Intervention
Safety for both the client and the nurse is the priority when
providing care for the client with schizophrenia. The client may be paranoid
and suspicious of the nurse and the environment and may feel threatened and
intimidated. Although the client’s behavior may be threatening to the nurse,
the client also is feeling unsafe and may believe his or her well-being to be
in jeopardy. Therefore, the nurse must approach the client in a nonthreatening
manner. Making demands or being authoritative only increases the client’s
fears. Giving the client ample personal space usually enhances his or her sense
of security.
A fearful or agitated client has the potential to harm self or
others. The nurse must observe for signs of building agitation or escalating
behavior such as increased intensity of pacing, loud talking or yelling, and
hitting or kicking objects. The nurse must institute interventions to protect
the client, nurse, and others in the environment. This may involve
administer-ing medication; moving the client to a quiet, less stimulating
environment; and, in extreme situations, temporarily using seclusion or
restraints.
Establishing trust between the client and the nurse also helps to
allay the fears of a frightened client. Initially, the client may tolerate only
5 or 10 minutes of contact at one time. Establishing a therapeutic relationship
takes time, and the nurse must be patient. The nurse provides expla-nations
that are clear, direct, and easy to understand. Body language should include
eye contact but not staring, a relaxed body posture, and facial expressions
that convey genuine interest and concern. Telling the client one’s nameand calling the client by name are helpful in
establishing trust as well as reality orientation.
The nurse must assess carefully the client’s response to the use of
touch. Sometimes gentle touch conveys caring and concern. At other times, the
client may misinterpret the nurse’s touch as threatening and therefore
undesirable. As the nurse sits near the client, does he or she move or look
away? Is the client frightened or wary of the nurse’s presence? If so, that
client may not be reassured by touch but frightened or threatened by it.
Communicating with clients experiencing psychotic symptoms can be
difficult and frustrating. The nurse tries to understand and make sense of what
the client is saying, but this can be difficult if the client is hallucinating,
with-drawn from reality, or relatively mute. The nurse must maintain nonverbal
communication with the client, espe-cially when verbal communication is not
very successful. This involves spending time with the client, perhaps through
fairly lengthy periods of silence. The presence of the nurse is a contact with
reality for the client and also can demonstrate the nurse’s genuine interest
and caring to the client. Calling the client by name, making references to the
day and time, and commenting on the environment are all helpful ways to
continue to make contact with a cli-ent who is having problems with reality
orientation and verbal communication. Clients who are left alone for long
periods become more deeply involved in their psychosis, so frequent contact and
time spent with a client are impor-tant even if the nurse is unsure that the
client is aware of the nurse’s presence.
Active listening is an important skill for the nurse try-ing to
communicate with a client whose verbalizations are disorganized or nonsensical.
Rather than dismissing what the client says because it is not clear, the nurse
must make efforts to determine the meaning the client is trying to convey.
Listening for themes or recurrent statements, ask-ing clarifying questions, and
exploring the meaning of the client’s statements are all useful techniques to
increase understanding.
The nurse must let the client know when his or her meaning is not
clear. It is never useful to pretend to under-stand or just to agree or go
along with what the client is saying: this is dishonest and violates trust
between client and nurse.
Nurse: “How are you feeling today?” (using a broad opening
statement)
Client: “Invisible.”
Nurse: “Can you explain that to me?” (seek-ing
clarification)
Client: “Oh, it doesn’t matter.”
Nurse: “I’m interested in how you feel; I’m just not sure I understand.” (offering self/seeking
clarification)
Client: “It doesn’t mean much.”
Nurse: “Let me see if I can understand. Do you feel like you’re being ignored, that no one is really
listening?” (verbal-izing the implied)
The client experiencing delusions utterly believes them and cannot
be convinced they are false or untrue. Such delusions powerfully influence the
client’s behavior. For example, if the client’s delusion is that he or she is
being poisoned, he or she will be suspicious, mistrustful, and probably
resistant to providing information and taking medications.
