NURSING CARE

AND MANGEMENT
OF
SCHIZOPHRENIA

SITI NORHIDAYAH BINTI MD ISA​

AGENDA
INTRODUCTION

ETIOLOGY

SIGN AND SYMPTOM

DEMOGRAPHIC DATA

MSE

MANAGEMENT AND TREATMENT

NURSING DIAGNOSIS AND INTERVENTION

SUMMARY

REFERENCE
 INTRODUCTION
• Over the years, schizophrenia has remained a contentious diagnosis. The issues would not be
rehearse here, but to say that there is no “construct validity” – there is still no way of
demonstrating that this condition exists: there are no X-ray, scan, blood test or post-mortem
findings to confirm the condition. The diagnosis is made exclusively on the basis of the
observed behaviour. Do read around the history of schizophrenia – it will hold your attention. It
is generally accepted that about one percent of the population will have this disorder (APA,
2000). Usually, it is noticed and diagnosed in late adolescence and early adulthood, with a
slight variation in the peak incidence of onset for man and women. The incidence of onset
peaks around the ages of 15 to 25 years for man and 25 to 35 years for women.

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 ETIOLOGY
Did you know that there is no one thing that caused schizophrenia? The cause or causes
are yet unknown. Researchers have investigated genetic, physical, psychological and
environmental factors as likely contributing factors in the development of the disorder.
Clearly for some individuals who are susceptible, a stressor such as an emotional life
event can bring about a psychotic episode. The following are said to be risks that
increase the possibility of developing schizophrenia:

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 5

1.GENETICS
2.BRAIN DEVELOPMENT
3.BRAIN CHEMICALS
(NEUROTRANSMITTERS)
4.RECREATIONAL DRUG USE
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 SIGN AND SYMPTOM
• Schizophrenia is not a simple disorder; it is complex and can take many forms. Take
note that some of these symptoms can appear in other conditions too such as mania
and severe depression. The symptoms are explained as follows:

• Hallucinations

• Illusion

• Delusions

• Loose Association

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CONT.. 7

The symptoms of schizophrenia are usually thought of as belonging to two major groupings, namely
positive symptoms and negative symptoms. There are many other concepts that you will come across
in the course of our discussion, followed by appropriate explanations. Let us learn more on these
symptoms as follows:

(a) Positive Symptoms These are exaggerations or distortions of normal thoughts, emotions and
behaviour for example, hallucinations, delusions, disorganised thinking − affecting speech and
behaviour.

(b) (b) Negative Symptoms On the other hand, these are characterised by behavioural deficits
(absence) or functioning below what is normal. The following are some examples of negative
symptoms

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 Negative symptom Definition
Avolition Lack of energy and inability to
persist in routine activities.
Alogia (poverty of speech) Reduction in the amount or
content of speech.
Anhedonia Inability to experience
pleasure.
Asociality Severe impairment in social
relationships.
Flat affect Lack of facial or bodily
response that indicate emotion
or mood.
Catatonia A psychological state in which
the patient is immobile as
though in trance; can also
become excited and agitated.

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 DEMOGRAPHIC DATA PATIENT
The patient is a 29 –year old lady, married Malay, with a history of treatment- resistance
schizophrenia. The patient was brought to the hospital and her boyfriend after they noticed
behavioural changes in four days in the last week. The patient has been taken to the hospital
a couple of times last year, the last one was from 4/06/2021- 24/06 2021.Tab.Clozapine and
propanol seemed to be the only medication that was working on her producing reasonable
improving and enabling her to be allowed to go home for home-based care. However, with
time she developed neutropenia from tab.clozapine and tab.propanol and this resulted in a
major relapse. The results of the investigation indicated that the patient had an intellectual
disability with behavioural issues. Her boyfriend explained that she had disorganized
behaviours around the house and she also tried to take others people’s belongings. In the
interview, she explained that the reason why wanted to take other people's belongings is that
she wanted to buy a new house in Johor where her father stays.
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The patient was still mumbling and smiling to herself. The patient claimed that she had male and
female voices commanding in nature asking her to kill everyone. She claims that she hears such
voices when she is half asleep her boyfriend also explained that sometimes she got agitated and
punched him a couple of times. She said she was married but they are not on good terms. Her
husband works as a construction worker and the patient expressed that her relationship with her
husband was not that good. Her husband always scolded her for being slow in doing house chores.
Currently, her husband is her neighbour. The patient had a history of not taking her medication.
Her husband used to supervise her taking medication but since they have not been on good terms
no one is there to supervise her taking the medication. She is aware of this because when she
asked why she explained that she forgot to take them and there was no one to remind her. She
spoke loudly, quickly, and haphazardly when giving a presentation to the day program, though. She
had a tangential line of thought, and her insights and judgment were lacking. It was clear that she
needed additional in-patient treatment because of her persistent psychosis and aggressive
behavior. She has a bad feeling that someone has bad intentions for her. Other symptoms that
could be noted in the patient include delusions, hallucinations and poverty of speech/ incoherent
speech.

