Schizophrenia in mental health nursing

1. Saurabh Manikpuri
B.Sc. Nursing
Pratibha Institute of Nursing
Raipur

2. Contents
Definition……………………………………
Epidemiology……………………………….
Etiology……………………………………...
Clinical features…………………………….
Subtypes of S.Z.P…………………………
Prognostic factors…………………………...
Treatment……………………………………
Nursing care………………………………...
Terminology…………………………………
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Schizophrenia
Definition
Is a functional psychosis characterized by disturbance in thinking, emotions, volit ion,
and perception, which occur in a state of, clear consciousness, which usually l ead to
social withdrawal
Incidence:-
❖ Is the most common disease of psychiatric disease prevalent in all cultures and
in all part of the world .
❖ Three to four per 1000 persons in any community suffer from schizophrenia.
❖ About 15% of new admission in mental hospitals are schizophrenic patient.
❖ About two thirds of the cases are in the 15 to 30 years age group.
❖ Schizophrenia is more common in the lower socioeconomic group.
ETIOLOGY
1) The main causes is uncertain.
2) Factors contribute to schizophrenia:-

4. 3) A) BIOLOGICAL FACTORS:
These factors determine an individual's susceptibility to illness . THESE FACT ORS
INCLUDE the following:
1) Genetic factors: - it play important role in causation of schizophrenia. S ee
table below..
Population Incidence
General population 1.0%
Sibling of schizophrenic p.t 8.5%
child with one schizophrenic parents 12.0%
Dizygotic twin of schizophrenic p.t 12.0%
child of tow schizophrenic parents 40.0%
Monozygotic twins of schizophrenic p.t 47.0%
2) Biochemical factors:
A- Dopamine Hypothesis: Increase Of Dopamine.
B- Other Hypothesis:
• Abnormalities In Neurotransmitters such as:
-Norepinephrine -Serotonin
-Acetylcholine -Gamma Amino Butyric Acid (GABA)
• Abnormalities In Neuro regulators such as:-

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-Prostaglandins -Endorphins
B) precipitating factors:
This factors help to fast appear of illness. THESE FACTORS INCLUDE:
1) Social factors:
1- Poverty 2- High social mobility
3- Unemployment 4- Disorganization
5- Stress
2) Psychological factors :
These factors are responsible for aggravating or prolonging the disease
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(family relationship). These factors include:
▪ Mother – Child relationship.
▪ Dysfunctional family system as hostility between parents
▪ Double-bind communication
Clinical features
• Essential features:
Most common features: positive and negative symptoms.
Positive symptoms Negative symptoms

6. Hallucination
Delusions
Illusion
Disorganized (speech or behavior)
Catatonia
Flat affect or blunting
Volition-apathy
Attention impairment
Anhedonia
Alogia
Asocialty (social withdrawal)
Others Signs and symptoms : according to mind functions:
Functions
Of Mind
cognitive mood behavior

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A) Cognitive Disorders:- 1)
Consciousness: normal
2) Concentration: distraction or impaired concentration
3) Orientation : disoriented.
4) Memory:
-0)disturbed memory OR memory loss.
-1)Impaired intelligence.
-2)Poor Insight.
-0) Poor judgment
5) Perception:
▪Hallucination: - Auditory - Tactile -
Gustatory - Olfactory - Visual.
▪Illusion.
6) Thought :(content or process):
Content ( delusion ):
-0)Persecution
-1)Grandiose
-2)Reference
-3)Control
-4)Somatic
-5)Others .
Process:
-6) Flight of ideas.
-0)Thought block.

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B) Affects ( Mood ) Disorder:-
• Emotional blunting
• Emotional flattening.
• Anhedonia
• Incongruent emotion
• Inappropriate emotional response
• Ambivalence
C) Behaviors Disorder: (G.A, motor,
speech, eating and sleep):
General appearance:
-0)Decrease self – care.
-1)Poor grooming.
-2)Bizarre dress.
Motor :
-3)Decrease or increase in psychomotor activity.
-4)Stereotypes.
-5)Catatonia ( waxy flexibility).
-6)Bizarre position.
Speech:
-0) Loosening of association
-0)Neologism
-1) Poverty of speech
-2) Poverty of ideation
-3) Echolalia

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-4) Preservation -5) Verbigeration Sleep : (Disturbance):
-0) Insomnia. Eating:
-0)Anorexia
-1)Bulimia Sexual:
-2)Dysfunction
D)Other Thought Disorder :
▪ Over inclusion
▪ impaired abstraction
▪ Concreteness
▪ ambivalence
▪ Mannerisms
▪ Grimacing Aggressive
▪ Suicide can occur .

