Medical Management

Here’s how schizophrenia is medically managed:

 Drug Therapy. Schizophrenia is mainly treated by antipsychotics (neuroleptic)

drugs.

o These prevent relapse of acute symptoms.

o Psychotic symptoms must be present 12 to 24 months before patients

receive their first medical treatment.

o Examples of these drugs include the typical or conventional typical

antipsychotic chlorpromazine (Thorazine) and the atypical

 Electroconvulsive Therapy. Rarely used but is for patients with acute

schizophrenia and those who can’t tolerate or don’t respond to medication. It is
effective in reducing depressive and catatonic symptoms of schizophrenia.

 Other treatments include compliance promotion programs, psychosocial

treatment and rehabilitation, vocational counseling, supportive psychotherapy, and
appropriate use of community resources.

Maintenance/DrugTherapy

Antipsychotic medications, also known as neuroleptics, are prescribed primarily

for the efficacy in decreasing psychotic symptoms. They do not cure schizophrenia; rather,
they are used to manage the symptoms of the disease.

First-generation antipsychotics

These first-generation antipsychotics (conventional antipsychotics) have frequent and

potentially significant neurological side effects, including the possibility of developing a
movement disorder (tardive dyskinesia) that may or may not be reversible. They are
dopamine agonists. These antipsychotics are often cheaper than second-generation
antipsychotics, especially the generic versions, which can be an important consideration
when long-term treatment is necessary.

Second-generation antipsychotics

These newer, second-generation medications are generally preferred because they pose a
lower risk of serious side effects than do first-generation antipsychotics. These newer or
atypical antipsychotic medications are both dopamine and serotonin agonists.
Long-acting injectable antipsychotics

Some antipsychotics may be given as an intramuscular or subcutaneous injection. The

vehicle for depot injections is sesame oil; therefore, the medications are absorbed slowly
over time into the client’s system. Common medications that are available as an injection
include: fluphenazine (Prolixin) in decanoate and enanthate preparations and haloperidol
(Haldol) in decanoate.

The effects of the medications last 2 to 4 weeks, eliminating the need for daily oral
antipsychotic medications. The duration of action is 7 to 28 days for fluphenazine and 4
weeks for haloperidol.

SIDE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS:

Serious neurologic side effects:

Extrapyramidal side effects – are reversible movement disorders induced by

neuroleptic medication.
o Dystonic reactions
 appear early in the course of treatment and are characterized by spasms
in discrete muscle groups such as neck muscles (torticollis) or eye
muscles (oculogyric crisis).

o Pseudoparkinsonism (neuroleptic-induced parkinsonism)

 includes a shuffling gait, mask-like facies, muscle stiffness, (continuous)
or cogwheeling rigidity (ratchlike movements of joints), drooling, and
akinesia (slowness and difficulty initiating movement).

o Akathisia
 is characterized by restless movement, pacing, inability to remain still,
and the client’s report of inner restlessness.

Tardive dyskinesia – a late-appearing side effect of antipsychotic medications, is

characterized by abnormal, involuntary movements such as lip smacking, tongue
protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and
feet.

Seizures – is a sudden, uncontrolled electrical disturbance in the brain. It is an

infrequent side effect associated with antipsychotic medications.

Neuroleptic Malignant Syndrome (NMS) – is a serious and frequently fatal

condition seen in those being treated with antipsychotic medications. It is
characterized by muscle rigidity, high fever, increased muscle enzymes, and
leukocytosis.
 Agranulocytosis – failure of bone marrow to produce adequate white blood cells.
Develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and
leukopenia.
Nonneurologic side effects include:

Weight gain
Sedation
Photosensitivity
Anticholinergic symptoms such as dry mouth, blurred vision, constipation, urinary
retention, and orthostatic hypotension.

Psychosocial interventions

Once psychosis recedes, in addition to continuing on medication, psychological and social

(psychosocial) interventions are important. These may include:

 Individual therapy. Psychotherapy may help to normalize thought patterns. Also,

learning to cope with stress and identify early warning signs of relapse can help people
with schizophrenia manage their illness.

