Schizophrenia

Introduction:

The exact cause of schizophrenia is not known. There is a familial tendency to the
disease, and genes have been identified that are associated with the disease.
Dysfunction of the neurotransmitter dopamine seems to be partially responsible
for the development of the symptoms of psychosis associated with schizophrenia.
NMDA receptors may also be involved in the disease.

PROGNOSIS

Patients with schizophrenia typically need long-term medication to control symp-
toms. Medication compliance can be difficult for some patients, whether due to
accessibility of medications, side effects, symptoms of disease, or desire not to take
daily medication. Symptom recurrence is likely.

SIGNS AND SYMPTOMS

• Impairment in reality testing
• Flat affect
• Disorganized speech
• Disorganized thought process
• Unusual behavior
• Delusions
• Auditory hallucinations

TREATMENT

• Antipsychotic medications:
• clozapine
• aripiprazole
• ziprasidone
• loxapine
• risperidone
• olanzapine
• quetiapine
• thiothixene
• Psychotherapy.
• Behavioral therapy.

NURSING DIAGNOSIS

• Impaired environmental interpretation syndrome
• Disturbed thought process
• Disturbed auditory sensory perception

NURSING INTERVENTION

• Monitor medication intake.
• Discuss patient response to therapy.
• Discuss importance of medication compliance.
• Structured environment.

Bipolar Disorder

Patients suffering from mood disorders often have difficulty with interpersonal
interactions. Substance abuse occurs as patients attempt to self-medicate.

Introduction:

Some patients experience episodes of depression alternating with episodes of mania
or hypomania. These episodes may occur in a mixed or cyclic manner. There tends
to be a high comorbidity with substance abuse in these patients. Depressive
episodes tend to last longer than the manic episodes. During mania the patients are
overenthusiastic, elated, hyperactive, and often engage in activities that they later
regret. Others may be drawn to the patient during manic episodes due to their out-
going, engaging behavior. Later the patient’s behavior tends to alienate due to
mood swings, irritability, aggression, and grandiosity. There is a positive correla-
tion between creative behavior and mood disorders. During the manic phase, the
patient has grandiose ideas.

PROGNOSIS

Proper medication management is necessary to control the symptoms of bipolar
disorder. Initial diagnosis and treatment of depression without recognition of the
coexisting mania can lead to the onset of mania due to the antidepressant treat-
ment. It is important to treat both components of the disorder to effectively man-
age the patient. Ongoing treatment is often necessary to prevent the patient from
cycling into another manic or depressive episode. Some patients may have psy-
chotic symptoms as part of the disease process.

SIGNS AND SYMPTOMS

• Elation
• Hyperactivity
• Increased irritability
• Flight of ideas
• Grandiosity
• Diminished need for sleep
• Rapid speech
• Easily distracted
• Excessive spending
• Hypersexuality
• Episodes of depression
• The patient may stray from medication regimen because he or she feel weighed
down

TREATMENT

• Mood stabilizers:
• lithium
• valproic acid
• carbamazapine
• lamotrigine
• Antipsychotic medications:
• olanzapine
• risperidone
• aripiprazole
• Psychotherapy.
• Assess suicide risk.
• Antidepressants.

NURSING DIAGNOSIS

• Powerlessness
• Social isolation
• Risk for loneliness
• Altered sexuality patterns


NURSING INTERVENTION
• Monitor patient frequently when first admitted.
• Ask about suicidal ideation.
• Monitor medication intake.
• Discuss patient response to therapy.

Depression

Patients with depression have a persistent sense of sadness, more days than not,
often associated with somatic complaints. The medical work-ups for varied
physical complaints will be negative. Patients typically have a loss of interest in
normal activities and alterations in sleep and eating habits. Up to one-third of
patients will seek care from primary care providers. Patients can also present as
unkempt, dirty, withdrawn, and unwilling to engage in conversation. They see
life as a state of hopelessness. The patient’s depression must be treated seriously,
since it can lead to suicide. A patient’s request for help might be his or her last
recourse.

Introduction:

Several different theories exist involving the cause of depression. Genetic factors
may lead to changes in the normal functioning of neurotransmitters. Neurotrans-
mitters are released from one side of a synapse and land on a specific receptor
site on the other side of the synapse. When a balance is maintained between the
amount released and the amount needed to fill the receptor sites, normal function
continues. When there is an imbalance, the neurotransmission is altered. Develop-
mental factors can often be traced back to childhood. Personality disorders may
begin during school age or adolescence. Psychosocial stressors are another factor
linked to the development of depression. Major life changes such as the death of
a family member, unemployment, or moving away from family and friends may
lead to the onset of depression. A sense of sadness or grief is considered a normal
response to this type of loss and should resolve as the person progresses through
the normal stages of grieving. Depression, however, is not a normal response to loss.
A grieving person will have a sustained sense of self-esteem, whereas a person
with depression will have a sense of worthlessness.

