MBALA SCHOOL OF NURSING AND PUBLIC HEALTH

Nursing care for schizophrenia

1. Impaired verbal communication. Decreased, reduced, delayed, or absent ability to receive,

process, transmit, or use a system of symbols.

Due to or May be related to:

 Altered perceptions.

 Biochemical alterations in the brain of certain neurotransmitters.

 Psychological barriers (lack of stimuli).

 Side effects of medication.

Possibly evidenced by

 Difficulty communicating thoughts verbally.

 Difficulty in discerning and maintaining the usual communication pattern.

 Disturbances in cognitive associations (e.g., perseveration, derailment, poverty of speech,

tangentiality, illogicality, neologism, and thought blocking).

 Inappropriate verbalization.

Desired Outcomes

 Patient will express thoughts and feelings in a coherent, logical, goal-directed manner.

 Patient will demonstrate reality-based thought processes in verbal communication.

 Patient will spend time with one or two other people in structured activity neutral topics.

 Patient will spend two to three 5-minute sessions with nurse sharing observations in the
environment within 3 days.

 Patient will be able to communicate in a manner that can be understood by others with the
help of medication and attentive listening by the time of discharge.

 Patient will learn one or two diversionary tactics that work for him/her to decrease anxiety,
hence improving the ability to think clearly and speak more logically.

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Nursing Interventions Rationale

Establishing a baseline facilitates the establishment

Assess if incoherence in speech is chronic or if it is more
of realistic goals, the foundation for planning
sudden, as in an exacerbation of symptoms.
effective care.

Therapeutic levels of an antipsychotic aids clear

Identify the duration of the psychotic medication of the
thinking and diminishes derailment or looseness of
client.
association.

High-pitched/loud tone of voice can

Keep voice in a low manner and speak slowly as much as
elevate anxiety levels while slow speaking aids
possible.
understanding.

Keep environment calm, quiet and as free of stimuli as Keep anxiety from escalating and
possible. increasing confusion and hallucinations/delusions.

Short periods are less stressful, and periodic

Plan short, frequent periods with a client throughout the
meetings give a client a chance to develop
day.
familiarity and safety.

Use clear or simple words, and keep directions simple as Client might have difficulty processing even simple
well. sentences.

Minimizes misunderstanding and/or incorporating

Use simple, concrete, and literal explanations.
those misunderstandings into delusional systems.

Focus on and direct client’s attention to concrete things in Helps draw focus away from delusions and focus on
the environment. reality-based things.

Look for themes in what is said, even though spoken words Often client’s choice of words is symbolic of
appear incoherent (e.g., fearful, sadness, guilt). feelings.

Pretending to understand limits your credibility in

When you do not understand a client, let him/her know
the eyes of your client and lessens the potential for
you are having difficulty understanding.
trust.

When client is ready, introduce strategies that can Helping client to use tactics to lower anxiety can
minimize anxiety and lower voices and “worrying” help enhance functional speech.
thoughts, teach client to do the following:

 Focus on meaningful activities.

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  Learn to replace negative thoughts with
constructive thoughts.

 Learn to replace irrational thoughts with rational

statements.

 Perform deep breathing exercise.

 Read aloud to self.

 Seek support from a staff, family, or other

supportive people.

 Use a calming visualization or listen to music.

Use therapeutic techniques (clarifying feelings when

Even if the words are hard to understand,
speech and thoughts are disorganized) to try to
try getting to the feelings behind them.
understand client’s concerns.

2. Impaired Social Interaction: The state in which an individual participates in an insufficient or

excessive quantity or ineffective quality of social exchange.

Due to or May be related to

 Difficulty with communication.

 Difficulty with concentration.

 Exaggerated response to alerting stimuli.

 Feeling threatened in social situations.

 Impaired thought processes (delusions or hallucinations).

 Inadequate emotional responses.

 Self concept disturbance (verbalization of negative feelings about self).

Possibly evidenced by

 Appears upset, agitated, or anxious when others come too close in contact or try to engage
him/her in an activity.

 Dysfunctional interaction with others/peers.

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  Inappropriate emotional response.

