NCLEX-RN: Psychiatric Nursing

Psychiatric Nursing: Schizophrenic Disorders

Focus topic: Psychiatric Nursing

Definition: Schizophrenia is a psychiatric syndrome characterized by thought disturbance, delusions, hallucinations, disorganized speech and behavior, and severely impaired interpersonal relationships. DSM-V does not include sub types.

Characteristics
A. Schizophrenia may result from many possible factors: genetic constellation and abnormalities in levels of neurotransmitters, in vitro insult, a deficit in cognitive development, or other biological origin.
B. Major maladaptive disturbances include impaired interpersonal relationships, inappropriate mental and emotional processes, and disturbances in overt behavior patterns.
C. Manifestations of the illness include acute psychosis involving the total personality or a group of symptoms circumscribed to one area of the personality.
D. Schizophrenia symptoms are often classified as positive or negative.

Psychiatric Nursing

Positive Symptoms
Definition: Excessive symptoms not normally present in healthy adults.
A. Delusions—fixed misinterpretation of reality; false beliefs maintained despite evidence to the contrary (somatic delusions are false beliefs that something is wrong with the body).
B. Hallucinations—unwilled sensory perceptions with no basis in reality; auditory, visual, olfactory, tactile, gustatory.
C. Disordered speech and behavior.

  •  Disordered speech includes frequent derailment or incoherence.
  •  Behavior is disorganized catatonic or random, purposeless.

D. Terms associated with disordered speech or behavior.

  •  Withdrawal—adoption of more satisfying regressive behavior; focus on internal world (autism).
  •  Depersonalization feelings of estrangement or unconnectedness of body parts.
  • Echolalia—a condition in which the individual consistently repeats what is heard.
  • Echopraxia—a condition in which the individual mimics what is done.
  •  Neologism—term that refers to the coining of a new word.
  • Word salad—communication characterized by jumbled words with no coherent message.

Negative Symptoms
Definition: Loss of normal function normally present in healthy adults.
A. Flat affect—feelings or emotions minimal (i.e., flat, blunted, or inappropriate).
B. Alogia or poverty of speech. Client answers questions with one word, which may signify lack of thoughts.
C. Avolition is when the client is unable to follow goal-directed behavior; this is not the same as laziness.
D. Anhedonia is the inability to experience joy or pleasure in any aspect of life.
E. The previous four symptoms can be remembered by the “four As”: affect flattened, alogia, avolition, and anhedonia.

Schizophrenic Sub types
A. Paranoid type.

  •  Persecutory or grandiose delusions are prominent; often delusions are part of a system where several delusions fit together.
  •  Extreme suspiciousness and withdrawal are common manifestations.

B. Catatonic type.

  •  Secondary symptoms of motor involvement are present.
    a. Under activity results in bizarre posturing; labeled waxy flexibility.
    b. Over activity leads to agitation.
  •  Negativism: doing the opposite of what is asked.
    a. Rigidity is the simplest form of negativism.
    b. Mute behavior is another form of negativism.
  •  Catatonic excitement—the opposite of mute, withdrawn behavior when client is agitated and out of control.

C. Disorganized type.

  •  Flat or inappropriate affect: giggling and silly laughter (formerly labeled hebephrenia).
  •  Disorganization of speech.
  •  Disorganized behavior.
  •  Absence of systematized delusions.

D. Undifferentiated type.

  •  This type is characterized by a combination of symptoms, none of which discriminates a specific type of disorder.
  •  Flat affect and/or autism is usually present.
  •  Association disorders and thought disturbance, such as delusions or hallucinations, are usually present.
  •  This condition includes other behavioral maladaptations that cannot be otherwise classified.

E. Residual type.

  •  A sub type that refers to a client who has had one episode of schizophrenia but now has no positive symptoms.
  •  Negative symptoms are present.

Assessment
A. Assess any disturbance in thought processes.

  •  Client’s thoughts are confused and disorganized, and ability to communicate clearly is limited.
  • Client manifests tangential (off target or off the original point) or circumstantial speech and has problems with symbolic meaning of certain words.
    a. May be very concrete in thinking and demonstrate an inability to think in abstract terms.
    b. May live in a fantasy world, responding to reality in a bizarre or autistic manner, thereby having great difficulty in testing reality.

B. Assess any disturbance in affect.

  •  Client has difficulty expressing emotions appropriately, and subjective emotional experience may be blunted or flattened.
  •  Client has difficulty expressing positive or warm emotions; when they are expressed, it is often in an inappropriate manner.
  •  While client’s feelings may seem inappropriate to the thoughts expressed, they are appropriate to the client’s inner experience and are meaningful to him.
  •  Client’s inappropriate affect makes it difficult to establish close relationships with others.

