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1 NCM-117:Care of Clients with Maldaptive Patterns of Behavior,

Acute and Chronic

PREFACE

This learning packet is designed to assists students understand the

concepts, theories, and principles of Caring of Clients with Maladaptive
Patterns of Behaviour. It incorporates learning activities that will help
students meet the objectives of the course.

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INSTRUCTIONS:
INSTRUCTIONS:
This COURSE is divided into 4 learning packets (2 midterm period, and 2 final Period). It is
important for the student to acquire a textbook (see requirements). Access to the internet is
advantageous but in its absence, any Maternal and Child Health Nursing book will suffice. Each topic
includes an overview about the topic, along with student learning objectives. Self-assessment questions
and activities (SAQA) are provided. It is required that students should answer all SAQA and Related
Learning Experience (RLE) Activities (RLEA). Answers should be handwritten on a separate
notebook/journal. Students should acquire 4 or more notebooks (BLUE Cattleya ) for the whole
semester (4 learning packets/semester). It is important that students accomplish the reading
activity before proceeding with the text/discussion. All activities in SAQA should be answered since
this will be included as a summative evaluation of student’s performance. After posting of the
learning packets in ssuclassroom.com, students should submit their activity notebook/s within
seven 7 days. Late submission is tantamount to failure for the corresponding learning packet.

REQUIREMENTS:
 Psychiatric-Mental Health Nursing book (latest Edition) by Sheila L. Videbeck
 4 Cattleya (or more) notebooks

GRADING SYSTEM:
Major Examination - 40%
Summative Quiz - 25%
Class Participation - 15%
Term Project/Requirements - 20%

1.0. INTENDED LEARNING OBJECTIVE:

The student will be able to:
1. Integrate relevant physical, social, natural and health science and humanities, concepts
and principles relevant to the care of clients with maladaptive patterns of behavior
2. Apply appropriate nursing concepts and actions holistically and comprehensively
3. Discuss appropriate therapeutic models and its relevance to nursing practice
4. Discuss the psychopathological and psychodynamic basis in maladaptive patterns of
behaviour.
1.1 INTRODUCTION
This unit introduces the concepts of mental health and mental illness, as well as the state state
of mental health and mental illness in the country and the world. It also explains the
psychobiologic bases of behaviour.

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1.2 Concepts of Mental Health and Mental Illness

1.2.1. State of Mental Health and Mental Illness in the Country and the World
1.2.1.1. Mental Health Care Delivery System in the Philippines and its Importance
and Impact in the Community
1.2.2. Psychobiologic Bases of Behavior
Neuroscience: Biology and Behavior
1.2.2.1. Neuro-Anatomy and Neurophysiology
Neurons
Central Nervous System
Memory, Repetition and
Learning Neurotransmitters
1.2.2.2. Concepts and Patterns of Human Behavior
Family Dynamics
Patterns of Behavior
Concept of Human Behavior
 Needs
 Frustrations and Conflict
 Anxiety, Anxiety Responses
 Patterns of Adaptation
Concepts of Human Health and Mental Illness Crisis
1.2.2.3. Global and Regional Perspectives on Mental Health
1.2.3. Understanding Stress
1.2.3.1. Acute and long Term Effects of Stress
1.2.3.2. Physical Responses
1.2.3.3. Psychological Responses
1.2.3.4. General Adaptation Syndrome (GAS)
1.2.3.5. Psychoneuroimmunological Mode
1.2.3.6. Measuring Stress and Coping Styles
1.2.4. Diagnosis –DSM IV/V
1.2.5. Psychopathology, Etiology and Psychodynamics
1. Disturbances in Thought Content/Processes: Schizophrenia and other
Psychosis

DISCUSSION
Mental Health:
 “The successful adaptation to stressors from the internal or external
environment, evidenced by thoughts, feelings, and behaviours that are age-
appropriate and congruent with local and cultural norms.”
Mental Health (MH)/Mental Illness (MI):
 Mental illness encompasses more than brain functioning.
 MH and MI are not polar opposites. Rather than an end points on a continuum.
Considering H and I as points along a continuum is useful in communicating
that neither state exists in isolation from the other.
 MI is associated with distress and impaired functioning. These alterations in
thinking, mood and behaviour contribute to a host of other problems in the

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person’s life.
 Somewhere between optimal functioning (MH) and functional impairment
(MI), people can experience distressful states that are of insufficient intensity
to qualify as MI. nevertheless, using a “Continuum” model presumes that there
is a pure state called “MH” that can serve as a basis for comparison.
Aspects of Mental Health
 Emotional Intelligence
 Resiliency
 Spirituality
Factors influencing Mental Health
 Individual
 Interpersonal
 Social/cultural

SAQA-1
Describe your personal understanding about what is mental health?

