Learning Objectives
By the end of this section, you will be able to:
- Define schizophrenia and its prevalence, course, and causes
- Understand the symptoms associated with schizophrenia
- Explain the stages of schizophrenia
- Outline approaches used to treat schizophrenia
- Plan nursing care for a client living with schizophrenia
The severe mental illness and disturbance involving a collection of cognitive, affective, and behavioral symptoms that negatively affect social, educational, and/or occupational functioning is called schizophrenia. The course of the disorder varies. Some individuals endure episodes of the disease with asymptomatic breaks between them. Other people have continuous symptoms of the disorder with no remission. There are several theories of how this disturbance emerges, but there is no single etiology and no cure, only treatment for symptoms, including medications, therapies, and psychoeducation. The nurse’s role is to assess clients for critical signs of the disorder, evaluate the impact of these symptoms on their functioning, plan and implement care during treatment, review the efficacy of drug and psychosocial interventions, and check for adverse events with medications.
Unfolding Case Study
Schizophrenia: Part 1
The nurse is assessing a twenty-year-old male who reports to the emergency department with his mother and best friend.
| PMH | Client is a second-year college student studying engineering. He is a bright young person attending college on a scholarship. He has no documented health issues outside of typical colds and ear infections as a child and a bout of influenza last year. Family history: Father has a history of bipolar disorder and substance use and has been out of their lives for fifteen years. Mother does not know his current whereabouts. Social history: Client has been active in sports and has played basketball through high school and up until last semester when he quit the team unexpectedly. Grades have been above average, and mother reports he has “never been in trouble.” Mother reports the client has experimented with marijuana in the past, but she is not aware of any substance use at this time. The client has no current medications and no known allergies. |
| Nursing Notes | 1930: Triage Assessment Client presents with confusion and delirium, pacing and muttering to himself. When questioned, he became agitated and suspicious of the staff’s intent to help. Client declined to change into a gown and did not want vitals taken. Eventually he did comply, after talking with him and reassuring him he is safe. His Mother and friends report changes in personality over the course of the past several weeks with today becoming an acute emergency situation. The client was found taping tinfoil to his bedroom windows and made comments that there was a helicopter flying overhead and that the FBI was watching him. Client self-reports hearing voices in his head telling him to block the windows and hide. The client does not report any homicidal or suicidal ideation. Client unable to void to provide urine specimen. |
| Flow Chart | 1930: Triage Assessment Blood pressure: 138/80 mmHg Heart rate: 107 beats/minute Respiratory rate: 22 breaths/minute Temperature: 99.1°F (37.2°C) Oxygen saturation: 98% on room air Pain: 0/10 |
| Lab Results | Declining labs and unable to provide urine specimen |
Defining Prevalence, Course, and Causes of Schizophrenia
It is posited that schizophrenia is created from a diverse genetic, environmental, and neurobiological etiology that manifests in specific neuronal changes in childhood that result in a cluster of positive, negative, and cognitive symptoms. The disturbance is seen globally and in all ethnic groups, and it usually emerges in early adulthood.
Prevalence of Schizophrenia
Schizophrenia affects nearly twenty-four million people or one in 222 adults (World Health Organization, 2022). Schizophrenia is found in every culture and population across the globe. Although it is not as common as other mental health disorders, the burden of the disease is high. Costs associated with schizophrenia in the United States exceed $150 billion annually (Kadakia et al., 2022). Aside from health-care costs like frequent hospital admissions, there are expenses related to lost work productivity of the person with the disorder and their caregivers and expenditures for legal problems encountered by those with symptoms. Individuals with schizophrenia have a higher risk of suicide, greater involvement with the legal system and incarceration, and increased incidence of homelessness. Schizophrenia is associated with significant functional limitations, distress, and familial and social impairment. The lifespan of those burdened with the disturbance is fifteen years shorter than average due to common comorbidities, such as cardiovascular disease, metabolic disturbance, other mental health disorders, substance misuse, suicide, and infection (Hjorthøj et al., 2017).
The Course of Illness
The age of onset for schizophrenia varies with the average first episode at 23.7 years of age. Youth-onset schizophrenia’s average age of onset is 13 years, and late-onset schizophrenia appears on average at 60.7 years of age. Earlier onset is associated with a poorer prognosis (Immonen et al., 2017). Subtle signs of the illness, such as language, motor, and cognitive abnormalities, may be present during childhood. Children who later develop schizophrenia demonstrate some social disturbances such as social withdrawal. Children who experience subtle prepsychotic symptoms are at higher risk for developing psychotic disorders later in life. These children may present with neuromotor delays, speech or language impairments, and lower IQ or declining IQ scores (Liu et al., 2015).
The course of the illness is highly variable. Some clients will have a single acute episode and then achieve complete remission; some may have several acute episodes with remissions in between them, while others may have continuous psychosis. Long term, however, most clients achieve remission and recovery after the initial illness, can go several years between psychotic episodes, and can find meaningful employment.
Potential Causes of Schizophrenia
The cause of schizophrenia is unknown. There are no biomarkers to assist in the diagnosis. Laboratory exams and radiographic studies do not confirm the diagnosis. There are some genetic and environmental factors that do, however, appear to increase individual risk for developing schizophrenia.
Heritability appears to have a significant influence on the development of schizophrenia. The risk of schizophrenia in the general population is 1 percent. Those with siblings diagnosed with schizophrenia have a 10 percent risk of developing the disease. Monozygotic twins will have a concordance rate of 40 to 50 percent rate of disease expression while dizygotic twins have a 15 percent rate (Imamura et al., 2020).
