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 (seeing or hearing things that aren’t real) and delusions (false beliefs). Negative symptoms, conversely, represent a reduction or absence of normal functions, like reduced emotional expression (flat affect), decreased motivation, and social withdrawal.
The causes of schizophrenia are complex and not fully understood, but research indicates a combination of genetic, biological, and environmental factors. Individuals with a family history of schizophrenia have a higher risk, suggesting a genetic component. Brain abnormalities and issues during prenatal development, such as viral infections, are also considered contributing factors. Environmental stressors, including poverty, trauma, and abuse, can further increase vulnerability to the illness.
The Nursing Process in Schizophrenia Care
Nurses play a crucial role in the multidisciplinary care of individuals with schizophrenia. Often, these patients present with co-occurring physical and mental health conditions, requiring holistic and integrated care. Inpatient treatment within a specialized behavioral health unit is frequently necessary, particularly during acute phases of the illness. Mental health nursing demands unique skills in therapeutic communication, crisis intervention, and maintaining a safe environment for patients experiencing significant distress and altered perceptions of reality. A core component of effective nursing care is the development and implementation of individualized nursing care plans.
Nursing Care Plans for Schizophrenia
Nursing care plans are essential tools for guiding and organizing nursing care. For patients with schizophrenia, these plans are built upon identified nursing diagnoses and serve to prioritize assessments, interventions, and outcome goals. Care plans address both immediate needs and long-term recovery goals. Below are examples of nursing care plans for common nursing diagnoses in schizophrenia.
Disturbed Sensory Perception (Auditory/Visual)
Psychosis, a hallmark of schizophrenia, can lead to significant distortions in sensory perception. Hallucinations and delusions are manifestations of this disturbed perception, causing a disconnect from reality.
Nursing Diagnosis: Disturbed Sensory Perception (Auditory/Visual)
Related Factors:
- Severe stress
- Sleep deprivation
- Sensory overload
- Altered sensory input
- Substance misuse (alcohol, drugs, medications)
As Evidenced By:
- Anxiety and panic reactions
- Talking or laughing to oneself
- Rapid mood changes
- Reporting seeing or hearing things not present (hallucinations)
- Inappropriate or illogical responses
- Disorientation and confusion
- Tilting head or appearing to listen to internal stimuli
Expected Outcomes:
- The patient will identify and modify contributing external factors to sensory distortions.
- The patient will maintain safety throughout psychotic episodes.
- The patient will verbalize understanding that hallucinations are not reality-based and demonstrate techniques to manage them.
Nursing Assessment:
-
Medication Adherence Assessment: Determine if the current psychotic episode is linked to medication non-adherence or substance use. These factors can significantly exacerbate psychotic symptoms.
-
Hallucination Content Assessment: Inquire about the content of hallucinations without validating them as real. For example, ask, “What are the voices saying?” or “What are you seeing?” This helps assess potential for harm to self or others and guides safety interventions. Avoid directly asking “Do you hear voices?” as this can reinforce the hallucination.
-
Agitation and Anxiety Monitoring: Closely monitor for escalating agitation, anxiety, or changes in behavior that could indicate worsening psychosis. Early intervention is crucial to prevent potential harm and manage distress.
Nursing Interventions:
-
Environmental Management: Reduce environmental stimuli that can worsen hallucinations. Move the patient to a quieter, less stimulating area, reducing noise and dimming lights. Maintain close supervision in a safe environment.
-
Safety Measures: Prioritize patient safety at all times. Unpredictable behavior during psychosis necessitates constant observation, potentially 1:1 supervision. Remove potentially harmful objects from the patient’s environment.
-
Distraction Techniques: Teach and encourage distraction strategies to help the patient manage hallucinations. These can include listening to music with headphones, reading, writing, drawing, or engaging in simple games. Suggesting the patient verbally command hallucinations to stop (“Go away!” or “Leave me alone!”) can also empower them to regain a sense of control.
-
Trigger Identification: Work with the patient to identify triggers for delusional thinking and hallucinations, such as periods of high stress or anxiety. Develop coping mechanisms to manage these triggers and reduce symptom exacerbation.
Impaired Social Interaction
Social interaction deficits are common in schizophrenia, stemming from thought disturbances, negative symptoms, and difficulties in processing social cues.
Nursing Diagnosis: Impaired Social Interaction
Related Factors:
- Disturbed thought processes
- Social isolation
- Deficient social skills and knowledge (understanding social roles, cues, and interaction goals)
- Mistrust of others
- Difficulty interpreting intentions of others
- Challenges in forming and maintaining relationships
- Impaired communication abilities
As Evidenced By:
- Flat or blunted affect
- Difficulty focusing attention
- Fearfulness or anxiety in social situations
- Inappropriate emotional responses in social contexts
- Poor eye contact
- Social withdrawal and preference for solitude
- Disorganized speech or thought patterns
Expected Outcomes:
- The patient will develop a supportive social network.
