know

2. HISTORICAL BACKGROUND
 Ayurveda --- Morel described schizophrenia
as demence precoce;
Kahlbaum described schizophrenia as
catatonia
Hecker described schizophrenia as
hebephrenia
The scientific study of schizophrenia began with the
description of dementia precox by Emil Kraepelin
Dementia= deterioration; precox=earlyonset

3. EMIL KRAEPELIN
 In 1986 he differentiated the major psychiatric
illnesses into two clinical types
1. Dementia precox (delusions,
hallucinations, disturbances of affect, &
motor disturbances)
2. MDP

4. EUGEN BLEULER(1911)
 Renamed dementia precox as Schizophrenia (splitting of
mind) (1908) group of disorders rather than distinct entity so,
he used the word group of schizophrenias.
 Described characteristic symptoms as
 Fundamental symptoms(diagnostic of schizophrenia)
 Ambivalence,
 Autism,
 Affect disturbance,
 Association disturbance
 Accessory symptoms(secondary to Fundamental
symptoms)
 Delusions,
 Hallucinations,
 Negativism

5. KURT SCHNEIDER (1959)
 Described symptoms which though not specific of
schizophrenia, were of great importance in making
a clinical diagnosis
 Schneider First rank symptoms (SFRS)
A. Hallucinations
1. Audible thoughts(thought echo)
2. Voices heard arguing
3. Voices commenting on one’s action

6. B. Thought Alienation phenomena
4. Thought withdrawal
5. Thought insertion
6. Thought diffusion or broadcasting
C. Passivity phenomena
7. Made feeling or affect
8. Made impulses
9. Made volition or acts (robot like)
10. Somatic passivity
D. Delusional perception
11. Delusional perception

7. SCHIZOPHRENIA
 The word schizophrenia is derived from Greek word
Schizo=split; Phrenic=mind
 Term was coined by Swiss psychiatrist Eugen
Bleuler
 Major mental disorder characterized by Group of
disturbances which sometimes occur in different
combinations and intensities. Hence it is
heterogeneous in nature

8. DEFINITION OF SCHIZOPHRENIA
“Schizophrenia is defined as functional
psychotic condition characterized by disturbances
in thinking, emotion, volition and perception in
presence of clear consciousness, which usually
leads to social withdrawal”.

9. EPIDEMIOLOGY
 Most common of the psychotic disorders
 50% 0f beds in psychiatric hospitals are occupied
 2/3rds of the cases are in the 15-30 years age group
 Common in lower social classes
 Acc to world health report 2001, 24 million people worldwide
suffer from schizophrenia
 Prevalence rate 0.5-1%, Prevalent in all cultures races and in
all parts of the world
 Incidence rate 0.5 per 1000
 Onset is later in women and often runs benign course, as
compared to men

10. ETIOLOGY
 Unknown
 However several theories have been propounded
I. BIOLOGICAL THEORIES
1. Genetic hypothesis
 8-10% of first degree relatives 3% of second degree
relatives and 2% of third degree relatives of patients with
schizophrenia can have schizophrenia as compared with
0.5-1% prevalence rate in the general population

11. POPULATION INCIDENCE(%)
General population 1.0
Sibling of schizophrenic patient 8.0
Child with one schizophrenic parent 12.0
Child with two schizophrenic parent 40.0
Dizygotic twin of schizophrenic pt 14.0
Monozygotic twin of schizophrenic pt 46.0
2. Biochemical theories
 Functional increase in dopamine level at post synaptic
receptor
 Other NT’s like 5-HT, GABA, Acetyl choline

12. 3. Brain imaging
 Cranial CT Scan, MRI Scan, and post mortem studies show
enlarged ventricles and mild cortical atrophy
 PET Scan shows hypofrontality and decreased glucose
utilization in the dominant temporal lobe
 Attempts are being made to localize symptoms of
schizophrenia to the various brain regions by PET
4. Other theories
Biological basis of schizophrenia
 Antipsychotics block the D2 receptor, cause improvement, and
relapse occurs on stopping antipsychotic medication

13.  Newer atypical antipsychotics are D2-5-HT2 antagonists
 Drugs like LSD, amphetamines, and mescaline, can cause
schizophrenia like symptoms in normal subjects.
 Organic mental disorders with schizophrenia like symptoms may be
seen in Huntington’s chorea, homocystinuria, acute intermittent
porphyria, Wilson’s disease and hemachromatosis.
 Soft neurological signs (SNS), minor physical anomalies, and
impaired eye tracking (smooth pursuit eye movements) are more
oftenly seen
 Viral and auto-immune factors have also been implicated by some,
while others (Wein berger) have suggested a neurodevelopmental
hypothesis for schizophrenia.

