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11/27/23, 3:43 AM Realizeit for Student Application of the Nursing Process Assessment Schizophrenia affects thought processes and content, perception, emotion, behavior, and social functioning; however, it affects each individual differently. The degree of impairment in both the acute or psychotic...

11/27/23, 3:43 AM Realizeit for Student Application of the Nursing Process Assessment Schizophrenia affects thought processes and content, perception, emotion, behavior, and social functioning; however, it affects each individual differently. The degree of impairment in both the acute or psychotic phase and the chronic or long-term phase varies greatly; thus, so do the needs of and the nursing interventions for each affected client. The nurse must not make assumptions about the client’s abilities or limitations solely on the basis of the medical diagnosis of schizophrenia. For example, the nurse may care for a client in an acute inpatient setting. The client may appear frightened, hear voices (hallucinate), make no eye contact, and mumble constantly. The nurse would deal with the positive, or psychotic, signs of the disease. Another nurse may encounter a client with schizophrenia in a community setting who is not experiencing psychotic symptoms; rather, this client lacks energy for daily tasks and has feelings of loneliness and isolation (negative signs of schizophrenia). Although both clients have the same medical diagnosis, the approach and interventions that each nurse takes would be different. History The nurse first elicits information about the client’s previous history with schizophrenia to establish baseline data. He or she asks questions about how the client functioned before the crisis developed, such as “How do you usually spend your time?” and “Can you describe what you do each day?” The nurse assesses the age at onset of schizophrenia, knowing that poorer outcomes are associated with an earlier age at onset. Learning the client’s previous history of hospital admissions and response to hospitalization is also important. The nurse also assesses the client for previous suicide attempts. Of all people with schizophrenia, 10% eventually commit suicide. The nurse might ask, “Have you ever attempted suicide?” or “Have you ever heard voices telling you to hurt yourself?” Likewise, it is important to elicit information about any history of violence or aggression because a history of aggressive behavior is a strong predictor of future aggression. The nurse might ask, “What do you do when you are angry, frustrated, upset, or scared?” The nurse assesses whether the client has been using current support systems by asking the client or significant others the following questions: Has the client kept in contact with family or friends? Has the client been to scheduled groups or therapy appointments? Does the client seem to run out of money between paychecks? Have the client’s living arrangements changed recently? https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 1/26 11/27/23, 3:43 AM Realizeit for Student Finally, the nurse assesses the client’s perception of his or her current situation—that is, what the client believes to be significant present events or stressors. The nurse can gather such information by asking, “What do you see as the primary problem now?” or “What do you need help managing now?” General Appearance, Motor Behavior, and Speech Appearance may vary widely among different clients with schizophrenia. Some appear normal in terms of being dressed appropriately, sitting in a chair conversing with the nurse, and exhibiting no strange or unusual postures or gestures. Others exhibit odd or bizarre behavior. They may appear disheveled and unkempt with no obvious concern for their hygiene, or they may wear strange or inappropriate clothing (for instance, a heavy wool coat and stocking cap in hot weather). Overall, motor behavior may also appear odd. The client may be restless and unable to sit still, exhibit agitation and pacing, or appear unmoving (catatonia). He or she may also demonstrate seemingly purposeless gestures (stereotypic behavior) and odd facial expressions, such as grimacing. The client may imitate the movements and gestures of someone whom he or she is observing (echopraxia). Rambling speech that may or may not make sense to the listener is likely to accompany these behaviors. Conversely, the client may exhibit psychomotor retardation (a general slowing of all movements). Sometimes the client may be almost immobile, curled into a ball (fetal position). Clients with the catatonic type of schizophrenia can exhibit waxy flexibility; they maintain any position in which they are placed, even if the position is awkward or uncomfortable. The client may exhibit an unusual speech pattern. Two typical patterns are word salad (jumbled words and phrases that are disconnected or incoherent and make no sense to the listener) and echolalia (repetition or imitation of what someone else says). Speech may be slowed or accelerated in rate and volume; the client may speak in whispers or hushed tones or may talk loudly or yell. Latency of response refers to hesitation before the client responds to questions. This latency or hesitation may last 30 or 45 seconds and usually indicates the client’s difficulty with cognition or thought processes. Box 16.3 lists and gives examples of these unusual speech patterns. BOX 16.3 Unusual Schizophrenia Speech Patterns of Clients with Clang associations are ideas that are related to one another based on sound or rhyming rather than meaning. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 2/26 11/27/23, 3:43 AM Realizeit for Student Example: “I will take a pill if I go up the hill but not if my name is Jill, I don’t want to kill.” Neologisms are words invented by the client. Example: “I’m afraid of grittiz. If there are any grittiz here, I will have to leave. Are you a grittiz?” Verbigeration is the stereotyped repetition of words or phrases that may or may not have meaning to the listener. Example: “I want to go home, go home, go home, go home.” Echolalia is the client’s imitation or repetition of what the nurse says. Example: Nurse: “Can you tell me how you’re feeling?” Client: “Can you tell me how you’re feeling, how you’re feeling?” Stilted language is use of words or phrases that are flowery, excessive, and pompous. Example: “Would you be so kind, as a representative of Florence Nightingale, as to do me the honor of providing just a wee bit of refreshment, perhaps in the form of some clear spring water?” Perseveration is the persistent adherence to a single idea or topic and verbal repetition of a sentence, phrase, or word, even when another person attempts to change the topic. Example: Nurse: “How have you been sleeping lately?” Client: “I think people have been following me.” Nurse: “Where do you live?” Client: “At my place, people have been following me.” Nurse: “What do you like to do in your free time?” Client: “Nothing because people are following me.” Word salad is a combination of jumbled words and phrases that are disconnected or incoherent and make no sense to