Sunday, February 8, 2009

Nursing Care Plans For Schizophrenia

Nursing Care Plans For Patient With Schizophrenia
Schizophrenia is characterized by disturbances (for at least 6 months) in thought content and form, perception, affect, language, social activity, sense of self, volition, interpersonal relationships, and psychomotor behavior. The DSM-IV-TR recognizes catatonic, paranoid, disorganized, residual, and undifferentiated schizophrenia.
Schizophrenia affects approximately 0.85% of individuals worldwide, with a lifetime prevalence of 1% to 1.5%. Onset of symptoms usually occurs during late adolescence and has an insidious onset and poor outcome. It can progress to social withdrawal, perceptual distortions, chronic delusions, and hallucinations
This disorder produces varying degrees of impairment. As many as one-third of schizophrenic patients have just one psychotic episode and no more after that. Some patients have no disability between periods of exacerbation; other patients need continuous institutional care. The prognosis worsens with each acute episode

Causes For Schizophrenia
Schizophrenia may result from a combination of genetic, biological, cultural, and psychological factors with genetic and environmental insults most associated. For example, some evidence supports a genetic predisposition to this disorder. Close relatives of schizophrenic patients are up to 50 times more likely to develop schizophrenia; the closer the degree of biological relatedness, the higher the risk.

The most widely accepted biochemical hypothesis holds that schizophrenia results from excessive activity at dopaminergic synapses. Other neurotransmitter alterations may also contribute to schizophrenic symptoms.

Numerous psychological and sociocultural causes, such as disturbed family and interpersonal patterns, also have been proposed as possible causes. Schizophrenia has a higher incidence among lower socioeconomic groups, possibly related to downward social drift or lack of upward socioeconomic mobility, and to high stress levels, possibly induced by poverty, social failure, illness, and inadequate social resources. Gestational and birth complications, such as Rh factor incompatibility, prenatal exposure to influenza during the second trimester, and prenatal nutritional deficiencies, have been associated.

Complications For Schizophrenia
Because of disordered thought processes, the schizophrenic patient often neglects personal hygiene or ignores health needs. As a result, the patient has a shorter life expectancy than the general population. Ten percent of schizophrenic patients commit suicide.

Assessment Nursing Care Plans For Schizophrenia
Schizophrenia is associated with a wide variety of abnormal behaviors; therefore, assessment findings vary greatly, depending on both the type and phase of the illness. The individual may exhibit a decreased emotional expression, impaired concentration, and decreased social functioning, loss of function, or anhedonia. Individuals with these particular symptoms (present in one-third of the schizophrenic population) are associated with poor response to drug treatment and poor outcome.

Although behaviors and functional deficiencies can vary widely among patients and even in the same patient at different times, watch for the following characteristic signs and symptoms during the assessment interview:
  1. ambivalence coexisting strong positive and negative feelings, leading to emotional conflict
  2. apathy
  3. clang associations words that rhyme or sound alike used in an illogical, nonsensical manner; for instance, It's the rain, train, pain.
  4. concrete thinking inability to form or understand abstract thoughts
  5. delusions false ideas or beliefs accepted as real by the patient. Delusions of grandeur, persecution, and reference (distorted belief regarding the relation between events and one's self; for example, a belief that television programs address the patient on a personal level) are common in schizophrenia. Also common are feelings of being controlled, somatic illness, and depersonalization.
  6. echolalia meaningless repetition of words or phrases
  7. echopraxia involuntary repetition of movements observed in others
  8. flight of ideas rapid succession of incomplete and poorly connected ideas
  9. hallucinations false sensory perceptions with no basis in reality. Usually visual or auditory, hallucinations may also be olfactory (smell), gustatory (taste), or tactile (touch).
  10. illusions—false sensory perceptions with some basis in reality; for example, a car backfiring might be mistaken for a gunshot.
  11. loose associations not connected or related by logic or rationality
  12. magical thinking belief that thoughts or wishes can control other people or events
  13. neologisms bizarre words that have meaning only for the patient
  14. poor interpersonal relationships
  15. regression return to an earlier developmental stage
  16. thought blocking sudden interruption in the patient's train of thought
  17. withdrawal disinterest in objects, people, or surroundings
  18. word salad illogical word groupings; for example, She had a star, barn, plant. It's the extreme form of loose associations.

