Paranoid Schizophrenia

Nicole LemermeierNatalie Stottlemyer

Katie WhartonNicole McNamee-Nelan

Britney Yousif

Developmental Process of Schizophrenia

Schizophrenia: Disturbance in thought process perception and affect in variable result in a severe deteriation of social and

occupational functioning

Most current theory is schizophrenia is a biologic based diseaseInfluenced by external or internal environment

There are 7 theories of paranoid schizophrenia

Developmental Process of Schizophrenia

Theory of GeneticsTheory of Family relationshipThe Biological TheoryThe Physiological TheoryThe Physical TheoryThe Environmental TheoryTheory of Stressful life Events

History of Schizophrenia

Schizophrenia has been around since the ancient Egyptians

The term Schizophrenia is Greek and means split mind

In 1908 Swiss psychiatrist Eugen Bleuler coined the phrase schizophrenia

History of Schizophrenia

Clinicians believe there will never be one treatment for schizophrenia

It is now widely believed that many factors cause schizophrenia

In psychology, schizophrenia is the most widely studied disorders to date

History of Schizophrenia

Suicide is the primary cause of premature death among schizophrenics

40%-55% of schizophrenics experience some form of suicidal ideation

20%- 50% have made at least one attempt at suicide

History of Schizophrenia

About 1% of the entire population of the United States is schizophrenic

Even thought the cause is unknown genetics are believed to play a large role in the disorder

Siblings are 5%- 10% more likely to become schizophrenic

Twins are 50 times more likely than any other group

SymptomatologyOne of the most damaging of all mental

disordersCauses its victims to lose touch with

realityBegin to hear, see, or feel things that

aren't really there (hallucinations) Become convinced of things that simply

aren't true (delusionsSymptoms begin in late 20’s to late 30’sDevelops gradually, although onset can be

sudden

Symptomatology

Confusion Inability to make decisions Hallucinations Changes in eating or sleeping habits, energy level, or weight Delusions Nervousness Strange statements or behavior Withdrawal from friends, work, or school Neglect of personal hygiene Anger Indifference to the opinions of others A tendency to argue A conviction that you are better than others, or that people are

out to get you

Symptomatology

Less likely to be affected by mood and thinking problems, concentration and attention

Most affected by positive symptomsIndicate the presence of unusual thoughts

and perceptions that often involve a loss of contact with reality

Delusions and hallucinations are considered positive symptoms

Symptomatology

Negative symptoms effect social interactions

Less predominate symptoms of schizophrenia

Associated with loss or reduction in emotions, motivation, and pleasures

May show social withdrawal, lack of conversation, indifference to appearance, and safety

Inability to change facial expressions according to mood, monotone voice, and disinterest with their surroundings

Case Study

J.H. is a 24 y/o male who was brought in to the ED by the local police. He had attacked his sister with a knife. She was trying to convince him that the voices he was hearing were not telling him to kill himself. His family claims he has not been taking his medications. In the ED, he tells the nurse “I see secret agents watching me at night. They want to implant chips in me. The voices told me if I kill myself then they will fail.”

Nursing Diagnosis Short Term & Long Term Goals

Interventions Rationales Evaluation

Risk for injury to self and others.R/T Auditory

hallucinations Command

hallucinations Visual hallucinations Paranoid delusions Suicidal ideations Homicidal ideationsS: “I see secret agents watching me at night. They want to implant chips in me. The voices told me if I kill myself then they will fail.” O: At home patient attacked his sister with a knife. Patient was threatening to kill himself because the voices told him to.

STG: By day five of hospitalization patient will report a decrease in auditory and visual hallucinations, delusions, suicidal ideations and homicidal ideations.LTG:Patient will remain free from harming self and others during length of hospital stay.

STG1) Use distraction or redirection of patient’s attention when agitated.2) Ask what the voices are telling the patient3) Administer antipsychotic medications as prescribed.LTG1) Remove items such as belts, scarves, razor blades, shoelaces, scissors- anything that could be used for self-harm. Check all items brought into the unit by patient. Instruct family members to avoid bringing into the unit any hazardous items.2) Routinely check environment for hazards and ensure environmental safety.3) Intervene at earliest signs of agitation. Use direct commands to bring about positive behavior in patient.

