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Nursing Management
Assessment
Nursing
diagnosis
Evaluation
nursing
intervention
planing
Assessment
The nurse must be aware of the client’s status and of
changes in the client’s personal life, family situation, and
environment to plan care & intervenetio effectively.
The symptoms of schizophrenia are divided into positive
symptoms ,which represent an excess or distortion of normal
functioning & negative symptoms, which represent a deficit in
functioning .
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Assessing Positive Symptoms of Schizophrenia
The positive symptoms appear early in the first phase of
the illness.
The positive symptoms are presented in terms of
alterations of thought, perception, & behavior
I- Alteration of thought
1- Delusions:
Most common delusional thinking includes :
a- Ideas or reference.
b- Delusions of persecution.
c- Delusions of grandeur.
d- somatic delusions.
e- Delusions of jealousy.
Other delusions observed:Thought broadcasting , the belief that one’s thoughts can
be heard by others (e.g. “My brain is connected to the
world mind”)
Thought insertion, the belief that thoughts of others are
being inserted into one’s mind
Thought withdrawal , the belief that thoughts have been
removed from one’s mind by an outside agency
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Delusions of being controlled, beliefs that one’s body or
mind is controlled by an outside agency
2- Autistic thinking.
3- Looseness of associations.
4- Clang association.
5- Neologism.
6- Concrete thinking.
7- Echolalia.
8- Word salad.
II- Alterations in perception
Hallucinations are the major examples of alterations in
perception in schizophrenia, especially auditory hallucinations,
and loss of ego boundaries (depersonalization & derealization
1- Hallucinations
It is estimated that 90% of the people with
schizophrenia experience hallucinations at some time
during their illness.
Although manifestations of hallucinations are varied,
auditory hallucinations are most common in
schizophrenia.
These voices may seem to come from outside or inside
the person’s head .
The voice may be familiar or strange, single or multiple.
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Voices speaking directly to the person or commenting
on the person’s behavior are most common in
schizophrenia.
A person may believe the voices are from. God ,the
devil, deceased relatives, or strangers.
The auditory hallucinations may occasionally take the
form of sounds rather than voices.
Commanding hallucinations must be assessed for, because
the “voices” may command the person to hurt himself or
others. For examples, a client might state “the voices” are
telling him to “ jump out of the window” or “take a knife & kill
my child”.
Commanding hallucinations are often frightening for
the individual.
A person experiencing them is often in panic levels of
anxiety , & commanding hallucinations may signal a
psychiatric emergency.
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2- Loss of ego boundaries :?????????????????????
People with schizophrenia often lack a sense of their body
in relationship to the rest of the world, where they leave off
and others begin. For this reason, many schizophrenics are
confused over their own sexual identity.
A client might say he or she is merging with others or is part
of inanimate objects.
a- Depersonalization ??????????????????????????
Is a nonspecific feeling that a person has lost his or her
identity, that he or she is different and unreal . The person may
be concerned that body parts do not belong to him or her. Or
the person may have an acute sensation that his or her body
has drastically changed. For example, people may see their
fingers as snakes or their arms as rooting wood. Another may
look in a mirror and state his face is that of an animal.
b- Derealization ???????????????????????
Is the false perception by a person that the environment
has changed. For example, everything seems bigger or smaller ,
or familiar surroundings have become somehow strange and
unfamiliar.
Both Depersonalization & Derealization can be interpreted
as loss of ego boundaries .
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III - Alterations in behavior
Bizarre and agitated behavior is associated
schizophrenia and may take a variety of forms.
with
1. Bizarre behavior
May take the forms of a stilted rigid demeanor, eccentric
dress or grooming & rituals.
The following behaviors are often seen in catatonia
Extreme motor agitation
Extreme motor agitation is agitated physical behavior
Stereotyped behaviors
Stereotyped
purposeless
behaviors
are
motor
patterns
that
Automatic obedience
Waxy flexibility
Waxy flexibility consists of excessive maintenance of
posture evidenced when a person’s arms or legs can be
placed in any position and the position is held for long
periods of time.
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Stupor
The person who is in stupor may sit motionless for long
periods of time and may be motionless to the point of
apparent coma.
Negativism
Agitated behavior
Assessing Negative Symptoms of Schizophrenia
These symptoms are that most interfere with
individual’s adjustment and ability to survive.
the
Initiate and maintain relationships
Initiate and maintain conversations
Hold a job
Make decisions
Maintain adequate hygiene and grooming
It is the presence of negative symptoms that contributes to
the personal poor social functioning and social withdrawal .