Diagnostic criteria Nursing Care Plans For Schizophrenia
Complete physical and psychiatric examinations rule out an organic cause of schizophrenic symptoms such as an amphetamine-induced psychosis. Diagnosis rests on fulfilling the criteria in the DSM-IV-TR.
Several tests, including brain imaging studies, tissue studies, functional and metabolic studies, and psychological tests, can be helpful in the diagnosis of schizophrenia

Treatment For Schizophrenia
In schizophrenia, treatment focuses on meeting both the physical and psychosocial needs of the patient based on his previous level of adjustment and his response to medical and nursing interventions. Treatment typically includes a combination of drug therapy, long-term psychotherapy for the patient and his family, vocational counseling, and the use of community resources
The primary treatment (for more than 30 years), antipsychotic drugs (sometimes called neuroleptic drugs) appear to work by blocking postsynaptic dopamine receptors. These antipsychotic drugs reduce the incidence of psychotic symptoms, such as hallucinations and delusions, as well as relieve anxiety and agitation. Other psychiatric drugs, such as antidepressants and anxiolytics, may also be prescribed to control associated signs and symptoms.

Some antipsychotic drugs cause numerous adverse reactions, several of which are irreversible. Most experts admit that patients who are withdrawn, isolated, or apathetic show little improvement after this drug treatment.
High-potency antipsychotics include fluphenazine, haloperidol, thiothixene, and trifluoperazine. Loxapine, molindone, and perphenazine are intermediate in potency, and chlorpromazine and thioridazine are low in potency. Haloperidol and fluphenazine are depot formulations that are implanted I.M. to provide gradual release over a 30-day period, thus improving compliance.

Risperidone (Risperdal), ziprasidone (Geodon), and olanzapine (Zyprexa) are atypical antipsychotic agents used to treat both the positive and negative symptoms of schizophrenia. A newer drug, aripiprazole (Abilify), is a dopamine system stabilizer that also shows promise in treating both the positive and negative symptoms of schizophrenia. Clozapine, which differs chemically from other antipsychotic drugs, may be prescribed for severely ill patients who fail to respond to standard treatment. This agent effectively controls a wider range of signs and symptoms without the usual adverse effects. However, clozapine can cause drowsiness, sedation, excessive salivation, hyperglycemia, tachycardia, dizziness, seizures, and agranulocytosis, a potentially fatal blood disorder characterized by a low white blood cell count and pronounced neutropenia.

Routine blood monitoring is essential to detect the estimated 1% to 2% of all patients taking clozapine who develop agranulocytosis. If the disorder is caught in the early stages, agranulocytosis is reversible.
Clinicians disagree about the effectiveness of psychotherapy in treating schizophrenia. Although a patient who has experienced a single acute psychotic episode may respond, psychotherapy is often futile in a patient with a long history of chronic disease. Nonetheless, some physicians use it as an adjunct to reduce loneliness, isolation, and withdrawal and enhance productivity.

Other studies suggest that psycho-education and social skills training are a more productive approach for the chronic schizophrenic. Besides improving understanding of the disorder, these methods teach the patient and his family coping strategies, effective communication techniques, and social skills such as grocery shopping.
Because schizophrenia is so disruptive to the family, all members may require psychotherapy. Family therapy can reduce guilt and disappointment as well as improve acceptance of the patient and his bizarre behavior.