- The patient will identify personal factors, behaviors, and feelings that impede social interaction.
- The patient will implement strategies to improve social interaction skills.
- The patient will express increased comfort and safety in social situations, demonstrated by participation in group activities.
- The patient will establish a trusting relationship with the nurse and communicate openly by discharge.
Nursing Assessment:
-
Perceptions and Feelings about Social Interaction Assessment: After establishing rapport, explore the patient’s subjective experience of social interactions. Patients may express feelings of anxiety, fear, or discomfort that are not immediately apparent but provide valuable insight into their social challenges.
-
Family and Support System Assessment: Assess the patient’s existing social support network. Determine who they rely on for support, their living situation, and the presence or absence of close friendships or family support. This helps understand the patient’s social context and identify potential support resources.
-
Observation of Verbal and Nonverbal Communication: Observe the patient’s communication patterns, including speech (disorganized, pressured, slow), nonverbal cues (body language, fidgeting, restlessness), and eye contact. These observations provide data on factors contributing to impaired social interaction.
Nursing Interventions:
-
Building Trust and Rapport: Recognize that patients with schizophrenia may exhibit mistrust. Establish a trusting nurse-patient relationship through active listening, empathy, and consistent, reliable interactions. Acknowledge and validate their thoughts and feelings.
-
Positive Reinforcement: Provide positive reinforcement and encouragement when the patient engages in positive social interactions, even small steps like leaving their room or initiating conversation. Acknowledge and praise their efforts to promote motivation and build confidence.
-
Encouraging Group Participation: Offer opportunities for social interaction through group activities. While respecting the patient’s potential lack of motivation or social anxiety, gently encourage participation without pressure. Group settings can help reduce social isolation and improve social skills.
-
Referral for Social Skills Training: Recommend and facilitate referrals to specialized social skills training programs. These programs, often conducted in small groups led by trained professionals, teach essential communication skills, appropriate social behaviors, and strategies for developing and maintaining relationships, employment, and independent living skills.
Risk for Self/Other-Directed Violence
Suspiciousness, paranoia, and distorted perceptions in schizophrenia can elevate the risk of violent behavior towards self or others, particularly during psychotic episodes. Command hallucinations or delusional beliefs can instruct harmful actions.
Nursing Diagnosis: Risk for Self/Other-Directed Violence
Related Factors:
- Suspiciousness and paranoia
- Anxiety and agitation
- Command hallucinations
- Delusional thinking
- History of violence or threats
- Suicidal ideation
- Perceived threatening environment
- Rage reactions
Note: Risk diagnoses are potential problems and are not evidenced by existing signs and symptoms. Nursing interventions are preventative, aimed at reducing the risk and ensuring safety.
Expected Outcomes:
- The patient will remain free from self-injury.
- The patient will not harm others (staff, patients, family).
- The patient will recognize and report urges to harm self or others.
Nursing Assessment:
-
Suicidal and Homicidal Ideation Assessment: Directly assess for suicidal or homicidal plans. Ask specific questions about thoughts of harming themselves or others, including the presence of a plan, to determine the immediate level of risk and need for intervention.
-
Early Warning Sign Observation: Closely monitor for early cues of escalating distress and potential loss of control. These can include changes in body posture, facial expressions, increased agitation, restlessness, or decreased cooperation. Early identification allows for timely intervention.
Nursing Interventions:
-
Maintain Calm Demeanor: Maintain a calm and reassuring attitude to avoid escalating the patient’s agitation. Communicate in a straightforward, clear manner to minimize suspicion and avoid misinterpretations.
-
Maintain Safe Distance: While close supervision is often necessary, maintain a safe physical distance from the patient. Avoid turning your back and refrain from touching the patient without explicit permission, unless physical intervention is required for safety.
-
Environmental Safety: Ensure a safe environment by removing any objects that could be used to inflict harm, such as sharp objects, cords, or heavy items.
-
Medication Administration: Administer prescribed tranquilizers, anti-anxiety, or antipsychotic medications as needed to manage agitation and reduce the risk of violence, especially when de-escalation techniques are insufficient.
-
Restraint Use (Last Resort): Utilize manual restraints only as a last resort when all other interventions have failed to ensure safety. Restraints should be applied according to facility policy, with continuous monitoring and reassessment, and discontinued as soon as the patient’s 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/
