Psychotic disorders are a category of mental illnesses that significantly impair an individual’s thinking, perception, emotional response, and behavior. Schizophrenia is a prominent example of a psychotic disorder characterized by a range of symptoms that can be categorized as positive or negative. Understanding the nuances of these disorders and their manifestations is crucial for healthcare professionals, especially nurses, to provide effective care.
Positive symptoms in psychotic disorders represent an excess or distortion of normal functions. These are often the most dramatic symptoms and include hallucinations (experiencing sensory perceptions in the absence of external stimuli, such as hearing voices or seeing things that are not there) and delusions (fixed false beliefs that are not amenable to change in light of conflicting evidence).
Negative symptoms reflect a diminution or absence of normal functions. These symptoms can be more subtle but significantly impact a patient’s quality of life and functional abilities. Negative symptoms include blunted affect (reduced emotional expression), alogia (poverty of speech), avolition (lack of motivation), anhedonia (inability to experience pleasure), and asociality (social withdrawal).
The etiology of psychotic disorders is complex and multifactorial, involving a combination of genetic, neurobiological, and environmental influences. Research indicates a significant genetic component, with individuals having relatives with schizophrenia at a higher risk of developing the disorder. Furthermore, disruptions during prenatal development, such as viral infections or birth complications, and structural and functional abnormalities in the brain have been implicated. Environmental stressors, including socioeconomic disadvantage, trauma, and adverse childhood experiences, can also contribute to the development and course of psychotic disorders.
The Nursing Process in Psychotic Disorder Care
Nurses play a vital role in the multidisciplinary care of individuals with psychotic disorders. Often, nurses are at the forefront of managing not only the psychiatric symptoms but also the physical health comorbidities that are frequently seen in this population. Inpatient psychiatric units provide a structured and safe environment for patients experiencing acute exacerbations of psychotic symptoms, requiring specialized nursing skills in communication, therapeutic interaction, and safety management. Mental health nursing demands a unique skill set to effectively engage with patients who may be experiencing distorted reality, emotional lability, and behavioral disturbances, all while prioritizing safety and promoting a therapeutic milieu.
Nursing Care Plans for Psychotic Disorders
Nursing care plans are essential tools in providing structured and individualized care for patients with psychotic disorders. They serve to prioritize nursing diagnoses, guide assessments, and direct interventions towards achieving both short-term and long-term patient goals. The following sections provide examples of nursing care plans addressing common nursing diagnoses relevant to psychotic disorders.
Disturbed Sensory Perception (Auditory/Visual)
Psychosis, a hallmark of disorders like schizophrenia, frequently involves a disconnect from reality, manifested by delusions and hallucinations. Disturbed Sensory Perception, specifically auditory or visual, becomes a primary nursing diagnosis when a patient experiences these perceptual distortions.
Nursing Diagnosis: Disturbed Sensory Perception (Auditory/Visual)
Related to:
- Severe psychological stress
- Sleep pattern disturbances and deprivation
- Sensory overload or excessive environmental stimulation
- Altered sensory reception, transmission, and/or integration
- Substance misuse (including medications, alcohol, and illicit drugs)
As evidenced by:
- Reports of auditory or visual hallucinations (hearing voices, seeing things not present)
- Delusional thinking and beliefs
- Anxiety, fear, or panic reactions
- Agitation and restlessness
- Talking or laughing to oneself
- Rapid and unpredictable mood swings
- Disorientation to time, place, or person
- Inappropriate responses to environmental stimuli
- Attending to internal stimuli (e.g., tilting head as if listening)
Expected Outcomes:
- The patient will accurately interpret and respond to their environment.
- The patient will distinguish between reality and misperceptions.
- The patient will maintain personal safety and the safety of others throughout the psychotic episode.
- The patient will verbalize an understanding that hallucinations and delusions are not based in reality and demonstrate techniques to manage them.
- The patient will identify and, when possible, modify factors that contribute to sensory perceptual alterations.