The nurse must avoid openly confronting the delusion or arguing
with the client about it. The nurse also must avoid reinforcing the delusional
belief by “playing along” with what the client says. It is the nurse’s
responsibility to present and maintain reality by making simple statements such
as
“I have seen no
evidence of that.” (presenting reality)
or
“It doesn’t
seem that way to me.” (casting doubt)
As antipsychotic medications begin to have a therapeutic effect, it
will be possible for the nurse to discuss the delu-sional ideas with the client
and identify ways in which the delusions interfere with the client’s daily
life.
The nurse also can help the client minimize the effects of
delusional thinking. Distraction techniques, such as lis-tening to music,
watching television, writing, or talking to friends, are useful. Direct action,
such as engaging in posi-tive self-talk and positive thinking and ignoring the
delu-sional thoughts, may be beneficial as well.
Intervening when the client experiences hallucinations requires the
nurse to focus on what is real and to help shift the client’s response toward
reality. Initially, the nurse must determine what the client is
experiencing—that is, what the voices are saying or what the client is seeing.
Doing so increases the nurse’s understanding of the nature of the client’s
feelings and behavior. In command hallucinations, the client hears voices
directing him or her to do some-thing, often to hurt self or someone else. For
this reason, the nurse must elicit a description of the content of the
hallucination so that health-care personnel can take pre-cautions to protect
the client and others as necessary. The nurse might say,
“I don’t hear
any voices; what are you hearing?” (presenting reality/seeking
clarification)
This also can help the nurse understand how to relieve the client’s
fears or paranoia.
For example, the client might be seeing ghosts or monster-like
images, and the nurse could respond,
“I don’t see
anything, but you must be frightened. You are safe here in the hospital.” (presenting reality/translating into feelings)
This acknowledges the client’s fear but reassures the client that
no harm will come to him or her.
Clients do not always report or identify hallucinations. At times,
the nurse must infer from the client’s behavior that hallucinations are
occurring. Examples of behavior that indicate hallucinations include
alternately listening and then talking when no one else is present, laughing
inappropriately for no observable reason, and mumbling or mouthing words with
no audible sound.
A helpful strategy for intervening with hallucinations is to engage
the client in a reality-based activity such as play-ing cards, participating in
occupational therapy, or listen-ing to music. It is difficult for the client to
pay attention to hallucinations and reality-based activity at the same time, so
this technique of distracting the client is often useful.
It also may be useful to work with the client to identify certain
situations or a particular frame of mind that may precede or trigger auditory
hallucinations. Intensity of hallucinations often is related to anxiety levels;
therefore, monitoring and intervening to lower a client’s anxiety may decrease
the intensity of hallucinations. Clients who rec-ognize that certain moods or
patterns of thinking precede the onset of voices may eventually be able to
manage or control the hallucinations by learning to manage or avoid particular
states of mind. This may involve learning to relax when voices occur, engaging
in diversions, correct-ing negative self-talk, and seeking out or avoiding
social interaction.
Teaching the client to talk back to the voices forcefully also may
help him or her manage auditory hallucinations. The client should do this in a
relatively private place rather than in public. There is an international
self-help move-ment of “voice-hearer groups,” developed to assist people to
manage auditory hallucinations. One group devised the strategy of carrying a
cell phone (fake or real) to cope with voices when in public places. With cell
phones, members can carry on conversations with their voices in the street— and
tell them to shut up—while avoiding ridicule by look-ing like a normal part of
the street scene. Being able to verbalize resistance can help the client feel
empowered and capable of dealing with the hallucinations (Farhall, Greenwood,
& Jackson, 2007).
Clients can also benefit from openly discussing the voice-hearing
experience with designated others. Talking with other clients who have similar
experiences with audi-tory hallucinations has proved helpful (McLeod, Morris,
Birchwood, & Dovey, 2007), so the client doesn’t feel so isolated and alone
with the hallucination experience. Some clients wanted to discuss the
hallucinations with their community mental health nurse (Coffey & Hewitt,
2008) to better understand the hallucinations and what they might mean.