 Observed use of unsuccessful social interactions behaviors.

 Spends time alone by self.

 Unable to make eye contact, or initiate or respond to social advances of others.

 Verbalized or observed discomfort in social situations.

Desired Outcomes

 Patient will attend one structured group activity within 5-7 days.

 Patient will seek out supportive social contacts.

 Patient will improve social interaction with family, friends, and neighbors.

 Patient will use appropriate social skills in interactions.

 Patient will engage in one activity with a nurse by the end of the day.

 Patient will maintain an interaction with another client while doing an activity (e.g., simple
board game, drawing).

 Patient will demonstrate interest to start coping skills training when ready for learning.

 Patient will engage in one or two activities with minimal encouragement from nurse or family
members.

 Patient will state that he or she is comfortable in at least three structured activities that are goal
directed.

 Patient will use appropriate skills to initiate and maintain an interaction.

Nursing Interventions Rationale

Many of the positive symptoms

of schizophrenia (hallucinations, delusions, racing
Assess if the medication has reached therapeutic levels.
thoughts) will subside with medications, which will
facilitate interactions.

Identify with client symptoms he experiences when he or Increased anxiety can intensify agitation,
she begins to feel anxious around others. aggressiveness, and suspiciousness.

Keep client in an environment as free of stimuli (loud Client might respond to noises and crowding with
noises, crowding) as possible. agitation, anxiety, and increased inability to

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 concentrate on outside events.

Touch by an unknown person can be misinterpreted

Avoid touching the client. as a sexual or threatening gesture. This particularly
true for a paranoid client.

Avoids pressure on the client and sense of failure on

Ensure that the goals set are realistic; whether in the
part of nurse/family. This sense of failure can lead to
hospital or community.
mutual withdrawal

Structure activities that work at the client’s pace and Client can lose interest in activities that are too
activity. ambitious, which can increase a sense of failure.

Structure times each day to include planned times for

Helps client to develop a sense of safety in a non-
brief interactions and activities with the client on one-
threatening environment.
on-one basis

If client is unable to respond verbally or in a coherent An interested presence can provide a sense of being
manner, spend frequent, short period with clients. worthwhile.

Client is free to choose his level of interaction;

If client is found to be very paranoid, solitary or one-on-
however, the concentration can help minimize
one activities that require concentration are appropriate.
distressing paranoid thoughts or voice.

If client is delusional/hallucinating or is having trouble

concentrating at this time, provide very simple concrete Even simple activities help draw client away from
activities with client (e.g., looking at a picture or do a delusional thinking into reality in the environment.
painting).

If client is very withdrawn, one-on-one activities with a Learn to feel safe with one person, then gradually
“safe” person initially should be planned. might participate in a structured group activity.

Try to incorporate the strengths and interests the client Increase likelihood of client’s participation and
had when not as impaired into the activities planned. enjoyment.

Teach client to remove himself briefly when feeling

agitated and work on some anxiety relief exercise (e.g., Teach client skills in dealing with anxiety and
meditations, rhythmic exercise, deep breathing increasing a sense of control.
exercise).

Useful coping skills that client will need include These are fundamental skills for dealing with the
conversational and assertiveness skills. world, which everyone uses daily with more or less

Nursing care for schizophrenia Alitili B.M. (EN, RN, RM, BSN, PG cert ADH, RHR) Page 5
 skill.

Remember to give acknowledgment and recognition for

Recognition and appreciation go a long way to
positive steps client takes in increasing social skills and
sustaining and increasing a specific behavior.
appropriate interactions with others.

Provide opportunities for the client to learn adaptive

social skills in a non-threatening environment. Initial Social skills training helps client adapt and function at
social skills training could include basic social behaviors a higher level in society, and increases client’s quality
(e.g., appropriate distance, maintain good eye contact, of life.
calm manner/behavior, moderate voice tone).

As client progresses, provide the client with graded

activities according to level of tolerance e.g., (1) simple Gradually the client learns to feel safe and competent
games with one “safe” person; (2) slowly add a third with increased social demands.
person into “safe”.

