Lesson Objective for Nursing Care Plan (NCP) for Schizophrenia

What is Schizophrenia?

Schizophrenia is a mental health condition that affects how a person thinks, feels, and behaves. It’s like the brain is getting mixed signals or confusing information.

Symptoms:

People with schizophrenia might hear voices that aren’t there (auditory hallucinations) or believe things that aren’t true (delusions).  They might have trouble organizing their thoughts or seem like they’re not showing any emotion.  Sometimes, they might have trouble focusing or remembering things.

Upon completion of this care plan, nursing students will be able to:

1. Understand the pathophysiology of Schizophrenia, including neurotransmitter imbalances and structural brain abnormalities.
2. Conduct a comprehensive nursing assessment, incorporating signs and symptoms of Schizophrenia, risk factors, and potential co-occurring conditions.
3. Formulate and prioritize nursing diagnoses, addressing both the cognitive and psychosocial aspects of Schizophrenia.
4. Develop evidence-based nursing interventions, focusing on symptom management, promoting medication adherence, and facilitating therapeutic communication.
5. Educate patients and caregivers on coping strategies, stigma reduction, and community resources to enhance the patient’s overall well-being and functioning.

Pathophysiology of Schizophrenia:

Schizophrenia is a complicated mental health disorder that affects how people think, perceive things, feel, and behave. While we don’t fully understand its exact causes, several factors contribute to its development:

• Neurotransmitter Imbalance:
  • The dopamine hypothesis suggests that overactivity of dopamine transmission, particularly in the mesolimbic pathway, is associated with positive symptoms of Schizophrenia (hallucinations, delusions, disorganized thinking).
• Neurodevelopmental Factors:
  • Genetic Predisposition: Schizophrenia has a strong genetic connection, meaning people with a family history of the disorder are at a higher risk. Multiple genes are believed to contribute, each with a small effect.
• Immunological Factors:
  • Immune System Dysfunction: Some individuals with Schizophrenia show abnormalities in their immune system, including inflammation. This suggests a potential role of immunological factors in the disorder.
• Neurochemical Abnormalities:
  • Glutamate Dysfunction: Imbalances in glutamate, a key neurotransmitter, may contribute to cognitive issues in Schizophrenia. NMDA receptor hypofunction is one aspect that has been implicated.
• Neurocognitive Impairment:
  • Executive Function Deficits: People with Schizophrenia often struggle with executive functions, impacting their decision-making, attention, and working memory.
• Neuroinflammation:
  • Microglial Activation: Evidence suggests that the activation of microglia and neuroinflammation may play a role in Schizophrenia, influencing how the brain develops and prunes synaptic connections.

Etiology for Nursing Care Plan (NCP) for Schizophrenia

Diagnostic Criteria:

• Genetic Factors:
  • Family History: Individuals with a first-degree relative (parent or sibling) diagnosed with Schizophrenia have an increased risk.
  • Polygenic Inheritance: Multiple genes are believed to contribute, each with a small effect.
• Neurodevelopmental Factors:
  • Prenatal and Perinatal Influences: Adverse events during pregnancy or birth, such as malnutrition, infections, or complications, may increase the risk.
• Brain Structure and Function:
  • Enlarged Ventricles: Structural abnormalities, including enlarged ventricles, suggest neuroanatomical differences in individuals with Schizophrenia.
  • Dysregulation of Neurotransmitters: Imbalances in neurotransmitters, particularly dopamine and glutamate, contribute to altered brain function.
• Psychosocial Factors:
  • Stressful Life Events: Exposure to chronic stress, trauma, or significant life events may trigger the onset of Schizophrenia in susceptible individuals.
  • Urban Environment: Growing up in urban environments has been linked to an increased risk, possibly due to higher stress levels.
• Drug Use:
  • Substance Abuse: The use of psychoactive substances, especially during adolescence, can increase the risk of developing Schizophrenia or trigger its onset in vulnerable individuals.
• Immunological Factors:
  • Immune System Dysfunction: Abnormalities in the immune system, including autoimmune responses, have been implicated in the etiology of Schizophrenia.
• Neurochemical Imbalances:
  • Dopaminergic Dysregulation: Overactivity of the dopamine system, particularly in the mesolimbic pathway, is associated with positive symptoms of Schizophrenia.
  • Glutamate Dysfunction: Abnormalities in the glutamatergic system, particularly NMDA receptor hypofunction, have been linked to cognitive deficits.
• Social Isolation and Loneliness:
  • Social Factors: Lack of social support, social isolation, or feelings of loneliness may increase the vulnerability to Schizophrenia.

