You are on page 1of 72

SIDAVEERAPPA. B.

TUPPAD
Lecturer Department of psychiatry
SIONS Bagalkot
HISTORICAL BACKGROUND
ë Ayurveda --- aorel described schizophrenia
as r     
Oahlbaum described schizophrenia
as   


ecker described schizophrenia as
2 2 

The scientific study of schizophrenia began with
the description of r  
   by Emil
Oraepelin
Dementia= deterioration;
precox=earlyonset
§ IL KRA§§LIN
ë In 1986 he differentiated the major psychiatric
illnesses into two clinical types
1. Dementia precox (delusions,
hallucinations, disturbances of affect, &
motor disturbances)
2. D
§UG§N BL§UL§R(1911)
ë Renamed dementia precox as 2
2 
 (splitting of
mind) (1908) group of disorders rather than distinct entity
so, he used the word group of schizophrenias.
ë Described characteristic symptoms as

O undamental symptoms(diagnostic of schizophrenia)


ë Ambivalence,
ë Autism,

ë Affect disturbance,

ë Association disturbance

O Accessory symptoms(secondary to undamental


symptoms)
ëDelusions,
ë Hallucinations,

ë Negativism
KURT SCHN§ID§R (1959)
ë Described symptoms which though not specific of
schizophrenia, were of great importance in
making a clinical diagnosis
O Schneider First rank symptoms (SFRS)
A.
allucinations
1. Audible thoughts(thought echo)
2. Voices heard arguing
3. Voices commenting on one·s action
B. Thought Alienation phenomena
º. Thought withdrawal
5. Thought insertion
6. Thought diffusion or broadcasting
C. Passivity phenomena
7. ade feeling or affect
8. ade impulses
9. ade volition or acts (robot like)
10. Somatic passivity
D. Delusional perception
11. Delusional perception
SCHIZOHR§NIA
ë The word schizophrenia is derived from Greek
word 2

 2 

r
ë Term was coined by Swiss psychiatrist §ugen
Bleuler
ë ajor mental disorder characterized by Group of
disturbances which sometimes occur in different
combinations and intensities. Hence it is
2     in nature
D§INITION O SCHIZOHR§NIA
´Schizophrenia is defined as functional
psychotic condition characterized by disturbances
in thinking, emotion, volition and perception in
presence of clear consciousness, which usually
leads to social withdrawalµ.
§ID§ IOLOGY
ë ost common of the psychotic disorders
ë 50% 0f beds in psychiatric hospitals are occupied

ë 2/3rds of the cases are in the 15-30 years age group

ë Common in lower social classes

ë Acc to world health report 2001, 2º million people


worldwide suffer from schizophrenia
ë revalence rate 0.5-1%, revalent in all cultures races and
in all parts of the world
ë Incidence rate 0.5 per 1000

ë Onset is later in women and often runs benign course, as


compared to men
§TIOLOGY
ë Unknown
ë However several theories have been propounded

I. BIOLOGICAL T
EORIES
1. Genetic hypothesis
ë 8-10% of first degree relatives 3% of second degree
relatives and 2% of third degree relatives of patients with
schizophrenia can have schizophrenia as compared with
0.5-1% prevalence rate in the general population
OULATION INCID§NC§(%)
General population 1.0
Sibling of schizophrenic patient 8.0
Child with one schizophrenic parent 12.0
Child with two schizophrenic parent º0.0
Dizygotic twin of schizophrenic pt 1º.0
onozygotic twin of schizophrenic pt º6.0
£. Biochemical theories
ë unctional increase in dopamine level at post synaptic
receptor
ë Other NT·s like 5-HT, GABA, Acetyl choline
D. Brain imaging
ë Cranial CT Scan, RI Scan, and post mortem studies show
enlarged ventricles and mild cortical atrophy
ë §T Scan shows hypofrontality and decreased glucose
utilization in the dominant temporal lobe
ë Attempts are being made to localize symptoms of
schizophrenia to the various brain regions by §T
º. Other theories
Biological basis of schizophrenia
O Antipsychotics block the D2 receptor, cause improvement, and
relapse occurs on stopping antipsychotic medication
O Newer atypical antipsychotics are D2-5-HT2 antagonists
O Drugs like LSD, amphetamines, and mescaline, can cause
schizophrenia like symptoms in normal subjects.
O Organic mental disorders with schizophrenia like symptoms
may be seen in Huntington·s chorea, homocystinuria, acute
intermittent porphyria, Wilson·s disease and hemachromatosis.
O Soft neurological signs (SNS), minor physical anomalies, and
impaired eye tracking (smooth pursuit eye movements) are more
oftenly seen
O Viral and auto-immune factors have also been implicated by
some, while others (Wein berger) have suggested a
neurodevelopmental hypothesis for schizophrenia.
II.PSYC
OLOGICAL T
EORIES
1. Stress ²Diathesis model
ë Stressful life events

