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Schizophrenia: Nursing Diagnosis

by Brenda Marshall, EdD, MSN, RN

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    00:01 We've talked about the fact that schizophrenia is a thought disorder.

    00:08 And it's important to understand that it is a spectrum disorder, meaning that it goes from mild to severe.

    00:16 And we want to start thinking that as the nurse, we are going to be seeing that client.

    00:23 We are going to be thinking nursing diagnosis, not medical diagnosis, not psychiatric diagnosis.

    00:30 We're going to be thinking about how to observe this person, so that we can be able to identify if they have emotional or environmental stressors that might be exacerbating the symptoms of their disease.

    00:44 We also want to address that need for safety, and make sure that that person has those basic requirements, that's going to keep them happy.

    00:56 Also, we want to make sure that this person is protected from others, that this person is not going to be made fun of, is not going to experience stigma, is not going to be hurt in any way.

    01:10 Remember, one of the problems is they might be willing to do whatever they are told.

    01:16 They may not really have an understanding of what's being asked of them.

    01:20 And so we have to keep them safe.

    01:23 And as medications are ordered, we have to provide them the medication.

    01:28 And even if it's hard for them to understand, we want to make sure that we are giving them the information that they need, so that they can have a little bit of psychoeducation.

    01:40 I just want to take a second here to remind you of SAFE.

    01:44 SAFE, that we want to keep the patient and the patient's surroundings safe.

    01:50 We want to assess that individual, assess that individual in the moment that the person is in.

    01:57 Focus on their needs.

    01:59 Focus on who this person is.

    02:02 And evaluate, evaluate the environment, evaluate what we are doing, and evaluate their progress.

    02:11 So let's take another look at a different case study.

    02:14 This time, let's look at a 31-year-old woman, we'll call her Phoebe.

    02:21 And Phoebe comes into the emergency room.

    02:24 And she's there with law enforcement.

    02:27 Why? Because she had stabbed a cab driver with a pencil.

    02:32 Now the client stated that she was raped by the cab driver, who then while in the emergency room stated that the dirty cops brought her here.

    02:44 And she was admitted to the inpatient psychiatric unit.

    02:48 She had been in many previous hospitals with a known history of schizophrenia, and also an additional diagnosis of amenorrhea, hyper chromathermia and obesity.

    03:04 So what are we thinking here? What are we thinking here for this 31-year-old woman? Well, the first thing that we really want to think about is that there is a history here that she has auditory hallucinations.

    03:21 She also has paranoid delusions, and it started when she was only 14.

    03:27 And at that time, she was diagnosed with major depressive disorder with psychotic features.

    03:33 Remember, psychotic features and psychosis are not only with schizophrenia.

    03:41 If you have an extreme case of depression, if you have bipolar disease, you can also have psychotic features with it.

    03:53 So by the time that this woman was 18 years old, she was diagnosed with schizophrenia, the paranoid type.

    04:02 And she had multiple previous hospitalizations, also a history of poor compliance as an outpatient.

    04:09 What do we mean by poor compliance as an outpatient? When we're saying poor compliance, we're saying that she either wasn't taking her medication, she wasn't coming in for group therapy, she wasn't coming in for individual therapy, she wasn't being able to follow the regimen that had been prescribed for her.

    04:28 So here's this person unable to follow their regimen.

    04:33 And there's no known history that she's using tobacco or alcohol or any illicit drugs at all.

    04:40 Her family history tells us that there is significant risk for schizophrenia, diabetes mellitus and also for drug use.

    04:50 Remember, we said there is that genetic family predisposition and the client reports abusive behavior by her grandmother who was her primary caretaker as a child.

    05:05 So during the time that she's hospitalized with you, she continues to report sexual assaults, accusing clients as well as staff of rape, and declining to participate in any groups at all.

    05:19 She denies that she has any visual or auditory hallucinations, but she continues to exhibit her paranoid delusions.

    05:30 So this woman has quite a history, and is obviously in a lot of despair.

    05:39 What are we going to be thinking for her as far as her nursing diagnosis? Well, there is a risk for violence.

    05:47 And where does that risk for violence come? It could be violence against herself, but it could be violence against others.

    05:55 When a person has a delusion that someone is raping them or hurting them, they might want revenge.

    06:03 And therefore this person has the risk for not only for violence for herself, but also for violence for others.

    06:11 Because of her diagnosis and the way she's behaving, we know she has an altered thought process.

    06:19 And so our nursing diagnosis of altered thought process has to be in our minds about how do we keep her safe with an altered thought process.

    06:30 She also is at risk for social isolation.

    06:33 She is not joining groups, and part of her not joining groups might be related to her delusions and her paranoia.

    06:42 And as her medication begins to work, hopefully those delusions will diminish, and her paranoia will go down.

    06:52 But we have to start thinking, what is the desired outcome to reverse this social isolation? We want to make sure that she has some times to be able to connect with others in a safe environment.

    07:07 She also has sensory and perceptual distortions, and that is her hallucinations.

    07:12 And so we want to make sure that that environment is safe, that she's not going to have something that she's going to pick up and throw.

    07:20 We want to keep her in a safe environment.

    07:23 And we want to be able to monitor as she's getting her medications to make sure that she is able to be able to be in her room, be able to be in other rooms and feel safe.

    07:36 Remember, increased stress, exacerbates all of these symptoms.

    07:42 And we want to keep the stress level low.

    07:45 She has impaired verbal communications.

    07:48 Why? Because she has a thought disorder that is messing up her ability to be able to talk coherently, get her thoughts out, plus she has these delusions that are persisting and these hallucinations.

    08:04 Also, she doesn't have very good coping mechanisms.

    08:10 Why? Because she has delusions, she has hallucinations, and she has this thought disorder.

    08:17 And so we want to work with her to develop some small coping mechanisms to help her feel a little bit more as though she has control over herself and her environment.


    About the Lecture

    The lecture Schizophrenia: Nursing Diagnosis by Brenda Marshall, EdD, MSN, RN is from the course Schizophrenia (Nursing).


    Included Quiz Questions

    1. “My client asked me what their antipsychotic medications were for today. I didn’t want to embarrass or confuse my client, so I told them that the medications were just vitamins.”
    2. “My client has to move houses and recently had a death in the family. These stressors may have caused the exacerbation of his positive symptoms.”
    3. “My client has difficulty getting dressed and has even gone into the dining room without any clothes on. It is my job to make sure that my client is properly dressed to ensure privacy and dignity.”
    4. “My client has schizophrenia, but I know I need to provide care based on their own unique needs instead of focusing on their diagnosis.”

    Author of lecture Schizophrenia: Nursing Diagnosis

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN


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