Mental Illness
 “A clinically significant behaviour or psychological syndrome or pattern that
occurs in an individual and is associated with present distress, or disability, or
with a significantly increased risk of suffering death, pain and disability, or an
important loss of freedom.”
General Criteria
 Dissatisfaction with one’s characteristics, abilities, and accomplishments
 Ineffective or unsatisfying relationships
 Dissatisfaction with one’s place in the world
 Ineffective coping with life’s events
 Lacking or personal growth
Elements of Mental Health
 Self-governance
 Progress toward growth or self-realization
 Tolerance of uncertainty
 Self-esteem
 Reality orientation

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 Mastery of environment
 Stress management

Mental Health Care Delivery System in the Philippines and its Importance and Impact in the
Community
 “Accordingly, the majority of mental healthcare is provided in hospital settings and there are
underdeveloped community mental health services. The National Center for Mental Health was
previously estimated to account for 67% of the available psychiatric beds nationally (Conde,
2004). More recent data indicate that there are 1.08 mental health beds in general hospitals and
4.95 beds in psychiatric hospitals per 100 000 of the population (WHO, 2014). There are 46
out-patient facilities (0.05/100 000 population) and 4 community residential facilities (0.02/100
000) (WHO, 2014). There are only two tertiary care psychiatric hospitals: the National Center
for Mental Health in Mandaluyong City, Metro Manila (4200 beds) and the Mariveles Mental
Hospital in Bataan, Luzon (500 beds). There are 12 smaller satellite hospitals affiliated with
the National Center for Mental Health which are located throughout the country.
Overcrowding, poorly functioning units, chronic staff shortages and funding constraints are
ongoing problems, particularly in peripheral facilities. There are no dedicated forensic
hospitals, although forensic beds are located at the National Center for Mental Health.”

 “Prohibitive economic conditions and the inaccessibility of mental health services limit access
to mental healthcare in the Philippines. Further, perceived or internalised stigma has been
shown to be a barrier to help-seeking behaviour in Filipinos (Tuliao & Velasquez, 2014), just
as is the case in Western populations (Lally et al, 2013). There is a cultural drive to ‘save face’
when there is a threat to or loss of one's social position, and as such Filipinos may have
difficulty in admitting to mental health problems or seeking help. There is a strong sense of
family in the Philippines and so, when problems are thought to be socially related, Filipinos
will turn to family and peer networks before seeking medical help (Tuliao, 2014).” (Mental health
services in the Philippines by John Lally, John Tully,and Rene Samaniego)

Psychobiologic Bases of Behavior

Neuroscience: Biology and Behavior
a. Psychoanalytic Perspective
 Sigmund Freud (1856-1939) developed his ideas about psychoanalytic theory
from work with mental patients. Freud believed that personality has three
structures: the id, the ego, and the superego.
o The id is the Freudian structure of personality that consists of instincts,
which are an individual's reservoir of psychic energy. In Freud's view,
the id is totally unconscious; it has no contact with reality.
o As children experience the demands and constraints of reality, a new
structure of personality emerges- the ego, the Freudian structure of
personality that deals with the demands of reality. The ego is called the
executive branch of personality because it uses reasoning to make
decisions. The id and the ego have no morality. They do not take into
account whether something is right or wrong.
o The superego is the Freudian structure of personality that is the moral
branch of personality. The superego takes into account whether
something is right or wrong. Think of the superego as what we often
refer to as our "conscience."

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 In Sigmund Freud's topographical model of personality, the ego is the aspect

of personality that deals with reality. While doing this, the ego also has to cope
with the conflicting demands of the id and the superego. The id seeks to fulfill
all wants, needs and impulses while the superego tries to get the ego to act in
an idealistic and moral manner.
 What happens when the ego cannot deal with the demands of our desires, the
constraints of reality and our own moral standards? According
to Freud, anxiety is an unpleasant inner state that people seek to avoid. Anxiety
acts as a signal to the ego that things are not going right.
 Defense Mechanisms
o When anxiety occurs, the mind first responds by an increase in problem-
solving thinking, seeking rational ways of escaping the situation. If this
is not fruitful (and maybe anyway), a range of defense mechanisms may
be triggered. These are tactics which the Ego develops to help deal with
the Id and the Super Ego.
o All Defense Mechanisms share two common properties :
 They often appear unconsciously.
o Defense Mechanisms include:
 Denial: claiming/believing that what is true to be actually false.
 Displacement: redirecting emotions to a substitute target.
 Intellectualization: taking an objective viewpoint. The idea is
conscious but the feeling is missing.
 Projection: attributing uncomfortable feelings to others.
 Rationalization: creating false but credible justifications.
 Reaction Formation: overacting in the opposite way to the fear.
 Regression: going back to acting as a child.
 Repression: pushing uncomfortable thoughts into the
subconscious.
 Sublimation: redirecting 'wrong' urges into socially acceptable
actions.
 Isolation: Severing the connection between thoughts and
feelings associated with an event so the event can remain
conscious without the anxiety.
 Conversion: expressing unconscious emotional conflicts through
a physical symptoms for which there is no demonstrable organic
basis.
 Undoing: engaging in certain thoughts and actions so as to cancel
out, or atone for, threatening thoughts or actions that have
previously occurred.
 Introjection: Incorporating another person to a void the threat
posed by him or one’s own urges.