Diagnoses Nursing Care Plans For Schizophrenia
  • Anxiety
  • Bathing or hygiene self-care deficit
  • Disabled family coping
  • Disturbed body image
  • Disturbed personal identity
  • Disturbed sensory perception (auditory, visual, kinesthetic)
  • Disturbed sleep pattern
  • Disturbed thought processes
  • Dressing or grooming self-care deficit
  • Fear
  • Hopelessness
  • Imbalanced nutrition: Less than body requirements
  • Impaired home maintenance
  • Impaired social interaction
  • Impaired verbal communication
  • Ineffective coping
  • Ineffective role performance
  • Powerlessness
  • Risk for injury
  • Risk for other-directed violence
  • Risk for self-directed violence
  • Social isolation

Key outcomes Nursing Care Plans For Schizophrenia
  1. The patient will consider an alternative interpretation of a situation without becoming unduly hostile or anxious.
  2. The patient will perform bathing and hygiene activities to the fullest extent possible.
  3. The patient's family will demonstrate adaptive coping behaviors.
  4. The patient will verbalize positive feelings about self.
  5. The patient will identify internal and external factors that trigger delusional episodes.
  6. The patient will maintain maximum functioning within the limits of his auditory, visual, or kinesthetic impairment.
  7. The patient will resume appropriate rest and activity patterns.
  8. The patient will identify and perform activities that decrease delusions.
  9. The patient will perform dressing and grooming activities to the fullest extent possible.
  10. The patient will express fears and concerns.
  11. The patient and his family will participate in care and prescribed therapies.
  12. The patient will remain free from signs of malnutrition.
  13. The patient will develop effective coping behaviors.
  14. The patient will maintain usual roles and responsibilities to the fullest extent possible.
  15. The patient will recognize symptoms and comply with medication regimen.
  16. The patient will demonstrate effective social interaction skills in both one-on-one and group settings.
  17. The patient will express his needs.
  18. The patient will gradually join in self-care and the decision-making process.
  19. The patient will remain free from injury.
  20. The patient won't harm others.
  21. The patient won't harm self or others.
  22. The patient will maintain family and peer relationships.

Interventions Nursing Care Plans For Schizophrenia
  1. Assess the patient's ability to carry out the activities of daily living, paying special attention to his nutritional status. Monitor his weight if he isn't eating. If he thinks that his food is poisoned, allow him to fix his own food when possible, or offer him foods in closed containers that he can open. If you give liquid medication in a unit-dose container, allow the patient to open the container.
  2. Maintain a safe environment, minimizing stimuli. Administer medication to decrease symptoms and anxiety. Use physical restraints according to your facility's policy to ensure the patient's safety and that of others.
  3. Adopt an accepting and consistent approach with the patient. Don't avoid or overwhelm him. Keep in mind that short, repeated contacts are best until trust has been established.
  4. Avoid promoting dependence. Meet the patient's needs, but only do for the patient what he can't do for himself.
  5. Reward positive behavior to help the patient improve his level of functioning.
  6. Engage the patient in reality-oriented activities that involve human contact: inpatient social skills training groups, outpatient day care, and sheltered workshops. Provide reality-based explanations for distorted body images or hypochondriacal complaints. Clarify private language, autistic inventions, or neologisms, explaining to the patient that what he says isn't understood by others. If necessary, set limits on inappropriate behavior.
  7. If the patient is hallucinating, explore the content of the hallucinations. If he has auditory hallucinations, determine if they're command hallucinations that place the patient or others at risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing about the hallucinations; if possible, change the subject.
  8. Don't tease or joke with the patient. Choose words and phrases that are unambiguous and clearly understood. For instance, a patient who's told, That procedure will be done on the floor, may become frightened, thinking he is being told to lie down on the floor.
  9. Don't touch the patient without telling him first exactly what you're going to do. For example, clearly explain to him, I'm going to put this cuff on your arm so I can take your blood pressure. If necessary, postpone procedures that require physical contact with facility personnel until the patient is less suspicious or agitated.
  10. Remember, institutionalization may produce new symptoms and handicaps in the patient that aren't part of his diagnosed illness, so evaluate symptoms carefully.
  11. Mobilize community resources to provide a support system for the patient and reduce his vulnerability to stress. Ongoing support is essential to his mastery of social skills.
  12. Encourage compliance with the medication regimen to prevent relapse. Also monitor the patient carefully for adverse effects of drug therapy, including drug-induced parkinsonism, acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome. Make sure you document and report such effects promptly.
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