Schizophrenia and Other Psychotic · PDF fileSchizophrenia and Other Psychotic Disorders...

CHAPTER 8

Schizophrenia andOther Psychotic

Disorders

OVERVIEWSchizophreniaThe schizophrenias are severe and persistent neurologicdiseases. These serious disorders affect a person’s:● Perceptions (hallucinations and delusions)● Thinking (delusions, paranoia, disorganized thinking)● Language (associative looseness, poverty of speech)● Emotions (apathy, anhedonia, depression)● Social behavior (aggressive, bizarre behaviors or extreme

social withdrawal)Schizophrenia affects approximately 1% of the popula-

tion, and 95% of individuals who become schizophrenichave the condition throughout their lifetime. Schizophreniais a relapsing psychotic disorder. A psychotic disorder is onein which people have difficulty with differentiating realityfrom fantasy (reality testing).

Major symptoms seen in psychotic disorders are hallu-cinations, delusions, and disorganized thinking. Hallucina-tions and delusions can be very frightening, oftenterrifying for individuals. They also can be very discon-certing initially and even frightening to nurses and otherhealth care individuals. These are the positive symptoms

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of schizophrenia. Nurses can greatly benefit from individ-ual or peer supervision when dealing with these challeng-ing phenomena. Communicating with clients who aredelusional and hallucinatory and have disorganized think-ing is a skill that is learned with guidance and practice.

The negative symptoms of schizophrenia are more sub-tle and are the most damaging to the client’s quality of life.Negative symptoms include feelings of emptiness, amoti-vational states, anhedonia, and apathy.

Cognitive symptoms (poor problem-solving, poor deci-sion-making skills, illogical thinking) also need to be tar-geted when planning care.

The symptoms of schizophrenia usually become appar-ent during adolescence or early adulthood (15 to 25 for men,25 to 35 for women). Paranoid schizophrenia has a lateronset. The schizophrenias are severe, biologically basedmental illnesses. Current theories of schizophrenia involveneuroanatomical and neurochemical abnormalities, whichmight be induced either genetically or environmentally(birth defects, viruses). Although the schizophrenias are notcaused by psychological events, stressful life events cantrigger an exacerbation of the illness. Therefore, psychoed-ucational and family treatment modalities can be crucial inhelping clients in a number of ways. Psychoeducational,family, group, and behavioral approaches, for example, canhelp clients increase their social skills, maximize their abil-ity in self-care and independent living, maintain medicaladherence, and, most important, increase the quality oftheir lives. Client and family education greatly improvesthe management of schizophrenia.

Schizophrenia is not a single disease, but rather a syn-drome that involves cerebral blood flow, neuroelectro-physiology, neuroanatomy, and neurobiochemistry. TheDiagnostic and Statistical Manual of Mental Disorders (4th edi-tion, text revision) (DSM-IV-TR) criteria for the diagnosis ofschizophrenia are listed in Box 8–1.

Box 8–2 identifies five subtypes of schizophrenia.

Other Psychotic Disorders

Schizophreniform DisorderThe essential features of this disorder are exactly those

of schizophrenia except that:

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214 PART II Diagnosis and Care Planning

1. Characteristic symptoms: Two (or more) of the following, eachpresent for a significant portion of the time during a 1-monthperiod (or less if successfully treated):● Delusions● Hallucinations● Disorganized speech (e.g., frequent derailment or incoherence)● Grossly disorganized or catatonic behavior● Negative symptoms, (i.e., affective flattening, alogia,or avolition)

Note: Only one Criterion 1 symptom is required if delusions arebizarre or hallucinations consist of a voice keeping up a runningcommentary on the person’s behavior or thoughts, or two ormore voices conversing with each other.2. Social/occupational dysfunction: For a significant portion of the

time since the onset of the disturbance, one or more majorareas of functioning, such as work, interpersonal relations, orself-care, are markedly below the level achieved prior to theonset (or when the onset is in childhood or adolescence, fail-ure to achieve expected level of interpersonal, academic, oroccupational achievement).

3. Duration: Continuous signs of the disturbance persist for atleast 6 months. This 6-month period must include at least 1month of symptoms (or less if successfully treated) that meetCriterion I (i.e., active-phase symptoms) and might includeperiods of prodromal or residual symptoms.

4. Symptoms are not caused by (a) another psychotic disorder;(b) a substance or general medical disorder; or (c) a pervasivedevelopmental disorder, unless prominent delusions or hallu-cinations are also present for at least 1 month.

Box8-1

DSM-IV-TRCriteria for Schizophrenia

Adapted from American Psychiatric Association (2000). Diagnostic andstatistical manual of mental disorders (4th ed., text revision). Washington,DC: American Psychiatric Association, p. 312; reprinted with permission.

● The total duration of the illness is at least 1 month, butless than 6 months.

● Impaired social or occupational functioning during somepart of the illness is not apparent (although it mightoccur).

This disorder might or might not have a good prognosis.

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Paranoid

Onset usually in the late 20s to 30s. People who developthis disorder usually function well before the onset of thedisorder (good premorbid functioning). Paranoia (anyintense and strongly defended irrational suspicion) is themain characteristic; the main defense is projection.Hallucinations, delusions, and ideas of reference are dominant.

Disorganized

The most regressed and socially impaired of all the schizo-phrenias. The person has highly disorganized speech andbehavior and inappropriate affect. Bizarre mannerismsinclude grimacing, along with other oddities of behavior.

Catatonia

The essential feature is abnormal motor behavior. Twoextreme motor behaviors are seen in catatonia. Oneextreme is psychomotor agitation, which can lead toexhaustion. The other extreme is psychomotor retardationand withdrawal to the point of stupor. The onset is usuallyacute, and the prognosis is good with medications andswift interventions. Other behaviors might include autism,waxy flexibility, and negativism.

Undifferentiated (Mixed Type)

Clients experience active hallucinations and delusions, butno one clinical picture dominates (e.g., not paranoid, cata-tonic, or disorganized; rather the clinical picture is one of amixture of symptoms).

