Nursing Diagnoses

Risk for injury

Risk for injury is an important nursing diagnosis to make especially if the patient is currently experiencing psychosis. Auditory and visual hallucinations and impaired judgment can cause a patient to react in a way they normally would not and cause injury. It is critical for the nurse to create as safe an environment as possible to decrease the risk of the patient getting hurt. 

Disturbed thought processes

As I have explained throughout this blog, schizophrenia can create changes in the way a person thinks and rationalizes. Add in hallucinations and it can be extremely difficult to rationalize even the simplest of tasks. Using short, simple sentences and helping the patient work through a situation can help the patient improve his/her thought processes. It is always important to recognize that the patient is experiencing a change in thought processing and to cater your communication to the patient's current level of understanding.

Social Isolation

Social isolation can be very common in schizophrenic patients. Auditory hallucinations may be telling the individual to stay away from other people or the person may be feeling stigmatized due to having schizophrenia. Social isolation is not the way to rehabilitation and recovery for those with schizophrenia. In an inpatient setting the patient needs to be out in the milieu, attending groups, and eating meals in the dining room. In an outpatient setting a patient who missed an appointment may need to be called or checked on to make sure he/she is not staying isolated within his/her own home. 

Disturbed sensory perception

A patient currently experiencing psychosis will have some form of disturbed sensory perception whether it is auditory, visual, or kinesthetic. The nurse should acknowledge that he/she is hearing that the patient is currently experiencing hallucinations and that they can be scary, but that the nurse is not seeing or hearing the same things. It's important to acknowledge what the patient is experiencing, but also letting the patient know that the hallucinations are not reality.

Caregiver role strain

Parents, siblings, friends, or spouses may feel upset and hopeless when it comes to the patient's diagnosis and recovery. Often caregivers may think the recovery will be much quicker than it actually is for the patient. Patient and family education on schizophrenia and giving the caregiver a realistic timeline of the patient's recovery can help alleviate some of this strain and stress. 

The following are websites that can be of help for those living with schizophrenia and for those who know people with the disease:

http://schizophrenia.com/

http://www.nami.org/

http://www.sardaa.org/

Nursing Care

Acute and crisis phase

For a patient who is actively psychotic, whether it be the first psychotic break or a relapse, the most important goal for the nurse is to keep the patient safe on the inpatient unit, while helping him/her become stable. It is important to remember that while a patient can remember what happened during psychosis after psychiatric stability has been reached, the patient is not his/her normal self, has very impaired judgment, and often can harm his/herself due to responses to hallucinations.1 Communicating with a psychotic patient can be difficult so it is important to not speak very complexly, but in short, simple sentences that are easier for the patient to understand among the hallucinations.

The following chart, adapted from table 20-4 of Stuart's book, lays out the various nursing interventions based on a given symptom:1 

Symptom	Nursing Interventions
Difficulty with perception and interpretation of sensory stimuli	Review the perceived situations with the patient. Discuss basic thought processes in interpreting events. Help patient orient self to reality. Reinforce positive and productive processes for handling the event.
Slowed information processing	Allow patient plenty of time to process and respond to information or questions asked. Minimize patient’s anxiety to facilitate an environment for information processing. Be clear and simple when communicating with the patient.
Inappropriate social behaviors	Ask patient about behaviors and identify his/her thought processes leading to the behavior. Help correct inaccurate perceptions. Teach appropriate social skills and help identify undesirable outcomes of certain behaviors.
Difficulty with decision making	Help patient determine his/her desired outcome and prioritize goals. Help establish a time line for each goal to be achieved. Help patient with small, concrete steps towards achieving goals.
Concrete thinking	Understand the patient sees every problem as only having one solution. Teach patient to look at and think about alternative solutions, or create alternative solutions for him/her.
Forced isolation because of stigma	Maximize the patient’s understanding of the illness. Identify comments that are difficult to handle and teach ways to handle the stigma and rude comments. Develop concrete, humorous comebacks. Role play various situations with the nurse as the patient

Maintenance phase

The maintenance phase of schizophrenia comes after the individual has been stabilized and is ready to be discharged. The person may receive home health visits or may have to go to an outpatient clinic to continue recovery and improvement. It is during this phase that nurses need to help the patient identify early symptoms of relapse and the symptom triggers.1 The better the patient understand his/her own pathophysiology, the more successful the prevention of relapse will be. 

The Schizophrenia Patient Outcomes Research Team (PORT) gathers information to improve the long-term treatment of schizophrenia and even has recommendations for specific drugs and administration routes (by mouth, intramuscular injection, etc).2 It is a good reference for those providing care to a patient in the maintenance phase of schizophrenia.

For patients, families, and friends a great resource is www.sardaa.org. This is the website for Schizophrenia and Related Disorders Alliance of America. It is an organization founded in 2008 and is geared towards helping those living with schizophrenia and their support systems.

References:

1: Stuart, G. (2013). Chapter 20: Neurobiological Responses and Schizophrenia and Psychotic Disorders. In Principles and practice of psychiatric nursing (10th ed., pp. 549-555). Maryland Heights, Mo.: Elsevier Saunders.

2: Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B., & Dixon, L. B. (2010). The schizophrenia Patient Outcomes Research Team (PORT): Updated treatment recommendations 2009. Schizophrenia Bulletin, 36(1), 94-103. doi:10.1093/schbul/sbp130