Schizophrenia is a complex and chronic mental illness that fundamentally alters a person’s perception of reality, thought processes, emotional responses, and behavior. Psychosis is a hallmark feature of schizophrenia, characterized by a disconnection from reality manifested through symptoms like hallucinations and delusions. Understanding the Nursing Diagnosis Psychosis is crucial for healthcare professionals to provide effective and compassionate care for individuals experiencing this challenging condition. This article delves into the nursing care plans specifically designed to address psychosis within the context of schizophrenia, offering a comprehensive guide for assessment, interventions, and expected outcomes.
Understanding Psychosis in Schizophrenia
Psychosis, a severe symptom of schizophrenia, disrupts an individual’s ability to think clearly, make sound judgments, respond appropriately emotionally, and communicate effectively. It’s important to distinguish between the positive and negative symptoms of schizophrenia to fully grasp the impact of psychosis.
Positive symptoms represent an excess or distortion of normal functions. These are often the most dramatic and noticeable signs of psychosis, including:
- Hallucinations: Experiencing sensory perceptions that are not real, such as hearing voices (auditory hallucinations), seeing things that aren’t there (visual hallucinations), or feeling sensations without a physical source.
- Delusions: Holding firmly to false beliefs that are not based in reality and are not accepted by others in the person’s culture. Common delusions can include paranoia, grandiose beliefs, or thoughts of reference.
Negative symptoms, in contrast, reflect a deficit or decrease in normal functions. While not directly psychotic, they significantly impact a patient’s quality of life and ability to function. These include:
- Flat affect: Reduced emotional expression, appearing emotionally unresponsive.
- Alogia: Poverty of speech, reduced amount and content of speech.
- Avolition: Lack of motivation and drive, difficulty initiating and persisting in goal-directed activities.
- Anhedonia: Inability to experience pleasure or interest in normally enjoyable activities.
- Social withdrawal: Decreased engagement in social interactions.
The etiology of schizophrenia and its associated psychosis is multifactorial. Genetic predisposition plays a significant role, with relatives of individuals with schizophrenia having a higher risk of developing the disorder. Biological factors, such as neurodevelopmental issues during prenatal stages or structural and functional brain abnormalities, are also implicated. Environmental stressors, including adverse childhood experiences, socioeconomic disadvantage, and substance misuse, can further contribute to the onset and course of schizophrenia.
The Nursing Process for Psychosis in Schizophrenia
Inpatient treatment within a behavioral health unit is often necessary for individuals experiencing acute psychosis due to schizophrenia. Nurses play a vital role in the multidisciplinary care team, utilizing the nursing process to provide structured and patient-centered care. Mental health nursing demands specialized skills in communication, therapeutic engagement, and crisis management to effectively interact with patients experiencing psychosis while prioritizing safety.
The nursing process, encompassing assessment, diagnosis, planning, implementation, and evaluation, provides a framework for addressing the complex needs of patients with schizophrenia and psychosis. Identifying accurate nursing diagnoses is the cornerstone of this process, guiding the development of individualized nursing care plans. These care plans prioritize nursing assessments and interventions, establishing both short-term and long-term goals to optimize patient outcomes and recovery.
Nursing Care Plans for Psychosis: Key Diagnoses
Addressing psychosis in schizophrenia requires targeted nursing interventions guided by specific nursing diagnoses. The following sections outline key nursing diagnoses relevant to psychosis, focusing on disturbed sensory perception, impaired social interaction (often exacerbated by psychosis), and the critical risk for self or other-directed violence during psychotic episodes.
Disturbed Sensory Perception (Auditory/Visual)
Psychosis frequently manifests as disturbed sensory perception, leading to a disconnection from reality characterized by hallucinations and delusions.
Nursing Diagnosis: Disturbed Sensory Perception (Auditory/Visual)
Related to:
- Severe psychological stress and anxiety
- Sleep deprivation and disrupted sleep patterns
- Sensory overload and excessive environmental stimulation
- Pre-existing alterations in sensory perception processing
- Substance misuse, including alcohol and illicit drugs, or medication non-adherence
As evidenced by:
- Report of anxiety, fear, or panic related to sensory experiences
- Talking or laughing to oneself, seemingly responding to internal stimuli
- Rapid and unpredictable mood swings, emotional lability
- Verbalization or demonstration of seeing or hearing things that are not present (hallucinations)
- Inappropriate or illogical responses to environmental stimuli
- Disorientation to time, place, or person
- Physical behaviors suggesting internal preoccupation, such as tilting head as if listening or staring blankly
Expected Outcomes:
- Patient will identify and, when possible, modify external and internal factors that exacerbate sensory perceptual alterations.
- Patient will maintain personal safety and the safety of others throughout the psychotic episode until symptom resolution is achieved.
- Patient will verbalize an understanding that hallucinations are not reality-based experiences and demonstrate coping mechanisms to manage or interrupt them.
