11.4 Applying the Nursing Process to Schizophrenia

Now that we have discussed the symptoms and treatments for psychosis and schizophrenia, we will explain how to apply the nursing process to a patient experiencing an acute psychotic episode related to schizophrenia.

Recognizing Cues

Assessment includes interviewing the client, observing verbal and nonverbal behaviors, and completing a mental status examination and a psychosocial assessment. Common findings during a mental status examination for a patient with schizophrenia experiencing an acute psychotic episode are described in Table 11.2. Review information about performing a mental status examination and psychosocial assessment in Chapter 3. It is also important to assess for suicide risk for patients with psychosis. Review how to assess for suicide risk in the Chapter 2.

Table 11.2 Common Findings During a Mental Status Examination for Individual With Schizophrenia Experiencing an Acute-Psychotic Episode^[1]

How to Elicit Deeper Information

When assessing hallucinations, do not imply the perceptions are real. For example, a nurse should ask the patient, “What do you hear?” not “What are the voices saying?” It is important to assess for command hallucinations, such as, “Are you hearing a voice that is telling you to do something,” followed by, “Do you believe what you hear is real?” If the answer is “Yes,” the patient is at increased risk for acting on the command. Assess when the hallucinations began, their content, and the manner in which the patient experiences them (i.e., Are they supportive or distressing? In the background or intrusive?). Ask what makes them worse or better, how the patient responds, and what they do to cope with the hallucinations.^[2]

When assessing delusions, determine if the patient is capable of reality testing (i.e., questioning their thoughts and determining what is real). Ask the patient if they believe there is any danger related to the delusion.^[3]

Assess the patient’s ability to perform activities of daily living. Are they getting adequate food, fluid, sleep, and rest? Are they completing daily hygiene tasks and dressing safely for weather conditions? Are they able to control their impulses and make safe decisions?^[4]. When possible, assess family members and significant others’ knowledge of the patient’s illness and their response. Are they overprotective, frustrated, or anxious? Are they familiar with family support groups, respite, and other community resources?^[5]

Determine if the patient is taking their medications as prescribed, their effectiveness, and if they are experiencing side effects. Are there any barriers to medications or other treatment, such as cost, stigma, or mistrust of health care providers? It is best to say, “Tell me about your medications” rather than a yes-no question such as “Are you taking your medications?” ^[6]

Assessing Involuntary Movements

Nurses also assess for adverse effects of medications, such as involuntary movements associated with the use of antipsychotic medications (e.g., extrapyramidal side effects or tardive dyskinesia). This requires asking the patient about movements and observing the patient while conversing. Patients are routinely assessed for these adverse effects using scales like the Abnormal Involuntary Movement Scale.

Diagnostic and Lab Work

Ensure the patient has had a medical workup for other potential causes of psychosis. For example, dehydration, infection, electrolyte imbalances, abnormal blood glucose level, substance use, or withdrawal from substances can cause psychosis. Concurrent medical disorders are common and should be treated in addition to treating schizophrenia. Often, the patient has already been examined by a medical provider as part of the admission process.

If the patient is currently taking psychotropic medications, therapeutic drug levels of some types of medications are required. As always, review current information from a medication reference before administering medications.

 Analyzing Cues and Generating Hypotheses

Mental health disorders like schizophrenia are diagnosed by mental health providers using the DSM-5-TR. Nurses create individualized nursing care plans based on the client’s responses to their mental health disorders. See Table 11.3 for a list of common nursing hypotheses and human responses related to schizophrenia.

Table 11.3 Common Nursing Diagnoses (Hypotheses) Related to Schizophrenia^[8],[9]

Prioritizing Hypotheses and Generating Solutions

Outcomes Identification

Outcomes should be consistent with safety, stabilization, while emphasizing hope, resilience, living a full and productive life, and recovery from illness. Expected outcomes are identified based on the patient’s current phase of their illness: acute, stabilization, or maintenance^[10]:

