Nursing

1. Schizophrenia
Mohamed Mustafa Abdullah

2. definition
►It is a devastating brain disease that affecting
a person's thinking, language, emotions, social
behavior and ability to perceive reality
accurately with fundamental symptoms
known as Bleuler’s four A,
s:
1- Autistic thinking
2- loosening Of Associations (LOA)
3- Ambivalence
4- disturbances of Affect

3. • A severe psychotic illness characterised by
delusions, hallucinations (usually auditory),
thought disorder and behavioural disturbance
• Often deterioration in social, occupational and
cognitive function
• Occurs in Clear consciousness

4. Hitory
• Kraeplin (1855 –1926) – dementia praecox
• Bleuler (1857 – 1959) – schizophrenia
• Kraeplin suggested that aud. Hallucinations,
delusions, thought disorder, affective
falttening and impaired insight were common
to hebephrenia, paranoia, catatonia and
dementia simplex – group of disorders which
he called dementia praecox

5. History
• Bleuler – the four As – abnormal thought
association, affective abnormality,
ambivalence, autism
• Schneider (1887 – 1967) – first rank symptoms
• Current classification – ICD 10/ DSM IV

6. Classification
• Positive symptoms – hallucinations, delusions,
bizarre behaviour, formal thought disorder,
inappropriate affect
• Negative symptoms – affective flattening,
poverty of speech/thought, a volition (lacking
motivation) – apathy, anhedonia (lacking
pleasure or interest in enjoyable activities),
social withdrawal, inattentiveness

7. ICD 10
• Paranoid schizophrenia – prominent
delusions, and hallucinations. Usually not
much thought disorder or negative symptoms
• Hebephrenic (disorganised) SZP – affective
abnormality, thought disorder, mannerisms.
May have chronic course

8. ICD 10 contd.
• Catatonic schizophrenia – psychomotor symptoms eg
violent excitement, posturing, waxy flexibility,
automatic obedience, perseveration, stupor
• Residual SZP – “defect state” – positive symptoms
give way to negative symptoms
• Simple schizophrenia – insidious development of
negative symptoms without positive symptoms

9. Epidemiology
• Lifetime risk – 1%
• Incidence – 20/100 000 per year
• Equal prevalence in males and females
• Males diagnosed earlier than women (males
age 15-25 years, females age 25 – 35 years)
• Winter birth excess – increase of 7 – 15%

10. Aetiological Theories
• Biological:
– biochemical: (Main theories are dopamine,
serotonin and excitatory amino acid hypotheses).
– genetic
– Neurodevelopmental
• psychological
• social

11. Genetics
• Greatest risk factor is having a relative with
SZP
• MZ twin – 48% risk; DZ twin 17%
• Child of one parent with SZP – 13%
• Child of two parents with SZP – 46%

12. DSM-IV schizophrenia
• A. Characteristics of symptoms: two or more
of the following, each present for a significant
portion of time during a 1-month period (or
less if successfully treated):
• Delusions
• Hallucinations
• Disorganised speech
• Grossly disorganised or catatonic behaviour
• Negative symptoms (i.e. affective flattening,
alogia (reduced speech), or avolition)

13. N.B. only one (A) symptom is required if delusions are
bizarre or hallucinations consist of a voice keeping up
a running commentary on the person's behaviour or
thoughts, or two more voices conversing with each
other.
• B. Social/occupational dysfunction
• C. Duration: continuous signs of the disturbance
persist for at least 6-months. This 6-month period
must include at least one month of symptoms that
meet criterion A.

