UNIT- VI

NURSINGMANAGEMENT OF
PATIENT WITH
SCHIZOPHRENIA & OTHER
PSYCHOTIC DISORDERS
-Schizophrenia
Definition
Epidemiology
Etiology
ClinicalTypes
Diagnosis
Treatment modalities
Nursing management
CONTENT-
1. INTRODUCTION
2. DEFINITION
3. HISTORY
4. EPIDEMIOLOGY
5. ETIOLOGY
6. THE SYMPTOMS OF SCHIZOPHRENIA
7. SCHIZOPHRENIA DIAGNOSIS ACCORDING TO
ICD-10
8. CLINICAL FEATURE
9. TREATMENT MODELITIES $ MANAGENT OF
PATEINTS WITH SCHIZOPHRENIA
10. NURSING MANAGEMENT
11. CONCLUSION
12. REFERENCE
 INTODUCTION-
 Schizophrenia is an extremely complex mental disorder.
 Schizophrenia causes distorted and bizarre thoughts,
perceptions, emotions, movement, and behavior.
 It cannot be defined as a single illness; rather thought as
a syndrome or disease process with many different
varieties and symptoms.
 It is usually diagnosed in late adolescence or early
adulthood. Rarely does it manifest in childhood.
 The peak incidence of onset is 15 to 25 years of age for
men and 25 to 35 years of age for women.
 Schizophrenia is a chronic, severe, and disabling brain
disorder that has affected people throughout history.
Definition:
Schizophrenia is psychotic disorder
characterized by disturbance in thinking,
emotion and volition in clear conscious
which lead to social withdrawal.
 Schizophrenia is one of a group of disorders
known as psychoses. A person experiencing
psychosis has a loss of contact with reality.

HISTORY OF SCHIZOPHRENIA-
Early theories supposed that mental disorders were
caused by evil possession of the body.
German physician, Emil Kraepelin. He used the term
"dementia praecox" for individuals who had
symptoms that we now associate with schizophrenia.
Swiss psychiatrist, Eugen Bleuler, coined the term,
"schizophrenia" in 1911.
This word comes from the Greek roots schizo (split)
and phrene (mind) to describe the fragmented
thinking of people with the disorder.
Kurt Schneider, he emphasized the role of
psychotic symptoms, as hallucinations, delusions and
gave them the privilege of “the first rank symptoms”
even in the concept of the diagnosis of
schizophrenia.
 Bleuler maintained, that for the diagnosis of
schizophrenia are most important the following
four fundamental symptoms:

◦ Affective blunting.
◦ Association disturbance. (fragmented
thinking)
◦ Autism.
◦ Ambivalence. (fragmented emotional
response)

 These groups of symptoms, are called „four A’ s”

and Bleuler thought, that they are “primary” for
this diagnosis.
FIRST RANK SYMPTOMS(SFRS) OF
SCHIZOPHRENIA-
1. Hallucinations:
Audible thoughts: Voices speaking out thoughts
aloud or “thought echo”.
Voices heard arguing: Two or more
hallucinatory voices discussing the subject in
third person.
Voices commenting on one’s action.

2. Thought alienation phenomena

Thought withdrawal: Thought cease and subject
experience them as remove by external forces.
Thought insertion: Subject experiences
thoughts imposed by some external force on his
passive mind.
Thought diffusion or broadcasting: Subject
experiences that his thoughts are escaping the
confines of his self and are being experienced by
other around.
3. Passivity phenomena
‘Made’ feeling or effect.
‘Made’ impulses.
‘Made’ volition
Somatic passivity: Body sensations, especially
sensory symptoms, are experience as imposed
on body by some external force.
4. Delusional perception
Delusional perception: Normal perception has a
private and illogical meaning.
He also describe second rank of symptoms
of schizophrenia ( which are consider less
important for diagnosis of schizophrenia), like
other forms of hallucination, perplexity, and
effect disturbances.
EPIDEMIOLOGY-

 According to World (Mental) Health Report 2001,

about 24 million people world wide suffer from
schizophrenia.
 prevalence of schizophrenia about 0.5-1%.
Schizophrenia is prevalence a crossed racial, socio
cultural and national boundaries.
 The incidence of schizophrenia is believed to be
about 0.5/1000.
 The onset of schizophrenia occurs usually later in
women and often runs a more benign course, as
compared to men.
 