Residual

A person who is referred to as having residual schizo-phrenia no longer has active symptoms of the disease,such as delusions, hallucinations, or disorganized speechand behaviors. However, there is a persistence of somesymptoms—for example, marked social withdrawal;impairment in role function (wage earner, student, orhomemaker); eccentric behavior or odd beliefs; poor per-sonal hygiene; lack of interest, energy, initiative; and inap-propriate affect.

Box 8-2 Subtypes of Schizophrenia

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Brief Psychotic DisorderThis is a disorder in which there is a sudden onset of psy-chotic symptoms (delusions, hallucinations, disorganizedspeech) or grossly disorganized or catatonic behavior. Theepisode lasts at least 1 day, but less than 1 month, and thenthe individual returns to his or her premorbid level of func-tioning. Brief psychotic disorders often follow extremelystressful life events.

Schizoaffective DisorderThis disorder is characterized by an uninterrupted periodof illness during which there is a major depressive, manic,or mixed episode, concurrent with symptoms that meetthe criteria for schizophrenia. The symptoms must not bedue to any substance use or abuse or general medicalcondition.

Delusional DisorderThis disorder involves nonbizarre delusions (situationsthat occur in real life, such as being followed, infected,loved at a distance, deceived by a spouse, or having a dis-ease) of at least 1 month’s duration. The person’s ability tofunction is not markedly impaired, nor is the person’sbehavior obviously odd or bizarre. Common types of delu-sions seen in this disorder are delusions of grandeur, per-secution, or jealousy, or somatic or mixed delusions.

Shared Psychotic Disorder (Folie à Deux)A shared psychotic disorder is an occurrence in which oneindividual, who is in a close relationship with anotherwho has a psychotic disorder with a delusion, eventuallycomes to share the delusional beliefs either in total or inpart. Apart from the shared delusion, the person whotakes on the other’s delusional behavior is not otherwiseodd or unusual. Impairment of the person who shares thedelusion is usually much less than the person who has thepsychotic disorder with the delusion. The cult phenome-non is an example, as was demonstrated at Waco andJonestown.

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Induced or Secondary PsychosisPsychosis can be induced by substances (drugs of abuse,alcohol, medications, or toxin exposure) or caused by thephysiologic consequences of a general medical condition(delirium, neurologic conditions, metabolic conditions,hepatic or renal diseases, and many more). Medical condi-tions and substances of abuse must always be ruled outbefore a primary diagnosis of a schizophrenia or otherpsychotic disorder can be made.

Phases of SchizophreniaSchizophrenia has been divided into three phases:Phase I—Onset. This phase (acute phase) includes the pro-

dromal symptoms (e.g., acute or chronic anxiety, pho-bias, obsessions, compulsions, dissociative features) aswell as the acute psychotic symptoms of hallucinations,delusions, and/or disorganized thinking.

Phase II—Years following onset. Patterns that character-ize this phase are the ebb and flow of the intensity anddisruption caused by symptoms, which might, in somecases, be followed by complete or relatively completerecovery.

Phase III—Long-term course and outcome. This is thecourse that the severely and persistently mentally illclient follows when the disease becomes chronic. Forsome clients, the intensity of the psychosis might dimin-ish with age; however, the long-term dysfunctionaleffects of the disorder are not as amenable to change.

ASSESSMENT

Presenting Signs and Symptoms1. Positive symptoms

● Delusions● Hallucinations● Disorganized thinking/speech● Disorganized or catatonic behavior

2. Negative symptoms● Flat emotional affect● Sparse productivity of thought (Alogia)● Lack of goal directed activity (Avolition)

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3. Cognitive symptoms● Memory and attention deficits● Language difficulties● Protiens monitoring personal behavior, establishing

goals maintaining tasks, and so on

Assessment ToolThe Brief Psychiatric Rating Scale (BPRS) (Appendix D-5) isa useful tool for evaluating overall psychiatric functioning.It is particularly helpful in evaluating the degree to whichpsychotic symptoms affect a person’s ability to function.

Assessment Guidelines

Schizophrenias

Assessing Positive Symptoms1. Assess for command hallucinations (e.g., voices telling

the person to harm self or another). If yes:● Do you plan to follow the command?● Do you believe the voices are real?

2. Assess if the client has fragmented, poorly organized,well-organized, systematized, or extensive system ofbeliefs that are not supported by reality (delusions). If yes:● Assess if delusions have to do with someone trying to

harm the client and if the client is planning to retaliateagainst a person or organization.

● Assess if precautions need to be taken.3. Assess for pervasive suspiciousness about everyone and

their actions, for example:● Is on guard, hyperalert, vigilant● Blames others for consequences of own behavior● Is hostile, argumentative, or often threatening, in ver-

balization or behavior

Assessing Negative Symptoms4. Assess for negative symptoms of schizophrenia (see

Table 8-1 for definitions and suggested interventions).5. Assess if client is on medications, what the medications

are, and if treatment is adherent with medications.6. How does the family respond to increased symptoms?

Overprotective? Hostile? Suspicious?7. How do family members and client relate?


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8. Assess support system. Is family well informed aboutthe disease (e.g., schizophrenia)? Does family under-stand the need for medication adherence? Is familyfamiliar with family support groups in the community,or where to go for respite and family support?

NURSING DIAGNOSES WITHINTERVENTIONSPeople with schizophrenia often have multiple needs. Basicto these is safety. Refer to Chapters 16 and 17 for nursingcare plans identifying nursing interventions for suicideintent and violence toward others. Suicide and threat ofviolence to others are basic to nursing interventions for allclients in all settings, not just for people with schizophreniaor the hospitalized person.

Relating to people with schizophrenia can be a chal-lenge, especially in the acute phase; therefore guidelines for

Table 8-1 Negative (Deficit) Symptoms of Schizophrenia

Symptoms Clinical Findings Treatment

Apathy Slow onset The newer atypical Poverty of Interferes with a (novel) antipsychotics speech or person’s life might target some of content of Positive premorbid the negative symptoms.speech history The most used inter-

Poor social Chronic deterioration ventions include:functioning Family history of 1. Skill training

Anhedonia schizophrenia interventions:Social Cerebellar atrophy ● Identify areas

withdrawal and lateral and third of skill deficitventricular enlarge- person is willing ment on computed to work on.tomography ● Prioritize skills scan important to the

Abnormalities on person.neuropsychologic 2. Working with person testing to identify stressors:

Poor response to ● Identify which stres-antipsychotics sors contribute to mal-

adaptive behaviors.3. Work with person on

increasing appropriate coping skills.

