Schizophrenia is a mental illness that affects the way a person thinks, perceives information, responds emotionally, and behaves. There are different types of schizophrenia that produce their own set of clinical manifestations.
In this article:
- Symptoms & Causes
- Nursing Process
- Nursing Care Plans
- Impaired Social Interaction
- Risk for Self-Mutilation
- Risk for Self/Other-Directed Violence
- Risk for Suicide
Symptoms & Causes
Schizophrenia symptoms can be divided into positive or negative categories:
Positive symptoms are in addition to reality and include symptoms of psychosis such as hallucinations or delusions.
Negative symptoms are a lack or loss of abilities. This includes a lack of motivation, loss of interest or enjoyment, poor hygiene practices, and difficulty concentrating.
There are several proposed etiological causes of schizophrenia. Research has shown that there is a genetic connection as relatives of schizophrenic patients have a 5 to 10% risk of developing the disorder themselves. Viruses or other birth defects in utero as well as anatomical abnormalities of the brain are predisposing factors. Lastly, environmental factors such as poor socioeconomic conditions, abuse, or neglect can negatively affect mental health.
Nursing Process
Nurses will often navigate comorbidities of mental illness along with physical conditions when caring for patients. Patients being treated specifically for schizophrenia will require inpatient treatment in a behavioral health unit. Behavioral/mental health nursing requires a unique set of skills to properly communicate and interact with unstable patients while maintaining safety.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for schizophrenia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for schizophrenia.
Disturbed Sensory Perception (Auditory/Visual)
Psychosis from schizophrenia may result in a disconnection from reality with symptoms of delusions and hallucinations.
Nursing Diagnosis: Disturbed Sensory Perception (Auditory/Visual)
Related to:
- Severe stress
- Sleep deprivation
- Excessive stimulation
- Altered sensory perception
- Misuse of medications, alcohol, or illegal substances
As evidenced by:
- Anxiety
- Panic
- Talking or laughing to self
- Rapid mood swings
- Seeing or hearing things that aren’t there (hallucinations)
- Inappropriate responses
- Disorientation
- Tilting head as if to listen to something
Expected outcomes:
- Patient will identify and modify external factors that contribute to alterations in perception.
- Patient will maintain safety until the psychotic episode resolves.
- Patient will verbalize an understanding that hallucinations are not reality-based and demonstrate how to interrupt them.
Assessment:
1. Assess medication adherence.
Assess if the patient’s psychotic episode is related to nonadherence to their medications or the use of drugs or alcohol.
2. Assess contents of hallucinations.
The nurse should not reinforce the hallucination and should make it clear that they do not hear or see what the patient does. The nurse can ask the patient what the voices are saying or what they are visualizing to judge if the patient may react violently or harm themselves which requires further safety interventions.
3. Monitor for increasing agitation or anxiety.
Monitor the patient’s thoughts and behaviors closely for worsening agitation or anxiety and intervene quickly to prevent injury to the patient or others.
Interventions:
1. Remove the client from chaotic environments.
Reduce stimulation that may cause worsening hallucinations. If around people, move to an area that is solitary (with supervision) and reduce noise and lighting.
2. Provide safety.
Safety is always the #1 priority, especially when a patient is mentally and emotionally unstable. 1:1 supervision may be necessary and the removal of items that could be potentially harmful.
3. Aid distraction.
Patients can distract themselves from hallucinations by listening to music, wearing headphones, writing, drawing, or playing games. It can also be helpful to remind the patient that when experiencing a hallucination to loudly state “Go away!” or “Leave me alone!” to gain control.
4. Help the patient recognize triggers.
Attempt to decrease delusional behavior by uncovering triggers such as during times of intense stress or anxiety and learning how to cope with these feelings.
Impaired Social Interaction
Patients with schizophrenia may display a lack of social skills and struggle with navigating social constructs, roles, and cues.
Nursing Diagnosis: Impaired Social Interaction
Related to:
- Disturbed thought processes
- Isolation
- Lack of social knowledge (roles, cues, and goals of social interactions)
- Mistrust of others
- Inability to perceive or interpret the intentions of others
- Inability to maintain relationships
- Impaired communication
As evidenced by:
- Flat affect
- Difficulty focusing or paying attention
- Fearful or anxious around others
- Inappropriate emotional responses
- Poor eye contact
- Spends time alone
- Disorganized speech or thoughts
Expected outcomes:
- Patient will develop a social support system.