SAQA-2

Describe your personal understanding about what is mental

illness?

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b. Psychosocial Theory
 The word 'psychosocial' is Erik Erikson's term, effectively from the words
psychological (mind) and social (relationships).
 Erikson believed that his psychosocial principle is genetically inevitable in
shaping human development. It occurs in all people.
 Erikson, like Freud, was largely concerned with how personality and
behaviour is influenced after birth - not before birth - and especially during
childhood.

https://www.pinterest.ph/pin/200832464606388954/

c. Behavior Theory
 Behaviourist believed that the study of subjective experience did not provide
acceptable scientific data because observations and interpretations made by
psychoanalysts were not open to verification by other words. Therefore, only
the study of directly observable behavior and the stimuli and the stimuli and
reinforcing conditions that control it could serve as a basis for formulating
scientific principles of human behavior. Moreover, insight by way of
psychoanalysis did not equate to changing behavior.
 CONDITIONING
o Basic form of learning
 Classical – connection between a stimulus and a response.

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 Operant – individuals respond in order to achieve a certain goal;

they operate their environment
 Reinforcement – when a stimulus strengthens a new response by
its repeated association with that response.
 Punishment - A special kind of stimulus that operates in an
opposite way from reinforcement
d. Cognitive Theory
 recognizes the importance of the subjective experience of oneself, others, and
the world. It posits that irrational beliefs and thoughts about oneself, the
world, and one’s future can lead to psychopathology.
e. Cognitive-Behavior Theory
 Bandura’s term to explain the interaction between the Person (P), the Situation
(S), and the Behaviors (B). One’s beliefs about the world, and about
themselves will influence their behavior and the environments they place
themselves in. Feedback from the environment and behaviors will confirm or
disconfirm one’s beliefs.
f. Humanistic Perspective
 Humanism is a philosophical movement that emphasizes the personal worth of
the individual and the centrality of human values
g. Sociocultural Viewpoint
 The influence of culture in the lives of the people
 It consists of socially acquired and socially transmitted symbols, beliefs,
techniques, institutions, customs, and norms
h. Biophysiological Perspective
 Proposes that psychopathology results from some physiologic condition,
primarily a deviation within the CNS

NEUROANATOMY AND NEUROPHYSIOLOGY

 The brain influences and is responsible for behaviour. It governs all forms of behaviour.
 Neurons: the most abundant type of nerve cell, which generates and transmit nerve impulses.
 Dendrites : Projections from the neuron cell body that receive impulses from adjacent
neurons
 Axon : another projection from the cell body, is responsible for impulse propagation to other
cells

 Neurotransmitters: are compounds that are released at a synapse and diffuse across the
synaptic cleft to act on a receptor located on the membrane of a postsynaptic cell.

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SAQA-3
1. What happens during neurotransmission and what is its purpose?
2. What are the neurotransmitters associated with mental illness? Describe how it
affects the individual with mental illness.

 Central Nervous System

o The neurons enclosed in the bony coverings of the skull and vertebral column make
up the CNS, which consists of the :
 Spinal cord
 Brain
 Frontal Lobe- associated with reasoning, planning, parts of speech,
movement, emotions, and problem solving
 Parietal Lobe- associated with movement, orientation, recognition,
perception of stimuli
 Occipital Lobe- associated with visual processing
 Temporal Lobe- associated with perception and recognition of auditory
stimuli, memory, and speech
 The cerebellum, or "little brain", is similar to the cerebrum in that it has
two hemispheres and has a highly folded surface or cortex. This structure
is associated with regulation and coordination of movement, posture, and
balance.
 Limbic System: The limbic system supports a variety of functions
including adrenaline flow, emotion, behavior, motivation, long-term
memory, and olfaction
 Diencephalon: thalamus, hypothalamus, and pineal gland
o Thalamus – relay station through which sensory information passes
on its way to other cortical regions
o Hypothalamus – control center of the endocrine, somatic and
autonomic functioning; hormones are released – sexual activity,
salt balance, feeding, body temperature
o Pineal gland – secretes melatonin, a hormone that affects the sleep-
wake cycle
 Brain Stem: This structure is responsible for basic vital life functions such
as breathing, heartbeat, and blood pressure

Understanding Stress
 Physical responses to stress
o Hans Selye defined stress as “the state manifested by a specific syndrome which
consists of all the non-specifically induced changes within a biologic system.”
o “Fight-or-flight” syndrome
 General Adaptation Syndrome
 Alarm reaction stage- the physiological responses of fight or flight.

