Download Nursing Care For Patients With Schizophrenia

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SCHIZOPHRENIA
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INTRODUCTION
Before you start to read this topic, try to imagine what might
patient with this illness experience .
Schizophrenic patients known about they are seeing things or
hearing voices. For example, imagine that somebody calling your
name inside your room and you are certain that no one is inside
the house except you only !
Or seeing some one is not even at your local area setting beside
you .. and others keep staring at you when you talk with your
imaginary friend ?
Do you find it scary? bizarre? Now what does schizophrenic
patient really feels and how does it shape their life on many
aspects , mental , social and physical , and what is the nursing
expected to do when dealing with schizophrenic patients , that’s
what will be illustrated in this project.
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1.1-Definitions
“Schizophrenia is the most chronic and disabling of the severe mental disorders,
associated with abnormalities of brain structure and function, disorganized speech and
behavior, delusions, and hallucinations. It is sometimes
called a psychotic disorder or a psychosis”.
“psychotic disorder , marked by sever and often irreversible deterioration in
personality , affect , communication , and intellectual functions”.
“it’s a disorder that lasts for at least 6 months and includes at least 1 month of activephase symptoms (i.e., two [or more] of the following: delusions ,hallucination
,disorganized speech , grossly disorganized or catatonic behavior , negative symptoms)
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1.2-Medical background :
1.2A-First , what is the meaning of the term “ schizophrenia “ ?
[Schizophrenia from the Greek roots schizein "to split" and phrēn,phren- "mind" ]
Its diagnosis termed by Eugen Bleuler. (see
Figure 1)
 In 1908, Eugen Bleuler, a Swiss psychiatrist, introduced the term schizophrenia.
 which replaced the term dementia praecox, used by Emil Kraepelin (1896).
 Kraepelin viewed this disorder as a deteriorating organic disease.
 Bleuler viewed it as a serious disruption of the mind, a “splitting of the mind.” In
1948.
According to the DSM-IV , schizophrenia classified under the section of
“SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS”.
Fig.1 Eugen Bleuler.
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1.2B-Description
 When we talk about the symptoms we should keep in mind that not all the patient
share the same signs\symptoms of the disease, in
addition , ones symptoms could or may change over
The Schizophrenia Prodrome
time.
Tonya White, M.D., Afshan
 Also doctors recognized subtypes but no single
Anjum, M.D., and S. Charles
Schulz, M.D. A 13-year-old girl,
classification system has gained universal
currently in the eighth grade and
acceptance , also the DSM-IV-TR acknowledges
with a history of attention deficit
hyperactivity disorder, was
that its present classification of subtypes is not
brought by her mother to a
fully satisfactory for either clinical or research
university-affiliated outpatient
purposes, and states that “alternative sub typing
psychiatric clinic after a gradual
decline in her academic
schemes are being actively investigated.”
performance was noted. She had a
 Symptoms of schizophrenia can appears at any
previous history of receiving
grades of B and C in all her
time, after age of 6 or 7 , even under 5 but its very
classes, but currently she was
very rare , and in some over 80 years old also .
getting Ds and Fs. At age 8 years
 The onset can be sudden or gradual . often it goes
she had begun receiving stimulant
medication, with some benefit. She
undetected for about 2 to 3 years after the onset of
had tasted alcohol in the past but
diagnosable symptoms .
denied current use. She had also
used marijuana a half-dozen times.
 The patient may have had panic attacks, social
She reported having a small
phobia, or substance abuse problems, any of which
number of close friends. Although
can complicate the process of diagnosis.
she said that there were no recent
changes in her peer relationships,
 There is no “typical” pattern or course of the
her parents claimed that she had
disorder following the first acute episode. The
been withdrawn and had appeared
sad and that at times they needed
patient may never have a second psychotic
to prompt her to take a shower.
episode; others have occasional episodes over the
She had a maternal aunt with
course of their lives but can lead fairly normal lives
bipolar affective disorder and a
great uncle who had been
otherwise, some patients remain chronically ill .
