount & rate of speech composed of fragmented or unrelated ideas; racing, often unconnected thoughts

hallucination

false sensory perceptions or perceptual experiences that do not really exist

ideas of reference

client's inaccurate interpretation that general events are personally directed to him or her, such as a speech on the news & believing the message has a personal meaning

looseness of association

disorganized thinking that jumps from one idea to another w/ little or no evident relation between the thoughts

mute

inability to speak because of a physical defect or an emotional problem

Neologisms

invented words that have meaning only for the client

Neuroleptic malignant syndrome (NMS)

a potentially fatal, idiosyncratic reaction to an antipsychotic (or neuroleptic) drug

akinesia

slowness & difficulty initiating movement

choreiform

rapid jerky involuntary movements

paranoia

elaborate, overly suspicious system of thinking often includes delusions of persecution & grandeur usually centered on one major theme

perseveration

the involuntary and pathologic persistence of the same verbal response or motor activity

pseudo-parkinsonism

a type of extrapyradimal s/e of antipsychotic meds; drug induced parkinsonism; including shuffling gait, masklike facies, muscle stiffness, cogwheeling rigidity, drooling, & akinesia

psychodynamics

the study of the forces that motivate behavior

psychomotor retardation

overall slowed movements;a general slowing of  all movements, slow cognitive processing & slow verbal interaction

psychosis

cluster of symptoms including delusions, hallucinations, and grossly disordered thinking

religiosity

a psychiatric symptom characterized by the demonstration of excessive or affected piety

schizophrenia

psychotic d/o =  gross distortion of reality, distortion of reality, disturbances of language & communication, withdrawl from social interaction, disorganization & fragmentation of thought, perception, & emotional reaction

tangentiality

expressions or responses characterized by a tendency to regress from original topic using a common word to connect unrelated thoughts

tardive dyskinesia

a late onset, irresversible neurologic s/e of antipsychotic meds; characterized by abnormal, involuntary movements, such as lip smaking, tongue protrusion, chewing, blinking, grimacing, & choreiform movements of limbs and feet

therapeutic milieu/therapeutic community

beneficial environment; interaction among clients is seen as beneficial and treatment emphasizes role of client to client interaction

thought blocking

stopping abruptly in the middle of a sentence or train of thought; sometimes client is unable to continue idea

waxy flexibility

maintenance of posture or position over time even when it is awkward or uncomfortable

word salad

flow of unconnected words that convey no meaning to the listener

psychotic

not in contact w/ reality, a person exhibiting the characteristics of a psychosis

psychosis

any major mental d/o of organic or emotional origin characterized by gross impairment in reality testing

Anti-Psychotic Agents (Neuroleptic Agents)

 - used to treat acute and chronic psychoses.  Act by blocking dopamine receptors in the brain.  Also work by inhibiting dopamine-mediated transmission of neural impulses at the synapses.  

Types and Examples: 

Atypical Anti-psychotic drugs (treat positive and negative symptoms)

Typical anti-psychotic drugs (treat positive symptoms) 

Atypical Anti-psychotic Drugs

(treat positive and negative symptoms)

Aripoprozole (abilify)

Clozapine (Clozaril)**

Quetiapine (seroquel)

Olanzapine (Zyprexa)

Risperidone (risperadal)

Zipasidone (Geodan)

Treats positive and negative symptoms of schizophrenia and also used to target mood, cognitive impairment, and difficulty w/ socialization

Typical Anti-Psychotic drugs / Phenothiazines  & Butyphenone(older drugs)

(treat positive symptoms of schizophrenia)

Phenothazines:

Chlorpromazine (thorazine)

Fluphenazine (Prolixin)

Thioridazine (Mellaril)

Trifluoperazine (Stelazine)

Butyophenone:

Haloperidol (Haldol) most often used

Anti psychotic drugs Atypical and Typical

Contraindications

Cautions

Nursing Implications

Contra: hypersensitivity, narrow angle glaucoma, CNS depression

Caution: BPH, seizures, Cardiac disease, pregnancy, DM, respiratory insuficiency

Nursing Implications: 

assess ° of sedation

assess mental status (is it working?)