EPIDEMIOLOGICAL FINDINGS-
Schizophrenia is found in all countries and
incidence rate per 1000 people annually range from
0.15 in demark to 0.42 in India (WHO 1973).
About 1% of Americans have this illness.
Life time prevalence rates of schizophrenia based on
the epidemiology catchment area (ECA) data, were
approximately 1% (ranges across three sites, 1-
1.9%) (Robins el al.,1984).
Point prevalence rate based on International Pilot
study of Schizophrenia data showed no significant
difference across study centers: schizophrenia was
found universally with relatively equal frequencies
in a wide variety of culture.
 ETIOLOGY-

Foremost etiology of schizophrenia today is the

biologic perspective.
The new discoveries of genetic influence, the role of
neuroanatomy, endocrinology, and immunology in
producing symptoms.; and the issues of trauma and
disease in causation.
1. BIOLOGIC FACTOR:
1.Hereditary and genetics-
2.Neuroanatomics and
neurochemicals-
3.Neurotransmitter function-
4. Immunologic factors-
5 .High arousal level of stress, disease
trauma, and drugs-
6.Trauma from obstetric complication, head
trauma, and childhood accident-
7.Drugs such as cannabis and cocaine-
2.PSYCHO ANALYTIC AND DEVELOPMENTAL
FACTOR-
1.Distortion in mother child relation.
II. Ego distortion.
III. Faulty reality interpretation.
3. FAMILIAL FACTOR-
I. Repressed unhappiness.
II. Double-bind pattern.
III. Marital schism of parents.
IV. Destructive, expressed emotion
communication patterns
4.Cultural and environmental theories-
Low socio economic status.
Lessened social support of family and community;
changes in social roles.
5. Learning theories and Behavioural
models-

 Irrational problems solving methods ,

distorted thinking, and deficits
communication patterns learned from
parents.
 Generalized social interaction.
6. Theories of psychophysiologic effects of
environment-

Toxic substance (selenium) in

atmospheric population
 THE SYMPTOMS OF
SCHIZOPHRENIA-

1.Positive symptoms-
 Positive symptoms are psychotic behaviors not
seen in healthy people.
 The positive symptom are characterized
by the presence of hallucinations and
delusions.
 The division is not quite strict and lesser
or greater mixture of symptoms from
these two groups are possible
2. Negative symptoms-

 The negative symptoms are represented by

cognitive disorders, having its origin probably in
the disorders of associations of thoughts, combined
with emotional blunting.
 Affective flattening or blunting.
 Attentional impairment.
 Avolation- apathy (lack of initiative).
 Anhedonia (inability to experience pleasure).
 Asociatly (social withdrawal), and
 Alogia (lack of speech output).
 Schizophrenia diagnosis according to
ICD-10:
For the diagnosis of schizophrenia is necessary
 presence of one very clear symptom - from point a) to
d)
 or the presence of the symptoms from at least two
groups - from point e) to h) for one month or more:

a. Thought echo, through insertion or withdrawal, and

thought broadcasting.
b. Delusion of control, influence, or passivity, clearly
referred to body or limb moments or specific thoughts,
actions or sensations; delusional perception.
c. Hallucinatory voices giving a running commentary
on the patients behaviours, or discussing the patient
among themselves, or other types of hallucinatory
voices coming from some part of body.

d. Persistent delusions of other kinds that are

culturally inappropriate and completely impossible,
such as religious or political identity, or
superhuman powers and abilities (eg: being able to
control the weather, or being in communication
with aliens from another world);
e.Persistent hallucination in any modality, when
accompanied either by fleeting or half formed
delusions without clear affective content, or by
persistent over valued ideas, or when occurring
every day for week or months on end.

f. Breaks or interpolations in the train thought,

resulting in incoherence or irrelevant speech, or
neologisms.

g. Catatonic behaviour, such as excitement,

posturing, or waxy flexibility, negativism, mutism,
and stupor.
h. “Negative” symptoms such as marked apathy, paucity of
speech, and blunting or incongruity of emotional responses,
usually resulting in social withdrawal and lowering of social
performance it must be clear that these are not due to
depression or to neuroleptics medication.

