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SCHIZOPHRENIA: NURSING MANAGEMENT

“Arguably the worst disease affecting mankind”-(Nature 1988)

Introduction

When we think of madness, we think of schizophrenia. Schizophrenia causes distorted and bizarre thoughts, perceptions, emotions, movements, and behaviour. It cannot be defined as a single illness, rather schizophrenia is a syndrome or disease process with many different varieties and symptoms.

History

Schizophrenia was recorded in Indian history nearly 3,300 years ago by Charaka.

Early figures in the History of Psychiatry

§         1809 John Haslam (1764-1844) Superintendent of a British hospital. In Observations on Madness and Melancholy, he outlined a description of the symptoms of schizophrenia.

§         1802/1809 Philippe Pinel (1745-1826) A French physician who described cases of schizophrenia.

§         1852 Benedid Morel (1805-1873) Physician at a French institution who used the term demence precoce (in Latin,dementia praecox). meaning early or premature (precoce) loss of mind (demence) to describe schizophrenia.

§         1898/1899 Emil Kraepelin (1856-1926) A German psychiatrist who unified the distinct categories of schizophrenia (hebephrenic, catatonic and paranoid) under the name dementia precox. The scientific study of the disorder began with the description by Kraepelin

§         1908 Eugen Bleuler (1857-1939) A Swiss psychiatrist who introduced the term “schizophrenia” meaning splitting of the mind. It does not mean multiple personalities. Referred to the  associative splitting of the basic functions of   personality.

Prevalence of Schizophrenia

§         A recent meta-analysis of 13 epidemiological studies in India, comprising 33,572 individuals, concluded that the prevalence of mental illness is estimated as  58.2 per 1,000 population where schizophrenia—2.7/1,000

§         1% of world population

§         all ethnic groups in all parts of world

§         rare in tropics

§         10-100 times more reported in U.S. & Europe than 3rd world

o        Found more often in low socioeconomic classes (SES) & African Americans

§         first diagnosed at 15-30 years of age, 60 -70% doesn't disappear

Myths of “Madness”

§         People with schizophrenia have “split personalities.”

§         People with schizophrenia are intellectually disabled?

§         People with schizophrenia are dangerous?

§         People with schizophrenia are addicted to their drugs?

Schizophrenia is

§         NOT caused by bad parenting or an unhappy childhood.

§         NOT due to a weakness in character.

§         NOT a hopeless situation.

Society & Schizophrenia

         Concern for ultimate fate of these individuals in society

         Stigma associated with any mental disorder, especially Schizophrenia.

         Many fail to continue medication

         Estimated: 50% of U.S. homeless population suffers from inadequately controlled schizophrenia.

Onset and Course

§         Onset may be abrupt or insidious

§         Regardless of the onset and type schizophrenia, consequences for most clients and families are substantial and enduring

§         Those who develop the illness earlier show worst outcomes than those who develop later

§         Years immediately after the onset two clinical patterns emerge-ongoing course with varying severity or episodic patterns with near complete recovery

§         Long term course-intensity diminishes with age and may regain some social and occupational functioning

Psychopathology

Bleuler classification of symptoms (Bleuler 1911)

Fundamental symptoms

accessory symptoms

include 4 As- disturbances of associations, changes in emotional (affective) reactions, autism (withdrawal from reality), and ambivalence

Hallucinations, delusions, catatonia and abnormal behaviours

Schneider (1887-1967)

Schneider’s first rank symptoms of schizophrenia

Thought echo- hearing thoughts spoken aloud

Third person auditory hallucinations

Hallucinations in the form of a commentary

Somatic hallucinations

Thought withdrawal or insertion

Thought broadcasting

Delusional perception

Feelings or actions experienced a made or influenced by external agents-soamatic passivity

  1. Disorders of thought and verbal behaviour-usually identified from speech and writing

Delusions-false beliefs, unshakable, not affected by rational argument or evidence, firmly held on inadequate grounds that may accompany psychotic disorders

§         Primary, secondary and shared delusions

§         Grandeur – Great/Special Person

§         Reference – Special/Personal Meanings

§         Control – Controlled by Others

§         Bizarre-- unusual

Steam of thought-perseveration,  loosening of associations, derailment, word salad, neologisms

  1. Disorders of perception
    • Hallucinations-perception in the absence of stimuli to the sense organs in a similar quality to a true percept.

