BACHELOR OF SCIENCE IN NURSING

RLE MODULE RLE UNIT WEEK

1 4 5

WEEK 4 SCHIZOPHRENIA

● Read course and unit objectives

● Read study guide prior to class attendance
● Read required learning resources; refer to unit terminologies for jargons
● Proactively participate in classroom/online discussions
● Participate in weekly discussion board (Canvas)
● Answer and submit course unit tasks

At the end of the course unit (CM), learners will:

Cognitive
● Discuss the steps of the nursing process and how to apply in the care of client with
schizophrenia and related disorders
Psychomotor.
● Perform thorough assessment of clients with schizophrenia and related
disorders.
● Analyzes assessment data to determine priorities to establish a plan of care
● Set measurable and achievable short- and long-range goals
● Establish appropriate nursing diagnosis based from the assessment data gathered.
● Provide proper interventions to meet the health needs of the client.
Affective
● Provide education to clients, families, caregivers, and community members to increase
knowledge and understanding of schizophrenia and related disorders.
● Evaluate both the patient’s status and the effectiveness of the nursing care provided
 ● Evaluate continuously the care plan and modify as needed.

Computer device or smartphone with internet access (at lesst 54 kbps, average data subscription
is feasible)

Schizophrenia

Schizophrenia is a chronic, severe mental disorder that affects the way a person thinks, acts,
expresses emotions, perceives reality, and relates to others. Though schizophrenia isn’t as common as
other major mental illnesses, it can be the most chronic and disabling.

People with schizophrenia often have problems doing well in society, at work, at school, and in
relationships. They might feel frightened and withdrawn, and could appear to have lost touch with
reality. This lifelong disease can’t be cured but can be controlled with proper treatment.

Contrary to popular belief, schizophrenia is not a split or multiple personality. Schizophrenia involves a
psychosis, a type of mental illness in which a person can’t tell what’s real from what’s imagined. At
times, people with psychotic disorders lose touch with reality. The world may seem like a jumble of
confusing thoughts, images, and sounds. Their behavior may be very strange and even shocking. A
sudden change in personality and behavior, which happens when people who have it lose touch with
reality, is called a psychotic episode.

How severe schizophrenia is varies from person to person. Some people have only one psychotic
episode, while others have many episodes during a lifetime but lead relatively normal lives in between.
Still others may have more trouble functioning over time, with little improvement between full-blown
psychotic episodes. Schizophrenia symptoms seem to worsen and improve in cycles known as
relapses and remissions

Early Symptoms of Schizophren

The condition usually shows its first signs in men in their late teens or early 20s. It mostly affects
women in their early 20s and 30s. The period when symptoms first start and before full psychosis is
called the prodromal period. It can last days, weeks, or even years. It can be hard to spot because
there’s usually no specific trigger. You might only notice subtle behavioral changes, especially in teens.
This includes:
 ● A change in grades
● Social withdrawal
● Trouble concentrating
● Temper flares
● Difficulty sleeping

Positive Symptoms of Schizophrenia

In this case, the word positive doesn’t mean good. It refers to added thoughts or actions that aren’t
based in reality. They’re sometimes called psychotic symptoms and can include:

● Delusions: These are false, mixed, and sometimes strange beliefs that aren’t based in reality
and that the person refuses to give up, even when shown the facts. For example, a person with
delusions may believe that people can hear their thoughts, that they are God or the devil, or that
people are putting thoughts into their head or plotting against them.

● Hallucinations: These involve sensations that aren't real. Hearing voices is the most common
hallucination in people with schizophrenia. The voices may comment on the person's behavior,
insult them, or give commands. Less common types include seeing things that aren't there,
smelling strange odors, having a funny taste in your mouth, and feeling sensations on your skin
even though nothing is touching your body.

● Catatonia: In this condition, the person may stop speaking, and their body may be fixed in a
single position for a very long time.