Clients with schizophrenia often experience a loss of ego
boundaries, which poses difficulties for themselves and others in their
environment and community. Potentially bizarre or strange behaviors include
touching others with-out warning or invitation, intruding into others’ living
spaces, talking to or caressing inanimate objects, and engaging in such socially
inappropriate behaviors as undressing, masturbating, or urinating in public.
Clients may approach others and make provocative, insulting, or sexual
statements. The nurse must consider the needs of others as well as the needs of
clients in these situations.
Protecting the client is a primary nursing responsibility and
includes protecting the client from retaliation by oth-ers who experience the
client’s intrusions and socially unacceptable behavior. Redirecting the client
away from situations or others can interrupt the undesirable behavior and keep
the client from further intrusive behaviors. The nurse also must try to protect
the client’s right to privacy and dignity. Taking the client to his or her room
or to a quiet area with less stimulation and fewer people often helps. Engaging
the client in appropriate activities also is indicated. For example, if the
client is undressing in front of others, the nurse might say,
“Let’s go to
your room and you can put your clothes back on.” (encouraging
collaboration/ redirecting to
appropriate activity)
If the client is making verbal statements to others, the nurse
might ask the client to go for a walk or move to another area to listen to
music. The nurse should deal with socially inappropriate behavior nonjudg-mentally
and matter-of-factly. This means making factual statements with no overtones of
scolding and not talking to the client as if he or she were a naughty child.
Some behaviors may be so offensive or threatening that others
respond by yelling at, ridiculing, or even taking aggressive action against the
client. Although providing physical protection for the client is the nurse’s
first consid-eration, helping others affected by the client’s behavior also is
important. Usually, the nurse can offer simple and factual statements to others
that do not violate the client’s confi-dentiality. The nurse might make
statements, such as
“You didn’t do
anything to provoke that behavior. Sometimes people’s illnesses cause them to
act in strange and uncomfortable ways. It is im-portant not to laugh at
behaviors that are part of someone’s illness.” (presenting
reality/giving information)
The nurse reassures the client’s family that these behav-iors are
part of the client’s illness and not personally directed at them. Such
situations present an opportunityto educate family members about schizophrenia
and to help allay their feelings of guilt, shame, or responsibility.
Reintegrating the client into the treatment milieu as soon as
possible is essential. The client should not feel shunned or punished for
inappropriate behavior. Health-care personnel should introduce limited
stimulation grad-ually. For example, when the client is comfortable and
demonstrating appropriate behavior with the nurse, one or two other people can
be engaged in a somewhat structured activity with the client. The client’s
involvement is gradu-ally increased to small groups and then to larger, less
struc-tured groups as he or she can tolerate the increased level of stimulation
without decompensating (regressing to previ-ous, less effective coping
behaviors).
Coping with schizophrenia is a major adjustment for both the
clients and their families. Understanding the illness, the need for continuing
medication and follow-up, and the uncertainty of the prognosis or recovery are
key issues. Clients and families need help to cope with the emotional upheaval
that schizophrenia causes. See Client/Family Education for Schizophrenia for
education points.
Identifying and managing one’s own health needs are primary
concerns for everyone, but this is a particular challenge for clients with
schizophrenia because their health needs can be complex and their ability to
manage them may be impaired. The nurse helps the client to man-age his or her
illness and health needs as independently as possible. This can be accomplished
only through educa-tion and ongoing support.
Teaching the client and family members to prevent or manage relapse
is an essential part of a comprehensive plan of care. This includes providing
facts about schizo-phrenia, identifying the early signs of relapse, and
teaching health practices to promote physical and psychological well-being.
Early identification of these relapse signs has been found to reduce the
frequency of relapse; when relapse cannot be prevented, early identifi-cation
provides the foundation for interventions to man-age the relapse. For example,
if the nurse finds that the client is fatigued or lacks adequate sleep or
proper nutri-tion, interventions to promote rest and nutrition may pre-vent a
relapse or minimize its intensity and duration.
