Nursing Care of the Patient with Schizophrenia

and Other Psychotic Disorders

Denise Coe RN MSN HNC
What is Schizophrenia?
A disorder of the brain
Combination of:
Disordered thinking
Perceptual disturbances
Behavioral abnormalities
Affective disruptions
Impaired social competency

Etiologies
Uncertain-multiple etiologies:
Genetic?
Infection?
Birth or pregnancy complications?
Neuroanatomical theories?
A lesion in the limbic system?
Dopamine theory?

Risk Factors
Risk is greater if:
Single
from and industrialized nation
lives in a lower socio-economic class
lives in a urban center
is a product of a difficult labor and delivery
STRESS- recently experienced stressful events. ( increased cortisol
effects on cells in hippocampus).

Risk Factors
Social causation-
May be due to more stressful life situations in lower classes, less social
support?
Downward Drift Theory- as the disease progresses patient has greater
difficulty maintaining stable job and relationship.

Risk Factors
Stressful life event
Patients report a vulnerability to stress
Heightened sensitivity to the environment
Less able to screen out sounds, and stimuli.

What is Schizophrenia?
A type of psychosis
What is psychosis?
A state in which a person is unable to comprehend reality and has trouble
communicating to others.
History of schizophrenia
Emil Kraeplin, a European doctor, first described it in 1896.
History…..
In 1911 Dr Eugene Bleuler, from Europe, identified the behaviors typical of people with
schizophrenia.
He renamed it-schizophrenia- meaning “splitting of the mind”. The patient is split off
from reality, not a split personality.

History….
The four A’s of Bleuler:
Affect- the feelings reflected on our faces, in our expressions, and
by our demeanor or behavior.
 History
Associations

Autism
History….
Ambivalence experiences strong positive and negative feelings at the same
time; hard to make any decisions.

DSM-IV-TR Criteria

A.Characteristic Symptoms: Two or more of the following, each

present for a significant portion of the time during a I-month
period :
Delusions
Hallucinations
Disorganized speech
Grossly disorganized behavior
Negative Symptoms

Nature of the Disorder

The person has trouble thinking clearly, knowing what is real,
managing feelings, making decisions, and relating to others.
Phases of Onset
Phase 1- The Schizoid personality
a person sometimes described as a loner, indifferent to social
relationships and having a limited range of emotional
experience and expression.

Phases
Phase 2-The Prodromal phase
Begin to socially isolate
Have difficulty in role functioning
Odd behavior
Neglect of personal hygiene and grooming
Different affect
Changes in communication
Bizarre ideas
Lack of initiative
Phases…..
Schizophrenia-active disease See DSM IV TR.

DSM-IV-TR Criteria

A.Characteristic Symptoms: Two or more of the following, each

present for a significant portion of the time during a I-month
period :
Delusions
Hallucinations
Disorganized speech
Grossly disorganized behavior
Negative Symptoms

Phases…..
Phase4- Residual impairment- often increases between episode
A return to full premorbid functioning is not usual

Types of Schizophrenia and Other Psychotic

Disorders
Disorganized-Behavior very regressed and primitive.
Catatonic-marked abnormalities in motor behavior.
Stupor or excitement
Waxy flexibility
 Types…
Paranoid-characterized mainly by the presence of delusions of
persecution or grandeur related to a single theme.
Types…
Undifferentiated- Symptoms can not be classified
Residual-
Other Psychotic Disorders..
Schizoaffective-
Schizophrenic behaviors with a strong element of symptoms of
mood disorder
Other Psychotic Disorders
Brief psychotic disorder-sudden onset of psychosis usually following a
severe psychosocial stressor, with full return to normal.
Schizophreniform-duration is shorter but same symptoms.
Delusional disorder-presence of one or more non bizarre delusions.
Behavior not bizarre.
Other Psychotic Disorders
Psychotic disorder that develops due to a general medical
condition
Substance induced psychotic disorder
Negative and Positive Symptoms
They do not mean good and bad
Positive –added or excessive behaviors that are not normally seen
in mentally well persons
Negative-the loss of normal function that is normally seen in
mentally well persons
The negative symptoms less affected by medications and lead to
greater impairment
Characteristics of Schizophrenia
Cognitive
Delusions- false personal beliefs that are inconsistent with the person's
intelligence or background. The person holds firm to them despite
proof that the thought is false or irrational.
Types of delusions:
Persecution -most common.
Types of Delusions
Delusions- Table 14.3 of text
Grandiose
Jealous
Somatic delusions
Delusion of reference
Delusion of control or influence
Nihilistic delusion

