Week 13 MHD Schizophrenia Spectrum Student PDF 2024-2025

SCHIZOPHRENIA SPECTRUM NURS 1028 Chapter 21 1  SCHIZOPHRENIA Schizophrenia is a major psychotic disorder that affects a person’s thinking, language, emotions, social behaviour and ability to perceive reality. Individual symptoms differ from...

SCHIZOPHRENIA SPECTRUM NURS 1028 Chapter 21 1  SCHIZOPHRENIA Schizophrenia is a major psychotic disorder that affects a person’s thinking, language, emotions, social behaviour and ability to perceive reality. Individual symptoms differ from one another. The experience for a single individual may be different from episode to episode. Schizophrenia most often occurs in adolescence or early adult life and the symptoms can be easily confused with anxiety and moodiness of teenage years. It is treatable (best when detected early in the disease process) but it is a serious, chronic (life-long) and potentially disabling mental health illness. 2  RISK FACTORS Rare genetic changes that may be responsible for the onset of schizophrenia Stresses in the perinatal period impacting neurodevelopment (e.g., starvation, poor nutrition, infections), obstetrical complications and genetic and family susceptibilities Infants affected by maternal stressors may have conditions (i.e., low birth weight, short gestation, and early developmental difficulties) that create their own risk, such as inconsistent neuroanatomic brain changes impacting cell death and myelination In childhood, stressors may include central nervous system (CNS) infections Schizophrenia is higher among individuals born in urban settings than those born in rural ones 3  RISK FACTORS Age of Onset: Late adolescence to early adulthood (begins prior to age 25). Evidence such as, showing disruptions in the achievement of milestone events (e.g., education, employment settings and long-term relationships). Gender Differences: Men typically diagnosed earlier (middle 20’s) that women (late 20’s). Estrogen may play a protective role against the development of schizophrenia. Ethnic and Cultural Differences: Lower incidence in Asian versus non- Asian countries. Familial Differences: First degree biologic relatives (i.e., children, siblings, parents) of an individual with schizophrenia have 10 times greater risk for schizophrenia than the general population. Also, higher among monozygotic (identical) compared with dizygotic (fraternal) twins. 4  RISK FACTORS Comorbidities: Several somatic and psychological disorders coexist with schizophrenia (i.e., depression, diabetes mellitus and substance use) Depression: Depression is not unusual in all stages (acute, stabilization, recovery and relapse) of schizophrenia and deserves attention Diabetes Mellitus: Type II diabetes due to weight gain from antipsychotic medications used for treatment Substance Abuse: Cannabis use has been associated with an increased risk of psychosis onset Note. There is debate in the literature on the Neurotransmitters: Dopamine dysfunction leading to dopamine hyperactivity and increase in positive symptoms effect of cannabis on mental health, therefore, health professionals should not confuse Theory: The dopamine hypothesis of schizophrenia is considered that there is a dysfunction in the receptors correlation dopamine withancausation and this causes increased release of dopamine (hyperdopaminergic) and stimulates action in the brain. 5  DSM-5 DIAGNOSTIC CRITERIA: SCHIZOPHRENIA The current DSM V lists the following as schizophrenia classification guidelines in clients if two or more occur persistently. However, delusions or hallucinations alone can often be enough to lead to a diagnosis of schizophrenia. A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of the must be (1), (2), or (3): 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behaviour 5. Negative symptoms (i.e., diminished emotional expression or avolition) B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning). C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) 6  DIAGNOSTIC CRITERIA Positive Symptoms: “First rank,” symptoms, reflect an excess or distortion of normal functions. Delusions: Fixed false beliefs that usually involve a misinterpretation of experience. Examples: Clients believe what others are saying about them, reading their thoughts or plotting against them. They may see someone who doesn’t exist, feel that the person is tapping on the shoulder, or hear the imaginary person speak to them. Hallucinations: False perceptual experiences that occur without actual external sensory stimuli. They can involve any of the five senses (hearing, seeing, tasting, feeling, or smelling things that others do not experience). Example: Client hears voices carrying on a discussion about his or her own thoughts or behaviours. Common perception is being followed or chased by members of authority (e.g., police). 