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 Stage of resistance-attempting to adapt to the stressor.

 Stage of exhaustion-adaptive energy is gone, can no longer draw from
resources, and may become physically or psychologically ill.

https://drwilsons.com/got-stress/how-your-stress-response-works/
 Psychological Responses
o Anxiety and grief have been described as two major, primary psychological response
patterns to stress.
o A variety of thoughts, feelings, and behaviors are associated with each of these
response patterns.
o Adaptation is determined by the extent to which the thoughts, feelings, and behaviors
interfere with an individual’s functioning.
o Anxiety
 A diffuse apprehension that is vague in nature and is associated with feelings
of uncertainty and helplessness
 Extremely common in our society
 Mild anxiety is adaptive and can provide motivation for survival
o Peplau’s four levels of anxiety
 Mild - seldom a problem
 Moderate - perceptual field diminishes
 Severe - perceptual field is so diminished that concentration centers on one
detail only or on many extraneous details
 Panic - the most intense state
SAQA-4

How does stress affected your:

1. Body
2. Mood
3. Behavior

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Diagnostic and Statistical Manual (DSM)

 The Diagnostic and Statistical Manual of Mental Disorders is the handbook widely used by
clinicians and psychiatrists in the United States to diagnose psychiatric illnesses. Published
by the American Psychiatric Association (APA), the DSM covers all categories of mental
health disorders for both adults and children.

 It contains descriptions, symptoms, and other criteria necessary for diagnosing mental health
disorders. It also contains statistics concerning which gender is most affected by the illness,
the typical age of onset, the effects of treatment, and common treatment approaches.

 Just as with other medical conditions, the government and many insurance carriers require a
specific diagnosis in order to approve payment for treatment. Therefore, in addition to being
used for psychiatric diagnosis and treatment recommendations, mental health professionals
also use the DSM to classify patients for billing purposes.
 The Diagnostic and Statistical Manual has been updated seven times since it was first
published in 1952.
o Version Year Number of diagnoses
o DSM-I 1952 106
o DSM-II 1968 182
o DSM-III 1980 265
o DSM-III-R 1987 292
o DSM-IV 1994 297
o DSM-IV-TR 2000 365
 The newest version of the DSM, the DSM-5, was published in May of 2013. This latest
revision was met with considerable discussion and some controversy.
 A major issue with the DSM has been around validity. In response to this, the National
Institute of Mental Health (NIMH) launched the Research Domain Criteria (RDoC) project to
transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of
information to lay the foundation for a new classification system they feel will be more
biologically based. https://www.verywellmind.com/the-diagnostic-and-statistical-manual-dsm-2795758
 DSM-IV-TR Multiaxial System
o The DSM-IV was originally published in 1994 and listed more than 250 mental
disorders. An updated version, called the DSM-IV-TR, was published in 2000. This
version utilized a multiaxial or multidimensional approach for diagnosing mental
disorders.
o The multiaxial approach was intended to help clinicians and psychiatrists make
comprehensive evaluations of a client's level of functioning because mental illnesses
often impact many different life areas.
o It described disorders using five DSM "axes" or dimensions to ensure that all
factors—psychological, biological, and environmental—were considered when
making a mental health diagnosis.
 Axis I – Clinical Syndromes
Axis I consisted of mental health and substance use disorders that cause
significant impairment. Disorders were grouped into different categories such
as mood disorders, anxiety disorders, or eating disorders.
 Axis II – Personality Disorders and Mental Retardation

