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  1. 1. HISTORICAL BACKGROUND  Ayurveda --- Morel described schizophrenia as demence precoce; Kahlbaum described schizophrenia as catatonia Hecker described schizophrenia as hebephrenia The scientific study of schizophrenia began with the description of dementia precox by Emil Kraepelin Dementia= deterioration; precox=earlyonset
  2. 2. EMIL KRAEPELIN  In 1986 he differentiated the major psychiatric illnesses into two clinical types 1. Dementia precox (delusions, hallucinations, disturbances of affect, & motor disturbances) 2. MDP
  3. 3. EUGEN BLEULER(1911)  Renamed dementia precox as Schizophrenia (splitting of mind) (1908) group of disorders rather than distinct entity so, he used the word group of schizophrenias.  Described characteristic symptoms as  Fundamental symptoms(diagnostic of schizophrenia)  Ambivalence,  Autism,  Affect disturbance,  Association disturbance  Accessory symptoms(secondary to Fundamental symptoms)  Delusions,  Hallucinations,  Negativism
  4. 4. KURT SCHNEIDER (1959)  Described symptoms which though not specific of schizophrenia, were of great importance in making a clinical diagnosis  Schneider First rank symptoms (SFRS) A. Hallucinations 1. Audible thoughts(thought echo) 2. Voices heard arguing 3. Voices commenting on one’s action
  5. 5. B. Thought Alienation phenomena 4. Thought withdrawal 5. Thought insertion 6. Thought diffusion or broadcasting C. Passivity phenomena 7. Made feeling or affect 8. Made impulses 9. Made volition or acts (robot like) 10. Somatic passivity D. Delusional perception 11. Delusional perception
  6. 6. SCHIZOPHRENIA  The word schizophrenia is derived from Greek word Schizo=split; Phrenic=mind  Term was coined by Swiss psychiatrist Eugen Bleuler  Major mental disorder characterized by Group of disturbances which sometimes occur in different combinations and intensities. Hence it is heterogeneous in nature
  7. 7. DEFINITION OF SCHIZOPHRENIA “Schizophrenia is defined as functional psychotic condition characterized by disturbances in thinking, emotion, volition and perception in presence of clear consciousness, which usually leads to social withdrawal”.
  8. 8. EPIDEMIOLOGY  Most common of the psychotic disorders  50% 0f beds in psychiatric hospitals are occupied  2/3rds of the cases are in the 15-30 years age group  Common in lower social classes  Acc to world health report 2001, 24 million people worldwide suffer from schizophrenia  Prevalence rate 0.5-1%, Prevalent in all cultures races and in all parts of the world  Incidence rate 0.5 per 1000  Onset is later in women and often runs benign course, as compared to men
  9. 9. ETIOLOGY  Unknown  However several theories have been propounded I. BIOLOGICAL THEORIES 1. Genetic hypothesis  8-10% of first degree relatives 3% of second degree relatives and 2% of third degree relatives of patients with schizophrenia can have schizophrenia as compared with 0.5-1% prevalence rate in the general population
  10. 10. POPULATION INCIDENCE(%) General population 1.0 Sibling of schizophrenic patient 8.0 Child with one schizophrenic parent 12.0 Child with two schizophrenic parent 40.0 Dizygotic twin of schizophrenic pt 14.0 Monozygotic twin of schizophrenic pt 46.0 2. Biochemical theories  Functional increase in dopamine level at post synaptic receptor  Other NT’s like 5-HT, GABA, Acetyl choline
  11. 11. 3. Brain imaging  Cranial CT Scan, MRI Scan, and post mortem studies show enlarged ventricles and mild cortical atrophy  PET Scan shows hypofrontality and decreased glucose utilization in the dominant temporal lobe  Attempts are being made to localize symptoms of schizophrenia to the various brain regions by PET 4. Other theories Biological basis of schizophrenia  Antipsychotics block the D2 receptor, cause improvement, and relapse occurs on stopping antipsychotic medication
  12. 12.  Newer atypical antipsychotics are D2-5-HT2 antagonists  Drugs like LSD, amphetamines, and mescaline, can cause schizophrenia like symptoms in normal subjects.  Organic mental disorders with schizophrenia like symptoms may be seen in Huntington’s chorea, homocystinuria, acute intermittent porphyria, Wilson’s disease and hemachromatosis.  Soft neurological signs (SNS), minor physical anomalies, and impaired eye tracking (smooth pursuit eye movements) are more oftenly seen  Viral and auto-immune factors have also been implicated by some, while others (Wein berger) have suggested a neurodevelopmental hypothesis for schizophrenia.