Negative Symptoms of Schizophrenia

The word "negative" here doesn’t mean "bad." It notes the absence of normal behaviors in people with
schizophrenia. Negative symptoms of schizophrenia include:

● Lack of emotion or a limited range of emotions

● Withdrawal from family, friends, and social activities

● Less energy

● Speaking less

● Lack of motivation
 ● Loss of pleasure or interest in life

● Poor hygiene and grooming habits

Disorganized Symptoms of Schizophrenia

These are positive symptoms that show that the person can’t think clearly or respond as expected.
Examples include:

● Talking in sentences that don’t make sense or using nonsense words, making it difficult for the
person to communicate or hold a conversation

● Shifting quickly from one thought to the next without obvious or logical connections between
them

● Moving slowly

● Being unable to make decisions

● Writing excessively but without meaning

● Forgetting or losing things

● Repeating movements or gestures, like pacing or walking in circles

● Having problems making sense of everyday sights, sounds, and feelings

Cognitive Symptoms of Schizophrenia

The person have trouble:

● Understanding information and using it to make decisions (a doctor might call this poor
executive functioning)

● Focusing or paying attention

● Using their information immediately after learning it (this is called working memory)

● Recognizing that they have any of these problems

Causes of Schizophrenia
The exact cause of schizophrenia isn’t known. But like cancer and diabetes, schizophrenia is a real
illness with a biological basis. Researchers have uncovered a number of things that appear to make
someone more likely to get schizophrenia, including:

● Genetics (heredity): Schizophrenia can run in families, which means a greater likelihood to
have schizophrenia may be passed on from parents to their children.
● Brain chemistry and circuits: People with schizophrenia may not be able to regulate brain
chemicals called neurotransmitters that control certain pathways, or "circuits," of nerve cells that
affect thinking and behavior.
● Brain abnormality: Research has found abnormal brain structure in people with schizophrenia.
But this doesn’t apply to all people with schizophrenia. It can affect people without the disease.
● Environment: Things like viral infections, exposure to toxins like marijuana, or highly stressful
situations may trigger schizophrenia in people whose genes make them more likely to get the
disorder. Schizophrenia more often surfaces when the body is having hormonal and physical
changes, like those that happen during the teen and young adult years.

Who Gets Schizophrenia?

Anyone can get schizophrenia. It affects people all over the world, from all races and cultures. While it
can happen at any age, schizophrenia typically first appears in the teenage years or early 20s. The
disorder affects men and women equally, although symptoms generally appear earlier in men. The
earlier the symptoms start, the more severe the illness tends to be. Children over the age of 5 can have
schizophrenia, but it’s rare before adolescence.

How Is Schizophrenia Diagnosed?

If symptoms of schizophrenia are present, the doctor will perform a complete medical history and
sometimes a physical exam. While there are no laboratory tests to specifically diagnose schizophrenia,
the doctor may use various tests, and possibly blood tests or brain imaging studies, to rule out another
physical illness or intoxication (substance-induced psychosis) as the cause of the symptoms.

If the doctor finds no other physical reason for the schizophrenia symptoms, they may refer the person
to a psychiatrist or psychologist, mental health professionals trained to diagnose and treat mental
illnesses. Psychiatrists and psychologists use specially designed interviews and assessment tools to
evaluate a person for a psychotic disorder. The therapist bases her diagnosis on the person's and
family's report of symptoms and her observation of the person's attitude and A person is diagnosed with
schizophrenia if they have at least two of these symptoms for at least 6 months:
 ● Delusions

● Hallucinations

● Disorganized speech

● Disorganized or catatonic behavior

● Negative symptoms

One of the symptoms has to be

● Delusions

● Hallucinations

● Disorganized speech

During the 6 months, the person must have a month of active symptoms. (It can be less with successful
treatment.) Symptoms should negatively affect them socially or at work, and can’t be caused by any
other condition.

