Schizophrenia

Definition
 The schizophrenic disorders are characterized in general
by fundamental and characteristic distortions of thinking
and perception, and affects that are inappropriate or
blunted. Clear consciousness and intellectual capacity
are usually maintained although certain cognitive deficits
may evolve in the course of time.
 The most important psychopathological phenomena
include
 thought echo
 thought insertion or withdrawal
 thought broadcasting
 delusional perception and delusions of control
 influence or passivity
 hallucinatory voices commenting or discussing the patient in the
third person
 thought disorders and negative symptoms.
Schizophrenia
 Schizophrenia occurs with regular frequency nearly
everywhere in the world in 1 % of population and
begins mainly in young age (mostly around 16 to
25 years).

 Schizophrenia is defined by
 etymology of the term from the Greek roots skhizein ("to
split") and phrēn, phren- ("mind")
 Dr. Emile Kraepelin in the 1887 and the illness itself is
generally believed to have accompanied mankind through
its history
 Swiss psychiatrist, Eugen Bleuler, coined the term,
"schizophrenia" in 1911
 deterioration in social, occupational, or interpersonal
relationships
 continuous signs of the disturbance for at least 6 months
 History
 Emil Kraepelin: This illness develops relatively
early in life, and its course is likely deteriorating
and chronic; deterioration reminded dementia
(„Dementia praecox“), but was not followed by any
organic changes of the brain, detectable at that
time.
 Eugen Bleuler: He renamed Kraepelin’s dementia
praecox as schizophrenia (1911); he recognized the
cognitive impairment in this illness, which he
named as a „splitting“ of mind.
 Kurt Schneider: He emphasized the role of
psychotic symptoms, as hallucinations, delusions
and gave them the privilege of „the first rank
symptoms” even in the concept of the diagnosis of
schizophrenia.
 4 A (Bleuler)
 Bleuler maintained, that for the diagnosis of
schizophrenia are most important the following four
fundamental symptoms:
 affective blunting
 disturbance of association (fragmented thinking)
 autism
 ambivalence (fragmented emotional response)
 These groups of symptoms, are called „four A’ s”
and Bleuler thought, that they are „primary” for
this diagnosis.
 The other known symptoms, hallucinations,
delusions, which are appearing in schizophrenia
very often also, he used to call as a “secondary
symptoms”, because they could be seen in any
other psychotic disease, which are caused by quite
different factors — from intoxication to infection or
other disease entities.
Course of Illness
 Course of schizophrenia:
 continuous without temporary improvement
 episodic with progressive or stable deficit
 episodic with complete or incomplete remission

 Typical stages of schizophrenia:

 prodromal phase
 active phase
 residual phase
 Clinical Picture
 Diagnostic manuals:
 lCD-10 („International Classification of Disease“, WHO)
 DSM-IV („Diagnostic and Statistical Manual“, APA)

 Clinical picture of schizophrenia is according to lCD-

10, defined from the point of view of the presence
and expression of primary and/or secondary
symptoms (at present covered by the terms negative
and positive symptoms):
 the negative symptoms are represented by cognitive
disorders, having its origin probably in the disorders of
associations of thoughts, combined with emotional blunting
and small or missing production of hallucinations and
delusions
 the positive symptom are characterized by the presence of
hallucinations and delusions
 the division is not quite strict and lesser or greater mixture of
symptoms from these two groups are possible
Positive and Negative
Symptoms
Negative Positive
Alogia Hallucinations
Affective flattening Delusions
Avolition-apathy Bizarre behaviour
Anhedonia-asociality Positive formal thought
disorder
Attentional impairment

