Schizophrenia
Schizophrenia
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Causes distorted and bizarre thoughts, perceptions, emotions, movements, and
behavior
Cannot be defined as a single illness; rather, schizophrenia is thought of as a syndrome
or as a disease process with many different varieties and symptoms
Schizophrenia
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Usually diagnosed in late adolescence or early adulthood
Peak incidence of onset
o Men 15 to 25 years of age
o Women 25 to 35 years of age
Diagnosis
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Two (or more) of the following, each present for a significant portion of time during a
1-month period (or less if successfully treated). At least one of these must be (1), (2),
or (3):
o Delusions
o Hallucinations
o Disorganized speech (e.g., frequent derailment or incoherence)
o Grossly disorganized or catatonic behavior
o Negative symptoms (i.e., diminished emotional or avolition)
Schizophrenia
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Symptoms are divided into two major categories
o Positive symptoms/signs
o Negative symptoms/sign
Medication may control positive, but negative symptoms often persist
Schizophrenia
Positive Symptoms
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Ambivalence – Holding contradictory beliefs
Associative looseness – Fragmented ideas
Delusions
Echopraxia – Imitiation of movements of others
Flight of ideas – me_irl
Hallucinations – False sensory perceptions
Ideas of Reference – False impressions that events of special meaning for the person
Perseveration
Bizarre Behavior
Schizophrenia
Negative Symptoms
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Alogia – “Poverty of Speech”
Anhedonia – No joy or pleasure in life
Apathy – No care
Asociality
Blunted affect – Restricted range of emotion
Catatonia – Motionless as if in a trance
Flat affect
Avolition – Absence of will, ambition, or drive
Inattention – Can’t concentrate
Etiology
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Focus on genetic factors, neuroanatomic and neurochemical factors (structure and
function of the brain), and immunovirology
Schizophrenia
Psychopharmacology
Does not cure, manages
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Antipsychotics (also known as neuroleptics)
o Decrease psychotic symptoms
o 1st generation
 Dopamine antagonists; target the positive signs of schizophrenia
nd
o 2 generation
 Diminish positive signs but also lessens the negative signs
Schizophrenia
Psychopharmacology
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Side effects
o Extrapyramidal side effects (acute dystonic reactions, akathisia, parkinsonism)
 Dystonic reaction
 Spasm in discrete muscle groups
 Protrusion of tongue, dysphagia, laryngeal and pharyngeal spasm
 Treatment – diphenhydramine IM or IV or benztropine IM
 Pseudoparkinsonism
 Shuffling gait, masklike facies, muscle stiffness, drooling, akinesia
 Appear first few days after starting or increasing dosage
 Akathisia
 Characterized by restless movement, pacing, inability to remain
still, and the client’s report of inner restlessness
o Propranolol; benzodiazepines
Schizophrenia
Psychopharmacology
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Side Effects
o Tardive dyskinesia
 Lip smacking, tongue protrusion, chewing, blinking, grimacing, and
choreiform movements of the limbs and feet
 Can contribute to social isolation
 Irreversible
Schizophrenia
Psychopharmacology
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Tardive Dyskinesia
o Abnormal Involuntary Movement Scale (AIMS)
 Used to screen for symptoms of movement disorders
 If increased score on the AIMS, the nurse should notify the physician
 Schizophrenia
Psychopharmacology
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Side effects (continued)
o Neuroleptic malignant syndrome
 Serious and frequently fatal
 Muscle rigidity, high fever, increased muscle enzymes, and leukocytosis
 Treated by stopping medication
Schizophrenia
Psychopharmacology
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Side effects (continued)
o Agranulocytosis
 Clozapine
 Fever, malaise, ulcerative sore throat, leukopenia
 Can occur 18-24 weeks after initiation of therapy; weekly WBC weekly for
1st 6 months
 Must be discontinued immediately
Schizophrenia
Psychopharmacology
Side effects (continued)
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Weight gain
Sedation
Photosensitivity
Anticholinergic symptoms
Table 16-2 Videbeck (interventions r/t SE)
Psychosocial Treatment
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Individual and group therapy
o Supportive in nature
o Opportunity for social contact and meaningful relationships
o Focus on topics of concern
Psychosocial Treatment
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Family education and therapy
o Known to diminish the negative effects of schizophrenia
o Reduces relapse rate
o Helps make families part of the treatment plan
Psychosocial Treatment
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Family support groups
o Supportive environment that helps them cope with the many difficulties
presented when a loved one has schizophrenia
Nursing Process – Assessment
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Do not make assumptions about the client’s abilities or limitations solely based on the
diagnosis of schizophrenia
History
o “How do you usually spend your time?”
 “Can you describe what you do each day?”