 Social skills training. This focuses on improving communication and social

interactions and improving the ability to participate in daily activities.

 Family therapy. This provides support and education to families dealing with

schizophrenia.

 Vocational rehabilitation and supported employment. This focuses on helping

people with schizophrenia prepare for, find and keep jobs.

Nursing Management

Here are the nursing responsibilities for taking care of patients with schizophrenia:

Nursing Assessment

 Recognize schizophrenia. Note characteristic signs and symptoms of

schizophrenia (e.g., speech abnormalities, thought distortions, poor social
interactions).

 Establish trust and rapport. Don’t tease or joke with patients. Expect that
patient is going to put you through rigorous testing periods. Introduce yourself and
explain your purpose.

 Maximize level of functioning. Assess patient’s ability to carry out activities of

daily living (ADLs).

 Assess positive symptoms. Assess for command hallucinations; explore answers.

Assess if the client has fragmented, poorly organized, well-organized,
systematized, or extensive system of beliefs that are not supported by reality.
Assess for pervasive suspiciousness about everyone and their actions (e.g.,
vigilant, blames others for consequences of own behavior, argumentative,
threatening).
  Assess negative symptoms. Assess for the negative symptoms of schizophrenia
(as mentioned above).

 Assess medical history. Assess if the client is on medications, what these are,

and adherence to therapy.

 Assess support system. Determine whether the family is well informed about the
disease. Does the family understand the need for medication adherence?

Nursing Diagnoses

 Impaired Physical Mobility related to depressive mood state and reluctance to

initiate movement.

 Impaired Social Interaction related to problems in thought patterns and speech.

 Decreased Cardiac Output related to orthostatic hypotensive drug effects.

 Risk for Suicide related to impulsiveness and marked changes in behavior.

 Risk for Injury related to hallucinations and delusions.

 Risk for Imbalanced Nutrition: less than body requirements related to self-

neglect and refusal for self-care.

Nursing Care Planning and Goals

6 Schizophrenia Nursing Care Plans

 Reduce severity of psychotic symptoms

 Prevent recurrence of acute episodes

 Meet patient’s’ physical and psychosocial needs

 Help patient gain optimum level of functioning

 Increase client’s compliance to treatment and nursing plan

Nursing Interventions

 Establish trust and rapport. Don’t touch client without telling him first what you
are going to do. Use an accepting, consistent approach; short, repeated contacts
are best until trust has been established. Language should be clear and
unambiguous. Maintain a sense of hope for possible improvement, and convey this
to the patient.

 Maximize level of functioning. Avoid promoting dependence by doing only what

the patient can’t do for himself. Reward positive behavior and work with him to
increase his personal sense of responsibility in improving functioning.

 Promote social skills. Provide support in assisting him to learn social skills.

 Ensure safety. Maintain a safe environment with minimal stimulation.

 Ensure adequate nutrition. Monitor patient’s nutritional status and if the patient
thinks his food is poisoned, let him fix his own food if possible or offer him foods in
closed containers that he can open. Institute suicide and/or homicide precautions
as appropriate.

 Keep it real. Engage patient in reality-oriented activities that involve human

contact (e.g., workshops, inpatient social skills training). Clarify private language,
autistic inventions, or neologisms.

 Deal with hallucinations by presenting reality. Explore the content of

hallucinations. Avoid arguing about the hallucinations. Tell them you do not see,
hear, smell, or feel it but explain that you know that these hallucinations are real to
him.

 Promote compliance and monitor drug therapy. Administer prescribed drugs

and encourage the patient to comply. Ensure that patient is really taking the drug.
Observe for manifestations that warrant hypersensitivity reactions and toxicity.

 Encourage family involvement. Involve family in patient treatment and teach

members to recognize impending relapse (e.g. nervousness, insomnia, decreased
ability to concentrate). Suggest ways how families can manage symptoms.