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Impaired Verbal Communication are included. Again,during the acute phase, relating to others is difficult.Guidelines for interacting and gradually adding socialskills are included in Impaired Social Interaction. Workingwith clients who are hallucinating (Disturbed SensoryPerception), delusional (Disturbed Thought Processes),and paranoid (Defensive Coping) can be a great challenge.Therefore, these are included.

Also, importantly, often the families are left to cope withthe exhaustive needs of their family member. InterruptedFamily Processes should always be assessed, and referralsand teaching should be readily available.

Nonadherence to medications or treatment is a huge chal-lenge for mental health professionals. Nursing care plans forNonadherence/Noncompliance are found in Chapter 20.Table 8-2 provides a list of potential nursing diagnoses.

Selected Nursing Diagnoses and NursingCare Plans

IMPAIRED VERBAL COMMUNICATION

Decreased, delayed, or absent ability to receive, process,transmit, or use a system of symbols

Related To (Etiology)▲ Psychologic barriers (e.g., psychosis, lack of stimuli)▲ Side effects of medication▲ Altered perceptions● Biochemical alterations in the brain of certain neuro-

transmitters

As Evidenced By (Assessment Findings/Diagnostic Cues)

▲ Inappropriate verbalization▲ Difficulty expressing thoughts verbally▲ Difficulty in comprehending and maintaining the

usual communication pattern● Poverty of speech

▲ NANDA International accepted; ● In addition to NANDAInternational

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Table 8-2 Potential Nursing Diagnoses for Schizophrenia

Symptoms Nursing Diagnoses

Positive SymptomsHallucinations: Disturbed Sensory ● Hears voices (loud noises) Perception: Auditory/Visual

that others do not hear. Risk for Violence: Self-● Hears voices telling them to Directed and Other-

hurt self or others (command Directedhallucinations).

Distorted thinking not based Disturbed Thought Processesin reality, for example: Defensive Coping

● Persecution: thinking others are trying to harm them.

● Jealousy: thinking spouse or lover is being unfaithful, or thinks others are jealous when they are not.

● Grandeur: thinking they have powers they do not possess, or they are someone powerful or famous.

● Reference: believing all events within the environment are directed at or hold special meaning for them.

● Loose association of ideas Impaired Verbal (looseness of association). Communication

● Uses words in a meaningless, Disturbed Thought disconnected manner Processes(word salad).

● Uses words that rhyme in a nonsensical fashion (clang association).

● Repeats words that are heard (echolalia).

● Does not speak (mutism).● The person delays getting

to the point of communica-tion because of unnecessary and tedious details (circumstantiality).

● Concrete thinking: The in-ability to abstract; uses literal translations concerning aspects of the environment.

Continued

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Table 8-2 Potential Nursing Diagnoses forSchizophrenia—cont’d

Symptoms Nursing Diagnoses

Negative SymptomsUncommunicative, withdrawn, Social Isolationno eye contact.

Preoccupation with own Impaired Social Interactionthoughts.

Expression of feelings of Risk for Lonelinessrejection or of aloneness (lies in bed all day; positions back to door).

Talks about self as “bad” Chronic Low Self-Esteemor “no good.”

Feels guilty because of “bad Risk for Self-Directed thoughts”; extremely sensitive Violenceto real or perceived slights.

Lack of energy (anergia). Ineffective CopingLack of motivation (avolition); Self-Care Deficit unable to initiate tasks (social (bathing/hygiene, contact, grooming, and other dressing/grooming)aspects of daily living). Constipation

OtherFamilies and significant others Compromised Familybecome confused, over- Copingwhelmed, lack knowledge of Disabled Family Copingdisease or treatment, feel Impaired Parentingpowerless in coping with Caregiver Role Strainclient at home

Nonadherence to medications Deficient Knowledgeand treatment: Client stops Nonadherence taking medication (often (Noncompliance)because of side effects), stopsgoing to therapy groups.

● Disturbances in cognitive associations (e.g., loosenessof association, perseveration, neologisms)

● Inability to distinguish internally stimulated thoughtsfrom actual environmental events or commonly sharedknowledge

● In addition to NANDA International

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Outcome Criteria● Communicates thoughts and feelings in a coherent,

goal-directed manner (to client’s best ability)● Demonstrates reality-based thought processes in ver-

bal communication (to client’s best ability)

Long-Term GoalsClient will:● Be able to speak in a manner that can be understood by

others with the aid of medication and attentive listeningby discharge

● Learn two diversionary tactics that work for him/her tolower anxiety, thus enhancing ability to think clearly andspeak more logically by (date)

Short-Term GoalsClient will:● Spend three 5-minute periods with nurse sharing obser-

vations in the environment within 4 days● Spend time with one or two other people in structured

activity involving neutral topics by (date)

Interventions and RationalesIntervention Rationale1. Assess if incoherence 1. Establishing a baseline

in speech is chronic facilitates the establish-or if it is more sudden, ment of realistic goals, as in an exacerbation the cornerstone for of symptoms. planning effective care.

2. Identify how long 2. Therapeutic levels of client has been on anti- an antipsychotic helps psychotic medication. clear thinking and

diminishes looseness of association (LOA).

3. Plan short, frequent 3. Short periods are less periods with client stressful, and periodic throughout the day. meetings give client a

chance to develop familiarity and safety.

● In addition to NANDA International

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Intervention Rationale4. Use simple words, 4. Client might have diffi-

and keep directions culty processing even simple. simple sentences.

5. Keep voice low and 5. High pitched/loud tone speak slowly. of voice can raise anxiety

levels; slow speaking aids understanding.

6. Look for themes in 6. Often client’s choice what is said, even of words is symbolic of though spoken words feelings.appear incoherent (e.g., anxiety, fear, sadness).

7. When you do not 7. Pretending to under-understand a client, stand (when you do not) let him/her know you limits your credibility in are having difficulty the eyes of your client understanding (e.g., and lessens the potential “I want to understand for trust.what you are saying, but I am having difficulty.”)