§         Auditory-Second person, third person

may hear voices, respond & act on voices

§         Visual- false sensory experiences such as seeing something without any external visual stimulus

§         Olfactory

§         Somatic-tactile and deep

§         Pseudohallucinations

    • Illusions- misperceptions of external stimuli
  1. Disorders of affect
    • Congruence, apathy, blunted or flattened
    • Avolition – loss of motivation, “drained”
    • Flat affect: separation from external world
  2. Disorders of motor behavior-Psychomotor:

Psychomotor agitation or retardation

    • Agitation = purposeless or disorganized movement
    • Retardation = slowed or lack of movement
    • In extreme form = catatonia
    • Catatonic stupor – stopped responding to environmental stimulus

§         Waxy flexibility – posed like a wax statue

    • Rigidity – don’t move
    • Posturing – assume bizarre postures for long periods of time

Positive & Negative Symptoms

  • Primary difference - Positive outgoing & socially interactive,
  • Symptoms may reflect 2 different stages of disorder
  • Long term sufferers show atrophy of cerebral cortexes

Positive:

§         Excessive or additional to normal thoughts, emotions, or behaviors

§         Disorganized thoughts and speech

§         Excessive affect (emotion)

§         Active and socially functioning

Negative:

§         Flat affect: separation from external world

§         lack of behavior (diminished motor movements)

§         completely separated from interactions with others

§         Deficits or reductions in normal thoughts, emotions, and/or behaviors

§         Poverty of speech – reduced speech or content

§         Avolition – loss of motivation, “drained”

§         Social Withdrawal – distanced from others

Etiology: Theories About Schizophrenia

Whether schizophrenia is an organic disease with underlying physical brain pathology is studied for long.

Old:

1.      Cold, uncaring, domineering mothers use their children to fill their own needs and ignore those of child

2.      “Schizophrenogenic Mother”

3.      Discredited

4.      Behavioral: Operant Conditioning (also not much evidence)

Newer:

Biological

Biological theories of schizophrenia focus on genetic factors, neuroanatomic, neurochemical factors and immunovirology.

1.      Genetic contribution:

§         Genetic studies have concentrated on immediate families-parents, siblings, offsprings

§         Twin Studies – Identical twins have a 50% risk of schizophrenia (even though their genes are 100% equal) than Fraternal twins or other sibs with 15% risk

§         Adoption studies

§         May be polygenic

2.     Neurochemical and Neuroanatomic factors

Alterations in neurotransmitter systems of the brains of people with schizophrenia. Currently the most prominent neurochemical theories involve dopamine and serotonin.

Dopamine (“DA”) Hypothesis:

All can also lead to psychotic behaviors

§         too much DA linked to schizophrenic symptoms

§         Neurons using DA fire too often

§         Transmit too many messages, confusing the brain

§         Produces symptoms of disorder

§         Substance that decrease DA levels decrease symptoms of Schizophrenia.

§         Reserpine affects vesicles–reduces Schizophrenia

§         Substance that block access to DA receptors effective in Schizo

§         high correlation between blocking & effective treatment.

§         agonist of DA (apomorphine) or that increase DA formation (L-Dopa), or increase release (amphtamine), or block DA (cocaine) worsen schizophrenia

§         May best explain Type I –

§         Type II does not seem to be related to abnormal DA chemistry in the brain

Serotonin hypothesis:

§         Serotonin modulates and help to control excess dopamine.

§         Some believes excess serotonin contributes to schizophrenia

Structural Abnormalities-neuroanatomic

§         Many Type II patients have structural abnormalities in brain:

§         Enlarged ventricles (site in brain where cerebro-spinal fluid (CSF) is produced)

§         Found that people with schizophrenia has less brain tissue and CSF

§         PET studies suggest diminished glucose metabolism and oxygen in frontal cortical areas of the brain

§         Research shows decreased brain volume and abnormal brain function in the frontal and temporal areas of the brain of persons with schizophrenia

§         May be related to prenatal brain development or brain damage

§         Also linked to abnormal blood flow within brain, smaller temporal and frontal lobes, and less gray matter

3.     Viral Infection:

§         May result from prenatal exposure to certain viruses (don’t know which for sure) that come out of dormancy in teens, adulthood