ë Stress-Vulnerability Hypothesis

ë Increased expressed emotions(§§) of significant others in


the family can lead to early relapse
£. Family theories
ë Schizophrenogenic mothers (Cold, overprotective, &
domineering, mothers retard the ego development of the
child, Dependency on mother, Anxious mother)
ë Lack of real parents

ë arental marital schism or skew

ë Double-bind theory

ë Communication deviance

ë seudo mutuality
D. Information processing hypothesis
ë Disturbance in attention, inability to maintain a set, and
inability to assimilate and integrate percepts are common
findings
ë The patients may at first be overly attentive to stimuli
but later may reduce attention to stimuli
ë Breakdown in the internal representation of mental
events.
º. Psychoanalytical theories
ë Acc to reud regression to pre oral (and oral) stage of
psychosexual development, with the use of defense
mechanism of denial, projection and reaction formation
ë Acc to edern Loss of ego boundaries, with loss of touch
with reality.
III. SOCIO-CULTURAL T
EORIES
ë Although revalence is uniform across cultures, it was
found more common in low S§S which is now explained
due to a downward social drift which is a result of having
developed schizophrenia rather than causing it
ë igration
ë Disorganization
HAS§S O SCHIZOHR§NIA
ë RODRO AL HAS§
O DS -IV characterizes the prodromal phase as clear deterioration
in functioning before the active phase of the disturbance that is
not due to a disturbance in mood or to a psychoactive substance
use disorder and that involves at least two of the following s/s
ë Social isolation/ withdrawal
ë Impairment in role functioning

ë eculiar behavior

ë Impairment in personal hygiene

ë Blunted / inappropriate affect

ë Digressive, vague, over elaborative, or circumstantial speech, or poverty

of speech, or poverty of content of speech


ë Odd belief or magical thinking , influencing behavior and inconsistent

with cultural norms


ë Unusual perceptual experience

ë arked lack of initiative , interests, or energy.


ë ACTIV§ HAS§
O The patient exhibits frankly psychotic symptoms
O Delusions
O Hallucinations
O Loosening of associations
O Incoherence
O Catatonic behavior
O articular stress may be present before the onset of this phase
ë R§SIDUAL HAS§
O ollows active phase
O Two of the symptoms mentioned in prodromal phase persist
O Resembles prodromal phase except that disturbance in affect and
role functioning are more severe
O Hallucinations and delusions may persists
CLINICAL §ATUR§S
ë Disturbance in
O Thought and verbal behaviour
O erception
O Affect
O otor behavior
O Relationship to the external world
THOUGHT AND S§§CH DISORD§RS
ë Autistic thinking G     
  
r 
 2

r 
  2  2
r 
  r
  
r    
     
    r

ë Loosening of associations ---- incoherence
ë Thought block ² thought withdrawal
ë Neologism- word approximation or
par aphasias ---- stomach as food vessel
ë utism
ë overty of speech
ë overty of ideation
ë §cholalia
ë erseveration
ë Verbigeration
ë Delusions
O rimary Delusions (Autochthonous Delusions)
O Secondary Delusions
Types of Delusions
ë Delusions of persecution
ë Delusions of reference