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Axis II was reserved for mental retardation and personality disorders, such as
antisocial personality disorder and histrionic personality disorder. Personality
disorders cause significant problems in how a person relates to the world,
while mental retardation is characterized by intellectual impairment and
deficits in other areas such as self-care and interpersonal skills.
 Axis III – General Medical Conditions
 Axis III was used for coding medical conditions that influence or worsen Axis
1 and Axis II disorders. Some examples include HIV/AIDS and brain injuries.
Axis IV – Psychosocial and Environmental Problems
Any social or environmental problems that may impact Axis I or Axis II
disorders were accounted for in this axis. These include such things as
unemployment, relocation, divorce, or the death of a loved one.
 Axis V – Global Assessment of Functioning
Axis V is where the clinician gives their impression of the client's overall level
of functioning. Based on this assessment, clinicians could better understand
how the other four axes interacted and the effect on the individual's life.
 Changes in the DSM-5
o The DSM-5 contains a number of significant changes from the earlier DSM-IV.4
o The most immediately obvious change is the shift from using Roman numerals to
Arabic numbers.
o Perhaps most notably, the DSM-5 eliminated the multiaxial system. Instead the DSM-
5 lists categories of disorders along with a number of different related disorders.
Example categories in the DSM-5 include anxiety disorders, bipolar and related
disorders, depressive disorders, feeding and eating disorders, obsessive-compulsive
and related disorders, and personality disorders.
o A few other changes in the DSM-5:1
 Asperger's disorder was removed and incorporated under the category of
autism spectrum disorders.
 Disruptive mood dysregulation disorder was added, in part to decrease over-
diagnosis of childhood bipolar disorders.
o Several diagnoses were officially added to the manual including binge eating disorder,
hoarding disorder, and premenstrual dysphoric disorder
(https://www.verywellmind.com/the-diagnostic-and-statistical-manual-dsm-2795758)
PSYCHOPATHOLOGY, ETIOLOGY AND PSYCHODYNAMICS
A. Disturbances in Thought Content/Processes: Schizophrenia and other Psychosis
a. SCHIZOPHRENIA:
 defined literally as "splitting of the mind“
 A group of mental disorders characterized by psychotic features, inability to
trust others, disordered thought processes and disrupted interpersonal
relationships
 Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-
IV) a person should have at least two of the following symptoms:
 delusions, hallucinations, disorganized speech, grossly disorganized or
catatonic behavior and negative symptoms
2.Etiology:
 Cultural

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o Persons from different cultural and ethnic groups may have

health practices unique to their culture that might mimic altered
sensory perceptions
 Genetic
o there is a premise that genetic is only one part of the
pathogenesis of schizophrenia
 Psychodynamic
o schizophrenia developed because of the psychic alterations that
occurred within the person. These alterations are contingent on
the poor caregiving that is provided within the child’s
environment
 Neurobiological
o Heredity and genetics
o Neuroanatomic differences and neurochemicals; e.g. dopamine
hyperactivity
 Structure and function of nervous system
 Teratogenic drug exposure
 Neuroanatomic differences in the brain
o Neurotransmitter function : abnormal neurotransmitter-
endocrine interactions
o Immunologic factors: viral exposure during pregnancy
o High arousal levels from stress, disease, drugs and trauma
1. Stress such as bombardment of stimuli from life events
2. Diseases such as prenatal virus exposure: encephalitis
3. Trauma from birth complications
4. Drugs such as cannabis and cocaine
 Primary Symptoms: “4 A’s”
o Disturbances in association, affect (flattened affect), ambivalence
and autistic thinking
o Additional “A’s” include attention defects and activity disturbances
3.Major Symptoms:
 Positive
o Hallucinations: A sense perception for which no external
stimuli exists; can have an organic or functional etiology.
- Auditory
- Visual
- Olfactory
- Tactile
- Gustatory
o Delusions: is a belief that is clearly false and that indicates an
abnormality in the affected person's content of thought.
- Persecution - The thought that one is being
singled out for harm by others
- Grandeur – the false belief that one is a very
powerful and important person
- Jealousy - the false belief that one’s partner or
mate is going out with other people
o Abnormal thought processes

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- Neologisms – words that an individual makes up

that have meaning only for the individual; often
part of a delusional system
- Looseness of association – individual’s thinking
is haphazard, illogical, and confused and
connections in thought are interrupted
- Flight of ideas – a continuous stream of talk in
which the patient switches rapidly from one
topic to another and each subject is incoherent
and unrelated to the preceding one or is
stimulated by some environmental circumstance
- Blocking- when a person stops speaking
abruptly in the middle of a thought.
Circumstantiality – before getting to the point or
answering a question, the individual gets caught
up in countless details and explanations
- Confabulation is the spontaneous narrative
report of events that never happened. It consists
of the creation of false memories, perceptions,
or beliefs about the self or the environment -
usually as a result of neurological or
psychological dysfunction
- Word salad is a mixture of random words that,
while arranged in phrases that appear to give
them meaning, actually carry no significance.
 Negative
o Amotivation or decrease in ability to initiate and sustain
planned activity, apathy, and difficulty finding pleasure in daily
living
o Alogia: poverty of speech, is a general lack of additional,
unprompted content seen in normal speech
o Affective flattening or blunting: lack of emotional reactivity
o Avolition: is a psychological state characterized by general lack
of desire, drive, or motivation to pursue meaningful goals
o Anhedonia : is an inability to experience pleasurable emotions
from normally pleasurable life events such as eating, exercise,
social interaction or sexual activities
o Attentional impairment
 Cognitive Symptoms
o disorganized thinking
o slow thinking
o difficulty understanding
o poor concentration
o poor memory
o difficulty expressing thoughts
o difficulty integrating thoughts, feelings and behaviour
 2 phases of symptoms
o Prodromal phase