7  DIAGNOSTIC CRITERIA Negative Symptoms: “Second rank” symptoms, reflect a lessening or loss of normal functions and feeling out of touch with other people, family, or friends. Affective Flattening: Restriction in the range and intensity of emotion (e.g., facial expression or voice tone) and inability to initiate and persist in goal-directed activity. Avolition: Lack of motivation (e.g., loss of interest in everyday activities, like bathing, grooming, or getting dressed). Asocial: Social withdrawal or discomfort. Apathy: Indifference or the suppression of emotions such as concern, excitement, motivation, or passion. Alogia: Reduced fluency and productivity of thought and speech. Anergia: Lethargy; persistent and abnormal lack of energy. Anhedonia: Loss of pleasure in things previously enjoyed. 8  DIAGNOSTIC CRITERIA Neurocognitive Impairment: Related to short term (working memory) and long- term (intellectual functioning) memory, vigilance or sustained attention, verbal fluency or the ability to generate new words, and executive functioning, which includes volition (power of using one's will = strive), planning, purposive action, and self-monitoring behaviour. Working memory is a concept that includes short-term memory and the ability to store and process information. For many people with this disorder, symptoms may have interfered with completing educational opportunities. Disorganized Thinking: Disorganized perceptions often create oversensitivity to colours, shapes, and background activities. Illusions occur when the person misperceives or exaggerates stimuli that actually exist in the external environment (distortion of the senses). This is in contrast to hallucinations, which are perceptions in the absence of environmental stimuli. Example: A person sensing illusions can mistake a rope for a snake, so there is a stimulus but misunderstood. Secondary symptoms that may accompany schizophrenia include anxiety, depression, irritability, and hostility. 9  SIGNS AND SYMPTOMS DIFFERENCES BETWEEN PERCEPTION DISORDER Perception Disorder Definition Example Delusion Non-Bizarre Delusions: A situation that Imagining a spouse is could actually happen in real life. having an affair or Experienced by the person concerned being chased by the only. FBI. Bizarre Delusions: Include situations Being able to make that could never happen in real life. oneself invisible. Experienced by the person concerned only. Hallucination Hallucination is a false sensory Perceiving a snake perception, which a person experiences while there is nothing. without actual external stimulus. Experienced by the person concerned only. Illusion Illusion is the misperception of an real Perceiving a black external stimulus like perceiving the wire as a snake. shape, size, color, texture, height, etc. of the object differently. Experienced by many people. 10  DIAGNOSTIC CRITERIA Disorganized Behaviour: May manifest as a very slow, rhythmic, or ritualistic movement, coupled with disorganized speech, makes it difficult for someone with schizophrenia to partake in daily activities. Examples of disorganized behaviour include the following: Aggression: Behaviours or attitudes that reflect rage, hostility, and the potential for physical or verbal destructiveness (usually comes about if the person believes that someone is going to do him or her harm). Agitation: Inability to sit still or attend to others, accompanied by heightened emotions and tension. Catatonic Excitement: A hyperactivity characterized by purposeless activities and abnormal movements such as grimacing and posturing. Echopraxia: Involuntary imitation of another person’s movements and gestures. Regressed Behaviour: Behaving in a manner of a less mature life stage; childlike and immature. Stereotypy: Repetitive, purposeless movements that are idiosyncratic to the individual and to some degree outside of the individual’s control. Hypervigilance: Sustained attention to external stimuli as if expecting something important or frightening to happen. Waxy Flexibility: Posture held in odd or unusual fixed position for extended periods of time. 11 CATATONIC BEHAVIOURS 12  CATATONIC BEHAVIOURS Catatonic Rigidity (Waxy Flexibility): Withdrawn type characteristics (e.g., immobility, mutism, staring, rigidity, which can last seconds, minutes, hours or days). Catatonic Excitement: Characterized by purposeless and excessive motor activity that includes disorganized pressured speech, flight of ideas, verbigeration (i.e., dog cat ate car work”), disorientation and/or confusion, and confabulation. Example: 56 second video of Catatonic Excitement https://symptommedia.com/catatonia-associated-with-schizophrenia-ce-course-previe w/ 13  INTERDISCIPLINARY TREATMENT Nursing and Nurse Practitioners Psychiatry (OHIP funded) Psychology (private benefit coverage) Social