Running header: Schizophrenia 1

Student Name: Nicie Velancia Pinheiro

Meeting the Needs of People with Altered Mental Status in Schizophrenia

Word Count: 2167

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Meeting the Needs of People with Altered Mental Health Status

Historically, mental disorders were linked with evil spirits, witchcraft, and other

supernatural powers. The symptoms of psychiatric diseases implanted fear in people. In the

present age, even with developments in neuroscience and a better understanding of the

psychiatric illness, the stigma associated with psychotic disorders persists (Owen, 2014).

In this paper, one mental disorder namely Schizophrenia will be discussed. Emphasis

will be on the pathophysiology of schizophrenia and nursing management of patients

suffering from schizophrenia, consequently gaining knowledge to improve the quality of

nursing care of mentally ill patients with schizophrenia.

In 1908, Eugen Bleuler, a senior psychiatrist coined the word schizophrenia which is

a derivative of two Greek words ‘skhizo’ which means split and ‘phren’ which means mind.

Several other definitions were presented together with strategies for treatment. However, two

major concepts are being popularly accepted. Firstly that schizophrenia is not a

‘homogeneous disease’ but rather a ‘spectrum of disorders’ and is a ‘neurodevelopmental

disorder’. Secondly, as far as treatment is concerned, it is not possible to have one specific

treatment. The treatment would encompass a very inclusive strategy of medication combined

with psychosocial care together with living and social skills, rehabilitation and recovery.

About 1 percent of the general population constitutes of schizophrenics. Schizophrenics

become mentally disabled due to disturbances of perception and thought process which

results in the decline of occupational and social performance (Townsend & Morgan, 2018).

Pathophysiology of Schizophrenia

There is rising evidence that pathology of the synapses in the brain has been attributed

to be the main cause of numerous mental disorders including schizophrenia (Chelini,

Pantazopoulos, Durning & Berretta, 2018). The brain has an amazing capacity to restructure

itself constantly throughout its lifetime. This characteristic of the brain is known as
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plasticity. The plasticity of the brain depends, firstly on its ability to create new synapses or

to eliminate synapses. Secondly, it depends on its capability to change the

electrophysiological, structural and molecular properties of the existing synapses in reaction

to stimuli or experience (Chelini, Pantazopoulos, Durning & Berretta, 2018).

The process of the brain to regulate its synaptic plasticity is complicated. It involves

exchanges among ‘pre- and post-synaptic terminals, glial cells and the extracellular matrix

(ECM)’. These three elements are collectively called the ‘tetrapartite synapse’ (Chelini,

Pantazopoulos, Durning & Berretta, 2018).

From the findings and conclusion of a study conducted by Chelini, Pantazopoulos,

Durning, and Berretta (2018), via investigations on postmortem human brain tissue, it was

hypothesized that schizophrenia is a result of disturbances in the interactions between the

components of the tetrapartite synapse.

However, Lieberman et al. (2018) stated that although there has been development in

the hypothesis of pathophysiology and etiology of schizophrenia, these have not been helpful

in identifying a strategy for a diagnostic biomarker. Nor have they fully clarified the

pathophysiology of mental illness. Further, Lieberman et al. (2018) mention that as

evidenced extensively, ‘schizophrenia is a complex neurodevelopmental disorder reflecting

the interplay of genetics and the environment’. It is most likely that many different etiologies

might be combined due to genetic makeup and the environment which produces symptoms of

schizophrenia.

Lieberman et al. (2018) conducted a study to find a biomarker for the premorbid

phase of schizophrenia. This would assist in initiating interventions for the prevention of

mental disorders when the symptoms are lesser. To do this, they put forth a model on the

pathophysiology of schizophrenia, its onset, and progression. This model hypothesizes that

there is an increased activity of the neurons due to dysregulation in the neurotransmission of

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glutamate in a certain region of the hippocampus, which gives rise to attenuated psychotic

symptoms which are the start of the initial stage of schizophrenia. As this continues, the

dysfunction spreads to other areas of the hippocampus and frontal cortex. It causes atrophy

and degeneration of neurons, giving rise to psychotic symptoms of schizophrenia. Therefore,

Lieberman et al. (2018) suggested that administration of glutamate reducing agents could

reduce the progression of the disease if the treatment is started in the premorbid stage of the

disease.