14. II.PSYCHOLOGICAL THEORIES
1. Stress –Diathesis model
 Stressful life events
 Stress-Vulnerability Hypothesis
 Increased expressed emotions(EE) of significant others in the
family can lead to early relapse
2. Family theories
 Schizophrenogenic mothers (Cold, overprotective, &
domineering, mothers retard the ego development of the
child, Dependency on mother, Anxious mother)
 Lack of real parents
 Parental marital schism or skew
 Double-bind theory
 Communication deviance
 Pseudo mutuality

15. 3. Information processing hypothesis
 Disturbance in attention, inability to maintain a set, and
inability to assimilate and integrate percepts are common
findings
 The patients may at first be overly attentive to stimuli but
later may reduce attention to stimuli
 Breakdown in the internal representation of mental events.
4. Psychoanalytical theories
 Acc to Freud regression to pre oral (and oral) stage of
psychosexual development, with the use of defense
mechanism of denial, projection and reaction formation
 Acc to Federn Loss of ego boundaries, with loss of touch
with reality.

16. III. SOCIO-CULTURAL THEORIES
 Although Prevalence is uniform across cultures, it was found
more common in low SES which is now explained due to a
downward social drift which is a result of having developed
schizophrenia rather than causing it
 Migration
 Disorganization

17. PHASES OF SCHIZOPHRENIA
 PRODROMAL PHASE:
 DSM-IV characterizes the prodromal phase as clear deterioration in
functioning before the active phase of the disturbance that is not due
to a disturbance in mood or to a psychoactive substance use
disorder and that involves at least two of the following s/s
 Social isolation/ withdrawal
 Impairment in role functioning
 Peculiar behavior
 Impairment in personal hygiene
 Blunted / inappropriate affect
 Digressive, vague, over elaborative, or circumstantial speech, or poverty of
speech, or poverty of content of speech
 Odd belief or magical thinking , influencing behavior and inconsistent with
cultural norms
 Unusual perceptual experience
 Marked lack of initiative , interests, or energy.

18.  ACTIVE PHASE:
 The patient exhibits frankly psychotic symptoms
 Delusions
 Hallucinations
 Loosening of associations
 Incoherence
 Catatonic behavior
 Particular stress may be present before the onset of this phase
 RESIDUAL PHASE:
 Follows active phase
 Two of the symptoms mentioned in prodromal phase persist
 Resembles prodromal phase except that disturbance in affect and
role functioning are more severe
 Hallucinations and delusions may persists

19. CLINICAL FEATURES
 Disturbance in
 Thought and verbal behaviour
 Perception
 Affect
 Motor behavior
 Relationship to the external world

20. THOUGHT AND SPEECH DISORDERS
 Autistic thinking (Von Domarus Law) – patient may consider two
things identical because they have identical predicates – lord
Hanuman was celibate, I am celibate too; I am lord Hanuman
 Loosening of associations ---- incoherence
 Thought block – thought withdrawal
 Neologism- word approximation or
par aphasias ---- stomach as food vessel
 Mutism
 Poverty of speech
 Poverty of ideation
 Echolalia
 Perseveration
 Verbigeration

21.  Delusions
 Primary Delusions (Autochthonous Delusions)
 Secondary Delusions
Types of Delusions
 Delusions of persecution
 Delusions of reference
 Delusions of grandeur
 Delusions of control
 Somatic Delusions
 Overinclusion
 Impaired abstraction
 Concreteness
 Perplexity
 Ambivalence

22.  Disorders of perception
 Hallucination
 Disorders of affect
 Apathy
 Emotional blunting
 Emotional shallowness
 Anhedonia
 Inappropriate Emotional response
 Lack of rapport (due to lack of Emotional contact)
 Disorders of motor behavior
 Decreases (inertia, stupor) or
 increase in psychomotor activities (excitement, aggression,
restlessness, agitation)
 Mannerisms
 Stereotypies
 Decreased self care
 Poor grooming
 Catatonic features

