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Schizophrenia Nursing Care Plan (NCP)

Schizophrenia describes psychotic state that at some time is characterized by apathy, avolition, asociality, affective blunting, and alogia. The client has alterations in thoughts, percepts, mood, and behavior. Subjective experiences of disordered thought are manifested in disturbances of concept formation that sometimes lead to misinterpretations of reality, delusions (particularly delusions of influence and ideas of reference), and hallucinations. Mood changes include ambivalence, constriction or inappropriateness of feeling, and loss of empathy with others. Behavior may be withdrawn, regressive, or bizarre (Shader, 1994).

DSM-IV
SCHIZOPHRENIA
295.30 Paranoid type
295.10 Disorganized type
295.20 Catatonic type
295.90 Undifferentiated type
295.60 Residual type
(Refer to DSM-IV for other listings.)

ETIOLOGICAL THEORIES
Psychodynamics
Psychosis is the result of a weak ego. The development of the ego has been inhibited by a symbiotic parent/child relationship. Because the ego is weak, the use of ego defense mechanisms in times of extreme anxiety is maladaptive, and behaviors are often representations of the id segment of the personality.

Biological
Certain genetic factors may be involved in the susceptibility to develop some forms of this psychotic disorder. Individuals are at higher risk for the disorder if there is a familial pattern of involvement (parents, siblings, other relatives). Schizophrenia has been determined to be a sporadic illness (which means genes cannot currently be followed from generation to generation). It is an autosomal dominant trait. However, most scientists agree that what is inherited is a vulnerability or predisposition, which may be due to an enzyme defect or some other biochemical abnormality, a subtle neurological deficit, or some other factor or combination of factors. This predisposition, in combination with environmental factors, results in development of the disease. Some research implies that these disorders may be a birth defect, occurring in the hippocampus region of the brain. The studies show a disordering of the pyramidal cells in the brains of schizophrenics, while the cells in the brains of nonschizophrenic individuals appear to be arranged in an orderly fashion. Ventricular brain ratio (VBR) or disproportionately small brain (or specific areas of the brain) may be inherited and/or congenital. The cause can be a virus, lack of oxygen, birth trauma, severe maternal malnutrition, or cellular damage resulting from an RhD immune response (mother negative/fetus positive).

A biochemical theory suggests the involvement of elevated levels of the neurotransmitter dopamine, which is thought to produce the symptoms of overactivity and fragmentation of associations that are commonly observed in psychoses.

Although overall occurrence is relatively equal between males and females, resources report a predominant male bias with two-thirds of young adults with serious mental illnesses being male. Boys react more strongly than girls to stress and conflicts in the family home, and are more vulnerable to infantile autism. A significantly larger number of males than females exhibit obsessive and suicidal behaviors, fetishism, and schizophrenia. Schizophrenia develops earlier in males, and they respond less well to treatment and have less chance of recovery and return to normal life than females. The incidence in females may have more familial origins. The different brain organization of men and women, and the effect of sex hormones on brain growth are likely to result in subtle differences that define the “scope and range of sex differences in the incidence, clinical presentation, and course of specific psychiatric diseases” (Moir & Jessel, 1991).

Family Dynamics
Family systems theory describes the development of schizophrenia as it evolves out of a dysfunctional family system. Conflict between spouses drives one parent to become attached to the child. This overinvestment in the child redirects the focus of anxiety in the family, and a more stable condition results. A symbiotic relationship develops between parent and child; the child remains totally dependent on the parent into adulthood and is unable to respond to the demands of adult functioning.

Interpersonal theory relates that the psychotic person is the product of a parent/child relationship fraught with intense anxiety. The child receives confusing and conflicting messages from the parent and is unable to establish trust. High levels of anxiety are maintained, and the child’s concept of self is one of ambiguity. A retreat into psychosis offers relief from anxiety and security from intimate relatedness. Some research indicates that clients who live with families high in expressed emotion (e.g., hostility, criticism, disappointment, overprotectiveness, and overinvolvement) show more frequent relapses than clients who live with families who are low in expressed emotion.

Current research of genetic and biological influences suggests that these family interactions are more likely to be contributing factors to rather than the cause of the disorder.

NURSING PRIORITIES
1. Promote appropriate interaction between client and environment.
2. Enhance physiological stability/health maintenance.
3. Provide protection; ensure safety needs.
4. Encourage family/significant other(s) to become involved in activities to promote independent, satisfying lives.

