Schizophrenia is a mental illness that affects the way a person thinks, perceives information, responds emotionally, and behaves. There are different types of schizophrenia that produce their own set of clinical manifestations.
Schizophrenia symptoms can be divided into positive or negative categories:
Positive symptoms are in addition to reality and include symptoms of psychosis such as hallucinations or delusions.
Negative symptoms are a lack or loss of abilities. This includes a lack of motivation, loss of interest or enjoyment, poor hygiene practices, and difficulty concentrating.
There are several proposed etiological causes of schizophrenia. Research has shown that there is a genetic connection as relatives of schizophrenic patients have a 5 to 10% risk of developing the disorder themselves. Viruses or other birth defects in utero as well as anatomical abnormalities of the brain are predisposing factors. Lastly, environmental factors such as poor socioeconomic conditions, abuse, or neglect can negatively affect mental health.
Nursing Process
Nurses will often navigate comorbidities of mental illness along with physical conditions when caring for patients. Patients being treated specifically for schizophrenia will require inpatient treatment in a behavioral health unit. Behavioral/mental health nursing requires a unique set of skills to properly communicate and interact with unstable patients while maintaining safety.
Nursing Assessment
Effective nursing assessment and intervention are essential in managing schizophrenia to promote recovery, enhance quality of life, and prevent relapse.
Initial Assessment
The initial evaluation of a patient with schizophrenia involves a detailed medical history and a comprehensive psychiatric assessment. Key aspects to assess include:
Medical History:
- Obtain a thorough history of the patient’s psychiatric symptoms, including the onset, duration, and severity of hallucinations, delusions, and disorganized thoughts.
- Review the patient’s past psychiatric treatments, hospitalizations, and response to medications.
- Assess for any co-occurring mental health disorders, such as depression or anxiety, and substance use history.
- Inquire about the patient’s medical history, including any comorbid conditions that may affect treatment and recovery.
Psychiatric Assessment:
- Conduct a mental status examination to evaluate the patient’s current cognitive, emotional, and behavioral functioning.
- Assess for positive symptoms (e.g., hallucinations, delusions) and negative symptoms (e.g., social withdrawal, lack of motivation).
- Evaluate the patient’s insight into their condition and their adherence to prescribed treatments.
- Identify any immediate safety concerns, such as suicidal ideation or aggressive behavior.
Family and Social History:
- Gather information on the patient’s family history of mental illness and any genetic predispositions.
- Assess the patient’s social support system, including family, friends, and community resources.
- Evaluate the patient’s living situation, financial stability, and access to basic needs.
Laboratory Tests and Imaging
While schizophrenia is primarily diagnosed based on clinical evaluation, certain laboratory tests and imaging studies may be conducted to rule out other medical conditions that could mimic or exacerbate psychiatric symptoms:
- Basic blood tests, including complete blood count (CBC), electrolytes, liver function tests, and thyroid function tests.
- Urine toxicology screen to detect any substance use.
- Neuroimaging studies, such as MRI or CT scans, to exclude structural brain abnormalities.
Nursing Interventions
By conducting thorough evaluations, implementing evidence-based interventions, and providing comprehensive patient education, nurses can significantly improve patient outcomes and quality of life.
Medication Management
Antipsychotic medications are the cornerstone of schizophrenia treatment. Nurses play a crucial role in:
- Administering prescribed medications and monitoring the patient’s adherence.
- Educating patients and their families about the benefits, potential side effects, and importance of adherence to antipsychotic medications.
- Monitoring for and managing side effects, such as extrapyramidal symptoms (EPS), tardive dyskinesia, and metabolic syndrome.
- Collaborating with the healthcare team to adjust medication dosages or change medications based on the patient’s response and side effect profile.
Psychoeducation
Providing education to patients and their families is vital for promoting understanding and engagement in the treatment process:
- Educate patients about schizophrenia, including its symptoms, treatment options, and the importance of adherence to prescribed therapies.
- Offer information on coping strategies for managing symptoms and stress.
- Provide resources on support groups and community services available for individuals with schizophrenia and their families.
- Teach patients and families to recognize early warning signs of relapse and the importance of seeking prompt medical attention.