23.  Positive symptoms
 Delusions
 Hallucinations
 Bizarre behavior
 Aggression
 Agitation
 Suspiciousness
 Hostility
 Excitement
 Grandiosity
 Negative symptoms
 Affective flattening or blunting
 Attentional impairment
 Avolition-apathy (lack of initiative)
 Anhedonia
 Asociality
 Alogia
 Diminished emotional responsiveness
 Stereotyped thinking
 Psychomotor slowing, under activity
 Passivity and lack of initiative

24.  Other features
 Decreased functioning in work, social relations and self care
 Loss of ego boundaries
 Multiple somatic symptoms
 Insight will be absent
 Social judgment will poor
 No disturbance with consciousness, orientation, attention,
memory, intelligence.
 Variability in symptoms over time
 No underlying organic cause
 No prominent mood disorder of depressive or manic type
 Suicide

25.  DIAGNOSIS
 Acc to ICD-10 a minimum of 1 very clear symptom ( and usually 2
or more if less clear cut) belonging to any one of the groups of
referred to as (a) to (d) below, or symptoms from at least 2 of the
groups referred to as (e) to (h), should have been clearly present for
most of the time during a period of 1 month or more (DSM-IV-TR on
the other hand requires a minimum period of 6 months)
 If the duration of illness is less than 1 month then a diagnosis of
acute schizophrenia like psychotic disorder should be made.
a. Thought echo, Thought insertion, or withdrawal, or Thought
broadcasting;
b. Delusions of control, influence, or passivity, clearly referred to
body or limb movements or specific thoughts, actions, or
sensation; delusional perception;
c. Hallucinatory voices giving a running commentary on the
patient’s behavior or discussing the patient among themselves,
or other types of hallucinatory voices coming from some part of
the body;

26. d. Persistent delusions of other kinds that are culturally
inappropriate and completely impossible (e.g. being able to
control the weather, or being in communication with aliens from
another world);
e. persistent hallucinations occurring every day for weeks or
months or months
f. breaks or interpolations in the train of thought resulting in
incoherent or irrelevant speech or neologism;
g. Catatonic behavior
h. Negative symptoms
i. A significant and consistent change in the overall quality of
some aspects of personal behavior, (loss of interest,
aimlessness, idleness, a self absorbed attitude, and social
withdrawal)

27.  CLINICAL TYPES
F20-F29 Schizophrenia
F20- Schizophrenia
F20.0-Paranoid Schizophrenia
F20.1-Hebephrenic Schizophrenia
F20.2-Catatonic Schizophrenia
F20.3-Undifferentiated Schizophrenia
F20.4-Post- Schizophrenia depression
F20.5-Residual Schizophrenia
F20.6-Simple Schizophrenia

28.  F20.0-Paranoid Schizophrenia
 Delusions of Persecutory, Grandeur, control, infidelity (Jealousy)
 Hallucinations have Persecutory, Grandiose content
 Unfocussed anxiety
 Anger
 Argumentativeness
 Violence
 Doubts about gender identity
 Disturbances of affect, volition, speech, and motor behavior
 Personality deterioration is less
 Patients may be apprehensive (intelligent, fearful), evasive (escaping)
 Onset is insidious, occurs later in life, progressive and complete
recovery may not occur
 Frequent remissions and relapses are seen
 Slight impairment with functional capability

29. F20.1-Hebephrenic Schizophrenia
 In other classification this type is termed as Disorganized schizophrenia
 Marked thought disorder, incoherence and severe loosening of associations.
 Delusions and Hallucinations
 Emotional disturbances
Inappropriate affect
Blunted affect
Senseless giggling
 mannerisms
 Mirror gazing (for long periods of time)
 Poor self care and hygiene
 Impaired social and occupational ----social withdrawal
 ICD-10 recommends 2-3 months of continuous observation for confident
diagnosis
 Onset is insidious in early 2nd decade(15-25 years)
 Course is progressive and downhill
 Recovery never occurs, severe deterioration without remissions
 Has one of the worst prognosis among the subtypes of schizophrenia

