By F. Milok. Austin Peay State University.
The term ‘schizophrenia’ has been used to describe people who have been given a diagnosis of the illness from a mental health professional based on meeting the present criteria of the current medical model of schizophrenia discount 160 mg malegra dxt plus. As Schneider (2010 purchase malegra dxt plus 160 mg with visa, p18) states: “While I acknowledge the difficulties of using the word schizophrenia buy cheap malegra dxt plus 160mg on-line, our research is an attempt to change the meanings of this word by demonstrating the ability of people diagnosed with schizophrenia to make a significant contribution to knowledge about schizophrenia”. I refer to people with schizophrenia as “consumers” throughout the present study, to reflect the interaction between individuals and the health system. Whilst this reflects more politically correct terminology, the results of the present study indicate that the term “consumer” may not adequately describe the interaction between people with 5 schizophrenia and the health system, which in actuality is often entrenched with power imbalances in the favour of service providers(this interaction will be elaborated further in Chapter 7). It is acknowledged that some commentators have criticised use of the term “consumers” as a descriptor, as it implies that people with schizophrenia are aware that they have an illness and are thus, able to make treatment choices, which may not be the case amongst people who lack insight (i. Of note, there is a lack of consensus regarding the contributions of each of these risk factors and how they interact (Smith et al. The lifetime prevalence rate of schizophrenia has been estimated at approximately 0. Although these figures may appear modest, schizophrenia rates among the top ten causes of long- term disability in the world (Compton, 2007). The onset of schizophrenia symptoms typically occurs in adolescence and early adulthood (average age 25 years), although it can affect people at any age (Smith et al. The epidemiology for schizophrenia has undergone a major shift in the past decade (Beck et al. The prevailing view of the 1980s and 1990s was that schizophrenia occurs at similar rates in all populations around the world, irrespective of individual or group 6 characteristics such as gender and culture. This accepted notion rendered epidemiological studies seeking to identify risk factors for schizophrenia negligible as such studies would require heterogeneity in prevalence between groups and populations (Menezes, 2009). A recent renewed interest in the epidemiology of schizophrenia, especially in relation to incidence and outcomes, in conjunction with results from systematic reviews in the field have led to the replacement of received notions about schizophrenia with a more nuanced perspective. This systematic review yielded wide variation in the incidence rates of schizophrenia across populations, regions and groups. Namely, it was found that incidence rates vary considerably cross- culturally, with a fivefold variation observed between central estimates. Males also tend to develop schizophrenia earlier in life than females (Beck et al. Furthermore, it has been reported that males experience more severe symptoms, more negative symptoms, have less chance of recovery and have generally worse outcomes than females (Picchioni & Murray, 2007). The incidence of schizophrenia appears to be declining as it has recently been estimated at 0. Those born or residing in urban areas are reported to be at greater risk of developing schizophrenia than those born or residing in rural areas (Menezes, 2009). Migrants are additionally thought to be at greater risk of developing schizophrenia (Beck et al. Whilst the prevalence of schizophrenia in indigenous communities in Australia is unknown, elevated rates of hospitalisation and pervasive 7 disadvantage affecting communities suggest that the prevalence may be higher than in the wider community (Australian Institute of Health and Welfare, 2011). The outcomes for people with schizophrenia are varied and represent a topic of debate amongst researchers. Other researchers indicate that whilst variation exists in illness course and outcome amongst consumers, complete remission and return to pre-morbid status is rare (Sharif et al. It has been reported that about 60% of consumers will relapse more than once, but will return to pre-morbid levels of functioning in between episodes, whereas the remainder are likely to experience multiple episodes with residual symptoms in between (Birchwood & Jackson, 2001). Positively, the proportion of consumers whose illnesses improved substantially is thought to have increased significantly after the mid 1950s, coinciding with the introduction of antipsychotic medication (Hegarty et al. Current literature, based on a series of investigations conducted by the World Health Organisation, states that the prognosis is better for consumers living in lower and middle income countries compared to those living in wealthy countries, however, conflicting research exists (Menezes, 2009). Poorer outcomes have been associated with insidious onset and delayed initial treatment of the illness, social isolation, a strong family history, living in industrialised countries, male gender and substance misuse (Smith et al. Co-morbid substance use amongst people with schizophrenia is widespread (Cuffel, 1996). Estimates of the prevalence