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)
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)
“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.