Assessment:
1. Medication and Substance Use History: Rationale: Assessing medication adherence and substance use is critical as non-adherence to prescribed antipsychotic medications or the use of substances can trigger or exacerbate psychotic episodes. Determine if the patient is taking prescribed medications as directed, and inquire about any current or recent use of alcohol or illicit substances.
2. Content of Hallucinations and Delusions: Rationale: Understanding the content of hallucinations and delusions provides insight into the patient’s experience and potential safety risks. While it’s important not to validate the hallucinations, assessing their content can reveal themes of harm to self or others, guiding immediate safety interventions. Ask the patient directly about what they are hearing or seeing. For example, “What are the voices saying to you?” or “Can you describe what you are seeing?”. Assess for command hallucinations, which instruct the patient to perform specific actions, especially harmful ones.
3. Monitor Anxiety and Agitation Levels: Rationale: Increased agitation and anxiety can escalate to aggressive behaviors and pose a risk to the patient and others. Close monitoring allows for timely intervention to de-escalate situations and prevent potential harm. Observe for nonverbal cues of anxiety and agitation, such as restlessness, pacing, clenched fists, or increased verbal rate and volume. Utilize standardized anxiety scales if appropriate and available within the clinical setting.
Interventions:
1. Reduce Environmental Stimuli: Rationale: A chaotic or over-stimulating environment can worsen sensory misperceptions and exacerbate psychotic symptoms. Minimizing external stimuli can create a calmer atmosphere conducive to reducing symptom intensity. Move the patient to a quieter, less stimulating environment. Reduce noise levels, dim bright lights, and limit the number of people interacting with the patient at one time.
2. Ensure Patient Safety: Rationale: Safety is paramount when a patient is experiencing psychosis. Hallucinations and delusions can lead to impulsive actions that put the patient or others at risk. Continuous monitoring and proactive safety measures are essential. Implement 1:1 observation if necessary, particularly if the hallucinations are command in nature or the patient is acutely agitated. Remove any potentially harmful objects from the patient’s environment.
3. Employ Distraction Techniques: Rationale: Distraction can help shift the patient’s focus away from hallucinations and internal stimuli, providing temporary relief and a sense of control. Encourage the patient to engage in distracting activities such as listening to music (with headphones if appropriate in the setting), reading, writing, drawing, or playing simple games.
4. Reality Orientation and Reassurance: Rationale: Gently and clearly orient the patient to reality without directly challenging the content of their hallucinations or delusions. Reinforce that the healthcare team understands they are experiencing these perceptions but that these are symptoms of their illness and not real. Acknowledge the patient’s experience, for example, “I understand that you are hearing voices, but I am not hearing them.” Clearly state your perception of reality. Reassure the patient of their safety and that the team is there to help them.
5. Teach Hallucination Management Techniques: Rationale: Empowering patients with coping strategies can increase their sense of self-efficacy and reduce distress associated with hallucinations. Teach the patient simple techniques to manage hallucinations, such as telling the voices to go away forcefully, engaging in conversations with real people to ground themselves, or using relaxation techniques.
Impaired Social Interaction
Individuals with psychotic disorders often experience significant challenges in social functioning. Negative symptoms, cognitive deficits, and the disorganizing effects of psychosis can contribute to social withdrawal and impaired social interaction.
Nursing Diagnosis: Impaired Social Interaction
Related to:
- Disturbed thought processes and cognitive impairments
- Social isolation and withdrawal
- Deficient social skills and knowledge regarding appropriate social roles, cues, and expectations
- Mistrust of others and paranoia
- Difficulty perceiving or accurately interpreting the intentions of others
- Inability to form and maintain meaningful relationships
- Communication barriers and deficits
As evidenced by:
- Socially withdrawn behavior and preference for isolation
- Limited participation in social activities
- Difficulty initiating and maintaining conversations
- Flat or blunted affect and restricted range of emotional expression
- Poor eye contact and difficulty attending to social cues
- Inappropriate or unusual social behaviors
- Disorganized speech patterns and thought content
- Expressed feelings of discomfort or anxiety in social situations
- Mistrust or suspiciousness of others
Expected Outcomes:
- The patient will demonstrate a willingness to interact with others appropriately.
