psy

1. Plan of care should include, but is not limited to, the following components:
1. Signs and Symptoms.
2. Theory of what causes this mental illness (from your book).
3. Treatment options, including 2 medications your client might be receiving & pertinent lab tests.
For medications that might be used, you should know classification, mechanism of action, side effects and nursing implications.
4. At least 2 possible nursing diagnoses with expected client outcome.
5. Nursing interventions (with rationale) you may perform with this prototype.
Disorganized Schizophrenia
• Is marked by incoherent, disorganized speech and behaviors and by blunted or inappropriate affect.
• May have fragmented hallucinations and delusions with no coherent theme.
• Usually includes extreme social impairment.
• This type of schizophrenia may start early and insidiously, with no significant remissions.
Signs and Symptoms
• Incoherent, disorganized speech, with markedly loose associations.
• Grossly disorganized behavior.
• Blunted, silly, superficial, or inappropriate affect.
• Grimacing
• Hypochondriacal complaints.
• Extreme social withdrawal.
Nursing Interventions
• Spend time with the patient even if he’s mute and unresponsive, to promote reassurance and support.
• Remember that, despite appearances, the patient is acutely aware of his environment, assume the patient can hear – speak to him
directly and don’t talk about him in his presence.
• Emphasize reality during all patient contacts, to reduce distorted perceptions (for example, say, “The leaves on the trees are turning
colors and the air is cooler, It’s fall”)
• Verbalize for the patient the message that his behavior seems to convey, encourage him to do the same.
• Tell the patient directly, specifically, and concisely what needs to be done; don’t give him choice (for example, say, “It’s time to go for a
walk, lets go.”)
• Assess for signs and symptoms of physical illness; keep in mind that if he’s mute he won’t complain of pain or physical symptoms.
• Remember that if he’s in bizarre posture, he may be at risk for pressure ulcers or decreased circulation.
• Provide range-of-motion exercises.
• Encourage to ambulate every 2 hours.
• During periods of hyperactivity, try to prevent him from experiencing physical exhaustion and injury.
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2. • As appropriate, meet his needs for adequate food, fluid, exercise, and elimination; follow orders with respect to nutrition, urinary
catheterization, and enema use.
• Stay alert for violent outbursts; if these occur, get help promptly to intervene safely for yourself, the patient, and others.
1. Nursing Diagnosis for Schizophrenia: Risk for Violence
• Panic or anger
• Rigid posture, clenched fists
• Limited attention span
• Tormenting of others
• Irritability or restlessness
• Aggressive in verbal and non-verbal communication
Interventions
• Keep surrounding area free of high level stimuli.
• Routinely observe patient at regular intervals.
• Give the patient something to reflect its aggressive actions.
• Administer appropriate medications and monitor for effectiveness and side effects.
• Do not acknowledge rude comments or behavior.
• Have staff with the ability to restrain patient if needed and create a safe environment.
• Maintain a calm demeanor towards the patient and set boundaries for unacceptable actions.
2. Nursing Diagnosis for Schizophrenia: Altered Thought Processes
• Delusional thinking
• Shifting from one topic to another
• Unable to stay focused
• Escalated reaction to normal stimuli
• Inconsistent communication
• Hallucinations
• Difficulties in problem solving
Interventions
• Speak clearly and directly to patient in a simple and professional manner.
• Explain all treatments, tests and medications to patient before using them.
• Let patient have as much control as possible within therapy limits.
• Maintain consistent expectations and rules for acceptable and non-disruptive behavior.
• Teach patients how to use thought-stopping and focus techniques.
• Discuss patients' feelings when they are experiencing disturbing and delusional thoughts.
• Give alternative ways to express feelings in acceptable, non-threatening ways.
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3. 3. Nursing Diagnosis for Schizophrenia: Social Isolation
• Depression
• Limited or no interaction with others
• Sad facial expressions
• Limited or no eye contact with others
• Dependent use of non-verbal communication
• Avoidance of social situations
Interventions
• Establish schedule for frequent, yet brief patient meetings.
• Maintain distance from patient until trust established.
• Avoid touching patient unless appropriate and necessary.
• Teach social skills and how to interact with others.