Assessment:
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Assess medication adherence and substance use history: Determine if the current psychotic episode is potentially linked to non-adherence to prescribed antipsychotic medications or the use of substances that can induce or worsen psychosis. Understanding these factors is crucial for addressing potential contributing causes and tailoring interventions.
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Assess the content and nature of hallucinations: Engage with the patient about their hallucinatory experiences without validating the hallucinations as real. Clearly state that you do not share the same perceptions. Gently inquire about the content of the voices or visions to assess for potential command hallucinations (voices instructing harmful actions) or themes that indicate risk of violence towards self or others. This assessment is vital for implementing appropriate safety precautions and crisis interventions.
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Continuously monitor for escalating agitation, anxiety, or distress: Closely observe the patient’s behavior, verbalizations, and non-verbal cues for signs of increasing agitation, anxiety, or internal distress. Early identification of escalating distress allows for timely intervention to prevent potential harm to the patient or others. Changes in thought content and behavior patterns should be carefully tracked.
Interventions:
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Reduce environmental stimuli and create a calming environment: Minimize chaotic or overstimulating environments that can exacerbate hallucinations and delusions. If the patient is in a group setting, guide them to a quieter, more solitary space (while maintaining supervision for safety). Reduce noise levels and dim bright lighting to promote relaxation and reduce sensory overload.
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Prioritize safety measures and ensure continuous monitoring: Patient safety is paramount, especially during acute psychosis. Implement 1:1 supervision if necessary, based on risk assessment. Remove any potentially harmful objects from the patient’s immediate environment. Maintain a safe and therapeutic milieu.
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Employ distraction and reality orientation techniques: Engage the patient in diversional activities to redirect focus away from hallucinations. Suggest listening to calming music with headphones, writing or drawing in a journal, or engaging in simple games or puzzles. Gently and repeatedly remind the patient that hallucinations are not real and are symptoms of their illness. Teach grounding techniques to help the patient connect with the present reality.
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Collaborate with the patient to identify and manage triggers: Work with the patient to explore potential triggers for their psychotic symptoms, such as periods of intense stress, anxiety, or sleep disruption. Develop coping strategies and stress management techniques to help the patient proactively manage these triggers and potentially reduce the frequency or intensity of psychotic episodes. This may involve relaxation exercises, mindfulness techniques, or cognitive behavioral therapy (CBT) approaches.
Impaired Social Interaction
While impaired social interaction is a broader symptom in schizophrenia, psychotic symptoms can significantly worsen social withdrawal, mistrust, and difficulties in social engagement.
Nursing Diagnosis: Impaired Social Interaction
Related to:
- Distorted thought processes and cognitive impairments associated with schizophrenia and psychosis
- Social isolation and withdrawal secondary to psychotic experiences and negative symptoms
- Deficits in social knowledge, including understanding social cues, roles, and interaction goals
- Mistrust and paranoia, often intensified by delusions of persecution
- Difficulties in perceiving or accurately interpreting the intentions and behaviors of others
- Challenges in initiating and maintaining interpersonal relationships
- Impaired communication skills, both verbal and non-verbal
As evidenced by:
- Flat or blunted affect, limited emotional responsiveness in social situations
- Difficulty focusing attention and sustaining engagement in interactions
- Expressed fear, anxiety, or discomfort in social situations or around others
- Inappropriate emotional responses that are not congruent with social context
- Poor eye contact or avoidance of eye contact during interactions
- Preference for spending time alone, social withdrawal
- Disorganized speech patterns or illogical thought processes that impede communication
Expected Outcomes:
- Patient will gradually develop a supportive social network and identify at least one person they feel comfortable confiding in.
- Patient will verbalize personal factors, behaviors, and feelings that contribute to or hinder social interaction.
- Patient will actively incorporate learned techniques and strategies to improve social interaction skills.
- Patient will report feeling increasingly safe and comfortable in social situations, demonstrated by participation in group activities or therapeutic groups.
- Patient will build a trusting therapeutic relationship with the nurse and demonstrate increased openness in communication by discharge.
Assessment:
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Assess the patient’s perceptions and feelings regarding social interaction: After establishing a degree of trust and rapport, explore the patient’s subjective experience of social interactions. Inquire about their perceived difficulties, anxieties, fears, or discomfort in social situations. Understanding their internal perspective provides valuable insights that may not be apparent through observation alone.
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Determine current family and social support patterns: Gain a comprehensive understanding of the patient’s existing social network and support system. Assess who they rely on for emotional, practical, or social support. Determine the presence or absence of close friendships, family connections, or spousal support. Identify any perceived lack of support or social isolation.
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Observe verbal and nonverbal communication and body language in social contexts: Continuously observe the patient’s communication patterns during interactions. Assess speech for disorganization, pressured speech, or slowed speech. Pay attention to nonverbal cues, such as body posture, facial expressions (irritability, restlessness), fidgeting, eye contact (avoidance or poor contact), and overall responsiveness. These observations provide data regarding factors contributing to impaired social interaction.
Interventions:
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Develop a consistent, trusting therapeutic relationship: Recognize that patients with schizophrenia and psychosis may exhibit mistrust and suspicion of others, often due to paranoia or delusional beliefs. Prioritize building rapport by demonstrating genuineness, empathy, and active listening. Consistently acknowledge and validate the patient’s thoughts and feelings to foster trust and open communication.
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Provide positive reinforcement and encouragement for social engagement: When the patient makes efforts to improve social interaction, even small steps like leaving their room or initiating conversation, provide specific and genuine positive reinforcement. Acknowledge and support their efforts to encourage continued social engagement and build confidence.
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Facilitate participation in structured group activities and therapeutic groups: Schizophrenia and psychosis can lead to decreased motivation and social withdrawal. While respecting the patient’s autonomy and avoiding forced socialization, actively offer opportunities to participate in structured group activities or therapeutic groups. Group settings can provide a safe and supportive environment to practice social skills, reduce feelings of isolation, and address negative symptoms like emotional blunting.
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Refer to specialized social skills training programs: Social skills training, often conducted in small group settings by trained clinicians, provides structured learning opportunities to enhance social competence. Refer patients to these programs to develop essential communication skills, learn about appropriate and inappropriate social behaviors, and acquire strategies for building and maintaining personal relationships, as well as skills relevant to independent living and employment.
Risk For Self/Other-Directed Violence
Psychosis can significantly elevate the risk of violence directed towards oneself or others. Delusions of persecution, paranoia, and command hallucinations can lead to feelings of threat and impulsive, aggressive behaviors.
Nursing Diagnosis: Risk for Self/Other-Directed Violence
Related to:
- Suspiciousness, paranoia, and delusional beliefs about persecution or threats
- Elevated anxiety levels and internal distress
- Command hallucinations instructing harmful actions towards self or others
- Disorganized and illogical delusional thinking patterns
- History of prior threats or acts of violence against self or others
- Suicidal ideation and intent
- Perception of the environment as threatening or hostile
- Rage reactions and impulsive aggression
Note: As a risk diagnosis, there are no “as evidenced by” signs and symptoms, as the problem has not yet occurred. Nursing interventions are proactively aimed at prevention.
Expected Outcomes:
- Patient will remain free from episodes of self-harm throughout the course of treatment.
- Patient will refrain from causing harm or injury to other patients, staff members, or family members.
- Patient will develop the ability to recognize and report internal cues and warning signs indicating an increased urge to harm themselves or others.
Assessment:
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Directly assess for the presence of a plan for suicide or violence: It is crucial to directly and explicitly ask the patient if they are experiencing suicidal thoughts or have a plan to harm themselves. Similarly, directly assess for thoughts of harming others and if a plan exists. This direct inquiry is essential for determining the immediate level of risk and guiding appropriate interventions.
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Observe for early behavioral cues indicative of escalating distress and potential loss of control: Continuously monitor the patient’s behavior for subtle changes that may signal increasing agitation, anxiety, or a potential loss of impulse control. Pay attention to changes in body posture (increased tension, clenched fists), facial expressions (grimacing, furrowed brow), increased pacing, restlessness, or decreased cooperation and engagement in treatment. Early detection of these cues allows for proactive intervention to de-escalate situations and prevent violence.
Interventions:
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Maintain a calm and reassuring attitude and communication style: Staff demeanor should be consistently calm and non-threatening to avoid escalating patient anxiety or agitation. Maintain a neutral and supportive approach. Communication should be straightforward, clear, and concise to minimize misinterpretations and reduce patient suspicion or feelings of being manipulated.
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Maintain a safe physical distance and personal safety: While continuous supervision may be necessary, prioritize staff safety by maintaining a safe physical distance from the patient. Avoid turning your back on the patient and refrain from physical touch without explicit consent (unless restraint is clinically necessary and according to protocol). Be aware of exit routes and personal safety protocols.
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Ensure a safe and therapeutic environment: Proactively create a safe environment by removing any objects that could potentially be used to inflict self-harm or harm others (sharps, cords, heavy objects). Minimize environmental triggers that could escalate agitation.
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Administer pharmacological interventions as needed: For patients who cannot be effectively de-escalated through verbal interventions or who present an immediate and significant risk to themselves or others, administer prescribed tranquilizing medications as ordered. This may include anti-anxiety medications or rapid-acting antipsychotics to manage acute agitation and reduce the risk of violence.
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Utilize manual restraints as a last resort intervention: Manual restraints are to be employed only when all other de-escalation and intervention strategies have failed to ensure patient safety and the safety of others. Restraint is a last resort. When restraints are necessary, adhere strictly to facility policy and protocols, ensuring proper application, continuous monitoring of the patient’s physical and psychological well-being, and regular reassessment for the earliest possible removal of restraints as agitation subsides.
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/