Nursing Management and Evaluation of interventions

A nursing assessment of a person suffering from a mental disorder is quite complex as

information obtained from the patient is unreliable most of the time. This is due to the

process of the disease in an individual. Therefore, it is of utmost importance to obtain the

history of the patient from the family or other people involved with the patient and from

medical records, if available. A mental status examination of the patient should be performed

to look for the symptoms of schizophrenia in the patient. Therefore, a nurse should be well

aware of the characteristic behaviors that a schizophrenic patient exhibits (Guedes de Pinho,

Pereira & Chaves, 2017).

Providing holistic care to patients with mental health disorders should be the main

goal of a mental health nurse. Holistic care includes the promotion of physical and mental

health (Jormfeldt & Carlsson, 2018).

Building a Therapeutic Relationship

Establishing a therapeutic relationship with a patient with mental illness creates a

healing atmosphere that promotes health and prevents illness. It is generally difficult to

establish a therapeutic relationship with a schizophrenia patient as the patient is mostly

brought to a facility against his or her will and also lacks insight. Therefore, the nurse

should have a deeper understanding of the patient. She should realize that the patient’s
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behavior is influenced by the delusions and hallucinations they experience because these

seem real to them. Nurses should have a great capability to listen, understand,

empathize and non-stigmatize mental illness (Guedes de Pinho, Pereira & Chaves,

2017).

‘Peplau’s theory of interpersonal relations developed in 1952’ and explained by

Guedes de Pinho, Pereira & Chaves ( 2017), stresses on a collaboration between the

patient and the nurse in the plan to provide care. It comprises of four stages. In the first

stage of orientation, the patient should be made to recognize the difficulties he/she is

facing and the necessity to cooperate. Secondly, in the identification stage, the patient is

made to understand the disease and the difficulties they are facing. Thirdly in the

exploitation phase, the nurse should make the patient aware of all the possible available

services for recovery including ‘psychosocial rehabilitation programs’. In the fourth

stage or the resolution stage, the individualistic needs of the patient should be met. The

resolution phase is complete only after they are rehabilitated both psychologically as

well as socially. In other words, when they are capable of independently taking care of

their personal requirements and accept the disease as a part of life.

Compliance to medications

Adherence to psychiatric medications is more accurate when the decisions about

the treatment are made in collaboration with the patient. This is called “follow-through”.

Nurses interact with the patients more frequently. Thus, they are in a better position to

explain the importance of continuing the psychiatric medications as well as to find clues

of inconsistent follow-through like missed follow-up or appointment for long-acting

injectable (Mahone, Maphis & Snow, 2016). ‘Examples of evidence-based psychosocial

interventions include illness self-management, case management/assertive community

treatment (ACT), social skills training (SST), family psychoeducation, and supported
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employment’. Personal medicine refers to activities that are not pharmaceutical in origin.

These include actions like ‘helping others, working,, keeping busy, exercising, advocacy,

time with loved ones, sex, fishing, shopping, diet changes, a good cry, being with

“normal” people, being alone, being in nature, talking on the phone, taking a car ride, a

day off from work, pushing to achieve, or exposure to sunlight (Mahone, Maphis &

Snow, 2016).

Medication administration and its side effects

Medicines are the most important line of treatment for a patient with

schizophrenia. Sometimes, medication is the only way to treat the patient of the illness.

Nurses should be vigilant about the side effects Psychiatric drugs cause and notify the

psychiatrist concerned so that adjustments in the dosage or change of medications can be

done. Nurses should also educate the patient about the side effects, monitor physical

health and identify individual risk factors (Mahone, Maphis & Snow, 2016).

Physical activity

It is known as well as the evidenced fact that physical activity benefits a person’s

mental health. Exercise improves sleep patterns, cognition, and self-esteem. It also

decreases anxiety, stress and negative mood, thereby decreases symptoms of

schizophrenia. Family or caregivers are educated about the importance of exercise and

its positive effects on mental as well as cardiovascular health and that this should be

continued in their daily routine(Abd El-Fatah Ali Saraya, Fahamy Ibrahim, Mohamed

Darweesh, Ibraheem Sayied & Elaal Thabt, 2016).