30.  F20.2-Catatonic Schizophrenia
 Catatonia – marked disturbance in the motor behavior cata-
disturbed; tonic-tone;
 Onset is acute in late 2nd and early 3rd decade
 Course is episodic and recovery from episodes is complete,
residual symptoms may present after 2nd or 3rd episode
 3 clinical forms
 Excited Catatonia
 in psychomotor activity (restlessness, agitation,
excitement, aggressiveness, violent behavior)------furor
 in speech production, pressure of speech, loosening of association,
incoherence
 Stimuli for excitement is internal not the environmental (e.g. thoughts and
impulses) so excitement is not goal directed
 Some times very rarely excitement can become Severe -----rigidity,
hyperthermia, and dehydration leading to death then it is known as acute lethal
catatonia or pernicious catatonia

31.  Stuporous (or retarded) Catatonia--
 psychomotor function
 Mutism
 Rigidity
 Negativism
 Posturing
 Stupor
 Echolalia
 Echopraxia
 Waxy flexibility
 Ambitendency
 Other symptoms-----mannerisms, stereotypies, automatic obedience,
verbigeration
 Delusions and hallucinations may present but not prominent
 Catatonia alternating between excitement and stupor
 Very common feature of both excited and stuporous catatonia are alternatingly
present

32. F20.3-Undifferentiated Schizophrenia
 Very common type
 Diagnosed when features of no subtype are fully present or features of
more than one subtype are exhibited.
 F20.4-Post- Schizophrenia depression
 Some schizophrenics develop depressive features within 12
months of an acute episode associated with risk of suicide
 Can occur due to side effect of antipsychotics, regaining
insight after recovery or as just part of an schizophrenia
 It is important to distinguish the depressive features from
negative symptoms and EPS of antipsychotics

33. F20.5-Residual Schizophrenia
 Is similar to latent schizophrenia and symptoms are same
as prodromal symptoms of schizophrenia
 Diagnosed after at least one episode has occurred
 According to ICD-10 (CDDG) it is characterized by the following features in
addition to the general guidelines of schizophrenia
 Prominent negative schizophrenic symptoms
 Past h/o one clear cut psychotic episode
 A period of 1 year during which the intensity and frequency of florid
symptoms such as delusions and hallucinations have been minimal and
the negative symptoms have been present
 Absence of dementia or other organic brain disease and of chronic
depression or institutionalism for negative symptoms

34. F20.6-Simple Schizophrenia
 Most difficult to diagnose
 Early onset (2nd decade)
 Insidious and progressive course
 Negative symptoms are present
 Vague hypochondriacal features
 Drift down the social ladder
 Wandering aimlessly
 Delusions and hallucinations are usually absent, if present they
are short lived
 Prognosis -----very poor

35.  OTHER SUBTYPES
 Pseudoneurotic schizophrenia
 Described by Hoch and Polatin
 Initially presented with neurotic symptoms which last for 1 year and show
poor response to treatment
 3 classical symptoms are
 Pan-anxiety
 Pan-neurosis
 Pan-sexuality
 Now this subtype is subsumed under borderline personality disorder
 Schizophreniform disorder
 This is diagnostic category in DSM-IV-TR with features of schizophrenia.
Only difference is duration is less than 6 months and prognosis is better
than schizophrenia
 This term was introduced by Langfeldt (1961)
 Similar condition in ICD-10 is called acute schizophrenia like psychotic
disorder

36.  Oneiroid(dream) schizophrenia
 Described by Mayer-Gross,
 Acute onset
 Clouding of consciousness, disorientation
 Dream like states
 Perceptual disturbances with rapid shifting
 Episode- brief
 Van Gogh Syndrome
 Dramatic self –mutilation in schizophrenia is also called as Van Gogh
syndrome
 Van Gogh was a famous painter who cut his ear during active phase of illness

37.  Late Paraphrenia
 Described by Sir Martin Roth
 Occurs late in life (6th decade)
 Common in unmarried or widowed women
 Delusions of persecution as being raped or strangers entering their room
 Hallucinations of all kinds are present
 ≈25-40% of patients have some defect of sight or hearing
 Presently kept under paranoid schizophrenia, late onset
 Pfropf schizophrenia
 Schizophrenia occurring in the presence of MR
 Behavioral disturbances are more prominent than thought disorder