§         Mothers of schizophrenic patients report more instances of flu during winter

§         Increased levels of antibodies to certain viruses found in blood of schizophrenic patients

§         Not specific to Type I or Type II

4.     Psychological Theories

§         Stress-increased number of stressful life events probably triggering effect on onset of schizophrenia in predisposed individual

§         Increased Expressed Emotions(EE) (hostility, critical comments, emotional over involvement of “significant others”

§         Family Theories: “ schizophrenogenic mothers”, lack of “real parents”, dependency on mother, anxious mother, parental marital discord are examples

§         Information Processing Hypothesis: disturbances in attention, inability to maintain a set, and inability to assimilate and integrate percepts are common finding in schizophrenia

§         There is possibility of breakdown in the inter al representation of mental events

§         Psychoanalytical theories- According to Freud, there is regression to the pre-oral (and oral) stage of psychosexual development with the use of defense mechanisms of denial, reaction formation, and projection

5.     Socio-cultural:

§         Social influences (like poverty, abuse, family problems) affect an individual’s mental functioning

§         Not much evidence to support it as a cause, but it definitely affects the course of the disease

§         May have a diathesis-stress explanation: Biological predisposition and psychological/sociocultural stresses

Course of Schizophrenia:

Usually 3 phases:

  • Prodromal – no obvious symptoms, but everyday functioning is beginning to deteriorate
  • Active – Full-blown schizophrenia, with active symptoms
  • Residual – Symptoms subside, prodromal-like state.

Symptoms can return – back into active phase

Classification

  • Acute schizophrenia
  • Chronic schizophrenia

Classification ICD 10

  • Paranoid schizophrenia
  • Disorganized or Hebephrenic schizophrenia
  • Catatonic schizophrenia
  • Residual and latent schizophrenia
  • Undifferentiated schizophrenia
  • Simple schizophrenia
  • Post-schizophrenic depression
  • Others

Criteria as per ICD 10

  • A minimum of very clear symptom and usually 2 or more less clear cut belonging to SFRSS for a period of 1 month or more or
  • 2 of the following symptoms (persistent hallucinations in any modality, breaks or interpolations in the train of thought, catatonic behaviour, negative symptoms)
  • if duration less than one month, then diagnosis of acute schizophrenia like psychotic disorder

Classification (DSM IV)

The following disorders are included:

  • Schizophrenia
    • Paranoid,
    •  Disorganized
    • Catatonic
    • Undifferentiated
    • Residual

Criteria as per DSM IV

A.     Two or more of the following, each present for a significant portion of time during a 1 month period

1.      delusions (positive sx), e.g., grandeur, persecution

2.      hallucinations (positive sx)

3.      disorganized speech

4.      grossly disorganized or catatonic behavior

5.      negative symptoms, i.e., affective flattening,

6.      alogia (inability to speak), or avolition (inability to act).

B.      Social/occupational dysfunction: for a significant portion of the time, one or more areas of functioning (work, interpersonal relationships, or self-care) are markedly below prior levels.

C.     Duration: Continuous signs persist for at least 6 months, with at least 1 month meeting criteria for A. Can include “prodromal period”.

D.     Schizoaffective disorder, mood disorder, substance abuse, medical problem ruled out.

Types

nType I:       Mainly has positive symptoms

Tend to have better prognosis

Respond better to treatment

Linked to biochemical abnormalities in brain

nType II:      Mainly negative symptoms

Tend to have worse prognosis

Respond poorly to treatment

Tend to have poor premorbid functioning

Linked to abnormal brain structures

Sub Types of Schizophrenia:

These can be either Type I or II depending on what symptoms manifest

1.      Paranoid Schizophrenia:

Hallucinations-persecutory content, grandiose content

Delusions-persecution, reference, grandiosity, control, infidelity, well-systemized

Disturbances of affect, volition, speech, and motor behaviour

Tends to be organized in thought, speech, just bizarre

Usually Type I

John Nash  (“A Beautiful Mind”) had this type

2.     Catatonic Schizophrenia:

Psychomotor disturbance is prime symptom

Usually Type II

3.     Disorganized Schizophrenia:

Flat/Inappropriate Affect

Disorganized Thoughts/Speech

Confused, Incoherent

Prognosis usually poor

4.      Undifferentiated Schizophrenia:

Not easily classified into other types;