There is also evidence that in utero stressors may alter neurodevelopment (changes in glutamate receptors) and predispose a client to developing schizophrenia. These stressors include exposure to viruses, starvation, and complications during pregnancy. Other risk factors during early development include paternal age over fifty and under twenty, winter birth (in the Northern Hemisphere), and birth in urban areas. Risk factors during childhood and adolescence include being raised in an urban environment, migration, cannabis use, stressful life events, and trauma. Other factors that raise the risk of developing the disturbance include epilepsy or Huntington disease, head injury, tumors, cerebrovascular accidents, myxedema, Wilson disease, being from a lower socioeconomic class, having inadequate nutrition, and the absence of prenatal care.
There are three general neurobiological theories for the causes of schizophrenia. The first theory is that there is hyperactivity of dopamine in the mesolimbic pathway of the brain. The mesolimbic pathway connects the ventral tegmental area and the nucleus accumbens in the limbic system. It is here that the brain manages the reward system and desires. An overload of dopamine in this system increases the potential for aggression and psychotic symptoms.
The second hypothesis involves the neurotransmitter glutamate. Glutamate is a major excitatory neurotransmitter in the brain and is responsible for transmitting most of the sensory information in the body. The theory holds that due to genetic influences, changes in utero, or during critical neurodevelopmental stages, a hypofunction occurs in the N-methyl-D-aspartate (NMDA) receptors on glutamatergic neurons. This hypofunction results in two downstream effects: (1) too much dopamine in the mesolimbic dopamine pathways causing signs of psychosis, and (2) hypofunction in the mesocortical dopamine pathway in the prefrontal cortex causing the cognitive and negative symptoms of schizophrenia (Steullet et al., 2016). The final theory involves the neurotransmitter serotonin and its receptors. Hyperfunction, or too much activity at these receptors, causes the same hyperactivity in the mesolimbic dopamine pathway, leading to symptoms of psychosis.
There are four major dopamine pathways in the brain. These are important to know because the medications used to treat psychosis impact all four of them and potentially cause side effects:
- Mesolimbic pathway: This pathway connects the ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia in the forebrain. This pathway is responsible for memory, emotions, arousal, and pleasure. Increases in dopamine cause psychosis and aggression.
- Mesocortical pathway: This pathway connects the prefrontal cortex to the ventral tegmentum. It promotes higher-order functions, such as cognition, planning, organization, motivation, learning, and social behaviors. Decreased dopamine in this pathway can cause adverse symptoms, such as affective flattening, apathy, anhedonia, and lack of motivation.
- Nigrostriatal pathway: This pathway connects the substantia nigra and the basal ganglia. It is involved with bodily movement. Decreases in dopamine or neuronal degeneration in this pathway are associated with Parkinson disease and extrapyramidal symptoms, such as tardive dyskinesia.
- Tuberoinfundibular: This pathway connects the hypothalamus with the pituitary gland and manages metabolism, temperature control, thirst, digestion, and other endocrine actions. Decreases in dopamine in this pathway can cause amenorrhea or galactorrhea.
Symptoms of Schizophrenia
According to the DSM-5, to be diagnosed with schizophrenia, a client must experience at least two of the following symptoms for most of the time during a one-month period: (1) the presence of delusions, (2) hallucinations, (3) disorganized speech, (4) disorganized or catatonic behavior, (5) or negative symptoms. One of the two symptoms must be delusions, hallucinations, or disorganized speech. Signs of these symptoms must be present continuously for at least six months, and they cannot result from a medical disorder, another mental health disorder, or a substance. In addition, those with schizophrenia often experience cognitive deficits, such as memory problems, attentional shortfalls, and issues with problem-solving.
Defining Psychosis
As defined, psychosis is a severe mental condition where a person loses the ability to recognize reality or has lost contact with external reality, causing a loss of function and disorganization of personality. Schizophrenia is one type of psychotic disorder, though psychosis can be caused by medical illnesses, such as brain tumor and hyperthyroidism; substance misuse; or disorders, such as schizophrenia, schizoaffective disorders, delusional disorder, mania, severe depression, and personality disorders. The symptoms of psychosis include one or more of the following: delusions, hallucinations, disorganized thinking or speech, disorganized behavior, and negative symptoms.
Positive and Negative Symptoms of Schizophrenia
Active symptoms of schizophrenia include both positive symptoms and negative symptoms. Positive symptoms are symptoms that are “added” to a person who is nonpsychotic. These include any changes to behaviors or thought content, consisting of excessive, distorted thoughts and perceptions and the presence of symptoms, including hallucinations and delusions. Negative symptoms are symptoms that involve the “subtraction” or lessening of normal functions being “taken away” or are in deficit, such as behaviors that the individual is no longer demonstrating, including cognitive decline, apathy, anhedonia, and so forth.
Positive Symptoms of Schizophrenia
Positive symptoms of schizophrenia include delusions, hallucinations, and disorganized thoughts, speech, and behavior. These are symptoms the disease has “added” to the person. This section will cover some of the most common positive symptoms of schizophrenia.
A delusion is a fixed false belief that cannot be changed in the mind of those who hold them despite evidence to the contrary. Delusions can exist as a symptom of schizophrenia or as a symptom of a separate disorder called delusional disorder, which is discussed in detail in 15.3 Delusional Disorder. There are a number of different types of delusions experienced by clients who have been diagnosed with schizophrenia.
- Paranoid delusions, also known as persecutory delusions, are beliefs that the person who holds them is being watched, harmed, or stalked.
- Referential delusions are beliefs that ordinary events have a message or hidden meaning specifically for them.
- Grandiose delusions or delusions of grandeur are those where the individual believes they have unique gifts, are essential, or are influential.
- Somatic delusions are those that involve bodily functions or health. The individual believes that something is wrong with them despite evidence to the contrary.