i. A significant and consistent change in the over all quality of

some aspects of personal behaviour, manifest as loss of
interest, aimless, idleness, a self absorbed attitude, and
social withdrawal.
F20-F29 SCHIZOPHRENIA, SCHIZOTYPAL
AND DELUSIONAL DISORDERS-

F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified
F21 Schizotypal disorder

F22 Persistent delusional disorders

F22.0 Delusional disorder
F22.8 Other persistent delusional disorders
F22.9 Persistent delusional disorder, unspecified

F23 Acute and transient psychotic disorders

F23.1 Acute polymorphic psychotic disorder with
symptoms of schizophrenia
F23.2 Acute schizophrenia-like psychotic disorder
F23.3 Other acute predominantly delusional psychotic
disorders
F23.8 Other acute and transient psychotic disorders
F23.9 Acute and transient psychotic disorder,
unspecified
F24 Induced delusional disorder

F25 Schizoaffective disorders

F25.0 Schizoaffective disorder, manic type
F25.1 Schizoaffective disorder, depressive
type
F25.2 Schizoaffective disorder, mixed type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified

F28 Other nonorganic psychotic disorders

F29 Unspecified nonorganic psychosis

F20.0 PARANOID SCHIZOPHRENIA
Itis the commonest type. It is
characterized by persecutory delusion,
often systematized and by persecutory
auditory hallucinations.
Thought disorder and effective, catatonic
and negative symptoms are not prominent.
Personality is relatively well preserved. It
has a latter age of onset, and better
prognosis, than other sub type.
F20.1 HEBEPHRENIC SCHIZOPHRENIA-
It is also called disorganized schizophrenia,
thought disorder and effective symptoms are
prominent.
The mood is variable, with behaviour often
appearing silly and unpredictable.
Delusion and hallucination are fleeting and
not systematized. Mannerisms are common.
Speech is rambling and incoherent,
reflecting the thought disorder.
Negative symptoms occur early, and
contribute to a poor prognosis
F20.2 CATATONIC
SCHIZOPHRENIA-
The most striking feature are motor symptoms,
changes in activity ranging between excitement and
stupor.
F20.3 UNDIFFERENTIATED
SCHIZOPHRENIA-
 It is characterized by the insidious
development of odd behaviour, social
withdrawal , and declining performance at
work.
Delusions and hallucination are not evident.
 F20.4 POSTSCHIZOPHRENIC
DEPRESSION-
A depressive episode, which may be prolonged,
arising in the aftermath of a schizophrenic illness.
Some schizophrenic symptoms, either „positive“ or
„negative“, must still be present but they no longer
dominate the clinical picture.
These depressive states are associated with an
increased risk of suicide.
F20.5 RESIDUAL SCHIZOPHRENIA-
A chronic stage in the development of
schizophrenia with clear succession from
the initial stage with one or more episodes
characterized by general criteria of
schizophrenia to the late stage with long-
lasting negative symptoms and
deterioration
 F20.6 SIMPLE SCHIZOPHRENIA-
Simple schizophrenia is characterized by early and
slowly developing initial stage with growing social
isolation, withdrawal, small activity, passivity,
avolition and dependence on the others.

The patients are indifferent, without any initiative

and volition. There is not expressed the presence of
hallucinations and delusions.
CLINICAL FEATURE-

1.Thought and speech disorder.

2.Disorder of perception.
3.Disorder of affect.
4. Decreased in psychomotor activity and
increased in activity.
TREATMENT MODELITIES AND NURSING
MANGENT OF PATEINTS WITH
SCHIZOPHRENIA-

TREATMENT MODELITIES:
Research over the last 10 years has
shown that about 80% of patient with
schizophrenia respond to drugs; of these
20% recover well after first attack, but
60% (and the 20% who do not respond)
required psychosocial interventions.
DRUG THERAPY-

 The acute psychotic schizophrenic

patients will respond usually to
antipsychotic medication.
According to current consensus we use in
the first line therapy the newer atypical
antipsychotics, because their use is not
complicated by appearance of
extrapyramidal side-effects, or these are
much lower than with classical
antipsychotics.