8. Use therapeutic techni- 8. Even if the words are ques to try to under- hard to understand, try stand client’s concerns getting to the feelings (e.g., “Are you behind them.saying . . .?” “You mentioned demons many times. Are you feeling frightened?”).

9. Focus on and direct 9. Helps draw focus away client’s attention to from delusions and concrete things in the focus on reality-based environment. things.

10. Keep environment 10. Keeps anxiety from quiet and as free of escalating and increa-stimuli as possible. sing confusion and

hallucinations/delusions.11. Use simple, concrete, 11. Minimizes misunder-

and literal explana- standing and/or tions. incorporating those

misunderstandings into delusional systems.


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Intervention Rationale12. When client is ready, 12. Helping client to use

introduce tactics that tactics to lower anxiety can lower anxiety can help enhance and minimize voices functional speech.and “worrying” thoughts. Teach client to do the following:● Take time out.● Read aloud to self.● Seek out staff,

family, or other supportive person.

● Listen to music.● Learn to replace irra-

tional thoughts with rational statements.

● Learn to replace “bad” thoughts with constructive thoughts.

● Perform deep breathing exercises.

IMPAIRED SOCIAL INTERACTION

The state in which an individual participates in an insufficientor excessive quantity or ineffective quality of social exchange

Related To (Etiology)▲ Impaired thought processes (hallucinations or delu-

sions)▲ Self-concept disturbance (might feel “bad” about self

or “no-good”)▲ Difficulty with communication (e.g., associative

looseness)● Inappropriate or inadequate emotional responses● Feeling threatened in social situations● Exaggerated response to stimuli● Difficulty with concentration


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▲ Verbalized or observed discomfort in social situations▲ Observed use of unsuccessful social interactions

behaviors▲ Dysfunctional interaction with peers● Spends time alone by self● Inappropriate or inadequate emotional response● Does not make eye contact, or initiate or respond to

social advances of others● Appears agitated or anxious when others come too

close or try to engage him in an activity

Outcome Criteria● Improves social interaction with family, friends, and

neighbors● Engages in social interactions in goal directed manner● Uses appropriate social skills in interactions

Long-Term GoalsClient will:● Engage in one or two activities with minimal encourage-

ment from nurse or family members by (date)● Use appropriate skills to initiate and maintain an interac-

tion by (date)● State that he or she is comfortable in at least three struc-

tured activities that are goal directed by (date)● Demonstrate interest to start coping skills training when

ready for learning

Short-Term GoalsClient will:● Engage in one activity with nurse by the end of the day● Attend one structured group activity within 1 week● Maintain an interaction with another client while doing

an activity (drawing, playing cards, cooking a meal)


Au: M.S.not clear

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Interventions and RationalesIntervention Rationale1. Assess if medication 1. Many of the positive

has reached symptoms (paranoia, therapeutic levels. delusions, and halluci-

nations) will subside with medications, which will facilitate interac-tions.

2. Ensure that the goals 2. Avoids pressure on set are realistic, client, and sense of whether in the hospi- failure on part of nurse/tal or community. family. This sense of

failure can lead to mutual withdrawal.

3. Keep client in an 3. Client might respond environment as free to noises and crowding of stimuli (loud noises, with agitation, anxiety, high traffic areas) and increased inability as possible. to concentrate on

outside events.4. Avoid touching the 4. Touch by a “stranger”

client. can be misinterpreted as a sexual or threaten-ing gesture. This is particularly true for a paranoid client.

5. If client is unable 5. An interested presence to respond verbally can provide a sense of or in a coherent being worthwhile.manner, spend fre-quent, short periods with client.

6. Structure times each 6. Helps client to develop day to include a sense of safety in a planned times for nonthreatening environ-brief interactions ment.and activities with the client on a one-on-one basis.

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Intervention Rationale7. If client is delusional/ 7. Even simple activities

hallucinating or is help draw client away having trouble con- from delusional thinking centrating at this onto reality in the time, provide very environment.simple concrete acti-vities with client (e.g., looking at a picture book with nurse, drawing, painting).

8. Structure activities 8. Client can lose interest that work at the in activities that are too client’s pace and ambitious, which can ability. increase a sense of

failure.9. Try to incorporate 9. Increases likelihood

the strengths and of client’s participation interests the client and enjoyment.had when not as impaired into the activities planned.

10. If client is very 10. Client is free to choose paranoid, solitary his level of interaction; or one-on-one acti- however, the concentra-vities that require can help minimizeconcentration are distressing paranoid appropriate. thoughts or voice

(e.g., chess).11. If client is very 11. Learns to feel safe with

withdrawn, one-on- one person, then one activities with a gradually might partici-“safe” person initially pate in a structured should be planned. group activity.

12. As client progresses, 12. Gradually the client provide the client learns to feel safe and with graded activities competent with according to level of increased social tolerance e.g., demands.(1) simple games with one “safe” person; (2) slowly add a third person into “safe”

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Intervention Rationaleactivities; (3) introduce simple group acti-vities; and then (4) groups in which clients participate more.

13. Eventually engage 13. Client continues to feel other clients and safe and competent in significant others in a graduated hierarchy social interactions of interactions.and activities with the client (card games, ping-pong, sing-a-longs, group outings, etc) at client’s level.

14. Identify with client 14. Increased anxiety can symptoms he expe- intensify agitation, riences when he/she aggressiveness, and begins to feel anxious suspiciousness.around others.

15. Teach client to remove 15. Teaches client skills in himself briefly when dealing with anxiety feeling agitated and and increasing a sense work on some anxiety- of control.relief exercises (e.g., deep breathing, thought stopping).

16. Provide opportunities 16. Social skills training for the client to learn helps client adapt and adaptive social skills function at a higher level in a nonthreatening in society, and increases environment. Initial clients quality of life. social skills training These simple skills could include basic might take time for a social behaviors (e.g., client with schizo-maintain good eye phrenia, but can increase contact, appropriate self confidence as well distance, calm as more positive demeanor, moderate responses from others.voice tone).