PROGNOSIS
Proper treatment can help control the symptoms of depression. Adequate treatment
can cause remission of symptoms. It is not unusual for there to be a recurrence of
symptoms at some point in the future, even with appropriate treatment.


SIGNS AND SYMPTOMS
• Intense feeling of sadness
• Depressed mood
• Anhedonia (loss of interest in usual activities)
• Hopelessness or worthlessness
• Difficulty concentrating
• Indecision
• Changes in sleep (more or less than usual), eating (more or less than usual),
and activity (more or less than usual)
• Social withdrawal and isolation
• Decreased libido
• Thoughts of death
• Physical complaints include headache, malaise, decreased libido, and changes
in sleep, activity, and eating


TREATMENT
• Ask patient about suicidal thoughts.
• Ask patient about suicidal plan.
• Psychotherapy.
• Cognitive-behavioral therapy.
• Support groups.
• Antidepressant medications:
• SSRIs
• venlafaxine
• nefazodone
• bupropion
• mirtazapine
• tricyclics
• monoamine oxidase inhibitors
• Electroconvulsant therapy (ECT) in refractory cases.

NURSING DIAGNOSIS

• Hopelessness
• Risk for suicide
• Dysfunctional grieving
• Impaired social interaction
• Social isolation

NURSING INTERVENTION

• Monitor patient frequently when first admitted.
• One-to-one observation if patient is a suicidal risk.
• Develop a level of sensitivity and trust with the patient.
• Ask patient about suicidal ideation; do they have a plan, have they attempted
to carry out a plan.
• Monitor medication intake.
• Discuss patient response to therapy.
• Monitor vital signs; watch for elevation in blood pressure with some med-
ications.
• Monitor weight; some medications are associated with changes in weight.
• Monitor sleep; ask patient about restful sleep during the night, and difficulty
falling asleep.
• Disturbed self-esteem

Panic Disorder

Introduction:

Patients experience intermittent episodes that have a sudden onset and no pre-
dictable pattern, causing intense anxiety associated with pronounced physical symp-
toms. These episodes are short in duration and recurrent in nature. The disorder
tends to present before the age of 25, is twice as common in women as it is in men,
and tends to be familial. Some patients will choose to self-medicate with alcohol
in an attempt to escape the disease, diminish symptoms, or decrease the occur-
rence of the episodes. Others become dependent on tranquilizing medications.
Panic attacks can impede a person’s life and restrict activity, especially in antici-
pation of a panic attack.

PROGNOSIS

With proper treatment, the frequency and intensity of the episodes will decrease.
Some patients may not experience complete resolution of symptoms, even with
appropriate medications.

SIGNS AND SYMPTOMS

• Depersonalization, as if the symptoms are happening to someone else
• Sense of doom, fear of dying due to the intensity of the physical symptoms
• Fear of losing control due to the unpredictable nature of the episodes
• Worry about future attacks due to the unpredictable nature of the episodes
• Change in behavior due to anxiety about being in a place where an attack
might occur
• Palpitations, tachycardia, and chest pain
• Dyspnea
• Choking sensation
• Nausea
• Dizziness
• Diaphoresis
• Numbness

TREATMENT
• Cognitive-behavioral therapy.
• Relaxation therapy.
• Administer antidepressants:
• selective serotonin reuptake inhibitors
• tricyclics
• monoamine oxidase inhibitors
• Administer benzodiazepines as adjunctive treatment:
• clonazepam, alprazolam, lorazepam
• Provide reassurance to patient.

NURSING DIAGNOSIS

• Powerlessness
• Fear
• Social isolation

NURSING INTERVENTION

• Provide reassurance to patient.
• Reduce anxiety.
• Monitor vital signs.

