Schizophrenia is a chronic brain disorder that impacts a person’s ability to think, feel, and behave clearly. It’s characterized by a range of symptoms that can significantly disrupt daily life. These symptoms are often categorized as positive or negative. Positive symptoms are additions to normal experiences, such as hallucinations and delusions, while negative symptoms represent a decrease or lack of typical functions, like reduced emotional expression or motivation. Understanding these symptoms and their impact is crucial for effective nursing care.
The etiology of schizophrenia is multifaceted, involving genetic, biological, and environmental factors. Individuals with a family history of schizophrenia have an increased risk, suggesting a genetic component. Furthermore, disruptions during prenatal development, possibly due to viral infections or birth complications, and structural or functional brain abnormalities are considered predisposing factors. Environmental stressors, including socioeconomic hardship, trauma, and neglect, can also contribute to the development and course of schizophrenia.
The Nursing Process in Schizophrenia Care
Nurses play a vital role in the holistic care of individuals with schizophrenia, often managing co-occurring physical and mental health conditions. Inpatient behavioral health units provide a structured environment for patients requiring focused treatment for acute schizophrenia symptoms. Mental health nursing demands specialized skills in therapeutic communication, de-escalation techniques, and safety protocols to effectively engage with patients experiencing acute psychotic episodes and maintain a safe milieu.
Schizophrenia Nursing Care Plans: Addressing Key Needs
Developing comprehensive nursing care plans is essential for guiding individualized care for patients with schizophrenia. These plans are built upon identified nursing diagnoses and prioritize assessments and interventions to achieve both immediate and long-term patient goals. The following sections outline examples of nursing care plans addressing common challenges in schizophrenia: Disturbed Sensory Perception, Impaired Social Interaction, and Risk for Self/Other-Directed Violence.
Disturbed Sensory Perception (Auditory/Visual)
Psychosis, a hallmark of schizophrenia, can lead to a distorted perception of reality, manifesting as delusions (false beliefs) and hallucinations (sensory experiences without external stimuli). These perceptual disturbances significantly impact the patient’s understanding of and interaction with the world.
Nursing Diagnosis: Disturbed Sensory Perception (Auditory/Visual)
Related Factors:
- Acute or chronic stress
- Sleep pattern disturbances
- Sensory overload or deprivation
- Alterations in sensory processing
- Substance use or withdrawal (including alcohol and medications)
Defining Characteristics:
- Expresses feelings of anxiety or panic
- Talks or laughs to oneself inappropriately
- Demonstrates rapid or unpredictable mood changes
- Reports seeing, hearing, or sensing things that are not present (hallucinations – auditory, visual, tactile, olfactory, gustatory)
- Exhibits inappropriate responses to situations
- Shows signs of disorientation to time, place, or person
- Tilts head or appears to be listening to internal stimuli
Desired Outcomes:
- The patient will identify and manage modifiable factors that exacerbate perceptual distortions.
- The patient will maintain a safe environment for themselves and others throughout the psychotic episode.
- The patient will verbalize understanding that hallucinations are not based in reality and demonstrate coping mechanisms to manage them.
Nursing Assessment and Rationale:
1. Assess medication regimen and adherence. Rationale: Nonadherence to prescribed antipsychotic medications is a primary cause of psychotic relapse. Substance use, including alcohol and illicit drugs, can also induce or worsen psychotic symptoms. Identifying these factors is crucial for targeted intervention.
2. Assess the content and nature of hallucinations. Rationale: While acknowledging the patient’s experience, the nurse should avoid validating the hallucinations as real. Eliciting details about the hallucinations, such as what the voices are saying or what the patient is seeing, helps assess for command hallucinations (instructions to harm self or others) and guides safety precautions.
3. Monitor for escalating agitation, anxiety, or changes in behavior. Rationale: Increased agitation, anxiety, or sudden behavioral changes can precede aggressive or self-harming behaviors. Close monitoring allows for timely intervention to prevent injury and ensure safety.
Nursing Interventions and Rationale:
1. Minimize environmental stimuli. Rationale: Reducing excessive noise, bright lights, and chaotic environments can decrease sensory overload and potentially lessen the intensity of hallucinations. Moving the patient to a quieter, less stimulating area with supervision can be beneficial.
2. Ensure patient safety. Rationale: Safety is paramount. Patients experiencing psychosis may be unaware of their surroundings or react impulsively to hallucinations. One-to-one observation may be necessary, and removing potentially harmful objects from the patient’s environment is essential.
3. Promote reality orientation and distraction techniques. Rationale: Engage the patient in reality-based activities to redirect focus away from hallucinations. Suggest listening to music through headphones, writing, drawing, or playing simple games. Teach the patient to verbally challenge hallucinations by saying “Go away” or “Stop” to regain a sense of control.
4. Assist in identifying and managing triggers. Rationale: Help the patient explore potential triggers for psychotic symptoms, such as stress, anxiety, or specific situations. Developing coping mechanisms for these triggers can empower the patient to manage their symptoms proactively.
Impaired Social Interaction
Schizophrenia often affects social cognition and skills, leading to difficulties in understanding social cues, navigating social situations, and forming and maintaining relationships. Negative symptoms like flat affect and social withdrawal further contribute to social impairment.
