Assessment of Schizophrenic client

in Psychiatric nursing
by : Ghada Almukhaini

BSTRACT
Schizophrenia is a devastating psychiatric disorder thatAaffects ~1% of the population worldwide. It is
characterized by so-called ‘positive symptoms’–including delusions and hallucinations–‘negative symptoms’–
including blunted emotions and social isolation–and cognitive deficits–including impairments in attention and
working memory. Studies of the inheritance of schizophrenia have revealed that it is a multifactorial disease that is
characterized by multiple genetic susceptibility elements.
Outlines

• Introduction.

• What is schizophrenia?

• DSM IV –TR Diagnostic criteria of schizophrenia

• Periods of schizophrenia

• Positive and negative symptoms of schizophrenia.

• Assessment of schizophrenia.

• Data analysis for schizophrenia.

• Conclusion.

• Introduction.
The clinical picture of schizophrenia is complex. No one really knows what
the course of schizophrenia would be if patients were able to adhere to a
treatment regimen throughout their lives. ; individuals differ from one
another; and the experience for a single individual may be different from
episode to episode.

• What is schizophrenia?
In the early 1900s, Eugene Bleuler renamed the disorder schizophrenia,
meaning split minds, and began to determine that there was not just one
type of schizophrenia, but rather a group of schizophrenias. More recently,
Kurt Schneider differentiated behaviors associated with schizophrenia as
“first rank” symptoms (psychotic delusions, hallucinations) and “second
rank” symptoms (all other experiences and behaviors associated with the
disorder). These pioneering physicians had a great influence on the current
diagnostic conceptualizations of schizophrenia that emphasize the
heterogeneity of the disorder in terms of symptoms, course of illness, and
positive and negative symptoms.
Schizophrenia It is one of the most severe mental illnesses and is
present in all cultures, races, and socioeconomic groups. Schizophrenia is
thought of as a syndrome or disease process with many different varieties
and symptoms

• DSM IV –TR Diagnostic criteria of schizophrenia.

The current definition outlined in the American Psychiatric Association’s

Diagnostic and Statistical Manual of Mental Disorders, (DSMIV-TR) (APA,
2000) states that schizophrenia is a mixture of positive and negative
symptoms that present for a significant portion of a 1 month period but with
continuous signs of disturbance persisting for at least 6 months.

The DSM-IV-TR criteria for diagnosing schizophrenia include necessary

symptomatology, duration of symptoms, evaluation of functional
impairment, and elimination of alternate hypotheses that might account for
the symptoms.

• Positive and negative symptoms of schizophrenia.

• Positive symptoms:

Ambivalence, Associative looseness, Delusions, Echopraxia, Flight of

ideas, Hallucinations: Ideas of reference, Perseveration.

• Negative symptoms:
Alogia, Anhedonia, Apathy, Blunted affect, Catatonia, Flat affect ,Lack
of volition.
• Periods of schizophrenia.
1-Acute Illness Period: initially, the illness behaviors may be both
confusing and frightening to the patient and the family. The changes in
thought and behavior become so disruptive or bizarre that they can no
longer be overlooked such as, incoherent conversations, or aggressive
acts against self or others. patients are less able to care for basic needs,
such as eating, sleeping, and bathing. Patients usually are hospitalized to
protect themselves or others. The initial treatment focuses on alleviation
of symptoms through initiation of medications, decreasing the risk of
suicide through safety measures, normalizing sleep.

2-Stabilization Period: Symptoms become less acute but may be present.

Treatment is intense during this period as medication regimens are
established and patients and their families begin to adjust to the idea of a
family member having a long-term severe mental illness.

3- Maintenance and Recovery Period : After the patient’s condition is

stabilized, the patient focuses on regaining the previous level of functioning
and quality of life. Medication treatment of schizophrenia has generally
contributed to an improvement in the lifestyle of people with this disorder.
Family support and involvement are extremely important at this time.

4- Relapses: can occur at any time during treatment and recovery. it occurs
with sufficient regularity to be a major concern in the treatment of
schizophrenia. Relapses can occur and are very detrimental to the successful
management of this disorder. With each relapse, there is a longer period of
time to recover. Combining medications and psychosocial treatment greatly
diminishes the severity and frequency of recurrent relapses.
• Assessment of schizophrenia.

