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Thought Disorders

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Thought Disorders

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    1. 10/24/2011 1 Thought Disorders Adrianne Maltese

    2. 10/24/2011 2

    3. 10/24/2011 3 Schizophenria BLEULER’S four A’s Ambivalence—holding two different attitudes/emotions/feelings at the same time Autistic thinking—disturbances in thoughts –private fantasy world/abnormal responses to people/events of the real world

    4. 10/24/2011 4 Bleuler’s 4 A’s(cont) Loosening of Associations-rapid shift of ideas- unrelated manner Affective disturbance - may be blunt, flat,inappropriate/labile

    5. 10/24/2011 5 Positive Symptoms DELUSIONS(paranoid/reference) HALLUCINATIONS(auditory/visual) DISORANIZED SPEECH/THINKING(tangential/loa/incoherent/neologisms GROSSLY DISORGANIZED BEHAVIOR(difficulty with goal setting/ADL’s;unpredictable agitation/silliness/social disinhibition/bizarre behaviors CATATONIC BEHAVIORS(decrease reaction to environment/bizarre postures/aimless motor activity)

    6. 10/24/2011 6 Negative symptoms AFFECTIVE FLATTENING ALOGIA (poverty of speech/slowed speech/decrease fluency/content) AVOLITION(inability to initiate goal directed behavior)

    7. 10/24/2011 7 Types of Schizophrenia Disorganized Paranoid Catatonic Undifferentiated Residual Related Psychotic Disorders: Schizoaffective Disorder Schizophreniform disorder Delusional disorder Brief Psychotic disorder

    8. 10/24/2011 8 Paranoid Type Persistent delusions/persecuatory nature Auditory hallucinations-single or associated theme Guarded,suspicious,hostile,angry, possibly violent Pervasive anxiety Intensive,reserved,controlled social interactions Onset- later in life Generally more favorable dx. re: independent living/occupational functioning.

    9. 10/24/2011 9 Disorganized type Grossly inappropriate/flat affect Primitive / uninhibited behaivor Unusual mannerisms-giggle/cry out loud/distort facial expressions Hypochondriasis (multiple physical complaints) Socially inept/withdrawn Onset early- prepsychotic period- marked adjustment problems Hallucinations/delusions more fragmented

    10. 10/24/2011 10 Catatonic Type Marked disturbance of psychomotor activity May be immobile/or with psychomotor excitation Displays negativism/mutism Posturing Bizarre positions-waxy flexibility

    11. 10/24/2011 11 Undifferentiated type Florid psychotic symptoms : delusions/hallucinations incoherence disorganized speech/behavior *do not clearly fit into other categories

    12. 10/24/2011 12 Schizophreniform Disorder Meets criteria for schizophrenia except: 1) duration-at least 1 month but < 6 mos. 2)Social/ Occupational functioning may or may not be impaired vs. schizophrenia where functional disturbances ie:relationships,school,self care are present.

    13. 10/24/2011 13 Schizoaffective Disorder Symptoms of both Schizophrenia and affective (mood)disorders *delusions/hallucinations/disorganized speech Major depression, mania, mixed At least a two week period of psychotic symptoms only Onset is later than schizophrenia Prognosis is better than schizophrenia,but worse than Affective Disorder.

    14. 10/24/2011 14 Residual Type Client has had at least one acute episode Free of psychotic symptoms Continues to exhibit persistent social withdrawal/emotional blunting/illogical thinking/eccentric behavior

    15. 10/24/2011 15 Delusional Disorder Presence of one or more nonbizarre delusions persist for ONE month or more Bizarre delusion ie:brain removed by aliens-replaced with computer vs. nonbizarre delusion- more believable ie:believes the IRS is going to prosecute his family for his wrongdoings.

    16. 10/24/2011 16 Subtypes of Delusional Disorder Erotomanic—may involve stalking/spying Jealous—efforts made to follow & “Catch” Grandiose—has extraodinary talent/knowledge Persecutoy-victim of a conspiracy/poisining/spying Somatic-bodily sensations/believes body has a foul odor/insects or parasites on/in body/body part is nonfunctional

    17. 10/24/2011 17 Other Psychotic disorders BRIEF PSYCHOTIC DISORDER At least one of the following sx’s: Hallucinations,delusions, disorganized speech, behavior disturbance,(disorganized or catatonic) Sx’z last at least one day—but less than one month.—returns to premorbid level.

    18. 10/24/2011 18 SHARED PSYCHOTIC DISORDER Delusional disorder– also known as “folie `a deux” develops in a person who is involved in a relationship with another person who already has a psychotic d/o with prominent delusions.

