Caring for the Patient with Acute
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Caring for the patient with acute You may encounter patients with acute psychosis as a result of schizophrenia in any practice area. Understanding the patient’s experience and knowing how to respond are keys to a successful outcome. By Charles Alan Walker, PhD, RN In this article, we discuss how to recognize the event sequence that frequently takes place during a psychotic episode, measures to take when a patient with psychosis expe- riences anxiety, strategies to help patients with psychosis establish and maintain control of their behavior, how to monitor physical health in the patient with schizo- phrenia, effective communication tech- niques when a patient exhibits thought disturbances, and appropriate interventions to use when a patient expresses delusions or has hallucinations. What’s schizophrenia? Schizophrenic spectrum is a group of psychotic reactions in which the patient experiences loose association of thoughts, dulled or blunted affect, anhedonia, ambivalence, and impaired social relation- ships. Schizophrenia is characterized by ideas of reference, delusions, and hallucinations (see Common symptoms of schizophrenia). Many causative factors have been suggest- ed for this psychiatric disorder, including cortical atrophy, life stress, faulty family LAMY interactions, and low socioeconomic status. /A But prevailing notions about schizophrenia’s FOTOSTOCK etiology point to hereditary contributions of GE various genes, which predispose a person to A 40 Nursing made Incredibly Easy! May/June 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. 2.0 ANCC CONTACT HOURS psychosis Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. an increased number of and sensitivity to • level of everyday functioning in work dopamine-regulated neurons. and self-care markedly below expectation In the active phase of schizophrenia, • continuous disturbance of premorbid psychotic symptoms are prominent. The or acute symptoms lasting 6 months or more Diagnostic and Statistical Manual of Mental • schizoaffective, depressive, or bipolar Disorders, 5th edition, diagnostic criteria for disorder with psychotic features schizophrenia include two or more of the ruled out following: • the disturbance isn’t attributable to the • delusions physiologic effects of a substance or another • hallucinations medical condition. • disorganized speech Antipsychotic medications remain the • grossly disorganized behavior mainstay of treatment for psychotic disor- • negative symptoms such as apathy ders. Atypical antipsychotics, such as aripip- razole, olanzapine, and ziprasidone, have become the first line of therapy. These medi- Common symptoms of schizophrenia cations have a more favorable adverse reac- tion profile and they address both positive Symptom Definition Positive or and negative symptoms of schizophrenia. negative symptom Because schizophrenia is a chronic illness, Ambivalence Indecisiveness about a Negative patients require long-term integrated treat- course of action ment. For the majority of patients, the most Anhedonia Lack of pleasure in Negative effective treatment is a combination of anti- everyday pursuits psychotic medication and psychotherapy. Apathy Lack of motivation to Negative accomplish even the most Understanding the breakdown mundane tasks There are four stages of a schizophrenic Delusion A firmly fixed belief that Positive breakdown. During the first stage, patients can’t be corrected by logic experience a kind of euphoria with high Grandiose The belief that one has great Positive energy. They may feel quite good temporar- delusion power, prestige, or wealth ily as if they’re on a mission or quest and Hallucination A sensory-perceptual Positive their life has been given some greater mean- experience with no basis in ing. This phase usually lasts a few days dur- reality; often auditory, but may ing which the patient doesn’t get much sleep, be visual, tactile, or olfactory calls friends and family at all hours of the day Ideas of The irrational assumption Positive and night, and may be difficult to live with. reference that, when in the presence The second stage includes what are of others, one is the object termed ideas of reference—everything of their discussion or ridicule refers to the patient and there isn’t anything Loose association Thinking characterized by Positive that doesn’t have special and deep mean- speech in which focus shifts ing. There’s a subtle shift between the from one topic to another; if euphoric sense of purpose and the patient’s severe, speech may be belief that everything that’s happening has incoherent some personal significance. Words spoken Thought blocking The inability to complete a Negative on TV are specific messages to the patient, thought or finish a sentence; not general advertising. Little glances and this experience may be conversations between people on the street extremely frustrating/ aren’t to each other, but are secret codes to bewildering the patient. 42 Nursing made Incredibly Easy! May/June 2015 www.NursingMadeIncrediblyEasy.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. The third stage is associated with what’s known as the destructuring of perception. Events are either super strong or too weak for the patient to perceive, and there’s a A therapeutic, interpersonal breakdown in the sensory processing appa- relationship between nurse ratus. Have you ever seen the world through and patient helps the a kaleidoscope? People and places that were once predictable and familiar become disori- patient tolerate symptoms enting and unfamiliar; the world is on a tilt. when acutely ill and serves This is what happens to the patient experi- as a basis for further encing psychosis. In the fourth and final stage, patients interaction as the patient aren’t able to inhibit extraneous or irrelevant gets better. stimuli—everything comes flooding in on them. This is no longer a euphoric state, but a very frightening one. At this point in their breakdown, patients often exhibit full-blown The best approach to a patient whose delusions and hallucinations. Generally, psychosis appears to be increasing is to patients who experience such a break or reduce his or her anxiety. You can do this exacerbation of illness are hospitalized in by bringing the patient back to your reality. a community mental health center for a You might say, “I think I’m making you more short stay, usually averaging 5 to 7 days. anxious” or “Talking about this seems to Outpatient treatment is also recommended. make you more anxious.” For example, if a During this hospital stay, psychotropic patient says, “I’m Jesus Christ, I’m God”—a medications are administered and schizo- grandiose delusion—you shouldn’t respond phrenia will usually be brought under by interpreting that the delusion is a response control within 2 to 4 weeks. Measures will to the patient’s insecurity. Rather, you want be taken to reduce the patient’s anxiety and to respond to the process: the patient is get- care for the patient’s physical needs until ting more anxious, which is fueling the psy- he or she is well enough to assume these chosis. You might say, “I think right now responsibilities. A therapeutic, interpersonal you’re getting more anxious. Why don’t we relationship between nurse and patient helps stop this discussion and sit here quietly for a the patient tolerate symptoms when acutely minute” as opposed to “It sounds like what ill. The relationship also serves as a basis for you’re saying or feeling is...” further interaction as the patient gets better. There are times when sitting with the patient silently is the best response. You Reducing anxiety aren’t overstimulating the patient, but you’re Reducing the patient’s anxiety is one of the giving him or her a sense of security—the most important initial measures you can patient isn’t alone and he or she can rely on take. The patient having an acute psychotic your reality for a while. episode is intensely frightened. Fear is the To review, techniques that can help reduce prevailing problem in the initial phase of anxiety include sharing your reality, respond- treatment; the more intense the fear, the ing to the process rather than interpreting, more intense the psychotic symptoms. You and staying with the patient quietly. can assume that the more the patient is talk- ing through delusions, the more intense the Helping patients gain control hallucinations, the more frightened and In addition to reducing anxiety, you’ll anxious he or she is. want to help patients establish and maintain www.NursingMadeIncrediblyEasy.com May/June 2015 Nursing made Incredibly Easy! 43 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. control of their behavior. If you’re working You might say, “We know you may be terri- with a newly admitted patient experiencing bly frightened, but we want you to know psychosis, you need some capacity to relate that you’re safe here. These fears are symp- to that individual and these skills must be toms of your illness, and we’re going to pro- learned. You must learn to speak to the pa- tect you. We aren’t going to let you get out of tient’s concern without hemming him or her control if that should be a concern to you. in and without pressuring too much, yet And we would like you to warn us if you’re you have to set firm limits. concerned about getting out of control.” The symptoms of psychosis usually wax When you make that sort of unilateral state- and wane; that is, if the patient is having ment, the patient is often comforted. auditory hallucinations or ideas of reference, If patients sense, in the midst of their terror, the intensity of those symptoms—and the which is often inexpressible, that you under- patient’s capacity to distance him- or herself stand to some degree what they’re experienc- from them, control them, or resist them— ing, they’re often reassured. If patients fear probably varies throughout the day and day that they may lose control of their impulses— to day.