ë Delusions of grandeur

ë Delusions of control

ë Somatic Delusions

ë Overinclusion
ë Impaired abstraction

ë Concreteness

ë erplexity

ë Ambivalence
ë Disorders of perception
O Hallucination
ë Disorders of affect
O Apathy
O §motional blunting
O §motional shallowness
O Anhedonia
O Inappropriate §motional response
O Lack of rapport (due to lack of §motional contact)
ë Disorders of motor behavior
O Decreases (inertia, stupor) or
O increase in psychomotor activities (excitement, aggression,
restlessness, agitation)
O annerisms
O Stereotypies
O Decreased self care
O oor grooming
O Catatonic features
ë ositive symptoms
O Delusions
O Hallucinations
O Bizarre behavior
O Aggression
O Agitation
O Suspiciousness
O Hostility
O §xcitement
O Grandiosity
ë Negative symptoms
O Affective flattening or blunting
O Attentional impairment
O Avolition-apathy (lack of initiative)
O Anhedonia
O Asociality
O Alogia
O Diminished emotional responsiveness
O Stereotyped thinking
O sychomotor slowing, under activity
O assivity and lack of initiative
ë Other features
O Decreased functioning in work, social relations and self care
O Loss of ego boundaries
O ultiple somatic symptoms
O Insight will be absent
O Social judgment will poor
O No disturbance with consciousness, orientation, attention,
memory, intelligence.
O Variability in symptoms over time
O No underlying organic cause
O No prominent mood disorder of depressive or manic type

ë Suicide
ë DIAGNOSIS
O Acc to ICD-10 a minimum of 1 very clear symptom ( and usually
2 or more if less clear cut) belonging to any one of the groups of
referred to as (a) to (d) below, or symptoms from at least 2 of the
groups referred to as (e) to (h), should have been clearly present
for most of the time during a period of 1 month or more (DS -
IV-TR on the other hand requires a minimum period of 6
months)
O If the duration of illness is less than 1 month then a diagnosis of
acute schizophrenia like psychotic disorder should be made.
a. Thought echo, Thought insertion, or withdrawal, or Thought
broadcasting;
b. Delusions of control, influence, or passivity, clearly referred to
body or limb movements or specific thoughts, actions, or
sensation; delusional perception;
c. Hallucinatory voices giving a running commentary on the
patient·s behavior or discussing the patient among
themselves, or other types of hallucinatory voices coming from
some part of the body;
d. ersistent delusions of other kinds that are culturally
inappropriate and completely impossible (e.g. being able to
control the weather, or being in communication with aliens
from another world);
e. persistent hallucinations occurring every day for weeks or
months or months
f. breaks or interpolations in the train of thought resulting in
incoherent or irrelevant speech or neologism;
g. Catatonic behavior
h. Negative symptoms
i. A significant and consistent change in the overall quality of
some aspects of personal behavior, (loss of interest,
aimlessness, idleness, a self absorbed attitude, and social
withdrawal)
ë CLINICAL TYPES
F£ -F£ Schizophrenia
20- Schizophrenia
20.0-aranoid Schizophrenia
20.1-Hebephrenic Schizophrenia
20.2-Catatonic Schizophrenia
20.3-Undifferentiated Schizophrenia
20.º-ost- Schizophrenia depression
20.5-Residual Schizophrenia
20.6-Simple Schizophrenia
ë F£ . -Paranoid Schizophrenia
O Delusions of ersecutory, Grandeur, control, infidelity (Jealousy)
O Hallucinations have ersecutory, Grandiose content
O Unfocussed anxiety
O Anger
O Argumentativeness
O Violence
O Doubts about gender identity
O Disturbances of affect, volition, speech, and motor behavior
O ersonality deterioration is less
O atients may be apprehensive (intelligent, fearful), evasive
(escaping)
O Onset is insidious, occurs later in life, progressive and complete
recovery may not occur
O requent remissions and relapses are seen
O Slight impairment with functional capability
ëF£ .1-
ebephrenic Schizophrenia
O In other classification this type is termed as Disorganized schizophrenia
O arked thought disorder, incoherence and severe loosening of
associations.
O Delusions and Hallucinations
O §motional disturbances

ë Inappropriate affect
ë Blunted affect

ë Senseless giggling
O mannerisms
O irror gazing (for long periods of time)
O oor self care and hygiene
O Impaired social and occupational ----social withdrawal
O ICD-10 recommends 2-3 months of continuous observation for confident
diagnosis
O Onset is insidious in early 2nd decade(15-25 years)
O Course is progressive and downhill
O Recovery never occurs, severe deterioration without remissions
O Has one of the worst prognosis among the subtypes of schizophrenia
ë F£ .£-Catatonic Schizophrenia
ë Catatonia ² marked disturbance in the motor behavior  
r
  r 
  