As client progresses, Coping Skills Training should be

available to him/her (nurse, staff or others). Basically the
process:

1. Define the skill to be learned. Increases client’s ability to derive social support and
decrease loneliness. Clients will not give up substance
2. Model the skill.
of abuse unless they have alternative means to
3. Rehearse skills in a safe environment, then in the facilitate socialization they belong.
community.

4. Give corrective feedback on the implementation

of skills.

Eventually engage other clients and significant others in

social interactions and activities with the client (card Client continues to feel safe and competent in a
games, ping pong, sing-a-songs, group sharing activities) graduated hierarchy of interactions.
at client’s level.

3. Disturbed Sensory Perception: Change in the amount or patterning of incoming stimuli

accompanied by a diminished, exaggerated, distorted or impaired response to such stimuli.

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Due to or May be related to

 Altered sensory perception.

 Altered sensory reception; transmission or integration.

 Biochemical factors such as manifested by inability to concentrate.

 Chemical alterations (e.g., medications, electrolyte imbalances).

 Neurologic/biochemical changes.

 Psychological stress.

Possibly evidenced by

 Altered communication pattern.

 Auditory distortions.

 Change in a problem-solving pattern.

 Disorientation to person/place/time.

 Frequent blinking of the eyes and grimacing.

 Hallucinations.

 Inappropriate responses.

 Mumbling to self, talking or laughing to self.

 Reported or measured change in sensory acuity.

 Tilting the head as if listening to someone.

Desired Outcomes

 Patient will learn ways to refrain from responding to hallucinations.

 Patient will state three symptoms they recognize when their stress levels are high.

 Patient will state that the voices are no longer threatening, nor do they interfere with his or her
life.

 Patient will state, using a scale from 1 to 10, that “the voices” are less frequent and threatening
when aided by medication and nursing intervention.

 Patient will maintain role performance.

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  Patient will maintain social relationships.

 Patient will monitor intensity of anxiety.

 Patient will identify two stressful events that trigger hallucinations..

 Patient will identify to personal interventions that decrease or lower the intensity or frequency
of hallucinations (e.g, listening to music, wearing headphones, reading out loud, jogging,
socializing).

 Patient will demonstrate one stress reduction technique.

 Patient will demonstrate techniques that help distract him or her from the voices.

Nursing Interventions Rationale

Accept the fact that the voices are real to the client, Validating that your reality does not include voices can
but explain that you do not hear the voices. Refer to help client cast “doubt” on the validity of his or her
the voices as “your voices” or “voices that you hear”. voices.

Might herald hallucinatory activity, which can be very

Be alert for signs of increasing fear, anxiety or
frightening to client, and client might act upon command
agitation.
hallucinations (harm self or others).

Exploring the hallucinations and sharing the experience

Explore how the hallucinations are experienced by
can help give the person a sense of power that he or she
the client.
might be able to manage the hallucinatory voices.

Hallucinations might reflect needs for:

 Anger.
Help the client to identify the needs that might
underlie the hallucination. What other ways can  Power.
these needs be met?
 Self-esteem.

 Sexuality.

Helps both nurse and client identify situations and times

Help client to identify times that times that the
that might be most anxiety producing and threatening to
hallucinations are most prevalent and frightening.
the client.

If voices are telling the client to harm self or others, People often obey hallucinatory commands to kill self or
take necessary environmental precautions. others. Early assessment and intervention might save
lives.

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  Notify others and police, physician, and
administration according to unit protocol.

 If in the hospital, use unit protocols for

suicidal or threats of violence if client plans
to act on commands.

 If in the community, evaluate the need for

hospitalization.

Clearly document what client says and if he/she is a

threat to others, document who was contacted and
notified (use agency protocol as a guide).

Stay with clients when they are starting to

Client can sometimes learn to push voices aside when
hallucinate, and direct them to tell the “voices they
given repeated instructions. especially within the
hear” to go away. Repeat often in a matter-of-fact
framework of a trusting relationship.
manner.

Decrease environmental stimuli when possible (low Decrease potential for anxiety that might trigger
noise, minimal activity). hallucinations. Helps calm client.