the listener. Example: “Corn, potatoes, jump up, play games, grass, cupboard.” https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 3/26 11/27/23, 3:43 AM Realizeit for Student Mood and Affect Clients with schizophrenia report and demonstrate wide variations in mood and affect. They are often described as having flat affect (no facial expression) or blunted affect (few observable facial expressions). The typical facial expression is often described as masklike. The affect may also be described as silly, characterized by giddy laughter for no apparent reason. The client may exhibit an inappropriate expression or emotions incongruent with the context of the situation. This incongruence ranges from mild or subtle to grossly inappropriate. For example, the client may laugh and grin while describing the death of a family member or weep while talking about the weather. The client may report feeling depressed and having no pleasure or joy in life (anhedonia). Conversely, he or she may report feeling all-knowing, all-powerful and not at all concerned with the circumstance or situation. It is more common for the client to report exaggerated feelings of well-being during episodes of psychotic or delusional thinking, and a lack of energy or pleasurable feelings during the chronic, or long-term, phase of the illness. Thought Process and Content Schizophrenia is often referred to as a thought disorder because that is the primary feature of the disease: thought processes become disordered, and the continuity of thoughts and information processing is disrupted. The nurse can assess the thought process by inferring from what the client says. He or she can assess thought content by evaluating what the client actually says. For example, clients may suddenly stop talking in the middle of a sentence and remain silent for several seconds to 1 minute (thought blocking). They may also state that they believe others can hear their thoughts (thought broadcasting), that others are taking their thoughts (thought withdrawal), or that others are placing thoughts in their mind against their will (thought insertion). Clients may also exhibit tangential thinking, which is veering onto unrelated topics and never answering the original question: Circumstantiality may be evidenced if the client gives unnecessary details or strays from the topic but eventually provides the requested information: Thought broadcasting Nurse: “How have you been sleeping lately?” Client: “Oh, I go to bed early, so I can get plenty of rest. I like to listen to music or read before bed. Right now, I’m reading a good mystery. Maybe I’ll write a mystery someday. But it isn’t helping, reading I mean. I have been getting only 2 or 3 hours of sleep at night.” https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 4/26 11/27/23, 3:43 AM Realizeit for Student Poverty of content (alogia) describes the lack of any real meaning or substance in what the client says: Nurse: “How have you been sleeping lately?” Client: “Well, I guess, I don’t know, hard to tell.” Delusions Clients with schizophrenia usually experience delusions (fixed, false beliefs with no basis in reality) in the psychotic phase of the illness. A common characteristic of schizophrenic delusions is the direct, immediate, and total certainty with which the client holds these beliefs. Because the client believes the delusion, he or she, therefore, acts accordingly. For example, the client with delusions of persecution is probably suspicious, mistrustful, and guarded about disclosing personal information; he or she may examine the room periodically or speak in hushed, secretive tones. The theme or content of the delusions may vary. Box 16.4 describes and provides examples of the various types of delusions. External contradictory information or facts cannot alter these delusional beliefs. If asked why he or she believes such an unlikely idea, the client often replies, “I just know it.” Delusions of grandeur BOX 16.4 Types of Delusions Persecutory/paranoid delusions involve the client’s belief that “others” are planning to harm him or her or are spying, following, ridiculing, or belittling the client in some way. Sometimes the client cannot define who these “others” are. Examples: The client may think that food has been poisoned or that rooms are bugged with listening devices. Sometimes the “persecutor” is the government, FBI, or another powerful organization. Occasionally, specific individuals, even family members, may be named as the persecutor. Grandiose delusions are characterized by the client’s claim to association with famous people or celebrities or the client’s belief that he or she is famous or capable of great feats. Examples: The client may claim to be engaged to a famous movie star or related to some public figure, such as claiming to be the daughter of the president of the United States, or he or she may claim to have found a cure for cancer. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 5/26 11/27/23, 3:43 AM Realizeit for Student Religious delusions often center around the second coming of Christ or another significant religious figure or prophet. These religious delusions appear suddenly as part of the client’s psychosis and are not part of his or her religious faith or that of others. Examples: The client claims to be the Messiah or some prophet sent from God and believes that God communicates directly to him or her or that he or she has a special religious mission in life or special religious powers. Somatic delusions are generally vague and unrealistic beliefs about the client’s health or bodily functions. Factual information or diagnostic testing does not change these beliefs. Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in the brain. Sexual delusions involve the client’s belief that his or her sexual behavior is known to others; that the client is a rapist, prostitute, or pedophile or is pregnant; or that his or her excessive masturbation has led to insanity. Nihilistic delusions are the client’s belief that his or her organs are not functioning or are rotting away or that some body part or feature is horribly disfigured or misshapen. Referential delusions or ideas of reference involve the client’s belief that television broadcasts, music, or newspaper articles have special meaning for him or her. Examples: The client may report that the president was speaking directly to him on a news broadcast or that special messages are sent through newspaper articles. Initially, the nurse assesses the content and depth of the delusion to know what behaviors to expect and to try to establish reality for the client. When eliciting information about the client’s delusional beliefs, the nurse must be careful not to support or challenge them. The nurse might ask the client to explain what he or she believes by saying, “Please explain that to me” or “Tell me what you’re thinking about that.” Sensorium and Intellectual Processes One hallmark symptom of schizophrenic psychosis is hallucinations (false sensory perceptions or perceptual experiences that do not exist in reality). Hallucinations can involve the five senses and bodily sensations. They can be threatening and frightening for the client; less frequently, clients report hallucinations as pleasant. Initially, the client perceives hallucinations as real, but later in the illness, he or she may recognize them as hallucinations. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 6/26 11/27/23, 3:43 AM Realizeit for Student Hallucinations are distinguished from illusions, which are misperceptions of actual environmental stimuli. For example, while walking through the woods, a person believes he sees a snake at the side of the path. On closer examination, however, he discovers it is only a curved stick. Reality or factual information corrected this illusion. Hallucinations, however, have no such basis in reality. The following are the various types of hallucinations (Lewis, Escalona, & Owen, 2017): Auditory hallucinations, the most common type, involve hearing sounds, most often voices, talking to or about the client. There may be one or multiple voices; a familiar or unfamiliar person’s voice may be speaking. Command hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous. Visual hallucinations involve seeing images that do not exist at all, such as lights or a dead person, or distortions such as seeing a frightening monster instead of the nurse. They are the second most common type of hallucination. Olfactory hallucinations involve smells or odors. They may be a specific scent such as urine or feces or a more general scent such as a rotten or rancid odor. In addition to clients with schizophrenia, this type of hallucination often occurs with dementia, seizures, or cerebrovascular accidents. Tactile hallucinations refer to sensations such as electricity running through the body or bugs crawling on the skin. Tactile hallucinations are found most often in clients undergoing alcohol withdrawal; they rarely occur in clients with schizophrenia. Gustatory hallucinations involve a taste lingering in the mouth or the sense that food tastes like something else. The taste may be metallic or bitter or may be represented as a specific taste. Cenesthetic hallucinations involve the client’s report that he or she feels bodily functions that are usually undetectable. Examples would be the sensation of urine forming or impulses being transmitted through the brain. Kinesthetic hallucinations occur when the client is motionless but reports the sensation of bodily movement. Occasionally, the bodily movement is something unusual, such as floating above the ground. Judgment and Insight Judgment is frequently impaired in the client with schizophrenia. Because judgment is based on the ability to interpret the environment correctly, it follows that the client with disordered thought processes and environmental misinterpretations will have great difficulty with judgment. At times, lack of judgment is so severe that clients cannot meet their needs for safety and protection and place themselves in harm’s way. This difficulty may range from failing to wear warm clothing in cold weather to failing to seek medical care even when desperately ill. The client may also fail to recognize needs for sleep or food. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 7/26 11/27/23, 3:43 AM Realizeit for Student Insight can also be severely impaired, especially early in the illness, when the client, family, and friends do not understand what is happening. Over time, some clients can learn about the illness, anticipate problems, and seek appropriate assistance as needed. However, chronic difficulties result in clients who fail to understand schizophrenia as a long-term health problem requiring consistent management. Self-Concept Deterioration of the concept of self is a major problem in schizophrenia. The phrase loss of ego boundaries describes the client’s lack of a clear sense of where his or her own body, mind, and influence end and where those aspects of other animate and inanimate objects begin. This lack of ego boundaries is evidenced by depersonalization, derealization (environmental objects become smaller or larger or seem unfamiliar), and ideas of reference. Clients may believe they are fused with another person or object, may not recognize body parts as their own, or may fail to know whether they are male or female. These difficulties are the source of many bizarre behaviors such as public undressing or masturbating, speaking about oneself in the third person, or physically clinging to objects in the environment. Body image distortion may also occur. Roles and Relationships Social isolation is prevalent in clients with schizophrenia, partly as a result of positive signs such as delusions, hallucinations, and loss of ego boundaries. Relating to others is difficult when oneself concept is not clear. Clients also have problems with trust and intimacy, which interfere with the ability to establish satisfactory relationships. Low self-esteem, one of the negative signs of schizophrenia, further complicates the client’s ability to interact with others and the environment. These clients lack confidence, feel strange or different from other people, and do not believe they are worthwhile. The result is avoidance of other people. The client may experience great frustration in attempting to fulfill roles in the family and community. Success in school or at work can be severely compromised because the client has difficulty thinking clearly, remembering, paying attention, and concentrating. Subsequently, he or she lacks motivation. Clients who develop schizophrenia at young ages have more difficulties than those whose illness developed later in life because they did not have the opportunity to succeed in these areas before the illness. Fulfilling family roles, such as that of a son or daughter or sibling, is difficult for these clients. Often, their erratic or unpredictable behavior frightens or embarrasses family members, who become unsure what to expect next. Families may also feel guilty or responsible, believing they somehow failed to provide a loving, supportive home life. These clients may also believe they have disappointed their families because they cannot become independent or successful. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 8/26 11/27/23, 3:43 AM Realizeit for Student Physiological and Self-Care Considerations Clients with schizophrenia may have significant self-care deficits. Inattention to hygiene and grooming needs is common, especially during psychotic episodes. The client can become so preoccupied with delusions or hallucinations that he or she fails to perform even basic activities of daily living. Nursing Care Plan: Client with Delusions Nursing Diagnosis Disturbed Thought Processes: Disruption in cognitive operations and activities Assessment Data Non–reality-based thinking Disorientation Labile affect Short attention span Impaired judgment Distractibility Expected Outcomes Immediate The client will: Be free of injury throughout hospitalization. Demonstrate decreased anxiety level within 24 to 48 hours. Respond to reality-based interactions initiated by others; for example, verbally interact with staff for 5 to 10 minutes within 24 to 48 hours. Stabilization The client will: Interact on reality-based topics such as daily activities or local events. Sustain attention and concentration to complete tasks or activities. Community The client will: Verbalize recognition of delusional thoughts if they persist. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1up… 9/26 11/27/23, 3:43 AM Realizeit for Student Be free from delusions or demonstrate the ability to function without responding to persistent delusional thoughts. Implementation Nursing Interventions* Be sincere and Rationale honest when Delusional clients are extremely sensitive about others communicating with the client. Avoid and can recognize insincerity. Evasive comments or vague or evasive remarks. hesitation reinforces mistrust or delusions. Be consistent in setting expectations, Clear, consistent limits provide a secure structure for enforcing rules, and so forth. the client. Do not make promises that you cannot Broken promises reinforce the client’s mistrust of keep. others. Encourage the client to talk with you, Probing increases the client’s suspicion and interferes but do not pry for information. with the therapeutic relationship. Explain procedures and try to be sure the client understands the procedures before carrying them out. When the client has full knowledge of procedures, he or she is less likely to feel tricked by the staff. Positive feedback for genuine success enhances the Give positive feedback for the client’s client’s sense of well-being and helps make successes. nondelusional reality a more positive situation for the client. Recognize the client’s delusions as the Recognizing the client’s perceptions can help you client’s perception of the environment. understand the feelings he or she is experiencing. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 10/26 11/27/23, 3:43 AM Realizeit for Student Initially, do not argue with the client or try to convince the client that the delusions are false or unreal. Logical argument does not dispel delusional ideas and can interfere with the development of trust. Interact with the client on the basis of real things; do not dwell on the Interacting about reality is healthy for the client. delusional material. Engage the client in one-to-one activities at first, then activities in small groups, and gradually activities in larger groups. Recognize and accomplishments A distrustful client can best deal with one person initially. Gradual others as client the introduction tolerates is of less threatening. support (projects the client’s Recognizing the client’s accomplishments completed, can lessen anxiety and the need for responsibilities fulfilled, interactions initiated). delusions as a source of self-esteem. Show empathy regarding the client’s feelings; The client’s delusions can be distressing. reassure Empathy conveys your caring, interest, and the client of your presence and acceptance. acceptance of the client. The client’s delusions and feelings are not Do not be judgmental or belittle or joke about the funny to him or her. The client may not client’s beliefs. understand or may feel rejected by attempts at humor. Never convey to the client that you accept the Indicating belief in the delusions reinforces delusions as reality. the delusion (and the client’s illness). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 11/26 11/27/23, 3:43 AM Directly interject doubt regarding delusions as soon as the client seems ready to accept this (e.g., “I find that hard to believe.”). Do not argue but present a factual account of the situation. Realizeit for Student As the client begins to trust you, he or she may become willing to doubt the delusion if you express your doubt. As the client begins to doubt the delusions or is willing to discuss the possibility that they may not As the client begins to relinquish delusional be accurate, talk with the client about his or her ideas, he or she may have increased anxiety perceptions and feelings. Give the client support or be embarrassed about the beliefs. for expressing feelings and concerns. Ask the client if he or she can see that the Discussion of the problems caused by the delusions interfere with or cause problems in his delusions is a focus on the present and is or her life. reality based. If the delusions are persistent but the client can Learning to choose not to act on a acknowledge the consequences of expressing the delusional belief and not discuss it with beliefs, help him or her understand the difference others outside the therapeutic relationship between holding a belief and acting on it or may help the client avoid hospitalization and sharing it with others. other consequences in the future. *Collaborative interventions. Adapted from Schultz, J. M., & Videbeck, S. L (2013). Lippincott’s manual of psychiatric nursing care plans (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Clients may also fail to recognize sensations such as hunger or thirst, and food or fluid intake may be inadequate. This can result in malnourishment and constipation. Constipation is also a common side effect of antipsychotic medications, compounding the problem. Paranoia or excessive fears that food and fluids have been poisoned are common and may interfere with eating. If the client is agitated and pacing, he or she may be unable to sit down long enough to eat. Occasionally, clients develop polydipsia (excessive water intake), which leads to water intoxication. Serum sodium levels can become dangerously low, leading to seizures. Polydipsia is usually seen in clients who have had severe and persistent mental illness for many years as well as long-term therapy with antipsychotic medications. It may be caused by the behavioral state itself or may be https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 12/26 11/27/23, 3:43 AM Realizeit for Student precipitated by the use of antidepressant or antipsychotic medications (Sailer, Winzeler, & ChristCrain, 2017). Sleep problems are common. Hallucinations may stimulate clients, resulting in insomnia. Other times, clients are suspicious and believe harm will come to them if they sleep. As in other self-care areas, the client may not correctly perceive or acknowledge physical cues such as fatigue. To assist the client with community living, the nurse assesses daily living skills and functional abilities. Such skills—having a bank account and paying bills, buying food and preparing meals, and using public transportation—are often difficult tasks for the client with schizophrenia. He or she might never have learned such skills or may be unable to accomplish them consistently. Data Analysis The nurse must analyze assessment data for clients with schizophrenia to determine priorities and establish an effective plan of care. Not all clients have the same problems and needs, nor is it likely that any individual client has all the problems that can accompany schizophrenia. Levels of family and community support and available services also vary, all of which influence the client’s care and outcomes. The analysis of assessment data generally falls into two main categories: data associated with the positive signs of the disease and data associated with the