Cont.. 10
 MSE
Component Element assessed Findings.
Appearance and general behaviour Body habitus, grooming habits, posture and eye Malay lady in her 20s, medium build, in neat hospital attire. Her hair was well tied and she was wearing spectacles.
contact She was cool and calm and had good hygiene. Her eye contact was good, she maintained 40% while speaking and
60% while listening. This displayed interest and confidence. Overall her appearance and general behaviour were
good

Motor activity Physical and emotional reactions Although she had a history of being aggressive, she was calm and cooperative. However, we noted that the patient
tried a little hard to change the body posture and lethargic movements of the limps
Mood and affect Patient’s emotional state. The patient had restricted effects and was sad She was calm and cooperative during conversations.

Speech volume and tone, soft-loud monotone, weak, strong The quantity of her speech was reduced and she mumbled words all through the interview sessions.
mumbled speech
Thought process form of thinking, the flow of thoughts She had through disturbance as evidenced in the poverty of speech. The patient also had thought blocking, there
were some incidents during the conversations when were blank intervals in the tangibility of her brain.

Thought content
Perceptual disturbances,
Sensorium and cognition
insights
what is the patient thinking about The patient was delusional, she said she heard different voices in her head both male and female which instructed
her to kill from time to time.
Hallucinations The patient had no hallucinations or perceptual or thought disturbance.
stability of consciousness and attention/ Her stability/consciousness and concentration were low. This is because she was disturbed by female and male
concentration/ memory voices in her head that were instructing her to kill someone.
Patient's awareness and understanding of illness The patient was aware and understood that her illness needed treatment because when she was asked why she
and need for treatment. had not been taking her medication, she explained that she forgot to take them and there was nobody to help her
remember since they were not on good terms with her husband who used to assist and supervises medication.

Judgment Patients' recognition of consequences of actions She had poor judgment, the patient was taking other people's belongings and when asked why she explained that
she wanted to go and buy a house in Johor where her father lives. She had intellectual disability behaviour issues

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 MANAGEMENT AND TREATMENT
Categories of patient management what was done Goals
Coordination of care Nurses maintained safety by taking the necessary safety measures to reduce the likelihood of patients harming Coordination of care among nurses was
themselves suicide, or homicide. This was made easy by putting expectations in the nursing care plan, this ensured established to ensure that all patients’ needs were
that everyone on the unit is following the same behavioural expectations. We also planned for a high quality of life, met and to help her recover faster.
independence, and optimum recovery by using community services and support networks after discharge.

Health teaching Given the fact that the patient had been admitted to our hospital several times, we decided to create modify, and present The main aim of health teaching was to equip the
to clients health education on topics like stress management, coping techniques, and the control of delusions and patient with knowledge and skills on how to deal
hallucinations. We also informed patients about antipsychotics and anticipated recovery times. Present the client with all with her condition once she was discharged from
open drugs. Keep an eye out for and report any early signs of probable first-generation antipsychotic side effects such the hospital.
as tardive dyskinesia (TD) and extrapyramidal side effects (EPS).

Milieu Therapy Reduce arousal-provoking factors and excessive loudness to control the surroundings. A private room can be The main goal of this therapy was to reduce
necessary for the customer. To reroute aggressive behaviour, encourage physical activity. Utilize prescription drugs, arousal-provoking factors and excessive loudness
isolation, or restraint to prevent physical injury during acute psychosis with agitation. Promote involvement in groups to control the surroundings
that focus on stress reduction, mindfulness, social skills, and personal grooming. If the client is irritated, refrain from
competitive sports or activities.

Therapeutic relationship and As earlier said, relapse schizophrenia can also be managed using therapy sessions. To ensure the therapy sessions The main goal of this was to empower the patient
counselling were productive, we ensured that we developed relationships with the patient so she to be able to open up about what to delve deeper into issues she was facing and
she was going through. short, to-the-point statements and a firm, composed demeanour to clearly define expectations open up, for us to able to help her get back to her
in straightforward, concrete words with repercussions were used to equip her with the right knowledge and skills normal life as soon as possible.