- Religious delusions involve faith-based themes. These beliefs are outside normative cultural beliefs and usually involve the individual believing they are a supreme being or the devil.
- Erotomatic delusions feature unfounded assumptions that others are in love with them.
- Nihilistic delusions are those where the person believes that they have no existence, that life has no meaning, or that something catastrophic will happen. These delusions are commonly found in those diagnosed with severe depression and paranoid schizophrenia.
Delusions can be classified further as bizarre or non-bizarre; a bizarre delusion involves fixed false beliefs with content that is not reasonably possible in this world. They are strange, eccentric, and unrealistic. An example of a bizarre delusion is when an individual believes that an alien has implanted a chip in the person’s head, and that their parents are speaking to them through the chip. A non-bizarre delusion is a fixed false belief containing content that is plausible but inconsistent with evidence. An example of a non-bizarre delusion is one where the individual believes that a provider has removed their hymen during a medical procedure (a pap smear) and is insistent that the provider put it back. Sometimes it is difficult to discern a non-bizarre delusion from reality, especially if the client has experienced significant trauma, torture, political upheaval, or unrest.
Another common symptom of schizophrenia, a hallucination is the perception of sensory experiences without natural external stimuli. Types of hallucinations include auditory, visual, tactile, gustatory, and olfactory. An auditory hallucination is the altered perception of hearing in the absence of external stimuli. These hallucinations can be single or multiple voices or murmuring. They can include noise, music, or other sounds. A subset, command auditory hallucinations direct the individual to do things, like commit violence toward self or others. The person experiencing the symptom may or may not heed the command. A visual hallucination is a false sensory experience that is seen. They can be people, things, or flashes of light, sometimes in the periphery. A tactile hallucination is a false sensory perception involving the sense of touch; something is on the skin, crawling, biting, or touching.
Having a gustatory hallucination involves a false perception involving taste. It is usually strange or unpleasant flavors, such as something metallic. An olfactory hallucination, or phantosmia, is a false sensory experience involving the sense of smell.
These are more commonly caused by head injuries, aging, seizures, and tumors and often involve detecting scents not in the person’s immediate environment.
Many people afflicted with schizophrenia exhibit signs of disorganized thoughts, speech, and behavior. Table 15.1 provides information on these language and behavioral abnormalities and examples.
| Abnormality | Definition | Clinical Example |
|---|---|---|
| Loose association | When a client switches from one unrelated topic to another | “I like hotdogs. Come take a look at my houseboat.” |
| Circumstantial thinking | When a person delays getting to the point of a conversation, providing random, tedious, and unnecessary details | When asked about their day, the client provides all the tiny details of everything they did that day. |
| Tangentiality | Occurs when a person answers a question with indirectly related or unrelated information but never gets to the point of the topic | “I have a date tonight. Do you like dates? I think that all fruit is necessary for good fiber intake. I need to use the restroom.” |
| Concrete thinking | A literal interpretation of ideas or environmental stimuli with a lack of abstract thinking, such as being unable to understand metaphors or analogies | A client who is asked to shower takes their clothes off immediately regardless of where they are. |
| Neologism | Making up new words that have no meaning to others but make sense to the individual | “I have moxyplams for my tadonxses.” |
| Word salad | The random connection of words without logic | Cab Abu use eat too oh hi. |
| Clang associations | Connecting words according to sound | Cat bat mat sap lap. |
| Mutism | The inability to speak | The client does not respond when asked a question. |
| Perseverating | When someone repeatedly uses the exact words, phrases, and ideas when communicating | A client references the same person over and over again during a session. |
| Echolalia | The repetition of words that one hears from another person | A client is asked to sit down for dinner and responds, “Dinner, dinner, dinner, I want to go to dinner, dinner, dinner.” |
| Echopraxia | The imitation of the movement of others | The client mimics the movement of the nurse with whatever they do with their body position or limbs. |
| Catatonia | An abnormality of movement and behaviors | The client is found lying stiff in bed. |
| Negativism | Resistance to movement and instructions | The client does not move or respond when another client asks them to. |
| Stupor | A complete lack of response | The client is conscious but not interacting at all. |
| Catatonic excitement (or psychomotor agitation) | Excessive and stereotypic movements | The client is pacing, rocking, and grimacing. |
| Waxy flexibility | When a client allows their limbs to be placed in any position for long periods | The nurse puts the client’s hand up in a stop position, and the client does not move it at all. |
Negative Symptoms of Schizophrenia
The negative symptoms of schizophrenia “take away” from normative emotional expression. Negative symptoms often involve a decrease or absence of motivation, interest, and expression. Two specific and common negative symptoms include diminished or inappropriate affect and anhedonia. A diminished affect occurs when there is a decrease in the emotional expression of the client. It can range from restricted to flat, a complete lack of emotional expression. Inappropriate affects are emotional expressions incongruous with a current situation, such as crying during a comedy or laughing during a sad event, and anhedonia, an inability to feel pleasure. Other negative symptoms include poverty of speech (alogia), general apathy, lack of interest in self-care or physical energy, and lack of concentration.
Cognitive Symptoms of Schizophrenia
Some clients experience cognitive symptoms, deficits in their ability to think or reason. These symptoms can include deficits in working memory, such as the ability to do mental math; decision-making capabilities, such as the ability to make choices; organization, such as making mental arrangements or coordinating activities; problem-solving, such as identifying causes, solutions, and implementing processes; and, finally, the overall ability to process information.