Characteristics
Cognitive
Religiosity
Disorganized thinking
Looseness of associations
Concrete thinking
Impaired ability to solve problems
Memory deficits
“Magical thinking”
Neologisms
Clang Associations
Characteristics
Cognitive
Word salad
Circumstantiality
Tangentiality
Mutism
Preseveration
Perceptual Characteristics
Hallucinations
Auditory-Most common type
Usually voices, but can be noises.
Command hallucinations- must assess
Visual
Tactile
Gustatory
Olfactory

Perceptual Characteristics
Impaired Sensory Filtering
Affective Characteristics
Affect
Describes the behavior associated with a person’s feeling state or emotional
tone.
Descriptions of affect include:
Inappropriate affect
Bland or Flat affect
Apathy
Anhedonia
Overreactive affect
Behavioral Characteristics
Social Characteristics
Impaired interpersonal functioning
Social isolation-aloof
Emotional detachment
Poor personal appearance
Inadequate social skills

Concomitant Disorders
Dual diagnosis simultaneous substance abuse disorder
Both must be treated
Activity
Separate into groups of four. Read the Scenario and define a goal
or outcome for the nursing diagnosis. Write the interventions to
achieve that goal. Each person write an intervention, something
you would do to work toward that goal. Each one will write the
intervention and when time is up we will share.

Activity1
Read the case study and the nursing diagnosis. As a group, discuss and
decide on the nursing goal related to that nursing diagnosis. Write that
goal on the paper, and then each person take a turn writing an intervention
you would try in order to achieve that goal. When we are through we will
discuss the interventions.
Nsg diagnosis-Disturbed sensory perception: auditory hallucinations

Activity 1
Nsg diagnosis-Disturbed sensory perception: auditory
hallucinations related to panic anxiety, extreme loneliness,
and withdrawal into self evidenced by inappropriate responses,
and disordered thoughts.

Activity 2
Read the case study and the nursing diagnosis. As a group, discuss and
decide on the nursing goal related to that nursing diagnosis. Write that
goal on the paper, and then each person take a turn writing an intervention
you would try in order to achieve that goal. When we are through we will
discuss the interventions.
Nsg. Dx.: Social isolation
Activity 2
Nsg. Diagnosis- Social isolation related to inability to trust, panic
anxiety, delusional thinking, and regression as evidenced by
stating people are trying to poison her.
Activity 3
Read the case study and the nursing diagnosis. As a group, discuss and
decide on the nursing goal related to that nursing diagnosis. Write that
goal on the paper, and then each person take a turn writing an intervention
you would try in order to achieve that goal. When we are through we will
discuss the interventions.
Nsg. Dx. Risk for violence.
Activity 3
Nsg. Dx. Risk for violence: self- directed or other directed related
to extreme suspiciousness, panic anxiety,or possibly command
 hallucinations as evidenced by believing roommate wanted to
kill her and people are trying to harm her.
Activity 4
Read the case study and the nursing diagnosis .As a group, discuss and
decide on the nursing goal related to that nursing diagnosis. Write that
goal on the paper, and then each person take a turn writing an intervention
you would try in order to achieve that goal. When we are through we will
discuss the interventions.
Nsg. Dx.-Impaired verbal communication
Activity 4
Impaired verbal communication related to panic
anxiety, regression, disordered thinking as evidenced by
looseness of association.
Activity 5
Read the case study and the nursing diagnosis. As a group discuss and
decide on the nursing goal related to that nursing diagnosis. Write that
goal on the paper, and then each person take a turn writing an intervention
you would try in order to achieve that goal. When we are through we will
discuss the interventions.
Nsg Dx.self care deficit.
Activity 5
Nsg Dx. Self care deficit related to withdrawal, regression, panic
anxiety inability to trust as evidenced by inability to do hygiene,
grooming and dress.
Psychiatric Rehabilitation
Multidisciplinary and collaborative with the client, family, and
community
Nurse teaches, coaches, serves as resource
Psychological treatments:Focus is always on decreasing anxiety
and increasing trust
Group-Psycho education R/T meds, relapse prevention, social
skills, decrease isolation