ë Onset is acute in late 2nd and early 3rd decade

ë Course is episodic and recovery from episodes is complete,


residual symptoms may present after 2nd or 3rd episode
ë 3 clinical forms
O §xcited Catatonia
ë in psychomotor activity (restlessness, agitation,
excitement, aggressiveness, violent behavior)------
ë in speech production, pressure of speech, loosening of association,
incoherence
ë Stimuli for excitement is internal not the environmental (e.g. thoughts and
impulses) so excitement is not goal directed
ë Some times very rarely excitement can become Severe -----rigidity,

hyperthermia, and dehydration leading to death then it is known as 


 2   
   

   

O Stuporous (or retarded) Catatonia--
ë psychomotor function
ë utism
ë Rigidity

ë Negativism

ë osturing

ë Stupor

ë §cholalia

ë §chopraxia

ë Waxy flexibility

ë Ambitendency

ë Other symptoms-----mannerisms, stereotypies, automatic obedience,

verbigeration
ë Delusions and hallucinations may present but not prominent

O Catatonia alternating between excitement and stupor


ë Very common feature of both excited and stuporous catatonia are
alternatingly present
ë F£ .D-Undifferentiated Schizophrenia
O Very common type
O Diagnosed when features of no subtype are fully present or
features of more than one subtype are exhibited.
ë F£ .º-Post- Schizophrenia depression
O Some schizophrenics develop depressive features within 12
months of an acute episode associated with risk of suicide
O Can occur due to side effect of antipsychotics, regaining
insight after recovery or as just part of an schizophrenia
O It is important to distinguish the depressive features from
negative symptoms and §S of antipsychotics
ë F£ .5-Residual Schizophrenia
O Is similar to latent schizophrenia and symptoms are
same as prodromal symptoms of schizophrenia
O Diagnosed after at least one episode has occurred
ë According to ICD-10 (CDDG) it is characterized by the following
features in addition to the general guidelines of schizophrenia
ë rominent negative schizophrenic symptoms

ë ast h/o one clear cut psychotic episode

ë A period of 1 year during which the intensity and frequency of florid

symptoms such as delusions and hallucinations have been minimal


and the negative symptoms have been present
ë Absence of dementia or other organic brain disease and of chronic

depression or institutionalism for negative symptoms


ë F£ .6-Simple Schizophrenia
O ost difficult to diagnose
O §arly onset (2nd decade)
O Insidious and progressive course
O Negative symptoms are present
O Vague hypochondriacal features
O Drift down the social ladder
O Wandering aimlessly
O Delusions and hallucinations are usually absent, if present
they are short lived
O rognosis -----very poor
ë OT
ER SUBTYPES
O Pseudoneurotic schizophrenia
ë Described by
och and Polatin
ë Initially presented with neurotic symptoms which last for 1 year and

show poor response to treatment


ë 3 classical symptoms are

ë 


ë  


ë  


ë Now this subtype is subsumed under borderline personality disorder

O Schizophreniform disorder
ë This is diagnostic category in DS -IV-TR with features of
schizophrenia. Only difference is duration is less than 6 months and
prognosis is better than schizophrenia
ë This term was introduced by Langfeldt (161)

ë Similar condition in ICD-10 is called  2


2 
 
2

r
r 
O Oneiroid(dream) schizophrenia
ë Described by a !
ë Acute onset

ë Clouding of consciousness, disorientation

ë Dream like states

ë erceptual disturbances with rapid shifting

ë §pisode- brief

O Van Gogh Syndrome


ë Dramatic self ²mutilation in schizophrenia is also called as w  2

 
ë w  2was a famous painter who cut his ear during active phase of

illness
O Late Paraphrenia
ë Described by Sir artin Roth
ë Occurs late in life (6
th decade)

ë Common in unmarried or widowed women

ë Delusions of persecution as being raped or strangers entering their

room
ë Hallucinations of all kinds are present

ë §25-º0% of patients have some defect of sight or hearing

ë resently kept under paranoid schizophrenia, late onset

O Pfropf schizophrenia
ë Schizophrenia occurring in the presence of R
ë Behavioral disturbances are more prominent than thought disorder
O Type I and Type II Schizophrenia
ë T. J. Crow has divided schizophrenia in to two subtypes as
ë Type I and Type II Schizophrenia