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o acutely or slower onset

o Acute (Active) phase
o Hallmark symptoms of schizophrenia
o Positive, negative, and cognitive
 Disorders of movement :
o Akathisia – uncontrollable limb and body movements, usually caused
by drugs, especially some antipsychotic drugs
o Parkinson-like symptoms – making mask-like faces, drooling, and
having shuffling gait, tremors and muscular rigidity
o Waxy flexibility is a psychomotor symptom of catatonic
schizophrenia which leads to a decreased response to stimuli and a
tendency to remain in an immobile posture.For instance, if one were
to move the arm of someone with waxy flexibility, they would keep
their arm where one moved it until it was moved again, as if it were
made from wax.

http://www.minddisorders.com/Br-Del/Catatonic-disorders.html

o Tardive dyskinesia: A neurological syndrome characterized by

repetitive, involuntary, purposeless movements caused by the long-
term use of certain drugs called neuroleptics used for psychiatric,
gastrointestinal and neurological disorders such as Parkinson's
disease
 Epidemiology: Onset of the disease most commonly occurs between 18-34 years of
age; severe emotional problems begin in earl life, but may not be recognized
 women earlier onset than men

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 Types:
1.Paranoid-type schizophrenia:
 Paranoid-type schizophrenia is characterized by delusions and auditory
hallucinations but relatively normal intellectual functioning and
expression of affect. The delusions can often be about being persecuted
unfairly or being some other person who is famous. People with
paranoid-type schizophrenia can exhibit anger, aloofness, anxiety, and
argumentativeness.
 Auditory hallucinations, such as hearing voices
 Delusions, such as believing a co-worker wants to poison you
 Anxiety
 Anger
 Emotional distance
 Violence
 Argumentativeness
 Self-important or condescending manner
 Suicidal thoughts and behavior
 With paranoid schizophrenia, you're less likely to be affected by mood
problems or problems with thinking, concentration and attention.
 Nursing Interventions:
o Don’t touch the patient without telling him exactly what you’re
going to be doing and before obtaining his permission to touch
him
o Set limits but without anger; avoid a punitive attitude
o If patient has auditory hallucinations, explore content of
hallucinations; tell him you don’t hear the voices, but you know
they’re real to him
o Don’t try to combat patient’s s delusions with logic, instead
address feelings, themes, or underlying needs associated with
the delusion
o If patient expresses suicidal thoughts or says he hear voices
telling him to harm himself, institute suicide precautions;
document his behavior and precautions; document his behavior
and precautions
o If patient expresses homicidal thoughts, institute homicide
precautions.
2.Disorganized-type schizophrenia
 Disorganized-type schizophrenia is characterized by speech and

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behavior that are disorganized or difficult to understand, and flattening

or inappropriate emotions. People with disorganized-type
schizophrenia may laugh at the changing color of a traffic light or at
something not closely related to what they are saying or doing. Their
disorganized behavior may disrupt normal activities, such as
showering, dressing, and preparing meals.
o Disorganized thinking.
o Grossly disorganized behavior.
o Absent or inappropriate emotional expression.
o Other signs and symptoms of disorganized schizophrenia
Having beliefs not based on reality (delusions)
o Seeing or hearing things that don't exist (hallucinations),
especially voices
o Grimacing
o Odd postures
o Trouble functioning at school or work
o Social isolation
o Clumsy, uncoordinated movement
 Nursing Interventions
o Ask patient’s permission to touch him, as appropriate
o Set limits formally
o Explore content of hallucinations as appropriate
o Don’t combat patient’s delusions with logic
3.Catatonic-type schizophrenia
 Catatonic-type schizophrenia is characterized by disturbances of
movement. People with catatonic-type schizophrenia may keep
themselves completely immobile or move all over the place. They may
not say anything for hours, or they may repeat anything you say or do
senselessly. Either way, the behavior is putting these people at high
risk because it impairs their ability to take care of themselves.
o Physical immobility
o Excessive mobility
o Extreme resistance
o Peculiar movements
o Mimicking speech or movement.
o Other signs and symptoms of catatonic schizophrenia
Having beliefs not based on reality (delusions)
o Seeing or hearing things that don't exist (hallucinations),
especially voices
o Incoherent speech
o Neglect of personal hygiene

