Schizophrenia Nursing Care and Management

Schizophrenia disrupts thinking, perception, emotion, and social function, and it usually announces itself in late adolescence or early adulthood, right when a young person is building an independent life. Your job on the unit is to keep the patient safe, build trust with someone whose reality does not match yours, and protect the medication routine that holds relapse at bay.

What is Schizophrenia

Schizophrenia is a group of severe, disabling psychiatric disorders marked by withdrawal from reality, illogical thinking, possible delusions and hallucinations, and emotional, behavioral, or intellectual disturbance. The disturbances last at least 6 months, and functioning in work, relationships, and self-care drops markedly from the patient's previous baseline. These patients have real trouble separating reality from fantasy, and their speech and behavior can frighten or mystify the people around them.

Incidence

Schizophrenia occurs in every society regardless of class, color, or culture. It affects 1.1% of the population above age 18, an estimated 51 million people worldwide. In the United States, 2 million Americans are affected each year, with 7.2 in 1000 persons developing it during their lifetime. It hits men (late teens or early 20s) and women (mid-20s to early 30s) about equally, and its prevalence runs higher than diabetes mellitus, Alzheimer's disease, and multiple sclerosis.

Causes

The precise cause is unknown, and there is no way to predict who will develop it. Genetic factors carry the strongest evidence: multiple genes (most strongly chromosomes 13 and 6) appear to drive predisposition, though the manner of transmission is not clearly understood. Prenatal infections, perinatal complications, and environmental stressors are also under study. Biochemically, the disorder involves dopamine (the focus of most studies), serotonin, norepinephrine, and epinephrine. Excessive dopamine activity tracks with hallucinations, agitation, and delusion; high norepinephrine tracks with positive symptoms. Other contributors include structural brain abnormalities (enlarged ventricles), faulty neuronal connections, maternal influenza during the second trimester, temporal lobe epilepsy, and head injury.

Signs and Symptoms

Presentation varies widely. Symptoms fall into three clusters: positive, negative, and cognitive. Positive symptoms link to temporal lobe abnormalities; negative symptoms link to frontal cortex and ventricular abnormalities.

Positive Symptoms

These are symptoms that should be absent but are present, signaling lost contact with reality. They are primarily delusions and hallucinations.

Hallucinations are the most common feature: hearing, seeing, smelling, tasting, or feeling touched by things that are not there, classically voices commanding the patient toward abusive or self-destructive acts. Delusions are fixed false beliefs that logic and persuasion cannot shift, such as believing others can read your mind. Categories include persecutory delusions (being tormented, followed, tricked, or spied on), reference delusions (passages in books, music, or TV are directed at the patient), and thought withdrawal/thought insertion (others read or transmit the patient's thoughts, or outside forces impose thoughts on him).

Negative Symptoms

These reflect the absence of normal characteristics: apathy (lack of interest in people, things, and activities), anhedonia (diminished capacity for pleasure), blunted affect (an immobile, inexpressive face and flattened emotion that worsens as the disease progresses), and poverty of speech (brief speech that lacks content).

Cognitive Symptoms

These reflect abnormal thinking, poor decision-making, poor problem-solving, impaired communication, and strange behavior. Thought disorder shows as confused thinking and speech (incoherent ramblings, loose association, word salad, wandering). Bizarre behavior includes childlike silliness, laughing or giggling, agitation, and inappropriate appearance, hygiene, and conduct.

Phases of Schizophrenia

Schizophrenia usually moves through three phases. The prodromal phase appears before hospitalization or within the year, with a clear decline from prior functioning: withdrawal from friends, family, hobbies, and interests, peculiar behavior, and slipping work or school performance. The active phase, often triggered by a stressful event, brings acute psychotic symptoms (hallucinations, delusions, incoherence, catatonic behaviors), and prognosis worsens with each acute episode. In the residual phase the illness pattern is established, the disability level may stabilize, and late improvements may occur.

Types of Schizophrenia

Schizophrenia is classified into five subtypes. The paranoid type shows persecutory or grandiose delusional content and delusional jealousy, frequent auditory hallucinations, and stress-driven worsening, but lacks the incoherence, loose associations, and affect problems of other subtypes; these patients are less severely disabled and more responsive to treatment. The disorganized type brings incoherent, disorganized speech and behavior, blunted or inappropriate affect, and extreme social impairment, starting early and insidiously with no significant remissions. The catatonic type, rare, shows fixed stupor or held positions for long periods broken by brief spurts of extreme excitement, mutism, refusal to move or attend to personal needs, and increased potential for destructive, violent behavior when agitated. The undifferentiated type shows schizophrenic symptoms (delusions, hallucinations) in patients who do not fit the other subtypes. The residual type is a muted form that stops short of recovery, with no prominent psychotic symptoms but a history of acute episodes and persistent negative symptoms.

Diagnosis

Diagnosis rests on the mental status examination, psychiatric history, and careful clinical observation. There is no definitive diagnostic tool, but CT scans and MRIs may be ordered to rule out disorders that cause psychosis (vitamin deficiencies, enlarged ventricles). Ventricular-brain ratio may be elevated, and brain scans may reveal functional cerebral asymmetries in a reverse pattern.

Medical Management

Antipsychotic (neuroleptic) drugs are the mainstay; they prevent relapse of acute symptoms. Psychotic symptoms must be present 12 to 24 months before patients receive their first medical treatment. Examples range from the typical or conventional antipsychotic chlorpromazine (Thorazine) to the atypical agents. Electroconvulsive therapy is used rarely, for acute schizophrenia and for patients who cannot tolerate or do not respond to medication; it is effective against depressive and catatonic symptoms. Other treatments include compliance-promotion programs, psychosocial treatment and rehabilitation, vocational counseling, supportive psychotherapy, and community resources.

Nursing Management

Assessment

Recognize the characteristic signs (speech abnormalities, thought distortions, poor social interaction). Establish trust and rapport: do not tease or joke, introduce yourself, explain your purpose, and expect the patient to put you through rigorous testing periods. Assess the patient's ability to carry out activities of daily living (ADLs) to gauge functioning. For positive symptoms, assess for command hallucinations and explore the answers, map how organized and systematized the belief system is, and watch for pervasive suspiciousness (vigilance, blaming others, argumentativeness, threats). Assess negative symptoms as above. Check medication history and adherence, and determine whether the family understands the disease and the need for medication adherence.

Nursing Diagnoses

• Impaired Physical Mobility related to depressive mood state and reluctance to initiate movement.
• Impaired Social Interaction related to problems in thought patterns and speech.
• Decreased Cardiac Output related to orthostatic hypotensive drug effects.
• Risk for Suicide related to impulsiveness and marked changes in behavior.
• Risk for Injury related to hallucinations and delusions.
• Risk for Imbalanced Nutrition: less than body requirements related to self-neglect and refusal of self-care.

Planning and Goals

Reduce the severity of psychotic symptoms, prevent recurrence of acute episodes, meet the patient's physical and psychosocial needs, help the patient reach an optimum level of functioning, and increase compliance with treatment.

Interventions

Build trust with an accepting, consistent approach. Do not touch the patient without telling him first. Use short, repeated contacts until trust is established, keep language clear and unambiguous, and hold and convey a realistic sense of hope. Maximize functioning by doing only what the patient cannot do for himself, rewarding positive behavior, and building his sense of responsibility. Support him in learning social skills. Keep the environment safe with minimal stimulation. Monitor nutritional status; if he believes his food is poisoned, let him prepare his own or offer foods in closed containers he can open, and institute suicide and homicide precautions as appropriate. Engage him in reality-oriented activities involving human contact (workshops, inpatient social skills training), and clarify private language, autistic inventions, or neologisms. Handle hallucinations by presenting reality: explore their content, do not argue about them, and say you do not see, hear, smell, or feel what he does while acknowledging it is real to him. Promote compliance and monitor drug therapy: give prescribed drugs, confirm he actually takes them, and watch for hypersensitivity reactions and toxicity. Involve the family, teach them to recognize impending relapse (nervousness, insomnia, decreased concentration), and suggest ways to manage symptoms.

Evaluation

Evaluate drug-therapy effectiveness (absence of acute episodes and psychotic symptoms), compliance with instructions (timely medications, independence in activities, family involvement), level of functioning (ability to engage socially), and mental status (orientation to reality).

Documentation

Document the presenting signs and symptoms (positive and negative). For suicide precautions, document the behavior and your precautions. For homicide precautions, document the patient's comment and who was notified, and be sure to notify the doctor and the potential victim. For restraints, document the time of application and release.