of alcohol and drug 8 misuse amongst people with schizophrenia vary, but it has been reported as three times higher than that observed in the general population (Green, 2005). It is likely that the true prevalence of substance misuse in this population may be higher than self-report by consumers might indicate (McPhillips et al. Compared to the general population, schizophrenia is associated with increased mortality. It is estimated that people with schizophrenia have a two to three-fold increased mortality risk compared with the general population, which may have worsened in recent decades (McGrath & Susser, 2009). There is an increased probability of people with schizophrenia dying prematurely, with suicide posited as a major contributor to this discrepancy (Beck et al. Various studies have also indicated that people with schizophrenia have elevated mortality across a wide array of illnesses (Beck et al. Research regarding the prognoses for people with schizophrenia must be treated with caution, however, as factors such as institutionalisation, socialisation into the consumer or patient role, lack of rehabilitation resources, reduced economic opportunities, reduced social status, adverse side effects of medication, lack of staff expectations and loss of hope have been found to impact on, or mimic, the chronicity of the illness (Anthony, 1993; Harding, Zubin & Strauss, 1992). Additional moderating variables on 9 the recovery process that have been proposed include biological and psychosocial therapies, social relationships, cultural determinants, illness behaviour, coping strategies, the consumer’s developmental stage, stigma and community attitudes towards mentally ill consumers (McGorry, 1992). A radical perspective in relation to the chronicity of schizophrenia is that what was once thought to have been a result of the illness, is rather, caused by the way consumers are treated by the health system and by society (Anthony, 1993). An acute episode, or the active phase, refers to a period of extremely intense psychotic symptoms. It may start suddenly, or develop more gradually over a period of several months (McEvoy et al. The active phase is usually preceded by a prodromal phase, in which functioning deteriorates and low-grade positive and negative symptoms present (McGorry, 1992). Stabilisation (similar to remission) after an acute episode usually occurs once the intense psychotic symptoms are controlled by medication. During stabilisation there are usually periods of troublesome but much less severe symptoms. The maintenance phase occurs between acute episodes and refers to the longer term recovery phase of the illness. During maintenance, the most intense symptoms of the illness are controlled by medication; however, there may still be some milder, persistent symptoms (McEvoy et al. Of note, there is considerable variability in the clinical course of schizophrenia, which means that consumers frequently move in and out of recovery (Liberman & Kopelowicz, 2005). Consumers 10 who have achieved stabilisation and maintenance would be expected to relapse, as a result of medication non-adherence, substance use or significant stress, for example. Chronic in nature, schizophrenia is considered one of the most severe and disabling mental illnesses which significantly interferes with functioning in various domains, affecting approximately 0. Schizophrenia symptoms are consistently described by a medical model of clusters of positive, negative and cognitive symptoms. Of significant relevance to the present study, it has been estimated that 60% of individuals with schizophrenia will experience symptom relapse more than once but will return to premorbid levels of functioning in between episodes.
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Because catheters are a major factor in causing urinary tract infection generic malegra dxt plus 160 mg visa, the patient is observed for fever and cloudy urine buy generic malegra dxt plus 160 mg line. The urinary catheter is usually removed if the patient has a stable cardiovascular system and if no diuresis order malegra dxt plus 160mg overnight delivery, sepsis, or voiding dysfunction existed before the onset of coma. An intermittent catheterization program may be initiated to ensure complete emptying of the bladder at intervals, if indicated. An external catheter (condom catheter) for the male patient and absorbent pads for the female patient can be used for unconscious patients who can urinate spontaneously although involuntarily. As soon as consciousness is regained, a bladder-training program is initiated (Hickey, 2003). The incontinent patient is monitored frequently for skin irritation and skin breakdown. There is a risk for diarrhea from infection, antibiotics, and hyperosmolar fluids. Commercial fecal collection bags are available for patients with fecal incontinence. The nurse monitors the number and consistency of bowel movements and performs a rectal examination for signs of fecal impaction. Efforts are made to restore the sense of daily rhythm by maintaining usual day and night patterns for activity and sleep. The nurse touches and talks to the patient and encourages family members and friends to do so. Communication is extremely important and includes touching the patient and spending enough time with the patient to become sensitive to his or her needs. Family members can read to the patient from a favorite book and may