Nursing Process – Assessment
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History (continued)
o Age of onset
o Previous suicide attempts
 History of violence or aggression
o Use of current support systems
o Client’s perception of his or her current situation
Nursing Process – Assessment
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General appearance, motor behavior, speech
o Some appear normal in terms of dress and posture
o Odd or bizarre behavior; disheveled and unkempt
o Strange or inappropriate clothing
o Restless, unable to sit still
o Agitation, pacing, catatonia
Nursing Process – Assessment
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General appearance, motor behavior, speech (cont’d)
o Seemingly purposeless gestures
o Odd facial expressions
o Imitate movements and gestures of someone whom he/she is observing
(echopraxia)
o Rambling speech
o General slowing of all movements
Unusual Speech Patterns of Clients with Schizophrenia
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Clang associations
o Ideas that are related to one another based on sound or rhyming rather than
meaning
Neologisms
o Words invented by the client
Verbigeration
o Repetition of words or phrases that may or may not have meaning to the listener
Unusual Speech Patterns of Clients with Schizophrenia
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Echolalia
o Client’s imitation or repetition of what the nurse says
Stilted language
o Use of words or phrases that are flowery, excessive, and pompous
Word salad
o Combination of jumbled words and phrases that are disconnected or incoherent
and make no sense to the listener.
Nursing Process – Assessment
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Mood
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Flat affect; blunted affect; masklike
Silly, characterized by laughter for no reason
Expression/emotions incongruent with situation
Depressed; no pleasure or joy in life
 Feel all-knowing, all-powerful
Nursing Process - Assessment
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Thought process
o Thought blocking
 Stop talking in the middle of a sentence and remain silent for several
seconds to 1 minute
o Thought withdrawal
 Others are taking their thoughts
o Thought insertion
 Others are placing thoughts in their mind against their will
o Thought broadcasting
 State that they believe others can hear their thoughts
Nursing Process - Assessment
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Delusions
o Fixed, false beliefs with no basis in reality
o Common characteristic is the direct, immediate, and total certainty with which
the client holds these beliefs
o External contradictory information or facts cannot alter these delusional beliefs
Types of Delusions
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Persecutory/Paranoid delusions
o Belief that “others” are planning to harm him or her or are spying, following,
ridiculing, or belittling the client in some way
o Religious delusions
 Center around the second coming of Christ or another significant
religious figure or prophet
Types of Delusions
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Grandiose delusions
o Characterized by the client’s claim to association with famous people or
celebrities, or the client’s belief that he or she is famous or capable of great
feats.
Nursing Process – Assessment
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Hallucinations
o Can involve the five senses and bodily sensations
o Can be threatening and frightening for the client
o Initially, the client perceives them as real, but later in the illness may recognize
them as hallucinations
Nursing Process – Assessment
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Hallucinations
o Auditory hallucinations
 Involve hearing sounds, most often voices, talking to or about the client
o Visual hallucinations
 Seeing images that do not exist at all
Nursing Process - Assessment
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Sensorium
o Clients are commonly disoriented to time and sometimes place during episodes
of psychosis
o Depersonalization
 Client feels detached from his or her behavior
 Feels as if his or her body belongs to someone else
Nursing Process - Assessment
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Intellectual Processes
o Difficulty with abstract thinking
 Client may not understand what is being said and misinterpret
instructions
Nursing Process – Assessment
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Self-Concept
o Loss of ego boundaries
 Client’s lack of a clear sense of where his or her own body, mind, and
influence end and where those aspects of other animate and inanimate
objects begin
Nursing Process - Assessment
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Roles and relationships
o Social isolation
 Due to delusions, hallucinations, loss of ego boundaries
 Problems with trust and intimacy
o Frustration in attempting to fulfill roles
Nursing Process - Assessment
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Physiological and Self-Care Considerations
o Inattention to grooming and hygiene common
o Fail to perform basic activities of daily living
o May fail to recognize sensations such as hunger or thirst
o Sleep problems are common
o Assess daily living skills and functional abilities
Goals/Outcomes
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Acute, psychotic phase
o The client will not injure him/herself or others
o The client will establish contact with reality
o The client will interact with others in the environment
o The client will express thoughts/feelings in a safe, socially acceptable manner
o The client will participate in prescribed therapeutic interventions
Goals/Outcomes
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Continued care after the stabilization of acute symptoms
o The client will participate in the prescribed regimen
o The client will maintain adequate routines for sleeping and food and fluid intake
o The client will demonstrate independence in self-care activities
Goals/Outcomes
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Continued care after the stabilization of acute symptoms (continued)
o The client will communicate effectively with others in the community to meet his
or her needs
o The client will seek or accept assistance to meet his or her needs when indicated
Interventions
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Promoting the safety of the client and others
 Observe for signs of building agitation or escalating behavior
 Institute interventions to protect the client, nurse, and others in the
environment
 Administering medication; moving the client to a quiet, less
stimulating environment; and in extreme situations, temporarily
using seclusion or restraints.