C. Assess any disordered behavior.

  •  Client’s behavior is often disorganized and inappropriate and apparently lacks a purposeful activity.
  • Client typically lacks motivation or drive to change his or her circumstances; general condition is one of apathy and listlessness.
  •  Client’s behavior may appear to be bizarre and extremely inappropriate to the circumstances.

D. Assess any disturbance in interpersonal relationships.

  • Client typically has great difficulty in relating to others.

a. Cannot build close relationships; probably has not experienced close, meaningful relationships in the past.
b. Has difficulty trusting others and experiences fear, ambivalence, and dependency that influence client’s relationships with others.

c. Often learns to protect self from further hurt by maintaining distance, thus experiences lack of warmth, trust, and intimacy.

  •  Client’s relationships are impaired by the inability to communicate clearly and to react in an appropriate and empathic manner.

Implementation
A. General approaches.

  •  Establish a nurse–client relationship.
    a. Gradually increase client’s social contacts with others.
    b. Build a positive and trusting relationship with client.
    c. Provide client with a safe and secure environment.
  •  Stress reality, help client to reality test, to leave his or her fantasy world.
    a. Involve client in reality-oriented activities.
    b. Help client find satisfaction in the external environment.
  •  Accept client as he or she is.
    a. Do not invalidate disturbed thoughts or fantasies.
    b. Do not invalidate client by inappropriate responses.
  • Use therapeutic communication techniques.
    a. Encourage expression of emotions, negative or positive.
    b. Encourage expression of thoughts, fears, and problems.
    c. Attempt to have nonverbal behavior become congruent with verbal communications.
    d. Focus on clear communications with the client.
  •  Avoid fostering dependency relationship.
  •  Avoid stressful situations or increasing client’s anxiety.
  •  Use real objects or activities (singing, for example) to distract or redirect delusional client.
  •  Decrease client’s anxiety level.
  •  Use direct, honest, authentic, matter-of-fact approach.
  • Recognize that the nurse and others influence client even if client appears unresponsive, remote, and detached at times.

B. Approaches to specific symptoms.

  •  Delusions.
    a. Encourage client to recognize distorted views of reality.
    b. Focus on client’s ego assets, strengths, etc.
    c. Provide a safe, nonthreatening milieu.
    d. Divert focus from delusional material to reality; involve in games, tasks, simple activities.
    e. Provide experiences in which client can feel success.
    f. Utilize specific nursing responses:
    (1) Avoid confirming or feeding into delusion.
    (2) Stress reality by denying you believe the client’s delusion, but do not invalidate client by saying delusion is not true for the client, it is true.
    (3) Respond to feelings underlying the content of the delusion. For example, validate the feelings of client by asking, “I sense you are afraid. Is this true?”
  •  Hallucinations.
    a. Provide a safe, structured environment with routine activities.
    b. Protect client from self-injury or hurting others prompted by “voices.”
    c. Initiate short, frequent interactions.
    (1) Respond verbally to anything real that client talks about.
    (2) Avoid denying or arguing with client about the hallucinations he or she is experiencing.
    (3) Involve the client in reality-based tasks or activities (i.e., a person cannot sing and hallucinate at the same time).
    (4) Increase client’s social interaction gradually from interaction with one person to interaction with small groups as tolerated by client.
  • Withdrawn behavior.
    a. Assist client to develop satisfying relationships with others.
    (1) Initiate interaction; do not expect a withdrawn client to seek you out.
    (2) Build a trusting relationship by being consistent in keeping appointments, in attitudes, and in nursing practice.
    (3) Be honest and direct in what you say and do.
    (4) Deal with your own feelings in relation to client’s hostility or rejection.
    b. Help client to modify perception of self.
    (1) Do not structure situation in which client will fail.
    (2) Increase client’s self-esteem by focusing on genuine assets or strengths.
    (3) Relieve client from decision making until client is able to make decisions.

c. Teach client renewal of social skills.
(1) Gradually increase social contacts with staff and other clients.
(2) Increase social contacts with significant others when appropriate.
d. Focus on reality situations.
(1) Use a nonthreatening approach.
(2) Provide safe, nonthreatening milieu. e. Attend to physical needs (e.g., nutrition, sleep, exercise, occupational therapy).
C. Approaches to dealing with aggressive or combative behavior.

  •  Observe client acutely for clues that client is becoming agitated. Utilize medication if client is willing.
    a. Note rising anger verbal and nonverbal behavior.
    b. Note erratic or unpredictable response to staff or other clients.
  • Intervene immediately when loss of control is imminent.
  •  Use a nonthreatening approach to client.
  •  Set firm limits on unacceptable behavior.
  • Maintain calm manner and do not show fear.
  •  Avoid engaging in an argument or provoking client.
  •  Summon assistance only when indicated; sudden involvement of many people will increase client’s agitation.
  •  Remove client from the situation as soon as possible.
  •  Use seclusion and/or restraints only if absolutely necessary to prevent injury to client or others.
  • Attempt to calm client so that he or she may regain control.
  • Be supportive and stay with client.
  • Use problem-solving focus following outburst of aggressive or combative behavior.
    a. Encourage discussion of feelings surrounding incident.
    b. Attempt to look at causal factors of the behavior.
    c. Examine client’s response to stimulus and alternative responses.
    d. Point out consequences of aggressive behavior.
    e. Discuss client’s role of taking responsibility for his or her aggressive behavior.