Therapeutic Communication
Establishing a trusting and therapeutic nurse-patient relationship is essential for effective care:
- Use active listening and empathetic communication to understand the patient’s experiences and concerns.
- Validate the patient’s feelings and provide reassurance.
- Encourage patients to express their thoughts and emotions in a safe and non-judgmental environment.
- Use clear and simple language to explain complex medical information and instructions.
Psychosocial Interventions
Tailored psychosocial interventions can significantly improve the patient’s quality of life and functional abilities:
Cognitive Behavioral Therapy (CBT):
– Collaborate with mental health professionals to provide CBT, which helps patients identify and challenge distorted thoughts and develop healthier thinking patterns.
Social Skills Training:
– Engage patients in social skills training programs to enhance their interpersonal and communication skills.
Occupational Therapy:
– Involve occupational therapists to help patients develop and maintain daily living skills and vocational abilities.
Support Groups:
– Encourage participation in support groups where patients can share experiences and receive peer support.
Family Involvement
Involving the patient’s family in the treatment process is crucial for comprehensive care:
- Provide family therapy to address any relational issues and improve family dynamics.
- Educate family members about schizophrenia and how they can support their loved one’s recovery.
- Encourage family members to participate in the patient’s care plan and attend therapy sessions.
Community Integration
Facilitating community integration helps patients reintegrate into society and maintain a sense of normalcy:
- Assist patients in accessing community resources, such as housing programs, vocational training, and recreational activities.
- Collaborate with social workers to provide financial assistance and connect patients with appropriate community services.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for schizophrenia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for schizophrenia.
Disturbed Sensory Perception (Auditory/Visual)
Psychosis from schizophrenia may result in a disconnection from reality with symptoms of delusions and hallucinations.
Nursing Diagnosis: Disturbed Sensory Perception (Auditory/Visual)
Related to:
- Severe stress
- Sleep deprivation
- Excessive stimulation
- Altered sensory perception
- Misuse of medications, alcohol, or illegal substances
As evidenced by:
- Anxiety
- Panic
- Talking or laughing to self
- Rapid mood swings
- Seeing or hearing things that aren’t there (hallucinations)
- Inappropriate responses
- Disorientation
- Tilting head as if to listen to something
Expected Outcome:
- Patient will identify and modify external factors that contribute to alterations in perception
- Patient will maintain safety until the psychotic episode resolves
- Patient will verbalize an understanding that hallucinations are not reality-based and demonstrate how to interrupt them
Assessment:
1. Assess medication adherence.
Assess if the patient’s psychotic episode is related to nonadherence to their medications or the use of drugs or alcohol.
2. Assess contents of hallucinations.
The nurse should not reinforce the hallucination and should make it clear that they do not hear or see what the patient does. The nurse can ask the patient what the voices are saying or what they are visualizing to judge if the patient may react violently or harm themselves which requires further safety interventions.
3. Monitor for increasing agitation or anxiety.
Monitor the patient’s thoughts and behaviors closely for worsening agitation or anxiety and intervene quickly to prevent injury to the patient or others.
Interventions:
1. Remove the client from chaotic environments.
Reduce stimulation that may cause worsening hallucinations. If around people, move to an area that is solitary (with supervision) and reduce noise and lighting.
2. Provide safety.
Safety is always the #1 priority, especially when a patient is mentally and emotionally unstable. 1:1 supervision may be necessary and the removal of items that could be potentially harmful.
3. Aid distraction.
Patients can distract themselves from hallucinations by listening to music, wearing headphones, writing, drawing, or playing games. It can also be helpful to remind the patient that when experiencing a hallucination to loudly state “Go away!” or “Leave me alone!” to gain control.
4. Help the patient recognize triggers.
Attempt to decrease delusional behavior by uncovering triggers such as during times of intense stress or anxiety and learning how to cope with these feelings.
Impaired Social Interaction
Patients with schizophrenia may display a lack of social skills and struggle with navigating social constructs, roles, and cues.