    19. 10/24/2011 19 Psychotic Disorder due to medical conditions Characterized by: prominent hallucinations and /or delusions due to physiologic effect of medical condition

    20. 10/24/2011 20 Substance Induced Psychotic Disorder Characterized by: prominent hallucinations and /or delusions produced by the physiological effects of a substance ie: Drugs of abuse,medications or toxins The disorder first occurs during intoxication or withdrawal stages, but can last for weeks thereafter.

    21. 10/24/2011 21 Human Needs Assessment: Maslow Biologic & Physiologic Integrity: (Air, Fluids , Comfort, Activity, Nutrition, Elimination, Skin Integrity) Overall Decline in health maintenance Poor grooming/hygiene/ADL functions Increased risk for communicable diseases r/t i.e. TB, PNA, Infection homelessness & poor hygiene, poor judgment

    22. 10/24/2011 22 Oxygen & Fluids Assessment Note hx. of cigarette smoking –second hand in smoke filled facilities, Respiratory diseases Poor posture – shallow breathing patterns May drink too little or too much water due to delusional beliefs May be dehydrated upon admission Check Chem panel and electrolytes(hypo-hyper nutremia ;hypo-hyper kalemia)

    23. 10/24/2011 23 Mental Status Assessment Altered mood/depressive symptoms Anxiety/agitation Social withdrawal/isolation Perceptual distortions: Hallucinations, illusions,altered internal sensations,Agnosia,distorted body image,negative self-perception

    24. 10/24/2011 24 Comfort, Activity Assess Pain, discomfort ,injuries Activity level – normal vs. Psychomotor retardation, psychomotor agitation

    25. 10/24/2011 25 Mental Status Assessment Cognitive Distortions: Delusions,derealizations,ideas of reference,errors in memory recall,problems with attention/concentration Incorrect use of language which interferes with socialization (neologosisms/clanging) Flight of ideas

    26. 10/24/2011 26 Nutrition, Elimination, Skin Integrity Assess food intake ?mal-nourishment – where does client get food supply? # meals daily, usual diet, % eaten while on unit? B12 & Folate levels, Liver Panel, CBC w/diff , Protein levels Assess constipation/loose stools r/t S/E’s of psychotropic meds. Assess Skin Integrity- condition of skin- dry, cracked, sun-burned Foot care – may walk barefoot on surface streets

    27. 10/24/2011 27 Safety & Security Assessment Assess suicidal ideation(50% suicide rate) Assess potential for violence/aggression Maintain safe/secure environment Assess orthostatic B/P changes Assess Mental Status changes

    28. 10/24/2011 28 Belonging & Attachment Assessment (Psychosocial) Assess support system (effective or not?) Family attachments, friends, clergy, 12 step groups) Affect- may be labile, emotionless Coping ability Ability to form trusting & reciprocal relationships

    29. 10/24/2011 29 Self-Esteem & Self Efficacy Assessment What is client’s view of self ?(was education interrupted by illness?) Body image (distorted or realistic) What stage of development was effected by onset of illness? Decision making capacity Sense of control over life

    30. 10/24/2011 30 The Nursing Process: Assessment: Subjective/Objective Use of the Mental status exam Focus on four areas:disturbances in perceptions, Language & thought Process, affect &feelings, and Psychomotor behavior. Direct questions towards assessment of these areas

    31. 10/24/2011 31 Self Actualization & Self-Transcendence Assessment Ability to maintain health- compliance with med regime Ability to seek help when needed – keeps Dr.’s appt’s for f/u of illness Seeks ways to control stress

    32. 10/24/2011 32 Psychosocial Assessment Behavioral disturbances: Poor impulse control/anger management problems High risk for self harm (50% risk for Suicide) Lack of social support systems Substance abuse/med noncompliance

    33. 10/24/2011 33 Psychosocial Assessment Poor peer relationships-has few friends Social/occupational areas –poor functions Preoccupied/detached Poor achievements-lacks competativeness Avolition- lacks initiative to engage in self-initiated, goal –directed activity. Social withdrawal/self isolation

    34. 10/24/2011 34 Developmental Assessment Autistic like behaviors-lacks social skills Delayed development- immature Strikes in late adolescence—early adulthood effecting emotional development. Erikson’s stage(identity vs. role confusion) (intimacy vs. isolation)

    35. 10/24/2011 35 Spiritual Assessment Religiosity- delusional beliefs centered around religious beliefs Values and beliefs with which one is raised Impact of these beliefs on delusional system

    36. 10/24/2011 36 Nursing Diagnosis (Actual or Potential) Communication, Impaired verbal Disturbed personal Identity Coping, Ineffective Individual Family Process, altered Sensory/ perceptual alterations Thought processes, altered Violence, risk for: self/other directed Altered nutrition < body requirements Self care deficit (bathing/hygiene/grooming/ bathing/feeding/toileting)

    37. 10/24/2011 37 Outcome Identification/goals The client will: Demonstrate reduction in psychotic symptoms Demonstrate absence of self-mutilating,violent or aggressive behaviors Demonstrate reality based thinking & behaviors Socialize with peers/staff&participate in groups Comply with medication regimen Verbalize the role of medications in reduction of psychotic symptoms.