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 MEDICATIONS
There is not much proof that their use is consistently beneficial after two or three years. The following medications were
used to manage the patient.

 Clozapine: Clozapine is a psychiatric medication (anti-psychotic type) that works by helping restore the balance of
certain natural substances in the brain. This medication was administered to the patient for a period of one week and
the nurses kept monitoring and charting notable changes in the patient. Before this drug was administered to the
patient, she had problems with her sleeping patterns and was hallucinating. The patient responded well to the
medication because after one week in the hospital, she was able to sleep well. According to Prisco, Iannaccone and
Fabrazzo, (2015) clozapine help a patient think clearly and positively about themselves. This medication is
administered through the mouth. The family of the patient were advised that after taking the medication the patient
can show side effects such as dizziness, headache, shaking, vision problems drooling and drowsiness. The short-
term goal of administering this medication to the patient was that she would remain calm and that she would be able
to acknowledge risk factors within 24 hours after admission. Nurses kept monitoring the patient after administering
the medicine to see if any of the above-mentioned side effects got worse. The doctors had looked at the patient's
medical history before administering Clozapine to the patient.

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 Lorazepam: According to WebMD, (2019) this medication is used to treat anxiety and produce calm effects. It belongs to a group of drugs called
benzodiazepines. When the patient was brought to the hospital, her uncle and boyfriend explained to the physicians that she was agitated and at times
she punched her boyfriend. The purpose of administering this medication was to help the patient calm down and be more cooperative which was
important for the effectiveness of nursing care. This drug works by enhancing the effects of a certain natural chemical in the body and is taken through
the mouth with or without food. Some of the side effects of taking this medication include loss of coordination dizziness, headache, shaking, vision
problems drooling and drowsiness. After administering the medication the patient was monitored to deal with any side effects that got worse. This
medication had positive effects on the patient as it calmed her.
 Valium: Valium is a medication used to treat anxiety and seizures in patients with relapse schizophrenia. According to Thornton, (2019) it works by
calming the brain and nerves, it belongs to a class of medication called benzodiazepines. Side effects that are associated with this medication include
dizziness, blurred vision, unsteadiness, tiredness and drowsiness. If any of these effects last long or get worse, the patient needs to tell a doctor
promptly.
 Syrup Lactulose: This medication is used to help increase bowel movement per day, it works by increasing stool water content and softening the stool.
This medication is taken by mouth usually once a day. Side effects associated with taking this drug include gas, stomach pain, burping vomiting, muscle
cramps/ weakness, irregular heartbeat, seizures and mood change (Nagasawa, Sato and Kasumi, 2019). Patients are encouraged to call a doctor
promptly if any of these symptoms last longer or become more severe. This medication was given to the patient to help increase the number of bowel
movements and the number of days she has bowel movements.
The patient's look is consistent with her mental diagnosis because her general health and temperament have improved as a result of her pharmacological
medication and consultations. The patient made remarkable progress as compared to the mental state evaluation from the time of admission one week before
the time of the present examination. Although the patient's symptoms have been managed and improved, there is cause for concern that she may relapse if
her circumstances, such as her recent loss of employment and change in living arrangements, become excessive and worsen her problematic behaviours.

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 PSYCHOLOGICAL
Combination of therapy and medication is Due to issues with reimbursement or a lack of training,
psychotherapy is also highly recommended but is not frequently used in the treatment of schizophrenia. As
a result, psychiatric medication is frequently the only mode of treatment. Various psychosocial interventions
are important for relapse schizophrenia patients because they are usually under stress due to their medical
conditions. Nursing interventions can assist patients in managing these situations because many patients
struggle with social retreat and decreased social interaction. Training in social skills and other forms of
therapy are both possible in mental health nursing. We assisted the patients in learning various treatment
approaches, such as by offering chances for socialization. Additionally, we supported patients in learning
coping mechanisms so they can better manage their stress.

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 NURSING DIAGNOSIS
Nursing diagnoses/ outcome Nursing intervention

Impaired verbal communication. The patient exhibited poor -We Determined whether the patient’s speech incoherence was persistent or if it arose more
communication function. She was mumbling and smiling to herself suddenly, such as during a symptom flare.
from time to time.
- Despite how confusing the spoken words may seem, we first, listen for themes (e.g., fear,
sadness, guilt).

 - We determined the patient’s length of treatment for their psychosis.

- Nurses introduced techniques that could lessen anxiety and quiet voices and "worrying"
thoughts by teaching the patient to do the following :

 Focus on worthwhile pursuits.