D. Approaches to dealing with verbally abusive behavior.

  •  Do not respond in kind to abusive comments.
  • Do not take abuse personally.
  •  Interact with client on a therapeutic basis.
    a. Help client examine his or her feelings.
    b. Do not reject client despite abuse.
    c. Give client feedback concerning your reactions to abusive comments.
    d. Teach alternative ways for client to express his or her feelings.
  •  Maintain a calm, accepting approach to client.

E. Approaches to dealing with demanding behavior.

  •  Do not ignore demands; they will only increase in intensity. Respond to realistic demands.
  •  Attempt to determine causal factors of behavior (e.g., high anxiety level).
  •  Set limits when client is demanding.
  •  Control own feelings of anger and irritation.
  • Teach alternative means to getting needs met.
  • Plan nursing care to include frequent contacts initiated by the nurse.
  •  Alert the staff to try to give client the reassurance he or she needs.

Psychiatric Nursing: Schizoaffective Disorder

Focus topic: Psychiatric Nursing

Definition: Condition that does not directly fit either schizophrenia or a mood disorder and, thus, is a mixture of symptoms. Illness is characterized by episodes of depression, mania, or both, concurrent with symptoms of schizophrenia.

Characteristics
A. Client may experience depression, mania, or mixed symptoms.
B. Symptoms may include delusions, hallucination, disorganized speech and behavior.
C. Clients often have difficulty functioning in their lives.

Assessment
A. Assess thought processes as similar to schizophrenic disorder.
B. Observe for bizarre behavior and mood disorders ranging from depression to elation (bipolar disorder).

Implementation
A. Clients will be treated according to symptoms manifested schizophrenic and/or mood disorder.
B. Drug therapy may be either anti-psychotic (usually prescribed) or antidepressant drugs.
C. Check implementation section for both schizophrenic and mood disorders.

Psychiatric Nursing: Child Psychiatric Conditions

Focus topic: Psychiatric Nursing

Definition: Emotional disturbance in childhood encompassing markedly abnormal or impaired development in social interaction and communication and a marked restricted repertoire of activity and interests.

Psychiatric Nursing: Adolescent Adjustment Problems

Focus topic: Psychiatric Nursing

Definition: Adolescent emotional disturbances occur in adolescents when their behavior becomes maladaptive and they cease to function effectively.

Characteristics
A. Adolescence is a period of ambivalence—dependence versus independence.
B. Influenced by peer group pressures, the adolescent may experience an identity crisis because his or her own identity has not yet been resolved.
C. The adolescent evidences an inability to resolve conflicts and to master developmental tasks (identity versus role diffusion). For a full discussion of Erikson’s stages of development, see Chapter 3.
D. Tasks of this stage of growth.

  •  Emotional separation from the parents.
  •  Foundations for an adult sense of self. One of the most difficult situations parents must face is the arguing and the testing of limits in which their child engages to develop this sense of self.
  •  Sense of personal identity. Teenagers continue to need love, support, and consistency from the adults around them.
  •  Resolution of dependency and control issues.

E. Normal adolescent behavior can be perplexing at times, so abnormal behavior may not be so obvious or blatant. Families may become desensitized to abnormal behavior.

Assessment
A. Assess degree of maladaptation or adjustment problems.
B. Assess presence of confusion that may result in anxiety, depression, acting out, or antisocial behavior.

Psychiatric Nursing: ADOLESCENT BEHAVIOR CHART

Focus topic: Psychiatric Nursing

Psychiatric Nursing

C. Observe for specific behaviors in adolescent maladjustment.

  •  Defiance and hostility, especially toward authority figures.
  •  Sullenness and withdrawal.
  •  Sexual deviations.
  •  Addiction to drugs or alcohol.
  •  Depression and self-destructive impulses or risk.
  •  Acting out or testing.

D. Assess developmental level at which adolescent is functioning.
E. Assess skills in problem solving, motivation, and general attitude.
F. Assess if the client is in touch with his or her feelings; how does client see relationship with parents, other adults, own-age peers?
G. Determine if client is in treatment willingly or because of a court order, parental insistence, etc.
H. Evaluate client’s general communication skills, level of self-esteem, and interaction with peer group and adults.
I. Assess how client uses the problem behavior to meet needs.
J. Evaluate family structure.