14. Diagnosis and Investigation
• Diagnosis – presence of typical symptoms
• Exclusion of other disorder e.g. organic causes
»CVA
»Drug-induced e.g. cannabis, steroids
»Alcoholic hallucinosis
»dementia

15. Investigations
• No diagnostic test
• Screen for drugs of abuse (urine)
• Bloods for CBC, biochemistry, blood glucose,
TFT and VDRL
• EEG, ECG, CT and MRI brain

16. Treatment
• May require admission if acutely disturbed or
present a risk to self or others
• Admission may be useful in assessment
• Essential to assess suicide risk as there is a
mortality of about 10% from suicide in SZP

17. Treatment contd.
• Antipsychotic drugs (typical and atypical).
• May require depot injection
• Atypicals have fewer extra-pyramidal side
effects and tend to be better for negative
symptoms than typicals
• IM medication may be required in a very
disturbed, involuntary patient

18. • Maintenance treatment – generally
maintenance on one medication
• Compliance may be a significant problem
because of long-term nature of treatment and
lack of insight.

19. Treatment contd.
• Psychosocial treatment:
• Education of patient and carers
• Cognitive behavioural therapy
• Rehabilitation
• social skills training
• family therapy
• occupational therapy.

20. Prognosis
• Good outcome is associated with:
– Female
– Older age of onset
– Married
– Living in a developing (as opposed to developed)
country
– Good premorbid personality
– No previous psych history
– Good education and employment record
– Acute onset, affective symptoms, good compliance
with meds

21. Nursing Management
Assessment
Assessment of clients who have schizophrenia
occurs at individuals, family, and environmental
levels. The nurse must be aware of the client'
status and of changes in the client's personal life,
Family situation and environment to planed care
and intervene effectively.

22. The symptoms of schizophrenia are separated
into:-
1-positive symptoms: which represent and
excesses or distortion of normal functioning,
2- negative symptoms: which represent an deficit
in functioning.
3- cognitive symptoms
4- Depressive symptoms

23. Assessing Positive Symptoms
The positive symptoms appear early in the first
phase of the illness, it is the symptoms that gets
people's attention and often need
hospitalization .They are , usually respond to
antipsychotic and behavioral therapy . positive
symptoms:
►Hallucinations
►Delusions
►Bizarre behavior
►Thought disorders

24. Assessing Negative Symptoms of
Schizophrenia:
►aVolition;
►Poverty of content of speech.
►Poverty of speech.
►Thought blocking.
►A logia
►Apathy
►Anhedonia
►Attention deficits

25. Cognitive symptoms
►Difficulty with attention
►Difficulty with memory
►Difficulty with Executive functions (e.g.
decision making and problem solving)
►Self care problems

26. Depressive symptoms
►Increase likelihood of substance abuse
►Increase likelihood of suicide
►Impaired functioning

27. Nursing Diagnosis:
Nursing diagnoses are formulated from the
information obtained during the
assessment phase of the nursing process.
► The following is a listing of some of the
more common diagnoses applicable to
schizophrenia.

28. ►1. Altered thought processes.
►2. Sensory perceptual alterations.
► 3.. Impaired verbal communication.
►4. Social isolation.
►5. Ineffective individual coping.
►6. Self care deficit ( Bathing , hygiene,
dressing, grooming, feeding, toileting).
► 7. Altered family processes.
►8. Risk for violence directed at others
►9. Risk for violence self- directed.

29. 1/ Altered thought process.
Related factors:
► - Impaired ability to process and synthesize
internal and external stimuli.
► - Biologic factors( neurophysiologic,
genetic)
► - Sensory- perceptual alternations.
► - Psychosocial / environmental stressors.

30. Evidenced by :
►- Inability to distinguish internally stimulated irrational
ideas leading to faulty conclusions (autistic).
► Perceives that others in the environment can hear his
or her thoughts ( through broadcasting ).
►- Demonstrated neologisms, word salad, thought
blocking ,thought insertion, thought withdrawal ,
poverty of speech, or mutisim..
►- Believes that his or has thoughts are responsible for
world events or disasters.

31. Goals:
► Demonstrate reality –based thinking in verbal
and non-verbal behavior.
►- Demonstrate absence of psychosis
( delusions, incoherent, illogical speech , magical
thinking, ideas of references , thought blocking,
thought insertions, thought broadcasting).