The “newer antipsychotics” with clozapine do not

have moment disorders as a side effect, but blood
dyscrasia is a serious complication with clozapine.
Effectiveness of Antipsychotic Dugs in
Schizophrenia (Lieberman et al , 2005)
 TREATMENT OF THE ACUTE
PHASE-

 If the patient is not cooperative and violent, it may

be necessary to administered chlorpromazine or
haloperidol.
Simultaneous administration of antihistaminic will
prevent allergic reactions and addition of diazepam,
will improve the calming effect of the antipsychotics.
The parental administration may be repeated every 8
hours.
Ifthe patient becomes cooperative, oral medication
may be given. Antiparkinsonian agents can be
added to avoid the extra pyramidal side effects.
With improvement in agitation, restlessness and
violence, the doses may reduced.
 Reduction of the positive symptoms may take
much longer (2-4 weeks).
Patients should be treated prophylaticlly with
antipsychotics for 1-2 years after the first episodes
and 3-5 after multiple episodes.
Maintenance medication may be in the form of oral
drug only.
PHYSICAL THERAPY-
Indication for ECT in schizophrenia include:
◦ Catatonic stupor
◦ Uncontrolled catatonia excitement
◦ Severe side effects with drugs
◦ Schizophrenia refractory to all other forms of
treatment
◦ Usually 8-12 ECTs are required
 A combination if ECT and neuroleptics has been
better effects than ECT alone or neuroleptics
alone
 INDIVIDUAL PSYCHOTHERAPY-

The therapist tries to counteract the client’s anxiety,

offer warmth and reassurance, and move the fear
“almost automatically aroused by interpersonal
contact”.
 THE PRINCIPLES OF THE PSYCHOTHERAPY
OF THE SCHIZOPHRENIC CLIENT ARE AS
FOLLOWS-
1. Stimulate very little or create no anxiety, and
diminish the anxiety already present in the client.
2. Prevent the client from returning to his premorbid
(Pre-psychotic) state, which would promote
continued vulnerability for psychosis.
3. Achieve and maintain a state of “delicate balance”
prior to the client’s independence from treatment,
because of his continued poor tolerance for
frustration, discomfort and anxiety.
4. Employ a therapeutic approach by which the client
moves toward the client moves toward gradual and
progressive self acceptance.
The therapist needs to demonstrate certain process
and personal attributes like-
 Sense of self-confidence and self worth.
 Honesty.
 Commitment to the client and his welfare.
 Persistence and hope.
 Ability to postpone the gratification of feeling professional
competent.
 Tolerance for uncertainty.
 Tolerance for madness without becoming frightened or
rejecting.
 Tolerance for error.
GROUP THERAPY-
Various forms of group therapy may be
employed as a psychosocial form of
treatment for psychotic clients in mental
health settings.
 Concrete, brief, and direct or psycho-
analytically oriented group interactions
benefit the patient with schizophrenia
disorders.
 
MILIEU THERAPY-
 Milieu therapy provides nonthreatening
environment to the schizophrenia clients.
They feel free to talk, express their feeling and
relearn certain social skills.
 The overall milieu attitude reflects the therapeutic
effectiveness of the environment the has been
designed for clients.
The clients learn to gain responsibilities of
managing the ward activities and in turn it provides
the opportunity for clients to participate in decision
making relevant to their living situation.
BEHAVIOUR THERAPY-

 In a behaviorist approach, the

schizophrenic clients are seen as an
individual with specific and measurable
problems.
The main objectives of behaviour therapy is
to improve schizophrenia client’s social
adaptations, vocational functioning and
subjective well-being.
Cognitive behavior therapy for residual symptoms in
schizophrenia patients in community-
( Dickerson & Lehman, 2005)
RELAPSE IN SCHIZOPHRENIA:
CURRENT ISSUES-

Nature of relapse
What causes Relapse
How to minimize
What is beyond relapse prevention in
improving outcome
Relapse: ‘Life is never the same
again’

 Expected in 70% patients after First episode

 70% of patients show an incomplete remission after
first episode
This includes Cognitive decline ( in 55%)
 persistence of negative symptoms ( in 41%),
 often associated with Social disabilities,
Social Decline and a worsened QOL.
Risk of relapse after an episode remained increased
throughout the life.
 Relapse