• Assist patient in choosing and attending social activities.
• Provide words of encouragement and praise for all social interaction attempts.
4. Nursing Diagnosis for Schizophrenia: Sensory and Perceptual Alterations Related to Hallucinations
• Strange body sensations
• Little or no interaction with nurse or others
• Unable to concentrate
• Unsuitable reactions and responses to reality
Interventions
• Encourage patient to speak about their hallucinations and communicate with patient during event but do not counsel until
episode has ended.
• Do not argue with patients, but explain others don't share their sensory perceptions.
• Monitor for symptoms and signs of hallucinating, such as looking around or talking to themselves.
• Help identify and deal with triggers and feelings that bring on hallucinations or illusions.
• Place patient in quiet environment and encourage tasked-based activities.
• Teach patient distraction techniques and involve them in concrete activities so as to bring them back to reality.
5. Nursing Diagnosis for Schizophrenia: Impaired Verbal Communication
• Lack of emotion in verbal communication
• Inability to think abstractly
• Little use of speech
• Unable to express cause of agitation
• Incongruent non-verbal communication
Interventions
• Allow time for consistent one-on-one interaction with patient.
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4. • Inform patient when you are unable to understand what they are trying to convey.
• Verbalize feelings and model expressions of feelings for patients.
• Speak with patient about personal interests, favorite activities and hobbies.
• Look out for open communication on topics that are meaningful and important to patient.
6. Nursing Diagnosis for Schizophrenia: Ineffective Individual Coping
• Feelings of loneliness and rejection
• Avoidance of interaction and people
• Regression and projection defenses
• Unable to perform daily self-care tasks
• Physical and emotional withdrawal
Interventions
• Teach patient to verbalize feelings.
• Only touch patient when appropriate and assistance is needed.
• Assist patient in identifying bizarre or impulsive actions and how to control them.
• Teach and practice daily living skills with patient.
• Evaluate patient's reactions to unexpected events and situations in clinical environment.
7. Nursing Diagnosis for Schizophrenia: Ineffective Individual Coping
• Facial expressions of anger
• Increased psychomotor activity while self-absorbed
• Abundance of pacing
• Lack of control
• Speaking previous incidents of violence
• Verbal and non-verbal threats
Interventions
• Create a quiet, non-stimulating setting.
• Teach patient techniques to control agitation.
• Give patient appropriate medications and monitor side effects and effectiveness.
• Use physical restraints as a last resort.
• Assist patient in identifying stressors and triggers of agitation.
• Discuss negative feels and how to keep these emotions from escalating.
• Teach patient how to depart from situations that will trigger agitation.
• Reinforce positive behaviors.
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5. Diagnostic Test
• Clinical diagnosis is developed on historical information and thorough mental status examination.
• No laboratory findings have been identified that are diagnostic of schizophrenia.
• Routine battery of laboratory test may be useful in ruling out possible organic etiologies, including CBC, urinalysis, liver function
tests, thyroid function test, RPR, HIV test, serum ceruloplasmin ( rules out an inherited disease, wilson’s disease, in which the body
retains excessive amounts of copper), PET scan, CT scan, and MRI.
• Rating scale assessment:
◦ Scale for the assessment of negative symptoms.
◦ Scale for the assessment of positive symptoms.
◦ Brief psychiatric rating scale
Treatments and Medications
Currently, there is no method for preventing schizophrenia and there is no cure. Minimizing the impact of disease depends mainly on early
diagnosis and, appropriate pharmacological and psychosocial treatments. Hospitalization may be required to stabilize ill persons during an
acute episode. The need for hospitalization will depend on the severity of the episode. Mild or moderate episodes may be appropriately
addressed by intense outpatient treatment. A person with schizophrenia should leave the hospital or outpatient facility with a treatment
plan that will minimize symptoms and maximize quality of life.