32. Nursing Interventions:
►1/ Approach the client in a slow, calm matter
of –fact manner ,to avoid distorting the
client's sensory- perceptual field , which
could foster altered thoughts and perceptions.
►2/ Maintain facial expressions and behaviors
that are consistent with verbal statements.
Patients are very sensitive to other's
responses to their symptoms.

33. ►3/ Continue to assess the client's ability
to think logically and to utilize realistic
judgmental problem- solving abilities
►4/ Listen attentively to key themes and
reality –oriented phrases or thoughts.
Talk about real events of people.
ِِ

34. ►5/ interpret the client's misconceptions and
misperceived environmental events in a calm,
matter-of fact manner, identifications of
reality , by a trusted person is helpful.
►6/ Instruct the client to approach staff when
frightening thoughts occur. A respectful ,
interested approach will enable the patient to
discuss an usual and frightening thoughts.

35. ►7/ Refrain from touching client who is
experiencing a delusion especially if it is
persecutory type. Touch may be interpreted as
a physical or sexual assault.
►8/ A void challenging the client's delusional
system or arguing with challenging the belief ,
may force the client to adhere to it and
defend it.

36. ►9/ Distract client from delusion by engaging him
in a less threatening or more comforting topic or
activity at the first sign of anxiety or discomfort.
►10/ Focus on the meaning, feeling or intent
provoked by the delusion rater than on the
delusional content.
►11/ A void seeking the details of the client's
delusion so as not to reinforce the false belief and
further distance client from reality.

37. ►12 / Offer praise as soon as the client begins to
differentiate reality based on non- reality based
thinking.
►13/ Respond to the Clint's delusions of persecution
with calm, realistic statement.
►14/ Use simple declarative statements , when talking
to the client who demonstrates fragmented
,disconnected , incoherent, or tangential speech
patterns ,which reflect loose associations.

38. 2/ Sensory/ perceptual alteration.
Related factors:
► - Psychosocial stressors, loneliness and isolation
( perceived or actual).
►- Withdrawal from environment.
►- Lack of adequate support persons.
►- Chronic illness and institutionalization.
►- Disorientation.
►- Ambivalence.
►- Biologic factors ( neurophysiologic, genetic).

39. Evidenced by:
► - attentive to surroundings ( preoccupied with
hallucination).
►- Startles when approached and spoken to others.
►- Appears to be listening to voices or sounds when
neither are present (cocks head to side as if
concentrating on sounds tat are inaudible to others).
►- May act upon "voiced" commands ( may attempt
mutilating gesture to self or others that could be
injurious)
►- Describes hallucinatory experience: " it's my father's
voce and he's telling me I'm not good".

40. Goals:
► - Able to hold conversation without
hallucinating.
► - Remains in group activities.
► - Attends the task in hand (e.g. group
process, recreational or occupational therapy
activities. States that hallucinations are under
control.

41. Nursing Interventions:
►1. Continuously orient patient to actual
environmental events of activities.
►2/ Call the client and staff members by their
names to reinforce reality.
►3/ Utilize clear, concrete statements.
►4/ utilize clear, direct verbal communication
rather than unclear or nonverbal gestures.

42. ►5/ Focus on real events or activities to reinforce
reality and divert client from the hallucinating
experience.
►6/ Reassure the client ( frequently if necessary)
that he or she is safe and won't be harmed:
observe for verbal or nonverbal behaviors
associated with hallucinations.

43. ►7/ Attempt to determine precipitants of the
sensory alteration ( stressors that may trigger
the hallucination): explore the content of the
auditory hallucinations to determine the
possibility of harm to self, others or the
environment (auditory command and
hallucinations) to prevent destructive behavior.

44. ►8/ When danger of violence is imminent ,
protect the client and others by following
facility procedures and policies for seclusions
or chemical or mechanical restrict to prevent
harm or injury to client or others.
►9/ Teach the client techniques that will help
stop hallucinations.