1.2C-Prodromal symptoms :
Simply , prodromal symptoms means “signs and
symptoms that precede the actual onset of the disorder
and the time interval between the first manifestation of
the disorder and the first appearance of the full picture.”
Its involve mixture of behaviors like :
 angry outbursts
 withdrawal from social activities
 loss of attention to personal hygiene and grooming,
 anhedonia (loss of interest and joy )
 and other unusual behaviors like suspicion’s.
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institutionalized for unknown
reasons. During the clinical
interview, she was dressed in Goth
attire, including a black T-shirt
with images of letters dripping
blood; she had dyed black hair.
Her affect was blunted but was
slightly more animated when her
parents left the room. She denied
thoughts of suicide. She reported
occasionally hearing whispering
voices calling her name and saying
that she is worthless. She also
reported the belief that her friends
did not like her as much as they
had. Her mother, who recently met
a parent of a child with
schizophrenia, posed the question
of whether her daughter has
schizophrenia.?**
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1.3-Risk factors \ etiology :
Recent research suggests that schizophrenia involves problems with brain chemistry and
brain structure. However, no single cause has been identified to account for all cases of
schizophrenia. Scientists are currently investigating possible factors contributing to the
development of schizophrenia. These factors discussed in the form of hypotheses or
theory such as :
-GENTIC THEORY :
What is clear that schizophrenia tend to be inherited ,for example studies revealed that
monozygotic twins have the highest concordance rates for schizophrenia ,meaning that
they are more likely to both have schizophrenia if one of them has it, compared to people
who share less genetic material
-Biochemical and Biological Theory :
Increased dopamine level and brain dysfunction or structure abnormities, but it does not
really seems to be either a cause or consequence of the disorder.
- Environmental or Cultural Theory
Theorists also believe that persons who come from low socioeconomic areas or singleparent homes in deprived areas are not exposed to situations in which they can achieve
or become successful in life. Thus they are at risk for developing schizophrenia.
And there is several other factors and theory to the etiology of this disorder :
-Vitamin Deficiency Theory
-Perinatal Theory
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2.1-Diagnosis and finding:
Clinical diagnosis is developed on historical information and thorough mental
status examination.
 No laboratory finding have been identified that are diagnostic for schizophrenia ,
studies between groups of schizophrenic patients and other appropriate matched
control subject shows results on these exams :
1. Neuro-imaging exam.
2. Neuro-psychological exam.
3. Neuro-physiological exam .

Neuro-imaging :
-Enlargement of the lateral ventricles.fig.2
-decreased brain tissue evidenced by widened cortical sulci and decreased gray and
white matter.
-decreased blood flow for neural activity .
Neuro-psychological :
-deficits in memory attention psychomotor ability.
Neuro-physiological:
-deficits in perception and processing sensory stimuli.
-abnormal smooth pursuit.
-saccadic eye movement .
-slowed reaction time.
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Fig2. See the enlarged ventricles
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2.2A.DSM-IV . diagnostic criteria.
DSM-IV diagnostic criteria for schizophrenia
A. Characteristic Symptoms
Two (or more) of the following, each present for a significant portion of time during
a 1-month period (or less if successfully treated);
(1) delusions
(2) hallucinations
(3) disorganized speech (e.g. frequent derailment or incoherence)
(4) grossly disorganized or catatonic behavior
(5) negative symptoms, that is, affective flattening, alogia, or avolition.
Note: Only one Criterion A symptom is required if delusions are bizarre or
hallucinations consist of a voice keeping up a running commentary on the
person’s behavior or thoughts, or two or more voices conversing with each other.
B. Social/occupational dysfunction
For a significant portion of the time since the onset of the disturbance, one or more
major areas of functioning such as work, interpersonal relations, or self-care are
markedly below the level achieved prior to the onset (or when the onset is in
childhood or adolescence, failure to achieve expected level of interpersonal
academic, or occupational achievement).
C. Duration
Continuous signs of the disturbance persist for at least 6 months. This 6-month
period must include at least 1 month of symptoms (or less if successfully treated)
that meet Criterion A (i.e. active phase symptoms) and may include periods of
prodromal or residual symptoms. During these prodromal or residual periods, the
signs of the disturbance may be manifested by only negative symptoms or two or
more symptoms listed in Criterion A present in an attenuated form (e.g. odd
beliefs, unusual perceptual experiences).