38.  Type I and Type II Schizophrenia
 T. J. Crow has divided schizophrenia in to two subtypes as
 Type I and Type II Schizophrenia
 Very few patients have a pure TYPE I or TYPE II syndrome
 Admixtures are common

39. DIFFERENTIAL DIAGNOSIS
 Exclude organic psychosis
 Ex: complex partial seizures, drug (Amphetamine)
induced psychosis, metabolic disturbances or cerebral
neoplasm
 Rule out a possibility of mood disorder or
schizoaffective disorder
 Exclude other non organic psychosis like delusional
disorders, or acute and transient psychotic
disorders (ATPD)

40. PROGNOSIS
 Acute onset
 Onset after 35 years
 Presence of precipitating
factors
 Good premorbid adjustment
 Catatonic subtype (paranoid
intermediate prognosis)
 Short duration (< 6 months)
 Presence of depression
 Predominance of positive
symptoms
 Family h/o mood disorder
 Insidious onset
 < 20 yrs of age
 Absence of stressor
 Poor premorbid adjustment
 Disorganized, simple,
undifferentiated or chronic
catatonic subtypes
 Chronic course (>2 yrs )
 Absence of depression
 Predominance of negative
symptoms
 Family h/o schizophrenia
GOOD PROGNOSTIC
FACTORS
POOR PROGNOSTIC
FACTORS

41. PROGNOSIS
 First episode
 Pyknic (fat) physique
 Female sex
 Good social support
 Presence of confusion,
perplexity, or
disorientation in the acute
phase
 Proper treatment or good
response treatment
 OPD treatment
 Normal CT Scan
 Past h/o schizophrenia
 Asthenic physique
 Male sex
 Poor social support or
unmarried
 Flat or blunted affect
 Absence of proper
treatment or poor
response
 Institutionalization
 Evidence of ventricular
enlargement on CT Scan
GOOD PROGNOSTIC
FACTORS
POOR PROGNOSTIC
FACTORS

42. COURSE AND OUTCOME
 Progressive downhill course
 More hospitalization
 According to the study made by Luc Ciompi 1980
which included 5661 cases and which extended for
36.9 years the outcome was
 Complete remission (27%)
 Remission with minor residual deficit (22%)
 Intermediate out come (24%)
 Severe disability (18%)
 Unstable or uncertain outcome (9%)
 ALMOST 50% PATIENTS SHOWED COMPLETE OR NEAR
COMPLETE RECOVERY
 18% SHOWED SEVERE DISABILITY
 9% NEEDING HOSPITALIZATION

43. COURSE AND OUTCOME
 A study of factors associated with course and
outcome of schizophrenia (SOFACOS) conducted
by ICMR (Indian Council of Medical Research ) at 3
centers in India (Vellore, Madras, and Luknow)
 386 patients were followed up for 5 years (1981 to1986)
the out come was
 Very favorable outcome (27%)
 Favorable out come (40%)
 Intermediate out come (31%)
 Unfavorable outcome (2%)
 So 2/3rds (67%) of the patients had a favourable out
come as compared to 50% in Luc Ciompi ‘s study

44.  In ICD-10 the course of schizophrenia is specified under
the categories of :
i. Continuous
ii. Episodic with progressive deficit
iii. Episodic with stable deficit
iv. Episodic remittent
v. Incomplete remission
vi. Complete remission
if the period of observation is less than 1 year the course is not
specified
 Longer the duration of untreated psychosis (DUP)
worse is the out come
 Cause for increased mortality of patients in
schizophrenia is suicide
 Life time risk of suicide in schizophrenia is 5-10 times
higher as compared to normal population

45. MANAGEMENT
 SOMATIC TREATMENT
 PHARMACOLOGICAL TREATMENT
 ECT
 OTHERS
 PSYCHOSOCIAL TREATMENT AND
REHABILITATION
 NURSING MANAGEMENT

46. PHARMACOLOGICAL TREATMENT
 First drug used was reserpine (Rauwolfia
serpentina extract) by Sen and Bose in India in
1931----no longer used
 Antipsychotics were formally discovered by Delay
and Deniker in 1952
 Atypical antipsychotics are commonly used than
typical antipsychotics