Work Occupational and Recreational Therapies Pastoral Counselling Peer Support Workers Peer support work is a para-profession encompassing a range of social service and community work positions filled by people who share identities and experiences with the populations they serve. Peer support workers strategically call upon stories and lessons from their own lives to assist people in various capacities. Pharmacy Various health professionals are necessary because of the complex nature of schizophrenia symptoms and the continuum of interventions required to enhance best outcomes: Inpatient Teams Outpatient Teams Community-based Recovery-oriented programs 14  Differences Between Mental Health Professionals Professional Can Can Prescribe Key Services Diagnose Medications Psychologist Yes No Can evaluate and diagnose through assessment tests. Treats mental health disorders through psychotherapy. No (except No Can offer talk therapy to treat stress, Psychotherapist in relationships, and various mental health Quebec) disorders. Mental Health No No Discusses stress, marriage counselling, Counsellor and other mental health problems. Social Worker No No Helps individuals and families and connects them with the right resources in their community. Quebec: If regulated as a psychotherapist, can treat mental health disorders Psychiatrist Yes Yes Diagnoses and treats mental health Covered by provincial disorders. health plan Note. Doctor referral required. Inform client and/or family to check benefit coverage for services that may or may not be covered through work place insurance plans. 15  FAMILY RESPONSE TO DISORDER Mixed emotions but the initial period is very difficult: Shock Disbelief Fear Care Concern Hope Families initially may seek reasons for the psychotic episode, attributing it to taking illicit drugs or to extraordinary stress or fatigue. Parents may blame themselves. Some often do not know how to comfort their ill family member and may find themselves fearful of the behaviours. 16 NURSING CARE PLAN FOR SCHIZOPHRENIC CLIENTS 17  PREDISPOSING FACTORS BIOLOGIC SOCIAL PSYCHOLOGICAL 18  BIOLOGIC DOMAIN NURSING ASSESSMENT Current and Past Health Status and Physical Examination History and Physical: Rule out medical illness (e.g., Diabetes Mellitus) or substance abuse that could contribute to psychiatric symptoms. Smoking: Smoking can lower concentration of antipsychotic drugs such as clozapine. Individuals that smoke may require a higher dose of these medications than do non-smokers. Note. Individuals that are unable to smoke (due to smoke-free policies) or have quit smoking are at risk of increased antipsychotic blood levels and possible toxicity. Physical Functioning: Self-care deficits related to negative symptoms (i.e., avolition). Nutrition: Increased appetite and weight gain (as much as 20 or 30 pounds within 1 year). Note. Medications that alter nutrition (increased) and client may need to limit calories or fat intake. Fluid Imbalance: Polydipsia and polyuria, puffiness of the face or eyes, abdominal distention, and hypothermia to identify disordered water balance. Note. Psychotic polydipsia and the resetting (fully suppressed) of antidiuretic hormone (ADH) regulation leads to water intoxication. Medications: Physically awkward movements, poor coordination, motor abnormalities and abnormal eye tracking. Note. Side effects of medications; antipsychotic drugs block dopamine transmission in the brain and cause extrapyramidal symptoms (motor abnormalities). 19  PSYCHOLOGICAL DOMAIN NURSING ASSESSMENT Appearance Grooming and Hygiene: May look or dishevelled or have poor hygiene. Dress: Eccentric and bizarre dress. Is it appropriate for setting, season, age, gender, and social group? Posture: May suggest lethargy or stupor. Behavioural Responses Mood and Affect: Display altered mood states. May show heightened emotional activity; others may display severely limited emotional responses. Affect, the outward expression of mood, is categorized on a continuum: flat (absent), blunted (present but greatly diminished), and full range. Inappropriate affect is marked by incongruence between the emotional expression and the thoughts expressed. Speech: Speech patterns may reflect obsessions, delusions, pressured thinking, loose associations, or flight of ideas and neologisms. Both content and speech patterns should be noted. Flight of Ideas: Abrupt change, rapid skipping from topic to topic, practically continuous flow of accelerated speech; topics usually have recognizable associations or are plays on words Example: “Take this pill? The pill is blue. I feel blue. (sings) She wore blue velvet.” Disorganized Communication Cognitive Functions Memory and Orientation: Orientation to time, place, and person may remain relatively intact unless the client is particularly preoccupied with delusions and hallucinations. Registration or the recall within seconds of newly learned information may be particularly diminished. This affects the individual’s short-and long-term memories. The ability to engage in abstract thinking may be impaired. 