- Patient will verbalize factors, behaviors, and feelings that prevent social interaction.
- Patient will incorporate techniques that improve social interaction.
- Patient will verbalize feeling safe and comfortable in social situations by participating in group activities.
- Patient will build a trusting relationship and speak openly with the nurse by discharge.
Assessment:
1. Assess their perceptions and feelings toward social interaction.
After establishing a trusting relationship with the patient, the nurse can assess the patient’s perceived difficulties with social interactions. The patient may express thoughts of anxiety, fear, or general discomfort that provide insight that isn’t obvious from an outside perspective.
2. Determine family and support patterns.
Gain an understanding of the patient’s relationships by assessing whom they depend on for support or live with. Assess for close friendships or family/spousal support or a lack thereof.
3. Observe speech, nonverbal gestures, and body language.
The nurse is always assessing even when observing. Assess how the patient talks (disorganized, slow, or pressured speech), their body language (irritated, restless, fidgeting), or even a lack of eye contact, acknowledgment, or response can provide information on factors that cause impaired social interaction.
Interventions:
1. Develop a trusting relationship.
Patients with schizophrenia may be distrusting of others. By acknowledging and actively listening to the patient’s thoughts the nurse is establishing rapport and building trust.
2. Provide positive reinforcement.
When a patient takes a step to improve social interaction such as walking outside of their room acknowledge and support their efforts.
3. Encourage group activities.
Schizophrenia can cause a lack of motivation. Patients should never be forced to socialize but offering opportunities to interact may help with negative symptoms they may be experiencing such as the inability to express emotions.
4. Refer to specialists for social skills training.
Social skills training is conducted in small groups by trained clinicians. Patients learn communication skills, appropriate and inappropriate behaviors in public, and how to develop personal relationships as well as maintain jobs and live independently.
Risk for Self-Mutilation
Patients with schizophrenia are at risk for non-suicidal self-injury (NSSI) and deliberate self-harm, which can lead to suicide.
Nursing Diagnosis: Risk for Self-Mutilation
Related to:
- Disturbed interpersonal relationships
- Emotional disturbance
- Inability to express tension verbally
- Negative feelings
- Social isolation
- Depressive symptoms
- Hallucinations
- Substance misuse
- Ineffective impulse control
- Ineffective coping strategies
- Irresistible urge for self-directed violence
- Loss of control over problem-solving situations
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will refrain from self-mutilating behaviors.
- Patient will seek support when feeling the urge to self-mutilate.
Assessment:
1. Assess for psychotic features.
The presence of command hallucinations, persecutory delusions, or disorganized thinking increases the risk of self-harming behaviors.
2. Assess for symptoms of depression.
Patients with schizophrenia may also experience negative symptoms, which include a flat affect, social withdrawal, catatonia, anhedonia (loss of pleasure in activities enjoyed), and avolition (lack of motivation) which can also lead to self-injury.
3. Assess for suicide attempts.
In the general population, self-mutilation does not equate to a desire to end one’s life, but in schizophrenia, there is an overlap between suicide and self-harm, with some forms of self-harm (such as poisoning) leading to death.
Interventions:
1. Ask the patient why they self-harm.
Patients self-harm for various reasons. Patients who participate in NSSI may self-mutilate as a way to seek help or to escape negative emotions. Once the nurse understands the reason for self-injury, they can develop appropriate interventions.
2. Assist the patient in emotional regulation.
Patients with schizophrenia struggle with expressing and managing their emotions. This can cause depressive symptoms, psychosis, and aggression, leading to self-harm. The nurse can encourage mindfulness strategies, reappraisal (changing how we view a situation), and participation in therapy.
3. Provide distraction without overstimulation.
Keep the patient engaged in activities that will offer distraction and allow staff to monitor them closely. It’s important not to seem intrusive to cause paranoia, aggression, or anxiety.
4. Discuss managing self-harming behaviors at home.
The family may need to be involved to keep the patient safe. Advise on removing dangerous items or keeping them locked away. If an emergency occurs develop a plan that includes how to manage behaviors and who to contact for support.
Risk for Self/Other-Directed Violence
Schizophrenia can cause feelings of suspiciousness and a perception of threats where none exist. In a psychotic state, patients may have delusions or hear voices that tell them to behave in ways that are unsafe to themselves and others.