suggest radio and television programs that the patient previously enjoyed as a means of enriching the environment and providing familiar input (Hickey, 2003). When arousing from coma, many patients experience a period of agitation, indicating that they are becoming more aware of their surroundings but still cannot react or communicate in an appropriate fashion. Although this is disturbing for many family members, it is actually a positive clinical sign. At this time, it is necessary to minimize stimulation by limiting background noises, having only one person speak to the patient at a time, giving the patient a longer period of time to respond, and allowing for frequent rest or quiet times. After the patient has regained consciousness, videotaped family or social events may assist the patient in recognizing family and friends and allow him or her to experience missed events. Various programs of structured sensory stimulation for patients with brain injury have been developed to improve outcomes. Although these are controversial programs with inconsistent results, some research supports the concept of providing structured stimulation (Davis & Gimenez, 2003). If the patient has significant residual deficits, the family may require considerable time, assistance, and support to come to terms with these changes. Families may benefit from participation in support groups offered through the hospital, rehabilitation facility, or community organizations. The patient with a neurologic disorder is often pronounced brain dead before the heart stops beating. The term brain death describes irreversible loss of all functions of the entire brain, including the brain stem (Booth, Boone, Tomlinson, et al. The term may be misleading to the family because, although brain function has ceased, the patient appears to be alive, with the heart rate and blood pressure sustained by vasoactive medications and breathing continued by mechanical ventilation. When discussing a patient who is brain dead with family members, it is important to provide accurate, timely, understandable, and consistent information (Henneman & Karras, 2004). The longer the period of unconsciousness, the greater the risk for pulmonary complications. Vital signs and respiratory function are monitored closely to detect any signs of respiratory failure or distress. Total blood count and arterial blood gas measurements are assessed to determine whether there are adequate red blood cells to carry oxygen and whether ventilation is effective. Chest physiotherapy and suctioning are initiated to prevent respiratory complications such as pneumonia. If pneumonia develops, cultures are obtained to identify the organism so that appropriate antibiotics can be administered. Factors that contribute to impaired skin integrity (eg, incontinence, inadequate dietary intake, pressure on bony prominences, edema) are addressed. Care is taken to prevent bacterial contamination of pressure ulcers, which may lead to sepsis and septic shock. Prophylaxis such as subcutaneous heparin or low-molecular-weight heparin (Fragmin, Orgaran) should be prescribed if not contraindicated (Kurtoglu, Yanar, Bilsel, et al. Thigh-high elastic compression stockings or pneumatic compression devices should also be prescribed to reduce the risk for clot formation. Nursing Interventions Maintaining a Patent Airway The patency of the airway is assessed. The patient is hyperoxygenated before and after suctioning to maintain adequate oxygenation. The lung fields are auscultated at least every 8 hours to determine the presence of adventitious sounds or any areas of congestion. Elevating the head of the bed may aid in clearing secretions and improve venous drainage of the brain. Achieving an Adequate Breathing Pattern The patient must be monitored constantly for respiratory irregularities. Increased pressure on the frontal lobes or deep midline structures may result in Cheyne-Stokes respirations, whereas pressure in the midbrain can cause hyperventilation. If the lower portion of the brain stem (the pons and medulla) is involved, respirations become irregular and eventually cease. Repeated assessments of the patient are made (sometimes minute by minute) so that improvement or deterioration may be noted immediately. The head is kept in a neutral (midline) position, maintained with the use of a cervical collar if necessary, to promote venous drainage. Elevation of the head is maintained at 0 to 60 degrees to aid in venous drainage unless otherwise prescribed (Fan, 2004). When moving or being turned in bed, the patient can be instructed to exhale (which opens the glottis) to avoid the Valsalva maneuver. Before suctioning, the patient should be preoxygenated and briefly hyperventilated using 100% oxygen on the ventilator (Hickey, 2003). Corticosteroids may be used to reduce cerebral edema (except when it results from trauma), and fluids may be restricted (Brain Trauma Foundation, 2003). Skin turgor, mucous membranes, urine output, and serum and urine osmolality are monitored to assess fluid status. For the patient receiving mannitol, the nurse observes for the possible development of heart failure and pulmonary edema, because the intent of treatment is to promote a shift of fluid from the intracellular compartment to the intravascular system, thus controlling cerebral edema. For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status.
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