20  PSYCHOLOGICAL DOMAIN NURSING ASSESSMENT Thought Processes Process: Does this person make sense? Content: What the client says should be consistent and logical (i.e., delusions) Perceptions: Aware of reality? (i.e., illusions and hallucinations) Insight and Judgement: Insight is the ability to recognize one's own illness, need for treatment, and consequences of one's behaviour as stemming from an illness. Judgment is comparing and evaluate the alertness in a situation and make an action plan Delusions Disturbed thought processes Hallucinations Self-Concept: Usually poor. Clients often are aware that they are hearing voices others do not hear. They recognize that they are different from others and are often afraid of “going crazy.” Aware of the loss of expectations for their future achievements. Pervasive stigma associated with having a mental illness contributes to poor self-concept. Stress and Coping Patterns: Stressful events are often linked to psychiatric symptoms. Determine typical coping patterns, especially negative coping strategies, such as the use of substances or aggressive behaviour. 21 21  PSYCHOLOGICAL DOMAIN NURSING ASSESSMENT Risk Assessment: Suicide rate among individuals with schizophrenia is higher than that of the general population. Risk factors for suicide are male gender, chronic illness with frequent relapses, frequent short hospitalizations, a negative attitude toward treatment, impulsive behaviour, parasuicide (nonfatal self-harm or gesture), psychosis, and depression. Periods of untreated psychosis exceeding 1 year and treatment with older typical antipsychotic drugs also have been associated with a higher risk for suicide. Because of high suicide and attempted suicide rates among clients with schizophrenia, the nurse needs to assess clients risk for self-injury: Do clients speak of suicide? Delusional thinking that could lead to dangerous behaviour? Command hallucinations telling them to harm themselves or others? Have homicidal ideations? Have access to weapons? 22  SOCIAL DOMAIN NURSING ASSESSMENT Functional Status: Poor functioning and the inability to complete activities of daily living are manifested in poor hygiene (i.e., able to perform ADLs), malnutrition, and social isolation. Should be assessed initially and at regular intervals. Social Systems: Becomes very important in maintaining the client in the community. Assessment of the client’s formal support (e.g., family caregivers, health care providers) and informal support (e.g., neighbours, friends) should be conducted. Quality of Life: Often have a poor quality of life, due to the chronicity and incomplete symptom resolution, significant numbers of clients live in residential settings or long-term hospitalizations and do not reach such adult milestones as getting married, having children, and being gainfully employed. Stigma living with a mental illness. Poor resources and lifetime disability. Family Assessment: Often, the nurse’s first contact with the client and family is in the initial phases of the disorder. Family tension? (Client may feel like a burden and disconnected from parents and siblings) What stage (acute, stabilization, recovery and relapse) is the client in? Coping mechanisms? Family is usually dealing with the shock and disbelief of seeing a child or spouse with a mental illness that may have lifelong consequence. 23  NURSING DIAGNOSIS Common nursing diagnoses for positive symptoms include: Risk for Other-Directed Violence related to paranoia Risk for Suicide related to delusions Disturbed Thought Processes R/T…gross disorganized thinking Example: Disturbed thought processes related to overwhelming stressful life events as evidenced by persistent hallucinations and significant periods of memory deficits for the past three days Disturbed Sensory Perception related to hallucinations Disturbed Personal Identity related to delusions (of grandeur) Impaired Verbal Communication related to confused speech/echopraxia 24  NURSING DIAGNOSIS Common nursing diagnoses for negative symptoms and functional abilities include: Self-Care Deficits related to lethargy Example: Self-Care Deficits related to lethargy as evidenced by poor personal hygiene and client states, “I’m just can’t be bothered to wash or dress myself”. Social Isolation related to poverty of speech Deficient Diversional Activity related to loss of pleasure Ineffective Health Maintenance related to lack of motivation Ineffective Therapeutic Regimen Management related to apathy 25  PLANNING CLIENT OUTCOMES Expected outcomes for the acute, psychotic phase; the client will: Not injure self or others Establish contact with reality Interact with others Express thoughts and feelings in a safe and socially acceptable manner Participate in prescribed therapeutic interventions Decrease anxiety and increase trust 26  PLANNING CLIENT OUTCOMES Expected outcomes for the acute, psychotic phase; the client will: Not injure self or others Establish contact with reality Interact with others Express thoughts and feelings in a safe and socially acceptable manner Participate in prescribed therapeutic interventions Example: The client will be able to will express thoughts and feelings to help decrease anxiety during episodes of disturbed thought processes and develop an increase in trust of the interprofessional team within one month 27  PLANNING CLIENT OUTCOMES Expected outcomes for continued care; the client will: Participate in the prescribed regiment (including medication and follow-up appointments) Maintain adequate routines for sleeping and food and fluid intake Be independent in self-care activities Communicate effectively with others in the community to meet his or her needs Seek or accept assistance to meet his or her needs when indicated 28  BIOLOGIC DOMAIN NURSING INTERVENTIONS Promotion of Self-Care Activities Develop a daily schedule of routine activities (e.g., showering and shaving) as it helps structure the day. Encourage use of an alarm clock or voice alarm to get dressed. Activity, Exercise and Nutrition Instruct client to keep a food diary. Encourage attending diet, exercise and weight management support groups. Monitor for Type II Diabetes Mellitus (i.e., glucose levels). Measure weight at regular intervals and calculate BMI (≤ 27). Monitor lab values for cholesterol and triglycerides (cardiac disease). Note. Schizophrenia is usually made in late adolescence or early adulthood, it is possible to establish solid exercise patterns early. Thermoregulation Observe the client’s response to temperature as they can be oblivious to cold weather in winter and in the heat of summer, dress for winter. Encourage sun safety and regular use of sunscreen as several antipsychotic medications can cause photosensitivity. Instruct client and family to make sure summer clothes are put away in summer 29  BIOLOGIC DOMAIN NURSING INTERVENTIONS Promotion of Self-Care Activities Develop a daily schedule of routine activities (e.g., showering and shaving) as it helps structure the day. Encourage use of an alarm clock or voice alarm to get dressed. Activity, Exercise and Nutrition Instruct client to keep a food diary. Encourage attending diet, exercise and weight management support groups. Monitor for Type II Diabetes Mellitus (i.e., glucose levels). Measure weight at regular intervals and calculate BMI (≤ 27). Monitor lab values for cholesterol and triglycerides (cardiac disease). Note. Schizophrenia is usually made in late adolescence or early adulthood, it is possible to establish solid exercise patterns early. Thermoregulation Observe the client’s response to temperature as they can be oblivious to cold weather in winter and in the heat of summer, dress for winter. Encourage sun safety and regular use of sunscreen as several antipsychotic medications can cause photosensitivity. Instruct client and family to make sure summer clothes are put away in summer 30  THERMOREGULATION THEORIES Body temperature is regulated by the preoptic anterior hypothalamus with involvement of dopamine, serotonin, norepinephrine, and alpha- adrenergic receptors. Experimental data suggest that stimulation of serotonin and dopamine receptors can increase the body temperature. Additional clinical evidence indicates potent antagonists of serotonin (Risperidone) are more likely to cause hypothermia.“ The 'fractured self' of schizophrenia often leads to misinterpretation of bodily sensations. Why schizophrenic clients wear multiple layers of clothing is not well understood but the three possibilities are: 1. Subtle hypothalamic (or autonomic) dysfunction 2. Wearing layers to achieve a sense of security 3. Motor or cognitive dysfunction during dressing 31  BIOLOGIC DOMAIN NURSING INTERVENTIONS Promotion of Normal Fluid Balance Implement water intoxication protocol by doing daily weights and monitoring urine specific gravity and serum sodium levels Monitoring Actions and Side Effects of Medications Assess effectiveness of antipsychotic medications to produce a change in symptoms in 1 to 2 weeks. Continue to assess effectiveness during stabilization period, generally 6 to 12 weeks to determine if therapeutic outcomes have been achieved. Given the nature of a chronic illness like schizophrenia, clients generally face a lifetime of taking antipsychotic medications. Nonadherence to the medication regimen is an important factor in relapse. Clients and their families must be made aware of the importance of consistently taking medications, despite feeling better or the side effects. Example: Clozapine (Clozaril) = Atypical Antipsychotic Clozapine is exceptional in that it often works even when other medications have failed but it requires monitoring of white blood cell counts. Inform client that weekly blood draws are required. Tell client to notify the prescriber immediately if lethargy, weakness, sore throat, malaise, or other flu-like symptoms develop. Encourage client change positions slowly (may experience orthostatic hypotension). Instruct client to not abruptly discontinue Clozapine. 