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UNIT 3 ■ Care of Patients With Psychiatric Disorders
■■ Disturbances in affect: Affect describes the behavior associated with an individual’s feeling state or emo- tional tone. In inappropriate affect , the individual’s emotional tone is incongruent with the circum- stances (e.g., a young woman who laughs when told of the death of her mother). In bland (blunted) or flat affect , the emotional tone is very weak. The individual with flat affect appears to be devoid of emotional tone (or overt expression of feelings). ■■ Apathy: The client with schizophrenia often demonstrates an indifference to or uninterest in the environment. The bland or flat affect is a man- ifestation of the emotional apathy. ■■ Avolition: Impaired volition has to do with the inability to initiate goal-directed activity. In the indi- vidual with schizophrenia, this may take the form of inadequate interest, lack of motivation, neglect of activities of daily living including personal hygiene and appearance, or inability to choose a logical course of action in a given situation. ■■ Lack of interest or skills in interpersonal interaction: Impairment in social functioning may be reflected in social isolation, emotional detachment, and lack of regard for social convention. Some clients with acute schizophrenia cling to others and intrude on the personal space of others, exhibiting behav- iors that are not socially and culturally acceptable. Others may exhibit ambivalence in social relation- ships. Still others may withdraw from relationships altogether (asociality). ■■ Lack of insight: Some individuals lack awareness of there being any illness or disorder even when symp- toms appear obvious to others. The term for this is anosognosia. The DSM-5-TR identifies this symp- tom as the “most common predictor of nonadher- ence to treatment, and it predicts higher relapse rates, increased number of involuntary treatments, poorer psychosocial functioning, aggression, and poorer course of illness” (APA, 2022, p. 116). ■■ Anergia is a deficiency of energy. The individual with schizophrenia may lack sufficient energy to carry out activities of daily living or to interact with others. ■■ Inability to experience pleasure: This distressing symptom, called anhedonia, may increase one’s risk for suicide. ■■ Lack of abstract thinking ability: Concrete think- ing, or literal interpretations of the environment, represents a regression to an earlier level of cog- nitive development. Abstract thinking becomes impaired in some individuals with schizophrenia. For example, the client with this deficit would have
great difficulty describing the abstract meaning of sayings such as “I’m climbing the walls” or “It’s raining cats and dogs.” Associated Features ■■ Waxy flexibility describes a condition in which the client with schizophrenia allows body parts to be placed in bizarre or uncomfortable positions. This symptom is associated with catatonia. Once placed in position, the arm, leg, or head remains in that posi- tion for long periods, regardless of how uncomfort- able it is for the client. For example, the nurse may position the client’s arm in an outward position to take a blood pressure measurement. When the cuff is removed, the client may maintain the arm in the position in which it was placed to take the reading. ■■ Posturing is manifested by the voluntary assump- tion of inappropriate or bizarre postures. ■■ Pacing back and forth and body rocking (a slow, rhyth- mic, backward-and-forward swaying of the trunk from the hips, usually while sitting) are common psy- chomotor behaviors of the client with schizophrenia. ■■ Regression is the retreat to an earlier level of devel- opment. Regression, a primary defense mecha- nism of schizophrenia, is a dysfunctional attempt to reduce anxiety. It provides the basis for many of the behaviors associated with schizophrenia. ■■ Eye movement abnormalities may manifest in sev- eral ways including difficulty maintaining focus on a stationary object and difficulty with smooth pursuit of a moving object. Research (Benson et al., 2012) has found that simple eye movement tests can distinguish the abnormalities common in schizophrenia with exceptional accuracy. Diagnosis and Outcome Identification Using information collected during the assessment, the nurse completes the client database from which the selection of appropriate nursing diagnoses is determined. Table 15–1 presents a list of patient behav- iors and the NANDA International, Inc. (NANDA-I) nursing diagnoses (Herdman et al., 2021) that corre- spond to those behaviors, which may be used in plan- ning care for patients with schizophrenia. Outcome Criteria The following criteria may be used for measurement of outcomes in the care of the patient with schizo- phrenia. The patient: ■■ Demonstrates an ability to relate satisfactorily with others. ■■ Recognizes distortions of reality.
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