The nurse can use the list of relapse risk factors in sev-eral
ways. He or she can include these risk factors in dis-charge teaching before
the client leaves the inpatient set-ting so that the client and family know
what to watch for and when to seek assistance. The nurse also can use the list
when assessing the client in an outpatient or clinic set-ting or when working
with clients in a community support program. The nurse also can provide
teaching to ancillary personnel who may work with the client so they know when
to contact a mental health professional. Taking med-ications as prescribed,
keeping regular follow-up appoint-ments, and avoiding alcohol and other drugs
have been associated with fewer and shorter hospital stays. In addi-tion,
clients who can identify and avoid stressful situations are less likely to
suffer frequent relapses. Using a list of relapse risk factors is one way to
assess the client’s progress in the community.
Families experience a wide variety of responses to the illness of
their loved one. Some family members might be ashamed or embarrassed or
frightened of the client’s strange or threatening behaviors. They worry about a
relapse. They may feel guilty for having these feelings or fear for their own
mental health or well-being. If the client experiences repeated and profound
problems with schizo-phrenia, the family members may become emotionally
exhausted or even alienated from the client, feeling they can no longer deal
with the situation. Family members need ongoing support and education,
including reassur-ance that they are not the cause of schizophrenia.
Partici-pating in organizations such as the Alliance for the Mentally Ill may
help families with their ongoing needs.
Teaching Self-Care and Proper Nutrition. Because of apathy or lack of energy over the
course of the illness, poor per-sonal hygiene can be a problem for clients who
are experi-encing psychotic symptoms as well as for all clients with
schizophrenia. When the client is psychotic, he or she may pay little attention
to hygiene or may be unable to sustain the attention or concentration required
to complete grooming tasks. The nurse may need to direct the client through the
necessary steps for bathing, shampooing, dressing, and so forth. The nurse
gives directions in short, clear statements to enhance the client’s ability to
complete the tasks. The nurse allows ample time for grooming and performing
hygiene and does not attempt to rush or hurry the client. In this way, the
nurse encourages the client to become more independent as soon as possible—that
is, when he or she is better oriented to reality and better able to sustain the
concentration and attention needed for these tasks.
If the client has deficits in hygiene and grooming result-ing from
apathy or lack of energy for tasks, the nurse may vary the approach used to
promote the client’s indepen-dence in these areas. The client is most likely to
perform tasks of hygiene and grooming if they become a part of his or her daily
routine. The client who has an established structure that incorporates his or
her preferences has a greater chance for success than the client who waits to
decide about hygiene tasks or performs them randomly. For example, the client
may prefer to shower and sham-poo on Monday, Wednesday, and Friday upon getting
up in the morning. This nurse can assist the client to incorpo-rate this plan into
the client’s daily routine, which leads to it becoming a habit. The client thus
avoids making daily decisions about whether or not to shower or whether he or
she feels like showering on a particular day.
Adequate nutrition and fluids are essential to the cli-ent’s
physical and emotional well-being. Careful assess-ment of the client’s eating
patterns and preferences allows the nurse to determine whether the client needs
assistance in these areas. As with any type of self-care deficit, the nurse
provides assistance as long as needed and then grad-ually promotes the client’s
independence as soon as the client is capable.
When the client is in the community, factors other than the
client’s illness may contribute to inadequate nutritional intake. Examples include
lack of money to buy food, lack of knowledge about a nutritious diet,
inadequate transpor-tation, or limited abilities to prepare food. A thorough
assessment of the client’s functional abilities for commu-nity living helps the
nurse to plan appropriate interven-tions. See the section “Community-Based
Care.”
Teaching Social Skills. Clients may be isolated from
oth-ers for a variety of reasons. The bizarre behavior or state-ments of the
client who is delusional or hallucinating may frighten or embarrass family or
community members. Cli-ents who are suspicious or mistrustful may avoid contact
with others. Other times, clients may lack the social or conversation skills
they need to make and maintain rela-tionships with others. Also, a stigma
remains attached to mental illness, particularly for clients for whom
medica-tion fails to relieve the positive signs of the illness.