Moreover, some clients may not understand that they are ill or psychotic. When a client is unaware that they are ill because of the illness itself, it is called anosognosia. It creates a situation where they often do not engage in treatment, leading to nonadherence to medications. Nonadherence to medication results in adverse outcomes, such as symptom relapse, repetitive hospitalizations, and interactions with the legal system (involuntary commitments or incarceration). Clients who are experiencing paranoia may become aggressive or assaultive, but those with the disease are more likely to be victims than aggressors. Table 15.2 summarizes the symptoms of schizophrenia.
| Positive Symptoms of Schizophrenia | Negative Symptoms of Schizophrenia | Cognitive Symptoms of Schizophrenia |
|---|---|---|
| Delusions Persecutory Referential Grandiose Somatic Religious Erotomaniac Nihilistic Hallucinations Auditory Visual Tactile Gustatory Olfactory Disordered thought Loose associations Circumstantial thinking Tangentiality Concrete thinking Disordered Speech Echolalia Echopraxia Disordered behavior Aggression Stereotypy Catatonic excitement |
Affective Affective flattening Decreased eye contact Inappropriate affect Disordered movement Negativism Avolition Anergia Disordered speech Poverty of speech Mutism Alogia Disordered behavior Apathy Decreased response to social interaction |
Slow thinking Difficulty understanding Poor concentrating Difficulty with memory Disorganized thoughts Difficulty with vigilance Difficulty with reason Difficulty with problem-solving |
Stages of Schizophrenia
There are three phases of schizophrenia: prodromal, acute, and recovery. The prodromal phase is when nonspecific symptoms first appear. Active psychotic symptoms characterize the acute phase. The recovery phase is when the individual begins to notice symptoms diminishing.
Prodromal Phase
The first phase is the prodromal phase, which occurs before the first signs of psychosis appear. During the prodromal phase, there is a gradual onset of nonspecific behaviors, such as sleep disturbances, suspiciousness, decreased attention to activities of daily living, disconnection with peers and family members, depressed mood, irritability, and problems focusing or understanding. The prodromal phase can last for a few weeks to several years. Of those diagnosed with schizophrenia, almost 75 percent have expressed prodromal symptoms.
Acute Phase
The second phase is the acute phase, which features active psychotic symptoms. During this phase, clients often encounter the medical and mental health system of care for the first time. During this phase, the disease is most visible and clients exhibit both the positive and negative symptoms of psychosis.
Unfolding Case Study
Schizophrenia: Part 2
See Schizophrenia: Part 1 for a review of the client data.
| Nursing Notes | 1945: Intervention Client became aggressive with staff, mother, and friend, and tried to hit the friend. The client fell out of the bed and landed on buttocks. No head trauma, bruising, or bleeding noted. Security called; client was restrained. |
Recovery Phase
The next stage of the progression is called the recovery or residual phase. During this phase, there is a quieting of the symptoms, a diminishing of the active symptoms or “clearing,” and more clarity of thought. In this phase, additional mood symptoms can emerge, such as depression, as the client considers the impact of the disease on the trajectory of their life. Although the residual phase is mainly devoid of active, psychotic symptoms, clients in this phase often do report blunted affect, conceptual disorganization, and social withdrawal. The progression or continuation in this stage depends on treatment, medication adherence, and determinants of health, such as housing, transportation, education, income, access to food, language, health literacy skills, and social support.
The phases may not be entirely linear. Remember that clients can lapse into another active phase of psychosis at any time; most clients with schizophrenia relapse multiple times during their lifetime. Risk factors of relapse include nonadherence to medications, substance misuse, another mental health diagnosis, short treatment duration, disparities in mental health treatment, and preexisting childhood adversity (Saria et al., 2014).
Treatment of Schizophrenia
Treatment options for schizophrenia require ongoing assessment and management of active symptoms and how they manifest and impair daily functioning. Collaboration with the family and/or primary caregivers and mental health providers is essential in developing the treatment platform. Families can be affected by stigma, stress, grief, anxiety, and isolation as they navigate the trajectory of the disturbance with their loved ones. Recommendations for family support groups and family therapy are paired with improved outcomes in those with schizophrenia. Finally, the inclusion of community-based resources helps clients to optimize treatment outcomes. Treatment for those with schizophrenia should be client-centered and include a combination of medication and psychosocial interventions.
Client-Centered Care Approaches
When a client presents for care with a possible diagnosis of schizophrenia, it is essential to take a client-centered care approach. Client-centered care considers client preferences, health literacy, treatment barriers, cultural beliefs, and lifestyle when helping clients to make decisions about their health. Determine realistic outcomes and psychosocial interventions that align with the client’s availability of resources and support systems. Clients diagnosed with schizophrenia have optimal outcomes when they have psychopharmaceutical intervention in conjunction with nonpharmacological options. Part of determining the best treatment options is to complete a full assessment inclusive of medical and social history, medication history, family history, and support systems. Safety is paramount; risk for suicide and violence should be part of every assessment.
Medications
Medications used to treat schizophrenia belong to a class called antipsychotic medications. These medications generally block dopamine to reduce the positive symptoms of psychosis. Antipsychotics were developed as a preanesthetic medication in the 1950s, but with further research, the first medication, chlorpromazine, treated mania effectively, ultimately leading to the first generation of antipsychotic medications.
First-Generation Antipsychotics
After the invention of chlorpromazine, a dopamine and serotonin receptor antagonist, in the 1950s, the first-generation antipsychotics, or neuroleptics, were introduced into mainstream psychiatry. These medications included haloperidol, trifluoperazine, thioridazine, and fluphenazine, and their primary function was to block dopamine (D2) receptors. They also have some actions at histamine, cholinergic, and alpha-adrenergic receptors. The high-potency medications (haloperidol, trifluoperazine, and fluphenazine) have a high risk for extrapyramidal side effects. The low potency medications (chlorpromazine and thioridazine) have significant anticholinergic properties, are sedating, and can cause weight gain, but do not cause as many extrapyramidal side effects. Overall, any of these first-generation antipsychotics can cause extrapyramidal symptoms, sedation, anticholinergic symptoms, prolactin elevation, QT prolongation and potential for sudden death, lowering of the seizure threshold, orthostatic hypotension, sexual dysfunction, and metabolic disturbance. They have significant drug/drug interactions. Due to the sedating nature of some of these medications, assessment for fall risk is essential, especially in vulnerable populations.