  13. 13. II.PSYCHOLOGICAL THEORIES 1. Stress –Diathesis model  Stressful life events  Stress-Vulnerability Hypothesis  Increased expressed emotions(EE) of significant others in the family can lead to early relapse 2. Family theories  Schizophrenogenic mothers (Cold, overprotective, & domineering, mothers retard the ego development of the child, Dependency on mother, Anxious mother)  Lack of real parents  Parental marital schism or skew  Double-bind theory  Communication deviance  Pseudo mutuality
  14. 14. 3. Information processing hypothesis  Disturbance in attention, inability to maintain a set, and inability to assimilate and integrate percepts are common findings  The patients may at first be overly attentive to stimuli but later may reduce attention to stimuli  Breakdown in the internal representation of mental events. 4. Psychoanalytical theories  Acc to Freud regression to pre oral (and oral) stage of psychosexual development, with the use of defense mechanism of denial, projection and reaction formation  Acc to Federn Loss of ego boundaries, with loss of touch with reality.
  15. 15. III. SOCIO-CULTURAL THEORIES  Although Prevalence is uniform across cultures, it was found more common in low SES which is now explained due to a downward social drift which is a result of having developed schizophrenia rather than causing it  Migration  Disorganization
  16. 16. PHASES OF SCHIZOPHRENIA  PRODROMAL PHASE:  DSM-IV characterizes the prodromal phase as clear deterioration in functioning before the active phase of the disturbance that is not due to a disturbance in mood or to a psychoactive substance use disorder and that involves at least two of the following s/s  Social isolation/ withdrawal  Impairment in role functioning  Peculiar behavior  Impairment in personal hygiene  Blunted / inappropriate affect  Digressive, vague, over elaborative, or circumstantial speech, or poverty of speech, or poverty of content of speech  Odd belief or magical thinking , influencing behavior and inconsistent with cultural norms  Unusual perceptual experience  Marked lack of initiative , interests, or energy.
  17. 17.  ACTIVE PHASE:  The patient exhibits frankly psychotic symptoms  Delusions  Hallucinations  Loosening of associations  Incoherence  Catatonic behavior  Particular stress may be present before the onset of this phase  RESIDUAL PHASE:  Follows active phase  Two of the symptoms mentioned in prodromal phase persist  Resembles prodromal phase except that disturbance in affect and role functioning are more severe  Hallucinations and delusions may persists
  18. 18. CLINICAL FEATURES  Disturbance in  Thought and verbal behaviour  Perception  Affect  Motor behavior  Relationship to the external world
  19. 19. THOUGHT AND SPEECH DISORDERS  Autistic thinking (Von Domarus Law) – patient may consider two things identical because they have identical predicates – lord Hanuman was celibate, I am celibate too; I am lord Hanuman  Loosening of associations ---- incoherence  Thought block – thought withdrawal  Neologism- word approximation or par aphasias ---- stomach as food vessel  Mutism  Poverty of speech  Poverty of ideation  Echolalia  Perseveration  Verbigeration
  20. 20.  Delusions  Primary Delusions (Autochthonous Delusions)  Secondary Delusions Types of Delusions  Delusions of persecution  Delusions of reference  Delusions of grandeur  Delusions of control  Somatic Delusions  Overinclusion  Impaired abstraction  Concreteness  Perplexity  Ambivalence
  21. 21.  Disorders of perception  Hallucination  Disorders of affect  Apathy  Emotional blunting  Emotional shallowness  Anhedonia  Inappropriate Emotional response  Lack of rapport (due to lack of Emotional contact)  Disorders of motor behavior  Decreases (inertia, stupor) or  increase in psychomotor activities (excitement, aggression, restlessness, agitation)  Mannerisms  Stereotypies  Decreased self care  Poor grooming  Catatonic features