  •  Determine whether the parents will join in treatment program.
  •  Ask parents how they believe the client’s problems can be resolved.
  •  Determine the communication skills of each parent.
  • Observe how the client’s behavior meets the parents’ needs.
  •  Assess other problems in the family (marital problems, other children with behavioral problems, financial worries, etc.).

K. Family behaviors that foster adolescent dysfunction.

  • Scapegoating.
  • Child or sexual abuse.
  • Marital disharmony.
  • Parental indifference. Unhealthy communication patterns use of double messages.

Implementation
A. Provide the experience of a positive relationship.

  •  Encourage open interaction so that adolescent can share fears, problems, concerns.
  •  Reinforce authentic behavior from client.
  •  Encourage group interaction with peers.

B. Use behavioral approach.

  •  Set firm limits and be consistent in approach.
  •  Confront maladaptive behavior and reinforce efforts to change it.
  •  Avoid being manipulated or supportive of acting-out behavior.
  •  Give verbal positive reinforcement for appropriate behaviors.
  • Help client create alternate activities to use as substitutes for destructive behaviors.
  •  Assist client to notice when he or she returns to old patterns of destructive behavior.

C. Use clear, open communication.

  • Role model effective communication skills.
  •  Assist client to practice new styles of communicating; make use of role-playing, etc.
  •  Encourage exploration of feelings; provide safe environment for expression of feelings.

D. Assist adolescent to develop personal goals.

  •  Encourage client to set up personal goals, and provide encouragement and feedback.
  •  Assist client to identify steps in obtaining goal.
  •  Encourage client to examine his or her family’s rules and develop alternate rules for living.
  •  Support client in sharing alternate rules with family and explore areas of negotiation.

Psychiatric Nursing: Treatment Modalities

Focus topic: Psychiatric Nursing

Psychiatric Nursing: Eye Movement Desensitization and Reprocessing

Focus topic: Psychiatric Nursing

A. Recently developed therapy utilized in treatment of trauma and PTSD.
B. Reduces symptoms of depression, anxiety, and symptoms of PTSD.
C. Advantages of therapy.

  • Significant efficacy across symptom profile.
  • Often, positive results require only a few sessions; previously, it could take years to resolve these problems.

Psychiatric Nursing: Electroconvulsive Therapy

Focus topic: Psychiatric Nursing

Definition: Use of electronically induced seizures for the
safe and effective treatment of severe depression, depression
with psychotic features, and mania. Also called interventional
psychiatry.
A. Electroconvulsive therapy has been negatively perceived by general public; in fact, it is one of the most useful treatments for major depression, and does not cause tissue damage or brain damage. Studies have demonstrated its efficacy.
B. Involves induction of grandmal seizure via transdermal electric pulse unilaterally or bilaterally (usually at the temple) may reestablish biochemical balance.
C. Usually given several times a week for a total of 6 to 18 treatments.

D. Advantages.

  •  Works when antidepressants aren’t effective or can’t be used. Quicker acting than antidepressants; occasionally used when imminent risk of suicide requires quicker results.
  •  Safer for elderly with history of cardiac illness than antidepressant medication therapy.
  •  Highly effective in treatment of major depressive episode with vegetative aspects improvement rate.

E. Administration.

  •  Three types of medication administered: an anticholinergic (Robinul [atropine]) to block vagal stimulation so secretions are reduced; a short-acting general anesthesia, administered IV, to make the client more comfortable; and a muscle relaxant (such as Anectine [succinylcholine]), to reduce complications from the convulsion itself.
  •  Preoxygenation of the brain reduces risk of anoxia.
  •  EEG monitoring monitors the seizure to ensure a therapeutic effect.
  •  New shock wave forms are being used that require one-third as much power reduces amnesia, confusion, and EEG abnormalities.
  • Have emergency care available.
  •  Preparation: informed consent, medical history, and physical exam; lab work-up and education of client and family.
  •  Side effects: memory loss for recent events and difficulty learning new information effects usually resolve in 6–9 months (side effect of memory loss; occurs less often or is less severe with unilateral electrode); headaches, muscle aches, weight gain, hypertension, and, occasionally, cardiac arrhythmias.

F. Nursing considerations.

  •  Prior to procedure. Confirm client identity using two client identifiers.
    a. Explain to client and family about the procedure and how client will react upon awakening: confusion, disorientation.
    b. Keep NPO after midnight or for at least 6 hours.
    c. Have client void and remove lenses, dentures, and jewelry prior to treatment. Make note of implants such as pacemakers.
    d. Confirm consent form is signed.
  •  Following procedure.
    a. Place client in lateral, recumbent position for drainage.
    b. Remain with client until alert.
    c. Monitor vital signs after general anesthesia.
    d. Reorient to unit.
    e. Reassure regarding memory loss and confusion.
    f. Assist to eat.

FURTHER READING/STUDY:

Resources:

 

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