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Intervention Rationale17. As client progresses, 17. Increases client’s ability

Coping Skills Training to derive social support should be available to and decrease loneliness. him/her (nurse, staff, Clients will not give up or others). Basically substances of abuse the process is: unless they have alter-a. Define the skill to native means to facili-

be learned. tate socialization and b. Model the skill. feel they belong.c. Rehearse skills in

a safe environment, then in the community.

d. Give corrective feedback on the implementation of skills.

18. Useful coping skills 18. These are fundamental that client will need skills for dealing with include conversa- the world, which every-tional and asser- one uses daily with tiveness skills. more or less skill.

19. Remember to give 19. Recognition and appre-acknowledgment ciation go a long way and recognition for to sustaining and increa-positive steps client sing a specific behavior.takes in increasing social skills and appropriate interac-tions with others.

HallucinationsPresenting Signs and Symptoms● Clients state they hear voices.● Client denies hearing voices, but observer notes

client(‘s):●● Eyes following something in motion that observer can-

not see●● Staring at one place in room●● Head turning to side as if listening


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●● Mumbling to self or conversing when no one else ispresent

●● Inappropriate facial expressions, eye blinking● If hallucinations are from other causes (e.g., drugs, alco-

hol, delirium), the underlying cause needs to be treatedas soon as possible using accepted medical and nursingprotocols.


Hallucinations1. Assess for command hallucinations (e.g., voices telling

the person to harm self or another).2. Assess when hallucinations seem to occur the most (e.g.,

times of stress, at night).

Selected Nursing Diagnoses and Nursing Care Plans

DISTURBED SENSORY PERCEPTION:AUDITORY/VISUAL

Change in the amount or patterning of incoming stimuliaccompanied by a diminished, exaggerated, distorted, orimpaired response to such stimuli

Related To (Etiology)▲ Altered sensory reception: transmission or integra-

tion▲ Biochemical imbalance▲ Chemical alterations (e.g., drugs, electrolyte imbal-

ances)▲ Altered sensory perception▲ Psychologic stress● Neurologic/biochemical changes


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▲ Disorientation to time/place/person▲ Auditory distortions▲ Hallucinations● Tilting the head as if listening to someone● Frequent blinking of the eyes and grimacing● Mumbling to self, talking or laughing to self▲ Altered communication pattern▲ Change in problem-solving pattern▲ Reported or measured change in sensory acuity▲ Inappropriate responses

Outcome Criteria● Maintains social relationships● Maintains role performance● States that the voices are no longer threatening, nor do

they interfere with his or her life■ Learns ways to refrain from responding to hallucina-

tions

Long-Term GoalsClient will:● Demonstrate techniques that help distract him or her

from the voices by (date)● Monitor intensity of anxiety

Short-Term GoalsClient will:● State, using a scale from 1 to 10, that “the voices” are less

frequent and threatening when aided by medication andnursing intervention by (date)

● State three symptoms they recognize when their stresslevels are high by (date)


■ Adapted from NOC Objective Distortive Thought Self-Control

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● Identify two stressful events that trigger hallucinationsby (date)

● Demonstrate one stress reduction technique by (date)● Identify two personal interventions that decrease or

lower the intensity or frequency of hallucinations (e.g.,listening to music, wearing headphones, reading outloud, jogging, socializing) by (date)

Interventions and RationalesIntervention Rationale1. If voices are telling 1. People often obey

the client to harm hallucinatory commands self or others, take to kill self or others. necessary environ- Early assessment and mental precautions. intervention might save a. Notify others and lives.

police, physician, and administration according to unit protocol.

b. If in the hospital, use unit protocols for suicidal or threats of violenceif client plans to act on commands.

c. If in the community, evaluate need for hospitalization.

Clearly document what client says and, if he/she is a threat to others, document who was contacted and notified (use agency protocol as a guide).

2. Decrease environ- 2. Decrease potential for mental stimuli when anxiety that might possible (low noise, trigger hallucinations. minimal activity). Helps calm client.

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Intervention Rationale3. Accept the fact that 3. Validating that your

the voices are real reality does not include to the client, but voices can help client explain that you do cast “doubt” on the not hear the voices. validity of his or her Refer to the voices voices.as “your voices” or “voices that you hear.”

4. Stay with clients 4. Clients can sometimes when they are starting learn to push voices to hallucinate, and aside when given direct them to tell the repeated instruction, “voices they hear” to especially within the go away. Repeat often framework of a trusting in a matter-of-fact relationship.manner.

5. Keep to simple, basic, 5. Client’s thinking might reality-based topics be confused and disor-of conversation. Help ganized; this inter-client to focus on one vention helps client focusidea at a time. and comprehend

reality-based issues.6. Explore how the 6. Exploring the hallucina-

hallucinations are tion and sharing the experienced by experience can help give the client. the person a sense of

power that he or she might be able to manage the hallucinatory voices.

7. Help the client to 7. Hallucinations might identify the needs reflect needs for:that might underlie a. Powerthe hallucination. b. Self-esteemWhat other ways can c. Angerthese needs be met? d. Sexuality


X29168-P0208.qxd 6/24/05 8:42 PM 4


Intervention Rationale8. Help client to identify 8. Helps both nurse and

times that the halluci- client identify situations nations are most and times that might be prevalent and most anxiety producing frightening. and threatening to client.

9. Engage client in simple 9. Redirecting client’s physical activities or energies to acceptable tasks that channel activities can decrease energy (writing, draw- the possibility of acting ing, crafts, noncompeti- on hallucinations and tive sports, treadmill, help distract from voices.walking on track, exercise bike).

10. Work with the client 10. If clients’ stress triggers to find which activities hallucinatory activity, help reduce anxiety they might be more and distract the client motivated to find ways from hallucinatory to remove themselves material. Practice new from a stressful environ-skills with client. ment or try distraction

techniques.11. Be alert for signs 11. Might herald halluci-

of increasing fear, natory activity, which cananxiety, or agitation. be very frightening to

client, and client might act upon command hallucinations (harm self or others).

12. Intervene with 12. Intervene before anxiety one-on-one, seclusion, begins to escalate. or PRN medication If client is already out (as ordered) when of control, use chemical appropriate. or physical restraints

following unit protocols.

DelusionsPresenting Signs and Symptoms● The client has fragmented, poorly organized, well-organ-

ized, systematized, or extensive system of beliefs that arenot supported by reality.