Anxiety

Introduction:

Patients exhibit symptoms when an imbalance develops between the number of
open receptor sites and the number of available neurotransmitters. Neurotransmitters
are released from one side of a synapse and land on a specific receptor site across
the synapse. Asecond mechanism exists (a reuptake mechanism) to remove excess
neurotransmitters left within the space between where they are released and where
they fill the receptor sites. When there are insufficient neurotransmitters available
to fill the open neurotransmitter receptor sites, the patient develops symptoms.
Patients experience an uncontrollable feeling of anxiousness which is present more
days than not.
Symptom onset is typically in late teens through early thirties. Anxiety is more
common in women and in patients with a family history of anxiety.

PROGNOSIS
Without proper treatment the anxiety will continue, and symptoms may even
progress. The patient’s quality of life is adversely affected. Social functioning be-
comes impaired and in some cases the patient becomes more socially isolated.
Physical symptoms continue, at times necessitating visits to a primary care provider
or even the emergency room. With proper treatment, the symptoms are controlled,
neurotransmitter balance is restored, and remission is achieved. The symptoms will
typically recur at a later point, even when properly treated. It may be months or
years after a successful course of treatment before the symptoms recur. The treat-
ment that was effective in the past will typically be effective again in the future. A
longer treatment course is recommended for subsequent treatment cycles when
using SSRIs (selective serotonin reuptake inhibitors).

SIGNS AND SYMPTOMS

• Fear, tension, apprehension due to alteration in neurotransmission
• Persistent worry
• Trouble concentrating
• Irritability and restlessness
• Tachycardia, palpitations, elevated blood pressure due to autonomic nervous
system stimulation
• Hyperventilation due to fear, elevated heart rate, and palpitations
• Sweating, tremors due to autonomic nervous system stimulation
• Sleep disturbance and fatigue due to alteration in neurotransmission
• Headache due to nervous system irritability and lack of sleep

TREATMENT

• Administer anxiolytics for acute management:
• Monitor for respiratory depression or decrease in blood pressure.
• Have benzodiazepine antagonist (flumazenil) on hand to reverse effect if
needed.
• Administer antidepressants:
• selective serotonin reuptake inhibitors—paroxetine
• selective serotonin and norepinephrine reuptake inhibitors—venlafaxine
• tricyclics
• Administer buspirone.
• Administer beta-blockers for symptom control.
• Psychotherapy.
• Cognitive-behavioral therapy.
• Relaxation techniques such as biofeedback.
• Desensitization—repeated exposures to graded doses of the object or situa-
tion that produces the anxiety.
• Group therapy.
• Family therapy.
• Emotive therapy.
• alprazolam, clonazepam, clorazepate, diazepam, lorazepam, oxazepam

NURSING DIAGNOSIS

• Sleep pattern disturbance
• Anxiety
• Fear
• Impaired social interaction
• Ineffective role performance

NURSING INTERVENTION

• Monitor medication intake.
• Discuss patient response to therapy.
• Monitor vital signs, watch for elevation in blood pressure with some
medications.
• Monitor weight; some medications are associated with changes in weight.
• Monitor sleep; ask patient about restful sleep during the night or difficulty
falling asleep.
• Teach patient to avoid alcohol intake with benzodiazepine use.

Mental Health

Alterations in mental health can be more difficult to diagnose because there is no
definitive laboratory test or radiological study with which to isolate the disorder.
Patients may initially seek treatment from primary care practitioners for a variety
of complaints: anxiety, insomnia, generalized aches, or other somatic complaints.
A thorough patient history should include past medical conditions, any prior
mental health conditions and their treatment course, current medications, social
history (including habits, work, exercise, and substance use), cultural background,
environmental factors, family history, and changes in libido, appetite, or sleep.
Physical examination focuses on the chief complaint from the patient’s point
of view and traces the progression of symptoms in a chronological order from
the time of onset. Mental status examination is completed focusing on the patient’s
appearance, activity and behavior, affect, mood, speech, content of thought, thought
process, cognition, judgment, and insight.
The majority of patients are cared for on an outpatient basis. Hospitalization
should be considered for those who:
• Are too sick to care for themselves.
• Present a serious threat to themselves or to others.
• Neglect to care for themselves.
• Are violent or have bizarre behavior.
• Have suicidal ideation.
• Have paranoid ideation.
• Have delusions.
• Have a marked impairment in judgment.
Patients with a coexisting mental health disorder are also admitted to a medical
surgical floor only if the medical condition warrants medical management. Caring
for the patient admitted with a medical or surgical condition does not preclude the
need to care for the patient’s depression or schizophrenia as well. Patients may also
develop medical conditions as a result of their mental health issues. Patients with
inadequate nutritional intake due to an eating disorder may have significant elec-
trolyte imbalances or cardiac dysfunction.