Second-Generation Antipsychotics
Second-generation antipsychotics entered psychiatric practice in the 1970s with the invention of clozapine. These drugs function by antagonizing dopamine and serotonin (2A) receptors. This atypical antipsychotic medication class has fewer extrapyramidal symptoms due to their dual actions on dopamine and serotonin receptors. Second-generation antipsychotics include aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine, iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine, risperidone, and ziprasidone. Like their first-generation family members, second-generation antipsychotics also have potential interactions with other medications. Table 15.3 summarizes antipsychotic medications.
| Medication | Common Side Effects | Routes of Administration | Contraindications |
|---|---|---|---|
| Chlorpromazine (Thorazine) Fluphenazine Haloperidol (Haldol) Thioridazine Trifluoperazine |
Extrapyramidal side effects (dystonia, akathisia, tardive dyskinesia, pseudoparkinsonism, neuroleptic malignant disturbance), galactorrhea and amenorrhea, sexual dysfunction, hypotension, anticholinergic symptoms (dry mouth, constipation, blurred vision), weight gain, and risk for metabolic syndrome | Pill, liquid, depot (haloperidol) | Use with caution in older adult populations, in those with cardiac disease, in clients with seizure disorder |
| Aripiprazole (Abilify) Asenapine (Saphris) Brexpiprazole (Rexulti) Cariprazine (Vraylar) Clozapine (Clozaril) Iloperidone (Fanapt) Lumateperone (Caplyta) Lurasidone (Latuda) Olanzapine (Zyprexa) Paliperidone (Invega) Pimavanserin (Nuplazid) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon) |
Metabolic side effects (insulin resistance, hyperglycemia, dyslipidemia, weight gain), nausea, constipation, dry mouth, lowered incidence for extrapyramidal side effects (dystonia, akathisia, tardive dyskinesia, pseudo-Parkinson’s, neuroleptic malignant disturbance), agranulocytosis, neutropenia (for Clozaril), galactorrhea and amenorrhea (risperidone) | Pill, depot (Risperdal, Invega, aripiprazole, olanzapine) | Use with caution in older adult populations, in those with cardiac disease (quetiapine, ziprasidone), in clients with seizure disorder |
Medication recommendations depend upon different variables, such as the presence of positive or negative symptoms, medication efficacy, side effect management, and nonadherence. The first-line choice for managing positive symptoms is second-generation antipsychotics, except for clozapine due to its risk for neutropenia. The second line choice is clozapine and first-generation antipsychotics. In acute cases, choices for managing positive symptoms include first- and second-generation antipsychotics and benzodiazepines. For the treatment of mainly negative symptoms, second-generation antipsychotics are the first choice, with antidepressants, modafinil, and clozapine as secondary choices. First-line choices for clients concerned about weight gain include ziprasidone, lurasidone, and aripiprazole. To enhance sedation, the best choices include quetiapine, clozapine, asenapine, and olanzapine. First-line choices for clients concerned about sedation include ziprasidone, lurasidone, and aripiprazole. Finally, for clients who struggle with nonadherence, choose depot forms of both first- and second-generation antipsychotics (National Library of Medicine, 2016). Depots are long-acting injectable forms of antipsychotic medications. They promote medication adherence because the drug is injected every two to six months. Table 15.4 summarizes the nursing interventions for the side effects of antipsychotic medications.
| Side Effect | Intervention or Education |
|---|---|
| Extra pyramidal symptoms |
|
| Anticholinergic | |
| Dry mouth |
|
| Blurred vision |
|
| Constipation |
|
| Urinary hesitancy |
|
| Sedation |
|
| Orthostatic hypotension |
|
| Amenorrhea/gynecomastia |
|
| Metabolic side effects (Metabolic syndrome) |
|
| ECG changes |
|
| Agranulocytosis |
|
The blockade of dopamine in the nigrostriatal pathway has the potential to cause movement disorders and side effects called extrapyramidal side effects (Table 15.5). These can be movement side effects, such as dystonia, pseudoparkinsonism, tardive dyskinesia, and akathisia, or critical side effects, such as neuroleptic malignant disturbance, a medical emergency.