A comprehensive treatment program can include:
• Antipsychotic medication
• Education & support, for both ill individuals and families
• Social skills training
• Rehabilitation to improve activities of daily living
• Vocational and recreational support
• Cognitive therapy
Medication is one of the cornerstones of treatment. Once the acute stage of a psychotic episode has passed, most people with
schizophrenia will need to take medicine indefinitely. This is because vulnerability to psychosis doesn’t go away, even though some or all
of the symptoms do. In North America, atypical or second generation antipsychotic medications are the most widely used. However, there
are many first-generation antipsychotic medications available that may still be prescribed. A doctor will prescribe the medication that is the
most effective for the ill individual
Another important part of treatment is psychosocial programs and initiatives. Combined with medication, they can help ill individuals
effectively manage their disorder. Talking with your treatment team will ensure you are aware of all available programs and medications.
In addition, persons living with schizophrenia may have access to or qualify for income support programs/initiatives, supportive housing,
and/or skills development programs, designed to promote integration and recovery.
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6. SCHIZOPHRENIA
CONCEPT
• Schizophrenia is a group of psychotic disorders that affect thinking, behavior, emotions, and the ability to perceive reality.
• The term “Psychosis” refers to the presence of hallucinations, delusions, or disorganized speech or catatonic behavior.
• The typical age at onset is late teens and early twenties, but schizophrenia has occurred in young children and may begin in later adulthood.
TYPES/
SUBTYPES
PARANOID DISORGANIZED CATATONIC RESIDUAL UNDIFFERENTIATED
(MIXED TYPE)
FEATURES
• Characterized by
suspicion
toward others
• Dominant:
Hallucinations
and Delusions
(positive
symptoms)
• NO
Disorganized
speech,
disorganized
behavior,
catatonia or
inappropriate
affect present.
(No negative
symptoms)
• Characterized by
withdrawal from
society and very
inappropriate
behaviors, such as
poor hygiene, or
muttering constantly to
self.
• Frequently seen in the
homeless population
• Dominant:
Disorganized speech,
disorganized behavior,
and inappropriate
affect.
• Marked regression
• Poor Reality Testing
• Poor social skills
• Inappropriate
emotional responses
• Outbursts of laughter
• Silly behavior
• Characterized by abnormal motor
movements.
• There are two stages: the
withdrawn stage and the excited
stage.
• WITHDRAWN STAGE:
o Psychomotor retardation;
client may appear
comatose.
o Waxy Flexibility or stupor
o Echolalia and/or
Echopraxia
o Client often has extreme
self-care needs, such as for
tube feeding due to inability
to eat
• EXCITED STAGE:
o Peculiar voluntary
movement: Unusual
posturing, Stereotyped
movements, Prominent
mannerisms, Prominent
Grimaces
o Excessive purposeless
motor activity (agitation)
o Self-care needs may
predominate
o Client may be a danger to
self or others
• Active-phase (positive)
symptoms are not
longer present
(Delusions,
hallucinations,
disorganized speech and
behaviors)
• However, the client has
two or more “residual
symptoms” (some
negative symptoms) such
as:
o Marked social
isolation or
withdrawal
o Impaired role
function (wage
earner, student,
homemaker)
o Anergia,
Anhedonia, or
Avolition
o Alogia (speech
problems)
o Odd behavior, such
as walking in a
strange way
o Impaired personal
hygiene
o Lack of initiative,
interest or energy
o Blunted or
inappropriate affect
• Client has symptoms for
schizophrenia, but does
not meet criteria for any
of the other types (no one
clinical presentation
dominates (e.g. paranoid,
disorganized, catatonic)
• Any positive or negative
symptoms may be
present (has active-
phase symptoms (does
have hallucinations,
delusions, and bizarre
behaviors)
• Eccentric
• Psychotic features are
extreme:
o Fragmented
delusions
o Vague
hallucinations
o Bizarre,
disorganized
behavior
o Disorientation,
Incoherence
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7. ASSESSMENT
Diagnostic criteria: The four “A”s:
1. Affect: Refers to the outward manifestation of a person’s feelings or emotions. In Schizophrenia, clients may display flat, blunted affect.
2. Associative Looseness: Refers to haphazard and confused thinking that is manifested in jumbled and illogical speech and reasoning. The term
“looseness of association” is also used
3. Autism: Refers to thinking that is not bound to reality, but reflects the private perceptual world of the individual. Delusions, hallucinations, and
neologisms are examples of autistic thinking in persons with schizophrenia. (Also termed as “response to internal stimuli”)
4. Ambivalence: Refers to simultaneously holding two opposite emotions, attitudes, ideas, or wishes toward the same person, situation, or object.
