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Care of the Patient with Schizophrenia

1.00 Contact Hour
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Kelley Madick (MSN/ED, PMHNP)

Outcomes

The purpose of this course is to prepare Nursing Assistants to successfully care for the patient with Schizophrenia.  

Objectives

  1. Define schizophrenia
  2. Discuss symptoms and progression of schizophrenia
  3. Explain how to care for a patient with schizophrenia
  4. List what needs to be reported to the nurse

Case Study 1

Mary is a patient assigned to you today. You are told that Mary has schizophrenia and is hearing voices today. The nurse asks that you spend extra time with Mary because she has been wandering the halls into other patient’s rooms. You tentatively approach Mary and introduce yourself. You notice that Mary has on dirty wrinkled clothes and has not eaten her breakfast yet. She is talking to the wall like there is someone there. She even reaches over and appears to touch someone. Although you talk to her, Mary does not look at you or respond to you. The nurse also asks that you monitor her output and get her to bathe today. You wonder what you are going to do with Mary.

Case Study 2

John is a 46-year-old-black male with a long history of psychosis. He is currently a resident at the facility where you work.  The patient has refused to eat and take his medication for the last week. The patient states, “The food and medication have been contaminated by the spies.” The patient goes on to say… “God spoke to me and told me not to eat or take my medication because it is poison.” You notice that John does not show any emotion when he speaks, and his eyes are mostly looking at the floor.  He has a strong body odor and his clothes are very dirty. He is very distracted, frequently stops talking and looks toward the end of the room with a frightened look on his face. What will you do with John?

Introduction

Schizophrenia is a devastating disease that affects how the patient thinks, acts, and feels. People with schizophrenia often have trouble telling the difference between what is real and what is imaginary. It is not a split personality or multiple personalities. This group of people have a brain disorder that causes them to experience and react to the world differently. However, people with schizophrenia are often stigmatized as being violent or crazy. Statistics show that those diagnosed with schizophrenia are no more violent than the average population (Halter, 2014).

Schizophrenia is more common in males than in females and affects about 1% of the American population (“NAMI: National Alliance on Mental Illness | schizophrenia,” 2015). The average onset of the disease for men is in their early 20’s and for women in their late 20’s or early 30’s. Although uncommon in children, the disease can be seen in approximately one in every 40,000 children (Halter, 2014).

German psychiatrist, Emil Kraepelin, was the first to recognize the illness in 1887 (Burton, 2012). He recognized this form of psychosis as being different for psychosis that can appear in mood disorders. He called the disease “dementia praecox” and believed that it only occurred in young people (Burton, 2012). However, documentation of an illness with symptoms much like schizophrenia has been discovered in Egypt dating back to 1550 BC. Kraepelin’s classification of schizophrenia and other diseases has been the bases for the classifications of mental disorders we use today; the ICD-10 and the Diagnostic and Statistical Manual of Mental Disorder 5 (DSM-5). Interestingly, archeologists have found stone age skulls with holes drilled into them perhaps to let the evil spirits out.

Additionally, EugenBleuler was the first to call the disease schizophrenia (Halter, 2014). Bleuler believed that contrary to Kraepelin’s belief that the disease led to mental deterioration, believed that schizophrenia led to a heightened experiences and memories (Burton, 2012). He was also the first to view schizophrenia as a group of disorders with the most noticeable symptoms being what he called a ‘loosening’ of thoughts and feelings (Burton, 2012). Bleuler’s fundamental signs of schizophrenia are still used today and are called the four A’s (Halter, 2014):

  1. Affect- Normally feeling or emotions that can be seen on a person’s face. In Schizophrenia, there are no visible feelings. The patient is said to have a flat or blunt affect.
  2. Associative looseness – This is disorganized thought pattern. Disorganized thought patterns can be seen as mixed-up or illogical words and the inability to think logically.
  3. Autism – This refers to the person being in their own world. It is evidenced by delusions, hallucinations or making up words that only has meaning to the patient.
  4. Ambivalence – Two emotions, attitudes or ideas are present that conflict each other. The patient may state they want the hallucinations to stop but refuses to take medications due to paranoia.

The causes of schizophrenia are unclear. Researchers believe that the disease can be inherited and may be triggered by the environment, viral infections, stress or a combination of these that affect how the brain works (Halter, 2014). Particularly how the brain uses chemicals or neurotransmitters. Scientists believe that there is an imbalance in the brain of the chemicals serotonin and dopamine called neurotransmitters (Halter, 2014). These neurotransmitters are what cause nerve cells to send messages through the brain that tells the person how to respond, feel or act or respond to stimuli. Normally, a person can respond to words, music or thoughts in a rational manner because of these neurotransmitters. However, someone with schizophrenia may misinterpret the stimuli such as music or words and react differently because they understand it differently. This misinterpretation of the environment or thoughts may lead to a response of hallucinations, delusions, or paranoia. It is important to understand each of these responses, why they may occur and how to care for the patient.