  22. 22.  Positive symptoms  Delusions  Hallucinations  Bizarre behavior  Aggression  Agitation  Suspiciousness  Hostility  Excitement  Grandiosity  Negative symptoms  Affective flattening or blunting  Attentional impairment  Avolition-apathy (lack of initiative)  Anhedonia  Asociality  Alogia  Diminished emotional responsiveness  Stereotyped thinking  Psychomotor slowing, under activity  Passivity and lack of initiative
  23. 23.  Other features  Decreased functioning in work, social relations and self care  Loss of ego boundaries  Multiple somatic symptoms  Insight will be absent  Social judgment will poor  No disturbance with consciousness, orientation, attention, memory, intelligence.  Variability in symptoms over time  No underlying organic cause  No prominent mood disorder of depressive or manic type  Suicide
  24. 24.  DIAGNOSIS  Acc to ICD-10 a minimum of 1 very clear symptom ( and usually 2 or more if less clear cut) belonging to any one of the groups of referred to as (a) to (d) below, or symptoms from at least 2 of the groups referred to as (e) to (h), should have been clearly present for most of the time during a period of 1 month or more (DSM-IV-TR on the other hand requires a minimum period of 6 months)  If the duration of illness is less than 1 month then a diagnosis of acute schizophrenia like psychotic disorder should be made. a. Thought echo, Thought insertion, or withdrawal, or Thought broadcasting; b. Delusions of control, influence, or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensation; delusional perception; c. Hallucinatory voices giving a running commentary on the patient’s behavior or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;
  25. 25. d. Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather, or being in communication with aliens from another world); e. persistent hallucinations occurring every day for weeks or months or months f. breaks or interpolations in the train of thought resulting in incoherent or irrelevant speech or neologism; g. Catatonic behavior h. Negative symptoms i. A significant and consistent change in the overall quality of some aspects of personal behavior, (loss of interest, aimlessness, idleness, a self absorbed attitude, and social withdrawal)
  26. 26.  CLINICAL TYPES F20-F29 Schizophrenia F20- Schizophrenia F20.0-Paranoid Schizophrenia F20.1-Hebephrenic Schizophrenia F20.2-Catatonic Schizophrenia F20.3-Undifferentiated Schizophrenia F20.4-Post- Schizophrenia depression F20.5-Residual Schizophrenia F20.6-Simple Schizophrenia
  27. 27.  F20.0-Paranoid Schizophrenia  Delusions of Persecutory, Grandeur, control, infidelity (Jealousy)  Hallucinations have Persecutory, Grandiose content  Unfocussed anxiety  Anger  Argumentativeness  Violence  Doubts about gender identity  Disturbances of affect, volition, speech, and motor behavior  Personality deterioration is less  Patients may be apprehensive (intelligent, fearful), evasive (escaping)  Onset is insidious, occurs later in life, progressive and complete recovery may not occur  Frequent remissions and relapses are seen  Slight impairment with functional capability
  28. 28. F20.1-Hebephrenic Schizophrenia  In other classification this type is termed as Disorganized schizophrenia  Marked thought disorder, incoherence and severe loosening of associations.  Delusions and Hallucinations  Emotional disturbances Inappropriate affect Blunted affect Senseless giggling  mannerisms  Mirror gazing (for long periods of time)  Poor self care and hygiene  Impaired social and occupational ----social withdrawal  ICD-10 recommends 2-3 months of continuous observation for confident diagnosis  Onset is insidious in early 2nd decade(15-25 years)  Course is progressive and downhill  Recovery never occurs, severe deterioration without remissions  Has one of the worst prognosis among the subtypes of schizophrenia