| Extrapyramidal Side Effect | Symptoms | Treatments |
|---|---|---|
| Akathisia | Subjective complaints of leg or arm movements, rocking, pacing, feeling restless like they cannot sit still Develops within the first few weeks of starting or increasing dose of medication or reducing or removing a medication that is used to mitigate EPS |
Dose reduction, switch to another antipsychotic medication, treatment with beta blocker, benzodiazepine, or amantadine |
| Dystonia | Involuntary contractions and spasms of the muscles, painful, starts in the face, neck, shoulders Develops within a few days of starting or increasing dose of medication or reducing or removing a medication that is used to mitigate EPS |
Dose reduction, and switch to another antipsychotic medication, treatment with Cogentin or Benadryl |
| Tardive dyskinesia | Involuntary facial movements, sucking, chewing, lip smacking, tongue protruding, blinking eyes | Dose reduction, removal of the offending agent, and switch to another antipsychotic medication, treatment with tetrabenazine or deutetrabenazine |
| Pseudoparkinson’s (Drug induced parkinsonism) | Shuffling gait, stiff facial muscles, tremors, bradykinesia, akinesia Develops within a few weeks of starting or increasing a dose of medication or reducing or removing a medication that is used to mitigate EPS |
Dose reduction, removal of the offending agent and switch to another antipsychotic medication, treatment with amantadine or levadopa |
| Neuroleptic malignant disturbance | Onset is usually two weeks after the initiation of antipsychotic treatment or a change in dosage High fever (102 to 104 degrees Fahrenheit), irregular pulse, tachycardia, tachypnea, muscle rigidity, confusion, hypertension, diaphoresis This is a medical emergency |
Removal of the offending agent, supportive care, maintenance of cardiovascular status through monitoring, mechanical respiration, medications, maintenance with IV fluids, treatment of hyperthermia with cooling blankets, benzodiazepines for agitation, and dantrolene for muscle rigidity and elevated CK and bromocriptine/amantadine for moderate to severe symptoms |
Clinical Judgment Measurement Model
Side Effects: AIMS
A twenty-three-year-old client has been admitted to the inpatient psychiatric unit after spending two days waiting on a bed in the emergency department. The client had been experiencing auditory and visual hallucinations and delusions that the government has been watching them. The client was irritable and aggressive while in the emergency department. They were given several doses of haloperidol 5 mg with 25 mg of Benadryl by mouth during their time in the emergency department. Upon arrival to the inpatient unit, the client is calm but still experiencing hallucinations. The client was given an additional dose of haloperidol 5 mg with another 25 mg of Benadryl. During their one month on inpatient, the client was transferred to risperidone, and is now taking 3 mg by mouth at bedtime. One evening, after the nighttime dose of their medication, the client approached the nurse complaining that their mouth felt like it was “twitching.” Consider these skills in the assessment of this client using the Abnormal Involuntary Movement Scale (AIMS) (see Appendix B Abnormal Involuntary Movement Scale).
1. Recognize cues: The RN uses assessment skills to evaluate potential side effects of antipsychotic medications, such as extrapyramidal side effects like tardive dyskinesia. Using the AIMS assessment tool, the entire examination can be completed in ten minutes by the nurse. There are twelve items on the scale that are assessed in various areas of the body.
The first step in completing the AIMS exam is to monitor the client discreetly while at rest. Then ask if they are wearing dentures or mouth fixtures. If so, do they or their teeth hurt the client? Then ask the client to sit with their hands on their knees and feet flat on the floor. Observe for movement. Then ask the client to put their hands between their knees unsupported. Observe again for movement. Then ask if there is any unusual movement in their body. If the answer is yes, ask if the movement is bothersome or interferes with any daily activities. Then have the client open their mouth and stick their tongue out twice. Observe any tongue movements. Then ask the client to tap their fingers to their thumbs rapidly. Have them do this on both hands. Then ask the client to stand. Observe the client in profile and look for any abnormal movements. Then have them extend their hands out with palms down. Observe for movement. Then have the client walk back and forth. Have them do this twice, observing for abnormal movement. After this is done, complete the AIMS form.
2. Analyze cues: Analyze any cues to abnormal movements in the body. Are there any mouth or facial movements, any in the hands or legs? Is the client aware of these movements, and if so, are they bothersome to the client? If it is bothersome to the client, how bothersome? This is also a good time to assess for any other extrapyramidal symptoms, such as parkinsonism, dystonia, and akathisias.
3. Prioritize hypotheses: If there are signs and symptoms of tardive dyskinesia, identify possible medications that could be contributing to the adverse events. While antipsychotics are the most likely culprits, other medications have been known to cause the symptoms: antidepressants, antiemetics, and stimulants.
4. Generate solutions: The intended outcome is reduction in adverse events related to the medication.
5. Act: Notify provider of assessment details, take vital signs, administer medications as needed, monitor client response per agency policy, and evaluate the effects of the medications by reassessing the client one-hour postadministration.
6. Evaluate outcomes: Evaluate the client’s response to the medications provided. Assess for worsening of symptoms, worsening of side effects, and functional impairment.
Psychosocial Treatments
Psychopharmaceutical treatments are the cornerstone for managing clients with schizophrenia. But the long-term success for clients also depends on the psychosocial and rehabilitative treatment options available in medical, nursing, and community settings. Treatment options include social skills training, cognitive remediation, cognitive behavioral therapy, family therapy, support groups, peer-to-peer counseling, occupational therapy, school and work assistance programs, and care management. Communication and collaboration between care providers, avoiding gaps in service delivery, and managing transitions of care are all critical in managing psychosocial treatments for clients.
Social Skills Training
Clients diagnosed with schizophrenia frequently experience symptoms causing them to struggle socially, often resulting in stigma and isolation. Social skills training improves social competence by providing skills, such as basic conversation, medication management, and community reintegration. Social skills interventions have been influential in reducing mental health symptoms, decreasing repeated hospitalizations, and improving social outcomes.
Cognitive Remediation
Cognitive symptoms of schizophrenia can result in deficits in processing, attention span, and memory. Cognitive training or remediation focuses on repetitive exercises designed to reorganize information, aid in learning, and provide behavioral prompts to assist in memory.
Family Education Groups
These groups focus on two interventions to assist clients, family members, and loved ones of those with schizophrenia. The first treatment approach emphasizes coping skills related to stress from living with the illness. The second approach highlights education on the diagnosis, symptoms, interventions, medications, side effects, and adverse events. Those engaging in family groups and interventions have seen positive outcomes, such as decreased relapse rates, fewer hospitalizations, and greater adherence to medications.