STG1) Using patients distractibility avoids confrontation and maintains safety (Swearingen, 2008, p.754)2) It is essential to know if “voices” are command hallucinations that tell the patient to harm self or others. This question also communicates that the nurse does not hear the voices while at the same time validates presence of the voices in the patient’s reality. (Swearingen, 2008, p.771)3) Antipsychotic medications reduce psychotic symptoms including hallucinations. (Swearingen, 2008, p.771LTG1) This provides environmental safety and removes potential suicide weapons. (Swearingen, 2008, p.764)2) Minimizing opportunities for self-harm is an ongoing concern requiring constant vigilance. (Swearingen, 2008, p.764)3) Early intervention assists patient in regaining control, defuses a difficult situation, prevents violence, and enables treatment to continue in least restrictive manner. (Swearington, P. 746)

STGBy day five from admission patient states “ I don’t see people at night, I still hear voices sometimes but not as much, and I know there are still people out to get me. I know if I keep taking my medications the voices will go away hopefully.” Continue with plan and reevaluate in two days.LTGPatient was discharged in ten days from admission and remained free from any self induced injuries or injuries towards others.

Nursing Diagnosis Short Term & Long Term Goals

Interventions Rationales Evaluation

Disturbed sensory perceptionR/T Auditory

hallucinations Visual

hallucinationsS: “I see secret agents watching me at night. They want to implant chips in me. The voices told me if I kill myself then they will fail.” O:Patient is talking to himself. He appears to turn towards stimuli unseen by others.

STG:Patient will report a decrease in hallucinations by day four of taking antipsychotic medications as scheduled.LTG:By discharge patient will recognize hallucinations are not part of reality.

STG:1) Ask what the voices are telling the patient2) Assure patient that you will provide safety for him regardless of what the voices say will happen.3) Avoid touching patientLTG:1) Administer antipsychotic medications as prescribed.2) Evaluate and observe for hallucinations. Redirect back to reality by distracting patient with conversation. 3) Investigate with patient sources of stress and explain the relationship of anxiety and stress to hallucinations.

1) It is essential to know if “voices” are command hallucinations that tell patient to harm self or others. This question also communicates that the nurse does not hear the voices while at the same time validates presence of the voices in the patient’s reality. (Swearingen, 2008, p.771)2) This provides an anchor to reality and decreases patient’s fear that harm will occur based on what voices say. (Swearingen, 2008, p.771)3) Distortion of reality may lead patient to misinterpret physical touch which along with excessive environmental stimuli can increase anxiety and precipitate hallucinations or aggressive response. (Swearingen, 2008, p.771)1) Antipsychotic medications reduce psychotic symptoms including hallucinations. (Swearingen, 2008, p.771)2) Early assessment enables evaluation of patient’s response for hallucinations and how much time patient focuses on them. It also enables the nurse to assess if hallucinations place patient or others at risk and permits early intervention to protect patient as well as others.3) Providing information about the relationship of anxiety and stress to hallucinations gives the patient increased control over the occurrence of hallucinations. (Swearingen, 2008, p.772)

STG: By day five from admission patient states “I don’t see people at night, I still hear voices sometimes but not as much, and I know there are still people out to get me. I know if I keep taking my medications the voices will go away hopefully.” Continue with plan and reevaluate in two days.LTG: Patient states “I know that the hallucinations are part of my schizophrenia and not part of other people’s lives”

Nursing Diagnosis Short Term and Long Term Goals

Interventions Rationale Evaluation

Noncompliance medication therapyR/T Perceived

negative consequences of the treatment.

Exacerbation of psychotic thinking and behavior.

S: Patient refused to answer questions regarding why he has not been taking his medications. O: Family notes patient has not been taking his medications.

STG:Patient will willingly take all prescribed medications in one week from admission.LTG:By discharge patient will state reasons for taking medications and commitment to taking all scheduled medications at home.