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TYPES OF SCHIZOPHRENIA

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1) Paranoid schizophrenia:
The essential features are
• Delusion (grandiosity, persecution, jealousy).
• Hallucination are common (visual and auditory)
• Anger and violence also present
2) Hebephrenic (disorganized) schizophrenia:
The essential features are
• Marked thought disorder
• Incoherence and flat
• Extra social impairment grimacing
• Senseless giggling.
3) Catatonic schizophrenia:
It is characterized by motor behavior disturbance; it is pres ent
in three types (excited catatonic, stupor catatonia and
catatonia alternating).
Clinical features of excited catatonia:-
• Increase In psychomotor activity (restlessness, agitation,
excitement and aggressiveness)
• increase in speech production
• Loosening of associations
• Incoherence .
Clinical features of stupor catatonia:
Mutism Echolalia
Rigidity Echopraxia
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12. Negativism Waxy flexibility
Posturing Ambitendency
Stupor Automatic obedience
4) Residual schizophrenia:
Symptoms of this type include-
▪ Emotional blunting Social withdrawal
▪ Eccentric behavior Loosening of association
Illogical thinking
5) Undifferentiated schizophrenia:
Prominent psychotic symptoms that cannot be classified in any
category previously listed or have feature of more than one.
6) Simple schizophrenia:
Characterized by:
▪ Early and insidious onset Wandering tendency
▪ Poor progression Self-absorbed idleness
▪ Presence of characteristic negative Aimless activity symptoms
▪ Vague hypochondriacally feature
7) Post-schizophrenia depression:
Depressive features:-
▪ Develop in the presence of residual or active features of schizophrenia
▪ Associated with an increased risk of suicide .

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Prognostic factors in schizophrenia
Good prognostic factor Poor prognostic factor
Abrupt or acute onset Insidious onset
Later onset Younger onset
Female sex Male sex
Married Single, divorced or widowed
Out-patient treatment Institutionalization
Family history of mood disorder Family history of SZP
Presence of precipitating factor Absence of precipitating factor
Good personality Poor personality
Predominance of positive symptoms Predominance of negative symptoms
Good social support Poor social support
Short duration 6 months Long duration 6months
Paranoid and catatonic subtype Simple and undifferentiated subtype
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Treatment
1) Antipsychotic drug ( typical , atypical ): A.
Typical antipsychotic :
Example of drugs Trade name Oral dose mg/day Parenteral dos
e (mg)
Chlorpromazine Megatill,Largactil
Tranchlor,thorazine
300-1500 50-100
IM only
Trifluoperazine Espazine 15-60 1-5 IM
Fluphenazine decanoat
e
Prollinate 25-50 IM every
1
-3 WK
Haloperidol Senorm,Serenace
Haldol ,Relinace
5-100 5-20 IM
B. Atypical antipsychotic
Example of drugs Trade name Oral dose mg/day
Clozapine Sizopin,lozapin 50-450
Risperidone Sizodon,sizomax 2-10
2) Electroconvulsive therapy (ECT):
Indication:- Frequency
Catatonic stupor Usually 8-12 ECT
Uncontrolled catatonic excitement
SZP refractory to all form of treatment
Severe side-effect with drugs

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3) Psychological therapies:
-Group therapy -Behavior therapy
-Cognitive therapy -Family therapy
4) Psychosocial Rehabilitation:
This include activity therapy to develop the work habits training in new vocation or retraini ng in
previous skill, vocation guidance and independent job placement 5) Education about the
illness for p.t and families.
Nursing diagnosis for schizophrenia
• Delusion
• Hallucination
• Social isolation
• Ineffective family coping
• Self -esteem disturbance
• Potential risk for self-directed violence
• Impaired verbal communication
• Deficit self-care
• Insomnia
Nursing care for schizophrenia:
Nursing diagnosis Nursing planning Nursing intervention