By assessing any kind of psychiatric nursing cases, the nurses are getting
some tricks in diagnosing the patient as schizophrenia . it is really
challenging For example, clients may refuse to communicate or
communicate ineffectively as a result of impaired cognition or the presence
of psychotic symptoms such as hallucinations or delusions. For example, the
nurse may care for a client in an acute inpatient setting. The client may
appear frightened, hear voices (hallucinating), make no eye contact, and
mumble constantly. The nurse would deal with the positive or psychotic signs
of the disease. Another nurse may encounter a client with schizophrenia in a
community setting who is not experiencing psychotic symptoms; rather, this
client lacks energy for daily tasks and has feelings of loneliness and isolation
(negative signs of schizophrenia).

• Taking history:
1-The nurse first elicits information about the client’s previous history with
schizophrenia to establish baseline data. she asks questions about how the
client functioned before the crisis developed
2- assesses the age of onset of schizophrenia, knowing that poorer outcomes
are associated with an earlier age of onset.
3-the client’s previous history of hospital admissions and response to
hospitalization.
4-The nurse also assesses the client for previous suicide attempts. 10% of
all people with schizophrenia eventually commit suicide.
5-elicit information about any history of violence or aggression because a
history of aggressive behavior is a strong predictor of future aggression.
6-The nurse assesses if the client has been using current support systems by
asking the client or significant others the following questions:
• Has the client kept in contact with family or
friends?
• Has the client been to scheduled groups or
therapy appointments?
• Have the client’s living arrangements
changed recently?
7-Finally the nurse assesses the client’s perception of her current situation
that is, what the client believes to be significant present events or stressors.
The nurse can gather such information by asking, “What do you see as the
primary problem now?” or “What do you need help managing now?”

• General appearance, motor behavior, & speech:

*Appearance may vary widely among different clients with schizophrenia
They may appear disheveled and unkempt with no obvious concern for their
hygiene, or they may wear strange or inappropriate clothing (for instance, a
heavy wool coat and stocking cap in hot weather).
*Overall motor behavior also may appear odd. The client may be restless and
unable to sit still, exhibit agitation and pacing, or appear unmoving
(catatonia). also may demonstrate seemingly purposeless gestures
(stereotypic behavior)
*Speech The client may imitate the movements and gestures of someone
whom he or she is observing (echopraxia) or Psychomotor retardation.
unusual speech pattern Such as, word salad and echolalia

• Mood & Affect

Clients with schizophrenia report and demonstrate wide variances in mood
and affect. They often are described as having flat affect or blunted
affect .The client may report feeling depressed and having no pleasure or
joy in life (anhedonia).

• Thought process& content:

The nurse can assess thought process by inferring from what the client says.
r she can assess thought content by evaluating what the client actually says.
For example, clients may suddenly stop talking in the middle of a sentence
and remain silent for several seconds to 1 minute (thought blocking). They
also may state that they believe others can hear their thoughts (thought
broadcasting); that others are taking their thoughts (thought withdrawal); or
that others are placing thoughts in their mind against their will (thought
insertion). Clients also may exhibit tangential thinking, which is veering onto
unrelated topics and never answering the original question
 • Roles& Relationships:
Social isolation is prevalent in clients with schizophrenia, partly as a result of
positive signs such as delusions, hallucinations, and loss of ego boundaries.
Low self-esteem, one of the negative signs of schizophrenia, further
complicates the client’s ability to interact with others. The client may
experience great frustration in attempting to fulfill roles in the family and
community. it is difficult for the client to fulfilling family roles.

• Judgment & Insight:

Judgment is frequently impaired in the client with schizophrenia. Because
judgment is based on the ability to interpret the environment correctly.
Insight also can be severely impaired, especially early in the illness, when
the client, family, and friends do not understand what is happening. Over
time, some clients can learn about the illness, anticipate problems, and seek
appropriate assistance as needed.

• Data analysis for schizophrenia.

The nurse must analyze assessment data for clients with schizophrenia to
determine priorities and establish an effective plan of care. Not all clients will
have the same problems and needs, Levels of family and community support
and available services also will vary. The analysis of assessment data
generally falls into two main categories: data associated with the positive
signs of the disease and data associated with the negative signs.

•
• Conclusion.

As explained, schizophrenia is very disabling. But as research progresses treatment is

slowly but surely becoming more and more effective. Fewer patients have to be kept in
hospitals and damage to the brain is not as severe. Scientists discovered the effects of
estrogen, and learned it could be used as a medicine (though long term medications
using estrogen have side effects). They discovered age and gender differences, and
learned that there were structural changes even at a cellular level. In conclusion, though
schizophrenia is disabling and sometimes even deadly, modern science has made
many medical breakthroughs, and perhaps, if it is even possible, scientists may
discover a complete or partial cure.