    38. 10/24/2011 38 Nursing Interventions/Rationales: Involve client/family in treatment process (avoids misunderstandings;resistance from client/family/or financial/environmental constraints) Establish a therapeutic relationship with client first (the client must first feel he can trust the nurse-assists with safety and security) Institute measures to maintain/regain physical health (the client’s safety and physical health are priority!)

    39. 10/24/2011 39 Interventions/rationales Use clear/concrete statements vs. generalizations (they may exacerbate misperceptions or hallucinations) Determine stressors that may trigger sensory-perceptual disturbances (hallucinations may be exacerbated by external/environmental stressors)

    40. 10/24/2011 40 Interventions/rationales Distract client from delusions that exacerbate aggressive/potentially violent episodes (engaging the client in more functional,less anxiety provoking activities increases the reality base and decreases risk of violent episodes that may be provoked by delusions)

    41. 10/24/2011 41 Interventions/rationales Begin with one to one interactions, accompany client to group activities starting with more structured, less threatening groups and progressing to more informal spontaneous activities(limited contact at first-often better tolerated – later increase in socialization to assist with social skills & to expand reality base) Focus on meaning behind delusion rather than content-recognize as client’s perception of the environment(meets clients needs,reinforces reality,non challenging or threatening)

    42. 10/24/2011 42 Questions-Thought disorders& Schizophrenia: A client is a withdrawn catatonic state exhibits waxy flexibility. During the initial phase of hospitalization for this client the nurse’s first priority is to: Watch for edema and cyanosis of the extremities. Encourage the client to discuss concerns that led to the catatonic state. Provide warm, nurturing, relationship, with therapeutic use of touch. Identifying the predisposing factors to the illness.

    43. 10/24/2011 43 2. A client with schizophrenia, disorganized type is admitted to the inpatient unit. He frequently giggles and mumbles to himself. He hasn’t taken a shower in 3 days. His appearance is disheveled and unkempt. The nurse would best persuade the client to shower by saying: “Clients on this unit take showers daily.” “It’s time to shower, I will help you.” “You’ll feel better if you shower.” “Would you like to take a shower?”

    44. 10/24/2011 44 3. The nurse identifies the nursing diagnosis of Disturbed thought process related to exhibiting delusions of reference for a client with schizophrenia. Which outcome would be most appropriate? Client will talk about concrete events in the environment without talking about delusions. Client will state 3 symptoms that occur when feeling stressed. Client will identify 2 personal interventions that decrease intensity of delusional thinking. Client will use distracting techniques when having delusions.

    45. 10/24/2011 45 4. During a community meeting, a client with schizophrenia begins to shout and gesture in an angry manner. Which nursing intervention would be the priority? Determine the reason for the client’s agitation. Encourage appropriate group behavior? Facilitate group process in responding to the client. D. Maintaining safety of client and others.

    46. 10/24/2011 46 A male client who has schizophrenia is admitted to the inpatient psychiatric unit. The client is actively hallucinating and is unable to provide information for the admission process. What is the nurse’s best option for getting information? Wait until the medication works Ask the next shift to do the admission Get the information from the physician Ask the client’s family for information.

    47. 10/24/2011 47 A 32 year-old client admitted with catatonic schizophrenia has been mute and motionless for 2 days. The priority nursing diagnosis is: High risk for fluid and electrolyte imbalance Impaired mobility Impaired verbal communication Ineffective individual coping.

    48. 10/24/2011 48 In planning care for a client experiencing paranoid delusions, which of the following is the priority goal? Absence of delusions Establishing trust Participation in all unit activities Performing independent activities

    49. 10/24/2011 49 Which nursing response would be most appropriate when a client is hearing voices? “I do not hear the voices that you say you hear.” “Those voices will disappear as soon as the medicine works.” “Try to think about positive things instead of the voices.” “Voices are only in your imagination.”

    50. 10/24/2011 50 The nurse expects to assess which of the following in a client diagnosed with schizophrenia, paranoid type? Anger, auditory hallucinations, persecutory delusions. Abnormal motor activity, frequent posturing, autism. Flat affect, anhedonia, alogia. Silly behavior, poor personal hygiene, incoherent speech.