DISEASE
PROGRESSION
:
Schizophrenia is characterized by periods of exacerbations and remissions. Has three phases:
o ACUTE PHASE: Periods of both positive and Negative symptoms
o MAINTENANCE PHASE: Acute symptoms decrease in severity
o STABILIZATION PHASE: Symptoms in remission
CHARACTERIS
TIC
DIMENSIONS
OF
SCHIZOPHREN
IA
(No single
symptom is
always present in
all cases)
POSITIVE SYMPTOMS:
These are the most easily identified symptoms
o Alterations in perception: Hallucinations: Sensory perceptions for which no external
stimulus exists (auditory, visual, olfactory, tactile), Personal Boundary Difficulties,
Depersonalization, Derealization
o Alterations in thinking:: Delusions: A false belief held and maintained as true, even with
evidence to the contrary, concrete thinking, thought broadcasting, thought insertion, thought
withdrawal, delusions of being controlled)
o Alterations in speech: Associative looseness (Disorganized Speech), Neologisms, Echolalia,
Clang Association, Word Salad.
o Alterations in behavior (Bizarre behavior): Extreme motor agitation, stereotyped
behaviors, Automatic obedience, waxy flexibility, stupor, negativism)
NEGATIVE SYMPTOMS (THE FIVE “A”s):
These symptoms are more difficult to treat
successfully than positive symptoms
o AFFECT: usually Blunted (narrow range of normal expression) or Flat (Facial expression
never changes).
o ALOGIA: Poverty of thought or speech; client may sit with a visitor but may only mumble
or respond vaguely to questions
o AVOLITION: Lack of motivation in activities and hygiene
o ANHEDONIA: Inability to find pleasure in life; the client is indifferent to things that often
make others happy
o ANERGIA: Lack of energy, chronic fatigue
COGNITIVE SYMPTOMS:
Problems with thinking make it very difficult for the
client to live independently
o Disordered thinking
o Poor problem-solving skills
o Poor decision-making skills
o Inattention; easily distracted (Difficulty concentrating to perform tasks)
o Impaired judgment
o Impaired memory
▪ Long-term memory loss
▪ Working Memory loss (such as inability to follow directions to find an address)
DEPRESSIVE SYMPTOMS:
o Hopelessness
o Suicidal Ideation
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8. EXPECTED
OUTCOMES
ACTIVE PHASE:
-Client safety and medical stabilization
MAINTENANCE PHASE:
-Adherence to medication regimen
-Understanding schizophrenia
-Participation of client and family in psycho
educational activities
STABILIZATION PHASE:
-Target negative symptoms
-Anxiety Control
-Relapse prevention
INTERVENTIO
NS
ACUTE PHASE: (Hospitalization, Client Safety,
Stabilization Of Symptoms)
1. Administer antipsychotic medication as prescribed
2. Observe client behavior closely
3. Set limits on inappropriate behavior
4. Increase reality testing when delusional or hallucinating
5. Do not touch without warning
6. Offer foods that are not easily contaminated
7. Assist with ADLs as needed
8. Supportive counseling
9. Milieu Therapy
10. Family psycho education
MAINTENANCE AND STABILIZATION PHASES:
-Psychosocial education
-Relapse prevention skills
MEDICATIONS
TYPICAL (CLASSIC) ANTISYCHOTICS (Treatment of
positive symptoms)
o HALDOL (Haloperidol)
o THORAZINE (Chlorpromazine)
o PROLIXIN (Fluphenazine)
o SERENTIL (Mesoridazine)
o TRILAFON (Pherphenazine)
o MELLARIL (Thioridazine)
ATYPICAL ANTIPSYCHOTICS (Treatment of both positive and negative symptoms)
o ZYPREXA (Olanzapine)
o RISPERDAL (Risperidone)
o SEROQUEL (Quetiapine)
o GEODONE (Ziprasidone)
o CLORAZIL (Clozpine)
o ABILIFY (Aripriprazole)
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