Definition of terms

Psychosis- The patient is not able to understand or see reality. The person is sometimes said to be in their own world. They do not respond to the same reality as the average person (Sorrentino & Remmert, 2013)

Delusion – A false fixed belief. For example, the patient believes they are a millionaire. Delusions can also be classified by the content. For example, delusions of grandeur are beliefs that the patient is someone of importance (“I am the Queen of England) or delusions of persecution in which the patient believes they are being singled out for abuse or harm (Halter, 2014).

Hallucination- Hearing, seeing, smelling or feeling something that is not there. For example, the patient may hear voices telling them to do things or may see a person, animal or object that is not there (Sorrentino & Remmert, 2013).

Illusion- A misinterpretation of an object (Sorrentino & Remmert, 2013). For example, an IV pole may be next to the patient’s bed, but the patient sees the pole as a person standing over them.

Paranoia – The patient has irrational suspicions that cannot be changed (Halter, 2012). For example, the patient may state that the FBI has their room bugged.

Symptoms of Schizophrenia

Schizophrenia has a predictable pattern or phases. Symptoms are further classified into positive, negative, cognitive, and affective. Positive symptoms are not normally present such as hallucinations or delusions. Negative symptoms are described as behaviors that should be present but are not such as motivation or thought processes. Cognitive symptoms are unusual thinking patterns. Affective symptoms describe emotions and expressions (Halter, 2014). According to the DSM-V, the patient must have at least two symptoms for one month in a six -month time period (Nussbaum, 2013).

The symptoms in each phase can vary in length and acuity (APA, 2006).  The phases are as follows (Halter, 2014; National Institute of Mental Health, 2009):

  • The prodromal phase usually occurs in teen and features social deficits such as decreases in school performance. There may be changes in thoughts process such as bizarre ideas. The patient may exhibit social isolation when they were once very outgoing. The sign are very subtle in this stage.
  • The acute phase is the onset of the disease. Symptoms are present and active. The symptoms may be hallucinations, delusions, withdrawal or any other symptoms associated with the disorder. The patient is usually hospitalized and treate
  • The stabilization phase is the patient’s return to a more normal function. Symptoms begin to subside and become manageable. The patient maybe placed in a day program or a residential facility.
  • The maintenance phase is the return to a baseline function. Note that patients may never return to pre-schizophrenic diagnosis function. They can function on their own with minimal help. They are, however, on life long medication treatments.

The patient with schizophrenia suffers from impairments in thinking or cognitive functions. Along with hallucinations, delusions, and paranoia, it is important to remember that this patient may not be able to respond or communicate appropriately. Speech may not be understandable, and they may not interact normally. 

Caring for the patient with Schizophrenia

Understanding and patience are the most important characteristics of caring for this person. Hallucinations, delusions a paranoia is scary for them. Good communication is very important. Do not pretend to see or hear the person’s hallucinations. Likewise, do not agree with the delusions or the paranoia. Finally, do not try to convince the patient that what they are experiencing is not real. To them it is real. Speak slowly and calmly. Be careful about touching the person, this may upset them more (Halter, 2014; Sorrentino & Remmert, 2012). Stating “I know that the voices are real to you, I do not hear them” allows the care giver to be honest and may help the patient accept that the voices are not real. This allows for the patient to gain control over the hallucination (Townsend, 2014; Halter, 2014).

Communicating with the patient may be difficult as they can mix up words or develop their own language. Remember the patient thinks you can understand them. It is important to orient the patient to realty by using their name and validating any part of the conversation you understand. Try to decode the conversation by anticipating their needs. Clarifying what the patient is trying to tell you by stating “I am not sure what you mean or I am not sure what you are trying to tell me. Can you try to explain it to me again please?” (Halter, 2014) Notice that the responsibility for understanding the patient is placed on the caregiver. This helps the patient understands how they are being perceived and alleviates any anxiety or blame for the patient. The patient may also exhibit concrete thinking or literal thinking. Avoid using abstract phrases or clichés such as “the early bird gets the worm.” This can be misinterpreted by the patient (Townsend, 2014).