- The patient will participate in social activities and group settings to their level of tolerance.
- The patient will verbalize factors that contribute to their impaired social interaction, including behaviors and feelings.
- The patient will learn and implement techniques to improve social interaction skills.
- The patient will express increased comfort and reduced anxiety in social situations.
- The patient will establish and maintain a trusting relationship with at least one member of the healthcare team by discharge.
- The patient will develop a beginning social support system.
Assessment:
1. Assess Perceptions and Feelings About Social Interaction: Rationale: Gaining insight into the patient’s subjective experience of social interaction is crucial for understanding the barriers they face and tailoring interventions effectively. After establishing rapport, explore the patient’s feelings and perceptions about social situations. Ask about their comfort level in social settings, any anxieties or fears they experience, and their perception of their own social skills. For example, “How do you feel when you are around other people?” or “What makes social situations difficult for you?”.
2. Determine Social Support Systems and Patterns: Rationale: Understanding the patient’s existing social network and support system provides valuable information for discharge planning and identifying potential resources to enhance social integration. Assess the patient’s living situation, family relationships, and friendships. Inquire about who they rely on for support and the quality of these relationships. Explore any history of social isolation or loneliness.
3. Observe Verbal and Nonverbal Communication: Rationale: Observation of the patient’s communication patterns, both verbal and nonverbal, can reveal specific areas of social skills deficits that need to be addressed in interventions. Pay close attention to the patient’s speech (e.g., disorganized, tangential, pressured, slow), nonverbal cues (e.g., eye contact, facial expressions, body posture), and overall communication style during interactions. Note any difficulties in initiating or maintaining conversations, understanding social cues, or expressing emotions appropriately.
Interventions:
1. Build Trusting Nurse-Patient Relationship: Rationale: Trust is foundational to therapeutic relationships, especially for patients who may be suspicious or have difficulty forming connections. A trusting relationship provides a safe base for the patient to explore social interactions and practice new skills. Consistently demonstrate empathy, genuineness, and respect in all interactions. Actively listen to the patient’s concerns and validate their feelings. Be reliable and follow through on commitments to build trust over time.
2. Provide Positive Reinforcement for Social Engagement: Rationale: Positive reinforcement encourages desired behaviors and motivates patients to engage in social interactions, even if they are initially hesitant. Acknowledge and praise any attempts by the patient to engage socially, even small steps like initiating a conversation or joining a group activity for a short time. Focus on the effort and process rather than the outcome.
3. Facilitate Group Activities and Social Skills Training: Rationale: Group activities provide a structured and supportive environment for patients to practice social skills and interact with others. Social skills training programs offer explicit instruction and practice in specific social skills deficits. Encourage participation in therapeutic groups and structured social activities within the inpatient or outpatient setting. Refer the patient to social skills training programs conducted by qualified professionals, which focus on teaching communication skills, understanding social cues, and navigating social situations effectively.
4. Role-Playing and Social Skills Practice: Rationale: Role-playing provides a safe and controlled environment to practice specific social skills and rehearse appropriate responses to social situations, reducing anxiety and increasing confidence. Utilize role-playing scenarios to practice specific social skills, such as initiating conversations, responding to questions, or expressing feelings appropriately. Provide constructive feedback and encouragement during practice sessions.
Risk for Self-Directed Violence / Risk for Other-Directed Violence
Psychotic disorders can, in some instances, increase the risk of violence towards oneself or others. Factors such as paranoia, command hallucinations, and delusional beliefs can contribute to this risk. Assessing and mitigating this risk is a critical nursing responsibility.