D. Schizoaffective and Mood Disorder exclusion
Schizoaffective Disorder and Mood Disorder With Psychotic Features have been
ruled out because either (1) no Major Depressive, Manic or Mixed Episodes have
occurred concurrently with the active-phase symptoms, or (2) if mood episodes
have occurred during active-phase symptoms, their total duration has been brief
relative to the duration of the active and residual periods.
E. Substance/general medical condition exclusion
The disturbance is not due to the direct physiological effects of a substance (e.g. a
drug of abuse, a medication) or a general medical condition.
F. Relationship to a Pervasive Developmental Disorder
If there is a history of Autistic Disorder or another Pervasive Developmental
Disorder, the additional diagnosis of Schizophrenia is made only if prominent
delusions or hallucinations are also present for at least a month (or less if
successfully treated).
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2.2B.Positive and Negative symptoms.
-Positive signs :
Positive symptoms are excesses in behavior (excessive function/distortions).
-Negative symptoms :
Negative symptoms are deficits in behavior (reduced function; self care deficits)
Positive
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Delusion
Hallucination.
Disorganized thinking.
Disorganized behaviors.
Catatonic behaviors.
Excitement or agitation.
Possible suicidal tendencies.
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Negative
 Avolition ( withdrawal behaviors ).
 Anhedonia ( loss of feeling or an
inability to experience pleasure )
 Alogia ( poverty of speech )
 Flat presentation , poor or no eye
contact , unchanged facial
expressions.
 Difficulty in abstract thinking.
 Anergia (lack of energy)
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2.3-Classification of Subtypes of Schizophrenia
The Diagnostic and Statistical Manual of Mental Disorders 4 Text Revision have
diagnostic criteria according to the subtypes of the disorder which are :
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Paranoid. [295.30]
Catatonic.[295.20]
Disorganized.[295.10]
Undifferentiated.[295.90]
Risdual.[295.60]
2.3A. Paranoid:
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Preoccupation with one or more delusions or frequent auditory hallucinations
None of the following is prominent: disorganized speech, disorganized or
catatonic behavior, or flat or inappropriate affect
patients exhibiting paranoid schizophrenia tend to experience persecutory or grandiose
delusions. They also may exhibit behavioral changes such as anger, hostility, or violent
behavior. Clinical symptoms may cause a threat to the safety of self or others.
CLINICAL EXAMPLE.1
The Client With Schizophrenia, Paranoid Type
BW, a 35-year-old mechanic, was brought to the admissions office by his wife because he had
exhibited strange behavior for several months. He accused his wife of poisoning his food,
spending all his money, having an affair with his boss, and telling stories about him. He
displayed no facial expressions during his initial interview and became quite argumentative
when questioned about his job. At the end of the interview, BW confided in the interviewer that
he had been receiving messages from Jesus Christ while watching television.
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2.3B.Catatonic:
At least two of the following are present:
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Motor immobility ,waxy flexibility, or stupor.
Excessive motor activity that is purposeless.
Extreme negativism or mutism.
Peculiarities of voluntary movement as evidenced by posturing, stereotyped
movements, prominent mannerisms or prominent grimacing.
Echolalia (repeats all words or phrases heard) or echopraxia (mimics actions of
others)
Patients are at risk medically because of extreme withdrawal, which can result in a
vegetative condition or excessive motor activity that could produce exhaustion or selfinflicted injury.
CLINICAL EXAMPLE.2
The Client With Schizophrenia, Catatonic Type
CS, a 25-year-old engineer, was admitted to the hospital as result of dehydration because of
refusing to eat. During his hospitalization, CS was negativistic, refusing nursing care, food, and
medication. He rarely spoke and assumed uncomfortable positions in bed for long periods.
When placed in various positions by the nurse during the morning bath or shower, CS remained
in the positions until the nurse changed them. He also exhibited purposeless movements of his
hands and feet while sitting in a chair.