32 Atypical Antipsychotic Medications Typical Antipsychotic Medications Abilify (aripiprazole) Clopixol (zuclopenthixol) Abilify Maintena (aripiprazole extended Fluanxol (flupentixol) release) Haldol (haloperidol) Clozaril (clozapine) Largactil (chlorpromazine) Invega (paliperidone) Loxapac (loxapine) Invega Sustenna (paliperidone Majeptil (thioproperazine) palmitate) Modecate (fluphenazine) Invega Trinza (paliperidone palmitate) Navane (thiothixene) Latuda (lurasidone) Nozinan (methotrimeprazine) Risperdal (risperidone) Neuleptil (periciazine) Risperdal Consta (risperidone) Nozinan (methotrimeprazine) Saphris (asenapine) Orap (pimozide) Seroquel (quetiapine) Stelazine (trifluoperazine) Zeldox (ziprasidone) Stemetil (prochlorperazine) Zyprexa (olanzapine) Trilafon (perphenazine) Zyprexa Intramuscular (olanzapine tartrate) 33  ATYPICAL VERSUS TYPICAL ANTIPSYCHOTICS The key characteristic of atypical antipsychotics is that the drugs effectively treat psychoses at doses which do not induce extra pyramidal adverse effects. In contrast, the typical drugs tend to cause extra pyramidal adverse effects at the doses which are effective for psychotic symptoms. The extrapyramidal side effects of antipsychotic drugs can appear early in drug treatment and include acute parkinsonism or pseudoparkinsonism, dystonia, and akathisia, or they can appear late in treatment after months or years. The primary example of late- appearing extrapyramidal side effects is tardive dyskinesia, which is a severe syndrome of abnormal motor movements of the mouth, tongue, and jaw. Dystonia: Muscles tense and their body contorts. The experience often starts with stiffness experienced in the muscles, eye movements tense and pull the eyeball so that the client is looking toward the ceiling. This may be followed by torticollis, in which the neck muscles pull the head to the side. Akathisia: Clients are restless and report that they feel driven to keep moving. They are very uncomfortable. Frequently, this response is misinterpreted as anxiety or increased psychotic symptoms, and the client may be inappropriately given increased dosages of the antipsychotic drug, which only perpetuates the side effect. Tardive Dyskinesia: Typical movements involve the mouth, tongue, and jaw and include lip smacking, sucking, puckering, tongue protrusion, the bon-bon sign (where the tongue rolls around in the mouth and protrudes into the cheek as if the client were sucking on a piece of hard candy), athetoid (wormlike) movements in the tongue, and chewing. Other facial movements, such as grimacing and eye blinking, also may be present. 34  PSYCHOLOGICAL DOMAIN NURSING INTERVENTIONS Special Issues in the Nurse-Client Relationship Approach the client in a calm and caring manner Accept the client as being a worthy human being. Be consistent in interactions Follow through on promises will help establish trust within the relationship Note. Establishing a therapeutic relationship is crucial. Some clients with schizophrenia deny having a mental illness, they may take medication and attend treatment activities because they trust the nurse. Management of Disturbed Thoughts and Sensory Perceptions Never tell a client that these experiences are not real. Discounting the experiences blocks communication. Validate the client’s experiences and identify the meaning of these thoughts and feelings to the client = Decrease anxiety Example: A client feels frightened and suspicious of everyone. The nurse acknowledging how frightening it must be to always feel like you are being watched, the nurse is focusing on the feelings generated by the delusion, not the delusion itself. Offer to help the client feel safe within this environment = Increase in trust. 