Introduction
The nurse may assess a client with a known history of schizophrenia or a client with a unknown to the mental health care system. Assessment begins with an interview and focuses on establishing the client's signs and symptoms, degree of impairment in the thought process, risk for self injury or violence towards others, and available support systems. The nurse may wish to interview the client with a family member or a friend to obtain all information regarding family history, previous episodes of psychotic symptoms, onset of symptoms, and thoughts of suicide or violent behaviour.
Assessment:
1. Assessing mood and cognitive state:
- The nurse is alert for the signs and symptoms such as :
- Absence of expression of feelings
- Language content that is difficult to follow
- Pronounced paucity of speech and thoughts
- Preoccupation with odd ideas
- Ideas of reference
- Expression of feelings of unreality
- Evidence of hallucinations such as comments that the way they things appear, sound, or smell is different.
The nurse can also inquire about recent stressors, which can precipitate a psychotic episode in the client with a thought disorder, and signs and symptoms of impending relapse. These signs include disturbed sleep cycle, significant mood changes( mostly depression), decreased appetite, and somatic complaints such as headache, malaise, and constipation. Relapse eads to client withdrawal, resistance, and preoccupation with psychotic symptoms.
2. Assessing potential for violence:
The nurse assess the potential for violence by inquiring about the following:
- History of violent or suicidal behavior
- Extreme social isolation
- Feeling of persecution or being controlled by others.
- Auditory hallucinations that tells the client to commit violent acts.
- Concomitant substance use.
- Medication noncompliance
- Feelings of anger, suspiciousness, or hostility.
3. Assessing social support:
- Availability and responsiveness of a social support network and the client's role in the family and community are important factors in nursing assessment
4. Assessing knowledge
- The nurse assess the client's and families knowledge of schizophrenia, its treatment, and the potential for relapse. Adherence to medication regimens and other therapeutic schedules is bolstered when cients and families understand the biologic basis of the illness, signs of recovery and relapse, and their role in treatment.
NURSING DIAGNOSIS:
- 1. Disurbed thought process related to biochemical imbalances, as evidenced by hypervigilence, distractibility, por concentration, disordered thought sequencing, inappropriate responses, and thinking not based in reality.
- 2. Disturbed sensory perception( auditory/visual) related to biochemical imbalances, as evidencd by auditory or visual hallucinations.
- 3. Risk for other- directed or self directed violence related to delusional thoughts and hallucinatory commands, history of childhood abuse, or panic,as evidencedby overt aggressive acts, threatening stances, pacing, or suicidal ideation or plan.
- 4. Social isolation related to alterations in mental status and an ability to engage in satisfying personal relationships, as evidenced by sad, flat affect, absence of supportive significant others, withdrawal, uncommunicativeness and inability to meet the expectations of others.
- 5. Noncompliance with medication regimen related to health beliefs and lack of motivation, as evidenced by failure to adhere to medication schedule.
- 6. Ineffective coping related to disturbed thought process as evidenced by inability to meet basic needs.
- 7. Interrupted family process related to shift in health status of a family member and situational crisis, as evidenced by changes in the family's goals, plans, and activities and changes in family pattern and rituals.
- 8. Risk for ineffective family management of therapeutic regimen related to knowledge deficit and complexity of client,s healthcare needs.
Disturbed Thought Processes
- Convey acceptance of client's need for false belief but that you do not share the belief
- Do not argue or deny the belief
- Reinforce and focus on reality
- If client is suspicious
- Consistent staff
- Honest, keep all promises
Disturbed Sensory Perception Auditory/Visual
- Observe for signs of hallucinations
- Avoid touching client without warning
- Do not reinforce the hallucination - let the client know that you do not share the perception - "Even though I know the voices are real to you, I do not hear them"
- Help client understand connection between anxiety and hallucinations
- Try to distract
Social Isolation
- Convey accepting attitude by making brief, frequent contacts. Show unconditional positive regard
- Offer to be with client during group activities that he/she finds frightening
- Give recognition and positive reinforcement for client voluntary interactions with others
Self Care Deficit
- Provide assistance as appropriate
- Encourage independence - positive reinforcement
- concrete communications
Impaired verbal communication
- Seek validation and clarification
- Consistent staff
- Verbalizing the implied
- Orient to reality
References:
- Schultz J M & Videbeck S L. Lippincott,s Manual of psychiatric nursing care plans. (7 th edn). Philadelphia: Lippincott. Williams and Wilkins.
- Mohr W K. Psychiatric mental health nursing ( edn 6).Lippincotts, Williams and Wilkins. Philadelphia:
- Fortinash K M 7 Worret H. Psychiatric nursing care plan. ( 5 th edn). Mosby publications; 2003.