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2.3C.Disorganized :
All of the following are prominent and criteria are not met for catatonic type:
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Disorganized speech
Disorganized behavior
Flat or inappropriate affect
The criteria are not met for the catatonic type.
The behavior disorganization may lead to sever disruption in the ability to perform
activities of daily living . And one of the associated symptoms could be mannerisms and
grimace .
CLINICAL EXAMPLE .3
The Client With Schizophrenia, Disorganized Type
MJ, a 19-year-old waitress, was seen in the admitting office of a psychiatric hospital. During
the initial interview, she giggled inappropriately. Her long, uncombed hair fell over her face,
concealing her facial expressions. She mumbled incoherently at times and displayed the
behavior of a 13- or 14-year-old adolescent. She complained of numerous aches and pains and
stated that voices told her she was being punished for not cleaning her room. MJ's mother
stated that she remained in her room at home and did not socialize with friends. Her parents
sought help when they noticed her behavior regressing during the past 2 months.
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2.3D.Undeffrentiated:
The patient could have both of negative and positive signs of schizophrenia , also
delusion , hallucination , in addition to bizarre or add behavior .
The most important note to be in consideration is that the criteria are not met for the
paranoid , disorganized , or catatonic type.
2.23.Risdual :
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Absence of prominent delusions, hallucinations, disorganized speech, and
grossly disorganized or catatonic behavior
Continuing evidence of, in attenuated form, the presence of negative symptoms or
two or more symptoms of diagnostic characteristics
Is labeled on the patient who have at least one episode of schizophrenia but currently
does not have noticeable positive signs , the disturbance is indicated by the presence of
negative signs.
The patient may have some positive signs but its not prominent and not accompanied by
strong affect .
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3.1.Treatment and Therapy
A.Pharmacological treatments :
Antipsychotic drugs are used in schizophrenia management , antipsychotic drugs are not
a homogeneous group, and there are various classes.
There is the typical ones , or what so called “first generation” also the newer atypical or
“second generation“
Below is a table show the most common medication from both types and further details
about some of it .
Type
Class
Example
Typical antipsychotics
Phenothiazines
Chloropromazine, Thioridazine
Trifluoperazine, Fluphenazine
Butyrophenones
Haloperidol, Droperidol
Thioxanthenes
Flupenthixol, Zuclopenthixol
Diphenylbutylpiperidines
Pimozide, Fluspiraline
Dibenzodiazepines
Clozapine
Benzixasoles
Risperidone, iloperidone
Dibenzothiazepines
Quetiapine
Thienobenzodiazepines
Olanzapine
Imidazolidinones
Sertindole
Benzothiazolylpiperazines
Ziprasidone
Substituted benzamides
amisulpride, sulpiride
sulpiride is considered by
some to be a typical
antipsychotic
Quinolinones
Aripiprazole
Atypical antipsychotics
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** Detailed information about some of the antipsychotic drugs :
Olanzapine:
-indication:
 Short and long term management of schizophrenia.
 Mono therapy in acute mixed , manic episode of bipolar disorder.
-Contraindication :
 Lactation.
-side effect :
 Nuroleptic malignant syndrome .
 Dyskinesia (involuntary, repetitive movements)
 Increased salivation.
Haloperidol :
-indication:
 Prolonged therapy in chronic schizophrenia
 Sever behavior problem in children with explosive hyperexcitability .
-contraindication :
Use with extra caution or not at all with parkinsonism or lactation .
-side effect :
 Akathisia.( feeling of inner restlessness and a compelling)
 Dystonia.( muscle contractions cause twisting and repetitive movements or
abnormal postures)
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B.Psychological therapy:
Psychoanalytic psychotherapies have largely been discredited in the management of
schizophrenia, and indeed cast something of a shadow over the development of more
effective approaches to treatment. However, a number of very promising new
approaches are now emerging.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) encompasses a variety of interventions. At its core is
the idea that if patients can be presented with a credible ‘cognitive’ model of their
symptoms, they may develop more adaptive coping strategies, leading to reduced
distress, improved social function and possibly even symptom reduction. CBT involves
regular one-to-one contact over a defined time period between patient and therapist.