Andreasen N.C., Roy M.-A., Flaum M.: Positive and negative symptoms. In:
Schizophrenia, Hirsch S.R. and Weinberger D.R., eds., Blackwell Science, pp. 28-45, 1995
The Criteria of Diagnosis
For the diagnosis of schizophrenia is necessary
 presence of one very clear symptom - from point a) to d)
 or the presence of the symptoms from at least two groups -
from point e) to h)
for one month or more:

a) the hearing of own thoughts, the feelings of thought

withdrawal, thought insertion, or thought broadcasting
b) the delusions of control, outside manipulation and influence,
or the feelings of passivity, which are connected with the
movements of the body or extremities, specific thoughts,
acting or feelings, delusional perception
c) hallucinated voices, which are commenting permanently the
behavior of the patient or they talk about him between
themselves, or the other types of hallucinatory voices, coming
from different parts of body
d) permanent delusions of different kind, which are
inappropriate and unacceptable in given culture
The Criteria of Diagnosis
e) the lasting hallucination of every form
f) blocks or intrusion of thoughts into the flow of thinking and
resulting incoherence and irrelevance of speach, or
neologisms
g) catatonic behavior
h) „the negative symptoms”, for instance the expressed apathy,
poor speech, blunting and inappropriatness of emotional
reactions
i) expressed and conspicuous qualitative changes in patient’s
behavior, the loss of interests, hobbies, aimlesness, inactivity,
the loss of relations to others and social withdrawal

 Diagnosis of acute schizophorm disorder (F23.2) – if the

conditions for diagnosis of schizophrenia are fulfilled, but
lasting less than one month
 Diagnosis of schizoaffective disorder (F25) - if the
schizophrenic and affective symptoms are developing
together at the same time
F20-F29 Schizophrenia, Schizotypal and
Delusional Disorders
F20 Schizophrenia
F20.0 Paranoid schizophrenia
F20.1 Hebephrenic schizophrenia
F20.2 Catatonic schizophrenia
F20.3 Undifferentiated schizophrenia
F20.4 Post-schizophrenic depression
F20.5 Residual schizophrenia
F20.6 Simple schizophrenia
F20.8 Other schizophrenia
F20.9 Schizophrenia, unspecified
F20-F29 Schizophrenia, Schizotypal and
Delusional Disorders
F21 Schizotypal disorder

F22 Persistent delusional disorders

F22.0 Delusional disorder
F22.8 Other persistent delusional disorders
F22.9 Persistent delusional disorder, unspecified

F23 Acute and transient psychotic disorders

F23.1 Acute polymorphic psychotic disorder with
symptoms of schizophrenia
F23.2 Acute schizophrenia-like psychotic disorder
F23.3 Other acute predominantly delusional
psychotic disorders
F23.8 Other acute and transient psychotic disorders
F23.9 Acute and transient psychotic disorder,
unspecified
F20-F29 Schizophrenia, Schizotypal and
Delusional Disorders
F24 Induced delusional disorder

F25 Schizoaffective disorders

F25.0 Schizoaffective disorder, manic type
F25.1 Schizoaffective disorder, depressive type
F25.2 Schizoaffective disorder, mixed type
F25.8 Other schizoaffective disorders
F25.9 Schizoaffective disorder, unspecified

F28 Other nonorganic psychotic disorders

F29 Unspecified nonorganic psychosis

F20.0 Paranoid Schizophrenia
 Paranoid schizophrenia is characterized
mainly by delusions of persecution, feelings of
passive or active control, feelings of intrusion,
and often by megalomanic tendencies also.
The delusions are not usually systemized too
much, without tight logical connections and
are often combined with hallucinations of
different senses, mostly with hearing voices.
 Disturbances of affect, volition and speech,
and catatonic symptoms, are either absent or
relatively inconspicuous.
F20.1 Hebephrenic Schizophrenia
 Hebephrenic schizophrenia is characterized by
disorganized thinking with blunted and
inappropriate emotions. It begins mostly in
adolescent age, the behavior is often bizarre. There
could appear mannerisms, grimacing, inappropriate
laugh and joking, pseudophilosophical brooding and
sudden impulsive reactions without external
stimulation. There is a tendency to social isolation.

 Usually the prognosis is poor because of the rapid

development of "negative" symptoms, particularly
flattening of affect and loss of volition. Hebephrenia
should normally be diagnosed only in adolescents or
young adults.