Intervene before anxiety begins to escalate. If the client is

Intervene with one-on-one, seclusion, or PRN
already out of control, use chemical or physical restraints
medication (As ordered) when appropriate.
following unit protocols.

Client’ thinking might be confused and disorganized; this

Keep to simple, basic, reality-based topics of
intervention helps client focus and comprehend reality-
conversation. Help client focus on one idea at a time.
based issues.

Work with the client to find which activities help If clients’ stress triggers hallucinatory activity, they might
reduce anxiety and distract the client from be more motivated to find ways to remove themselves
a hallucinatory material. Practice new skills with from a stressful environment or try distraction
the client. techniques.

Engage client in reality-based activities such as card Redirecting client’s energies to acceptable activities can
playing, writing, drawing, doing simple arts and decrease the possibility of acting on hallucinations and
crafts or listening to music. help distract from voices.

4. Disturbed thought process: Disruption in cognitive operations and activities.

Due to or May be related to

 Chemical alterations (e.g., medications, electrolyte imbalances).

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  Inadequate support systems.

 Overwhelming stressful life events.

 Possibility of a hereditary factor.

 Panic level of anxiety.

 Repressed fears.

Possibly evidenced by

 Delusions.

 Inaccurate interpretation of environment.

 Inappropriate non-reality-based thinking.

 Memory deficit/problems.

 Self-centeredness.

Desired Outcomes

 Patient will verbalize recognition of delusional thoughts if they persist.

 Patient will perceive environment correctly.

 Patient will demonstrate satisfying relationships with real people.

 Patient will demonstrate decrease anxiety level.

 Patient will refrain from acting on delusional thinking.

 Patient will develop trust in at least one staff member within 1 week.

 Patient will sustain attention and concentration to complete task or activities.

 Patient will state that the “thoughts” are less intense and less frequent with the help of the
medications and nursing interventions.

 Patient will talk about concrete happenings in the environment without talking about delusions
for 5 minutes.

 Patient will demonstrate two effective coping skills that minimize delusional thoughts.

 Patient will be free from delusions or demonstrate the ability to function without responding to
persistent delusional thoughts.

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Nursing Interventions Rationale

Attempt to understand the significance of these beliefs Important clues to underlying fears and issues can be
to the client at the time of their presentation. found in the client’s seemingly illogical fantasies.

Recognizes the client’s delusions as the client’s Recognizing the client’s perception can help you
perception of the environment. understand the feelings he or she is experiencing.

Identify feelings related to delusions. For example:

 If client believes someone is going to harm

him/her, client is experiencing fear. When people believe that they are understood,
anxiety might lessen.
 If client believes someone or something is
controlling his/her thoughts, client is
experiencing helplessness.

Explain the procedures and try to be sure the clients When the client has full knowledge of procedures, he
understand the procedures before carrying them out. or she is less likely to feel tricked by the staff.

Interact with clients on the basis of things in the

When thinking is focused on reality-based activities,
environment. Try to distract client from their delusions
the client is free of delusional thinking during that
by engaging in reality-based activities (e.g., card games,
time. Helps focus attention externally.
simple arts and crafts projects etc).

Suspicious clients might misinterpret touchas either

aggressive or sexual in nature and might interpret it
Do not touch the client; use gestures carefully.
as threatening gesture. People who are psychotic
need a lot of personal space.

Initially do not argue with the client’s beliefs or try to Arguing will only increase client’s defensive position,
convince the client that the delusions are false and thereby reinforcing false beliefs. This will result in the
unreal. client feeling even more isolated and misunderstood.

Encourage healthy habits to optimize functioning:

 Maintain medication regimen.

 Maintain regular sleep pattern. All are vital to help keep the client in remission.

 Maintain self-care.

 Reduce alcohol and drug intake.

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 The client’s delusion can be distressing. Empathy
Show empathy regarding the client’s feelings; reassure
conveys your caring, interest and acceptance of the
the client of your presence and acceptance.
client.

Teach client coping skills that minimize “worrying”

thoughts. Coping skills include:

 Going to a gym.