Desired Outcome for Nursing Care Plan (NCP) for Schizophrenia

• Symptom Management:
  • Short-Term Goal: Reduce the severity and frequency of psychotic symptoms (e.g., hallucinations, delusions).
  • Interventions: Administer antipsychotic medications as prescribed. Monitor and document changes in symptomatology.
• Medication Adherence:
  • Intermediate-Term Goal: Promote consistent adherence to prescribed medications.
  • Interventions: Educate the patient and family about the importance of medication compliance. Explore and address any concerns or barriers to adherence.
• Functional Independence:
  • Long-Term Goal: Enhance the patient’s ability to perform activities of daily living (ADLs) independently.
  • Interventions: Collaborate with occupational therapists to develop and implement strategies for improving ADLs. Provide ongoing support and encouragement.
• Community Integration:
  • Intermediate-Term Goal: Facilitate the patient’s integration into the community and reduce social isolation.
  • Interventions: Encourage participation in community-based activities, support groups, or vocational programs. Foster social connections and provide resources for community engagement.
• Cognitive Functioning:
  • Long-Term Goal: Improve cognitive function and executive skills.
  • Interventions: Implement cognitive remediation strategies. Collaborate with the mental health team to address cognitive deficits through therapy and skill-building activities.
• Relapse Prevention
  • Long-Term Goal: Minimize the risk of relapse and hospital readmission.
  • Interventions: Develop a relapse prevention plan with the patient, including early warning signs and coping strategies. Encourage regular follow-up appointments.
• Therapeutic Alliance:
  • Short-Term Goal: Establish and maintain a positive therapeutic alliance between the patient and the healthcare team.
  • Interventions: Utilize therapeutic communication techniques. Foster a non-judgmental and supportive environment to build trust.

Schizophrenia Nursing Care Plan

Nursing Assessment for Schizophrenia

• Mental Status Examination:
  • Appearance and Behavior: Observe the patient’s appearance, grooming, and overall behavior.
  • Thought Process: Assess for thought disorders like derailment or thought blocking.
  • Mood and Affect: Evaluate the patient’s mood and affect, noting any signs of depression, anxiety, or mood swings.
  • Perception: Explore the presence of hallucinations or delusions.
• Functional Assessment:
  • Activities of Daily Living (ADLs): Evaluate the patient’s ability to perform self-care tasks independently.
  • Occupational Functioning: Assess the patient’s current employment status, if applicable, and the impact of symptoms on work performance.
• Social and Interpersonal Relationships:
  • Family Dynamics: Explore the patient’s relationships with family members and the level of family support.
  • Social Connections: Assess the patient’s social network, friendships, and community involvement.
  • Isolation: Determine the degree of social isolation and its impact on the patient’s well-being.
• Cognitive Functioning:
  • Memory and Concentration: Evaluate memory and concentration abilities.
  • Executive Function: Assess problem-solving skills, decision-making, and ability to plan and organize.
• Medical History:
  • Co-occurring Conditions: Explore the presence of any co-occurring medical conditions, such as diabetes or cardiovascular disease.
  • Medication History: Review the patient’s history of medication use, including adherence and any side effects experienced.
• Substance Use History:
  • Substance Abuse: Assess for any history of substance use or dependence, as it can impact the course of Schizophrenia.
  • Current Substance Use: Inquire about current substance use, including tobacco, alcohol, or illicit substances.
• Suicide and Self-Harm Risk Assessment:
  • Suicidal Ideation: Screen for thoughts of self-harm or suicide.
  • Self-Harm History: Explore any history of self-harm or suicide attempts.
  • Protective Factors: Identify protective factors, such as supportive relationships or coping strategies.
• Medication Adherence:
  • Current Medication Use: Assess the patient’s current use of prescribed medications.
  • Barriers to Adherence: Identify any barriers to medication adherence, such as side effects or forgetfulness.
• Insight and Judgment:
  • Insight: Evaluate the patient’s awareness and understanding of their mental health condition.
  • Judgment: Assess the patient’s judgment and decision-making abilities.
• Therapeutic Relationship:
  • Patient-Caregiver Relationship: Evaluate the quality of the therapeutic relationship between the patient and the healthcare team.
    Communication Skills: Assess the effectiveness of therapeutic communication techniques.

Nursing Interventions and Rationales

• Obtain history and assess patient for hostile or self-destructive behaviors

• Provide encouragement in a non-judgemental, compassionate way, understanding that symptoms are real to the patient

• Encourage the patient to communicate (verbally, by drawing, and writing) how hallucinations make them feel

• Ask if hallucinations are instructing them to harm themselves or others. Provide safety for patients and others per facility protocol if needed.

• Provide redirection for inappropriate behaviors, and maintain boundaries and guidelines.

• Encourage reality-based activities (music, art, playing cards, etc.)

• Explain all procedures slowly and carefully before beginning

• Avoid using large gestures or touching the patient except when necessary

• Gently reorient the patient as necessary

• Avoid arguing with a patient regarding delusions or hallucinations

• Teach patient coping skills to help manage hallucinations or delusions
  • Exercise
  • Singing/listening to music
  • Writing
  • Drawing
  • Talking with someone they trust

• As symptoms improve, allow the patient to make small decisions such as what to eat, wear or choose activities

• Administer medication appropriately

References

• https://emedicine.medscape.com/article/288259-overview
• http://www.mentalhealthamerica.net/conditions/schizophrenia
• https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml