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Schizophrenia is composed of a broad collection of symptoms from all

domains of mental function. The term schizophrenia literally means


split mind it is often confused with a split or multiple personality.
Individuals affected with such syndrome may show a wide range of
disruptions in their ability to see, hear and otherwise process information
from the world around them. They may also experience disruption in their
normal thought processes, as well as their emotions and behaviors.

This basic aspect of disturbance in a patient can be resulted in a lifetime


disability, periodic hospitalization and a failure and social relationships.
These relationships are often disrupted as a direct consequence of the
affected individuals withdrawal and inability to communicate, which may
be alternate with bouts of disruptive behavior. Family
with schizophrenia can exacerbate a strain of caring for a mentally ill
relative and the stigma of mental illness.
Because of the disorder is so severe, and many people will be afflicted
sometime in their life. Schizophrenia is now recognized as major public
health concerns.

Nursing Diagnosis:Disturbed Thought Processes


Possible Etiologies
(Related to)

Inability to trust

Panic level of anxiety

Low self-esteem

Inadequate support systems

Negative role model

Repressed fears

Underdeveloped ego

Possible hereditary factor

Defining Characteristics
(Evidenced by)
Suspiciousness of others, resulting in

Alteration in societal participation

Inability to meet basic needs

Inappropriate use of defense mechanisms

Hypervigilance Distractibility Inappropriate nonreality-based thinking


Inaccurate interpretation of environment
Goals/Objectives
Short-Term Goal
Client will develop trust in at least one staff member within 1 week.
Long-Term Goal
Client will demonstrate use of more adaptive coping skills, as evidenced
by appropriateness of interactions and willingness to participate in the
therapeutic community.
Outcome Criteria

Client is able to appraise situations realistically and to refrain


from projecting own feelings onto the environment.

Client is able to recognize and clarify possible misinterpretations


of the behaviors and verbalizations of others.

Nursing actions

Rationale

Encourage same staff to work with client

To promote development of trusting

as much as possible

relationship

Avoid physical contact.

Suspicious clients may perceive touch as a


threatening gesture.

Avoid laughing, whispering, or talking

Suspicious clients often believe others are

quietly where client can see but not hear

discussing them, and secretive behaviors

what is being said.

reinforce the paranoid feelings.

Be honest and keep all promises.


A creative approach may have to be
used to encourage food intake (e.g.,
canned food and clients own can opener
or family-style meals).

Honesty and dependability promote a trusting


relationship.

Suspicious clients may believe they are being


poisoned and refuse to eat food from the
individually prepared tray.
To verify that client is swallowing the tablets

Mouth checks may be necessary after

or capsules. Suspicious clients may believe

medication administration

they arebeing poisoned with their medication


and attempt to discard the pills.

Activities should never include anything


competitive. Activities that encourage a

Competitive activities are very threatening to

one- to-one relationship with the nurse

suspicious clients.

or therapist are best.


Encourage client to verbalize true
feelings. The nurse should avoid
becoming defensive when angry feelings
are directed at him or her.

Verbalization of feelings in a nonthreatening


environment may help client come to terms
with long-unresolved issues.

An assertive, matter-of-fact, yet genuine

The suspicious client does not have the

approach is the least threatening to the

capacity to relate to an overly friendly, overly

suspicious person.

cheerful attitude.

Client eats food from tray and takes medications without


evidence of mistrust.4.Client appropriately interacts and
cooperates with staff and peers in therapeutic community
setting.

Schizophrenia (NCP)Nursing Care PlanDisturbed Thought Processes


References:

Psychiatric/Mental Health Nursing: Concepts of Care 4th edition of Townsend, M.C. (2003)
Schizophrenia 3rd edition by Oxford University Press 2011