ë Very few patients have a pure TYPE I or TYPE II syndrome

ë Admixtures are common


DI§R§NTIAL DIAGNOSIS
ë §xclude organic psychosis
O §x complex partial seizures, drug (Amphetamine)
induced psychosis, metabolic disturbances or cerebral
neoplasm
ë Rule out a possibility of mood disorder or
schizoaffective disorder
ë §xclude other non organic psychosis like
delusional disorders, or acute and transient
psychotic disorders (ATD)
ROGNOSIS
GOOD PROGNOSTIC POOR PROGNOSTIC
FACTORS FACTORS
ë Acute onset ë Insidious onset
ë Onset after 35 years ë < 20 yrs of age
ë resence of precipitating ë Absence of stressor
factors
ë Good premorbid adjustment ë oor premorbid adjustment
ë Catatonic subtype (paranoid ë Disorganized, simple,
intermediate prognosis) undifferentiated or chronic
ë Short duration (< 6 months) catatonic subtypes
ë resence of depression ë Chronic course (>2 yrs )
ë redominance of positive ë Absence of depression
symptoms ë redominance of negative
ë amily h/o mood disorder symptoms
ë amily h/o schizophrenia
ROGNOSIS
POOR PROGNOSTIC
FACTORS
ë irst episode ë ast h/o schizophrenia
ë yknic (fat) physique ë Asthenic physique
ë emale sex ë ale sex
ë Good social support ë oor social support or
ë resence of confusion, unmarried
perplexity, or ë lat or blunted affect
disorientation in the ë Absence of proper
acute phase treatment or poor
ë roper treatment or response
good response treatment ë Institutionalization
GOOD PROGNOSTIC
ë OD treatment ë §vidence of ventricular
ë
FACTORS
Normal CT Scan enlargement on CT Scan
COURS§ AND OUTCO §
ë rogressive downhill course
ë ore hospitalization
ë According to the study made by Luc Ciompi
1 which included 5661 cases and which
extended for 36.9 years the outcome was
O Complete remission (£)
O Remission with minor residual deficit (££)
O Intermediate out come (£º)
O Severe disability (1)
O Unstable or uncertain outcome ()
ë ALaOST 5  PATIENTS S
OWED COaPLETE OR
NEAR COaPLETE RECOVERY
ë 1 S
OWED SEVERE DISABILITY

ë  NEEDING
OSPITALIZATION
COURS§ AND OUTCO §
ë A study of factors associated with course and
outcome of schizophrenia (SOACOS) conducted
by IC R (Indian Council of edical Research )
at 3 centers in India (Vellore, adras, and
Luknow)
O 386 patients were followed up for 5 years (1981
to1986) the out come was
ë Very favorable outcome (27%)
ë avorable out come (º0%)

ë Intermediate out come (31%)

ë Unfavorable outcome (2%)

ë So 2/3rds (67%) of the patients had a favourable


out come as compared to 50% in Luc Ciompi ¶s
study
ë In ICD-10 the course of schizophrenia is specified
under the categories of 
i. Continuous
ii. §pisodic with progressive deficit
iii. §pisodic with stable deficit
iv. §pisodic remittent
v. Incomplete remission
vi. Complete remission
if the period of observation is less than 1 year the course is not
specified
ë Longer the duration of untreated psychosis (DU)
worse is the out come
ë Cause for increased mortality of patients in
schizophrenia is suicide
O Life time risk of suicide in schizophrenia is 5-10 times
higher as compared to normal population
ANAG§ §NT
ë SO ATIC TR§AT §NT
O HAR ACOLOGICAL TR§AT §NT
O §CT
O OTH§RS