The nurse can help the client develop social skills through
education, role modeling, and practice. The client may not discriminate between
the topics suitable for shar-ing with the nurse and those suitable for using to
initiate a conversation on a bus. The nurse can help the client learn neutral
social topics appropriate to any conversation, such as the weather or local
events. The client also can benefit from learning that he or she should share
certain details of his or her illness, such as the content of delusions or
hal-lucinations, only with a health-care provider.
Modeling and practicing social skills with the client can help him or
her experience greater success in social inter-actions. Specific skills such as
eye contact, attentive listen-ing, and taking turns talking can increase the
client’s abilities and confidence in socializing.
Medication Management. Maintaining the medication regimen is vital to a
successful outcome for clients with schizophrenia. Failing to take medications
as prescribed is one of the most frequent reasons for recurrence of psychotic
symptoms and hospital admission (Kane & Marder, 2005). Clients who respond
well to and maintain an antipsychotic medication regimen may lead relatively
normal lives with only an occasional relapse. Those who do not respond well to
antipsychotic agents may face a lifetime of dealing with delusional ideas and
hallucina-tions, negative signs, and marked impairment. Many cli-ents find
themselves somewhere between these two extremes. See Client Education for
Medication Manage-ment: Antipsychotics.
There are many reasons why clients may not maintain the medication
regimen. The nurse must determine the barriers to compliance for each client.
Sometimes clients intend to take their medications as prescribed but have
difficulty remembering when and if they did so. They may find it difficult to
adhere to a routine schedule for medica-tions. Several methods are available to
help clients remem-ber when to take medications. One is using a pillbox with
compartments for days of the week and times of the day.
After the box has been filled, perhaps with assistance from the
nurse or case manager, the client often has no more difficulties. It is also
helpful to make a chart of all admin-istration times so that the client can
cross off each time he or she has taken the medications.
Clients may have practical barriers to medication com-pliance, such
as inadequate funds to obtain expensive medications, lack of transportation or
knowledge about how to obtain refills for prescriptions, or inability to plan
ahead to get new prescriptions before current supplies run out. Clients usually
can overcome all these obstacles once they have been identified.
Sometimes clients decide to decrease or discontinue their
medications because of uncomfortable or embarrass-ing side effects. Unwanted
side effects are frequently reported as the reason clients stop taking medications
(Kane & Marder, 2005). Interventions, such as eating a proper diet and
drinking enough fluids, using a stool soft-ener to avoid constipation, sucking
on hard candy to mini-mize dry mouth, or using sunscreen to avoid sunburn, can
help to control some of these uncomfortable side effects (see Table 13.2). Some
side effects, such as dry mouth and blurred vision, improve with time or with
lower doses of medication. Medication may be warranted to combat com-mon
neurologic side effects such as EPS or akathisia.
Some side effects, such as those affecting sexual func-tioning, are
embarrassing for the client to report, and the client may confirm these side
effects only if the nurse directly inquires about them. This may require a call
to the client’s physician or primary provider to obtain a prescrip-tion for a
different type of antipsychotic.
Sometimes a client discontinues medications because he or she
dislikes taking them or believes he or she does not need them. The client may
have been willing to take the medica-tions when experiencing psychotic symptoms
but may believe that medication is unnecessary when he or she feels well. By
refusing to take the medications, the client may be denying the existence or
severity of schizophrenia. These issues of noncompliance are much more
difficult to resolve. The nurse can teach the client about schizophrenia, the
nature of chronic illness, and the importance of medications in managing
symp-toms and preventing recurrence. For example, the nurse could say, “This
medication helps you think more clearly” or “Tak-ing this medication will make
it less likely that you’ll hear troubling voices in your mind again.”
Even after education, some clients continue to refuse to take
medication; they may understand the connection between medication and
prevention of relapse only after experiencing a return of psychotic symptoms. A
few clients still do not understand the importance of consistently taking
medication and, even after numerous relapses, continue to experience psychosis
and hospital admission fairly frequently.
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