Schizophrenia is a disorder that involves characteristic psychotic symptoms (e.g., delusions, hallucinations, and disturbances in mood and thought) and impairment in the individual’s level of functioning in major life areas. The characteristic symptoms of schizophrenia (APA, 2000) are listed below. Clients typically experience symptoms in several of these areas.
1. Thought content. Delusional thoughts are fragmented, sometimes bizarre, and frequently unpleasant for the client. Many clients believe that their thoughts are “broadcast” to the external world, so others are able to hear them (thought broadcasting), that the thoughts are not their own but are placed there by others (thought insertion), and that thoughts are being removed from their head (thought withdrawal). The client believes all this thought control occurs against his or her will and feels powerless to stop it.
2. Perception. The major perceptual disturbance is hallucinations, most commonly auditory (voices). The voices may be familiar to the client and may command the client to do things that may be harmful to the client or others; there may be more than one voice “speaking” at once. Visual, tactile, gustatory, kinesthetic, and olfactory hallucinations also
can occur, but less commonly.
3. Language and thought process. The client is unable to communicate meaningful information to others. There may be loose associations or jumping from one topic to an unrelated topic. The poverty of speech or alogia (little verbalization), poverty of content (much verbalization but no substance), neologisms (invented words), perseveration (repetitive speech), clanging (rhyming speech), or blocking (inability to verbalize thoughts) may occur. The client may be unaware that others cannot comprehend what he or she is saying.
4. Psychomotor behavior. The client may respond excitedly to the environment, demonstrating agitated pacing or other movements, or maybe almost unresponsive to the environment and exhibit motor retardation, posturing, or stereotyped movements. These disturbances are usually seen during acute psychotic episodes and in severely chronically ill clients.
5. Affect. The client has a restricted mood, may feel numb or lack the intensity of normal feelings, and demonstrates a flat or inappropriate affect. The client with a flat affect has a lack of expression, a monotonous tone of voice, and immobile facies. (Note: Many psycho- tropic medications produce effects that resemble a flat affect.) An inappropriate effect occurs when the client’s expression is incongruent with the situation; for example, the client may talk of a sad event yet be laughing loudly.
6. Avolition. The client’s ability to engage in self-initiated, goal-directed activity is disturbed. This can persist into a residual phase, resulting in marked impairment in the client’s social, vocational, and personal functioning.
The symptoms of schizophrenia often are categorized as hard or soft signs. Hard signs include delusions and hallucinations, which are more amenable to the therapeutic effects of medication. Soft signs, such as lack of volition, impaired socialization, and affective disturbances, can persist after major symptoms of psychosis have abated and caused the client continued distress.
The major types of schizophrenia and associated characteristics are as follows:
• Catatonic: generalized motor inhibition, stupor, mutism, negativism, waxy flexibility, or excessive, sometimes violent motor activity
• Disorganized: grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior
• Paranoid: persecutory or grandiose delusions, hallucinations, sometimes excessive religiosity, or hostile, aggressive behavior
• Undifferentiated: mixed schizophrenic symptoms along with disturbances of thought, affect, and behavior
• Residual: symptoms are not currently psychotic, but the client has had at least one previous psychotic episode and currently has other symptoms, which may include social withdrawal, flat affect, or looseness of associations Schizoaffective disorder is no longer categorized as a subtype of schizophrenia (APA, 2000).
The symptoms are neither exclusively those of a major mood disorder nor of schizophrenia; rather, they are a combination of both. Schizophrenia is equally prevalent in men and women; it affects approximately 1.1% of adults in the United States in a given year. The average age of onset is in the late teens or early twenties for men and the twenties or early thirties for women (National Institute of Mental Health 2010).
Schizophrenia is not diagnosed until relevant symptoms have been present for at least six months. Most clients continue to have symptoms that necessitate long-term management; these symptoms may wax and wane, be relatively stable, or progressively worsen over time (APA, 2000).
The prognosis for a client with schizophrenia is better when onset is acute; a precipitating event is present; or the client has a history of good social, occupational, and sexual adjustment.
Interventions with clients with schizophrenia focus on safety, meeting the client’s basic needs, symptom management, medication management (see Appendix E: Defense Mechanisms), and long-term care planning.