assess VS (√ for orth hypo) (measure ortho bp during titrations of meds)

determine pt takes med

anticholinergic s/e: dry mouth, blurred vision, constip, urinary retention, ortho hypo

extrapyr. s/e: pseudo parkinsoniam s/e: difficulty speaking/swallowing, shuffling gait, pill rolling, cogwheel rigidity & dytonic s/e: muscle spasms, inability to move eyes, weakness of arms and legs

monitor for tardive dyskinesia: uncontrolled rhythmic movement of mouth, face & extremities, lipsmaking, uncontrolled chewing, rapid movement of tongue*****if TD s/s present notify dr immediately

monitor for neuroleptic malignant syndrome: sever allergic reaction to antipsychotic med s/s: fever, resp dist., tachy, convulsions, diaphoresis, hyper or hypotension, rigidity, elevated CPK, delirium**notify dr immediately

Clozapine

may cause agranulocytosis, check WBC weekly for 6 months them q2 weeks thereafter

Clozapine is used for treatment of resistant illness

Haldol & Prolixin & Risperadal Consta

each are available in decanoate form (sustained released given IM every 2-4 weeks)

Haldol - given IM q4 weeks

Prolixin - given IM q2 weeks

Risperadal Consta - given IM q2-3 weeks

Patient family teaching regarding antipsychotic meds

drink sugar free fluids and sugar free hard candy for anticholinergic s/e of dry mouth

increase fluid and fiber to avoid constipation

stool softeners are ok, no laxatives

photosensitive, use sun screen, avaoid long periods in sun

rise slowly, ortho hypo

avoid driving until response time and reflex normalize

if missed dose is <3-4h late can take, if >4h, omit dose

Anti-Parkinsonian/Anticholinergic Agents

indicated for the treatment of all forms of parkinsonism and for the relief of drug induced extrapyradimal reactions

Anticholinergics:

Benztropine (Cogentin) *drug of choice

Biperclen (akineton)

Trihexyphenidyl (artane)

Dopamine agonists:

Amiantadine (Symmetral)

Bromocriptine (Parlodel)

Antihistamines:

Diphenhydramine (benadryl)

Anti-Parkinsonian/Anticholinergic Agents

Contraindications

Cautions

Nursing Implications

Contraindications: narrow angle glaucoma, BPH, myasthenia gravis

Caution: cardiac disease, urinary retention, additive anti cholinergic effects & potentially fatal paralytic ileus can occur when antiparkinsonian agents are used w/ other drugs that possess these properties

Nursing Implications:

assess for extrapyr. & parkinsonian s/s

assess VS, ortho hypo

decreased perspiration

ck w/ dr prior to OTC drug use

prevent constipation, monitor for urinary retention

perform good oral hygiene

Dopamine and Serotonin

New prominent theories suggest that altercations in both the levels of dopamine and serotonin are involved in schizophrenia

At what age is schizophrenia typically diagnosed?

Schizophrenia is typically diagnosed earlier in men ( ages 15-25yrs) than women (25-35yrs).

Echolalia & schizophrenia

A patient w/ schizophrenia may exhibit echolalia, an abnormal speech pattern in which the pt repeats or imitates words or phrases spoken by another individual

Thought broadcasting

Thought broadcasting is the false belief that someone knows what they are thinking.

Communication & delusions

In communicating with a pt experiencing a delusion, it is important for the nurse to avoid confronting  (by not supporting or challenging) the false belief

SAD

Schizoaffective Disorder

SAD describes a condition in which a client exhibits symptoms of psychosis and a modd d/o such as depression

Torticollis

Tortocollis is a dystonic reaction that results in muscle spasms in the neck, and can be very painful

Neuroleptic Malignant Syndrome

Neuroleptic Malignant Syndrome is a potentially life threatening reaction seen w/ pts taking antipsychotic meds

Gustatory Hallucination

Pts may experience a false perception of taste known as a gustatory hallucination

Polydispia

Polydipsia, an excessive ingestion of water, can have potentially life threatenting efects on fluid and electrolyte balances

Thought Process disorders

Reality

Patient's perception of reality is their reality

Autism

is a developmental disorder that is biologically based

most severe of autistic spectrum disorders

characterized by pervasive and usually severe impairment in reciprocal social interaction & communication skills and has restrictive stereotypical behavioral patterns

Causative Factors of Autism

Genetic: many autistic children have a relative w/ autism

Biological: maternal rubella, anoxia, fragile X syndrome, increased brain development in first years of life

Epigenetic: dopamine overactivation, elevated serotonin

Clinical Manifestations of Autism

Social Relationships: unable to establish meaningful relationships

Developmental: mental retardations/savants

Language: mutism, parrot speech, echolalia, reverse pronouns & literal use of words

Sensory & Perceptual: sensory deficits, hallucinations, may act deaf, aversion to touch (heightened sensory awareness)