47. ATYPICAL ANTIPSYCHOTICS:
 Are more useful in negative symptoms (chronic
schizophrenia)
 Respseridone 2-10 mg/day PO
 Olanzapine 10-20 mg/ day PO
 Quetiapine 150-750mg/day PO
 Aripiprazole
 Ziprasidone 20-80 mg/day PO
 Clozapine 50-450mg day PO
effective drug in 30% of patients who had no
beneficial response to traditional (typical and atypical
antipsychoticsc) but leads to agranulocytosis ans
seizures so used with caution

48. TYPICAL ANTIPSYCHOTICS:
 Trifluoperazine 15-60 mg/day PO
 Haloperidol 5-100 mg/day PO
 Chlorpromazine 300-1500 mg/day PO
 Drug treatment is usually given in OPD setting
because
 Few number of psychiatric beds
 Families are willing to take care
 Majority pts do not need hospitalization

49.  Hospitalization is indicated when
 Pt neglects food & water
 Pt is Danger to self and other
 Poor drug compliance
 Neglect of self care
 Lack of social support
 Antipsychotics act by blocking D2 receptors in the
mesolimbic system, other receptors like 5-HT, muscarinic
receptors and GABA are also important
 Atypical antipsychotic are also called as SDAs have
action on both dopamine and 5-HT

50. IN ACUTE EXCITEMENT
 Haloperidol 5 mg IV / IM with or without diazepam
or 50 mg promethazine
 Chlorpromazine IM abscess
IV hypotension

51. MAINTENANCE TREATMENT WITH ANTIPSYCHOTICS
TO PREVENT RELAPSE
 Treatment should be continued for 6 months to 1 year
for 1st episode
 For 1-2yrs for the subsequent episodes
 Indefinite period for repeated episodes or persistent
symptoms

52. DEPOT ANTIPSYCHOTIC PREPARATIONS
WITH LONG DURATION OF ACTION
AVAILABLE IN INDIA
 Fluphenazine decanoate, 25-50mg IM every 2-3
weeks
 Penfluridol, 20-60mg oral every week
 Flupenthixole decanoate, 20-40mg IM every
2weeks
 Haloperidol decanoate, 100-250mg IM every 4 wks
 Zuclopenthixole decanoate, 200-400mg IM, every
2-4 weeks

53. ANTIPARKINSONIAN MEDICATIONS
 Needed when pt is receiving older typical
antipsychotics (haloperidol)
 Trihexiphenidyl (THP) 6 mg / day
 Orphenadrine 150 mg / day
 Procyclidine 7.5-15 mg / day

54. ECT
 Not a 1o indication for ECT
 Indications for ECT in schizophrenia are
 Catatonic stupor
 Uncontrolled Catatonic excitement
 Acute exacerbation not controlled by drugs
 Severe side effects with drugs
 8-12 ECTs are needed (up to 18) 3 times a week

55. MISCELLANEOUS TREATMENTS
 Psychosurgery
 rarely used
 when used limbic leucotomy (small subcaudate lesion with
cingulate lesion) in severe and prominent depression, anxiety or
obsessional symptoms
 Antipsychotics are far better
 Many other methods used in past
 Megavitamine therapy
 Dialysis
 Malaria therapy
 High dose propranolol
 High dose insulin (insulin coma therapy)

56. PSYCHOSOCIAL TREATMENT
 Important component of comprehensive
management: it has following steps
 Psycho education
 Group psychotherapy
 Family therapy
 Milieu therapy
 Individual psychotherapy
 Psychosocial rehabilitation

57. NURSING MANAGEMENT
 General principles of management of
schizophrenic pts
 I
 Chronic illness which needs long term treatment
 Total cure may not occur in most of the cases
 Aim is ---good improvement with regular and
appropriate treatment
 In times of stress the pt may get relapse in spite of
regular treatment

58.  Pts need to
 Increase in their own self esteem
 Be assisted to live with the real world
 Environment where he gets a change to use his own initiative and
judgment
 Have human contacts
 Find a nurse who is having stable and consistent nature and who is
having patience
 Accept him as he is. Accept the pt whole heartedly
 Nurse should not expect the impossible from the pt.
 Assign small responsibilities
 Engage and support
 Supervise him
 Appreciate for every achievements
 Do not -------- Ignore
Criticize
Exert social behavior
Refrain from over involvement