The nurse needs to work closely with the interdisciplinary treatment team to coordinate acute care, referrals for continued care, and appropriate resources for support in the community.
NURSING DIAGNOSES ADDRESSED IN THIS CARE PLAN
- Disturbed Personal Identity
- Social Isolation
- Bathing Self-Care Deficit
- Dressing Self-Care Deficit
- Feeding Self-Care Deficit
- Toileting Self-Care Deficit
Nursing Diagnosis
Disturbed Personal Identity
Inability to maintain an integrated and complete perception of self.
ASSESSMENT DATA
• Bizarre behavior
• Regressive behavior
• Loss of ego boundaries (inability to differentiate self from the external environment)
• Disorientation
• Disorganized, illogical thinking
• Flat or inappropriate affect
• Feelings of anxiety, fear, or agitation
• Aggressive behavior toward others or property
EXPECTED OUTCOMES
Immediate
The client will
• Be free from injury throughout hospitalization
• Refrain from harming others or destroying property throughout hospitalization
• Establish contact with reality within 48 to 72 hours, Demonstrate or verbalize decreased psychotic symptoms within 24 to 48 hours
• Demonstrate decreased feelings of anxiety, agitation, and so forth within 3 to 5 days
• Participate in the therapeutic milieu, for example, respond verbally to simple questions,within 48 to 72 hours
Stabilization
The client will
• Take medications as prescribed
• Express feelings in an acceptable manner, for example, talk with staff about feelings for a specific time period or frequency
Community
The client will
• Reach or maintain his or her optimal level of functioning
• Cope effectively with the illness
• Continue compliance with prescribed regimen, such as medications and follow-up appointments
IMPLEMENTATION
| Nursing Interventions | Rationale |
|---|---|
| Protect the client from harming himself or herself or others. | Client safety is a priority. Self-destructive ideas may come from hallucinations or delusions. |
| Reassure the client that the environment is safe by briefly and simply explaining routines, procedures, and so forth. | The client is less likely to feel threatened if the surround- ings are known. |
| Decrease excessive stimuli in the environment. The client may not respond favorably to competitive activities or large groups if he or she is actively psychotic. | The client is unable to deal with excess stimuli. The environment should not be threatening to the client. |
| Be aware of as needed (PRN) medications and the client’s varying needs for them. | Medication can decrease psychotic symptoms and can help the client gain control over his or her own behavior. |
| Reorient the client to person, place, and time as indicated (call the client by name, tell the client where he or she is, etc.). | Repeated presentation of reality is concrete reinforcement for the client. |
| Spend time with the client even when he or she is unable to respond coherently. Convey your interest and caring. | Your physical presence is reality. Nonverbal caring can be conveyed even when verbal caring is not understood. |
| Limit the client’s environment to enhance his or her feel- ings of security. | Unknown boundaries or a perceived lack of limits can foster insecurity in the client. |
| Help the client establish what is real and unreal. Validate the client’s real perceptions, and correct the client’s misperceptions in a matter-of-fact manner. Do not argue with the client, but do not give support for misperceptions. | The unreality of psychosis must not be reinforced; reality must be reinforced. Reinforced ideas and behavior will recur more frequently. |
Nursing Diagnosis
Social Isolation
Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.