**Communication is key**

Nursing Care for Autistic Disorder

Risk for Injury

Impaired Social Interactions

Disturbed Thought Processes

Maintain routine, work closely w/ family to determine habits and preferences

maintain consistent staff for the child

Determine ways child communicates

provide family support

 Schizophrenia

a syndrome or disease process of the brain causing distorted and bizarre thoughts, perceptions, emotions, movements and behavior

usually diagnosed in late adolescence and early adulthood

Related disorders of schizphrenia

schizophreniform disorder: s/s of schizo experienced < 6mos

schizoaffective disorder: (SAD) s/s of psychosis and thought disorder along w/ features of mood d/o

delusional disorder: one or more bizarre delusions w/ no impairment in psychosocial functioning

True schizophrenia - more flat afect, little or no interaction

Etiology of Schizophrenic Process

specific cause unknown

probably NOT a homogenous (sam thing happens to all) disease

biologic theory = brain chemistry d/o = overactive dopamine, genetic predisposition

psychosocial 

Clinical Types of Adult Schizophrenia

Disorganized (hebephrenic) type

Catatonic Type

Paranoid Type

Residual Type

Undifferentiated Type

Disorganized Type (SCDT)

most severe, needs most help to manage 'world'

don't remember when they were better

begins in adolescence

s/s inappropriate or silly emotions & incoherent speech

regression, hypochondriais, hallucinations, delusions, extreme social w/drawal, chronic

Not Paranoid**

Catatonic Type (SCCT)

least common

brain in state of overexcitement, similar to a panic attack

give Ativan to break catatonia - Ativan 1mg/IM

differentiated by behavior or psychomotor s/s: (involuntary**):

catatonic posturing

catatonic rigidity

waxy flexibility

catatonic stupor

catatonic excitement

sudden onset & short duration, good prognosis

Paranoid Type (SCPT)

most common

Do Not challenge Paranoia too much

main behavior : suspiciousness (fear & paranoia)

s/s:

overuse of projection

delusions of persecution or grandeur

auditory hallucinations

IQ unaffected

homicial and/or suicial ideation is often present

"acting out"

Residual Type

partial remission

no obvious s/s psychosis

may exhibit:

isolation

associative looseness

illogical thinking

eccentric behavior

Undifferentiated Type (SCUT)

mixture of psychotic s/s

delusions

hallucinations

disorganized behavior

s/s of Schzophrenia

Content of Thought: delusions, religiosity, paranoia, magical thinking

Form of Thought: LOA, neologisms, concrete think., clang assoc, word salad, tangentiality

Perceptions: hallucinations (auditory are the most common)

Affect: inappropriate, flat, apathy

Sense of self: echolalia, echopraxia, depersonalization (detachment from self)

Volition: avolition, absence of will, ambition, & drive, emotional ambivilance

Impaired Interpersonal Relationships: austistic like behavior, deteriorated appearance

Nursing Dx  (a pt experiencing hallucinations may have this DX)

Alteration in Safety 

re: voices 

*want pt to recognize symptom of illness

Assure their safety

Believe Them

Present Reality

1. Ask if the voices are mean or derragatory?

2. Ask if the voices are commanding them to do anything?

3. Assure safety and instruct them not to listen to voice

4. Use distraction

Hard of Positive Symptoms of  Schizophrenia

(Objective; easier to see)

delusions

hallucinations

grossly disorganized thinking, speech and behavior

Soft or Negative symptoms of Schizophrenia

(subjective)

flat affect

avolition

social withdrawal or discomfort

apathy

alogia (lack of talking0

phases of Schizophrenia

Phase 1 - Schizoid personality (eccentric & odd)

Phase 2 - Prodromal phase, more regressed, disorganized thought

Phase 3 - Schizophrenia

Phase 4 - Residual phase

Goal - keep pt from being psychotic, so they can unction

Assessing Judgement & insight in the Schizophrenic Patient

Give them a scenario to solve

Ask them if they believe they have an illness

Ask them why they are here?

Ask them to tell you their story (good way to begin assessment)

Patient Confidentiality

right to privacy

pt information is personal property

promotes trust

RN may share info that:

may result in harm

non-compliance w/ plan

threatens self-injury

law broken

Basic rights of Psychiatric Patient

communicate w/ Lawyer

send & receive uncensored mail

have visitors

basic necessities of life

safety from harm

can refuse meds (if pt demonstrates danger to self and others, 2 doctors must agree that pt is in clear & present danger to force medications)

Types of Psychiatric Commitments

Voluntary Civil Court Commitment (not criminal)

Involuntary Civil Court Commitment:

1. Emergency :5 days, danger to self & others or unable to care for oneself

2. Extended