negative signs. The North American Nursing Diagnosis Association’s (NANDA) nursing diagnoses commonly established based on the assessment of psychotic symptoms or positive signs are the following: Risk for other-directed violence Risk for suicide Disturbed thought processes Disturbed sensory perception Disturbed personal identity Impaired verbal communication The NANDA nursing diagnoses based on the assessment of negative signs and functional abilities include the following: Self-care deficits Social isolation Deficient diversional activity Ineffective health maintenance https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 13/26 11/27/23, 3:43 AM Realizeit for Student Ineffective therapeutic regimen management Outcome Identification It is likely that the client with an acute psychotic episode of schizophrenia will receive treatment in an intensive setting, such as an inpatient hospital unit. During this phase, the focus of care is stabilizing the client’s thought processes and reality orientation as well as ensuring safety. This is also the time to evaluate resources, make referrals, and begin planning for the client’s rehabilitation and return to the community. Examples of outcomes appropriate to the acute, psychotic phase of treatment are the following: 1. The client will not injure him or herself or others. 2. The client will establish contact with reality. 3. The client will interact with others in the environment. 4. The client will express thoughts and feelings in a safe and socially acceptable manner. 5. The client will participate in prescribed therapeutic interventions. Once the crisis or the acute, psychotic symptoms have been stabilized, the focus is on developing the client’s ability to live as independently and successfully as possible in the community. This usually requires continued follow-up care and participation of the client’s family in community support services. Prevention and early recognition and treatment of relapse symptoms are important parts of successful rehabilitation. Dealing with the negative signs of schizophrenia, which medication generally does not affect, is a major challenge for the client and caregivers. Examples of treatment outcomes for continued care after the stabilization of acute symptoms are the following: 1. The client will participate in the prescribed regimen (including medications and follow-up appointments). 2. The client will maintain adequate routines for sleeping and food and fluid intake. 3. The client will demonstrate independence in self-care activities. 4. The client will communicate effectively with others in the community to meet his or her needs. 5. The client will seek or accept assistance to meet his or her needs when indicated. The nurse must appreciate the severity of schizophrenia and the profound and sometimes devastating effects it has on the lives of clients and their families. It is equally important to avoid treating the client as a “hopeless case,” someone who no longer is capable of having a meaningful and satisfying life. It is not helpful to expect either too much or too little from the client. Careful ongoing assessment is necessary so that appropriate treatment and interventions address the client’s needs and difficulties while helping the client reach his or her optimal level of functioning. Intervention Promoting the Safety of the Client and Others https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 14/26 11/27/23, 3:43 AM Realizeit for Student Safety for both the client and the nurse is the priority when providing care for the client with schizophrenia. The client may be paranoid and suspicious of the nurse and the environment and may feel threatened and intimidated. Although the client’s behavior may be threatening to the nurse, the client is also feeling unsafe and may believe his or her well-being is in jeopardy. Therefore, the nurse must approach the client in a nonthreatening manner. Making demands or being authoritative only increases the client’s fears. Giving the client ample personal space usually enhances his or her sense of security. A fearful or agitated client has the potential to harm him or herself or others. The nurse must observe for signs of building agitation or escalating behavior such as increased intensity of pacing, loud talking or yelling, and hitting or kicking objects. The nurse must institute interventions to protect the client, nurse, and others in the environment. This may involve administering medication; moving the client to a quiet, less stimulating environment; and in extreme situations, temporarily using seclusion or restraints. Establishing a Therapeutic Relationship Establishing trust between the client and the nurse also helps allay the fears of a frightened client. Initially, the client may tolerate only 5 or 10 minutes of contact at one time. Establishing a therapeutic relationship takes time, and the nurse must be patient. The nurse provides explanations that are clear, direct, and easy to understand. Body language should include eye contact, but not staring, a relaxed body posture, and facial expressions that convey genuine interest and concern. Telling the client one’s name and calling the client by name is helpful in establishing trust as well as reality orientation. The nurse must carefully assess the client’s response to the use of touch. Sometimes gentle touch conveys caring and concern. At other times, the client may misinterpret the nurse’s touch as threatening and therefore undesirable. As the nurse sits near the client, does he or she move or look away? Is the client frightened or wary of the nurse’s presence? If so, that client may not be reassured by touch but frightened or threatened by it. Using Therapeutic Communication Communicating with clients experiencing psychotic symptoms can be difficult and frustrating. The nurse tries to understand and make sense of what the client is saying, but this can be difficult if the client is hallucinating, withdrawn from reality, or relatively mute. The nurse must maintain nonverbal communication with the client, especially when verbal communication is not successful. This involves spending time with the client, perhaps through fairly lengthy periods of silence. The presence of the nurse is a contact with reality for the client and can also demonstrate the nurse’s genuine interest and caring to the client. Calling the client by name, making references to the day https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 15/26 11/27/23, 3:43 AM Realizeit for Student and time, and commenting on the environment are all helpful ways to continue to make contact with a client who is having problems with reality orientation and verbal communication. Clients who are left alone for long periods become more deeply involved in their psychosis, so frequent contact and time spent with a client are important even if the nurse is unsure that the client is aware of the nurse’s presence. NURSING INTERVENTIONS For Clients with Schizophrenia Promoting safety of client and others and right to privacy and dignity Establishing therapeutic relationship by establishing trust Using therapeutic communication (clarifying feelings and statements when speech and thoughts are disorganized or confused) Interventions for delusions: Do not openly confront the delusion or argue with the client. Establish and maintain reality for the client. Use distracting techniques. Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs. Interventions for hallucinations: Help present and maintain reality by frequent contact and communication with client. Elicit description of hallucination to protect the client and others. The nurse’s understanding of the hallucination helps him or her know how to calm or reassure the client. Engage client in reality-based activities, such as card playing, occupational therapy, or listening to music. Coping with socially inappropriate behaviors: Redirect the client away from problem situations. Deal with inappropriate behaviors in a nonjudgmental and matter-of-fact manner; give factual statements; and do not scold the client. Reassure others that the client’s inappropriate behaviors or comments are not his or her fault (without violating client confidentiality). Try to reintegrate the client into the treatment milieu as soon as possible. Do not make the client feel punished or shunned for inappropriate behaviors. Teach social skills through education, role modeling, and practice. Client and family teaching Establishing community support systems and care Active listening is an important skill for the nurse trying to communicate with a client whose verbalizations are disorganized or nonsensical. Rather than dismissing what the client says because it is not clear, the nurse must make efforts to determine the meaning the client is trying to convey. Listening for themes or recurrent statements, asking clarifying questions, and exploring the meaning of the client’s statements are all useful techniques to increase understanding. The nurse must let the client know when his or her meaning is not clear. It is never useful to pretend to understand or just to agree or go along with what the client is saying; this is dishonest and violates https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 16/26 11/27/23, 3:43 AM Realizeit for Student trust between client and nurse. Nurse: “How are you feeling today?” (using a broad opening statement) Client: “Invisible.” Nurse: “Can you explain that to me?” (seeking clarification) Client: “Oh, it doesn’t matter.” Nurse: “I’m interested in how you feel; I’m just not sure I understand.” (offering self/seeking clarification) Client: “It doesn’t mean much.” Nurse: “Let me see if I can understand. Do you feel like you’re being ignored, that no one is really listening?” (verbalizing the implied) Implementing Interventions for Delusional Thoughts The client experiencing delusions utterly believes them and cannot be convinced that they are false or untrue. Such delusions powerfully influence the client’s behavior. For example, if the client’s delusion is that he or she is being poisoned, he or she will be suspicious, mistrustful, and probably resistant to providing information and taking medications. The nurse must avoid openly confronting the delusion or arguing with the client about it. The nurse must also avoid reinforcing the delusional belief by “playing along” with what the client says. It is the nurse’s responsibility to present and maintain reality by making simple statements such as “I have seen no evidence of that.” (presenting reality) or “It doesn’t seem that way to me.” (casting doubt) As antipsychotic medications begin to have a therapeutic effect, it will be possible for the nurse to discuss the delusional ideas with the client and identify ways in which the delusions interfere with the client’s daily life. The nurse can also help the client minimize the effects of delusional thinking. Distraction techniques, such as listening to music, watching television, writing, or talking to friends, are useful. Direct action, https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 17/26 11/27/23, 3:43 AM Realizeit for Student such as engaging in positive self-talk and positive thinking and ignoring the delusional thoughts, may be beneficial as well. Implementing Interventions for Hallucinations Intervening when the client experiences hallucinations requires the nurse to focus on what is real and to help shift the client’s response toward reality. Initially, the nurse must determine what the client is experiencing—that is, what the voices are saying or what the client is seeing. Doing so increases the nurse’s understanding of the nature of the client’s feelings and behavior. In command hallucinations, the client hears voices directing him or her to do something, often to hurt him or herself or someone else. For this reason, the nurse must elicit a description of the content of the hallucination so that health care personnel can take precautions to protect the client and others as necessary. The nurse might say, “I don’t hear any voices; what are you hearing?” (presenting reality/seeking clarification) This can also help the nurse understand how to relieve the client’s fears or paranoia. For example, the client might be seeing ghosts or monster-like images, and the nurse could respond, “I don’t see anything, but you must be frightened. You are safe here in the hospital.” (presenting reality/translating into feelings) This acknowledges the client’s fear but reassures the client that no harm will come to him or her. Clients do not always report or identify hallucinations. At times, the nurse must infer from the client’s behavior that hallucinations are occurring. Examples of behavior that indicate hallucinations include alternately listening and then talking when no one else is present, laughing inappropriately for no observable reason, and mumbling or mouthing words with no audible sound. A helpful strategy for intervening with hallucinations is to engage the client in a reality-based activity, such as playing cards, participating in occupational therapy, or listening to music. It is difficult for the client to pay attention to hallucinations and reality-based activity at the same time, so this technique of distracting the client is often useful. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 18/26 11/27/23, 3:43 AM Realizeit for Student It may also be useful to work with the client to identify certain situations or a particular frame of mind that may precede or trigger auditory hallucinations. Intensity of hallucinations is often related to anxiety levels; therefore, monitoring and intervening to lower a client’s anxiety may decrease the intensity of hallucinations. Clients who recognize that certain moods or patterns of thinking precede the onset of voices may eventually be able to manage or control the hallucinations by learning to manage or avoid particular states of mind. This may involve learning to relax when voices occur, engaging in diversions, correcting negative self-talk, and seeking out or avoiding social interaction. Teaching the client to talk back to the voices forcefully may also help him or her manage auditory hallucinations. The client should do this in a relatively private place rather than in public. There is an international self-help movement of “voice-hearer groups,” developed to assist people to manage auditory hallucinations. One group devised the strategy of carrying a cell phone (fake or real) to cope with voices when in public places. With cell phones, members can carry on conversations with their voices in the street—and tell them to shut up—while avoiding ridicule by looking like a normal part of the street scene. Being able to verbalize resistance can help the client feel empowered and capable of dealing with the hallucinations. Clients can also benefit from openly discussing the voice-hearing experience with designated others. Talking with other clients who have similar experiences with auditory hallucinations has proved helpful, so the client does not feel so isolated and alone with the hallucination experience. Some clients wanted to discuss the hallucinations with their community mental health nurse to better understand the hallucinations and what they might mean. Coping with Socially Inappropriate Behaviors Clients with schizophrenia often experience a loss of ego boundaries, which poses difficulties for themselves and others in their environment and community. Potentially bizarre or strange behaviors include touching others without warning or invitation, intruding into others’ living spaces, talking to or caressing inanimate objects, and engaging in socially inappropriate behaviors such as undressing, masturbating, or urinating in public. Clients may approach others and make provocative, insulting, or sexual statements. The nurse must consider the needs of others as well as the needs of clients in these situations. Protecting the client is a primary nursing responsibility and includes protecting the client from retaliation by others who experience the client’s intrusions and socially unacceptable behavior. Redirecting the client away from situations or others can interrupt the undesirable behavior and keep the client from further intrusive behaviors. The nurse must also try to protect the client’s right to privacy and dignity. Taking the client to his or her room or to a quiet area with less stimulation and https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 19/26 11/27/23, 3:43 AM Realizeit for Student fewer people often helps. Engaging the client in appropriate activities is also indicated. For example, if the client is undressing in front of others, the nurse might say, “Let’s go to your room and you can put your clothes back on.” (encouraging collaboration/redirecting to appropriate activity) If the client is making verbal statements to others, the nurse might ask the client to go for a walk or move to another area to listen to music. The nurse should deal with socially inappropriate behavior nonjudgmentally and matter-of-factly. This means making factual statements with no overtones of scolding and not talking to the client as if he or she were a naughty child. Some behaviors may be so offensive or threatening that others respond by yelling at, ridiculing, or even taking aggressive action against the client. Although providing physical protection for the client is the nurse’s first consideration, helping others affected by the client’s behavior is also important. Usually, the nurse can offer simple and factual statements to others that do not violate the client’s confidentiality. The nurse might make statements, such as “You didn’t do anything to provoke that behavior. Sometimes, people’s illnesses cause them to act in strange and uncomfortable ways. It is important not to laugh at behaviors that are part of someone’s illness.” (presenting reality/giving information) The nurse reassures the client’s family that these behaviors are part of the client’s illness and not personally directed at them. Such situations present an opportunity to educate family members about schizophrenia and help allay any feelings of guilt, shame, or responsibility. Reintegrating the client into the treatment milieu as soon as possible is essential. The client should not feel shunned or punished for inappropriate behavior. Health care personnel should introduce limited stimulation gradually. For example, when the client is comfortable and demonstrating appropriate behavior with the nurse, one or two other people can be engaged in a somewhat structured activity with the client. The client’s involvement is gradually increased to small groups and then to larger, less structured groups as he or she can tolerate the increased level of stimulation without decompensating (regressing to previous, less effective coping behaviors). Teaching the Client and Family Coping with schizophrenia is a major adjustment for both clients and their families. Understanding the illness, the need for continuing medication and follow-up, and the uncertainty of the prognosis or recovery are key issues. Clients and families need help to cope with the emotional upheaval that schizophrenia causes. See “Client and Family Education for Schizophrenia” for education points. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 20/26 11/27/23, 3:43 AM Realizeit for Student Identifying and managing one’s own health needs are primary concerns for everyone, but this is a particular challenge for clients with schizophrenia because their health needs can be complex and their ability to manage them may be impaired. The nurse helps the client manage his or her illness and health needs as independently as possible. This can be accomplished only through education and ongoing support. Teaching the client and family members to prevent or manage relapse is an essential part of a comprehensive plan of care. This includes providing facts about schizophrenia, identifying the early signs of relapse, and teaching health practices to promote physical and psychological well-being. Early identification of these relapse signs (Box 16.5) has been found to reduce the frequency of relapse; when relapse cannot be prevented, early identification provides the foundation for interventions to manage the relapse. For example, if the nurse finds that the client is fatigued or lacks adequate sleep or proper nutrition, interventions to promote rest and nutrition may prevent a relapse or minimize its intensity and duration. BOX 16.5 Early Signs of Relapse Impaired cause-and-effect reasoning Impaired information processing Poor nutrition Lack of sleep Lack of exercise Fatigue Poor social skills, social isolation, loneliness Interpersonal difficulties Lack of control, irritability Mood swings Ineffective medication management Low self-concept Looks and acts different Hopeless feelings Loss of motivation Anxiety and worry Disinhibition Increased negativity Neglecting appearance Forgetfulness CLIENT AND FAMILY EDUCATION For Schizophrenia How to manage illness and symptoms Recognizing early signs of relapse Developing a plan to address relapse signs https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 21/26 11/27/23, 3:43 AM Realizeit for Student Importance of maintaining prescribed medication regimen and regular follow-up Avoiding alcohol and other drugs Self-care and proper nutrition Teaching social skills through education, role modeling, and practice Seeking