 Adopt the skill of thinking positively instead of negatively.
 Learn to convert illogical thoughts into rational arguments
 Breathing exercises were done.
 Self-read out loud activities.
 

 Staff, family, or other supportive people were sought for assistance.

 Played some soothing music and used a calming visualization.
- Therapeutic techniques were employed to understand the patient's concerns.

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 NURSING DIAGNOSIS 17

Impaired social interactions. The patient - Assessed if the medication had reached therapeutic levels.
was sad upset and agitated. It was also
-we took the patient to a ward that was free of stimuli ( loud noise, crowding)
discovered that the patient spends a lot of
time alone. She had poor social support, - We avoided touching the patient during interviews or when giving her instructions.
the patient used to stay alone at her
- Because the client was delusional, we provided some simple concrete activities to help keep away delusional thinking from
boyfriend’s house.
reality in the environment.

-We gave the patient a chance to practice developing their social skills in a relaxed setting. Initial social skills instruction could
cover fundamental social skills including acceptable distance, maintaining eye contact, remaining cool, and using a moderate
voice tone.

- Coping Skills Training was introduced to the patient as she advanced (nurse, staff or others). The patient

 Defined the skill that has to be acquired.

 Practice the skill.
 Practice skills first in a secure setting before using them in public.
 Provide constructive criticism on how talents are being used.
-Eventually, we engaged other patients in social interactions with her by introducing card games, group sharing activities and
singing songs. This was made to make the client feel safe when interacting with others.

Nurses can assist with educational needs as well. To further understand the disease, this may entail collaborating with both the
patient and their family members or caregivers. Nursing interventions also include finding efficient methods for calming the
patient down if they become irritated and assisting them in developing better communication skills. You must teach family
members both how to make the patient feel more at ease and how to prevent unintentionally escalating the current condition.

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 NURSING DIAGNOSIS
Interrupted family process, the patient had some issues with her - On learning that the patient was not on good terms with her husband and that she had
husband who was always nagging her for her slowness when moved to her boyfriend's house, an assessment of the level of knowledge about her
conducting household chores. conditions and medications that had been used to treat the patient.

We informed the patient’s boyfriend in simple terms about the psychopharmacologic

therapy, dose duration indication of side effects and toxic effects.

We also taught the patient's family about these symptoms and warning of relapse

The patient’s family was also equipped with knowledge and skills on disease treatment
strategies, nurses can best intervene when they understand the family's experience and
needs.

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 NURSING DIAGNOSIS
The disturbing thought process, the patient was experiencing According to Salvatore et al., (2018) a patient can be free from delusional thinking when
delusions that she was hearing both male and female voices in thinking is focused on reality-based activities.
her head and this largely affected her thought process.
-We tried to comprehend how important these views were to the patient at the time they
were presented.

- Different nurses on duty expressed understanding of the patient’s emotions and

reassurance of their presence and acceptance.

- We determined the emotions that go along with illusions. For instance, the patient was
afraid because she thought to think someone wanted her to hurt others

We engaged in the patient's interactions based on the surroundings. This helped distract
the patient from their fantasies by involving them in activities that are grounded in reality
(e.g., card games, simple arts and crafts projects etc.).

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 SUMMARY
• Psychiatric mental health problems are among the major causes of diseases and disabilities worldwide. Psychiatric mental health problems
can cause problems in your daily life such as at school or work or in relationships. The main aim of this paper was to develop a case study
of a patient with psychiatric mental problems whom I nursed during my clinical practice. Our case study in this paper involved a patient
diagnosed with relapse schizophrenia who was still under medication in the hospital Discussion conducted in this paper revealed that
Relapse Schizophrenia is among the most severe and impairing medical diseases. Even when the symptoms have faded away, relapse
schizophrenia required a lifetime of therapy. Both the patient and the family are overwhelmed by the illness. It is crucial to remember that
every patient is different, and there is no one-size-fits-all treatment plan that can meet their needs. To satisfy the unique needs of each
patient, typical psychiatric therapies must be modified. This study highlights the significance of having a thorough awareness of the
patient's mental health history as well as the current history presenting the condition for doctors in order to manage psychiatrically related
mental illnesses such relapse schizophrenia. This is important as it provides them with information that helps them to make decisions on
the kind of nursing management that the patient should be offered. To conclude, health workers can do a case study on mental health to
determine and understand mental health issues in real life context. This case studies are important because they can be used by other
health practitioners. This paper discussed the demographic data, the history of the patient’s psychiatric illness, symptoms, mental health
history of the patient and nursing management for the patient.

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 THANK
YOU
SITI NORHIDAYAH MD ISA
830424115374001