Schizophrenia Overview
Schizophrenia is a mental disorder characterized by a breakdown of thought processes and by poor emotional responsiveness.
It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social or occupational dysfunction. The onset of symptoms typically occurs in young adulthood, with a global lifetime prevalence of about 0.3–0.7%. Diagnosis is based on observed behavior and the patient's reported experiences.
Genetics, early environment, neurobiology, and psychological and social processes appear to be important contributory factors; some recreational and prescription drugs appear to cause or worsen symptoms.
Current research is focused on the role of neurobiology, although no single isolated organic cause has been found. The many possible combinations of symptoms have triggered debate about whether the diagnosis represents a single disorder or a number of discrete syndromes. Despite the etymology of the term from the Greek roots skhizein ("to split") and phrēn, phren ("mind"), schizophrenia does not imply a "split mind" and it is not the same as dissociative identity disorder—also known as "multiple personality disorder" or "split personality"—a condition with which it is often confused in public perception. (wikipedia.org)
Nursing Care Plan for Schizophrenia | Nursing Priorities; Discharge Goals
Nursing Priorities | Nursing Care Plan for Schizophrenia
- Promote appropriate interaction between client and environment.
- Enhance physiological stability/health maintenance.
- Provide protection; ensure safety needs.
- Encourage family/significant other(s) to become involved in activities to promote independent, satisfying lives.
Discharge Criteria | Nursing Care Plan for Schizophrenia
- Physiological well-being maintained with appropriate balance between rest and activity.
- Demonstrates increasing/highest level of emotional responsiveness possible.
- Interacts socially without decompensation.
- Family displays effective coping skills and appropriate use of resources.
- Plan in place to meet needs after discharge.
Nursing Care Plan for Schizophrenia | Nursing Diagnosis for Schizophrenia
Nursing Care Plan for Schizophrenia | Nursing Diagnosis for Schizophrenia; Desired Outcomes
Nursing Diagnosis for Schizophrenia: Thought Processes, Altered
May Be Related to:
- Disintegration of thinking processes; impaired judgment
- Psychological conflicts; disintegrated ego boundaries (confusion with environment)
- Sleep disturbance
- Ambivalence and concomitant dependence (part of need-fear dilemma interferes with ability to self-initiate fulfilling diversional activities)
Possibly Evidenced by:
- Presence of delusional system (may be grandiose, persecutory, of reference, of control, somatic, accusatory); commands, obsessions
- Symbolic and concrete associations; blocking ideas of reference
- Inaccurate interpretation of environment; cognitive dissonance; impaired ability to make decisions
- Simple hyperactivity and constant motor activity (ritualistic acts, stereotyped behavior) to withdrawal and psychomotor retardation
- Interrupted sleep patterns
Desired Outcomes/Evaluation Criteria | Nursing Care Plan for Schizophrenia
Client Will:
- Recognize changes in thinking/behavior.
- Identify delusions and increase capacity to cope effectively with them by elimination of pathological thinking.
- Maintain reality orientation.
- Establish interpersonal relationships.
Nursing Care Plan for Schizophrenia | Nursing Interventions for Schizophrenia
Nursing Care Plan for Schizophrenia | Nursing Interventions for Schizophrenia and Rationale;
Nursing Interventions for Schizophrenia and Rationale
Nursing Interventions for Schizophrenia (Independent) | Nursing Care Plan for Schizophrenia
- Determine severity of client’s altered thought processes, noting form (dereistic, autistic, symbolic, loose and/or concrete associations, blocking); content (somatic delusions, delusions of grandeur/persecution, ideas of reference); and flow (flight of ideas, retardation). Rationale: Identification of symbolic/primitive nature of thinking/communications promotes understanding of the individual client’s thought processes and enables planning of appropriate interventions.
- Establish a therapeutic nurse-client relationship.Rationale: Provides an emotionally safe milieu that enables interpersonal interaction and decreases autism.
- Use therapeutic communications (e.g., reflection, paraphrasing) to intervene effectively. Rationale: Therapeutic communications are clear, concise, open, consistent, and require use of self. This reduces autistic thinking.
- Structure communications to reflect consideration of client’s socioeconomic, educational, and cultural history/values. Rationale: Lack of consideration of these factors can cause misdiagnosis/inaccurate interpretation (otherwise normal thinking viewed as pathological).
- Express desire to understand client’s thinking by clarifying what is unclear, focusing on the feeling rather than the content, endeavoring to understand (in spite of the client’s unclearness), listening carefully, and regulating the flow of the thinking as needed (Active-listening). Rationale: Client is often unable to organize thoughts (easily distracted, cannot grasp concepts or wholeness but focuses on minutiae), and flow of thoughts is often characterized as racing, wandering, or retarded. Active-listening identifies patterns of client’s thoughts and facilitates understanding. Expression of desire to understand conveys caring and increases client’s feelings of self-worth.
Nursing Interventions for Schizophrenia (Independent) - continuation | Nursing Care Plan for Schizophrenia
- Reinforce congruent thinking. Refuse to argue/agree with disintegrated thoughts. Present reality and demonstrate motivation to understand client (model patience). Rationale: Provides opportunity for the client to control aggressive behavior. Decreases altered (disintegrated, delusional) thinking as client’s thoughts compensate in response to presentation of reality.