Treatment and Management of Schizophrenia

The goal of schizophrenia treatment is to ease the symptoms and to cut the chances of a relapse, or
return of symptoms. Treatment for schizophrenia may include:

● Medications: The primary medications used to treat schizophrenia are called antipsychotics.
These drugs don’t cure schizophrenia but help relieve the most troubling symptoms, including
delusions, hallucinations, and thinking problems.

○ Older (commonly referred to as "first-generation") antipsychotic medications used

include:

■ Chlorpromazine (Thorazine)

■ Fluphenazine (Prolixin)

■ Haloperidol (Haldol)

■ Oxilapine (Loxapine)

■ Perphenazine (Trilafon)
 ■ Thiothixene (Navane)

■ Trifluoperazine (Stelazine)

○ Newer ("atypical" or second-generation) drugs used to treat schizophrenia include:

■ Aripiprazole (Abilify)

■ Aripiprazole Lauroxil (Aristada)

■ Asenapine (Saphris)

■ Brexpiprazole (Rexulti)

■ Cariprazine (Vraylar)

■ Clozapine (Clozaril)

■ Iloperidone (Fanapt)

■ Lumateperone tosylate (Caplyta)

■ Lurasidone (Latuda)

■ Olanzapine (Zyprexa)

■ Paliperidone (Invega Sustenna)

■ Paliperidone Palmitate (Invega Trinza)

■ Quetiapine (Seroquel)

■ Risperidone (Risperdal)

■ Ziprasidone (Geodon)

Note: Clozapine is the only FDA-approved medication for treating schizophrenia that is resistant to
other treatments. It’s also used to lessen suicidal behaviors in those with schizophrenia who are at risk.

● Coordinated specialty care (CSC) : This is a team approach toward treating schizophrenia
when the first symptoms appear. It combines medicine and therapy with social services,
employment, and educational interventions. The family is involved as much as possible. Early
treatment is key to helping patients lead a normal life.

● Psychosocial therapy: While medication may help relieve symptoms of schizophrenia, various
psychosocial treatments can help with the behavioral, psychological, social, and occupational
problems that go with the illness. Through therapy, patients also can learn to manage their
 symptoms, identify early warning signs of relapse, and come up with a relapse prevention plan.
Psychosocial therapies include:

○ Rehabilitation, which focuses on social skills and job training to help people with
schizophrenia function in the community and live as independently as possible

○ Cognitive remediation, which involves learning techniques to make up for problems

with information processing. It often uses drills, coaching, and computer-based exercises
to strengthen mental skills that involve attention, memory, planning, and organization.

○ Individual psychotherapy, which can help the person better understand his illness, and
learn coping and problem-solving skills

○ Family therapy, which can help families deal with a loved one who has schizophrenia,
enabling them to better help their loved one

○ Group therapy/support groups, which can provide continuing mutual support

● Hospitalization: Many people with schizophrenia may be treated as outpatients. But

hospitalization may be the best option for people:

○ With severe symptoms

○ Who might harm themselves or others

○ Who can’t take care of themselves at home

● Electroconvulsive therapy (ECT): In this procedure, electrodes are attached to the person's
scalp. While they’re asleep under general anesthesia, doctors send a small electric shock to the
brain. A course of ECT therapy usually involves 2-3 treatments per week for several weeks.
Each shock treatment causes a controlled seizure. A series of treatments over time leads to
improvement in mood and thinking. Scientists don’t fully understand exactly how ECT and the
controlled seizures it causes help, but some researchers think ECT-induced seizures may affect
the release of neurotransmitters in the brain. ECT is less well-proven to help with schizophrenia
than depression or bipolar disorder, so it isn’t used very often when mood symptoms are
absent. It can help when medications no longer work, or if severe depression or catatonia
makes treating the illness difficult.

