# data[].attributes.body
Risk for impaired verbal communication r/t manic phase of bipolar disorder and hallucinations, racing thoughts, and delusion.

# data[].attributes.body
Clozapine [antipsychotics]: decrease in - and + symptoms.

Haloperidol [antipsychotic]: decrease in hallucinations, delusions, agitation, hostility, and insomnia

Lurasidone [antipsychotics]: decrease in schizophrenia symptoms & depressive episodes in bipolar disorder.

Lorazepam [antianxiety agent]: increase sense of well being.

Lamotrigine [anticonvulsants]: decrease seizure activity and delay mood episodes.

Topiramate [anticonvulsant/mood stabilizer]: remission of manic symptoms.

Fluticasone [anti inflammatory steroidal]: manage of asthma symptoms.

Levothyroxine [hormones]: resolve hypothyroidism symptoms.

Oxybutynin [anticholinergics]: relief of bladder spasm and associated symptoms.

Pantoprazole [anti ulcer agent]: decrease in abd pain, heartburn, and gastric irritation.

Salbutamol [bronchodilators]: prevent/relief of bronchospasm.

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Disturbed auditory/visual sensory perception r/t manic phase of bipolar disorder as evidence by schizoaffective traits, sleep deprivation, hallucinations, delusion and confusion.

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References:

Dumpit, I. B., shija, M., & R, J. (2024, April 29). 6 schizophrenia nursing care plans. Nurseslabs. https://nurseslabs.com/schizophrenia-nursing-care-plans/

Kenneth, A., & Mensah, B. (2024, April 29). Insomnia & sleep deprivation nursing care plan and management. Nurseslabs. https://nurseslabs.com/insomnia/#h-assessing-the-client-s-sleep-history

Makic, M., & Martinez-Kratz, M. (2023). Ackley and Ladwig’s Nursing Diagnosis Handbook An Evidence-Based Guide to Planning Care 13th ed. Elsevier Inc.

Wagner, M. (2023, January 9). Schizophrenia nursing diagnosis & care plan. NurseTogether. https://www.nursetogether.com/schizophrenia-nursing-diagnosis-care-plan/

Wy, T. J. P., & Saadabadi, A. (2023, March 27). Schizoaffective disorder. StatPearls - NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK541012/#article-28758.r3

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Impaired Sleep Pattern related to medication side effects and psychotic symptoms as evidenced by increased sleep duration and altered sleep-wake cycle.

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The pathophysiology of schizoaffective traits involves complex interactions between genetic, neurobiological, and environmental factors. Dysregulation of neurotransmitter systems, particularly dopamine, serotonin, and glutamate, is believed to play a significant role. Structural abnormalities in brain regions involved in mood regulation, such as the prefrontal cortex and limbic system, may also contribute to the pathophysiology of schizoaffective traits.

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Schizoaffective traits refer to a mental health condition characterized by a combination of symptoms seen in schizophrenia, such as hallucinations or delusions, and mood disorder symptoms, including mania or depression. Individuals with schizoaffective traits experience periods of disturbed thoughts, mood disturbances, and changes in behavior, which can significantly impact their daily functioning and quality of life. Schizoaffective disorder usually begins in the late teen years or early adulthood, often between ages 16 and 30. It seems to happen slightly more often in people assigned female at birth. Some studies show that as high as 50% of people with schizophrenia also have comorbid depression.

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The etiology of schizoaffective traits is multifactorial. Genetic predisposition is a significant risk factor, with individuals having a family history of schizophrenia, bipolar disorder, or major depressive disorder being more susceptible. Environmental stressors, such as trauma, substance abuse, and chronic stress, can trigger the onset or exacerbation of symptoms in vulnerable individuals. Additionally, disruptions in early brain development and neurochemical imbalances may contribute to the development of schizoaffective traits.