Nursing Diagnosis: Impaired Social Interaction
Related to:
- Disturbed thought processes
- Isolation
- Lack of social knowledge (roles, cues, and goals of social interactions)
- Mistrust of others
- Inability to perceive or interpret the intentions of others
- Inability to maintain relationships
- Impaired communication
As evidenced by:
- Flat affect
- Difficulty focusing or paying attention
- Fearful or anxious around others
- Inappropriate emotional responses
- Poor eye contact
- Spends time alone
- Disorganized speech or thoughts
Expected Outcomes:
- Patient will develop a social support system
- Patient will verbalize factors, behaviors, and feelings that prevent social interaction
- Patient will incorporate techniques that improve social interaction
- Patient will verbalize feeling safe and comfortable in social situations by participating in group activities
- Patient will build a trusting relationship and speak openly with the nurse by discharge
Assessment:
1. Assess their perceptions and feelings toward social interaction.
After establishing a trusting relationship with the patient, the nurse can assess the patient’s perceived difficulties with social interactions. The patient may express thoughts of anxiety, fear, or general discomfort that provide insight that isn’t obvious from an outside perspective.
2. Determine family and support patterns.
Gain an understanding of the patient’s relationships by assessing whom they depend on for support or live with. Assess for close friendships or family/spousal support or a lack thereof.
3. Observe speech, nonverbal gestures, and body language.
The nurse is always assessing even when observing. Assess how the patient talks (disorganized, slow, or pressured speech), their body language (irritated, restless, fidgeting), or even a lack of eye contact, acknowledgment, or response can provide information on factors that cause impaired social interaction.
Interventions:
1. Develop a trusting relationship.
Patients with schizophrenia may be distrusting of others. By acknowledging and actively listening to the patient’s thoughts the nurse is establishing rapport and building trust.
2. Provide positive reinforcement.
When a patient takes a step to improve social interaction such as walking outside of their room acknowledge and support their efforts.
3. Encourage group activities.
Schizophrenia can cause a lack of motivation. Patients should never be forced to socialize but offering opportunities to interact may help with negative symptoms they may be experiencing such as the inability to express emotions.
4. Refer to specialists for social skills training.
Social skills training is conducted in small groups by trained clinicians. Patients learn communication skills, appropriate and inappropriate behaviors in public, and how to develop personal relationships as well as maintain jobs and live independently.
Risk For Self/Other-Directed Violence
Schizophrenia can cause feelings of suspiciousness and a perception of threats where none exist. In a psychotic state, patients may have delusions or hear voices that tell them to behave in ways that are unsafe to themselves and others.
Related to:
- Suspiciousness of others
- Anxiety
- Command hallucinations
- Delusional thinking
- History of threats or violence against self or others
- Suicidal ideation
- Perception of a threatening environment
- Paranoia
- Rage reactions
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
Expected Outcomes:
- Patient will remain free from injury and self-harm
- Patient will not harm other staff, patients, or family members
- Patient will recognize and report signs of wanting to harm themself or others
Assessment:
1. Assess for a plan for suicide or violence.
Patients should be directly asked if they have a plan to kill themselves or to hurt someone else so staff can intervene accordingly.
2. Observe for early cues of distress.
Monitor closely for changes in behavior that may indicate a loss of control such as a change in body posture or facial expressions, or a lack of cooperation.
Interventions:
1. Maintain and convey a calm attitude.
Staff should remain calm so as not to further escalate a situation. When interacting with the patient communication should be straightforward to prevent the patient from feeling suspicious or manipulated.
2. Maintain distance from the patient.
While constant supervision may be required, staff should keep themselves safe by never turning their back on the patient and never touching them without permission (unless required).
3. Keep the patient safe.
A safe environment includes removing any object that could be used as a weapon by the patient to injure themself or someone else.
4. Administer tranquilizers.
A patient that cannot be “talked down” or presents a risk to others may require the use of anti-anxiety or anti-psychotic medications.
5. Apply restraints.
Manual restraints are a last resort when all other interventions have failed. The patient’s safety remains a priority for the nurse and a patient in restraints should be monitored per facility policy and restraints should be removed as soon as the patient’s agitation subsides.
Nursing Diagnoses and Rationales for Schizophrenia
1. Disturbed Thought Processes
Rationale: Schizophrenia often manifests as delusions, hallucinations, and disorganized thinking, which can significantly impair a patient’s ability to reason logically and make sound judgments. Assessing the patient’s thought processes, providing a safe and structured environment, and implementing reality orientation techniques can help mitigate these symptoms. Medication adherence and regular psychiatric evaluations are crucial for managing thought disturbances.