Mix of symptoms

5.      Residual Schizophrenia:

Maps onto residual phase of disorder

Symptoms decrease in intensity & number

Some trace remains

Can be residual while on medication

6.      Post Schizophrenia Depression

Differential diagnosis

Organic Psychosis

    • Complex partial seizures
    • Drug induced psychosis (amphitamine )
    • Metabolic disturbance
    • Cerebral neoplasm

Possibility of Mood Disorder

    • Mania
    • Depression
    • Mixed episodes

Other non-organic psychosis-ATPD

Management of Schizophrenia:

Old:

§         Psychoanalysis

§         Shock Treatment (Insulin, ECT)

§         Lobotomy

§         Institutionalization

New:

§         Antipsychotic drugs, also known as neuroleptic drugs

§         ECT

§         Psychosocial Treatment- Psychotherapy to help increase functioning and compliance in taking medications

§         Psychosurgery-limbic lobotomy

1.     Antipsychotic Medications.

Typical Antipsychotics

§         Chlorpromazine

§         Thioridazine

§         Trifluperazine

§         Haloperidol

§         Pimozide

§         Triflupromazine

§         Prochlorperazine

§         Flupenthixol

§         Zuclopenthixol

Side effects

§         Anti-adrenergic effects-Sedation, postural hypotension, inhibition of ejaculation

§         Extrapyramidal effects: movement symptoms such as Parkinson’s-like shaking (pseudoparkinsonism), dystonia, akathesia and  tardive dyskinesia

§         Anticholinergic effects: dry mouth, reduced sweating, urinary hesitancy and retention, constipation and blurred vision, precipitation of glaucoma

§         Other effects: cardiac arrhythmias, weight gain, amenorrhoea, galacorroea, hypothermia

§         Work best with Type I

Atypical Antipsychotics:

§         Clozapine

§         Resperidone

§         Olanzapine

§         Quetipine

§         Ziprezidone

§         Aripiprazole

Side effects

§         Less side effects

§         Agranulocytosis

§         Weight gain

          Depot antipsychotics

§         Fluphenazine deconate

§         Flupenthixol

§         Zuclopenthixol

§         Haloperidol

2.     ECT

§         Catatonic stupor

§         Uncontrolled catatonic excitement

§         Acute exacerbation not controlled with drugs

§         Severe side effects with drugs

3.     Psychosocial Treatment

1.      Psychoeducation

2.      Group Psychotherapy

3.      Family therapy

4.      Milieu Therapy

5.      Individual Psychotherapy

6.      Psychosocial Rehabilitation

Psychotherapy: Addresses coping mechanism, family relationships, social skills

4.     Hospitalization, Day Programs may be necessary

Management in special Groups

Children, elderly and pregnancy

  • Children and  elderly are more prone to develop side effects. Elderly may have impaired renal and hepatic function
  • Pregnancy- because o the risk of developing teratogenesis
  • Breast feeding mothers- caution

Nursing Management-Nursing Process

History

Outline of psychiatric history

Name, age , address of patient, name of informant if any and their relationship to the patient

History of  present condition

Family History

Personal History

  • early development, health during childhood, nervous problems in childhood, education, occupation, menstrual history, sexual history, marriage,

Past illness

  • past physical illness, medical illness, forensic history

Personality

  • relationships, leisure activities, prevailing mood, character, attitudes and standards, premorbid personality

Drugs, alcohol, tobacco

Mental Status Examination

Appearance and behaviour

  • General appearance, facial appearance, posture and movement, social behaviour, consciousness, orientation

Speech –

  • coherent, relevant, goal-directed
  • rate and quantity
  • flow of speech

Mood

  • cheerful, elation, euphoric, exaltation
  • depression, anxiety
  • congruent or incongruent

Depersonalization and derealization

Delusions

  • content and form-persecutory, grandiose, nihilistic, hypochondriacal, religious, reference, guilt, unworthiness, jealousy
  • Well-systematized

Illusions

hallucinations-auditory or visual, command hallucinations, second person, third person

Attention and concentration

Memory-short term, recent and remote

Insight-Grade 1 to 5

 

A.     Nursing Diagnosis Disturbed Thought Processes

-Disruption in cognitive operations and activities

Assessment Data

§         Non-reality-based thinking, Disorientation, Labile affect, Short attention span, Impaired judgment, Distractibility

Expected Outcomes

§         Be free from injury

§         Demonstrate decreased anxiety level

§         Respond to reality-based interactions initiated by others

§         Verbalize recognition of delusional thoughts if they persist

§         Be free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts

 

NURSING INTERVENTIONS

 

RATIONALE

Be sincere and honest when communicating with the client. Avoid vague or evasive remarks.

