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CHAPTER 15 ■ Schizophrenia Spectrum and Other Psychotic Disorders
TABLE 15–1 Assigning Nursing Diagnoses to Behaviors Commonly Associated With Psychotic Disorders BEHAVIORS NURSING DIAGNOSES
Impaired communication (inappropriate responses), disordered thought sequencing, rapid mood swings, poor concentration, disorientation, stops talking in midsentence, tilts head to side as if to be listening Delusional thinking; inability to concentrate; impaired volition; inability to prob- lem-solve, abstract, or conceptualize; extreme suspiciousness of others; inaccurate interpretation of the environment Withdrawal, sad dull affect, need-fear dilemma, preoccupation with own thoughts, expression of feelings of rejection or of aloneness imposed by others, uncommunica- tive, seeks to be alone Risk factors: Aggressive body language (e.g., clenching fists and jaw, pacing, threaten- ing stance); verbal aggression; catatonic excitement; command hallucinations; rage reactions; history of violence; overt aggressive acts; goal-directed destruction of objects in the environment; self-destructive behavior; active, aggressive suicidal acts Loose association of ideas, neologisms, word salad, clang associations, echolalia, verbalizations that reflect concrete thinking, poor eye contact, difficulty expressing thoughts verbally, inappropriate verbalization Difficulty carrying out tasks associated with hygiene, dressing, grooming, eating, and toileting Neglectful care of client in regard to basic human needs or illness treatment, extreme denial or prolonged overconcern regarding client’s illness, depression, hostility and aggression Inability to take responsibility for meeting basic health practices, history of lack of health-seeking behavior, lack of expressed interest in improving health behaviors, demonstrated lack of knowledge regarding basic health practices, anosognosia (lack of insight about illness) Unsafe, unclean, disorderly home environment; household members express difficulty in maintaining their home in a safe and comfortable condition
Disturbed sensory perception*
Disturbed thought processes
Social isolation
Risk for violence: Self-directed or other-directed
Impaired verbal communication
Self-care deficit
Interrupted Family Processes
Ineffective health maintenance
Ineffective home maintenance
*This diagnosis has been resigned from the NANDA-I list of approved diagnoses. It is retained here because it is most compatible with the identified behaviors. Source: Adapted from Herdman et al. (2021).
■■ Has not harmed self or others. ■■ Perceives self realistically. ■■ Demonstrates the ability to perceive the environ- ment correctly. ■■ Maintains anxiety at a manageable level. ■■ Relinquishes the need for delusions and hallucinations. ■■ Demonstrates the ability to trust others. ■■ Uses appropriate verbal communication in inter- actions with others. ■■ Performs self-care activities independently. Planning and Implementation Table 15–2 provides a plan of care for the patient with schizophrenia. Selected nursing diagnoses are presented, along with outcome criteria, appropriate
nursing interventions, and rationales for each. In general, nursing interventions should be geared toward establishing trust because suspiciousness is a common symptom in this disorder. Use of a passive rather than a directive commu- nication approach, which offers the client with paranoia the opportunity to make decisions about activities, treatment goals, and other aspects of care, helps establish trust while incorporating a patient-cen- tered approach. Nurses must be aware of their own attitudes in order to avoid perpetuating stigmatization of this patient because this concern has often been respon- sible for individuals avoiding treatment from health- care professionals.
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