Cognitive Behavioral Therapy
Up to half of all clients with schizophrenia experience hallucinations and delusions. Using CBT to treat some of the positive symptoms of psychosis helps clients to challenge what they are experiencing and restructure what is happening to them. The cognitive model assumes that life events and experiences mold and shape core beliefs. It follows then that these beliefs influence everyday automatic thoughts. Automatic thoughts, like delusions and hallucinations, influence emotions, behaviors, and physiological responses. Therefore, the goal for CBT with respect to hallucinations and delusions is to facilitate a scenario with the client where they can challenge what they are experiencing:
“Is this a symptom, or is this actually happening to me?”
Nursing Care for a Client Suffering from Schizophrenia
Nurses should develop a plan of care that is in accord with the client, their family, and other caretakers and that is relevant and culturally appropriate. It should involve evidence-based medical and psychosocial interventions that will assist the client in meeting their treatment goals in the least restrictive environment.
Nursing Assessment
Nursing interventions for those with schizophrenia begin with an assessment. For those experiencing psychosis, crowded, noisy, bright rooms can be very distracting during an interaction. Ensure that the assessment is done in a quiet room, with soft lighting, without interruptions. Allow access to the door for egress for both the nurse and the client, even if safety is not a concern.
Ensure the safety of self and client. If the client is acting aggressively, use a soft, soothing voice, move slowly, and approach with hands in front and palms open (Table 15.6). Ask one question at a time, and allow the client time to answer questions. Observe their behavior. Are they looking at the interviewer or like they are responding to internal stimuli (hallucinations)? If they look like they are hallucinating, ask them if they see or hear things other than the interviewer’s voice. Have them describe what they see or hear. If the hallucinations are command in nature, ask about the content and keep them from acting on those commands. Assess for suicidal or homicidal content. Ask the client about delusions. Do not challenge their beliefs, but explore the nature of any expressed delusion. Assess any risk to self or others that may accompany the delusional thoughts.
| Category | Techniques |
|---|---|
| Environmental | Remove distractions, lower bright lights, take to a quiet place with fewer people. |
| Personal | Calm and center self; do not take things personally. Be aware of body language and take an assertive but nonconfrontational stance (hands in front at sides, palms open). Give personal space. Speak in a calm, quiet, low voice. Listen, provide empathy. Do not judge. Do not make promises. Give choices. Use active listening skills to determine sources of frustration. Allow the person to vent frustration. Provide a sense of safety if the person is exhibiting paranoia. Seek consensus resolution. Be flexible. |
Nursing Clinical Judgment
The goal for the client with schizophrenia is to maintain stability through adherence to medications, continued interaction with health-care providers, mitigation of adverse reactions and side effects, optimal nutritional status, and social and occupational functioning. The nursing clinical judgment measurement model assists the nurse in formulating clinical decisions based on critical thinking through client presentations to achieve optimal client outcomes. To prioritize clinical judgment, consider differing treatment and outcome goals through acute and maintenance phases of schizophrenia.
Unfolding Case Study
Schizophrenia: Part 3
See Schizophrenia: Part 2 for a review of the client data.
| Nursing Notes | 2025: Assessment Physical Examination: Client is clean and appropriately dressed, alert and oriented ×1, unable to state time, place, or why he is in the hospital. Confused as to why there are so many people in his “bunker.” HEENT: Pupils equal, reactive to light (PERRL), mucus membrane dry, pharynx without lesions, palate intact. No thyroid enlargement. Lymphatic: Tonsillar and cervical lymph nodes noted but not enlarged, hard, palpable left axillary lymph nodes, tender to touch; no enlargement of right axillary or inguinal nodes, no pain or tenderness noted. Respiratory: Clear to auscultation bilaterally, no stridor, no crackles or murmur. Cardiovascular: Regular rate and rhythm, no edema, peripheral pulses 2+ Abdomen: Bowel sign present in all four quadrants, no organomegaly or tenderness. Musculoskeletal: Bone and joint pain, full ROM Skin: Pale and dry, bruising noted on both elbows and forearms that are unexplained. Slight irritation and erythema around wrists and ankles due to attempts to remove restraints. Mental assessment: Client denies any depression or suicidal ideation, exhibits fear and suspicion of others; mood and affect: labile and incongruent |
| Flow Chart | 2025: Assessment Blood pressure: 140/82 mmHg Heart rate: 96 beats/minute Respiratory rate: 22 breaths/minute Temperature: 99.3°F (37.3°C) Oxygen saturation: 98% on room air Pain: 3/10 |
| Lab Results | Urine obtained. UDS: positive for marijuana |
Treatment and Outcome Goals
The client and the health-care team should identify realistic short- and long-term treatment goals. These can include taking medication as directed; mitigating side effects and adverse events associated with drugs; reducing positive, negative, and cognitive symptoms; improving self-care deficits; improving social/occupational/educational functioning; and engaging in therapeutic modalities. Each stage of schizophrenia will have different outcome goals that require attention.
Outcomes Identification for the Acute Phase
Priority goals for clients in the acute phase of the illness include decreasing psychotic symptoms and maintaining the client’s and others’ safety. Utilize internal safety protocols to maintain a safe environment for both the client and staff. Use the least restrictive measures when managing aggression in violent and paranoid clients, and continuously assess and document carefully after any hands-on interventions. Other treatment goals in the acute phase include medication adherence, minimizing side effects and adverse effects of medications, establishing trust, and transitioning to lower levels of care in the community.
Outcomes for Stabilization and Maintenance Phase
During the stabilization and maintenance phases, preservation of stability and reestablishment into the community are optimal goals for outcomes. This is done through connecting the client with community resources, pharmacy assistance programs, crisis intervention and assertive community treatment teams (ACT), social workers, case managers, faith-based organizations, and the Schizophrenia and Psychosis Action Alliance, an organization for support, advocacy, and research. Best nursing outcomes are specific, measurable, achievable, relevant, and time-bound (SMART). Other outcomes include mitigating side effects, ensuring medication adherence, coping with diagnosis/symptoms, and managing stigma.