ë SYCHOSOCIAL TR§AT §NT AND


R§HABILITATION
ë NURSING ANAG§ §NT
HAR ACOLOGICAL TR§AT §NT
ë irst drug used was reserpine (Rauwolfia
serpentina extract) by Sen and Bose in India in
1931----no longer used
ë Antipsychotics were formally discovered by
Delay and Deniker in 15£
ë Atypical antipsychotics are commonly used than
typical antipsychotics
ATYICAL ANTISYCHOTICS
ë Are more useful in negative symptoms (chronic
schizophrenia)
O Respseridone 2-10 mg/day O
O Olanzapine 10-20 mg/ day O
O Quetiapine 150-750mg/day O
O Aripiprazole
O Ziprasidone 20-80 mg/day O
O Clozapine 50-º50mg day O
   in 30% of patients who had no
beneficial response to traditional (typical and atypical
antipsychoticsc) but leads to  
 

  so used with caution
TYICAL ANTISYCHOTICS
å Trifluoperazine 15-60 mg/day O
å Haloperidol 5-100 mg/day O
å Chlorpromazine 300-1500 mg/day O

ë Drug treatment is usually given in OD setting


because
O ew number of psychiatric beds
O amilies are willing to take care
O ajority pts do not need hospitalization
ë Hospitalization is indicated when
O t neglects food & water
O t is Danger to self and other
O oor drug compliance
O Neglect of self care
O Lack of social support
ë Antipsychotics act by blocking D2 receptors in the
mesolimbic system, other receptors like 5-HT,
muscarinic receptors and GABA are also important
ë Atypical antipsychotic are also called as SDAs have
action on both dopamine and 5-HT
IN ACUT§ §CIT§ §NT
ë Haloperidol 5 mg IV / I with or without
diazepam or 50 mg promethazine
ë Chlorpromazine I abscess
IV hypotension
AINT§NANC§ TR§AT §NT WITH
ANTISYCHOTICS TO R§V§NT R§LAS§

O Treatment should be continued for 6 months to 1


year for 1st episode
O or 1-2yrs for the subsequent episodes
O Indefinite period for repeated episodes or persistent
symptoms
D§OT ANTISYCHOTIC R§ARATIONS
WITH LONG DURATION O ACTION
AVAILABL§ IN INDIA

ë luphenazine decanoate, 25-50mg I every 2-3


weeks
ë enfluridol, 20-60mg oral every week

ë lupenthixole decanoate, 20-º0mg I every


2weeks
ë Haloperidol decanoate, 100-250mg I every º
wks
ë Zuclopenthixole decanoate, 200-º00mg I , every
2-º weeks
ANTIARKINSONIAN §DICATIONS

ë Needed when pt is receiving older typical


antipsychotics (haloperidol)

ë Trihexiphenidyl (TH) 6 mg / day


ë Orphenadrine 150 mg / day

ë rocyclidine 7.5-15 mg / day


§CT
ë Not a 1o indication for §CT
ë Indications for §CT in schizophrenia are
O Catatonic stupor
O Uncontrolled Catatonic excitement
O Acute exacerbation not controlled by drugs
O Severe side effects with drugs
O 8-12 §CTs are needed (up to 18) 3 times a week
ISC§LLAN§OUS TR§AT §NTS

ë sychosurgery
O rarely used
O when used limbic leucotomy (small subcaudate lesion with
cingulate lesion) in severe and prominent depression, anxiety
or obsessional symptoms
O Antipsychotics are far better

ë any other methods used in past


O egavitamine therapy
O Dialysis
O alaria therapy
O High dose propranolol
O High dose insulin (insulin coma therapy)
SYCHOSOCIAL TR§AT §NT
ë Important component of comprehensive
management it has following steps
O sycho education
O Group psychotherapy
O amily therapy
O ilieu therapy
O Individual psychotherapy
O sychosocial rehabilitation
NURSING ANAG§ §NT
ëGeneral principles of management of
schizophrenic pts
ë I
O Chronic illness which needs long term treatment
O Total cure may not occur in most of the cases
O Aim is ---good improvement with regular and
appropriate treatment
O In times of stress the pt may get relapse in spite of
regular treatment
O ts need to
ë Increase in their own self esteem
ë Be assisted to live with the real world