Delusional clients are extremely sensitive about others and can recognize insincerity. Evasive comments or hesitation reinforces mistrust or delusions.

Be consistent in setting expectations, enforcing rules, and so forth.

Clear, consistent limits provide a secure structure for the client.

Do not make promises that you cannot keep.

Broken promises reinforce the client’s mistrust of others.

Encourage the client to talk with you, but do not pry for information.

Probing increases the client’s suspicion and interferes with the therapeutic relationship.

Explain procedures, and try to be sure the client understands the procedures before carrying them out.

When the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff.

Give positive feedback for the client’s successes.

 

Positive feedback for genuine success enhances the client’s sense of well-being and helps make non-delusional reality a more positive situation for the client.

Recognize the client’s delusions as the client’s perception of the environment.

 

Recognizing the client’s perceptions can help you understand the feelings he or she is experiencing.

Initially, do not argue with the client or try to convince the client that the delusions are false or unreal.

Logical argument does not dispel delusional ideas and can interfere with the development of trust.

Interact with the client on the basis of real things; do not dwell on the delusional material.

Interacting about reality is healthy for the client.

Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups

A distrustful client can best deal with one person initially. Gradual introduction of others when the client can tolerates is less threatening.

Recognize and support the client’s accomplishments (projects completed, responsibilities fulfilled, or interactions initiated).

Recognizing the client’s accomplishments can lessen anxiety and the need for delusions as a source of self-esteem.

Show empathy regarding the client’s feelings; reassure the client of your presence and acceptance.

The client’s delusions can be distressing. Empathy conveys your caring, interest and acceptance of the client.

Never convey to the client that you accept the delusions as reality.

Indicating belief in the delusion reinforces the delusion (and the client’ illness).

Ask the client if he or she can see that the delusions interfere with or cause problems in his or her life.

Discussion of the problems caused by the delusions is a focus on the present and is reality based.

B.      Nursing Diagnosis: Disturbed Sensory Perception (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory

-Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Assessment

·         Hallucinations (auditory, visual, tactile, gustatory, kinesthetic, or olfactory)

·         Listening intently to no apparent stimuli

·         Talking out loud when no one is present

·         Rambling, incoherent, or unintelligible speech

·         Inability to discriminate between real and unreal perceptions

·         Attention deficits

·         Inability to make decisions

·         Feelings of insecurity

·         Confusion

Expected Outcomes

·         Demonstrate decreased hallucinations

·         Interact with others in the external environment

·         Verbalize knowledge of hallucinations or illness and safe use of medications

·         Participate in the real environment

·         Make sound decisions based on reality

·         Participate in community activities or programs

NURSING INTERVENTIONS

 

RATIONALE

Be aware of all surrounding stimuli, including sounds from other rooms (such as television or stereo in adjacent areas).

Many seemingly normal stimuli will trigger or intensify hallucinations. The client can be overwhelmed by stimuli.

Try to decrease stimuli or move the client to another area.

Decreased stimuli decreases chances of misperception. The client has a diminished ability to deal with stimuli.

Avoid conveying to the client the belief that hallucinations are real. Do not converse with the “voices” or otherwise reinforce the client’s belief in the hallucinations as reality.

You must be honest with the client, letting him or her know the hallucinations are not real.

 

Explore the content of the client’s hallucinations during the initial assessment to determine what kind of stimuli the client is receiving, but do not reinforce the hallucinations as real. You might say, "I don’t hear any voices-what are you hearing?"

It is important to determine if auditory hallucinations are "command" hallucinations that direct the client to hurt himself or herself or others. Safety is always a priority.

 

Use concrete, specific verbal communication with the client. Avoid gestures, abstract ideas

The client’s ability to deal in abstractions is diminished. The client may misinterpret your gestures

Avoid asking the client to make choices. Don’t ask “Would you like to talk or be alone?” Rather, suggest that the client talk with you.