Related to:
- Suspiciousness of others
- Anxiety
- Command hallucinations
- Delusional thinking
- History of threats or violence against self or others
- Suicidal ideation
- Perception of a threatening environment
- Paranoia
- Rage reactions
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
Expected outcomes:
- Patient will remain free from injury and self-harm.
- Patient will not harm other staff, patients, or family members.
- Patient will recognize and report signs of wanting to harm themself or others.
Assessment:
1. Assess for a plan for suicide or violence.
Patients should be directly asked if they have a plan to kill themselves or to hurt someone else so staff can intervene accordingly.
2. Observe for early cues of distress.
Monitor closely for changes in behavior that may indicate a loss of control such as a change in body posture or facial expressions, or a lack of cooperation.
Interventions:
1. Maintain and convey a calm attitude.
Staff should remain calm so as not to further escalate a situation. When interacting with the patient communication should be straightforward to prevent the patient from feeling suspicious or manipulated.
2. Maintain distance from the patient.
While constant supervision may be required, staff should keep themselves safe by never turning their back on the patient and never touching them without permission (unless required).
3. Keep the patient safe.
A safe environment includes removing any object that could be used as a weapon by the patient to injure themself or someone else.
4. Administer tranquilizers.
A patient that cannot be “talked down” or presents a risk to others may require the use of anti-anxiety or anti-psychotic medications.
5. Apply restraints.
Manual restraints are a last resort when all other interventions have failed. The patient’s safety remains a priority for the nurse and a patient in restraints should be monitored per facility policy and restraints should be removed as soon as the patient’s agitation subsides.
Risk for Suicide
Schizophrenia carries a suicide rate of 10%, much higher than the general population.
Nursing Diagnosis: Risk for Suicide
Related to:
- Anxiety
- Depressive symptoms
- Hallucinations
- Awareness of symptoms
- Treatment nonadherence
- Difficulty expressing feelings
- Ineffective impulse control
- Inadequate social support
- Substance misuse
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain safe and will not harm self.
- Patient will adhere to their treatment plan.
- Patient will demonstrate connection in relationships.
Assessment:
1. Assess for current positive and negative features of schizophrenia.
Positive symptoms such as hallucinations and delusions increase suicide risk. Alternatively, negative symptoms, such as anhedonia (loss of pleasure in activities) or social withdrawal, are also risk factors. An awareness of these symptoms can also increase the risk.
2. Assess demographics and psychosocial factors that increase suicide risk.
The following demographics or psychosocial factors may increase the risk of suicide in patients with schizophrenia:
- Younger age
- Male gender
- Single status
- Unemployment
- Intelligence
- Ambitious mindset
- Sense of failure
- Poor work functioning
3. Assess treatment adherence.
Treatment adherence is the only protective factor for suicide in patients with schizophrenia. Consequently, nonadherence to the treatment plan is associated with a greater risk of suicide.
Interventions:
1. Ensure treatment adherence.
It is vital for the nurse to ensure the patient is adherent to their antipsychotic medication regimen, as these medications may reduce the risk of suicide.
2. Employ psychosocial interventions.
Along with cognitive-behavioral therapy, the nurse should encourage group therapy, social skill training, and vocational rehabilitation to improve the patient’s employment rate or educational status, which will, in turn, reduce feelings of isolation and hopelessness.
3. Involve family members.
The attitude of family members toward the patient’s schizophrenia can affect their risk for suicidal behavior. Family members must learn to be nonjudgmental and supportive of the patient’s diagnosis and care plan.
4. Take necessary environmental precautions.
If the patient is a danger to themselves, implement suicide precautions and remove potentially dangerous weapons from the environment and provide continuous surveillance.
References
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Kopelowicz, A., Liberman, R. P., & Zarate, R. (2006). Recent advances in social skills training for schizophrenia. Schizophrenia bulletin, 32 Suppl 1(Suppl 1), S12–S23. https://doi.org/10.1093/schbul/sbl023
- Langdon, R., Connors, M. H., & Connaughton, E. (2014, December 4). Social cognition and social judgment in schizophrenia. Science Direct. https://www.sciencedirect.com/science/article/pii/S2215001314000262
- What are the signs and symptoms of schizophrenia? (n.d.). Rethink Mental Illness. Retrieved February 24, 2022, from https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-conditions/schizophrenia/