Management of Hallucinations in schizophrenia

Hallucinations, especially auditory hallucinations are the most prevalent

symptom of schizophrenia. These are mostly voices that give bad advice to the patient

and may result in the patient harming him or others (Sayied & Ahmed, 2017).
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Sayied and Ahmed (2017) conducted a study aimed at evaluating the

implementation of self-management strategies for hallucinations in schizophrenia. They

deduced that patients were able to control their hallucinations and subsequently their

own behavior by adopting these strategies.

To patients experiencing hallucinations, these are really lifelike. Therefore these

individuals weird behavior is due to their response to hallucinations. It is essential to

empower them with self-management strategies so as to reduce their tension, increase

their self-confidence and ability to tackle their own chronic disease (El Ashry & Abdel

Al, 2015)

Self-management strategies are characterized by physiological techniques,

behavioral techniques, and cognitive techniques. In physiological strategies, the

patient’s arousal, disturbance, and agitation are curtailed by listening to music and taking

rest. On the other hand, if patients have to be aroused then exercise and listening to

music can be used. There are also cognitive strategies like auto-suggestion, calm

acceptance of voices, ignoring voices and verifying voices. Then there are behavioral

strategies such as praying, singing, watching television, talking to others and seeking

help from doctors or nurses (El Ashry & Abdel Al, 2015).

Management of schizophrenics with suspicious ideation

These patients misinterpret information and societal cues in their surroundings.

Thus, some interventions should be implemented so as to encourage communication and

trusting rapport. Do not touch these patients. If it is required to touch the patient for any

procedures, ask permission as the patient feels threatened and might become defensive

or violent. Do not laugh whisper or talk quietly where the patient cannot hear but see

you. Some patients might refuse to eat food which is served as they suspect it to be

poisoned. Thus she might have to be served in a particular manner. These patients
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might think that medicine is a poison and try to discard by hiding in the mouth. Hence it

is required to check her or his mouth after it is consumed. Approach to this patient

should be assertive and genuine and not visibly cheerful or instructive (Townsend &

Morgan, 2018).

Interventions for the patient with risk of harm to self or others

Patients at risk of harm should be observed carefully while doing daily activities

so that interventions can be implemented to ensure the safety of patients and others. The

patient’s surroundings should be very simple with low lighting, few people and less

noise. More stimuli will make the patient more anxious. Remove any sharp objects out

of reach of the patient to safeguard himself and others. Assess the patient for

hallucinations, suicidal and homicidal ideation (Townsend & Morgan, 2018).

Therapeutic Recreation

People who are experiencing mental illness often get secluded from society and

have a lot of spare time. This makes them prone to cultivating unhealthy habits which

lead to cardiovascular disease (Picton, Moxham and Patterson, 2016). Other causes of

shortened life expectancy are poor diet, weight gain, smoking, sedentary lifestyle and

side effects of psychotic medications. These patients are also not offered preventive care

and health promotion facilities because they do not have full access to health care

services (Jormfeldt and Carlsson, 2018).

Therapeutic recreation for mentally ill patients is a very good intervention to

encourage socialization, empowerment, and willpower. Activities like archery and the

flying fox can be organized during recreational outings or camps (Picton, Moxham and

Patterson, 2016).

Equine assisted therapeutic intervention can be considered for a mentally ill

patient’s rehabilitation. In this type of intervention, patients are involved in taking care
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of horses, grooming them, leading horses and horse riding. This is done under the

supervision of ‘a mental health physician and a trained veterinarian’. Patients with

schizophrenia benefit as they feel more confident and their self-esteem improves

(Jormfeldt and Carlsson, 2018).

Conclusion

Schizophrenia is a neurodevelopmental disorder caused due to the

malfunctioning of the different components of the brain. Nursing management of a

person with Schizophrenia consists of a holistic approach towards the patient. This

comprises of promotion of physical and mental health. Physical activity is supported

through regular therapeutic recreational activities. The promotion of mental health is

done by interacting with the patient according to the symptoms and by the administration

of medication.
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