35  PSYCHOLOGICAL DOMAIN NURSING INTERVENTIONS Self-Monitoring and Relapse Prevention Monitor high risk times, events, places, and stimuli surrounding recurrence of symptoms. Enhancement of Cognitive Functioning Improve attention (e.g., computer programmes, one-to-one) Help memory (e.g., make lists, write down information) Behavioural Interventions Assist client to improve motivation by organizing routines and daily activities by developing a schedule. Reinforcement of positive behaviours (e.g., getting up on time, completing hygiene, going to treatment activities). Stress and Coping Skills Development Counselling sessions to support the development of positive coping skills to deal with personal, social, and environmental stresses Reward positive coping skills. Implement digital applications, which can assist with coping with delusions and hallucinations. CopingTutor which includes presentations, games, and self-help worksheets. The download is available for a small cost. 36  PSYCHOLOGICAL DOMAIN NURSING INTERVENTIONS Client Education Promote an errorless learning environment Provide minimal distractions Utilize clear visual aids (e.g., music, art, drama) Encourage skills training (e.g., employment skills) Convening support groups Implement therapy Develop psychiatric rehabilitation strategies (e.g., communication skills) Family Support Schizophrenia Society of Canada: “Strengthening Families Together” is a 10-session national education program launched by our schizophrenia association, for family members and friends of individuals with serious and persistent mental illnesses. Educate the family regarding lifelong disorder of schizophrenia. Emphasize consistent taking medication. Encourage family to participate in support groups. Inform about local and provincial resources. Help negotiate healthcare system. Religious or spiritual beliefs can be a resource for both clients and their families. 37  SOCIAL DOMAIN NURSING INTERVENTIONS Promote Client Safety Increased staff monitoring during hallucinations or delusions. Reduce environmental stimulation by providing a secluded area (e.g., private room). Note. Make sure they and others feel safe! Demonstrate respect for the client and their personal space. Assess and monitor for signs of fear and agitation. Implement preventative interventions before client loses control (e.g., PRN medications). Help client to talk directly and constructively with those with whom they are angry with. Involve the client in formulating a contract that outlines client and staff behaviours, goals, and consequences. Assess for coercive interaction style of violence to obtain what is desired. Set limits with consistent and justly applied consequences. Schedule brief but regular time-outs. Convening Support Groups People with mental illness benefit from support groups that focus on daily problems and the stress of dealing with a mental illness. These groups are useful throughout the continuum of care and help reduce the risk for suicide. Provides opportunity to share stories of recovery. Friendships often develop from these groups. Note. Developing a positive support system for stressful periods will help promote a positive outcome. 38  SOCIAL DOMAIN NURSING INTERVENTIONS Implementing Milieu Therapy Form of psychotherapy that involves the use of therapeutic communities. Clients join a group of around 30, for between 9 and 18 months. Encourage clients to take responsibility for themselves and the others within the unit, based upon a hierarchy of collective consequences. Guide senior clients to model appropriate behavior for newer clients. Reinforce the importance of following rules. If one client violates the rules, others who were aware of the violation but did not intervene may also be disciplined to varying extents based upon their involvement. Developing Psychiatric Rehabilitation Strategies Rehabilitation strategies = integration into the community. Arrange daily home visits, transportation, occupational training, and group support (reinforces social skills). Instructions are taught by nurses through lecture, demonstration, role-playing, and homework assignments. Demonstrate careful attention to discharge planning encourages follow-up care in the community. Note. Continuity of care has been identified as a major goal of community mental health systems for patients with schizophrenia, because they are at risk for becoming “lost” to services if left alone after discharge. Family Interventions Schizophrenia is a lifetime disorder clients and families are properly educated about the course of the disorder, Encourage family members to participate in educational and support groups that help family members deal with the realities of living with a loved one with a mental illness. Provide information about local community and provincial resources and organizations such as mental health associations and those that can help families negotiate the complex system. Reinforce the importance of medication adherence, and the need for consistent care and support. Note. Research is demonstrating that interaction between patients and their families is key to the success of long-term treatments and outcomes. 39  REFERENCES Kunyk, D., Peternelj-Taylor, C., & Austin, W. (2022). Psychiatric and mental health nursing for Canadian practice (5th ed.). Wolters Kluwer. 40