Author: Amanda Eymard, Co-Author: Linda Manfrin-Ledet,
Title: Associate Professor
Institution: Nicholls State University College of Nursing and Allied Health
Evidence-Based Practice, Informatics, Patient-Centered Care, Quality Improvement, Safety, Teamwork and Collaboration
<p class="MsoNormal" style="margin-bottom: .0001pt; line-height:
normal; mso-layout-grid-align: none; text-autospace: none;”>This unfolding case study was designed to provide opportunities for nursing students to make decisions regarding a patient diagnosed with schizophrenia. There are KSA safety questions, teamwork questions (especially involving the use of SBAR), medication questions (including safety), a math problem, a video to illustrate schizophrenia, quality improvement questions, and also theory bursts are included.
The strategy is an unfolding case study involving a man diagnosed with schizophrenia. It begins with him encountering the police and evolves as he is transported to the emergency department and then to a psychiatric facility, and ends with his discharge. His family is involved in the patient-centered care scenario. Restraints, medication use, delegation, teamwork, communication, reflection, assessment, and laboratory/diagnostics are all included. It is designed to be an interactive, engaging exercise with students enrolled in a mental health nursing course. Questions and scenarios are posed, and then the next slide provides the answers. Theory bursts are also included.
<p class="MsoNormal" style="margin-bottom: .0001pt; line-height:
normal; mso-layout-grid-align: none; text-autospace: none;”>This unfolding case study is presented in the classroom to senior level nursing students enrolled in a mental health nursing course. The students are encouraged to participate by answering questions and collaborating regarding their answers. The students responded this semester with much enthusiasm; they were very engaged. They initially struggled with the SBAR activities when asked to notify a physician or other team member. This activity has been identified as a weakness in many new grads and was included in the case study for this very reason. As the case study progressed, the students became more confident with making the phone calls.
Steve is a 23 year old accountant and comes to the clinic because he feels strange about feeling unmotivated. He said even eating feels like a chore. He confirmed not taking a bath for three days straight because the water feels like needles on his skin. At work, he verbalizes that someone is whispering at him and this causes him to lose his concentration. He is convinced his co-workers envy him so much that they are planning to take him down.
Despite it being one of the most common psychiatric disorders, schizophrenia is usually misunderstood. Here is how it is described and defined:
- Schizophreniarefers to a group of severe, disabling psychiatric disorders marked by withdrawal from reality, illogical thinking, possible delusions and hallucinations, and emotional, behavioral, or intellectual disturbance.
- These disturbances last for at least for six (6) months. The level of functioning in work, interpersonal relationship, and self-care are markedly below the level since the onset of symptoms.
- Have difficulty distinguishing reality from fantasy. Their speech and behavior may frighten or mystify those around them.
Schizophrenia occurs in all societies without regard to class, color, and culture.
- It affects 1.1% of the population above age 18, which is estimated to be 51 million people worldwide.
- In the United States alone, 2 million Americans each year are affected, with 7.2 in 1000 persons developing it during their lifetime.
- Affects both men (late teens or early 20s) and women (mid-20s to early 30s) equally
- Prevalence is higher than diabetes mellitus, Alzheimer’s disease, and multiple sclerosis.
Like many diseases, schizophrenia is linked to various factors.
- Precise cause is unknown.
- There is currently no way to predict who will develop the disease.
- Genetic factors. It is believed that multiple genes (strongest evidence points to chromosomes 13 and 6) are involved in predisposition to schizophrenia. Other factors like prenatal infections, perinatal complications, and environmental stressors are also being studied. The manner of transmission of genetic predisposition is not clearly understood.
- Biochemical factors. Involves dopamine (focus of most studies), serotonin, norepinephrine, and epinephrine. Excessive dopamine activity is linked to hallucinations, agitation, and delusion. High norepinephrineis linked to positive symptoms of schizophrenia.
- Other factors include structural brain abnormalities (e.g. enlarged ventricles), developmental (e.g. faulty neuronal connections), and other possible causes (e.g. maternal influenza during second trimester of pregnancy, epilepsy of the temporal lobe, head injury, etc.)
Signs and Symptoms
Behaviors and functional deficiencies seen in schizophrenia vary widely among patients.
- Signs and symptoms are divided into three clusters: positive, negative, and cognitive symptoms.
- Positive symptoms are associated with temporal lobe abnormalities.
- Negative symptoms are associated with frontal cortex and ventricular abnormalities.
- Deviant symptoms. These are symptoms that are present but should be absent. They indicate that patient has lost touch with reality.
- Primarily include delusions and hallucinations.
- Hallucinations are the most common feature of schizophrenia. These involve hearing, seeing, smelling, tasting, and feeling touched by things in the absence of stimuli. An example is hearing voices that command the patient to do certain things, usually abusive and self-destructive.
- Delusions are fixed false beliefs. They cannot be changed by logic or persuasion. An example is a patient believing that people can read his mind. Several categories of delusions include:
- Persecutory delusions. Patient thinks he is being tormented, followed, tricked, or spied on.
- Reference delusions. Patient thinks that passages in books, music, TV shows, and other sources are directed at him.