Side effects Lack of efficacy

Psychosocial stress Interrupted activity

With partial With complete

With no adherence adherence Adherence

Attitude-
like/dislike Nature of illness

Acceptance-personal Loss of
choice effecnecy

Lack of information, Life events

education
 Combining Medication and Family
Education in Schizophrenia; Relapse Rates-
Expressed Emotion in relapse of
schizophrenia-
 One of the main contributors to relapse in
psychological disorders is expressed emotion.
Expressed emotion is the critical, hostile, and
emotionally over-involved attitude that relatives
have toward a family member.
Family members high in expressed emotion
cause relapse in schizophrenia,
The stress from negative criticism and pity
becomes a burden on the person with a disorder,
and the only way to cope is relapse.
cumulative relapse/rehospitalization rates during 18
to 24 months in randomized controlled
trials of long-term family intervention for
schizophrenia.

Kim et al. Medscape General

Medicine 3(1), 2001
 INTERVENTIONS FOR
HOSPITALISED CLIENTS-

1. THERAPEUTIC COMMUNICATION-
One way to build rapport is to allow clients to
express concerns openly at their own pace.
Excessive questioning may seem like praying and
increase of suspiciousness.
 EFFECTIVES COMMUNICATION
TECHNIQUES-
Use brief, short-word sentences and a non-
threatening tone.
Avoid ultimatums, arguments, and challenging
statements.
If trust is established, gently point out that client’
beliefs or hallucinations are not real. For instance,
“I don’t see anyone following you,” or “I don’t
hear any voices.”
Maintain an honest and consistent
approach.
Use supportive statements such as “The
world is a scary place,” or “It’s hard to
understand all that’s going on.”
Approach the client in calm manner, and
use frequent, short interactions to build
trust.
Explain procedures and the need for
medication simply.
MAINTAINING SAFETY-
 Reassure them that they are safe and
provide a non- stimulating, safe
environment.
One-to-one interactions may help minimize
paranoia and excess stimulation.
Avoid challenging or confrontational
statements.
Maintain a safe distance when clients
appears potentially dangerous while
continually assessing client safety.
 If behaviour escalates to hurting self or
others, consider seclusion and physical and
chemical restraint.
WAY TO PREVENT THE SEFL-HARM OR
DANGEROUS BEHAVIOUR-

Keep clients safe, particularly if “command”

hallucination are present that tell them to hurt
themselves.
Ensure that the client’s environment is safe and
non-stimulating.
Continuously assess the nature and severity of
hallucinations and delusions by asking clients to
describe them.
Reassure clients that they are safe and that you are
there to help.
PSYCHOSOCIAL REHABILITATION-

 There are many areas of function, dysfunction

and non-function in schizophrenia illness that
would required the “psychosocial” approach.

The range of interventions advised for patient is:

Social skill training.
Cognitive retraining.
Pre-vocational training.
Vocational training.
Job seeking/ preparation for open employment.
 1.Social skill training-
social skill training is a type of behaviour therapy
used in person who has marked deficits in social
skills.
 It includes retraining in the skills originally
possessed by the patient.
The inadequate personal care, difficulties in
carrying out the activities of daily living, poor
communication, difficulties in problem solving and
interpersonal relationship results in poor social and
occupational functioning.
The methods used in these training programs
generally include instruction, modeling, role
playing or drama.
2.COGNITIVE RETRAINING-
As a specialized intervention, is gaining
importance as deficits in attention and
concentration are being recognized and as major
contributors to the deficit state.
3.PREVOCATIONAL SKILLS-

The vocational skills/ technical skills.

Pre vocational training helps the person to be
punctual at the work spot, groom well, adhare to
the rules of the center, adjust well with fellow
workers and environment, respect the supervisor,
deep capacity of following instructions, request
for assistance when necessary and proper use of
leisure time during a working day (lunch and tea
break), and the time and money management.
 4.VOCATIONAL TRAINING-
Work improves the physical mental health
of the individual,
Particularly so in the case of those
recovered from mental illness because it-
Give time structured day.
Improves social contacts outside the family.
Gives a sense of doing things with others.
Improves social status.
Gives a chance to improve existing skills and
learn new skills.
Improves economic status.
Work therapy:
 To able him to work and learn to leaving
vocational training requires information
regarding-
Existing vocational skills.
Extent of disability.
Clinical state.
Family supports.
Social skills ad coping, and competence.
5.JOB SEEKING / JOB PLACEMENT-
They can return to his job and keep it with little
supportive therapy, family support and
understanding employer.
The family needs to keep in touch with agency
regarding continuing medication, job holding
and any other problems that might arise.
 NURSING MANAGEMENT-
NURSING DIAGNOSIS-