  29. 29.  F20.2-Catatonic Schizophrenia  Catatonia – marked disturbance in the motor behavior cata- disturbed; tonic-tone;  Onset is acute in late 2nd and early 3rd decade  Course is episodic and recovery from episodes is complete, residual symptoms may present after 2nd or 3rd episode  3 clinical forms  Excited Catatonia  in psychomotor activity (restlessness, agitation, excitement, aggressiveness, violent behavior)------furor  in speech production, pressure of speech, loosening of association, incoherence  Stimuli for excitement is internal not the environmental (e.g. thoughts and impulses) so excitement is not goal directed  Some times very rarely excitement can become Severe -----rigidity, hyperthermia, and dehydration leading to death then it is known as acute lethal catatonia or pernicious catatonia
  30. 30.  Stuporous (or retarded) Catatonia--  psychomotor function  Mutism  Rigidity  Negativism  Posturing  Stupor  Echolalia  Echopraxia  Waxy flexibility  Ambitendency  Other symptoms-----mannerisms, stereotypies, automatic obedience, verbigeration  Delusions and hallucinations may present but not prominent  Catatonia alternating between excitement and stupor  Very common feature of both excited and stuporous catatonia are alternatingly present
  31. 31. F20.3-Undifferentiated Schizophrenia  Very common type  Diagnosed when features of no subtype are fully present or features of more than one subtype are exhibited.  F20.4-Post- Schizophrenia depression  Some schizophrenics develop depressive features within 12 months of an acute episode associated with risk of suicide  Can occur due to side effect of antipsychotics, regaining insight after recovery or as just part of an schizophrenia  It is important to distinguish the depressive features from negative symptoms and EPS of antipsychotics
  32. 32. F20.5-Residual Schizophrenia  Is similar to latent schizophrenia and symptoms are same as prodromal symptoms of schizophrenia  Diagnosed after at least one episode has occurred  According to ICD-10 (CDDG) it is characterized by the following features in addition to the general guidelines of schizophrenia  Prominent negative schizophrenic symptoms  Past h/o one clear cut psychotic episode  A period of 1 year during which the intensity and frequency of florid symptoms such as delusions and hallucinations have been minimal and the negative symptoms have been present  Absence of dementia or other organic brain disease and of chronic depression or institutionalism for negative symptoms
  33. 33. F20.6-Simple Schizophrenia  Most difficult to diagnose  Early onset (2nd decade)  Insidious and progressive course  Negative symptoms are present  Vague hypochondriacal features  Drift down the social ladder  Wandering aimlessly  Delusions and hallucinations are usually absent, if present they are short lived  Prognosis -----very poor
  34. 34.  OTHER SUBTYPES  Pseudoneurotic schizophrenia  Described by Hoch and Polatin  Initially presented with neurotic symptoms which last for 1 year and show poor response to treatment  3 classical symptoms are  Pan-anxiety  Pan-neurosis  Pan-sexuality  Now this subtype is subsumed under borderline personality disorder  Schizophreniform disorder  This is diagnostic category in DSM-IV-TR with features of schizophrenia. Only difference is duration is less than 6 months and prognosis is better than schizophrenia  This term was introduced by Langfeldt (1961)  Similar condition in ICD-10 is called acute schizophrenia like psychotic disorder
  35. 35.  Oneiroid(dream) schizophrenia  Described by Mayer-Gross,  Acute onset  Clouding of consciousness, disorientation  Dream like states  Perceptual disturbances with rapid shifting  Episode- brief  Van Gogh Syndrome  Dramatic self –mutilation in schizophrenia is also called as Van Gogh syndrome  Van Gogh was a famous painter who cut his ear during active phase of illness
  36. 36.  Late Paraphrenia  Described by Sir Martin Roth  Occurs late in life (6th decade)  Common in unmarried or widowed women  Delusions of persecution as being raped or strangers entering their room  Hallucinations of all kinds are present  ≈25-40% of patients have some defect of sight or hearing  Presently kept under paranoid schizophrenia, late onset  Pfropf schizophrenia  Schizophrenia occurring in the presence of MR  Behavioral disturbances are more prominent than thought disorder