- Delusions of thought withdrawal/thought insertion. Patient believes others can read his mind, his thoughts are being transmitted to others, or outside forces are imposing their thoughts or impulses on him.
- Deficit symptoms. These symptoms reflect the absence of normal characteristics.
- Apathy is lack of interest in people, things, and activities.
- Anhedonia is diminished capacity to feel pleasure.
- Blunted affect is characterized by patient’s face appearing immobile and inexpressive; this is the flattening of emotions and becomes more pronounced as the disease progresses.
- Poverty of speech is a speech that is brief and lacks content.
- Reflect the patient’s abnormal thinking, poor decision-making skills, poor problem-solving skills, and ability to communicate and his strange behavior.
- Thought disorder is characterized by confused thinking and speech (e.g., incoherent ramblings, loose association, word salad, wandering).
- Bizarre behavior include childlike silliness, laughing or giggling, agitation, inappropriate appearance, hygiene, and conduct.
Phases of Schizophrenia
Schizophrenia usually progresses through three distinct phases:
- Occurs before hospitalization or within the year.
- Characterized by clear decline from his previous level of functioning.
- May withdraw from friends and families and hobbies and interests, exhibit peculiar behavior, and deterioration in work and school performance.
- Commonly triggered by a stressful event
- Characterized by presence of acute psychotic symptoms (e.g. hallucinations, delusions, incoherence, and catatonic behaviors).
- Prognosis worsens with each acute episode.
- This is at this point in which illness pattern is established, disability level may be stabilized, and late improvements may occur.
Types of Schizophrenia
Schizophrenia is classified into five subtypes:
- Characterized by persecutory or grandiose delusional thought content and delusional jealousy.
- Stressmay worsen patient symptoms.
- Experience frequent auditory hallucinations but lack symptoms of other subtypes like incoherence, loose associations, and affect problems.
- Tend to be less severely disabled than other schizophrenics and are more responsive to treatments.
- Marked by incoherent, disorganized speech and behaviors, and blunted or inappropriate affect.
- Usually includes extreme social impairment.
- Starts early and insidiously, with no significant remissions.
“Knowing that you’re crazy doesn’t make the crazy things stop happening.”
–Mark Vonnegut, The Eden Express: A Memoir of Insanity
- A rare disease form characterized by fixed stupor or positions for long periods and periodically yielding to brief spurts of extreme excitement.
- Increased potential for destructive, violent behaviors when agitated.
- They remain mute and have refusal to move about or tend to personal needs.
- Presence of schizophrenic symptoms such as delusions and hallucinations in patients who does not fall to the category of the other subtypes.
- Muted form of the disease that stops short of recovery.
- No prominent psychotic symptoms.
- Has history of acute schizophrenic episodes and persistence of negative symptoms.
The basis for diagnosing schizophrenia is formed by mental status examination, psychiatry history, and careful clinical observation.
- Diagnostic test results. No definitive diagnostic tool for schizophrenia but certain tests like CT scan and MRI may be ordered to rule out disorders than can cause psychosis (e.g. vitamin deficiencies and enlarged ventricles).
- Ventricular-brain ratio may find elevated VBR in schizophrenic patients. Brain scans reveal functional cerebral asymmetries in a reverse pattern.
Here’s how schizophrenia is medically managed:
- Drug Therapy. Schizophrenia is mainly treated by antipsychotics (neuroleptic) drugs.
- These prevent relapse of acute symptoms.
- Psychotic symptoms must be present 12 to 24 months before patients receive their first medical treatment.
- Examples of these drugs include the typical or conventional typical antipsychotic chlorpromazine (Thorazine) and the atypical
- Electroconvulsive Therapy. Rarely used but is for patients with acute schizophrenia and those who can’t tolerate or don’t respond to medication. It is effective in reducing depressive and catatonic symptoms of schizophrenia.
- Other treatments include compliance promotion programs, psychosocial treatment and rehabilitation, vocational counseling, supportive psychotherapy, and appropriate use of community resources.
Here are the nursing responsibilities for taking care of patients with schizophrenia:
- Recognize schizophrenia. Note characteristic signs and symptoms of schizophrenia (e.g., speech abnormalities, thought distortions, poor social interactions).
- Establish trust and rapport. Don’t tease or joke with patients. Expect that patient is going to put you through rigorous testing periods. Introduce yourself and explain your purpose.
- Maximize level of functioning. Assess patient’s ability to carry out activities of daily living (ADLs).
- Assess positive symptoms. Assess for command hallucinations; explore answers. Assess if the client has fragmented, poorly organized, well-organized, systematized, or extensive system of beliefs that are not supported by reality. Assess for pervasive suspiciousness about everyone and their actions (e.g., vigilant, blames others for consequences of own behavior, argumentative, threatening).
- Assess negative symptoms. Assess for the negative symptoms of schizophrenia (as mentioned above).
- Assess medical history. Assess if the client is on medications, what these are, and adherence to therapy.
- Assess support system. Determine whether the family is well informed about the disease. Does the family understand the need for medication adherence?