In the case of the 42-year-old female patient, her presentation with racing thoughts, delusions, auditory hallucinations, and mood disturbances, along with a history of bipolar disorder I, depression, and anxiety disorder, aligns with a diagnosis of schizoaffective traits. The current treatment regimen includes clozapine, lamotrigine, lorazepam, lurasidone, haloperidol, and other medications aimed at managing psychotic symptoms, stabilizing mood, and addressing comorbidities such as diabetes mellitus type 2 and hypothyroidism. Close monitoring and ongoing support are crucial for optimizing the patient's well-being and functioning. The treatment of schizoaffective disorder typically involves both pharmacotherapy and psychotherapy, (Wy & Saadabadi, 2023).

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Delusions: False, sometimes strange beliefs that the person refuses to give up, even when they get the facts.

·   Depression symptoms: Feeling empty, sad, or worthless, having a poor appetite, losing, or gaining weight, or sleeping too much or too little.

·   Hallucinations: Sensing things that are not real, such as hearing voices

·   Mania or sudden, out-of-character jumps in energy levels or happiness, racing thoughts, talking more or faster than usual, a decreased need for sleep.

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involve faulty functioning of neurotransmitter systems, particularly dopamine, serotonin, and norepinephrine. During manic phases, there is an increase in dopamine activity, leading to elevated mood, hyperactivity, and impulsivity. On the other hand, depressive episodes involve decreased activity in these neurotransmitter systems, resulting in feelings of sadness, fatigue, and decreased motivation. Additionally, abnormalities in brain structure and function, including alterations in the prefrontal cortex and amygdala, contribute to the manifestation of symptoms. Genetic predisposition, environmental factors, and stressors also play significant roles in the development and progression of bipolar I disorder. Most people are in their teens or early 20s when symptoms of bipolar disorder first appear. It is a lifelong condition that heavily relies on consistent treatment.

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Abnormally upbeat, jumpy, or wired

·        Increased activity, energy, or agitation

·        Exaggerated sense of well-being and self-confidence (euphoria)

·        Decreased need for sleep.

·        Unusual talkativeness

·        Racing thoughts

·        Distractibility

·        Poor decision-making

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depressed mood, such as feeling sad, empty, hopeless, or tearful (in children and teens, depressed mood can appear as irritability)

Marked loss of interest or feeling no pleasure in all — or all — activities

Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected can be a sign of depression)

Either insomnia or sleeping too much

Either restlessness or slowed behavior

Fatigue or loss of energy

Feelings of worthlessness or excessive or inappropriate guilt

Decreased ability to think or concentrate, or indecisiveness.

Thinking about, planning, or attempting suicide

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Complications associated with schizoaffective disorder bipolar type.

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Complications associated with schizoaffective disorder bipolar type.

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Problems related to drug and alcohol use.

·        Suicide or suicide attempts.

·        Legal or financial problems

·        Damaged relationships

·        Poor work or school performance

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Other mental health conditions that need to be treated along with schizoaffective disorder bipolar type:

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Other mental health conditions that need to be treated along with schizoaffective disorder bipolar type:

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Anxiety disorders

Depression disorders

Alcohol or drug problems

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There is no sure way to prevent mental illness. However, getting treatment at the earliest sign of a mental health disorder can help prevent schizoaffective bipolar disorder or other mental health conditions from worsening.

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Antipsychotics: Used to target psychosis and aggressive behavior in schizoaffective disorder. Other symptoms include delusions, hallucinations, negative symptoms, disorganized speech, and behavior.

·        Mood-stabilizers: Patients who have periods of distractibility, indiscretion, grandiosity, a flight of ideas, increased goal-directed activity, decreased need for sleep, and who are hyper-verbal fall under the bipolar-specifier for schizoaffective disorder.

·        Antidepressants: Used to target depressive symptoms in schizoaffective disorder.

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·      Individual therapy: This type of treatment aims to normalize thought processes and better help the patient understand the disorder and reduce symptoms.

·        Family and/or group therapy: Family involvement is crucial in the treatment of this schizoaffective disorder.