    51. 10/24/2011 51 AGGRESSIVE BEHAVIORS “Aggressive behavior” - is an acting out of aggressive or hostile impulses in a violent or destructive manner; may be directed towards objects, others, self. ETIOLOGY- r/t feelings of anger/hostility/homicidal ideation,psychotic process,substance use, personality disorders

    52. 10/24/2011 52 Which of the following comments by a client indicate the need for an urgent dose of an antipsychotic drug? “The voices are mumbling and I can’t hear them very well.” “The voices are telling me to rip my bed sheets and hang myself.” “The voice I heard this morning sounded like my dead grandmother.” “The voices told me to kill my neighbor when I get home.”

    53. 10/24/2011 53 De-escalating Aggressive Behaviors GENERAL INTERVENTIONS – SAFETY –most important- protect client & others Provide safe, non-threatening Therapeutic environment

    54. 10/24/2011 54 LEGAL /ETHICAL ISSUES – Staff is responsible to provide control to protect client & others MANAGING THE ENVIRONMENT- Persuade client to move to another area; have colleagues remove others from area (prevents anxiety/contagious responses from other clients/provides sense of safety/protects others)

    55. 10/24/2011 55 De-escalation techniques: Encourage Verbalization Ask the client open-ended ,non-threatening questions “How?” “What?” “Where?” “When?” – obtain details from client . Do NOT ask “WHY?” Keep voice calm,modulated(focuses on client problem-stops anger from escalating

    56. 10/24/2011 56 De-escalating techniques cont’d Use of Non-Verbal expression: Allow client body space > 8 feet Keep your body at a 45 degree angle Assume “OPEN POSTURE” –hands at side,palms outward. [this conveys a non-threatening message, gives client message that you are willing to listen and help]

    57. 10/24/2011 57 De-escalating techniques Personalize self and show concern Remind client who you are (that you are his nurse-he is in the hospital and is safe here) Use words ie: “we” or “us” Use encouraging responses ie: “go on…”[demonstrates empathy/encourages and reflects cooperation on your part]

    58. 10/24/2011 58 Managing aggressive Behaviors Hold regular drills with staff to practice strategies Practice use of disengagement breakaways Rehearse procedures regarding the removal of client to seclusion or restraints Document all events and hold debriefing sessions with staff [allows staff to de-escalate and learn from event]

    59. 10/24/2011 59 A client who is agitated begins to shout insults and threats at others, and starts demolishing the recreation room. What is the best response or action by the nurse? Firmly set limits on the behavior. Allow the client to continue, because this is an expression of his/her feelings. Let the client know that he/she does not need to express anger at the nurse by demolishing the recreation room. Tell the client that he/she is trying to intimidate other clients.

    60. 10/24/2011 60 A client who is agitated begins to shout insults and threats at others, and starts demolishing the recreation room. What is the best response or action by the nurse? Firmly set limits on the behavior. Allow the client to continue, because this is an expression of his/her feelings. Let the client know that he/she does not need to express anger at the nurse by demolishing the recreation room. Tell the client that he/she is trying to intimidate other clients.

    61. 10/24/2011 61 Which nursing intervention is inappropriate to use with a person who is expressing anger? Stating observations of the expressed anger. Assisting the person to describe his/her feelings. Helping the person find out what preceded the anger. Helping the person refrain from expressing the anger verbally.

    62. 10/24/2011 62 A teenager with acting-out behaviors tells the nurse, “I want you to go tell my teacher that I am sick and I should be allowed to do whatever I want.” The nurse determines that this statement best represents: Insight Manipulation Dependency Trust

    63. 10/24/2011 63 A client who is acutely agitated becomes increasingly aggressive despite staff’s verbal attempts to stop the aggression. The client shout threats at other clients, throws furniture, and begins to kick and bite clients and staff. A prn order for medication when agitated is available. Which action should the nurse take initially? Orient the client to reality, and place the client in a well lit, quiet room. Give the ordered tranquilizer and pout the client in bed with the side rails up. Lock the client in his/her room and call the doctor. Have at least two staff members physically restrain the client and take the client to a quiet room.

    64. 10/24/2011 64 Which nursing action would be best for a client who is hospitalized , and is constantly upset with the staff, easily angers, and frequently shouts at the nurses? A Request that the client be moved to another unit. B. Schedule a conference with the MD, nurse manager, and client about his behavior. C. Contact social services to meet with the client and family about the problem. D. Involve the client and the family in the development of the care plan.

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