1. Disturb thought process evidenced by delusions, exaggerated

responses related to inability to process and synthesized
information, in-ability to evaluate.
2. Social isolation as evidence by withdrawal anxiety in social
situations, inappropriate behaviour, and poor attention span
related to inability to concentrate, anxiety, preoccupation
with own thoughts, delusion, hallucinations.
3. Self care deficit evidenced by difficulty with grooming,
nutrition, hygiene related to regression, withdrawal, and
impaired thought processes.
4. Impaired verbal communication evidenced by flight
of ideas, neologisms, word salad, echolalia related to
disordered thinking, withdrawal, regression and
impaired judgment.
5. Disturbed personal identity related to loss of ego
boundaries, disorganized illogical thinking, feeling
of anxiety, fear, and aggressive behaviour towards
others or property.
6. Ineffective health maintenance related to in
adequate food and fluid intake, inability to follow
through with activities of daily living.
7.Disturbed sensory perception (specify visual,
auditory, etc) related to inability to discriminate
between real and unreal perceptions, feeling of
insecurity.
8.Risk for other-directed violence related to
agitation, hostile or threatening verbalization,
history of aggression towards property or others
fear and suspicion.
1.Distrub thought process evidenced by
hallucination, delusions, exaggerated responses
related to inability to process and synthesized
information, in-ability to evaluate.

Nursing goals:
The client will demonstrates improved reality
orientation.
To improve the reality based thinking.
To reduced evidence of hallucinations or
delusions.
Interventions:
Approach the client in a calm manner without
showing shock or judgmental responses to
behaviour, promote trust.
Focus on client’s current behaviour rather than
past behaviour or issues.
Maintain communication with client by making
short, frequent contacts without threatening or
challenging his or her beliefs. Avoid physical
contact any behaviour that could be interpreted as
threatening.
Incorporate reality orientation in all
communication.
Provide structured routine.
Encourage client to talk about real events. Avoid
listening to long, confusing stories that are not
based on reality. Rather, direct conversation to here
and now events. If client is hallucinating or is
delusional, let him or her know you realized these
can be frightening but do not react to them as if
they are real. Avoid talking back to the client’s
voices or getting involved in the delusion.
Focus on the feelings generated by the
hallucinations or delusion rather than the content
such as fear or comforts created by them.
Distract the client by focusing on less threatening
contents.
2.Social isolation as evidence by withdrawal anxiety
in social situations, inappropriate behaviour, and
poor attention span related to inability to
concentrate, anxiety, preoccupation with own
thoughts, delusion, hallucinations.

Nursing goals:
The client will demonstrates improvement in
appropriate communication with others.
Client will be less anxiety and appropriate
behaviour in social stimulations.
Client will express pleasure in participating in
social activities.
Intervention:
 Spend brief period with client engaging in non threatening
conversation reinforcing trust.
 Reinforce any attempts at communication and
participation in social activities.
 Identify client’s interest and focus discussion on that.
 Gradually encourage participation in social activities for
brief periods. Offer to be with client during these
activities.
 Ensure that the client can leave social situation if it
becomes very threatening. Teach client specific techniques
for coping with increasing tension and anxiety.
 Role model appropriate behaviour in situations. Give client
gentle feedback on inappropriate behaviour.
3.Self care deficit evidenced by difficulty with
grooming, nutrition, hygiene related to regression,
withdrawal, and impaired thought processes.