Asking if the patient is hearing voices can be an early intervention. If the patient is experiencing hallucinations, report your observations to the nurse. Also, observe for any trigger in the environment that can be removed. The patient may be laughing to themselves, talking to themselves, shifting eyes around the room or staring at a particular area (Townsend, 2014). Participating in activities can help decrease social withdrawal as well as inappropriate behaviors, and increase motivation (Halter, 2014). Remember that the activity has to be within the patient’s functioning level. Some activities to consider are drawing, reading, listening to music, or walking. These are activities in the “here-and-now” (Halter, 2014). Keeping the patient focused on reality based activities is important in helping them cope with these symptoms.

Likewise, when a patient experiences delusion, it is important to focus on reality. It is ok to ask about the delusion to obtain assessment information for the nurse, however; do not argue or deny the belief (Mason, Cardell, Armstrong, 2014). The patient may be using delusions as an attempt to understand their environment (Halter, 2014). If the patient is suspicious, attempt to promote trust by using the same staff if possible and being honest with the patient. Activities should be more one-to-one for a suspicious patient. Further, be aware that the patient may believe their food is poisoned or controlled (Townsend, 2014). Offer food they can open themselves with supervision or allow them to choose between actions so they feel some control over their environment. The patient may also become agitated or anxious. Offer empathy such as “You seem anxious. How can I help you?” This offers validation of the patient’s feelings and reinforces trust (Townsend, 2014).

Another important aspect of care is nonverbal communication of the care giver. Nonverbal communication involves what is not said but rather involves tone of voice, stance, eye contact, facial expressions, and movements. When interacting with the patient be sure to face the person, maintain eye contact, stand near the person but not too close, try to position yourself at the patient’s level, facial expressions should show your interest or concern, speak slowly and calmly (Townsend, 2014). It is also important to remember that patients with schizophrenia can have difficulty with memory. Repeating steps or phrases several times may be required (Halter, 2014). Also, this patient can react quickly to increase stimuli. It may be necessary to keep sessions or groups shorter. Interactions and communication should help the patient to feel more comfortable and reduce symptoms.

If the patient becomes agitated, the caregiver should first take measure to protect themselves. When interacting with the patient, make sure the door is closer to not between you and patient. You should have a clear escape route if needed. Call for help if needed. Never try to handle the situation yourself. Always be aware of your surroundings and understand how to recognize agitation or anxiety in the patient.

What to Report

Any changes that are observed should be reported to the nurse. Report any abnormal behaviors, emotions, hallucinations, delusions, or disorganized thoughts. Also, note if there are issues with the patient’s safety such as wandering, hearing voices telling them to hurt others or themselves. Report any triggers that seem to be causing the behavior or emotion. Some other observations to report are (Acello & Hegner, 2015):

  • Is there another person involved, real or in a hallucination?
  • What is the environment like? Lighting? Stimuli? What time of day is it?
  • What is the behavior?
  • Is there a pattern to the behavior? Same time of day? Same stimuli?
  • What happens right before the behavior starts?

Additionally, it is important to report the following:

  • Is the patient bathing and dressing themselves? Do they need help?
  • Is the patient eating? Does the patient feed themselves or need help?
  • Are bowel pattern regular?
  • Does the patient sleep or nap?
  • Does the patient participate in activities?
  • How does the patient get along with others?

A lack of understanding of schizophrenia leads to poor care and mismanagement of patient symptoms. The care giver should recognize symptoms of schizophrenia including hallucinations, delusions, paranoia or disorganized thoughts. Knowing what to expect from the patient and what triggers the symptoms is also important to care for the patient. The care giver should recognize the if the patient is agitated, anxious or stressed. Further, it is important to know what can be done to help alleviate the patient’s discomfort. Offering involvement in activities is one way to help the patient. The family should also be involved when appropriate. Helping the family understand the disease and what strategies can be done to help the patient.

Self Check

Working with this group of patients can be scary and uncomfortable for the health care worker. The patient may be slow to respond to treatment or care. This can lead the care giver to feel helpless or even angry (Caruso et al, 2013). Statement may be made such as “he will never get better” or “why bother, she doesn’t know what is happening anyway.” These feelings and statements are nontherapeutic and interfere with the patient’s care. It is important for the caregiver to recognize when they feel frustrated and talk to another staff member. Examining these feelings and developing other methods to cope and to help the patient may be necessary. Remember the patient also feel helpless and may even be angry at their circumstance or the patient may not recognize that they are ill (Halter, 2014).