assistance to avoid or manage stressful situations Counseling and educating family/significant others about the biologic causes and clinical course of schizophrenia and the need for ongoing support Importance of maintaining contact with the community and participating in supportive organizations and care Nurse: “How have you been sleeping lately?” Client: “Oh, I try to sleep at night. I like to listen to music to help me sleep. I really like countrywestern music best. What do you like? Can I have something to eat pretty soon? I’m hungry.” Nurse: “Can you tell me how you’ve been sleeping?” The nurse can use the list of relapse risk factors in several ways. He or she can include these risk factors in discharge teaching before the client leaves the inpatient setting so that the client and family know what to watch for and when to seek assistance. The nurse can also use the list when assessing the client in an outpatient or clinic setting or when working with clients in a community support program. The nurse can also provide teaching to ancillary personnel who may work with the client so they know when to contact a mental health professional. Taking medications as prescribed, keeping regular follow-up appointments, and avoiding alcohol and other drugs have been associated with fewer and shorter hospital stays. In addition, clients who can identify and avoid stressful situations are less likely to suffer frequent relapses. Using a list of relapse risk factors is one way to assess the client’s progress in the community. Families experience a wide variety of responses to the illness of their loved one. Some family members might be ashamed or embarrassed or frightened of the client’s strange or threatening behaviors. They worry about a relapse. They may feel guilty for having these feelings or fear for their own mental health or well-being. If the client experiences repeated and profound problems with schizophrenia, the family members may become emotionally exhausted or even alienated from the client, feeling they can no longer deal with the situation. Family members need ongoing support and education, including reassurance that they are not the cause of schizophrenia. Participating in organizations such as the Alliance for the Mentally Ill may help families with their ongoing needs. Teaching Self-Care and Proper Nutrition Because of apathy or lack of energy over the course of the illness, poor personal hygiene can be a problem for clients who are experiencing psychotic symptoms as well as for all clients with https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 22/26 11/27/23, 3:43 AM Realizeit for Student schizophrenia. When the client is psychotic, he or she may pay little attention to hygiene or may be unable to sustain the attention or concentration required to complete grooming tasks. The nurse may need to direct the client through the necessary steps for bathing, shampooing, dressing, and so forth. The nurse gives directions in short, clear statements to enhance the client’s ability to complete the tasks. The nurse allows ample time for grooming and performing hygiene and does not attempt to rush or hurry the client. In this way, the nurse encourages the client to become more independent as soon as possible—that is, when he or she is better oriented to reality and better able to sustain the concentration and attention needed for these tasks. If the client has deficits in hygiene and grooming resulting from apathy or lack of energy for tasks, the nurse may vary the approach used to promote the client’s independence in these areas. The client is most likely to perform tasks of hygiene and grooming if they become a part of his or her daily routine. The client who has an established structure that incorporates his or her preferences has a greater chance for success than the client who waits to decide about hygiene tasks or performs them randomly. For example, the client may prefer to shower and shampoo on Monday, Wednesday, and Friday upon getting up in the morning. This nurse can assist the client to incorporate this plan into the client’s daily routine, which leads to it becoming a habit. The client thus avoids making daily decisions about whether or not to shower or whether he or she feels like showering on a particular day. Adequate nutrition and fluids are essential to the client’s physical and emotional well-being. Careful assessment of the client’s eating patterns and preferences allows the nurse to determine whether the client needs assistance in these areas. As with any type of self-care deficit, the nurse provides assistance as long as needed and then gradually promotes the client’s independence as soon as the client is capable. When the client is in the community, factors other than the client’s illness may contribute to inadequate nutritional intake. Examples include lack of money to buy food, lack of knowledge about a nutritious diet, inadequate transportation, or limited abilities to prepare food. A thorough assessment of the client’s functional abilities for community living helps the nurse plan appropriate interventions. See the section “Community-Based Care.” Teaching Social Skills Clients may be isolated from others for a variety of reasons. The bizarre behavior or statements of the client who is delusional or hallucinating may frighten or embarrass family or community members. Clients who are suspicious or mistrustful may avoid contact with others. Other times, clients may lack the social or conversation skills they need to make and maintain relationships with https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IVD5YOX6GjyN8BXsE5kBD64UN3Harx67qLkpTVXS1u… 23/26 11/27/23, 3:43 AM Realizeit for Student others. Also, a stigma remains attached to mental illness, particularly for clients for whom medication fails to relieve the positive signs of the illness. The nurse can help the client develop social skills through education, role modeling, and practice. The client may not discriminate between the topics suitable for sharing with the nurse and those suitable for use to initiate a conversation on a bus. The nurse can help the client learn neutral social topics appropriate to any conversation, such as the weather or local events. The client can also benefit from learning that he or she should share certain details of his or her illness, such as the content of delusions or hallucinations, only with a health care provider. Modeling and practicing social skills with the client can help him or her experience greater success in social interactions. Specific skills such as eye contact, attentive listening, and taking turns talking can increase the client’s abilities and confidence in socializing. Medication Management Maintaining the medication regimen is vital to a successful outcome for clients with schizophrenia. Failing to take medications as prescribed is one of the most frequent reasons for recurrence of psychotic symptoms and hospital admission. Clients who respond well to and maintain an antipsychotic medication regimen may lead relatively normal lives with only an occasional relapse. Those who do not respond well to antipsychotic agents may face a lif