 Denoted also as disorganized schizophrenia

F20.2 Catatonic Schizophrenia
 Catatonic schizophrenia is characterized
mainly by motoric activity, which might be
strongly increased (hypekinesis) or
decreased (stupor), or automatic obedience
and negativism.
 We recognize two forms:
 productive form — which shows catatonic
excitement, extreme and often aggressive
activity. Treatment by neuroleptics or by
electroconvulsive therapy.
 stuporose form — characterized by general
inhibition of patient’s behavior or at least by
retardation and slowness, followed often by
mutism, negativism, fexibilitas cerea or by stupor.
The consciousness is not absent.
F20.3 Undifferentiated Schizophrenia
 Psychotic conditions meeting the general
diagnostic criteria for schizophrenia but
not conforming to any of the subtypes in
F20.0-F20.2, or exhibiting the features of
more than one of them without a clear
predominance of a particular set of
diagnostic characteristics.

 This subgroup represents also the former

diagnosis of atypical schizophrenia.
F20.4 Postschizophrenic Depression
 A depressive episode, which may be
prolonged, arising in the aftermath of a
schizophrenic illness. Some schizophrenic
symptoms, either „positive“ or „negative“,
must still be present but they no longer
dominate the clinical picture.
 These depressive states are associated
with an increased risk of suicide.
F20.5 Residual Schizophrenia
 A chronic stage in the development of
schizophrenia with clear succession from
the initial stage with one or more episodes
characterized by general criteria of
schizophrenia to the late stage with long-
lasting negative symptoms and
deterioration (not necessarily irreversible).
F20.6 Simple Schizophrenia
 Simple schizophrenia is characterized by
early and slowly developing initial stage
with growing social isolation, withdrawal,
small activity, passivity, avolition and
dependence on the others.
 The patients are indifferent, without any
initiative and volition. There is not
expressed the presence of hallucinations
and delusions.
F21 Schizotypal disorder
 According to lCD-10 this disorder is
characterized by eccentric behavior and by
deviations of thinking and affectivity,
which are similar to that occurring in
schizophrenia, but without psychotic
features and expressed symptoms of
schizophrenia of any type.
F22 Persistent Delusional Disorders
 Includes a variety of disorders in which
long-standing delusions constitute the
only, or the most conspicuous, clinical
characteristic and which cannot be
classified as organic, schizophrenic or
affective.
 Their origin is probably heterogeneous, but
it seems, that there is some relation to
schizophrenia.
F22.0 Delusional Disorder
 A disorder characterized by the
development of one delusion or of the
group of similar related delusions, which
are persisting unusually long, very often
for the whole life.
 Other psychopathological symptoms —
hallucinations, intrusion of thoughts etc.
are not present and are excluding this
diagnosis.
 It begins usually in the middle age.
F23 Acute and Transient Psychotic
Disorders
 The criteria should be the following features:
 acute beginning (to two weeks)
 presence of typical symptoms (quickly changing
“polymorphic symptoms”)
 presence of typical schizophrenic symptoms.

 Complete recovery usually occurs within a few

months, often within a few weeks or even
days.
 The disorder may or may not be associated
with acute stress, defined as usually stressful
events preceding the onset by one to two
weeks.
F24 Induced Delusional Disorder
 A delusional disorder shared by two or more
people with close emotional links. Only one of
the people suffers from a genuine psychotic
disorder; the delusions are induced in the
other(s) and usually disappear when the
people are separated.