·        ECT (Electroconvulsive Therapy) is usually a last resort treatment. However, not only has it been used in urgent cases and treatment resistance, but it should also merit consideration in augmentation of current pharmacotherapy

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Client was admitted with the diagnosis of schizoaffective traits

Client has 20 year history of bi polar disorder

Client has history of wandering into neighbour's house before admission

Client is experiencing auditory hallucinations of God and Jesus

Client is experiencing racing thoughts and delusion

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1. Use consistent staff as they will be better adjusted to client's behaviour and communication status

Having the same staff when it allows will let the staff and client create better relationships and build trust. Having the same staff can also help the client remain comfortable while in care.

2. Be mindful of word choice when communicating to avoid offending or judging the client

Being mindful of word choice can minimize offending or judging the client. If the client feels judged or offended this can hinder the recovery process as they may not trust the nurse anymore.

3. Validate client's feelings and focus on their strengths to maintain client's confidence

Validating the client's feelings can help them feel like a normal person and not just a patient. Focusing on their strengths can aid in the healing process and they may not get deterred by their weaknesses.

4. Do not pretend to understand the client's message when it is unclear as it may impact client and nurse safety

Misunderstanding and pretending to understand the message can discourage the client from communicating with the caregivers. Misinterpreting the message can impact client safety and health care professional safety.

5. Give antipsychotic medication as scheduled to decrease manic phase symptoms to improve thought process and communication

giving medication on a schedule will allow for the medication to maintain the same level and not drop, which may affect the client's manic phase recovery.

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Verbal communication is improved by the client taking routine antipsychotic medications [haloperidol, lurasidone, clozapine] to minimize symptoms [racing thoughts, delusion, auditory hallucinations] of manic episode of bi polar disorder.

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Cues:

•Admitted with schizoaffective traits.

•20-year history of bipolar disorder.

• Patient experienced auditory hallucinations of Jesus and God talking to her.

•Patient is experiencing confusion; wandered to the neighbour's house prior to admission.

•Patient’s mother stated she noticed a decline in the patient’s ability to perform ADLs, decreased appetite and decreased sleep.

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The patient will state that the “thoughts” are less intense and less frequent with the help of medications and nursing interventions.

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1. Encourage the client to engage in reality-based activities such as card playing, writing, drawing, doing simple arts and crafts, or listening to music.
Redirecting the client’s energies to acceptable activities can decrease the possibility of acting on hallucinations and help distract from voices. The nurse should remember that the activity must be within the client’s functioning level. Some activities to consider are drawing, reading, listening to music, or walking. Keeping the client focused on reality-based activities is important in helping them cope with these symptoms (Madick, 2022)

2.    Accept the fact that the voices are real to the client but explain that you do not hear the voices. Refer to the voices as “your voices” or “voices that you hear”.
Validating that your reality does not include voices can help the client doubt the validity of his or her voice. Do not argue with the hallucinations or deluded observations of the client. Instead, explain to the client that you each have your own perceptions of the world; do not focus on correcting their negative thoughts or encouraging their distorted reality (Smith & Bressler, 2022).

3. Keep to simple, basic, reality-based topics of conversation. Help the client focus on one idea at a time.
The client’s thinking might be confused and disorganized; this intervention helps the client focus and comprehend reality-based issues. The client may also show thought blocking, in which long pauses occur before they answer a question. The client has little insight into their problems, therefore, reinforcing reality is necessary (Frankenburg & Xiong, 2021)

4.  Administer Medications as prescribed by HCP and Provide Pharmacologic Support.

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Increased sleep: The patient reports an increase in sleep, which may indicate disturbances in her sleep pattern.

· Altered sleep-wake cycle: Patient's admission note mentions confusion and wandering behavior during the night, indicating disruptions in the normal sleep-wake cycle.

· Psychotic symptoms: Auditory hallucinations and delusions, such as believing in a romantic relationship with Jesus Christ, can disrupt sleep and lead to impaired sleep patterns.

· Medication side effects: Certain medications, such as clozapine and lorazepam, can cause sedation and impact sleep quality.

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The patient will achieve a regular sleep pattern, characterized by adequate duration and quality of sleep, within one week.

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1. Monitor and assess sleep patterns: Regular monitoring of the patient's sleep-wake cycle will help identify patterns of sleep disturbance and guide interventions.