The client’s ability to make decisions is impaired, and the client may choose to be alone (and hallucinate) rather than deal with reality (talking to you).

Respond verbally and reinforce the client’s conversation when he or she refers to reality.

Positive reinforcement increases the likelihood of desired behaviors.

Encourage the client to tell staff members about hallucinations.

The client has the chance to seek others (in reality) and to cope with problems caused by hallucinations.

If the client appears to be hallucinating, attempt to engage the client’s in conversation or a concrete activity.

It is more difficult for the client to respond to hallucinations when he or she is engaged in real activities and interactions.

Maintain simple topics of conversation to provide a base in reality.

The client is better able to talk about basic things; complexity is more difficult.

Provide simple activities that the client can realistically accomplish (such as uncomplicated craft projects).

Long or complicated tasks may be frustrating for the client. He or she may be unable to complete them.

 

Encourage the client to express any feelings of remorse or embarrassment once he or she is aware of psychotic behavior; be supportive.

It may help the client to express such feelings, particularly if you are a supportive, accepting listener.

Show acceptance of the client’s behavior and of the client as a person; do not joke about or judge the client’s behavior.

 

The client may need help to see that hallucinations were a part of the illness, not under the client’s control. Joking or being judgmental about the client’s behavior is not appropriate and can be damaging to the client.

C.     Nursing Diagnosis: Disturbed Personal Identity

-Inability to distinguish between self and nonself

Assessment data

·         Bizarre behavior, Regressive behavior, Loss of ego boundaries (inability to differentiate self from the external environment), Disorientation, Disorganized, illogical thinking, Flat or inappropriate affect, Feelings of anxiety, fear, or agitation, Aggressive behavior toward others or property

Expected Outcomes

·         Be free from injury

·         Not harm others or destroy property

·         Establish contact with reality

·         Demonstrate or verbalize decreased psychotic symptoms and feelings of anxiety, agitation, and so forth

·         Participate in the therapeutic milieu

·         Express feelings in an acceptable manner

·         Reach or maintain his or her optimal level of functioning

·         Cope effectively with the illness

·         Continue compliance with prescribed regimen, such as medications and follow-up appointments

NURSING INTERVENTIONS

RATIONALE

Reassure the client that the environment is safe by briefly and simply explaining routines, procedures, and so forth.

The client is less likely to feel threatened if the surroundings are known.

 

Protect the client from harming himself or herself or others

Client safety is a priority. Self-destructive ideas may come from hallucinations or delusions.

Remove the client from the group if his or her behavior becomes too bizarre, disturbing, or dangerous to others.

The benefit of involving the client with the group is outweighed by the group’s need for safety and protection.

Decrease excessive stimuli in the environment. The client may not respond favorably to competitive activities, or large groups if he or she is still actively psychotic.

The client is unable to deal with excess stimuli. The environment should not be threatening to the client.

 

*Be aware of SOS medications and the client’s varying need for them.

Medication can help the client gain control over his or her own behavior.

Reorient the client to person, place, and time as indicated (call the client by name, tell the client where he or she is, and so forth).

Repeated presentation of reality is concrete reinforcement for the client.

 

Spend time with the client even when he or she is unable to respond coherently. Convey your interest and caring.

Your physical presence is reality. Nonverbal caring can be conveyed to the client even when verbal caring is not understood.

Make only promises that you can realistically keep.

Breaking your promise can result in increasing the client’s mistrust.

Help the client establish what is real and unreal. Validate the client’s real perceptions, and correct the client’s misperceptions in a matter-of-fact manner. Do not argue with the client, but do not give support for misperceptions.

The unreality of psychosis must not be reinforced; reality must be reinforced. Reinforced ideas and behavior will recur more frequently.

Stay with the client when he or she is frightened. Touching the client can sometimes be therapeutic. Evaluate the effectiveness of the use of touch with the client before using it consistently.

Your presence and touch can provide reassurance from the real world. However, touch may not be effective if the client feels that his or her boundaries are being invaded.

Be simple, direct, and concise when speaking to the client.

The client is unable to process complex ideas effectively.

Talk with the client about simple, concrete things; avoid ideologic or theoretical discussions.