 The psychotic disorder of the dominant

member of this dyad is mainly, but not
necessarily, of schizophrenic type. The
original delusions of dominant member and
his partner are usually chronic, either
persecutory or megalomanic.
F25 Schizoaffective Disorders
 Episodic disorders in which both affective and
schizophrenic symptoms are prominent (during the
same episode of the illness or at least during few
days) but which do not justify a diagnosis of either
schizophrenia or depressive or manic episodes.
 Patients suffering from periodic schizoaffective
disorders, especially with manic symptoms, have
usually good prognosis with full remissions without
any remaining defects.
 They are divided in different subgroups:
 F25.0 Schizoaffective disorder, manic type
 F25.1 Schizoaffective disorder, depressive type
 F25.2 Schizoaffective disorder, mixed type
 F25.8 Other schizoaffective disorders
 F25.9 Schizoaffective disorder, unspecified
Genetics of Schizophrenia

 Many psychiatric disorders are

multifactorial (caused by the interaction of
external and genetic factors) and from the
genetic point of view very often
polygenically determined.

 Relative risk for schizophrenia is around:

 1% for normal population
 5.6% for parents
 10.1% for siblings
 12.8% for children
Etiology of Schizophrenia
 The etiology and pathogenesis of
schizophrenia is not known

 It is accepted, that schizophrenia is „the group

of schizophrenias“ which origin is
multifactorial:
 internal factors – genetic, inborn, biochemical
 external factors – trauma, infection of CNS, stress
 Etiology of Schizophrenia -
Dopamine Hypothesis
 The most influential and plausible are the
hypotheses, based on the supposed disorder of
neurotransmission in the brain, derived mainly from
1. the effects of antipsychotic drugs that have in common the
ability to inhibit the dopaminergic system by blocking
action of dopamine in the brain
2. dopamine-releasing drugs (amphetamine, mescaline,
diethyl amide of lysergic acid - LSD) that can induce state
closely resembling paranoid schizophrenia

 Classical dopamine hypothesis of schizophrenia:

Psychotic symptoms are related to dopaminergic
hyperactivity in the brain. Hyperactivity of
dopaminergic systems during schizophrenia is result
of increased sensitivity and density of dopamine D2
receptors in the different parts of the brain.
Etiology of Schizophrenia -
Contemporary Models
 Dopamine hypothesis revisited: various
neurotransmitter systems probably takes place in the
etiology of schizophrenia (norepinephric, serotonergic,
glutamatergic, some peptidergic systems); based on
effects of atypical antipsychotics especially.

 Contemporary models of schizophrenia conceptualize it

as a neurocognitive disorder, with the various signs
and symptoms reflecting the downstream effects of a
more fundamental cognitive deficit:
 the symptoms of schizophrenia arise from “cognitive dysmetria”
(Nancy C. Andreasen)
 concept of schizophrenia as a neurodevelopmental disorder
(Daniel R. Weinberger)
Etiology of Schizophrenia -
Neurodevelopmental Model
 Neurodevelopmental model supposes in
schizophrenia the presence of “silent lesion” in
the brain, mostly in the parts, important for the
development of integration (frontal, parietal and
temporal), which is caused by different factors
(genetic, inborn, infection, trauma...) during very
early development of the brain in prenatal or early
postnatal period of life.
 It does not interfere too much with the basic brain
functioning in early years, but expresses itself in
the time, when the subject is stressed by
demands of growing needs for integration, during
formative years in adolescence and young
adulthood.
 Treatment of Schizophrenia
 The acute psychotic schizophrenic patients will
respond usually to antipsychotic medication.
 According to current consensus we use in the first
line therapy the newer atypical antipsychotics,
because their use is not complicated by appearance
of extrapyramidal side-effects, or these are much
lower than with classical antipsychotics.
conventional chlorpromazine, chlorprotixene, clopenthixole,
antipsychotics levopromazine, periciazine, thioridazine
(classical droperidole, flupentixol, fluphenazine,
neuroleptics) fluspirilene, haloperidol, melperone,
oxyprothepine, penfluridol, perphenazine,
pimozide, prochlorperazine, trifluoperazine
atypical amisulpiride, clozapine, olanzapine, quetiapine,
antipsychotics risperidone, sertindole, sulpiride
Neuroleptics
 are drugs that modify psychotic symptoms, including
symptoms of bipolar disorder, schizophrenia, delusional
disorder and psychotic depression. 