DISCHARGE CRITERIA
1. Physiological well-being maintained with appropriate balance between rest and activity.
2. Demonstrates increasing/highest level of emotional responsiveness possible.
3. Interacts socially without decompensation.
4. Family displays effective coping skills and appropriate use of resources.
5. Plan in place to meet needs after discharge.

Nursing diagnosis for Schizophrenia: Altered Thought Processes may be related to Disintegration of thinking processes; impaired judgment; Psychological conflicts; disintegrated ego boundaries (confusion with environment); Sleep disturbance; and Ambivalence and concomitant dependence (part of need-fear dilemma interferes with ability to self-initiate fulfilling diversional activities) possibly evidenced by Presence of delusional system (may be grandiose, persecutory, of reference, of control, somatic, accusatory); commands, obsessions; Symbolic and concrete associations; blocking ideas of reference; Inaccurate interpretation of environment; cognitive dissonance; impaired ability to make decisions; Simple hyperactivity and constant motor activity (ritualistic acts, stereotyped behavior) to withdrawal and psychomotor retardation; and Interrupted sleep patterns.

Desired Outcomes
1. Recognize changes in thinking/behavior.
2. Identify delusions and increase capacity to cope effectively with them by elimination of pathological thinking.
3. Maintain reality orientation.
4. Establish interpersonal relationships.

Nursing intervention with rationale:
1. Determine severity of client’s altered thought processes, noting form (dereistic, autistic, symbolic, loose and/or concrete associations, blocking); content (somatic delusions, delusions of grandeur/ persecution, ideas of reference); and flow (flight of ideas, retardation).
Rationale: Identification of symbolic/primitive nature of thinking/communications promotes understanding of the individual client’s thought processes and enables planning of appropriate interventions.

2. Establish a therapeutic nurse-client relationship.
Rationale: Provides an emotionally safe milieu that enables interpersonal interaction and decreases autism.

3. Use therapeutic communications (e.g., reflection, paraphrasing) to intervene effectively.
Rationale: Therapeutic communications are clear, concise, open, consistent, and require use of self. This reduces autistic thinking.

4. Structure communications to reflect consideration of client’s socioeconomic, educational, and cultural history/values.
Rationale: Lack of consideration of these factors can cause misdiagnosis /inaccurate interpretation (otherwise normal thinking viewed as pathological).

5. Reinforce congruent thinking. Refuse to argue/ agree with disintegrated thoughts. Present reality and demonstrate motivation to understand client (model patience).
Rationale: Provides opportunity for the client to control aggressive behavior. Decreases altered (disintegrated, delusional) thinking as client’s thoughts compensate in response to presentation of reality.

6. Share appropriate thinking and set limits (cognitive therapy) if client tries to respond impulsively to altered thinking.
Rationale: Enhances self-esteem and promotes safety for the client and others. Cognitive therapy is directed specifically at thinking patterns that have developed (e.g., illogical associations are made between events that most of us would not believe to be connected). Aim is to modify apparently fixed beliefs, faulty interpretations, and automatic thoughts, and by relating them to “normal experience” to reduce some of the fear attached to them.

7. Assess rest/sleep pattern by observing capacity to fall asleep, quality of sleep. Graph sleep chart as indicated until acceptable pattern is established.
Rationale: Delusions, hallucinations, etc. may interfere with client’s sleep pattern. Fears may alter ability to fall asleep. Sleep deprivation can produce behaviors such as withdrawal, confusion, disturbance of perception. Sleep chart identifies abnormal patterns and is useful in evaluating effectiveness of interventions.

8. Help client identify/learn techniques that promote rest/sleep (e.g., quiet activities, soothing music, before bedtime, regular hour for going to bed, drinking warm milk).
Rationale: Enhances client’s ability to optimize rest/sleep, maximizing ability to think clearly.

9. Assess presence/degree of factors affecting client’s capacity for diversional activities.
Rationale: Presence of hallucinations/delusions; situational factors such as long-term hospitalization (characterized by monotony, sensory deprivation); psychological factors such as decreased volition; physical factors such as immobility contribute to deficits in diversional activity.

10. Monitor medication regimen, observing for therapeutic effect and side effects (e.g., anticholinergic [dry mouth, etc.], sedation, orthostatic hypotension, photosensitivity, hormonal effects, reduction of seizure threshold, extrapyramidal symptoms, and fatigue/weakness with sore throat or signs of infection [agranulocytosis]).
Rationale: Enables identification of the minimal effective dose to reduce psychotic symptoms with the fewest adverse effects. Prevention of side effects/timely intervention may enhance cooperation with drug regimen. Identification of the onset of serious side effects, such as neuroleptic malignant syndrome, provides for appropriate interventions to avoid permanent damage.
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