Affect of a schizophrenic person usually falls into one of
three categories:
Flat or blunted
Inappropriate
Bizarre
Flat or blunted affect is commonly seen in schizophrenia
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Inappropriate affect refers to an emotional response to a
situation that is not congruent with the tone of the situation
For example, a young man, told that his father is ill , breaks out
laughing .
Bizarre affect is especially prominent in the disorganized
form of schizophrenia.
Other negative symptoms include
Anergia
Anhedonia
Avolition
Poverty of speech.
Thought blocking
Nursing diagnoses are formulated from the information
obtained during the assessment phase of the nursing process.
The following is a listing of some of the more common
diagnoses applicable to schizophrenia.
1- Altered thought processes.
2- Sensory perceptual alterations.
3- Impaired verbal communication.
4- Social isolation.
5- Ineffective individual coping .
6- Self-care deficit
(bathing , hygiene , dressing , grooming , feeding , toileting ).
7- Altered family processes.
8- Risk for violence (directed at others)
9- Risk for violence (self-directed)
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1- Altered thought processes
Related to
Impaired ability to process and synthesize internal and
external stimuli
Biologic factors (neurophysiologic, genetic)
sensory-perceptual alterations.
Psychosocial/environmental stressors
Evidenced by
Inability to distinguish internally stimulated irrational ideas
leading to faulty conclusions(autistic)
Perceives that others in the environment can hear his or her
thoughts(thought broadcasting).
Demonstrated neologisms, word salad, thought blocking,
thought insertion, thought withdrawal,
poverty of speech , or Mutism
Believes that her thoughts are responsible for world events
Goals
Demonstrate reality-based thinking in verbal and nonverbal behavior.
Demonstrate absence of psychosis (delusions, incoherent,
illogical speech , magical thinking ideas of references,
thought
blocking
thought
insertions
,thought
broadcasting).
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Nursing Intervention
1. Approach the client in a slow , calm matter-of-fact manner,
to avoid distorting the client’s sensory-perceptual field,
which could foster altered thoughts and perceptions.
2. Maintain facial expressions and behaviors that are consistent
with verbal statements. Patients care very sensitive to
other’s responses to their symptoms.
3. Continue to assess the client’s ability to think logically and to
utilize realistic judgment and problem-solving abilities.
4. Listen attentively for key themes and reality-oriented
phrases or thoughts.
Interpret , the client’s misconceptions and misperceived
environmental events in a calm , matterof-fact manner ..Identification of reality by a trusted person is
helpful.
5. Instruct the client to approach staff when frightening
thoughts occur. A respectful, interested approach will enable
the patient to discuss unusual and frightening thoughts.
6. Refrain from touching a client who is experiencing a delusion
especially if it is a persecutory type. Touch may be
interpreted as a physical or sexual assault.
7. Avoid challenging the client’s delusional system or arguing
with the clients, since delusion cannot be changed through
logic, and challenging the belief, may force the client to
adhere to it and defend it.
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8. Distract the client from the delusion by engaging him in a
less threatening or more comforting topic or activity at the
first sign of anxiety or discomfort.
9. Focus on the meaning, feeling , or intent provoked by the
delusion rather than on the delusional content.
10.Avoid seeking the details of the client’s delusion so as not to
reinforce the false belief and further distance client from
reality.
11.Offer praise as soon as the client begins to differentiate
reality based and non-reality based thinking.
12.Respond to the client’s delusions of persecution with calm ,
realistic statements.
13.Use simple declarative statements when talking to the client
who demonstrates, disconnected , incoherent , or tangential
speech patterns , which reflect loose associations .
2. Sensory / perceptual alteration :
Related factors
Psychosocial stressors, loneliness and isolation ( perceived or
actual ).
Withdrawal from environment.
Lack of adequate support persons.
Chronic illness and institutionalization.
Altered thought processes.
Disorientation.
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Derealization , depersonalization.
Ambivalence .
Biologic factors (neurophysiologic, genetic).
Evidenced by
Negligent
to
surroundings
(preoccupied
with
hallucination)
Startles when approached and spoken to others.
Talks to self (lips move as if conversing with unseen
presence
Appears to be listening to voices or sounds when neither
are present (cocks head to side as if concentrating on
sounds that are inaudible to others ).
May act upon “voiced” commands ( may attempt
mutilating gesture to self or others that could be
injurious).
Describes hallucinatory experience “ It’s my father’s voice
and he’s telling me I’m not good”
Goals
Able to hold conversation without hallucinating.
Remains in group activities.
Attends to the task at hand (e.g. group process , recreational
or occupational therapy activity ).