The caregiver should make an attempt to recognize their own feelings. Studies have shown that when the caregiver feels helpless or stressed when caring for patients, they can develop physical and psychological problems themselves (Tan, et al, 2012). Furthermore, caregivers may get frustrated by the situation and quit their job. Additional training on how to cope and work with patient diagnosed with mental illness has been shown to be effective (Causo, et al, 2013).  Some strategies to overcome feelings of helplessness and frustration when working with a patient who suffers from schizophrenia are as follows (Halter, 2014):

  • Use empathy. Empathy conveys trust and support. This also helps establish a therapeutic relationship
  • Realistic expectations. Realizing what the patient can and cannot do may help in deceasing frustrations of caring for the patient.
  • Understand the disease. Learning about the how schizophrenia progresses as well as what symptoms are involved will help to decrease helplessness in staff.
  • Learn how to respond to the patient. Patients who suffer from hallucinations, delusions or other symptoms of schizophrenia may need to be approached and addressed differently. Learning how to respond can decrease stress and anxiety.

Recognizing feelings about taking care of a patient with schizophrenia can be an important step in helping the patient as well as the caregiver. Likewise, education on how to work with the patient in various stages of the disease can decrease feelings of helplessness. 

What about Mary

Mary is diagnosed with schizophrenia and has been assigned to you for her care. First, Mary is hallucinating. You observe that Mary talks to the hallucination like a child. She is sitting down in the chair and does not appear agitated. You are sure she is safe and not becoming anxious. You want to notify the nurse and then try to distract Mary from her hallucination. You approach Mary so she can see you and crouch down to her eye level. Speaking slowly and calmly in an empathetic tone you ask her if should would like to eat the new breakfast you brought for her. Once she has eaten and you have taken note of how much she has eaten, you ask her if she would like to wash up. You help her wash and get dressed. Mary begins to talk again to the person she believes is across from her. You suggest Mary go into the living room area where a drawing group has started. You know that getting Mary into the group to draw will distract her and help keep her in reality. At the end or your shift, you report what worked to help Mary and what stimuli in the area seemed to trigger her hallucination. You also report how well she ate, that she had regular bowels and that she participated in the group.

What will you do with John?

John is suffering for auditory and visual hallucinations. It is important to tell the nurse what you have observed and any triggers that may have occurred prior to this episode. Also, ask the following questions: Did something happen? Did he have a visitor? What is in the environment? Did he sleep last night? You can try to distract John with an activity as long as you and he remain safe. You will want to stay on the same side of the room as where the door is so that your escape, if necessary, is not blocked. You will also want to report his eating habits over the last few days as well as his appearance. Try to get him to wash himself and change without agitating him. You may need the help of the nurse to do so. 

References

Acello, B., & Hegner, B. (2015). Nursing assistant: A nursing process approach. Cengage Learning.

American Psychiatric Association. (2006). American psychiatric association practice guidelines for the treatment of psychiatric disorders: Compendium 2006. Arlington, Virg.: American Psychiatric Association.

Burton, N. (2012, September 8). A brief history of schizophrenia. Retrieved January 1, 2016, from (Visit Source).

Caruso, R., Biancosino, B., Borghi, C., Marmai, L., Kerr, I. B., & Grassi, L. (2013). Working with the ‘difficult’patient: The use of a contextual cognitive-analytic therapy based training in improving team function in a routine psychiatry service setting. Community mental health journal, 49(6), 722-727.

Halter, Margaret J. Varcarolis' Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. 7th ed. St. Louis, Mo.: Elsevier, 2014. Print.

Mason, A. M., Cardell, R., & Armstrong, M. (2014). Malingering Psychosis: Guidelines for Assessment and Management. Perspectives In Psychiatric Care, 50(1), 51. doi:10.1111/ppc.12025

NAMI: National alliance on mental illness | schizophrenia.(2015). Retrieved January 2, 2016, from (Visit Source).

National Institute of Mental Health. (2009). Rethinking schizophrenia. Retrieved January 5, 2016, from (Visit Source).

Nussbaum, A. M. (2013). The pocket guide to the DSM-5 diagnostic exam. Washington, DC: American Psychiatric Publishing.

Sorrentino, S. A., & Remmert, L. (2013). Mosby's Textbook for Nursing Assistants-Soft Cover Version. Elsevier Health Sciences.

Tan, S. C., Yeoh, A. L., Choo, I. B., Huang, A. P., Ong, S. H., Ismail, H., ... & Chan, Y. H. (2012). Burden and coping strategies experienced by caregivers of persons with schizophrenia in the community. Journal of clinical nursing,21(17-18), 2410-2418.

Townsend, M. C. (2014). Psychiatric mental health nursing: Concepts of care in evidence-based practice. FA Davis.


This course is applicable for the following professions:

Certified Nursing Assistant (CNA), Home Health Aid (HHA)

Topics:

CPD: Practice Effectively, Psychiatric


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