Family treatments
Family therapy in schizophrenia is based on a ‘psycho-educational’ approach which
includes information about the nature of the disorder, its treatment, and factors which
might modify its course. It appears to have a modest effect in reducing the risk of
relapse in schizophrenia.
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Care Plan
For
Patient with Schizophrenia
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W
ASSESSMENT
hen assessing schizophrenic patient, you might have difficulties because of
the presence of psychotic symptoms.
use of assessment tools such a “Positive and Negative Syndrome Scale” , may
or may not be useful for collecting data about orientation, memory, thought and
perceptual processes, intellectual function, judgment, insight, affect, and mood.
So to collect data more correctly, its more professional to collect the data from :
 Family members or relatives if present.
 Health worker who take the care of the
patient.
 Patient file .
 Patient him self if he is cooperative.
During assessment phase , collect data
concerns the following :
 Personal data .
 History of psychiatric illness.
The schizophrenic patients share some
findings like :
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Hallucinations.
Delusions.
Self care deficits.
Decreased medication
compliance .
Sleep problems.
Isolation and withdrawal.
start gathering data according to physical , mental and social aspects in the basis of :
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physical dimension.
Emotional dimension.
Intellectual dimension
Social dimension.
Spiritual dimension.
Further details will be attached to the project .
Assessment findings is individualized for every patient , some could have chronic
illnesses like DM , hypertension, or other organic disease beside to mental disease.
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Diagnoses
The needs of patients will be interpreted in the following nursing diagnoses :
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Disturbed thought processes related to the presence of delusions.
Disturbed sensory perception related to the presence of hallucinations.
Self-care deficit related to poor personal hygiene.
Impaired verbal communication related to thought disturbance (looseness of
association).
Noncompliance related to refusal to take prescribed psychotropic medication.
Disturbed sleep pattern related to the presence of auditory hallucinations.
Social isolation related to fear or homelessness.
Ineffective coping related to fear.
Risk for Violence: Self-directed or Other-directed related to suspicion and
inability to recognize people or places.
Planning and Outcomes Identification
The patient problems were identified and the next step is to set the goals appropriate
for each patient in order to increase health , maintain it or prevent further
deteriorations.
In schizophrenic patient , planning for the care needed most take holistic approach , so
The desired results and outcomes reached , and these are examples of goals based on
the diagnosis mentioned above :
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The patient will communicate with members of the treatment team.
The patient will verbalize his or her physical needs.
The patient will have compliance with medication management.
The patient will demonstrate the ability to perform personal hygiene on a daily
basis with minimal assistance or prompting.
The patient will verbalize a decrease in the frequency of hallucinations.
The patient will verbalize a decrease in the presence of the delusions.
The patient will show an increase in the ability to socialize.
The patient will exhibit an accurate perception of reality.
The patient will not harm others or self and remain safe from injuries .
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Implementation \ intervention
This is were actions take place , and its time to focus on establishing a trusting
relationship, establishing clear, consistent, open communication, providing a safe
environment, alleviating positive, negative, and disorganized symptoms, and
maintaining biologic integrity by dealing with each given problem in therapeutic way.
Now , a set of interventions will be assigned for most common diagnosis so it can achieve
the desired outcomes .
Diagnosis :Disturbed thought processes related to the
presence of delusions.
Outcome: The patient will verbalize a decrease in the
presence of the delusions.
Intervention :
Do not argue with the client or attempt to disprove delusional or suspicious
thoughts.
interject doubt if its appropriate.
Do not whisper or laugh in the presence of the patient ( for suspicious
patient and persecutory ).
If the patient asks you if you believe the delusion, inform the client that you
do not share the perception or delusional belief.
Identify ways to help the patient control thoughts... Such as distracting
oneself from thinking the same thought repeatedly, using thoughtswitching techniques, identifying signs, such as staring, that indicate
thoughts are becoming disorganized; and anticipating new situations that
may increase anxiety or enhance delusional thoughts.
Encourage the patient to discuss the logic or reasoning behind the
delusion.
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Diagnosis : Disturbed sensory perception related to the
presence of hallucinations.