• Acute: The overall goal in the acute phase of schizophrenia is patient safety and stabilization. An example of an expected outcome is, “The patient will consistently be able to label their hallucinations as ‘not real’ and a symptom of their illness by discharge.”^[11] Safety includes monitoring and addressing risk for self-harm and risk for injury to others.
• Stabilization: Goals during the stabilization phase focus on understanding the illness and the prescribed treatment plan, as well as controlling and/or coping with symptoms using an optimal medication and psychosocial treatment regimen. Outcomes typically target negative and cognitive symptoms of schizophrenia during this phase because these symptoms respond less well to initial medication treatment than do positive symptoms.^[12] An example of an expected outcome during the stabilization phase is, “The patient will establish two goal-directed activities by the end of the shift.”
• Maintenance: Goals during the maintenance phase focus on maintaining and increasing symptom control and optimal functioning. Often, this phase occurs after discharge from acute care settings. Factors include treatment adherence, increasing independence, and a satisfactory quality of life.^[13] An example of an expected outcome during the maintenance phase is, “The patient will identify advantages for taking medications by the end of Week 2.”

Hospitalization is indicated during the acute phase of schizophrenia if the patient is considered a danger to self (e.g., refuses to eat or is too disorganized to function in the community) or to others (e.g., is behaving in a threatening manner to others).^[14] During hospitalization, the providers will work to optimize medication support to ease symptoms.

During the stabilization and maintenance phases, planning focuses on medication adherence, education, support, and skills training for the patient, family, and significant others. The patient may no longer need an acute care facility so the focus changes to where these needs can be met within the community. As explained previously in this chapter, relapse prevention efforts are vital. Each relapse can increase residual dysfunction and deterioration and can contribute to despair, hopelessness, and suicide risk. Additionally, recognizing early signs of relapse (e.g., reduced sleep, social withdrawal, and worsening concentration) and implementing intensive treatment are needed to minimize the disruption of the patient’s life.^[15]

Taking Action

During the acute phase of schizophrenia, hospitalization provides safety, structure, and support. As discussed earlier, anosognosia may impair the patient’s ability to recognize their mental illness. In this case, court-ordered hospitalization may be required.^[16] Read more about court-ordered hospitalization in Chapter 5. Nursing interventions focus on providing safety, promoting hygiene and nutrition, improving socialization, encouraging hope and self-esteem, preventing injury, using specific therapeutic techniques, addressing physiological needs, and implementing collaborative interventions.

Provide Safety

Clients with command hallucinations require close monitoring for suicide, homicide, and other violence risk. Implement interventions to reduce risk of suicide as described in the Chapter 2. Review how to care for patients who are at risk for injury to self or others.

Interpersonal conflict, paranoia, delusions, impaired judgment, limited impulse control, fear, and disagreement with rules increase the risk for aggressive behavior.^[17] Nursing interventions addressing increased risk for violence to self and others are described in the following box.

Promote Hygiene and Nutrition

Promote hygiene in patients experiencing psychosis by concisely and explicitly stating expected hygiene tasks. Break tasks into smaller, more manageable tasks and assist when needed. Use visual cues to prompt hygiene tasks, such as putting clean clothes on the bed or clean towels and a toothbrush in the bathroom. Share potential benefits of improved hygiene such as improved socialization with others. Reinforce progress in performing hygiene with verbal praise or concrete rewards like additional privileges on the unit.^[19]

Patients who are experiencing catatonia require assistance with nutrition, as well as other activities of daily living.

Improve Socialization

Regularly engage with the patient. Initially interact briefly about low-anxiety topics like the weather or pets and gradually increase the duration and frequency of interactions as they become more comfortable. Encourage patients to participate in unit activities without pressure, such as “We would like to see you at the morning meeting.” Reinforce the patient’s control in their choices, such as, “If you become uncomfortable in the group, you can leave and try again on another day.” Provide positive reinforcement for attempts at socialization, such as, “It was nice to see you in the morning meeting today.”^[20]

Encourage Hope and Self-Esteem

Convey unconditional acceptance, empathy, and support. For example, say, “Sometimes it can feel very discouraging to go through all of this. I am wondering how you are feeling?” If the patient cannot identify their feelings, suggest words that may apply, such as, “Sometimes it is hard to say what you are feeling. Do you feel sad, frustrated, or anxious?” Validate the patient’s feelings and assure them they are not alone. Help the patient identify their positive traits or previous accomplishments. Suggest coping strategies such as journaling and attending a support group.

Prevent Injuries

Fall risk may be increased due to orthostatic hypotension, impaired balance, bradykinesia, or other movement disorders. Assess the patient’s gait and for orthostatic hypotension. Teach the client to slowly change position from lying to sitting to standing and encourage the use of handrails or seeking assistance when feeling unsteady. Implement additional fall precautions as needed according to agency policy.