● Research: Researchers are looking at a procedure called deep brain stimulation (DBS) to treat
schizophrenia. Doctors surgically implant electrodes that stimulate certain brain areas believed
to control thinking and perception. DBS is an established treatment for severe Parkinson's
disease and essential tremor, but it’s still experimental for the treatment of psychiatric disorders.
STUDY GUIDE
ASSESSMENT TOOL

Components of Mental Status Examination

Appearance
● Age (chronological age and whether person looks this age)
● Sex, Race
● Body build (thin, obese, athletic, medium)
● Position (lying, sitting, standing, kneeling)
● Posture (rigid, slumped, slouched, comfortable, threatening)
● Eye contact (eyes closed, good contact, avoids contact, stares)
● Dress (what individual is wearing, cleanliness, condition of clothes, neatness,
appropriateness of garments)
● Grooming (malodorous, unkempt, dirty, unshaven, overly meticulous, hairstyle, disheveled,
makeup)
● Manner (cooperative, guarded, pleasant, suspicious, glib, angry, seductive, ingratiating,
evasive, friendly, hostile)
● Attentiveness to examiner (disinterested, bored, internally preoccupied, distractible,
attentive)
● Distinguishing features (scars, tattoos, bandages, bloodstains, missing teeth, tobacco-
stained fingers)
● Prominent physical irregularity (missing limb, jaundice, profuse sweating, goiter, wheezing,
coughing)
● Emotional facial expression (crying, calm, perplexed, stressed, tense, screaming,
tremulous, furrowed brow)
● Alertness (alert, drowsy, stupor, confused)
Motor/Behaviour
● Retardation (slowed movements)
● Agitation (unable to sit still, wringing hands, rocking, picking at skin or clothing, pacing,
excessive movement, compulsive)
● Unusual movements (tremor, lip smacking, tongue thrust, mannerisms, grimaces, tics)
● Gait (shuffling, broad-based, limping, stumbling, hesitation)
● Catatonia (stupor, excitement)
Speech
● Rate (slowed, long pauses before answering questions, hesitant, rapid, pressured)
● Rhythm (monotonous, stuttering)
● Volume (loud, soft, whispered)
 ● Amount (monosyllabic, hyper-talkative, mute)
● Articulation (clear, mumbled, slurred)
● Spontaneity
Mood/Affect
● Stability (stable, fixed, labile)
● Range (constricted, full)
● Appropriateness (to content of speech and circumstance)
● Intensity (flat, blunted, exaggerated)
● Affect (depressed, sad, happy, euphoric, irritable, anxious, neutral, fearful, angry, pleasant)
● Mood (reported by patient/client)
Thought Content
● Suicidal or homicidal ideations (intent, plan, access to means, time-frame)
● Depressive cognition (guilt, worthlessness, hopelessness)
● Obsessions (persistent, unwanted, recurring thought)
● Ruminations
● Phobias (strong, persistent, fear of object or situation)
● Ideas of reference
● Paranoid ideation
● Magical ideation
● Delusions (false belief kept despite no supportive evidence)
● Overvalued ideas
● Thought broadcasting, insertion or withdrawal
● Other major themes discussed by patient/client
Thought Process
● Coherence (coherent, incoherent)
● Logic (logical, illogical)
● Stream (goal-directed, circumstantial, tangential [diverges suddenly from a train of thought],
looseness of associations, flight of ideas, rambling, word salad)
● Perseveration (pathological repetition of a sentence or word)
● Neologism (use of new expressions, phrases, words)
● Blocking (sudden cessation of flow of thinking and speech related to strong emotions)
● Attention (distractibility, concentration)
Perception
● Hallucinations (auditory [including command, running commentary], visual, olfactory
[smelling], gustatory [taste], tactile)
● Illusions (misinterpretation of actual external stimuli)
● Depersonalization
● Déjà vu, Jamais vu

Cognition

● Orientation (time, person, place)

● Memory (short-term, long-term)
 ● Intellect
● Abstract thought
● Capacity to read and write
● Level of consciousness