● The content of the delusions can be grandiose, persecu-tory, jealous, somatic, or based on guilt.

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Delusions1. Assess if delusions have to do with someone trying to

harm the client, or if the client is planning to retaliateagainst a person or organization.a. If client is a threat to self or others, notify person and

authorities.b. Confer with physician and administration if precau-

tions need to be taken.2. Assess when delusional thinking is the most point (e.g.,

when under stress, in the presence of certain situationsor people, at night).


DISTURBED THOUGHT PROCESSES

Disruption in cognitive operations and activities

Related To (Etiology)● Biochemical/neurologic imbalances● Panic levels of anxiety● Overwhelming stressful life events● Chemical alterations (e.g., drugs, electrolyte imbal-

ances)

As Evidenced By(Assessment Findings/Diagnostic Cues)

▲ Inaccurate interpretation of environment▲ Memory deficit/problems▲ Egocentricity▲ Inappropriate non-reality-based thinking● Delusions


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Outcome Criteria● Refrains from acting on delusional thinking● Demonstrates satisfying relationships with real people.● Delusions no longer threaten or interfere with his or her

ability to function in family, social, and work situations.■ Perceive environment effectively

Long-Term GoalsClient will:● Demonstrate two effective coping skills that minimize

delusional thoughts by (date)

Short-Term GoalsClient will:● State that the “thoughts” are less intense and less fre-

quent with aid of medications and nursing interventionsby (date)

● Talk about concrete happenings in the environment with-out talking about delusions for 5 minutes by (date)

● Begin to recognize that his or her frightening (suspicious)“thinking” occurs most often at times of stress and whenhe or she is anxious

Interventions and RationalesIntervention Rationale1. Utilize safety measures 1. During acute phase,

to protect clients or client’s delusional others, if clients believe thinking might dictate they need to protect to them that they might themselves against a have to hurt others or specific person. self in order to be safe. Precautions are needed. External controls might

be needed.2. Attempt to understand 2. Important clues to

the significance of these underlying fears and beliefs to the client at issues can be found in the time of their the client’s seemingly presentation. illogical fantasies.

■ NOC objective Distance Thought Self-Control

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Intervention Rationale3. Be aware that client’s 3. Identifying the client’s

delusions represent experience allows the the way that he or nurse to understand the she experiences reality. client’s feelings.

4. Identify feelings related 4. When people believe to delusions. For that they are understood, example: anxiety might lessen.a. If client believes some-

one is going to harm him/her, client is experiencing fear.

b. If client believes some-one or something is controlling his/her thoughts, client is experiencing helplessness.

5. Do not argue with the 5. Arguing will only client’s beliefs or try increase client’s defen-to correct false beliefs sive position, thereby using facts. reinforcing false beliefs.

This will result in the client feeling even more isolated and misunder-stood.

6. Do not touch the client; 6. A psychotic person use gestures carefully. might misinterpret touch

as either aggressive or sexual in nature and mightinterpret gestures as aggressive moves. People who are psychotic need a lot of personal space.

7. Interact with clients on 7. When thinking is focusedthe basis of things in the on reality-based environment. Try to activities, the client is distract client from their free of delusional delusions by engaging thinking during that in reality-based activities time. Helps focus (cards, simple board attention externally.games, simple arts and crafts projects, cooking with another person, etc.).


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Intervention Rationale8. Teach client coping 8. When client is ready,

skills that minimize teach strategies client “worrying” thoughts. can do alone.Coping skills include:● Talking to a trusted

friend● Phoning a helpline● Singing● Going to a gym● Thought-stopping

techniques9. Encourage healthy habits 9. All are vital to help

to optimize functioning: keep client in remission.● Maintain regular

sleep pattern.● Reduce alcohol and

drug intake.● Maintain self-care.● Maintain medication

regimen.

ParanoiaPresenting Signs and Symptoms● Pervasive suspiciousness about one or more persons and

their actions● On guard, hyperalert, vigilant● Blames others for consequences of own behavior● Hostile, argumentative, often threatening verbalizations

or behavior● Poor interpersonal relationships● Has delusions of influence, persecution, and grandiosity● Often refuses medications because “nothing is wrong

with me”● Might refuse food if believes it is poisoned


Paranoia1. Assess for suicidal or homicidal behaviors.2. Assess for potential for violence.3. Assess need for hospitalization.


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DEFENSIVE COPING

Repeated projection of falsely positive self-evaluation basedon a self-protective pattern that defends against underlyingperceived threats to positive self-regard

Related To (Etiology)● Perceived threat to self● Suspicions of the motives of others● Perceived lack of self-efficacy/vulnerability


▲ Projection of blame/responsibility▲ Grandiosity▲ Denial of obvious problems▲ Rationalization of failures▲ Superior attitude toward others▲ Hostile laughter or ridicule of others▲ Difficulty in reality testing of perceptions▲ Difficulty establishing/maintaining relationships● Hostility, aggression, or homicidal ideation● Fearful● False beliefs about the intentions of others

Outcome Criteria● Interacts with others appropriately● Maintains medical compliance● Demonstrates decreased suspicious behaviors interact-

ing with others■ Avoids


■ NOC outcome for Impulse Self-Control

Au: M.S.not clear

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Long-Term GoalsClient will:● Acknowledge that medications help lower suspiciousness● State that he/she feels safe and more in control in inter-

actions with environment/family/work/social gather-ings by (date)

● Be able to apply a variety of stress/anxiety-reducingtechniques on own by (date)

Short-Term GoalsClient will:● Remain safe with the aid of medication and nursing

interventions (either interpersonal, chemical, or seclu-sion), as will others in the client’s environment

● Focus on reality-based activity with the aid of medica-tion/nursing intervention by (date)

● Demonstrate two newly learned constructive ways todeal with stress and feelings of powerlessness by (date)

● Demonstrate the ability to remove himself or herselffrom situations when anxiety begins to increase with theaid of medications and nursing interventions by (date)

● Identify one action that helps client feel more in controlof his or her life

Interventions and RationalesIntervention Rationale1. Use a nonjudgmental, 1. There is less chance

respectful, and neutral for a suspicious client approach with the to misconstrue intent or client. meaning if content is

neutral and approach is respectful and nonjudgmental.