·  Monitoring sleep patterns allows for timely identification of any changes or improvements, facilitating appropriate interventions.

2. Collaborate with Pt’s inter-professional healthcare team to adjust medication timing: Coordinate with the team to optimize the timing of medications such as clozapine and lorazepam to minimize sedative effects during the night and promote better sleep quality.

·  Adjusting medication timing can help minimize sedative effects during the night, promoting better sleep quality without compromising therapeutic efficacy.

3. Implement sleep hygiene measures: Encourage the patient to maintain a consistent sleep schedule, avoid stimulating activities before bedtime, and create a comfortable sleep environment to facilitate relaxation and improve sleep quality. (Porwal et al., 2021)

·  Implementing sleep hygiene measures creates an environment conducive to sleep, enhancing the patient's ability to achieve restorative sleep.

4. Provide education on relaxation techniques: Teach the patient relaxation techniques such as deep breathing exercises, progressive muscle relaxation, or guided imagery to promote relaxation and reduce anxiety, which can contribute to improved sleep patterns.

·  Teaching relaxation techniques empowers the patient to manage anxiety and stress, promoting relaxation and facilitating sleep initiation and maintenance.

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Additional References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, DSM-5. (5th ed.). Washington, DC: APA

Centre of Addiction and Mental Health. (n.d.). Psychosis. https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/psychosis

Halpepe, K. (n.d.). Clozapine Monitoring [Figure].

Kunyk, D., Peternelj-Taylor, C and Austin, W. (2023). Psychiatric and mental health nursing for Canadian practice. 5th edition. Wolters Kluwer.

Nuguru, S. P., Rachakonda, S., Sripathi, S., Khan, M. I., Patel, N., & Meda, R. T. (2022). Hypothyroidism and Depression: A Narrative Review. Curēus (Palo Alto, CA), 14(8), e28201–e28201. https://doi.org/10.7759/cureus.28201

Osser, D. N. (2022). Mania With Psychosis vs Schizophrenia vs Schizoaffective Disorder, Bipolar Type. The Psychiatric Times, 39(1), 26.

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Schizoaffective disorder signs & symptoms present:

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Schizoaffective disorder signs & symptoms present:

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S&S schizophrenia + mood disorder per pt’s Hx Dx (bipolar and depression); based on current findings, client recently experienced manic episodes with psychosis which indicate a schizoaffective disorder bipolar type (Osser, 2022).

Psychosis which is a primary symptom of schizophrenia and mood disorder based on a full affect demonstrated by the pt with a mood change from being sad to elated from the start to the end of shift is a concurrent occurrence and monitor potential alternating symptoms.

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Positive schizophrenia signs & symptoms present:

# data[].attributes.subject
Positive schizophrenia signs & symptoms present:

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Hallucinations:

auditory: pt. stated unconsistent hearing a voiced of God and a choir singing; Jesus talking to her while performing her ADLs “don’t give up”;

command; pt. states following auditory hallucinations telling her to go on walks

Delusions:

erotomania, pt. stated being in a romantic relationship with Jesus Christ;

mood-congruent delusion during manic episode with racing thoughts about heaven being on top of a mountain;

reference, pt. interpreted male patients leaving the dining room as “Jesus leaving her”.

control, per command hallucinations with the belief of auditory hallucinations controlling her behaviour

guilt, verbalized self-blame over the reference of “Jesus leaving her”.

Anxiety/agitation:

difficulty concentrating and rationalized by pt. by “thoughts get blocked”, which may indicate thought blocking in assessing for thought process & hesitant to engage in conversation, however memory is intact;

crying noted by the pt. on the belief that Jesus left her; self-reported “some anxiety”

Unorganized behaviour:

confusion Hx before admission and going into neighbour’s house while listening to meditation music;

avoided eye contact except when expressing feelings;

guarding position when asked how the patient was hesitant to talk in a conversation

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Strengths & Potential positive schizophrenia symptoms to monitor:

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Strengths & Potential positive schizophrenia symptoms to monitor:

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Organized speech: although clear and logical per last MSE, monitor coherence to signify prevention of worsening of schizoaffective traits.