2. Impaired Social Interaction
Rationale: Patients with schizophrenia may experience social withdrawal, difficulty forming relationships, and challenges in communicating effectively. Assessing the patient’s social skills, encouraging participation in group therapy, and providing opportunities for positive social interactions can improve their social functioning. Educating the patient and their family about schizophrenia can also reduce stigma and enhance social support.
3. Self-Care Deficit
Rationale: The cognitive and functional impairments associated with schizophrenia can lead to difficulties in performing activities of daily living (ADLs) such as personal hygiene, dressing, and feeding. Assessing the patient’s ability to perform ADLs, providing assistance as needed, and promoting the use of adaptive equipment can enhance self-care capabilities. Involving family members or caregivers in the care plan can further support the patient’s independence and well-being.
4. Risk for Violence
Rationale: Patients with schizophrenia may exhibit aggressive or violent behaviors due to paranoia, hallucinations, or frustration with their condition. Assessing the patient’s risk for violence, ensuring a safe environment, and using de-escalation techniques are vital interventions. Administering antipsychotic medications and providing psychotherapy can also help manage these behaviors.
5. Ineffective Coping
Rationale: The chronic nature of schizophrenia and the stress of managing the condition can overwhelm patients, leading to ineffective coping mechanisms. Assessing the patient’s stress levels, providing education on healthy coping strategies, and referring to mental health professionals as needed can help improve coping skills. Encouraging participation in stress-reduction techniques such as mindfulness and relaxation exercises can also be beneficial.
6. Risk for Self-Harm
Rationale: Feelings of hopelessness, depression, and low self-esteem can increase the risk of self-harm in patients with schizophrenia. Assessing for signs of self-harm, providing emotional support, and involving mental health professionals are crucial interventions. Creating a safety plan and encouraging patients to engage in activities that promote a sense of accomplishment can help mitigate this risk.
7. Noncompliance with Treatment
Rationale: Noncompliance with medication and therapy is a common issue among patients with schizophrenia, often due to a lack of insight into their condition. Assessing the patient’s understanding of their treatment, providing education on the importance of adherence, and using motivational interviewing techniques can enhance compliance. Involving family members in the treatment plan and using medication reminders or pill organizers can also be helpful.
8. Impaired Memory
Rationale: Cognitive deficits in schizophrenia can lead to difficulties with memory and concentration. Evaluating the patient’s cognitive status, providing cognitive-behavioral therapy (CBT) as needed, and promoting activities that stimulate mental function can address this issue. Ensuring consistent and effective treatment adherence can also help improve cognitive outcomes.
9. Risk for Depression
Rationale: The chronic and debilitating nature of schizophrenia can contribute to feelings of sadness, hopelessness, and depression. Monitoring for signs of depression, providing emotional support, and referring to mental health professionals as needed can help address this risk. Encouraging participation in enjoyable activities and fostering a positive outlook are also important strategies.
10. Risk for Social Isolation
Rationale: Social isolation is a common issue for patients with schizophrenia due to stigma, withdrawal, and difficulty in forming relationships. Assessing the patient’s social network, providing opportunities for social interactions, and involving them in community activities can help reduce isolation. Educating the patient and their family about the condition can also improve social support and decrease stigma.
REFERENCES
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Kopelowicz, A., Liberman, R. P., & Zarate, R. (2006). Recent advances in social skills training for schizophrenia. Schizophrenia bulletin, 32 Suppl 1(Suppl 1), S12–S23. https://doi.org/10.1093/schbul/sbl023
- Langdon, R., Connors, M. H., & Connaughton, E. (2014, December 4). Social cognition and social judgment in schizophrenia. Science Direct. https://www.sciencedirect.com/science/article/pii/S2215001314000262
- Townsend, M. C. (2011). Nursing Diagnoses in Psychiatric Nursing Care Plans and Psychotropic Medications. Retrieved February 24, 2022, from https://images.template.net/wp-content/uploads/2016/04/04060256/Psychotropic-Medication-Nursing-Care-Plan-Free-PDF.pdf
- What are the signs and symptoms of schizophrenia? (n.d.). Rethink Mental Illness. https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-conditions/schizophrenia/
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