Interventions
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Establishing a therapeutic relationship
o Takes time and the nurse must be patient
o Provide explanations that are clear, direct, and easy to understand
o Eye contact, relaxed body posture, facial expressions that convey interest and
concern
o Tell the client your name and call the client by name
Interventions
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Therapeutic Communication
o Maintain nonverbal communication with the client, especially when verbal
communication not successful
o Active listening
 Listen for themes, ask clarifying questions, explore the meaning of the
client’s statements
Therapeutic Communication Example
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Nurse: “How are you feeling today?” (using a broad opening statement)
Client: “Invisible.”
Nurse: “Can you explain that to me?” (seeking clarification)
Client: “Oh, it doesn’t matter.”
Nurse: “I’m interested in how you feel; I’m just not sure I understand.” (offering
self/seeking clarification)
Client: “It doesn’t mean much.”
Nurse: “Let me see if I can understand. Do you feel like you’re being ignored, that no
one is really listening?” (verbalizing the implied)
Interventions
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Interventions for delusional thoughts
o Avoid openly confronting the delusion or arguing with the client about it
o The nurse must also avoid reinforcing the delusional belief by “playing along”
with what the client says
o Distraction techniques, such as listening to music, watching television, writing, or
talking to friends, are useful
Interventions
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Interventions for delusional thoughts (continued)
o Present and maintain reality
 “I have seen no evidence of that.” (presenting reality)
 “It doesn’t seem that way to me.” (casting doubt)
Interventions
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Interventions for hallucinations
o Determine what the client is experiencing
 “I don’t hear any voices; what are you hearing?” (presenting
reality/seeking clarification)
 “I don’t see anything, but you must be frightened. You are safe here in the
hospital.” (presenting reality/translating into feelings)
Interventions
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Interventions for hallucinations
o Dismissal intervention
 Talk back to the voices forcefully
Client and Family Teaching
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How to manage illness and symptoms
Recognizing early signs of relapse
Developing a plan to address relapse signs
Importance of maintaining prescribed med regimen and follow-up
Avoid alcohol and other drugs
Client and Family Teaching (continued)
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Self-care and proper nutrition
Teaching social skills through education, role modeling, and practice
Seeking assistance to avoid or manage stressful situations
Counseling and educating family/significant others about clinical course and need for
ongoing support
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Importance of maintaining contact with the community and participating in supportive
organizations
Early Signs of Relapse
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Impaired cause-and-effect reasoning
Impaired information processing
Poor nutrition
Lack of sleep
Lack of exercise
Fatigue
Poor social skills, social isolation, loneliness
Interpersonal difficulties
Lack of control, irritability
Mood swings
Ineffective medication management
Low self-concept
Looks and acts different
Hopeless feelings
Loss of motivation
Anxiety and worry
Disinhibition
Increased negativity
Neglecting appearance
Forgetfulness
Medication Management (Of relapse)
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Determine the barriers to compliance for each client
o Difficulty remembering when and if they did take med -> Pill box or chart
o Practical barriers (cost, transportation, refills)
o Side effects
 Eating proper diet, drinking enough fluids, stool softener, sucking on hard
candy, using sunscreen
Medication Management
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Determine the barriers to compliance for each client (continued)
o Dislikes taking them or believes they don’t need them
 May feel the medication is unnecessary when they feel well
Client and Family Education Related to Medication Management
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Drink sugar-free fluids and eat sugar-free hard candy to ease the anticholinergic effects
of dry mouth
Constipation can be prevented or relieved by increasing intake of water and bulkforming foods in the diet and by exercising; stool softeners
Use sunscreen to prevent burning. Avoid long periods of time in the sun, and wear
protective clothing.
Rising slowly from a lying or sitting position prevents falls from orthostatic hypotension
or dizziness due to a drop in blood pressure.
Monitor the amount of sleepiness or drowsiness you experience.
Client and Family Education Related to Medication Management
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If you forget a dose of antipsychotic medication, take it if the dose is only 3 to 4 hours
late. If the missed dose is more than 4 hours late or the next dose is due, omit the
forgotten dose
Evaluation
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Have the client’s psychotic symptoms disappeared? If not, can the client carry out his or
her daily life despite the persistence of some psychotic symptoms?
Does the client understand the prescribed medication regimen? Is he or she committed
to adherence to the regimen?
Evaluation
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Does the client possess the necessary functional abilities for community living?
Are community resources adequate to help the client live successfully in the
community?
Is there a sufficient aftercare or crisis plan in place to deal with recurrence of symptoms
or difficulties encountered in the community?
Evaluation
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Are the client and family adequately knowledgeable about schizophrenia?
Does the client believe he or she has a satisfactory quality of life?