- Cogwheel rigidity

- Leadpipe rigidity

Anticholinergic

  Benztropine (Cogentin) - Antihistamine

Diphenhydramine (Benadryl)

Trihexyphenidyl (Artane) 

  Amantadine (Symmetrel) - Anuti-viral

Antihypertensive

Propanolol (Inderal) - reduces tremor

• Smoking: increases risk of tardive dyskinesia

• Alcohol: Additive effect with other CNS depressants

• Dehydration: Can result in decreased excretion through the kidneys

• Nutrition: Decreased protein can result in higher amounts of drug reaching the brain and CNS

• Setting – Hospital – Community – Residential or long term care

• Psychosocial treatment – Psychosocial rehab – Psychoeducation – Individual or family interventions

• Medication – Conventional antipsychotics – Atypical antipsychotics

• Maintain safety

• Establish trusting relationship

• Promotion of self care

• Provide education, structure, consistency

• Assessment and treatment of co-morbidities

• Collaboration with other disciplines (OT, Expressive Therapists, Social Workers, Psychologists, Psychiatrists, health care administrators, insurance companies)

• Based on the idea of schizophrenia as a severe, disabling, chronic and incurable illness

• Stresses integration of resources (including psychiatry, case management, PACT, ACT, psycho-education, socialization, vocational planning, medication compliance)

• Goal is to improve outcomes and reduce hospitalization by engaging the client’s strengths

• Family bears high level of burden.

• Social isolation is a frequent cause of relapse/exacerbation/rehospitalization.

• Negative symptoms militate against socialization and forming relationships.

• Relationship with a trusted provider improves outcomes, reduces need for hospitalization.

• Driving

• Friendship and family relationships

• Romantic relationships

• Work

• School

• Recreational drinking/drug use

• Medical issues

• Economic downward drift

• Remain free of harm, and demonstrate absence of violence toward others

• Be able to establish trusting, open relationship with therapist/nurse

• Report or experience no hallucinations

• Report or experience no delusional thought processes • Demonstrate increased socialization skills and decreased isolative behavior

• Demonstrate appropriate affect and improved thought processes

• Report the ability to experience pleasure and improved interest in activities

• Demonstrate improved ability to concentrate and complete tasks

• Demonstrate improved speech patterns and congruent communications

• Adhere to medication regimen as prescribed

• Demonstrate no EPS or adverse reactions to medication regimen

• Verbalize side effects and adverse reactions to report to prescriber

• Verbalize indication, dosage, route and schedule of medication regimen

• Demonstrate ability to complete ADLs with or without assistance

• Demonstrate effective coping patterns

• Utilize appropriate community resources

• Use of restraints is typically last resort after de-escalation and prn medications have been attempted • Avoidance of mechanical and chemical restraints begins hours before a crisis arises

– Checks person needs to be scanning environment

– Check in with patients frequently to nip violence in the bud

• “How are your thoughts today?”

• “How are the voices?”

• “What have you been thinking about lately?”

• “Are your medications helping?”

• “Any problems with side effects?”

• “How did the (fill in blank) go?”

– Be friendly and approachable and spend time on the unit and encourage that with your staff

– Feed a psychosis

– Determine if a room change is needed

– When beginning shift make a list of potentially violent or volatile patients and check to see what their medications (prn and standing) are

– Offer PRN medications to relieve distress, anxiety, impulsivity, anger

– Communicate with the patient’s doctor and the nursing administration about any concerns

– Alert other units and security if you think there may be a code call in the near future so they’ll be prepared

• Use of restraints is highly regulated by state departments of mental health

• Inpatient staff training: – De-escalation techniques – The safe use of mechanical and chemical restraints

• Institutional policy: – Safe staffing – Fast, effective communication among staff members – Continuous Quality Improvement issue – Involvement of the patient

• Code team

• The code team leader (chosen at the time of the incident based on amount of experience, knowledge of patient)

• The show of force

• Putting hands on to subdue patient is point of no return

• Immobilize on floor, use a safety blanket for transport to QR, search pockets etc, apply restraints, administer medication, constant one to one arms length supervision, vital signs, monitor intake and output

• Calls the code

• Delegates tasks such as restraint team leader

• Makes sure checks person stays on task

• Request cooperation of other patients (i.e.: go to rooms)

• Communicates with the patient’s inpatient psychiatrist and the nursing administration

• Responsible for making sure that doctor’s orders are received, carried out, transcribed

• Responsible for documentation of restraint

• Responsible for staffing the one to one

• Addresses the concerns of the other patients by discussing specific details about the restraint

• At the outpatient and residential setting, dangerous or threatening behavior is managed by calling 911

• No doctor’s order required to call 911

• For adult populations, hospitals are the only sites where chemical and mechanical restraints are allowed