  37. 37.  Type I and Type II Schizophrenia  T. J. Crow has divided schizophrenia in to two subtypes as  Type I and Type II Schizophrenia  Very few patients have a pure TYPE I or TYPE II syndrome  Admixtures are common
  38. 38. DIFFERENTIAL DIAGNOSIS  Exclude organic psychosis  Ex: complex partial seizures, drug (Amphetamine) induced psychosis, metabolic disturbances or cerebral neoplasm  Rule out a possibility of mood disorder or schizoaffective disorder  Exclude other non organic psychosis like delusional disorders, or acute and transient psychotic disorders (ATPD)
  39. 39. PROGNOSIS  Acute onset  Onset after 35 years  Presence of precipitating factors  Good premorbid adjustment  Catatonic subtype (paranoid intermediate prognosis)  Short duration (< 6 months)  Presence of depression  Predominance of positive symptoms  Family h/o mood disorder  Insidious onset  < 20 yrs of age  Absence of stressor  Poor premorbid adjustment  Disorganized, simple, undifferentiated or chronic catatonic subtypes  Chronic course (>2 yrs )  Absence of depression  Predominance of negative symptoms  Family h/o schizophrenia GOOD PROGNOSTIC FACTORS POOR PROGNOSTIC FACTORS
  40. 40. PROGNOSIS  First episode  Pyknic (fat) physique  Female sex  Good social support  Presence of confusion, perplexity, or disorientation in the acute phase  Proper treatment or good response treatment  OPD treatment  Normal CT Scan  Past h/o schizophrenia  Asthenic physique  Male sex  Poor social support or unmarried  Flat or blunted affect  Absence of proper treatment or poor response  Institutionalization  Evidence of ventricular enlargement on CT Scan GOOD PROGNOSTIC FACTORS POOR PROGNOSTIC FACTORS
  41. 41. COURSE AND OUTCOME  Progressive downhill course  More hospitalization  According to the study made by Luc Ciompi 1980 which included 5661 cases and which extended for 36.9 years the outcome was  Complete remission (27%)  Remission with minor residual deficit (22%)  Intermediate out come (24%)  Severe disability (18%)  Unstable or uncertain outcome (9%)  ALMOST 50% PATIENTS SHOWED COMPLETE OR NEAR COMPLETE RECOVERY  18% SHOWED SEVERE DISABILITY  9% NEEDING HOSPITALIZATION
  42. 42. COURSE AND OUTCOME  A study of factors associated with course and outcome of schizophrenia (SOFACOS) conducted by ICMR (Indian Council of Medical Research ) at 3 centers in India (Vellore, Madras, and Luknow)  386 patients were followed up for 5 years (1981 to1986) the out come was  Very favorable outcome (27%)  Favorable out come (40%)  Intermediate out come (31%)  Unfavorable outcome (2%)  So 2/3rds (67%) of the patients had a favourable out come as compared to 50% in Luc Ciompi ‘s study
  43. 43.  In ICD-10 the course of schizophrenia is specified under the categories of : i. Continuous ii. Episodic with progressive deficit iii. Episodic with stable deficit iv. Episodic remittent v. Incomplete remission vi. Complete remission if the period of observation is less than 1 year the course is not specified  Longer the duration of untreated psychosis (DUP) worse is the out come  Cause for increased mortality of patients in schizophrenia is suicide  Life time risk of suicide in schizophrenia is 5-10 times higher as compared to normal population
  45. 45. PHARMACOLOGICAL TREATMENT  First drug used was reserpine (Rauwolfia serpentina extract) by Sen and Bose in India in 1931----no longer used  Antipsychotics were formally discovered by Delay and Deniker in 1952  Atypical antipsychotics are commonly used than typical antipsychotics
  46. 46. ATYPICAL ANTIPSYCHOTICS:  Are more useful in negative symptoms (chronic schizophrenia)  Respseridone 2-10 mg/day PO  Olanzapine 10-20 mg/ day PO  Quetiapine 150-750mg/day PO  Aripiprazole  Ziprasidone 20-80 mg/day PO  Clozapine 50-450mg day PO effective drug in 30% of patients who had no beneficial response to traditional (typical and atypical antipsychoticsc) but leads to agranulocytosis ans seizures so used with caution