 Phoning a helpline. When client is ready, teach strategies client can do

alone.
 Singing or Listening to a song.

 Talking to a trusted friend.

 Thought-stopping techniques.

During acute phase, client’s delusional thinking might

Utilize safety measures to protect clients or others, if the
dictate to them that they might have to hurt others or
client believe they need to protect themselves against a
self in order to be safe. External controls might be
specific person. Precautions are needed.
needed.

5. Defensive Coping: Repeated projection of falsely positive self-evaluation based on a self-

protective pattern that defends against underlying perceived threats to positive self-regard.

Due to or May be related to

 Perceived lack of self-efficacy/vulnerability.

 Perceived threat to self.

 Suspicions of the motives of others.

Possibly evidenced by

 Denial of obvious problems.

 Difficulty in reality testing of perceptions.

 Difficulty establishing/maintaining relationships.

 False beliefs about the intention of others.

 Fearful.

 Grandiosity.

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  Hostile laughter or ridicule of others.

 Hostility, aggression, or homicidal ideation.

 Projection of blame/responsibility.

 Rationalization of failures.

 Superior attitude towards others.

Desired Outcomes

 Patient will avoid high-risk environments and situations.

 Patient will interact with others appropriately.

 Patient will maintain medical compliance.

 Patient will identify one action that helps client feel more in control of his or her life.

 Patient will demonstrate two newly learned constructive ways to deal with stress and feeling of
powerlessness.

 Patient will demonstrate learn the ability to remove himself or herself from situations when
anxiety begins to increase with the aid of medications and nursing interventions.

 Patient will demonstrate decreased suspicious behaviors regarding with the interaction with
others.

 Patient will be able to apply a variety of stress/anxiety-reducing techniques on their own.

 Patient will acknowledge that medications will lower suspiciousness.

 Patient will state that he/she feels safe and more in control with interactions with
environment/family/work/social gatherings.

Nursing Interventions Rationale

Prepares the client beforehand and minimizes

Explain to client what you are going to do before you do it.
misinterpreting your intent as hostile or aggressive.

Assess and observe clients regularly for signs of increasing

Intervene before client loses control.
anxiety and hostility.

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 There is less chance for a suspicious client to
Use a nonjudgemental, respectful, and neutral approach
misinterpret intent or meaning if content is neutral
with the client.
and approach is respectful and non-judgemental.

Use clear and simple language when communicating with Minimize the opportunity for miscommunication
a suspicious client. and misconstruing the meaning of the message.

When staff become defensive, anger escalates for

both client and staff. a non-defensive and non-
Diffuse angry verbal attacks with a non defensive stand.
judgemental attitude provides an atmosphere in
which feelings can be explored more easily.

Set limits in a clear matter-of-fact way, using a calm

Calm and neutral approach may diffuse escalation
tone. Giving threatening remarks to Jeremy is
of anger. Offer an alternative to verbal abuse by
unacceptable. We can talk more about the proper ways
finding appropriate ways to deal with feelings.
in dealing with your feelings.

Suspicious people are quick to discern honesty.

Be honest and consistent with client regarding
Honesty and consistency provide an atmosphere in
expectations and enforcing rules.
which trust can grow.

Maintain low level of stimuli and enhance a non- Noisy environments might be perceived as
threatening environment (avoid groups). threatening.

Be aware of client’s tendency to have ideas of reference;

do not do things in front of client that can be
misinterpreted: Suspicious clients will automatically think that they
are the target of the interaction and interpret it in a
 Laughing or whispering. negative manner (e.g., you are laughing or
whispering about them).
 Talking quitely when client can see but not hear
what is being said.

Initially, provide solitary, noncompetitive activities that

If a client is suspicious of others, solitary activities
take some concentration. Later a game with one or more
are the best. Concentrating on environmental
client that takes concentration (e.g., chess checkers,
stimuli minimizes paranoid rumination.
thoughtful card games such as ridge or rummy).

Provide verbal/physical limits when client’s hostile

behavior escalates: We cannot allow you to verbally attack Often verbal limits are effective in helping a client
someone here. If you cant held/control yourself, we are gain self control.
here in order to help you.