2. Be honest and consis- 2. Suspicious people are tentwith client quick to discern dis-regarding expecta- honesty. Honesty and tions and enforcing consistency provide an rules. atmosphere in which

trust can grow.


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Intervention Rationale3. Use clear and simple 3. Minimize the opportu-

language when nity for miscommunica-communicating with tion and misconstruing a suspicious client. the meaning of the

message.4. Explain to client what 4. Prepares the client

you are going to do beforehand and mini-before you do it. mizes misinterpreting

your intent as hostile or aggressive.

5. Be aware of client’s 5. Suspicious clients will tendency to have ideas automatically think that of reference; do not they are the target do things in front of the interaction and of client that can be interpret it in a negative misinterpreted: manner (e.g., you are a. Laughing laughing at them, b. Whispering whispering about them, c. Talking quietly etc.).

when client can see but not hear what is being said

6. Diffuse angry and 6. When staff become hostile verbal attacks defensive, anger with a nondefensive escalates for both client stand. and staff. A nondefen-

sive and nonjudgmental attitude provides an atmosphere in which feelings can be explored more easily.

7. Assess and observe 7. Intervene before client client regularly for loses control.signs of increasing anxiety and hostility.

8. Provide verbal/ 8. Often verbal limits are physical limits when effective in helping a client’s hostile client gain self-control.behavior escalates: We won’t allow you to hurt anyone here. If you can’t control yourself, we will help you.


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Intervention Rationale9. Set limits in a clear, 9. Calm and neutral

matter-of-fact way, approach may diffuse using a calm tone. escalation of anger. Threatening John is not Offer an alternative to acceptable. Let’s talk verbal abuse by finding About appropriate appropriate ways ways to deal with To deal with feelings.your feelings.

10. Maintain low level 10. Noisy environments of stimuli and might be perceived as enhance a nonthrea- threatening.tening environment (avoid groups).

11. Initially, provide 11. If a client is suspicious solitary, noncompe- of others, solitary titive activities that activities are the best. take some concentra- Concentrating on tion. Later a game environmental stimuli with one or more minimizes paranoid clients that takes rumination.concentration (e.g., chess, checkers, thoughtful card games such as bridge or rummy).

Providing Support to Family/Others

INTERRUPTED FAMILY PROCESSES

Change in family relationships and/or functioning

Related To (Etiology)▲ Shift in health status of a family member▲ Situational crisis or transition▲ Family role shift▲ Developmental crisis or transition● Mental or physical disorder of family member


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As Evidenced By(Assessment Findings/Diagnostic Cues)

▲ Changes in participation in decision making▲ Changes in mutual support▲ Changes in stress reduction behavior▲ Changes in communication patterns▲ Changes in participation in problem solving▲ Changes in expression of conflict in family● Inability to meet needs of family and significant oth-

ers (physical, emotional, spiritual)● Knowledge deficit regarding the disease and what is

happening with ill family member (might believeclient is more capable than they are)

● Knowledge deficit regarding community and health-care support

Outcome CriteriaFamily members/significant others will:● State they have received needed support from commu-

nity and agency resources that offer support, education,coping skills training, and/or social network develop-ment (psychoeducational approach)

● Demonstrate problem-solving skills for handling tensionsand misunderstanding within the family environment

● Recount in some detail the early signs and symptoms ofrelapse in their ill family member, and know whom tocontact

Long-Term GoalsFamily members/significant others will:● Know of at least two contact people when they suspect

potential relapse by (date)● Discuss the disease (schizophrenia) knowledgeably by

(date):●● Understand the need for medical adherence●● Support the ill family member in maintaining opti-

mum health


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●● Know about community resources (e.g., help with self-care activities, private respite)

● Have access to family/multiple family support groupsand psychoeducational training by (date)

Short-Term GoalsFamily members/significant others will:● Meet with nurse/physician/social worker the first day

of hospitalization and begin to learn about this neuro-logic/biochemical disease, treatment, and communityresources

● Attend at least one family support group (single family,multiple family) within 4 days from onset of acuteepisode

● Problem-solve, with the nurse, two concrete situationswithin the family that all would like to change

● State what the medications can do for their ill member,the side effects and toxic effects of the drugs, and theneed for adherence to medication at least 2 to 3 daysbefore discharge

● Be included in the discharge planning along with client● State and have written information identifying the signs

of potential relapse and whom to contact before dis-charge

● Name and have complete list of community supports forill family member and supports for all members of thefamily at least 2 days before discharge

Interventions and RationalesIntervention Rationale1. Identify family’s ability 1. Family’s needs must

to cope (e.g., experience be addressed to stabilizeof loss, caregiver family unit.burden, needed supports).

2. Provide opportunity 2. Nurses and staff can for family to discuss best intervene when feelings related to ill they understand the family member and family’s experience identify their and needs.immediate concerns.

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Intervention Rationale3. Assess the family 3. Family might have

members’ current level misconceptions and of knowledge about misinformation about the disease and schizophrenia and medications used to treatment, or no treat the disease. knowledge at all.

Teach at client’s and family’s level of understanding and readiness to learn.

4. Provide information 4. Meet family members’ on disease and needs for information.treatment strategies at family’s level of knowledge.

5. Inform the client and 5. Understanding of the family in clear, simple disease and the treat-terms about psycho- ment of the disease pharmacologic therapy: encourages greater dosage, the need to family support and take medication as client adherence.prescribed, side effects, and toxic effect. Written information should be given to client and family members as well. Refer to the client and family teaching guide-lines in Chapter 21 under Antipsychotic Medication.

6. Provide information 6. Schizophrenia is an on family and client over-whelming disease community resources for both the client and for client and family the family. Groups, after discharge: support support groups, and groups, organizations, psychoeducational day hospitals, psycho- centers can help:educational programs, respite centers, etc. See list of associations and Internet sites at end of chapter.


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Intervention Rationalea. Develop family

skillsb. Access resourcesc. Access supportd. Access caringe. Minimize isolationf. Improve quality

of life for all family members

7. Teach family and 7. Rapid recognition client the warning of early warning symp-symptoms of poten- toms can help ward off tial relapse. potential relapse when

immediate medical attention is sought.