  47. 47. TYPICAL ANTIPSYCHOTICS:  Trifluoperazine 15-60 mg/day PO  Haloperidol 5-100 mg/day PO  Chlorpromazine 300-1500 mg/day PO  Drug treatment is usually given in OPD setting because  Few number of psychiatric beds  Families are willing to take care  Majority pts do not need hospitalization
  48. 48.  Hospitalization is indicated when  Pt neglects food & water  Pt is Danger to self and other  Poor drug compliance  Neglect of self care  Lack of social support  Antipsychotics act by blocking D2 receptors in the mesolimbic system, other receptors like 5-HT, muscarinic receptors and GABA are also important  Atypical antipsychotic are also called as SDAs have action on both dopamine and 5-HT
  49. 49. IN ACUTE EXCITEMENT  Haloperidol 5 mg IV / IM with or without diazepam or 50 mg promethazine  Chlorpromazine IM abscess IV hypotension
  50. 50. MAINTENANCE TREATMENT WITH ANTIPSYCHOTICS TO PREVENT RELAPSE  Treatment should be continued for 6 months to 1 year for 1st episode  For 1-2yrs for the subsequent episodes  Indefinite period for repeated episodes or persistent symptoms
  51. 51. DEPOT ANTIPSYCHOTIC PREPARATIONS WITH LONG DURATION OF ACTION AVAILABLE IN INDIA  Fluphenazine decanoate, 25-50mg IM every 2-3 weeks  Penfluridol, 20-60mg oral every week  Flupenthixole decanoate, 20-40mg IM every 2weeks  Haloperidol decanoate, 100-250mg IM every 4 wks  Zuclopenthixole decanoate, 200-400mg IM, every 2-4 weeks
  52. 52. ANTIPARKINSONIAN MEDICATIONS  Needed when pt is receiving older typical antipsychotics (haloperidol)  Trihexiphenidyl (THP) 6 mg / day  Orphenadrine 150 mg / day  Procyclidine 7.5-15 mg / day
  53. 53. ECT  Not a 1o indication for ECT  Indications for ECT in schizophrenia are  Catatonic stupor  Uncontrolled Catatonic excitement  Acute exacerbation not controlled by drugs  Severe side effects with drugs  8-12 ECTs are needed (up to 18) 3 times a week
  54. 54. MISCELLANEOUS TREATMENTS  Psychosurgery  rarely used  when used limbic leucotomy (small subcaudate lesion with cingulate lesion) in severe and prominent depression, anxiety or obsessional symptoms  Antipsychotics are far better  Many other methods used in past  Megavitamine therapy  Dialysis  Malaria therapy  High dose propranolol  High dose insulin (insulin coma therapy)
  55. 55. PSYCHOSOCIAL TREATMENT  Important component of comprehensive management: it has following steps  Psycho education  Group psychotherapy  Family therapy  Milieu therapy  Individual psychotherapy  Psychosocial rehabilitation
  56. 56. NURSING MANAGEMENT  General principles of management of schizophrenic pts  I  Chronic illness which needs long term treatment  Total cure may not occur in most of the cases  Aim is ---good improvement with regular and appropriate treatment  In times of stress the pt may get relapse in spite of regular treatment
  57. 57.  Pts need to  Increase in their own self esteem  Be assisted to live with the real world  Environment where he gets a change to use his own initiative and judgment  Have human contacts  Find a nurse who is having stable and consistent nature and who is having patience  Accept him as he is. Accept the pt whole heartedly  Nurse should not expect the impossible from the pt.  Assign small responsibilities  Engage and support  Supervise him  Appreciate for every achievements  Do not -------- Ignore Criticize Exert social behavior Refrain from over involvement
  58. 58.  II  Careful assessment--------diagnosis----------formulating a treatment plan  Nsg management depends on  Defining reality  Handling pt control  Strengthening the patient’s self image and Strengthening the IPR  Giving emotional support
  59. 59.  Nsg diagnosis: I Alteration in thought process r/t inability to trust, panic anxiety, evidenced by delusional thinking, inability to concentrate, impaired volition, extreme suspiciousness of others  Objective: pt will eliminate patterns of delusional thinking and demonstrate trust in others