Nursing Diagnosis: Impaired Social Interaction
Related Factors:
- Disorganized thought processes and impaired cognitive function
- Social isolation and withdrawal
- Deficient knowledge of social skills (understanding social roles, cues, and interaction goals)
- Mistrust and suspiciousness of others
- Difficulty interpreting the intentions and emotions of others
- Challenges in forming and maintaining interpersonal relationships
- Communication deficits (verbal and nonverbal)
Defining Characteristics:
- Displays a flat or blunted affect (reduced emotional expression)
- Exhibits difficulty focusing attention or concentrating
- Expresses fear or anxiety in social situations
- Demonstrates inappropriate or unusual emotional responses
- Avoids eye contact
- Spends excessive time alone or withdraws from social activities
- Exhibits disorganized or incoherent speech and thought patterns
Desired Outcomes:
- The patient will develop and utilize a social support system.
- The patient will identify personal factors, behaviors, and feelings that hinder social interaction.
- The patient will implement techniques to improve social interaction skills.
- The patient will express increased comfort and safety in social situations, as evidenced by participation in group activities.
- The patient will establish a trusting relationship with the nurse and communicate openly by discharge.
Nursing Assessment and Rationale:
1. Assess patient’s perceptions and feelings about social interaction. Rationale: Building rapport and trust is essential before exploring sensitive topics. Understanding the patient’s subjective experiences of social situations, including feelings of anxiety, fear, or discomfort, provides valuable insights into their social challenges.
2. Determine family and social support networks. Rationale: Assessing the patient’s existing support system, including family, friends, and living situation, helps identify available resources and potential areas for support enhancement. Lack of social support can exacerbate social isolation and hinder recovery.
3. Observe verbal and nonverbal communication patterns. Rationale: Continuous observation of the patient’s communication style, including speech patterns (e.g., disorganized, pressured, slow), body language (e.g., restlessness, fidgeting, posture), and nonverbal cues (e.g., eye contact, facial expressions), provides objective data on social interaction difficulties.
Nursing Interventions and Rationale:
1. Foster a therapeutic nurse-patient relationship. Rationale: Patients with schizophrenia may exhibit mistrust and paranoia. Establishing a trusting relationship through active listening, empathy, and genuine regard is foundational for effective intervention and encourages patient engagement in care.
2. Provide positive reinforcement for social engagement. Rationale: Negative symptoms like avolition (lack of motivation) can hinder social initiation. Acknowledging and positively reinforcing even small steps towards social interaction, such as leaving their room or participating in a brief conversation, encourages continued effort.
3. Facilitate participation in group activities. Rationale: Group activities offer structured opportunities for social interaction in a safe and supportive environment. While patients should not be forced to participate, offering and encouraging group involvement can address negative symptoms and promote social skill development.
4. Refer for social skills training. Rationale: Social skills training programs, often led by specialized clinicians, provide structured learning of essential social skills. These programs focus on communication skills, appropriate social behaviors, relationship building, and independent living skills, significantly improving social functioning.
Risk for Self/Other-Directed Violence
Schizophrenia, particularly during psychotic episodes, can increase the risk of violence towards oneself or others. Paranoia, suspiciousness, delusions of persecution, and command hallucinations can contribute to agitation, fear, and potential aggression.
Nursing Diagnosis: Risk for Self/Other-Directed Violence
Related Factors:
- Paranoid delusions and suspiciousness
- Elevated anxiety levels
- Command hallucinations instructing harm to self or others
- Delusional thinking and distorted reality perception
- Past history of violent behavior or threats
- Suicidal ideation and intent
- Perception of a threatening environment
- Rage reactions and impulsivity
Note: As a risk diagnosis, there are no “as evidenced by” statements, as the problem has not yet occurred. Nursing interventions are preventative.
Desired Outcomes:
- The patient will remain safe and free from self-harm.
- The patient will not inflict harm on staff, other patients, or family members.
- The patient will recognize and report escalating thoughts or urges to harm self or others.
Nursing Assessment and Rationale:
1. Directly assess for suicidal or homicidal ideation and plans. Rationale: Directly asking about thoughts and plans for self-harm or violence is essential for immediate risk assessment. This information guides the level of intervention and safety precautions required.
2. Observe for early warning signs of agitation and potential loss of control. Rationale: Changes in behavior, such as increased restlessness, pacing, changes in posture or facial expression, pressured speech, or decreased cooperation, can indicate escalating agitation and impending loss of control. Early detection allows for proactive intervention.
Nursing Interventions and Rationale:
1. Maintain a calm and reassuring demeanor. Rationale: The staff’s demeanor significantly impacts the patient’s agitation level. Maintaining a calm and non-threatening approach can de-escalate anxiety and prevent further agitation. Clear, straightforward communication minimizes suspicion and misinterpretation.
2. Maintain a safe distance and personal space. Rationale: Maintaining a safe distance protects both the staff and the patient. Avoiding sudden movements, respecting personal space, and not turning one’s back on the patient are crucial safety measures. Physical touch should be avoided without clear therapeutic reason and patient consent (unless restraint is necessary for safety).
3. Ensure a safe environment. Rationale: Proactively remove any objects that could be used to inflict harm, such as sharp objects, cords, or heavy items. A safe environment minimizes the potential for impulsive acts of violence.
4. Administer pharmacological interventions as prescribed. Rationale: When de-escalation techniques are insufficient, and the patient poses an immediate risk, medications such as anxiolytics (anti-anxiety) or antipsychotics may be necessary to rapidly manage agitation and psychosis.
5. Utilize physical restraints as a last resort. Rationale: Restraints are used only when all other interventions have failed to ensure the safety of the patient and others. Restraint use must adhere to facility policies, with continuous monitoring and reassessment, and discontinued as soon as the patient regains self-control.
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.
- 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. Retrieved February 24, 2022, from https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-conditions/schizophrenia/