Paranoid schizophrenia: even that auditory hallucinations are present, monitor auditory command hallucinations with the potential of self-harm to a severe extent of paranoia or any persecutory form of delusion.

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Negative schizophrenia signs & symptoms present:

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Negative schizophrenia signs & symptoms present:

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Slow or soft speech: delayed response to questions, monitor absence of speech (mutism);

Flat affect: pt. stated mood as “7/10” with 10 being full of happiness with an observed sad facial expression when asked at the time of interview early in shift.

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Strengths & Potential negative schizophrenia symptoms to monitor:

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Strengths & Potential negative schizophrenia symptoms to monitor:

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Catatonic schizophrenia: slow motor activity noted when walking; monitor any immobility with muscle rigidity, staring, disorientation including lacking responsiveness;

Pt. demonstrates partial insight with seeking treatment for self-reported symptoms of spiritual distress but does not understand that symptoms of auditory command hallucinations are not real; pt. is compliant with medication.

Anhedonia: inability to feel pleasure from self-engaging activities observed from pt: coloring, reading and watching TV

Apathy: consistent inability to respond emotionally as appropriately

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Outlined Potential Risk Factors – Depression

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Outlined Potential Risk Factors – Depression

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Family Hx

Diathesis stress concept to genetic predisposition

Hormonal changes (endocrine)

Alcohol/substance abuse

Chronic illness (medical) or psychiatric comorbidities r/t neurochemical dysregulation

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Outlined Potential Risk Factors – Bipolar

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Outlined Potential Risk Factors – Bipolar

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Neurochemical dysregulation

Genetic predisposition

Brain lesions & r/t neuroanatomy

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Outlined Potential Risk Factors – Schizophrenia

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Outlined Potential Risk Factors – Schizophrenia

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Neurochemical chemistry alteration

Genetic predisposition & family history

Substance abuse including alcohol

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- Depression S&S demonstrated by pt (slowed psychomotor when walking; feeling hopeless and states relying on auditory command hallucinations to motivate performing her ADLs)

- Mania S&S

Elated euphoric affect observed at end of shift (MSE);

Racing thoughts expressed by pt about auditory hallucinations and mood-dependent delusions about heaven being on top of a mountain before admission;

Inability and decreased appetite and sleep before admission;

Unorganized thinking with wandering into neighbour’s house then listened to meditation music; Hx of wandering with Dx bipolar type 1.

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Potential bipolar signs & symptoms to monitor:

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Potential bipolar signs & symptoms to monitor:

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Depression symptoms

Anhedonia (inability to feel pleasure);

Significant unintentional wt’ loss and loss of energy

Mania symptoms

Prone to agitation, irritation or distraction (continue assessing of safety risk for any changes);

Flight of ideas with assessing thought content & rapid rate of speech (subsequent MSE)

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Diagnostics; Bipolar S&S (either depressive/manic phases) may be evaluated and monitored through:

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Diagnostics; Bipolar S&S (either depressive/manic phases) may be evaluated and monitored through:

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- Performing subsequent MSE, mental status examination

- Focused mood disorder questionnaire (15-question via self-reporting) to examine altered mood

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Diagnostics via rule/out with medical history comorbidities r/t psychiatric history & Rx

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Diagnostics via rule/out with medical history comorbidities r/t psychiatric history & Rx

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- Hypothyroidism r/t mood disorders; check T4(Rx)/T3 in bloodwork, comorbid with depression (Nuguru et al., 2022)

- DM2; check BGM which may affect neurological status especially if hypoglycemic as evidenced by lack of appetite

- Clozapine monitoring for agranulocytosis (low neutrophils & WBC, high Temp) & myocarditis (troponin I, HsCRP)

(obtain baseline VS, labs; daily VS/assess S&S infection, myocarditis/review labs; weekly bloodwork) (Halpepe, n.d.)

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r/t physician decreased atypical anti-psychotics clozapine dose 25mg → 12.5mg (1mo. before admission)