 There are two classes of neuroleptic drugs.

 Typical antipsychotics were discovered and first used in the 1950s,
 Atypical antipsychotics were developed and used in the 1970s. Atypical
neuroleptic drugs generally are regarded as more effective and less likely
to cause side effects than typical neuroleptic drugs.

 Tardive dyskinesia is a type of repetitive movement the

patient cannot control
Side Effects: EPS
 Extrapyramidal syndrome is a condition that causes
involuntary muscle movements or spasms that
usually occur in the face and neck. It occurs when the
release and re-uptake of the
neurotransmitter dopamine is not regulated
correctly. 
 Muscle movement problems that may
accompany extrapyramidal syndrome include
constantly
 smacking the lips
 moving the tongue,
 blinking,
 neck twitches
 and finger spasms. 
 [edit]Medium Strength

Neuroleptics
Mild Strength
Generic name Brand names
Chlorprothixene Truxal
Levomepromazine Levium,
Levomepromazine
Neuraxph., Neurocil
Perazine Perazin Neuraxph.,
Taxilan
Promethazine Atosil, Closin,
Promethazin Neuraxph.,
Proneurin, Prothazin

Prothipendyl Dominal
Sulpiride Dogmatil, Dogmatyl,
Sulpirid
iMedium Strength
Thioridazine Melleril, Thioridazin
Generic name Brand names
Neuraxph.
Zuclopenthixol Cisordinol, Clopixol
Strong Strength
Generic name Brand names
Perfenazine Trilafon
Very Strong Strength
[
Generic name Brand names
Benperidol Benperidol Neuraxph.,
Glianimon
Bromperidol Impromen
Fluphenazine decanoate Anatensol, Dapotum D,
Deconoat, Fludecate,
Modecate, Prolixin
Decanoate, Sinqualone
enanthate Dapotum Injektion,
Flunanthate, Moditen
Enanthate Injection,
Sinqualone Enantat
hydrochloride
Dapotum, Permitil, Prolixin,
   Lyogen, Moditen, Omca,
Sediten, Selecten, Sevinol,
Siqualone, Trancin

Fluspirilen Fluspi, Fluspirilen Beta,

Imap
 Generic name Brand names
Amisulpride Solian
Aripiprazole Abilify
Asenapine Saphris
Benztropine Cogentin
Buspirone Ansial, Ansiced, Anxiron, Axoren, Bespar,
Buspar, Buspimen, Buspinol, Buspisal,
Narol

Chlorpromazine Largactil, Thorazine

Clozapine Clozaril, Fazaclo, Leponex
Atypical Neuroleptics

Flupenthixol Depixol, Fluanxol

Iloperidone Fanapt
Melperone Eunerpan, Melneurin
Olanzapine Zyprexa
Paliperidone Invega, Invega Sustenna
Penfluridol Semap
Quetiapine Seroquel
Risperidone Belivon, Risperdal, Risperdal Consta

Sertindole Serdolect, Serlect

Thiothixene Navane
Trifluoperazine Eskazinyl, Eskazine, Jatroneural, Modalina,
Stelazine, Terfluzine, Trifluoperaz, Triftazin

Ziprasidone Geodon, Zeldox

Zotepine Nipolept
Carbamazepine, Valproic acid sometimes used
Nursing Management
 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.
Diagnoses Nursing Care Plans For
Schizophrenia
 Anxiety
 Bathing or hygiene self-care
deficit
 Disabled family coping
 Disturbed body image
 Disturbed personal identity
 Disturbed sensory perception
(auditory, visual, kinesthetic)
 Disturbed sleep pattern
 Disturbed thought processes
 Dressing or grooming self-care
deficit
 Fear
 Hopelessness
 Imbalanced nutrition: Less than
body requirements
 Impaired home maintenance
 Impaired social interaction
 Impaired verbal communication
 Ineffective coping
 Ineffective role performance
 Powerlessness
 Risk for injury
 Risk for other-directed violence
 Risk for self-directed violence
 Social isolation
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
 Key outcomes Nursing Care Plans For
Schizophrenia The patient will express fears and concerns.