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o Apparent lack of emotions

o Emotions inappropriate to the situation
o Angry outbursts
o Trouble functioning at school or work
o Social isolation
o Clumsy, uncoordinated movements
 Nursing Interventions
o Spend time with patient
o Tell patient directly, specifically, and precisely what needs to
be done
o Assess for signs and symptoms of physical illness
o If patient is in bizarre posture, provide range-of-motion
exercises and ambulate patient every 2 hours to prevent
pressure ulcers or decreased circulation
o Stay alert for violent outbursts
4.Undifferentiated-type schizophrenia
 Undifferentiated-type schizophrenia is characterized by some
symptoms seen in all of the above types but not enough of any one of
them to define it as another particular type of schizophrenia.
 Delusions and/or hallucinations
 Disorganized speech or behavior and certain negative symptoms.
 affective flattening (lack of display of emotions)
 alogia (lack of speech)
 avolition (lack of motivation or desire).
5.Residual-type schizophrenia
 Residual-type schizophrenia is characterized by a past history of at
least one episode of schizophrenia, but the person currently has no
positive symptoms (delusions, hallucinations, disorganized speech or
behavior). It may represent a transition between a full-blown episode
and complete remission, or it may continue for years without any
further psychotic episodes
 Has been diagnosed with another subtype of schizophrenia in the past
 Shows no signs of hallucinations, delusions, disorganized speech, or
grossly disorganized or catatonic behavior
 Has negative symptoms
 Has two or more very low-key versions of classic positive
schizophrenia symptoms such as odd beliefs, strange perceptual
experiences, or peculiar behaviour
 Fundamental Principles
1.Provide a safe, familiar environment; provide direct supervision as necessary;
provide a consistent caregiver foster trust

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2.Continually orient the client to time, date, and place

3.Keep client involved in reality and in the home situation as long as possible
4.Allow client to assume as much responsibility for self-care as possible
5.Provide a quiet environment; reduce stimuli; help client maintain relationships
6.Plan care so the staff approaches these clients when they appear receptive
7.Attempt to follow familiar routines; keep the schedule of activities flexible to
make use of the client’s lability of mood and easy distractibility
Nursing Process (https://nurseslabs.com/schizophrenia/)
Assessment:
 Recognize schizophrenia. Note characteristic signs and symptoms of
schizophrenia (e.g., speech abnormalities, thought distortions, poor social
interactions).
 Establish trust and rapport. Don’t tease or joke with patients. Expect that patient is
going to put you through rigorous testing periods. Introduce yourself and explain
your purpose.
 Maximize level of functioning. Assess patient’s ability to carry out activities of
daily living (ADLs).
 Assess positive symptoms. Assess for command hallucinations; explore answers.
Assess if the client has fragmented, poorly organized, well-organized,
systematized, or extensive system of beliefs that are not supported by reality.
Assess for pervasive suspiciousness about everyone and their actions (e.g.,
vigilant, blames others for consequences of own behavior, argumentative,
threatening).
 Assess negative symptoms. Assess for the negative symptoms of schizophrenia
(as mentioned above).
 Assess medical history. Assess if the client is on medications, what these are, and
adherence to therapy.
 Assess support system. Determine whether the family is well informed about the
disease. Does the family understand the need for medication adherence?
Nursing Diagnoses
 Impaired Physical Mobility related to depressive mood state and reluctance to
initiate movement.
 Impaired Social Interaction related to problems in thought patterns and speech.
 Decreased Cardiac Output related to orthostatic hypotensive drug effects.
 Risk for Suicide related to impulsiveness and marked changes in behavior.
 Risk for Injury related to hallucinations and delusions.
 Risk for Imbalanced Nutrition: less than body requirements related to self-neglect
and refusal for self-care.
Nursing Care Planning and Goals
 Reduce severity of psychotic symptoms
 Prevent recurrence of acute episodes
 Meet patient’s’ physical and psychosocial needs
 Help patient gain optimum level of functioning
 Increase client’s compliance to treatment and nursing plan
Nursing Interventions
 Establish trust and rapport. Don’t touch client without telling him first what you are
going to do. Use an accepting, consistent approach; short, repeated contacts are best