ASSESSMENT DATA
• Inappropriate or inadequate emotional responses
• Poor interpersonal relationships
• Feeling threatened in social situations
• Difficulty with verbal communication
• Exaggerated responses to stimuli
EXPECTED OUTCOMES
Immediate
The client will
• Engage in social interaction, for example, verbally interact with other clients for specified periods or specified frequency, for example, for 5 minutes at least twice a day within 2 days
• Identify at least two strengths or assets with nursing assistance within 2 to 3 days
• Verbalize increased feelings of self-worth within 5 to 7 days
Stabilization
The client will
• Demonstrate appropriate emotional responses
• Communicate effectively with others
• Demonstrate basic social skills, for example, talk with others about weather, local events,or activities
Community
The client will
• Demonstrate use of strengths and assets
• Establish interpersonal relationships in the community
IMPLEMENTATION
| Interventions | Rationale |
|---|---|
| Provide attention in a sincere, interested manner. | Flattery can be interpreted as belittling by the client. |
| Support any successes, responsibilities fulfilled, interactions with others, and so forth. | Sincere and genuine praise that the client has earned can improve self-esteem. |
| Avoid trying to convince the client verbally of his or her own worth. | The client will respond to genuine recognition of a concrete behavior rather than unfounded praise or flattery. |
| Initially, interact with the client on a one-to-one basis. Man- age nursing assignments so that the client interacts with a variety of staff members, as the client tolerates. | Your social behavior provides a role model for the client. Interacting with different staff members allows the client to experience success in interactions within the safety of the staff–client relationship. |
| Introduce the client to other clients in the milieu and facilitate their interactions on a client basis. Gradually facilitate social interactions between the client and small groups, then larger groups. | Gradually increasing the scope of the client’s social interac- tions will help the client build confidence in social skills. |
| Teach the client social skills. Describe and demonstrate specific skills, such as approaching another person for interaction, eye contact, attentive listening, and so forth. Discuss the type of topics that are appropriate for casual social conversation, such as the weather, local events, and so forth. | The client may have little or no knowledge of social interac- tion skills. Modeling provides a concrete example of the desired skills. |
| Talk with the client about his or her interactions and observations of interpersonal dynamics. | Awareness of interpersonal and group dynamics is an important part of building social skills. Sharing observations provides an opportunity for the client to express his or her feelings and receive feedback about his or her progress. |
| Help the client improve his or her grooming; assist when necessary in bathing, doing laundry, and so forth. | Good physical grooming can enhance confidence in social situations. |
Nursing Diagnosis
Bathing Self-Care Deficit
Impaired ability to perform or complete bathing activities for self.
Dressing Self-Care Deficit
Impaired ability to perform or complete dressing activities for self.
Feeding Self-Care Deficit
Impaired ability to perform or complete self-feeding activities.
Toileting Self-Care Deficit
Impaired ability to perform or complete toileting activities for self.
ASSESSMENT DATA
• Poor personal hygiene
• Lack of awareness of or interest in personal needs
• Disturbance of appetite or regular eating patterns
• Disturbance of self-initiated, goal-directed activity
• Inability to follow through with completion of daily tasks
• Apathy
• Anergy, or inability to use energy productively.
EXPECTED OUTCOMES
Immediate
The client will
• Establish an adequate balance of rest, sleep, and activity with nursing assistance within 2 to 4 days.
• Establish nutritional eating patterns with nursing assistance within 2 to 4 days.
• Participate in self-care activities, such as bathing, washing hair, toileting within 48 to 72 hours.
Stabilization
The client will
• Complete daily tasks with minimal assistance
• Initiate daily tasks
Community
The client will
• Maintain adequate routines for physiologic well-being
• Demonstrate independence in self-care activities
IMPLEMENTATION
| Interventions | Rationale |
|---|---|
| Be alert to the client’s physical needs. | The client may be unaware of or unresponsive to his or her needs. Physical needs must be met to enhance the client’s ability to meet emotional needs. |
| Monitor the client’s food and fluid intake; you may need to record intake, output, and daily weight. | The client may be unaware of or may ignore his or her needs for food and fluids. |
| Offer the client foods that are easily chewed, fortified liquids such as nutritional supplements, and high-protein malts. | If the client lacks interest in eating, highly nutritious foods that require little effort to eat may help meet nutritional needs. |
| Try to find out what foods the client likes, including cultur- ally based foods or foods from family members, and make them available at meals and for snacks. | The client may be more apt to eat foods he or she likes or has been accustomed to eating. |
| Monitor the client’s elimination patterns. You may need to use PRN medication to establish regularity. | Constipation frequently occurs with the use of major tranquilizers, decreased food and fluid intake, and decreased activity levels. |
| Encourage good fluid intake. | Constipation may result from the inadequate fluid intake. |
| Explain any task in short, simple steps. | A complex task will be easier for the client if it is broken down into a series of steps. |
| Using clear, direct sentences, instruct the client to do one part of the task at a time. | The client may not be able to remember all the steps at once. |
Atrendynurse 