59.  II
 Careful assessment--------diagnosis----------formulating a
treatment plan
 Nsg management depends on
 Defining reality
 Handling pt control
 Strengthening the patient’s self image and Strengthening the
IPR
 Giving emotional support

60.  Nsg diagnosis: I
Alteration in thought process r/t inability to trust,
panic anxiety, evidenced by delusional thinking, inability
to concentrate, impaired volition, extreme suspiciousness
of others
 Objective: pt will eliminate patterns of delusional thinking and
demonstrate trust in others

61.  Nsg diagnosis: II
Sensory-perceptual alteration: Auditory, visual, r/t
panic anxiety, withdrawal into self, as evidenced by
inappropriate responses, disordered thought process,
poor concentration and disorientation.
 Objective: pt will be able to define and test reality, eliminating
the occurrence of hallucinations

62.  Nsg diagnosis: III
Social isolation r/t inability to trust, panic anxiety,
delusional thinking, evidenced by withdrawal, sad, dull
affect, preoccupation with own thoughts, expression of
feelings of rejection of aloneness imposed by others.
 Objective: pt will voluntarily spend time with other pts and staff
members in group activities on the units

63.  Nsg diagnosis: IV
Potential for violence, self directed or directed to
others, r/t extreme suspiciousness, panic anxiety,
catatonic excitement, rage reactions, command
hallucinations, as evidenced by physical violence,
destruction of objects in the environment, self destructive
behavior or active aggressive suicidal acts.
 Objective: pt will not harm self or others

64.  Nsg diagnosis: V
Impaired verbal communication r/t panic anxiety,
disordered, unrealistic thinking as evidenced by
loosening of associations, echolalia, verbalizations that
reflect concrete thinking and poor eye contact
Objective: pt will be able to communicate appropriately and
comprehensibly by the time of discharge

65.  Nsg diagnosis: VI
Self care deficit r/t withdrawal, panic anxiety,
perceptual or cognitive impairment as evidenced by
difficulty in carrying out tasks associated with hygiene,
dressing, grooming, eating, and toileting.
 Objective: patient will demonstrate ability to meet self care
needs independently

66. DTH:”L;;
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 Nsg diagnosis: VII
ineffective family coping r/t highly ambivalent
family relationships, impaired family communications, as
evidenced by neglectful care of the client, extreme denial
or prolonged over concern regarding his illness
 Objective: family will identify more adaptive coping strategies
for dealing with patients illness and treatment regimen.

67. EVALUATION
 Has the pt established trust with at least one staff
member?
 Is delusional thinking still prevalent?
 Are hallucination still evident?
 Is the pt able to interact with other appropriately?
 Is the pt able to carry out all activities of daily living
independently?

68. NSG CARE OF THE ACUTELY ILL
SCHIZOPHRENICS
 Common in catatonic and paranoid types
 Main nursing concern is controlling his impulsive
behavior when hears voices and respond to them
 Pt may be abusive to the staff so the nurse who has
established trust should collect the data
 Physical need of the pt should be met
 Inj: Haloperidol 10 to 20 mg IM/IV
 Inj: Chlorpromazine 100 mg IM
 Check for injuries
 Approach the patient with assistants

69. NSG CARE OF THE CHRONIC SCHIZOPHRENICS
 Usually withdrawn and have lot of negative
symptoms
 Engage the patient in useful activities (idle mind is a
devils workshop)
 The patients who live in fantasy have bad prognosis
 He should be encouraged to do some positive,
physical work (rehabilitation)
 Encourage and motivate the pt
 Appreciate him at appropriate time

70. PHYSICAL, EMOTIONAL, AND THERAPEUTIC
NEEDS OF THE CHR PTS
 Physical needs:
 Nutrition
 Personal hygiene
 Elimination
 Emotional needs:
 To improve Social contacts, communication, and IPR
 Give importance to personal identity

71.  Therapeutic needs:
 Accept the pt as human being
 Give responsibility about ward routine works
 Patiently and positively hear the suggestions from the pt himself in
implementing routine ward work
 Chronic patients need stimulation, occupational and recreational
therapies
 Nursing care of Chronic patients emphasis should be placed on
the 5 R’s
 Reassurance
 Readjustment
 Reeducation
 Rehabilitation
 Recreation