Nursing goals:
Client will increased ability to care for self.
Client will increased interest in self care.
Reports any need for assistance with personal care.
Intervention:
 Assess client’s ability to meet basic self care needs such as
nutrition, hydration and elimination.
 Provide assistance with self care needs.
 Encourage wearing appropriate clothing.
 Role model appropriate behaviour and give concentrate
directions on what is expected.
 Develop structured schedule for client’s routine for hygiene,
toileting and meals. Ensure that all the staff are aware of the
schedule and follow it for consistency.
 If the client is not eating, offer food and fluids on a regular
schedule.
 Encourage client to ask for assistance.
 Gently correct or assist client when demonstrating behaviour.
Considered limiting social situations until able to do some things
for him-self or her-self such as eating.
4.Impaired verbal communication evidenced by flight
of ideas, neologisms, word salad, echolalia related
to disordered thinking, withdrawal, regression and
impaired judgment.

Nursing goals:
Client will improve ability to express self.
Patient can identifies factors that influence
inappropriate response.
Client will reduced incidence of inappropriate
communication.
Intervention:

 1.Facilitate trust by communicating your concern about

client.
 2.Arrange for consistent staff to work with client to facilitate
understanding of client and enhance trust.
 3.point out incongruous communication that can make the
client’s massage confusing. Role model appropriate and
congruous behaviours and massages.
 4.Assist client in communicating his or her needs to others.
 5.Demonstrate a calm, patient demeanor especially if the
client is unable to communicate his or her needs. Anticipate
needs when possible.
 6.Maintain brief but frequent contact with client to
encourage verbal communication.
5.Disturbed personal identity related to loss of ego
boundaries, disorganized illogical thinking, feeling
of anxiety, fear, and aggressive behaviour towards
others or property.

Nursing goals:
Remains free from injury.
Establishes contact with reality.
Demonstrates or verbalize decreased psychotic
symptoms and feelings of anxiety, agitation, and so
forth.
Does not harm others or destroy property.
Participates in the therapeutic milieu.
Intervention:

 Reassure the client that the environment is safe by briefly

and simply explaining routines, procedures, and so forth.
 Protect the client from harming himself or herself or other.
Remove items that could be used in self-destructive
behaviour.
 Remove the client from the group if his or her behaviour
becomes too bizarre, disturbing, or dangerous to others.
 Help the client’s accept the client’s “strange” behaviour.
Give simple explanations to the client’s group as needed.
 Consider the other client’s needs. Plan for at least for at
least one staff member to be available to other clients if
several staff member needed to care for this client.
 Explain to other clients that they have not done anything to
warrant the client’s verbal or physical threats; rather, the
threats are the result of the client’s illness.
 Set limits on the client’s behaviour when he or she is unable
to do so. Do not set the limits to punish the client.
 Decrease excessive stimuli in the environment.
 Reorient the client to person, place and time as indicated.
 Spend time with the client even when he or she is unable to
respond verbally or in a coherent manner. Convey your
interest and caring.
 Make only promises that you can realistically keep.
6.Inaffective health maintenance related to in
adequate food and fluid intake, inability to follow
through with activities of daily living.

Nursing goals:
Establish a balance of rest, sleep, and activity.
Ingest adequate amounts of food and fluids.
Take medications as administered.
Completes necessary daily activities with minimal
assistance.
Intervention:

 If the client has delusions that prevent or limit rest, sleep, or

food or fluid intake it may be necessary to institute measures
that deal directly with physical health.
 If the client thinks that his or her food is poisoned or that he or
she is not worthy food, it may be necessary to alter routines to
increase the clients control over issues involving food. As a
trust relationship develops, gradually introduce more routine
procedures.
 If the client is too suspicious to sleep, try to allow the client to
choose a place and time in which he or she feel most
comfortable sleeping. Sedatives as needed may be indicated.
 If the client is suspicious or schedules or is reluctant to take
medications and times of administration. The client can record
medications as they are taken.
7.Disturbed sensory perception (specify visual,
auditory, etc) related to inability to discriminate
between real and unreal perceptions, feeling of
insecurity.