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Delusion To decrease the pattern 1) Acceptance of patient at he is. s
of delusion thinking 2) Do not argue or deny that belief.
3) Reinforce and focus on reality.
4) Encourage patient to express his feeling.
5) Do not share the patient in his belief.
6) Establish security for patient.
7) Try to distract patient away from the
delusional by
• Involve him in interpersonal activity
• Watching TV and listen to music 8) Do not touch patient without warning.
9) Avoid laughing, whispering –or-talking
quietly where the patient can see but cannot hear
what is being said. 10) Avoid competitive
activates.
Nursing diagnosis Nursing planning Nursing intervention
Hallucination TO eliminating the
occurrence of the
hallucination
• Patient become able to define
the reality
1) Accept the p.t as he is.
2) Observe the signs of hallucination
3) Encourage the p.t to express his
feelings.
4) Do not judgment the p.t
hallucination.
5) Do not reinforced the patient
hallucination.
6) Reinforce any trying from p.t to
maintain reality.
7) Avoid any express that tell p.t
that you accept –or-not accept his
hallucination.
8) Teach the p.t about that it is not
gat.
9) Distract the client away from
hallucination by
• Involve him in
interpersonal activity
• Take more time to talking
with other
• Watch T.V and listen
music.

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10) Avoid touching the p.t without warning.
11) Any attitude of acceptance will encourage the p.t
to share the content of the hallucination with you.
12) Help the p.t to understand the connection between
anxiety and hallucination
High risk for violence To prevent harm to sel f and to
other
1) Maintain low level of stimuli on the patient
environment
2) Maintain safety patient environment (removing all
dangerous object from the patient environment
3) Observe the patient behavior frequently
4) Redirect violent behavior with the
physical activity
5) Maintain clam attitude toward the
patient 6) Have sufficient same
staff available as possible 7) Never
turn your back on the pt.
8) Do not challenge or
confront a violent pt
9) Use restrains either
(mechanical or
pharmacological)
10) Administering of tranquilizer as
Nursing diagnosis Nursing planning Nursing intervention
Social Isolation To reduce social isolation 1)
2)
3)
4)
Convey an acceptance attitude and
unconditional positive regard.
Make brief frequent contact be honest and keep
all promises.
Halted group activities with the p.t that may be
frightening for him.
Give recognition and positive reinforcement for
voluntary interaction with others.
Nursing diagnosis Nursing planning Nursing intervention
Ineffective Family
Coping
To Improve family relationshi 1) Determine individual situation and feelings p
of individual family members.
2) Assess pattern of communicate.
3) Determine pattern of behavior displayed by
patient in his relationship with other.
4) Assess the role of p.t in the family.
5) Provide information about behavior pattern
and expected course of the illness.
Nursing diagnosis Nursing planning Nursing intervention

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prescribed
Nursing diagnosis Nursing planning Nursing intervention
Deficit Self Care To facilities adequate clea
nliness and grooming
1) Assess p.t level of cleanliness.
2) Ensure that he take his bath regularly and
remind the p.t to go to the toilet at regular
intervals.
3) Compliment the p.t when he looks good.
4) When the p.t has taken care for himself
express realistic appreciation.
5) Remember to check finger and toes nails eat
the if p.t cat not to do it by himself.
6) Encourage the p.t to remove dirty clothes and
wear of clean and good clothes.
7) Encourage the p.t and help in bathing and
cleaning teeth.
8) Do not ask the p.t permission for bathe.
9) Encourage the p.t to perform many activities
independently as possible.
Nursing diagnosis Nursing planning Nursing intervention
Altered Nutrition Less t
han Body Requirement
To Promote the nut
rition requirement
1) Assess the body weight of the patient regularly
2) Assess the patient period of eating
3) Provide high caloric and protein nutrient
4) Finger food and drinks that can be consumed on
the raw
5) Assess the patient like and dislike food and
provide favorite food
6) Maintain accurate record of intake and output and
caloric account
7) Supplement the diet with vitamins and minerals
8) Record the patient pattern of elimination 9)
Encourage more fluid intake (6-8 glasses per day)
and roughage diet and green leafy vegetables
Nursing diagnosis Nursing planning Nursing intervention
Self -esteem disturbanc e To enhance the patient
Accepting the patient as
he is and