- Share appropriate thinking and set limits (cognitive therapy) if client tries to respond impulsively to altered thinking. Rationale: Enhances self-esteem and promotes safety for the client and others. Cognitive therapy is directed specifically at thinking patterns that have developed (e.g., illogical associations are made between events that most of us would not believe to be connected). Aim is to modify apparently fixed beliefs, faulty interpretations, and automatic thoughts, and by relating them to “normal experience” to reduce some of the fear attached to them.
- Assess rest/sleep pattern by observing capacity to fall asleep, quality of sleep. Graph sleep chart as indicated until acceptable pattern is established. Rationale: Delusions, hallucinations, etc. may interfere with client’s sleep pattern. Fears may alter ability to fall asleep. Sleep deprivation can produce behaviors such as withdrawal, confusion, disturbance of perception. Sleep chart identifies abnormal patterns and is useful in evaluating effectiveness of interventions.
Nursing Interventions for Schizophrenia (Independent) - continuation | Nursing Care Plan for Schizophrenia
- Structure appropriate times for rest and sleep; adjust work/rest activity patterns as needed. Rationale: Consistency in scheduling reduces fears/insecurities, which may be interfering with sleep. Sleep is enhanced by balancing activity (physical, occupational) with rest/sleep.
- Help client identify/learn techniques that promote rest/sleep (e.g., quiet activities, soothing music, before bedtime, regular hour for going to bed, drinking warm milk). Rationale: Enhances client’s ability to optimize rest/sleep, maximizing ability to think clearly.
- Assess presence/degree of factors affecting client’s capacity for diversional activities. Rationale: Presence of hallucinations/delusions; situational factors such as long-term hospitalization (characterized by monotony, sensory deprivation); psychological factors such as decreased volition; physical factors such as immobility contribute to deficits in diversional activity.
- Monitor medication regimen, observing for therapeutic effect and side effects (e.g., anticholinergic [dry mouth, etc.], sedation, orthostatic hypotension, photosensitivity, hormonal effects, reduction of Schizophrenia threshold, extrapyramidal symptoms, and fatigue/weakness with sore throat or signs of infection [agranulocytosis]). Rationale: Enables identification of the minimal effective dose to reduce psychotic symptoms with the fewest adverse effects. Prevention of side effects/timely intervention may enhance cooperation with drug regimen. Identification of the onset of serious side effects, such as neuroleptic malignant syndrome, provides for appropriate interventions to avoid permanent damage.
Nursing Interventions for Schizophrenia (Collaborative) | Nursing Care Plan for Schizophrenia
Administer medications as indicated, e.g.:
- Antipsychotics: Phenothiazines, such as chlorpromazine (Thorazine), thioridazine (Mellaril), fluphenazine (Prolixin), perphenazine (Trilafon); Thioxanthenes, such as chlorprothixene (Taractan), thiothixene (Navane); Butyrophenones, such as haloperidol (Haldol); Dibenzoxazepines, such as loxapine (Loxitane); Rationale: Used to reduce psychotic symptoms. May be given orally or by injection. For long-term maintenance therapy, a depot neuroleptic such as Prolixin may be the drug of choice to maintain medication adherence and prevent relapse in problematic clients. When given at bedtime, the sedative effects of psychotropic medication can enhance quality of sleep and reduce hypotensive side effects.
- Atypical antipsychotics: clozapine (Clozaril); Rationale: Useful in treating clients resistant to other medications or in the presence of unacceptable side effects. Clozapine causes no muscular rigidity and is associated with a relatively low rate of akathisia (feeling of restlessness, urgent need for movement). May not be used as first-line therapy because of a lowered Schizophrenia threshold or a 1%–2% potential for agranulocytosis, necessitating weekly blood testing for the duration of treatment. Note: Combination therapy, e.g., clozapine and a neuroleptic, such as fluphenazine or haloperidol, may be useful for some clients.
- olanzapine (Zyprexa); Rationale: Becoming a first-line drug choice as it specifically targets D4 dopamine receptors, which may be present in unusually high numbers in clients with schizophrenia. Drug seems well tolerated, with many side effects appearing to be dose-related and no known drug interactions that affect plasma level or compromise efficacy.
- Risperidone (Risperdal); Rationale: Effective therapeutic agent has been associated with few uncomfortable or serious side effects, especially agranulocytosis.
Nursing Interventions for Schizophrenia (Collaborative) - continuation | Nursing Care Plan for Schizophrenia
Administer medications as indicated, e.g.:
- Antiparkinsonism drugs: Anticholinergics, such as trihexyphenidyl HCl (Artane), benztropine mesylate (Cogentin), procyclidine HCl(Kemadrin), biperiden HCl (Akineton); Rationale: Used to relieve drug-induced extrapyramidal reactions and treat all other forms of parkinsonism. They block action of acetylcholine, thereby reducing excitation of the basal ganglia.
- Antihistamines, such as diphenhydramine (Benadryl); Rationale: Suppress cholinergic activity and prolong the action of dopamine by inhibiting its reuptake and storage.
- Miscellaneous agents, such as amantadine (Symmetrel). Rationale: These agents release dopamine from presynaptic nerve endings in basal ganglia.
This is a sample of Psychiatric Nursing: Nursing Care Plan for Schizophrenia.