Insight/Judgement
● Awareness of illness (insight)
● Ability to make a decision wisely considering pros and cons for a course of action
● Sex, Race
● Body build (thin, obese, athletic, medium)
● Position (lying, sitting, standing, kneeling)
● Posture (rigid, slumped, slouched, comfortable, threatening)
● Eye contact (eyes closed, good contact, avoids contact, stares)
● Dress (what individual is wearing, cleanliness, condition of clothes, neatness,
appropriateness of garments)
● Grooming (malodorous, unkempt, dirty, unshaven, overly meticulous, hairstyle, disheveled,
makeup)
Manner (cooperative, guarded, pleasant, suspicious, glib, angry, seductive, ingratiating, evasive,
friendly, hostile)
● Attentiveness to examiner (disinterested, bored, internally preoccupied, distractible,
attentive)
● Distinguishing features (scars, tattoos, bandages, bloodstains, missing teeth, tobacco-
stained fingers)
● Prominent physical irregularity (missing limb, jaundice, profuse sweating, goiter, wheezing,
coughing)
● Emotional facial expression (crying, calm, perplexed, stressed, tense, screaming,
tremulous, furrowed brow)
● Alertness (alert, drowsy, stupor, confused)

Application of the Nursing Process in the Care of Client with Schizophrenia Spectrum and
Related Disorders

The Nursing process in the care of client with schizophrenia

1. Assessment

1.1. History

1.2. General appearance and behavior

1.3. Mood and affect

1.4. Sensorium and Intellectual Processes

 1.5. Thought process and content

1.6. Judgment and insight

1.7. Self-concept

1.8. Roles and relationships

1.9. Physiologic and self-care considerations

1.10. Depression rating scale

2. Diagnosis. The analysis of assessment data generally falls into two main categories: data
associated with the positive signs of the disease and data associated with the negative signs. The
North American Nursing Diagnosis Association’s nursing diagnoses commonly established based
on the assessment of psychotic symptoms or positive signs are as follows:

2.1. Risk for Other-Directed Violence

2.2. Risk for Suicide

2.3. Disturbed Thought Processes

2.4. Disturbed Sensory Perception

2.5. Impaired Verbal Communication

The North American Nursing Diagnosis Association’s nursing diagnoses based on the assessment
of negative signs and functional abilities include the following:

2.1. Self-Care Deficits

2.2. Social Isolation

2.3. Deficient Diversional Activity

3. Planning. Based on the assessment and diagnosis, the nurse sets measurable and achievable
short- and long-range goals for the patient. In stating the plan of care use the mnemonic SMART,

During the acute psychotic episode of schizophrenia will receive treatment in an intensive
setting such as an inpatient hospital unit. During this phase, the focus of care is stabilizing the
client’s thought processes and reality orientation as well as ensuring safety. This is also the time to
evaluate resources, make referrals, and begin planning for the client’s rehabilitation and return to
the community Examples of outcomes appropriate to the acute, psychotic phase of treatment are
as follows:
3.1. The client will not injure self or others.

3.2. The client will establish contact with reality.

3.3. The client will interact with others in the environment

. 3.4. The client will express thoughts and feelings in a safe and socially acceptable manner.

3.5. The client will participate in prescribed therapeutic interventions

4. Interventions

4.1. Promoting the Safety of Client and Others and right to privacy and dignity

4.2. Establishing therapeutic relationship by establishing trust

4.3. Using therapeutic communication (clarifying feelings and statements when speech and
thoughts are disorganized or confused)
4.4. Implementing interventions for delusions - Do not openly confront the delusion or
argue with the client. - Establish and maintain reality for the client. Use distracting techniques. -
Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs.

4.5. Implementing interventions for hallucinations - Help present and maintain reality by
frequent contact and communication with client. - Elicit description of hallucination to protect client
and others. The nurse’s understanding of the hallucination helps him or her know how to calm or
reassure the client. - Engage client in reality-based activities such as card playing, occupational
therapy, or listening to music.