Implementation of Nursing Care
After assessment and setting treatment measures to meet goals, it is time to implement nursing care. Implementation strategies during the acute phase include:
- ensuring the least restrictive care environment and its safety, management of the safety of the client and others
- mitigating risks if present
- completing safety checks in the milieu and per unit safety protocols
- monitoring for changes to mental status, medication adherence, side effects, the effectiveness of medication management; and client data, such as vital signs, intake and output, and height and weight
Implementation during the stabilization and maintenance phase includes:
- safe transfers of care
- communication with other health-care providers
- transfer of health records according to HIPAA requirements
- coordination with other community care providers
- facilitating the use of cognitive interventions with clients to help challenge residual hallucinations
- establishing therapeutic communication and trust with clients experiencing delusions and then helping the client to focus on reality-based themes
- working with family, friends, and other supportive caregivers to develop a relapse prevention plan
- working with the client to identify warning signs of psychosis, stressors, side effects, or behaviors that lead to medication nonadherence, and things to do and people to call when concerned about relapse or safety
Implementation of treatment during this phase also includes family education about resources, medication, side effects, health, diet, and exercise. There are a number of issues pertaining to the recovery of the client that have to be shared with the client and the family. The information for the client relates to their personal recovery and ability to remain healthy. The information shared with the family is in the form of explaining the condition to them and giving advice on how to support the client and maintain their role within the family (Table 15.7).
| Client Education | Family Education |
|---|---|
| Education on illness Side effects of medications Adverse events and drug/drug interactions Diet, exercise, nutrition Smoking cessation Substance use mitigation Relapse prevention Peer support groups Medical treatment adherence Community support groups Therapy options Reentry into the community |
Education on illness Stigma Reentry into community Living with the illness Symptoms Side effects of medications Adverse events and drug/drug interactions Relapse prevention Caregiver stress Peer support groups Therapy options |
One notable type of philosophy for care of those diagnosed with schizophrenia is a therapeutic milieu, which is a holistic, safe, and structured environment that helps facilitate emotional well-being and recovery. The idea behind milieu therapy is that the environment affects how one feels or thinks. The optimal milieu therapy for an individual experiencing psychotic symptoms is a quiet, safe, and nonthreatening one. The milieu will help reduce aggression and violence in those with schizophrenia. Specific components of milieu therapy to support the client with psychosis include:
- Structure: Ensure predictable times, places, appointments, and schedules. Ensure that the client is in the same room, receives meals and medications in the same place, and has uninterrupted morning and evening routines.
- Containment: The client is maintained on specific safety protocols and levels according to their current level of risk. This limits access to things considered a risk to self-harm or harm to others. Communicate these limitations clearly and consistently to everyone on the treatment team, including the client and family members.
- Safety: The milieu must be safe for clients and staff. Ensure that it is emotionally safe by projecting empathy and consistency with staff.
- Flexibility: A healthy milieu is adaptable and supportive, not rigid or controlling.
- Socialization: The milieu provides an opportunity to apply social skills and to have others reciprocate.
A highly functioning milieu will help accelerate recovery from the psychotic process, establish trust, and develop social skills and communication with others. In addition, it will help to build a sense of safety and security and provide a supportive environment for the client to build new psychosocial skills. The nurse’s role is to manage the milieu, set and enforce healthy boundaries, establish routines, and provide a supportive environment.
Clinical Safety and Procedures (QSEN)
Safety During and After the Restraint
Definition: Minimizes risk of harm to clients and providers through both system effectiveness and individual performance (QSEN Institute, n.d.).
A psychiatric RN was involved in a behavioral restraint with a male client who attacked a staff member with the leg of a chair. The client was diagnosed with a psychotic disorder; the etiology had yet to be determined. The least restrictive interventions were not successful, including the option to take oral medications. Orders were given for restraint by the provider. A five-person team gathered, and the client was placed in four-point restraints in the room designated for that purpose. The client was given an injection of olanzapine 10 mg in the right buttock. The restraint room has a video camera, but the RN sat one to one with the client as per protocol. The RN documented information about what led up to the restraint, including all least restrictive efforts employed. As soon as the client was placed into restraints, vital signs were assessed along with neurovascular status on all four extremities. After seven minutes, the client became calm. One arm was released without incident. Vital signs and neurovascular status were assessed every fifteen minutes and they were allowed to use the restroom if needed. The client was monitored for pressure ulcers and signs and symptoms of rhabdomyolysis (muscle cramps, aches, or dark urine). Once the client was released from the restraints, vital signs were repeated, and a mental status evaluation was done. Assessments were documented on the standardized form used by the facility as per protocol. The client was continuously monitored for the remainder of the day. The staff completed a debrief that included evaluation of the situation, performance, and adherence to training requirements.
Evaluation of Nursing Care
Evaluating the effectiveness of treatment and the progression toward recovery is integral in client-centered care. This involves gathering information from all stages of care, and all sources of care and communicating the information with all care providers and team members, including the client, their family, and other care providers. Nurses should evaluate the following after implementing treatment for clients with schizophrenia:
- reduction of harm to clients and staff during restraints
- integration of safety practices that reduce harm to clients (medication reconciliation, five rights, falls prevention)
- assessment for risk of violence and suicide using evidenced-based tools
- assessment and monitoring of side effects and adverse events of psychotropic medications
- identification of client preferences, health literacy, and other client-centered outcomes in client records
- promotion and documentation of “warm handoffs” and communication between providers, systems, and clients during care transitions; warm handoffs are communications (over the phone or in person) between providers when a care transfer occurs
- involvement of case management services, social work, and other community transition services to ensure recovery-oriented practices (Mayo Clinic, 2020)