Nursing Diagnosis: Risk for Self-Directed Violence / Risk for Other-Directed Violence
Related to:
- Paranoid delusions and suspiciousness of others
- Anxiety, fear, and agitation
- Command hallucinations instructing harm to self or others
- Delusional thinking and misinterpretations of reality
- History of previous threats or acts of violence against self or others
- Suicidal ideation and intent
- Perceived threatening environment
- Rage reactions and impulsivity
Note: “Risk for” diagnoses are not evidenced by actual signs and symptoms as the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected Outcomes:
- The patient will remain safe and free from self-harm.
- The patient will not harm other patients, staff, or family members.
- The patient will demonstrate a reduction in risk factors for violence, such as paranoia and agitation.
- The patient will identify and report any urges or intentions to harm self or others to staff.
- The patient will utilize coping mechanisms to manage agitation and impulses effectively.
Assessment:
1. Assess for Suicidal or Homicidal Ideation and Plan: Rationale: Direct assessment of suicidal and homicidal thoughts, intentions, and plans is crucial for determining the immediate risk level and guiding appropriate interventions. This information is essential for ensuring patient and staff safety. Directly and calmly ask the patient about suicidal or homicidal thoughts. For example, “Are you having thoughts of harming yourself or others?” If yes, inquire about the presence of a specific plan, the lethality of the plan, and access to means.
2. Observe for Early Warning Signs of Escalation: Rationale: Recognizing early cues of agitation and potential loss of control allows for proactive intervention to prevent escalation to violence. Early intervention is often more effective in de-escalating a situation than intervening once a patient is acutely agitated. Closely monitor the patient’s behavior for early signs of increasing agitation, anxiety, or potential loss of control. These cues may include changes in body language (e.g., clenched fists, pacing, rigid posture), verbal cues (e.g., increased volume, pressured speech, threats), and emotional cues (e.g., irritability, anger, fear).
Interventions:
1. Maintain Calm and Respectful Approach: Rationale: A calm and non-threatening approach from staff can help de-escalate agitation and reduce patient defensiveness. Clear and straightforward communication minimizes misinterpretations that could fuel paranoia or suspicion. Approach the patient in a calm, non-judgmental, and respectful manner. Speak clearly and simply, avoiding complex language or jargon. Maintain a neutral and supportive tone of voice.
2. Maintain Safe Distance and Personal Safety: Rationale: Maintaining a safe distance protects staff from potential harm if a patient becomes violent. Being aware of personal safety and positioning oneself strategically is essential in potentially volatile situations. Maintain a safe physical distance from the patient. Avoid turning your back on the patient or entering confined spaces with them alone if there is a perceived risk. Ensure easy access to exits and assistance if needed.
3. Ensure a Safe Environment: Rationale: Removing potentially dangerous objects minimizes the risk of the patient using them to harm themselves or others. Remove any objects from the patient’s environment that could be used to cause harm, such as sharp objects, belts, glass items, or cords.
4. Administer Medications as Prescribed: Rationale: Medications, particularly antipsychotics and anxiolytics, can be essential in managing acute agitation and psychotic symptoms that contribute to violence risk. Timely medication administration can help stabilize the patient and reduce the likelihood of aggressive behavior. Administer prescribed medications, such as antipsychotics or benzodiazepines, promptly as ordered. Monitor the patient’s response to medication and any potential side effects.
5. Utilize Restraints as a Last Resort: Rationale: Physical restraints are used only when all other de-escalation techniques have failed and the patient poses an imminent danger to themselves or others. Restraints are a safety measure of last resort, employed to prevent harm when no other options are effective. Apply physical restraints only if absolutely necessary to prevent imminent harm to self or others, and only after less restrictive interventions have been unsuccessful. Follow facility policies and procedures for restraint use, including proper application, monitoring, and documentation. Continuously reassess the patient’s need for restraints and remove them as soon as the patient is no longer an immediate danger.
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/