  60. 60.  Nsg diagnosis: II Sensory-perceptual alteration: Auditory, visual, r/t panic anxiety, withdrawal into self, as evidenced by inappropriate responses, disordered thought process, poor concentration and disorientation.  Objective: pt will be able to define and test reality, eliminating the occurrence of hallucinations
  61. 61.  Nsg diagnosis: III Social isolation r/t inability to trust, panic anxiety, delusional thinking, evidenced by withdrawal, sad, dull affect, preoccupation with own thoughts, expression of feelings of rejection of aloneness imposed by others.  Objective: pt will voluntarily spend time with other pts and staff members in group activities on the units
  62. 62.  Nsg diagnosis: IV Potential for violence, self directed or directed to others, r/t extreme suspiciousness, panic anxiety, catatonic excitement, rage reactions, command hallucinations, as evidenced by physical violence, destruction of objects in the environment, self destructive behavior or active aggressive suicidal acts.  Objective: pt will not harm self or others
  63. 63.  Nsg diagnosis: V Impaired verbal communication r/t panic anxiety, disordered, unrealistic thinking as evidenced by loosening of associations, echolalia, verbalizations that reflect concrete thinking and poor eye contact Objective: pt will be able to communicate appropriately and comprehensibly by the time of discharge
  64. 64.  Nsg diagnosis: VI Self care deficit r/t withdrawal, panic anxiety, perceptual or cognitive impairment as evidenced by difficulty in carrying out tasks associated with hygiene, dressing, grooming, eating, and toileting.  Objective: patient will demonstrate ability to meet self care needs independently
  65. 65. DTH:”L;; ‘;. “  Nsg diagnosis: VII ineffective family coping r/t highly ambivalent family relationships, impaired family communications, as evidenced by neglectful care of the client, extreme denial or prolonged over concern regarding his illness  Objective: family will identify more adaptive coping strategies for dealing with patients illness and treatment regimen.
  66. 66. EVALUATION  Has the pt established trust with at least one staff member?  Is delusional thinking still prevalent?  Are hallucination still evident?  Is the pt able to interact with other appropriately?  Is the pt able to carry out all activities of daily living independently?
  67. 67. NSG CARE OF THE ACUTELY ILL SCHIZOPHRENICS  Common in catatonic and paranoid types  Main nursing concern is controlling his impulsive behavior when hears voices and respond to them  Pt may be abusive to the staff so the nurse who has established trust should collect the data  Physical need of the pt should be met  Inj: Haloperidol 10 to 20 mg IM/IV  Inj: Chlorpromazine 100 mg IM  Check for injuries  Approach the patient with assistants
  68. 68. NSG CARE OF THE CHRONIC SCHIZOPHRENICS  Usually withdrawn and have lot of negative symptoms  Engage the patient in useful activities (idle mind is a devils workshop)  The patients who live in fantasy have bad prognosis  He should be encouraged to do some positive, physical work (rehabilitation)  Encourage and motivate the pt  Appreciate him at appropriate time
  69. 69. PHYSICAL, EMOTIONAL, AND THERAPEUTIC NEEDS OF THE CHR PTS  Physical needs:  Nutrition  Personal hygiene  Elimination  Emotional needs:  To improve Social contacts, communication, and IPR  Give importance to personal identity
  70. 70.  Therapeutic needs:  Accept the pt as human being  Give responsibility about ward routine works  Patiently and positively hear the suggestions from the pt himself in implementing routine ward work  Chronic patients need stimulation, occupational and recreational therapies  Nursing care of Chronic patients emphasis should be placed on the 5 R’s  Reassurance  Readjustment  Reeducation  Rehabilitation  Recreation