States that hallucinations are under control.
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Nursing Interventions
1. Continuously orient patient to actual environmental events
or activities , to present reality.
2. Call the client and staff members by their names to reinforce
reality.
3. Utilize clear statements.
4. Utilize clear, direct verbal communication rather than
unclear or nonverbal gestures.
5. Focus on real events or activities to reinforce reality and
divert client from the hallucinating experience.
6. Reassure the client (frequently if necessary ) that she is safe
& won’t be harmed
7. Observe for verbal or nonverbal behaviors associated with
hallucinations.
8. Attempt to determine precipitants of the sensory alteration
(stressors that may trigger the hallucination )
9. explore the content of the auditory hallucinations to
determine the possibility of harm to self, others or the
environment ( auditory command and hallucinations ) to
prevent destructive behavior.
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10.When danger or violence is imminent , protect the client
and others by the following facility procedures and policies
for seclusion , mechanical restraint to prevent harm or
injury to client or others.
11.Teach the client techniques that will help stop the
hallucinations .
3- Impaired verbal communication
Related factors
Disturbances in the form of thinking ( autistic ).
Altered thought processes (e.g. delusions , magical thinking
Poverty of speech / Mutism.
Sensory / perceptual alternations ( e.g. hallucinations )
Disturbances in structure of associations ( e.g. neologisms ,
word salad , preservation)
Evidenced by
Loose associations
Neologisms
Word salad
Clang associations
Echolalia
Goals
Communicates thoughts and feelings in a coherent , goal
directed manner.
Demonstrates reality-based thought processes in verbal
communication.
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Nursing Interventions
1. Assess the degree to which the client’s impaired verbal
communication interferes with her ability to get others
understand the meaning behind the message and to clarify
communication.
2. Demonstrate a calm , patient behavior , rather than
attempting to force the client to speak coherently , to
decrease the client’s fears & anxieties about the inability to
communicate needs to demonstrate acceptance of client.
3. Actively listen to , observe verbal & nonverbal cues &
behaviors during the communication process, to piece
together each method of communication , to understand
better the aim of the client’s message , and demonstrate a
willingness to meet the client’s needs.
4. Use communication strategies such as restatement ,
classification, and consensual validation , to help reveal the
intent of the client’s messages .
5. Acknowledge the client’s inability to use the spoken word
while encouraging alternative methods to convey messages (
gestures, writing, drawing ) to communication process.
6. Instruct the client to seek assistance from staff when
experiencing communication problems ,Staff can help
facilitate the communication process.
7. Praise the client’s attempt to speak more coherently and to
engage in more meaningful conversations with others , to
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increase self-esteem and promote continued functional
speech patterns.
4- Social isolation
Related factors
Altered sensory perception ( hallucinations or illusions )
Altered thought processes ( delusions , magical thinking ,
ideas of reference , thought blocking , thought insertion ).
Impaired verbal communication ( neologisms , word salad ,
loose associations , tangentially , incoherence , poverty of
speech , Mutism ).
Long-term illness, hospitalization , or environmental
withdrawal.
Evidenced by
Withdrawal from the environment and from others in the
environment ( Isolates himself in his room or bed for most
of the day and night ).
Difficulty in establishing relationship with others in the
environment ( fails to seek out or respond to others ).
Verbalizations that indicate feelings of rejection from others
in the environment.
Inability to engage in social interactions or milieu activities.
Inability to share or express feelings with others in groups or
one-to-one .
Goals
Verbalize willingness to engage in social interactions and
activities with others in the environment.
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Nursing Interventions
1. Assess the extent of the client’s self-imposed isolation , to
plan strategies to break the pattern of withdrawal with
interactions and activities.
2. Assist the client to meet basic needs during times of social
withdrawal (sleep, nutrition , personal hygiene ) to promote
the client’s physical health and well-being.
3. Structure each day to include planned times for brief
interactions and activities with the client to help the client
organize times to engage with others and to let the client
know that participation is expected and that he or she is a
worthwhile member of the community .
4. Spend brief intervals with the client each day , engaging in
meaningful , non challenging interactions , to ease the client
out into the community by first developing trust , rapport ,
and respect.
5. Discuss with the client anything of interest to her , such as
items in the client’s room , favorite activities, or hobbies , to
encourage the client’s social skills and decrease social
isolation.
6. Provide the client with stimulation from recreational and
other milieu activities to expose the client to social activities
and increase opportunities for socialization.
7. Encourage the client to engage in social activities that are
within her physical capabilities and tolerance, to provide the
client with successful social experiences that are likely to be
repeated.
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