Psychiatric Rehabilitation
Long term….requires from therapist exquisite patience and freedom from
the need to prove oneself by effecting change.
Psycho education:
On medications
On the disease process
On relapse symptoms
On social interaction
On expressing emotions
On handling frustration
Treatment
Group: inpatient phase of illness represents the most anxiety and social
inability.Reduce stimuli.
Group supportive, not confrontational.
Social skills through role-playing real life situations.
Behavior modification- but pts. may have difficulty generalizing to
community setting.
Treatment
Family therapy- All illness involves the family, sometimes that may be the
people at the halfway house or in the homeless camp.
Medications: 1954 Thorazine was the first antipsychotic. Response to
meds.-10% do not recover, 30% partial recover needing some assistance,
but able to work and care for needs, 30% poor recovery minimally
surviving, 30% recover completely.

Treatment
Medications-meds.+ supportive, ongoing therapy.Used both in the
acute phase as well as for maintenance
Long term use. See handout.
Medications
Review side effects:
Anticholinergic and movement ( pseudo parkinsonism, akinesia muscle
weakness or loss of muscle ability, akathesia, dystonia spasms of the face
arms, oculogyric crisis, tardive dyskinesia bizarre facial and
tongue movements, difficulty swallowing. neuroleptic malignant
syndrome.
 Medications

Non compliance may be an issue may have to use depot Haldol

and Prolixin.
Comes in pills, liquid concentrate, injectable, and depot injectable
for long acting effect
Have also begun using mood stabilizers.
Nursing Diagnoses
Altered thought process R/T……(delusions,loose associations, concrete
thinking)
Social Isolation R/T…….(withdrawal,lack of social network, anxiety,
preoccupation with symptoms)
Self esteem disturbance R/T……(chronic disease, feeling different from
others)
Knowledge deficit R/T……( not understanding disease, medications)

Nursing Diagnoses
High risk for violence, self or others R/T ( panic level anxiety,
command hallucinations, suspiciousness)
Self care deficit R/T….amotivation, inabbility to remember
Sensory perceptual alterations

Interventions

Active listening
Listen for themes
Redirect
Social skills training-role play, practice specific skills
Model social behavior
Self esteem enhancement-self esteem journal, give positive
feedback,collage of interests and talk about it
Interventions
Anxiety reduction-Relation techniques, notice and if possible
change environmental stimuli, exercise
Teaching- disease, signs of relapse, plans for relapse identification
symptoms, meds, schedule
Energy management- ADLS, naps, nutritional meals
Interventions
Self-care assistance- list of hygiene tasks and the steps, times
Suicide prevention-assess command hallucinations and teach client
what to do
Hallucination management-assess, help client describe needs that
might be reflected in the content of the hallucination, identify
triggers of hallucinations
Interventions
Delusion management-assess, correlate onset of delusion with onset of
stress, respond to the underlying feelings
Violence prevention encourage to talk rather than act out feelings, identify
triggers, give personal space to client who is escalating,verbally set limits
on aggressive behavior, avoid touching client who is scared
Interventions
Violence management
Assess the congruency of your behaviors
Involve family to the level of their ability and client confidentiality
Teach family-convey message they are not the cause, teach signs of relapse,
medications, how to deal with active symptoms, role play with them,
teach about keeping a moderate level of expressed emotion, establish
family rules,support groups, and family therapy