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self-esteem spend time with him
1. Provide him with simple achievable
activity
2. Encourage the patient to perform his
activity without any assistance
3. Teach assistive and coping skill
4. Encourage the patient to view life after
discharge
Nursing Diagnosis Nursing Planning Nursing Intervention
Impaired Verbal
Com
To improve verbal
comm
1. Attempt to decode incomprehensible
communication pattern
munication unication
2. Facilities trust and understanding by
maintain staff assignment as consistently as
possible
3. Convey empathy and encourage the patient
to disclose painful issue
4. Anticipate and fulfill the patient need
5. Observe verbal and non -verbal
communication
6. Use short statement
Nursing Diagnosis Nursing Planning Nursing Intervention
Insomnia To improve pattern 1. Observe p.t period of sleeping in morning
of sleep and weaning and don't allow the p.t to sleep
for long time during the day.
2. Help the p.t to organize the time sleeping and
wakeup.
3. Encourage p.t to get up from his bed.

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4. Provide calm environment by ensure a quiet
and peaceful environment where the p.t
preparing for sloop.
Provide comfort measures as (Back rub,
Tipped bathe, Warm milk).
5. Avoid the p.t to drink tea and coffee.
6. Encourage the p.t to do relaxation techniques.
7. Talk the p.t for brief period at bedtime and
avoid to enter in to tenthly conversation.
8. Discuses with p.t about the causes of insomnia.
9. Help the p.t to express his feeling.
10.Encourage p.t to share in social activities.
11.Give the p.t sedative as order.

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Important terminology
• Thought blocking: sudden interruption in thought process before though is
completed.
• Thought withdrawal: thought causes subject experiences than is removal
by an external force.
• Autistic thinking: pre occupations totally removing a person from reality.
• Loosening g of association: lack of meaningful relationship of speech with
each other.
• Neologism: invention of words to which meaning are attached new word
coined or everyday word used in special away not readily understood by
other.
• poverty of speech: decrease speech production.
• poverty of ideation: little information of speech content but amount of
speech id adequate.
• Perseveration: Persistent repetition of words or themes beyond the point of
relevance.
• Verbigeration: senseless repetition of some words or phrases over and
again.
• Delusion: False belief which is not amenable to reasoning or is not in
keeping with patient socio cultural and education background False thought
content disorder.
• Delusion reference : false belief that others are talking about him.

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Delusion Persecution: false belief that other is persecuted the Other False
belief that he is being attacked, harassed, spied, cheated or conspired against.
• Delusion Guilt: False belief that one is a sinner and is responsible for the ruin
of his family or society.
• Delusion grandiosity: Exaggerated conception of his importance, power or
identity.
• Nihilistic Delusion: False belief that other or oneself or world don’t exist.
• Somatic Delusion: False belief that involving functioning of the body (brain
is rotting or melting).
• Erotomania Delusion: False belief that other person is deeply in love with
him/her.
• Delusion jealousy: False belief that one lover is unfaithful to him/her.
• Circumstantially: unnecessary trivial details of speech.
• Hallucination: False sensory perception in the absence of an actual external
stimulus.
• Auditory Hallucination: False perception of voices .
• Visual Hallucination: False perception involving sight consisting of formed
or informed images Olfactory Hallucination False perception of smell.
• Gustatory Hallucination: False perception of taste.
• Tactile Hallucination: False perception of touch or surface sensation.
• Somatic Hallucination: False perception of things occurring in or to the
body.
• Illusion: False sensory belief in the present of the external stimulus.
• Insight: The capacity to appreciate that one disturbance of thought and feeling
are subjective and invalid.
• Anhedonia: Inability to experience pleasure in any activity.
• Mutism: absence of speech without pathological caution.

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• Rigidity: maintenance of rigid posture against effort to be moved.
Negativism: behavior that is opposite of that suggested by other motiveless
resistance to all attempt to be moved or to all instruction
• Posturing: bizarre posture for long period of time.

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Stupor: State in which the person does not react to his surroundings and
appears to be unaware of them.
• Echolalia: Pathological repetition of word or phrases of examiner.
• Echopraxia: Pathological repetition of the behavior of another .
• Waxy flexibility: part of body can be placed in position for long periods when
if every uncomfortable.
• Ambitendency: conflict to do or not to do Automatic obedience obeys every
commend.1
REFERANCE
1- A Guide To Mental Health And Psychiatric Nursing. "R.Sreevani ".