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6. Interrupted Family Process: Change in family relationships and/or functioning.

Due to or May be related to

 Developmental crisis or transition.

 Family role shift.

 Physical or mental disorder of a family member.

 Shift in health status of a family member.

 Situational crisis or transition.

Possibly evidenced by

 Changes in expression of conflict in family.

 Changes in communication patterns.

 Changes in mutual support.

 Changes in participation in decision making.

 Changes in participation in problem solving.

 Changes in stress reduction behavior.

 Knowledge deficit regarding community and health care support.

 Knowledge deficit regarding the disease and what is happening with ill family member (might
believe client is more capable than they are).

 Inability to meet the needs of family and significant others (physical, emotional, spiritual).

Desired Outcomes

 Family and/or significant others will recount in some detail the early signs and symptoms of
relapse in their ill family member, and know whom to contact in case.

 Family and/or significant others will state and have written information identifying the signs of
potential relapse and whom to contact before discharge.

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  Family and/or significant others will state that they have received needed support from
community and agency resources that offer education, support, coping skills training, and/or
social network development (psycho educational approach).

 Family and/or significant others will state what medications can do for their ill family member,
the side effects and toxic effects of the drugs, and the need for adherence to medication at least
2 to 3 days before discharge.

 Family and/or significant others will name and have a complete list of community supports for
ill family members and supports for all members of the family at least 2 days before the
discharge.

 Family and/or significant others will attend at least one family support group (single family,
multiple family) within 4 days from onset of acute episode.

 Family and/or significant others will be included in the discharge planning along with the client.

 Family and/or significant others will meet with nurse/physician/social worker the first day of
hospitalization and begin to learn about neurologic/biochemical disease, treatment, and
community resources.

 Family and/or significant others will problem-solve, with the nurse, two concrete situations
within the family that all would like to discharge.

 Family and/or significant others will recount in some detail the early signs and symptoms of
relapse in their ill family member, and know whom to contact.

 Family and/or significant others will demonstrate problem-solving skills for handling tensions
and misunderstanding within the family member.

 Family and/or significant others will have access to family/multiple family support groups and
psychoeducational training.

 Family and/or significant others will know of at least two contact people when they suspect
potential relapse.

 Family and/or significant others will discuss the disease (schizophrenia) knowledgeably:

o Know about community resources (e.g., help with self care activities, private respite).

o Support the ill family member in maintaining optimum health.

o Understand the need for medical adherence.

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Nursing Interventions
Assess the family members’ current level of
knowledge about the disease and medications used
to treat the disease.
Inform the client family in clear, simple terms about
psychopharmacologic therapy: dose, duration,
indication, side effects, and toxic effects. Written
information should be given to client and family
members as well.
Identify family’s ability to cope (e.g., experience of
loss, caregiver burden, needed supports).
Teach the client and family the warning symptoms of
relapse.
Provide information on disease and treatment
strategies at family’s level of understanding.
Provide an opportunity for the family to discuss
feelings related to ill family member and identify
their immediate concerns.
Provide information on client and family community
resources for the client and family after discharge:
day hospitals, support groups, organizations, psycho
educational programs, community respite centers
(small homes), etc.
Nursing care for schizophrenia Alitili B.M. (EN, RN, RM, BSN, PG cert ADH, RHR)
Rationale
Family might have misconceptions and
misinformation about schizophrenia and
treatment, or no knowledge at all. Teach
client’s and family’s level of understanding and
readiness to learn.
Understanding of the disease and the
treatment of the disease encourages greater
family support and client adherence.
Family’s need must be addressed to stabilize
family unit.
Rapid recognition of early warning symptoms
can help ward off potential relapse when
immediate medical attention is sought.
Meet family members’ needs for information.
Nurses and staff can best intervene when they
understand the family’s experience and needs.
Schizophrenia is an overwhelming disease for
both the client and the family. Groups, support
groups, and psycho educational centers can
help:
 Access caring.
 Access resources.
 Access support.
 Develop family skills.
 Improve quality of life for all family
members.
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  Minimizes isolation.

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