MEDICAL TREATMENT

PsychopharmacologyAntipsychotic medications are indicated for nearly all psy-chotic episodes of schizophrenia. To delay medication ther-apy too long can put the client at risk for suicide or otherdangerous behaviors.

Medications used to treat schizophrenia are calledantipsychotic medications. Two groups of antipsychoticdrugs exist: standard (traditional/conventional) and thenewer atypical (or novel) medications. Many physiciansurge the use of the atypical medications initially becauseof their better side effect profile and the fact that theatypical medications target the negative symptoms (apa-thy, lack of motivation) and anhedonia (lack of pleasurein life), thereby increasing the quality of life for clients.

Atypical (Novel) Antipsychotic MedicationsDuring the early 1990s, new types of antipsychotics beganappearing on the market, and they are currently used as first-line medications. (Clozapine [Clozaril] is the excep-tion because of its tendency to cause agranulocytosis and itshigh incidence for seizures.) These drugs not only target theacute and disturbing symptoms seen in acute active episodesof schizophrenia (hallucinations, delusions, associative


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looseness, paranoia), called positive symptoms, but alsotarget the negative symptoms, which allows improvementin the quality of life for clients (increased motivation,improved judgment, increased energy, ability to experiencepleasure and ↑ cognitive Function). These drugs also havea very low extrapyramidal symptom (EPS) profile and, ingeneral, have a more favorable side-effect profile.Pros● Target negative and positive symptoms● Lower risk of EPS● Lower SE profile, ↑ compliance● May improve symptoms of:

● Anxiety● Depression● ↓ Suicidal behavior

Cons● ↑ Weight gain● Metabolic abnormalities (glucose dysregulation, hyperc-

holesterolemia)● Are more expensive

Table 8-3 provides a list of atypical antipsychotics, theirdosages, and the side effects.

Standard MedicationsThe standard antipsychotic drugs target the more flagrantsymptoms of schizophrenia (hallucinations, delusions, sus-piciousness, associative looseness). These drugs can:● Reduce disruptive and violent behavior● Increase activity, speech, and sociability in withdrawn

clients● Improve self-care● Improve sleep patterns● Reduce the disturbing quality of hallucinations and delu-

sions● Improve thought processes● Decrease resistance to supportive therapy● Reduce rate of relapse● Decrease intensity of paranoid reactions

Antipsychotic agents are usually effective 3 to 6 weeksafter the regimen is started.

Side Effects There are some troubling side effects of thesedrugs that can at times limit medical adherence. Some of


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X29168-P0208.qxd 6/24/05 8:42 PM Page 249


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X29168-P0208.qxd 6/24/05 8:42 PM Page 250


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X29168-P0208.qxd 6/24/05 8:42 PM Page 251


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these side effects can be managed with other medications.EPS, cardiac side effects, and toxic effects of these drugs arediscussed further in Chapter 21.

One of the most disturbing side effects to clients are theEPS; medication is used to treat the EPS caused by thesestandard antipsychotics. Refer to Chapter 21 for a clientand family medication teaching plan.

PSYCHOSOCIAL APPROACHESTreatment of Comorbid ConditionsThere are many treatment approaches that can help clientswith schizophrenia better adjust to their environment andincrease their quality of life when used in conjunction withmedications. Some of the psychotherapeutic approachesthat seem to be useful for many people with these disor-ders are discussed here. However, treatment should notonly be aimed at the symptoms of schizophrenia but alsoneed to target some of the comorbid conditions that a clientmight exhibit. Some of the more common comorbid condi-tions in people with schizophrenia include:● Substance use problems● Depressive symptoms or disorders● Risk for suicide● Violent behaviors

If a comorbid condition is identified, it must be treated,if overall adherence to a second treatment approach is fol-lowed and/or successful.

Specific Psychosocial Treatments

Individual TherapyThere is evidence that supportive therapy that includes prob-lem-solving techniques and social skills training helpsreduce relapse and enhance social and occupational func-tioning when added to medication treatment for schizo-phrenic individuals who are treated in an outpatientenvironment. Cognitive behavioral therapy (CBT), cogni-tive rehabilitation, and social skills training (SST) are par-ticularly helpful in people with chronic schizophrenia whohave cognitive impairments.


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Family InterventionFamilies with a schizophrenic member endure considerablehardships while coping with the psychotic and residualsymptoms of schizophrenia. Often families are the sole care-takers of their schizophrenic member and need education,guidance, and support as well as training to help them man-age (APA, 2000b). A Psychoeducational family approachprovides support, education, coping skills training, andsocial network expansion and has been proven very suc-cessful with both decreasing family stress and increasingclient adherence to treatment. Families can be helped by:● Understanding the disease and the role of medications● Setting realistic goals for their schizophrenic member● Developing problem-solving skills for handling tensions

and misunderstanding within the family environment● Identifying early signs of relapse● Having knowledge of where they can go for guidance

and support within the community and nationally

Group TherapyThe goals of group therapy for individual members are toincrease problem-solving ability, to enable realistic goalplanning, to facilitate social interactions, and to managemedication side effects (Kanas, 1996). Groups can helpclients develop interpersonal skills, resolution of familyproblems, utilization of community supports as well asincrease medication compliance by learning to deal withtroubling side effects.

NURSE, CLIENT, and FAMILYRESOURCES

ASSOCIATIONSNational Alliance for the Mentally III (NAMI)Colonial Place Three2107 Wilson Boulevard, Suite 300Arlington, VA 22201-3042(800) 950-NAMI (check this one out!)http://www.nami.org


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Schizophrenics Anonymous403 Seymour Avenue, Suite 202Lansing, MI 48933(517) 485-7168;(800) 482-9534 (consumer line) (check this

one out!)

Recovery, Inc.802 North Dearborn StreetChicago, II, 60610(312) 337-5661

INTERNET SITESDoctors Guide to the Internethttp://www.pslgroup.com/schizophr.htmMany articles; good site for schizophrenia information

Internet Mental Healthhttp://www.mentalhealth.comVast amount of information/booklets/articles and general

information

National Alliance for Research on Schizophrenia andDepression

http://www.narsad.org

Schizophrenia.comhttp://www.schizophrenia.com


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