1) Assess patient’s understanding of the disease process, medical management, and treatment plan. Explain or clarify information as indicated.2) Assess for causes of nonadherence, such as financial constraints, inconvenience, forgetfulness or memory problems, medication side effects, misunderstanding of instructions, or difficulty making significant lifestyle changes or following medication schedule.3) Promote patient’s expression of feelings. In addition, evaluate patient’s perception of effectiveness or ineffectiveness of treatment.1) Confront myths and stigmas. Provide realistic assessment of risks, and counter misconceptions. 2) Assess patient’s support systems. 3)After the reason for nonadherence is found, intervene accordingly. If it appears that changing medical treatment plan may promote adherence, discuss this possibility with health care provider. Provide patient with information about interventions that can minimize drug side effects.

1) This assessment enables nurse to explain or clarify information as indicated and facilitates development of an individualized care plan that promotes adherence.(Swearingen, 2008, p.330)2) Once causes are identified, the nurse can then focus the care plan accordingly. (Swearingen, 2008, p.330)3) This will help clarify patient’s perception of vulnerability to the disease process and signs of denial of the illness. (Swearingen, 2008, p.330)1) This will help determine if a value, cultural conflict, or spiritual conflict is causing nonadherence. (Swearingen, 2008, p.330)2) This will help determine if a family disruption pattern is making adherence difficult and “not worth it”. (Swearingen, 2008, p.331)3) All my help facilitate adherence. (Swearingen, 2008, p.331)

STG: By day four patient is willingly taking all medications prescribed.LTG:By discharge, patient is able to state “I know my medications will help my schizophrenia so I don’t have hallucinations and I plan to take them the way they are prescribed at home.”

Psychological Treatment

Individual Psychotherapy◦ 1 on 1 therapy. ◦ Primary Focus: decrease anxiety, increase trust.◦ Can be difficult because they can become defensive

and suspicious.

Group Therapy◦ Useful when combined with medication therapy.◦ Primary Focus: real life plans, problems, and relationships.◦ Reduces social isolation.◦ More effective for out patient treatment once their

medications are effective.

Social Treatment

Milieu Therapy◦ Focused on group/social interactions.◦ Goal oriented, clear communication.◦ More effective when used with psychotropic meds.

Family Therapy◦ Some therapist believe that in order to treat a paranoid schizophrenic, they must treat

the entire family.◦ Educate family on illness and how to help treatment with family communication and

problem solving.◦ Extremely positive results because it helps build a support system for the client.

Assertive communication Treatment◦ Involves a team of health care professionals: Psychiatrist, Nurses, Social Workers,

Vocational Rehabilitation Therapist, and Substance Abuse Counselors. ◦ “Individually tailored to basic living skills, helping clients work with community agency,

and assisting clients in developing a social support network.

Organic Treatment

Psychopharmacology:◦ Antipsychotics- very effective treatment.◦ “Without drug treatment, 70%-80% of people who have

experienced a schizophrenic episode will relapse over the next 12 months”

◦ Works best when combined with psychosocial therapy.◦ Takes several weeks for medications to take effect.

Meds used: ◦ Cholorpromazine ( Thorazine)◦ Thiothixene (Navane)◦ Italoperidol (Haldol)◦ Clozapine (Clozaril)◦ Aripiprazole (Abilify)

Organic Treatment

Common Side Effects:◦Nausea◦Skin rash◦Sedation◦Orthostatic hypotension◦Tachycardia◦Photosensitivity ◦Decreased libido◦Weight gain◦EPS◦Tardive dyskinesia◦NMS

Resources

Kennard, J. (December 12, 2007). Positive and negative symptoms: a helpful concept. Retrieved from http://www.healthcentral.com/schizophrenia/c/674/17705/concept

Mayo clinic staff (December 16, 2008). Paranoid schizophrenia. Retrieved from http://www.mayoclinic.com/health/paranoid-schizophrenia/DS00862/DSECTION=symptoms

Swearingen, P. L. (2008). All-in-one care planning resource. St. Louis, Missouri: Mosby Elsevier.

Townsend, M. (2008). Essentials of psychiatric mental heakth nursing. Philadelphia, PA: F.A. Davis Company.