Use Therapeutic Techniques for Delusions and Hallucinations

Recall that patients with schizophrenia may have memory and attention impairments. Repetition with visual and verbal reminders is helpful to promote task completion. Additionally, short but frequent interactions may be less stimulating to the patient and better tolerated.^[21] Additional techniques for helping patients who are experiencing delusions and hallucinations are described below.

Helping Patients Who Are Experiencing Delusions

Delusions feel very real to the patient and can be frightening. Nurses should acknowledge and accept the patient’s experience and feelings resulting from the delusion while conveying empathy. They can provide reassurance regarding their intentions to help the patient feel safer.

Avoid questioning the delusion. Until the patient’s ability to test reality improves, trying to prove the delusion is incorrect can intensify it and cause the patient to view the staff as people who cannot be trusted. Instead, focus on the fear and what would help the client feel safer. For example, if a client states, “The doctor is here. He wants to kill me,” the nurse could respond, “Yes, the doctor is here and wants to see you. They talk with all of the patients about their treatment. Would you feel more comfortable if I stayed with you during your meeting with the doctor?” Focusing of events in the present keeps the patient focused on reality and helps them distinguish what is real.^[22]

If a patient is exhibiting paranoia and is highly suspicious, it is helpful to maintain consistent staff assignments. Staff should avoid laughing, whispering, or talking quietly where the patient can see these actions but cannot hear what is being said. Staff should ask permission before touching the patient, such as before taking their blood pressure.

Helping Patients Who Are Experiencing Hallucinations

Hallucinations feel very real to the person experiencing them and can be distracting during their interactions with others. Hallucinations can be supportive or terrifying, faint or loud, or episodic or constant. For example, listen to simulations of auditory hallucinations in the following box. The nurse should focus on understanding the patient’s experiences and responses and convey empathy. Command hallucinations, suicidal ideation, or homicidal ideation requires safety measures as previously discussed in the “Provide Safety” subsection.

When working with a patient who has a history of hallucinations, watch for hallucination indicators, such as eyes tracking an unheard speaker, muttering or talking to oneself, appearing distracted, suddenly stopping a conversation as if interrupted, or intently watching a vacant area of the room. Ask about the content of the hallucinations and if they are experiencing command hallucinations. Assess how the patient is reacting to the hallucinations, especially if they are exhibiting anxiety, fear, or distress.^[23]

Avoid referring to the hallucinations as if they were real to promote reality testing. For example, do not ask, “What are the voices saying to you,” but instead ask, “You look as though you are hearing something. What do you hear?” Do not try to convince the patient the hallucinations are not real, but instead offer your perception and convey empathy. For example, “I don’t hear angry voices that you hear, but that must be very frightening for you.” Address any underlying emotion, need, or theme indicated by the hallucination.^[24]

Focus on reality-based activities in the “here and now,” such as a conversation or simple project, such as coloring. Promote and guide reality testing. For example, guide the patient to look around the room and see if others are frightened; if they are not, encourage them to consider what they are experiencing are hallucinations. Teach the patient to compare their perceptions to trusted others.^[25]

Address Physiological Needs

The patient may also be experiencing physiological problems related to nutritional status, sleep, and elimination due to their symptoms of psychosis. Encourage fluid and food intake. Provide snacks if necessary. Many medications can cause constipation, so assess frequency of bowel movements and provide PRN medications as needed. Help patients prepare for sleep through reducing stimuli and providing PRN medications.

Patients may have unaddressed medical problems, including pain. Assess daily for these and ensure that a medical provider is notified should the patient have physical complaints.

Implement Collaborative Interventions

See the Treatment subsection of the “Schizophrenia” section of this chapter for medications and therapies prescribed for patients with psychosis. Nurses often assist in implementing these collaborative interventions. A strong nurse-patient relationship promotes treatment plan adherence, including acceptance of medications.

APNA Standard of Implementation

The American Psychiatric Nursing Association (APNA) has organized interventions based on Implementation Standards. See Table 11.4 below.

Table 11.4 Nursing Interventions Based on the Categories of the APNA Implementation Standard^[29]

Evaluation

A patient’s progress is continually assessed using their individualized SMART outcomes and current status. Full recovery can take months. By setting small goals, it is easier to identify and recognize progress that may occur in small increments.^[30]