ë §nvironment where he gets a change to use his own initiative and


judgment
ë Have human contacts

ë ind a nurse who is having stable and consistent nature and who
is having patience
O Accept him as he is. Accept the pt whole heartedly
O Nurse should not expect the impossible from the pt.
O Assign small responsibilities
O §ngage and support
O Supervise him
O Appreciate for every achievements
O Do not -------- Ignore
Criticize
§xert social behavior
Refrain from over involvement
ë II
ë Careful assessment--------diagnosis----------formulating
a treatment plan
ë Nsg management depends on
O Defining reality
O Handling pt control
O Strengthening the patient·s self image and Strengthening
the IR
O Giving emotional support
ë Nsg diagnosis I
Alteration in thought process r/t inability to trust,
panic anxiety, evidenced by delusional thinking,
inability to concentrate, impaired volition, extreme
suspiciousness of others
O Objective pt will eliminate patterns of delusional thinking
and demonstrate trust in others
ë Nsg diagnosis II
Sensory-perceptual alteration Auditory, visual,
r/t panic anxiety, withdrawal into self, as evidenced by
inappropriate responses, disordered thought process,
poor concentration and disorientation.
O Objective pt will be able to define and test reality,
eliminating the occurrence of hallucinations
ë Nsg diagnosis III
Social isolation r/t inability to trust, panic anxiety,
delusional thinking, evidenced by withdrawal, sad,
dull affect, preoccupation with own thoughts,
expression of feelings of rejection of aloneness imposed
by others.
O Objective pt will voluntarily spend time with other pts and
staff members in group activities on the units
ë Nsg diagnosis IV
otential for violence, self directed or directed to
others, r/t extreme suspiciousness, panic anxiety,
catatonic excitement, rage reactions, command
hallucinations, as evidenced by physical violence,
destruction of objects in the environment, self
destructive behavior or active aggressive suicidal acts.
O Objective pt will not harm self or others
ë Nsg diagnosis V
Impaired verbal communication r/t panic anxiety,
disordered, unrealistic thinking as evidenced by
loosening of associations, echolalia, verbalizations that
reflect concrete thinking and poor eye contact
Objective pt will be able to communicate appropriately and
comprehensibly by the time of discharge
ë Nsg diagnosis VI
Self care deficit r/t withdrawal, panic
anxiety, perceptual or cognitive impairment as
evidenced by difficulty in carrying out tasks associated
with hygiene, dressing, grooming, eating, and toileting.
O Objective patient will demonstrate ability to meet self care
needs independently
DTHµL;;
¶;. Nsg diagnosis VII
ë
´ ineffective family coping r/t highly
ambivalent family relationships, impaired family
communications, as evidenced by neglectful care of the
client, extreme denial or prolonged over concern
regarding his illness
O Objective family will identify more adaptive coping
strategies for dealing with patients illness and treatment
regimen.
§VALUATION
ë Has the pt established trust with at least one
staff member?
ë Is delusional thinking still prevalent?

ë Are hallucination still evident?

ë Is the pt able to interact with other


appropriately?
ë Is the pt able to carry out all activities of daily
living independently?
NSG CAR§ O TH§ ACUT§LY ILL
SCHIZOHR§NICS

ë Common in catatonic and paranoid types


ë ain nursing concern is controlling his impulsive
behavior when hears voices and respond to them
ë t may be abusive to the staff so the nurse who
has established trust should collect the data
ë hysical need of the pt should be met

ë Inj Haloperidol 10 to 20 mg I /IV

ë Inj Chlorpromazine 100 mg I

ë Check for injuries

ë Approach the patient with assistants


NSG CAR§ O TH§ CHRONIC
SCHIZOHR§NICS

ë Usually withdrawn and have lot of negative


symptoms
ë §ngage the patient in useful activities (idle mind
is a devils workshop)
ë The patients who live in fantasy have bad
prognosis
ë He should be encouraged to do some positive,
physical work (rehabilitation)
ë §ncourage and motivate the pt

ë Appreciate him at appropriate time


HYSICAL, § OTIONAL, AND TH§RA§UTIC
N§§DS O TH§ CHR TS

ë hysical needs
O Nutrition
O ersonal hygiene
O §limination

ë §motional needs
O To improve Social contacts, communication, and IR
O Give importance to personal identity
ë Therapeutic needs
O Accept the pt as human being
O Give responsibility about ward routine works
O atiently and positively hear the suggestions from the pt
himself in implementing routine ward work
O Chronic patients need stimulation, occupational and
recreational therapies
O Nursing care of Chronic patients emphasis should be placed on
the 5 R·s
ë Reassurance
ë Readjustment

ë Reeducation

ë Rehabilitation

ë Recreation