The client’s ability to deal with abstractions is impaired.

Direct activities toward helping the client accept and remain in contact with reality.

Increased reality contact decreases the client’s retreat into unreality.

Initially, assign the same staff members to work with the client.

Consistency can reassure the client.

Begin with one-to-one interactions, and then progress to small groups as tolerated (introduce slowly). 

Initially, the client will better tolerate and deal with limited contact.

Set realistic goals. Set daily goals and expectations. Unrealistic goals will frustrate the client.

Daily goals are short term and easier for the client to accomplish.

At first, do not offer choices to the client (“Would you like to go to activities?” “What would you like to eat?”). Instead, approach the client in a directive manner (“It is time to eat. Please pick up your fork.”).

The client’s ability to make decisions is impaired. Asking the client to make decisions at this time may be very frustrating.

Gradually, as the client can tolerate it, provide opportunities for him or her to accept responsibility and make personal decisions.

The client needs to gain independence as soon as he or she is able. Gradual addition of responsibilities and decisions gives the client a greater opportunity for success.

D.     Nursing Diagnosis: Impaired Social Interaction

“Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state.”

Assessment data

·        Inappropriate or inadequate emotional responses, Poor interpersonal relationships, Feeling threatened in social situations, Difficulty with verbal communication, Exaggerated responses to stimuli, Difficulty trusting others, Difficulties in relationships with significant others, Poor social skills

Expected Outcomes

·         Report increased feelings of self-worth

·         Identify strengths and assets

·         Engage in social interaction

·         Participate in the trust relationship

·         Demonstrate ability to interact with staff and other clients within the therapeutic milieu

·         Assume increasing responsibility within the context of the therapeutic relationship

·         Use community support system successfully

·         Participate in follow-up or outpatient therapy as indicated

NURSING INTERVENTIONS

* denotes collaborative interventions

RATIONALE

Provide attention in a sincere, interested manner.

Flattery can be interpreted as belittling by the client.

Support any successes or responsibilities fulfilled, projects, interactions with staff members and other clients, and so forth.

Sincere and genuine praise that the client has earned can improve self-esteem.

Avoid trying to convince the client verbally of his or her own worth.

The client will respond to genuine recognition of a concrete behavior rather than to unfounded praise or flattery.

Teach the client social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, and so forth. Discuss the type of topics that are appropriate for casual social conversation, such as the weather, local events, and so forth.

The client may have little or no knowledge of social interaction skills. Modeling provides a concrete example of the desired skills.

Help the client improve his or her grooming; assist when necessary in bathing, doing laundry, and so forth.

Good physical grooming can enhance confidence in social situations.

E.      Nursing Diagnosis: Noncompliance

Assessment data

·         Objective tests indicating noncompliance, such as low neuroleptic blood levels

·         Statements from the client or significant others describing noncompliant behavior

·         Exacerbation of symptoms

·         Appearance of side effects or complications

·         Failure to keep appointments

·         Failure to follow through with referrals

Outcome Identification

·         Identify barriers to compliance

·         Recognize the relationship between noncompliance and undesirable consequences (i.e., increased symptoms, hospitalization

·         Verbalize acceptance of illness

·         Identify risks of noncompliance

·         Adhere to therapeutic recommendations independently

·         Inform care provider of need for changes in therapeutic recommendations

Films on Schizophrenia

A beautiful Mind (1949)

The Fisher King (1991)

Birdy (1984)

The Madness of King George (1994)

Promise (1986)

Taxi Driver (1976)

References

  1. Reddy MV, Chandrashekar CR. Prevalence of mental and behavioural disorders in India: A meta-analysis. Indian Journal of Psychiatry 1998;40(2):149–157.
  2. Gelder M., Gath D., Mayou R., owen P. Oxford Textbook of Psychiatry. Third Edition. Oxford University Press. New delhi 2000.
  3. Ahuja,N. A short Textbook of Psychiatry. 5th Edition Jaypee Brothers New Delhi 2002.
  4. Videbeck, SL. Psychiatric Mental heath Nursing 2nd edition. LWW Philadelphia 2004.
  5. Schultz, JM., Videbeck, SL. Psychiatric Nursing Care Plans. 7th Edition. LWW Philadelphia 2004
 
 
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