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until trust has been established. Language should be clear and unambiguous. Maintain
a sense of hope for possible improvement, and convey this to the patient.
 Maximize level of functioning. Avoid promoting dependence by doing only what the
patient can’t do for himself. Reward positive behavior and work with him to increase
his personal sense of responsibility in improving functioning.
 Promote social skills. Provide support in assisting him to learn social skills.
 Ensure safety. Maintain a safe environment with minimal stimulation.
 Ensure adequate nutrition. Monitor patient’s nutritional status and if the patient thinks
his food is poisoned, let him fix his own food if possible or offer him foods in closed
containers that he can open. Institute suicide and/or homicide precautions as
appropriate.
 Keep it real. Engage patient in reality-oriented activities that involve human contact
(e.g., workshops, inpatient social skills training). Clarify private language, autistic
inventions, or neologisms.
 Deal with hallucinations by presenting reality. Explore the content of hallucinations.
Avoid arguing about the hallucinations. Tell them you do not see, hear, smell, or feel
it but explain that you know that these hallucinations are real to him.
 Promote compliance and monitor drug therapy. Administer prescribed drugs and
encourage the patient to comply. Ensure that patient is really taking the drug. Observe
for manifestations that warrant hypersensitivity reactions and toxicity.
 Encourage family involvement. Involve family in patient treatment and teach
members to recognize impending relapse (e.g. nervousness, insomnia, decreased
ability to concentrate). Suggest ways how families can manage symptoms.
Evaluation
 Evaluate effectiveness of drug therapy (absence of acute episodes and psychotic
symptoms).
 Evaluate compliance to health instructions (taking medications on time, showing
independence in activities, involvement of family).
 Level of patient’s functioning (ability to engage in social interactions).
 Patient’s mental status (oriented to reality).
Documentation Guidelines
The following are to be documented in the patient’s chart:
 Document the assessed presenting signs and symptoms (e.g., positive and negative
signs).
 In instituting suicide precaution, document behavior and your precautions.
 In instituting homicide precaution, document patient’s comment and who was
notified. Be sure to notify the doctor and the potential victim.
 In using restraints, document time of application and release.

SAQA-5
1. Discuss current foremost etiology of schizophrenia.
2. As a nurse caring for a client with schizophrenia, paranoid type, how can you
evaluate your client’s response to medication and therapy? How can you
recognize that the client’s reality testing has improved?
3. What would be an appropriate nursing actions for a client whose behaviour is
characterized by:

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a. pathologic suspicion
b. persecutory delusions
4. As a psychiatric nurse, give appropriate actions to care for a delusional client
who refuses to eat because of a belief that the food is poisoned. Give the
rationale for your actions
5. A client is experiencing hallucinations that someone is telling him that he is a
good for nothing person. What is the most appropriate nursing response and
why?
6. What is the best nursing intervention to encourage a withdrawn, non-
communicative client to talk? Give the rationale.
7. How can the nurse handle the problem, when a regressed, emotionally disturbed
client voids on the floor in the sitting room of the psychiatric unit. Give the
rationale.
8. Why is it important to observe a withdrawn client?
9. What is best nursing action when a client verbally abuses the nursing staff? Give
the rationale.
10. What is the appropriate nursing intervention when a client openly masturbates?
Give the rationale.

References:
 Katona, C., Cooper, C. & Robertson, M. (2016). Psychiatry at a Glance (6th ed.). Chichester,
West Sussex: Wiley Blackwell.
 Bach, S. & Grant, A. (2015). Communication & interpersonal skills in Nursing (3rd Ed.).
London, UK: SAGE Publications Ltd.
 Carlson, N. R. (2014). Physiology of behavior (11th Ed.). Harlow, Essex: Pearson Education
Limited.
 O'Toole, M. T. (Ed.). Mosby's medical dictionary (10th Ed.). Missouri: Elsevier.
 Psychiatric-Mental Health Nursing (5th ed.)Videbeck, Sheila L. 2011
 Psychiatric- Mental Health Nursing Videbeck, Sheila, 2011
 VanPutte, C. Regan, J. & Russo, A. (2016). Seeley's Essentials of Anatomy & Physiology.
(9th ed.). Penn Plaza, New York NY: McGraw-Hill Education
 Wolters Kluwer. (2016). Nursing Drug Handbook 2016. Philadelphia, PA: Wolters
Kluwer.
 Katzung, B. G. Trevor, A. J. (2015). Basic & Clinical Pharmacolog (13th ed.). New York
NY: McGraw-Hill Education
 Allen, L. V. (2013). Rx Remington: The Science and Practice of pharmacy (22th ed.).:
London: PhP Pharmaceutical Press
 Albert, J. S. Wood, M. W. (2012). Targets and Emerging Therapies for Schizophrenia:
Hoboken, NJ: John Wiley & Son, Inc.
 Sreevani, R. (2011). Mental health nursing: Practical Record book: New Delhi: Jaypee
Brothers Medical (P) LTD

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 Videbeck, S. L. (2011). Psychiatric Mental health Nursing. (5th ed.).: Philadelphia:

Lippincott Williams & Wilkins
 https://nurseslabs.com/schizophrenia/
 http://www.minddisorders.com/Br-Del/Catatonic-disorders.html
 https://drwilsons.com/got-stress/how-your-stress-response-works/
 (https://www.verywellmind.com/the-diagnostic-and-statistical-manual-dsm-2795758)
 https://www.pinterest.ph/pin/200832464606388954/

Acknowledgment
The images, tables, figures and information contained in this module were
taken from the references cited above.

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