4.6. Coping with socially inappropriate behaviors - Redirect client away from problem
situations. - Deal with inappropriate behaviors in a nonjudgmental and matter-of-fact manner; give
factual statements; do not scold. - Reassure others that the client’s inappropriate behaviors or
comments are not his or her fault (without violating client confidentiality). - Try to reintegrate the
client into the treatment milieu as soon as possible. - Do not make the client feel punished or
shunned for inappropriate behaviors. - - Teach social skills through education, role modeling, and
practice.

4.7. Client and family teaching

4.8. Establishing community support systems and care

5. Evaluation. Evaluation of the treatment of schizophrenia is based on the following:

5.1. Have the client’s psychotic symptoms disappeared? If not, can the client carry out his
or her daily life despite the persistence of some psychotic symptoms?
5.2. Does the client understand the prescribed medication regimen? Is he or she committed
to adherence to the regimen?
5.3. Does the client possess the necessary functional abilities for community living? 5.4.
Are community resources adequate to help the client live successfully in the community?
5.5. Is there a sufficient after-care or crisis plan in place to deal with recurrence of
symptoms or difficulties encountered in the community?

5.6. Are the client and family adequately knowledgeable about schizophrenia?
 5.7. Does the client believe that he or she has a satisfactory quality of life?

APPLICATION OF THE NURSING PROCESS in the CARE OF CLIENT with SCHIZOPHRENIA

A. TASK CASE VIGNETTE:

Jino, 35 years old, has been admitted to the hospital for the third time with a diagnosis of
Schizophrenia. Jino had been taking Haloperidol (Haldol) but stopped taking it 2 weeks ago,
telling his case manager it was, and “The poison that is making me sick” Yesterday Jino
was brought to the hospital after neighbors called the police because he had been up all
night yelling loudly in his apartment. Neighbors reported him saying, “I can’t do it. They don’t
deserve to die!” And similar statements. Jino appears guarded and suspicious and has
very little to say to anyone. His hair is matted, he has a strong body odor, and he is dressed
in several layers of heavy clothing even though the temperature is warm. So far, Jino has
been refusing any offers of food and fluids. When the nurse approached John with a dose of
Haloperidol, he said “Do you want me to die? “

Answer the following questions: (50 points)

1. Discuss the positive and negative symptoms of Schizophrenia
2. Evaluate the effectiveness of antipsychotic medications and other treatment modalities in
managing clients with schizophrenia

2. Create a 2 NURSING CARE PLAN based from the case provided using the 4 columns
(50 points)

Boyd (2017), Essentials of Psychiatric Nursing, Wolters/Kluwer

Holland (2018), The Nurses Guide to Mental Health Medicines Elsevier/Mosby
Keltner (2019), Psychiatric Nursing 8th edition, St. Louis, Mo.: Elsevier/Mosby.
Kozier, Barbara, (2017) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and
Practice 10th edition Upper Saddle River, N.J.:Pearson Prentice Hall
Pullen, Richard (2010) Nursing Made Incredibly Easy. Varcarolis (2015), Manual of Psychiatric
Nursing Care Planning 5th edition, Elsevier/Mosby

Videbeck, Sheila L. (2017) Psychiatric-Mental Health Nursing 7th edition. Wolters

Kluwer/Lippincott Williams and Wilkins

Frankenburg, Frances R MD (2020). Schizophrenia, Medscape Journal

https://emedicine.medscape.com/article/288259-overview#a2
Feras Al Saif; StatPearls [Internet]. Shared Psychotic Disorder Yasir Al Khalili. 2019
https://www.ncbi.nlm.nih.gov/books/NBK541211/

American Nurses Association Journals policy/workforce/what

https://www.nursingworld.org/practice-- isnursing/thenursingprocess/

https://geekymedics.com/mental-state-examination/?fbclid=IwAR2gsvmG0Giw79VNk-
UkiNOd20epTl5cROCc6fr_uYUsnIqqjj3uetz8qmQ
https://www.webmd.com/schizophrenia/mental-health-schizophrenia?fbclid=IwAR2rV1-8-
66cqmZvNCknfjrXXbm8pcy-M2cRVglY7uUp1wFyAZjsu79_uq0#1