The patient and his family will participate in care and

 The patient will consider an alternative
interpretation of a situation without
becoming unduly hostile or anxious.
 The patient will perform bathing and
hygiene activities to the fullest extent
possible.
 The patient's family will demonstrate
adaptive coping behaviors.
 The patient will verbalize positive
feelings about self.
 The patient will identify internal and
external factors that trigger delusional
episodes.

prescribed therapies.
 The patient will remain free from signs of malnutrition.
 The patient will develop effective coping behaviors.
 The patient will maintain usual roles and responsibilities
to the fullest extent possible.
The patient will recognize symptoms and comply with

medication regimen.
 The patient will demonstrate effective social interaction
skills in both one-on-one and group settings.
 The patient will express his needs.
 The patient will gradually join in self-care and the
decision-making process.
The patient will remain free from injury.


 The patient won't harm others.

 The patient will maintain maximum
functioning within the limits of his  The patient won't harm self or others.
auditory, visual, or kinesthetic  The patient will maintain family and peer relationships.
impairment.
 The patient will resume appropriate rest
and activity patterns.
 The patient will identify and perform
activities that decrease delusions.
 The patient will perform dressing and
grooming activities to the fullest extent
possible.
 Interventions Nursing Care Plans For
Schizophrenia
 Assess the patient's ability to carry out the activities of daily living, paying special
attention to his nutritional status. Monitor his weight if he isn't eating. If he thinks
that his food is poisoned, allow him to fix his own food when possible, or offer him
foods in closed containers that he can open. If you give liquid medication in a unit-
dose container, allow the patient to open the container.
 Maintain a safe environment, minimizing stimuli. Administer medication to
decrease symptoms and anxiety. Use physical restraints according to your
facility's policy to ensure the patient's safety and that of others.
 Adopt an accepting and consistent approach with the patient. Don't avoid or
overwhelm him. Keep in mind that short, repeated contacts are best until trust
has been established.
 Avoid promoting dependence. Meet the patient's needs, but only do for the
patient what he can't do for himself.
 Reward positive behavior to help the patient improve his level of functioning.
 Engage the patient in reality-oriented activities that involve human contact:
inpatient social skills training groups, outpatient day care, and sheltered
workshops. Provide reality-based explanations for distorted body images or
hypochondriacal complaints. Clarify private language, autistic inventions, or
neologisms, explaining to the patient that what he says isn't understood by
others. If necessary, set limits on inappropriate behavior.
 If the patient is hallucinating, explore the content of the hallucinations. If he has auditory
hallucinations, determine if they're command hallucinations that place the patient or others at
risk. Tell the patient you don't hear the voices but you know they're real to him. Avoid arguing
about the hallucinations; if possible, change the subject.
 Don't tease or joke with the patient. Choose words and phrases that are unambiguous and
clearly understood. For instance, a patient who's told, That procedure will be done on the floor,
may become frightened, thinking he is being told to lie down on the floor.
 Don't touch the patient without telling him first exactly what you're going to do. For example,
clearly explain to him, I'm going to put this cuff on your arm so I can take your blood pressure.
If necessary, postpone procedures that require physical contact with facility personnel until the
patient is less suspicious or agitated.
 Remember, institutionalization may produce new symptoms and handicaps in the patient that
aren't part of his diagnosed illness, so evaluate symptoms carefully.
 Mobilize community resources to provide a support system for the patient and reduce his
vulnerability to stress. Ongoing support is essential to his mastery of social skills.
 Encourage compliance with the medication regimen to prevent relapse. Also monitor the
patient carefully for adverse effects of drug therapy, including drug-induced parkinsonism,
acute dystonia, akathisia, tardive dyskinesia, and malignant neuroleptic syndrome. Make sure
you document and report such effects promptly.
 Thank you for
Listening