010-Psychiatric-Mental Health Nursing, 5th Edition-Sheila L. Videbeck-160547861X-Lippincott Willi

260UNIT 4 • NURSING PRACTICE FOR PSYCHIATRIC DISORDERSSeizures. Seizures are an infrequent side effect associatedwith antipsychotic medications. The incidence is 1%of people taking antipsychotics. The notable exception isclozapine, which has an incidence of 5%. Seizures may beassociated with high doses of the medication. Treatment isa lowered dosage or a different antipsychotic medication.Neuroleptic Malignant Syndrome. Neuroleptic malignantsyndrome (NMS) is a serious and frequently fatal conditionseen in those being treated with antipsychotic medications.It is characterized by muscle rigidity, high fever,increased muscle enzymes (particularly creatine phosphokinase),and leukocytosis (increased leukocytes). It is estimatedthat 0.1% to 1% of all clients taking antipsychoticsdevelop NMS. Any of the antipsychotic medications cancause NMS, which is treated by stopping the medication.The client’s ability to tolerate other antipsychotic medicationsafter NMS varies, but use of another antipsychoticappears possible in most instances.Agranulocytosis. Clozapine has the potentially fatal sideeffect of agranulocytosis (failure of the bone marrow toproduce adequate white blood cells). Agranulocytosisdevelops suddenly and is characterized by fever, malaise,ulcerative sore throat, and leukopenia. This side effect maynot be manifested immediately but can occur as long as18 to 24 weeks after the initiation of therapy. The drugmust be discontinued immediately. Clients taking this antipsychoticmust have weekly white blood cell counts forthe first 6 months of clozapine therapy and every 2 weeksthereafter. Clozapine is dispensed every 7 or 14 days only,and evidence of a white cell count above 3,500 cells/mm 3is required before a refill is furnished.Psychosocial TreatmentIn addition to pharmacologic treatment, many other modesof treatment can help the person with schizophrenia. Individualand group therapies, family therapy, family education,and social skills training can be instituted for clientsin both inpatient and community settings.Individual and group therapy sessions are often supportivein nature, giving the client an opportunity forsocial contact and meaningful relationships with otherpeople. Groups that focus on topics of concern such asmedication management, use of community supports, andfamily concerns also have been beneficial to clients withschizophrenia (Pfammatter, Junghan, & Brenner, 2006).Clients with schizophrenia can improve their social competencewith social skill training, which translates into moreeffective functioning in the community. Basic social skilltraining involves breaking complex social behavior intosimpler steps, practicing through role-playing, and applyingthe concepts in the community or real-world setting.Cognitive adaptation training using environmental supportsis designed to improve adaptive functioning in the homesetting. Individually tailored environmental supports suchas signs, calendars, hygiene supplies, and pill containers cuethe client to perform associated tasks (Velligan et al., 2006).Moriana, Alarcon, and Herruzo (2006) found that psychosocialskill training was more effective when carried outduring in-home visits in the client’s own environment ratherthan in an outpatient setting.A new therapy, cognitive enhancement therapy (CET),combines computer-based cognitive training with groupsessions that allow clients to practice and develop socialskills. This approach is designed to remediate or improvethe clients’ social and neurocognitive deficits, such asattention, memory, and information processing. The experientialexercises help the client to take the perspective ofanother person, rather than focus entirely on self. Positiveresults of CET include increased mental stamina, activerather than passive information processing, and spontaneousand appropriate negotiation of unrehearsed socialchallenges (Hogarty, Greenwald, & Eack, 2006).Family education and therapy are known to diminishthe negative effects of schizophrenia and reduce the relapserate (Penn, Waldheter, Perkins, Mueser, & Lieberman,2005). Although inclusion of the family is a factor thatimproves outcomes for the client, family involvementoften is neglected by health-care professionals. Familiesoften have a difficult time coping with the complexitiesand ramifications of the client’s illness. This creates stressamong family members that is not beneficial for the clientor family members. Family education helps to make familymembers part of the treatment team. See Chapter 3 fora discussion of the National Alliance for the Mentally IllFamily to Family Education course.In addition, family members can benefit from a supportiveenvironment that helps them cope with the many difficultiespresented when a loved one has schizophrenia.These concerns include continuing as a caregiver for thechild who is now an adult; worrying about who will carefor the client when the parents are gone; dealing with thesocial stigma of mental illness; and possibly facing financialproblems, marital discord, and social isolation. Such supportis available through the National Alliance for the MentallyIll and local support groups. The client’s health-careprovider can make referrals to meet specific family needs.APPLICATION OF THE NURSING PROCESSAssessmentSchizophrenia affects thought processes and content, perception,emotion, behavior, and social functioning; however,it affects each individual differently. The degree ofimpairment in both the acute or psychotic phase and thechronic or long-term phase varies greatly; thus, so do theneeds of and the nursing interventions for each affectedclient. The nurse must not make assumptions about theclient’s abilities or limitations based solely on the medicaldiagnosis of schizophrenia.For example, the nurse may care for a client in an acuteinpatient setting. The client may appear frightened, hearvoices (hallucinate), make no eye contact, and mumble constantly.The nurse would deal with the positive, or psychotic,