Nursing goal:
Client will decreased hallucinations.
The client will interact with others in the external
environment.
Verbalizes plans to deal with hallucinations, if they
reoccur.
Make sound decisions based of reality.
Intervention:

 Be aware of all surrounding stimuli, including sounds from

other room (television or stereo in adjacent areas).
 Try to decrease stimuli or move the client to another area.
 Avoid conveying to the client the belief that hallucination
are real. Do not converse with the “voices” or otherwise
reinforce the client’s belief in the hallucination as reality.
 Explore the content of patient’s hallucination during the
initial assessment to determine what kind of stimuli the
client is receiving. Remember not to reinforce the
hallucinations as real.
 Communicate what the client verbally in direct, concrete,
specific term and avoid gestures, abstract ideas and
innuendos.
 Avoid placing the client in a situation in which choices need
to be made. client’s conversation when he or she refer
reality.
 Encourage the client
 Respond verbally to anything real that the client talks about;
reinforce the client to make staff member to aware the
hallucinations when they occur or when they interferes with
the client’s ability to converse and carry out activities.
 If the clients appears to be hallucinating, attempt to engage
the client’s attention, and provide conversation or a concrete
activity of interest to the client.
 Maintain simple, basic topics of conversation to provide a
basic in reality
8.Risk for other-directed violence related to agitation,
hostile or threatening verbalization, history of
aggression towards property or others fear and
suspicion.

Nursing goals:
 Remains free from injury.
 Does not injure others or destroy property.
 Expresses decreased feeling of agitation, fear, or anxiety.
 Takes medications as prescribed.
 Demonstrates methods of revealing anxiety.
 Verbalizes feelings of anger, frustration, or confusion.
Interventions:

 Provide protective supervision for the client, but avoid

hovering over him or her.
 Remain aware of cues indicating that the client is
hallucinating (intent listening for no apparent reason,
talking to some one when no one is present, and muttering
to self, inappropriate facial expression.)
 Provide a structured environment with schedule routine
activities of daily living. Explain unexpected changes. Make
your expectations clear to the client in simple, direct terms.
 Be alert for signs of increasing fear, anxiety, or agitation so
that you may intervene as early as possible and prevent to
client, others or property.
 Avoid backing the client verbally or physically.
Intervene with one-to-one contact, seclusion, and
medication as needed.
Be realistic in your expectations of the client; do
not expect more or less of the client than he or she
is capable of doing.
As agitation subsides, encourage the client to
express his or her feelings, first in one-to-one
contacts, then in small groups and then in larger
groups as tolerated.
Helps the client identify and practice way to
relieve anxiety, such as deep breathing,
meditation, listening to music and so forth.
A study by Dr. Hui11 on Relapse in schizophrenia in Hong
Kong shows that relapse rates in schizophrenia have been
studied extensively in both naturalistic and controlled
studies. Naturalistic studies have found that the cumulative
relapse rate was 70%-82% up to 5 years following the first
admission or episode, 93 first-episode psychosis patients
found that relapse rates were 21%, 33%, and 40% in the
first, second and third year respectively. Conclusions drawn
from naturalistic studies, however, failed to exclude the fact
that the high relapse rate is a result of medication
discontinuation where it is not uncommon in patients with
psychotic disorders.
A study on “Relapse and Re hospitalization Rates in Patients with
Schizophrenia: Effects of Second Generation Antipsychotics” by
E.K12 et. al conventional antipsychotic drugs, such as haloperidol
and fluphenazine, are effective in preventing relapse, second
generation antipsychotic drugs, such as clozapine, risperidone
and olanzapine, appear to be superior in preventing relapse and
improving the patient's quality of life. Minimising adverse effects
thus helps to improve treatment compliance and prevent relapse.
Second generation antipsychotic drugs tend to have fewer
adverse effects than conventional agents, especially
pseudoparkinsonism and akathisia. The societal costs of treating
patients with schizophrenia can be lessened by employing
strategies that decrease relapse and the need for
rehospitalisation, the most costly treatment alternative.
 
 CONCLUSION-

Schizophrenia is an extremely complex mental

disorder, which may increasing number of disability
produced by it has become a matter of great concern
in mental health care system. Psychosocial
treatments can help people with schizophrenia who
are already stabilized on antipsychotic medication.
Antipsychotic medications have been repeatedly
shown to be effective for the treatment of acute
psychosis and the prevention of relapse for persons
suffering from schizophrenia.
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URL:http://schizophreniabulletin.oxfordjournals.org/search
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http://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=1017&context=psychiatr
ypres
10. Expressed Emotion as a Precipitant of Relapse in Psychological
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http://www.personalityresearch.org/papers/mcdonagh.html
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http://www.ingentaconnect.com/content/adis/cns/2002/00000016/00000
007/art00004
THANK YOU………………