Outcome : The patient will verbalize a decrease in the
frequency of hallucinations.
Intervention :
Interrupt patient hallucination by simply starting dialogue or assign simple
task to make him busy and within reality.
Attempt to identify precipitating factors by asking the patient what
happened prior to the onset of hallucinations.
Decrease environmental stimuli such as loud music, extremely bright
colors, or flashing lights.
Monitor for command hallucinations that may precipitate aggressive or
violent behavior.
Diagnosis : Social isolation related to fear or homelessness
Outcome : The patient will show an increase in the ability to
socialize.
Intervention :
Build relationship with the patient based on trust and respect.
Try to start therapeutic communication with the patient , select
appropriate time .
Find and discuss with patient ways to spend his day .
Ask the patient to engage in the ward activity with other patient , like bed
making preparations .
plan for a schedule with treatment team to assign the patient in social
rehabilitation programs such as work therapy and play therapy .
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Diagnosis: Self-care deficit related to poor personal
hygiene low nutrition intake.
Outcome : The patient will demonstrate the ability to
perform personal hygiene on a daily basis with minimal
assistance or prompting and maintain proper weight and
physical conditions.
Intervention :
Ensure that the patient takes bath at daily basis or 2\1 day .
Make it habitual to ask the patient about his nails , hair , and teeth and
care about them.
Use clothing with elastic and Velcro for fastenings rather than buttons or
zippers, which may be too difficult for patient to manipulate.
Assess and monitor patient's ability to perform ADLs (activity of daily life ).
Give a positive reinforcement for good grooming and dress.
Monitor food and fluid intake.
Sit with patient during meals and assist him.
Weigh patient weekly.
Diagnosis : Impaired verbal communication related to
thought disturbance.
Outcome : The patient will communicate with members
of the treatment team.
Intervention :
Speak slowly and use short, simple words and phrases.
If patient becomes aggressive, shift the topic to a safer, more familiar one.
If patient becomes delusional, acknowledge feelings and reinforce reality.
Do not attempt to challenge the content of the delusion.
Use silence and at the same time keep in control of the discussion .
Reassure the patient so he can take his time while he is communicate with
you , and always try to make him in focus in the subject of the dialogue.
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Evaluation
The purpose of evaluation is “to compare the patient’s current mental status with
stated desirable outcomes identified”. If the outcomes have not been met,
consider the reasons why?..
For example, outcomes may not be achieved due to:
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the patient's lack of belief in success.
unrealistic expectations regarding recovery.
Lack of social support or income.
cognitive deficit that limits the patient's insight regarding his or her
illness.
Depression may occur due to a decline in dopamine level as the patient ages.
Additional specific nursing interventions and changes in outcomes may be
necessary.
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Its important to understand and recognize that is the
nursing process it’s DYNAMIC, change as the patient status
changes , further assessment must be done , and the care
have to continue as the patient deals with any problems on
his mental-social-physical and environmental status .
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REFERENCES :
-Mario Maj ,Norman Sartorius. "Schizophrenia" ,2nd edition ,(2002)
-Martin Stefan , Mike Travis , Robin M. Murray. "An Atlas of SCHIZOPHRENIA"
,(2002)
-ELLEN THACKERY ,MADELINE HARRIS ,"The GALE ENCYCLOPEDIA of MENTAL
Disorders", (2003)
-Miles Hewstone, Frank D. Fincham ,Jonathan Foster, "Psychollogy" , (2005)
-Darlene D. Pedersen , "Psych Notes - Clinical Pocket Guide " , (2005)
-American Psychatric Acociation , "DSM-IV-TR" Dignostic and statistical manual of
mental disorder , fourth eddition ,text revision , (2000)
-Shives, Louise Rebraca , "Basic Concepts of Psychiatric-Mental Health Nursing",
6th Edition ,(2005)
-Nettina, Sandra M.; Mills, Elizabeth Jacqueline , "Lippincott Manual of Nursing
Practice", 8th Edition , (2006)
-George R.spratto , adrienne L.Woods , "PDR NURSES DRUG HANDBOOK" , 2007
Edition , (2007)
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