Case Studies challenge your students’ clinical judgment and critical-thinking skills to prepare them for real-world practice and certification. Of all the mental illnesses, schizophrenia is likely responsible for longer hospitalizations, greater chaos in family life, more exorbitant costs to individuals and governments, and more fear than any other. Studies also have shown that people with a severe mental illness (SMI) such as schizophrenia have, on mogeneous disease entity. The Diagnostic and Statis- tical Manual of Mental Disorders, Fifth Edition (DSM-5), supports this concept by describing schizophrenia as one of the schizophrenia spectrum disorders (American Psychiatric Association [APA], 2013). Although current consensus points to schizophrenia as a neurodevelopmental disorder (Álvarez et al., 2015), schizophrenia spectrum disorders may have several etiological influences, including genetic pre- disposition, biochemical dysfunction, physiological factors, and psychosocial stress. Tripathi, Kar, and Shukla (2018) believe that the neurodevelopmental hypothesis falls short in explaining the magnitude of brain changes that occur in schizophrenia. They suggest that these changes can be better explained “as the cumulative effect neurodevelopmental abnor- mality, change in neural plasticity and alteration in neuronal maturation.” One factor with which clinicians agree is that there is not now and may never be a single treatment that cures schizophrenia. Effective treatment currently requires a comprehensive, multidisciplinary effort, including pharmacotherapy and various forms of psychosocial care, such as living skills and social skills training, cognitive remediation therapy, rehabilitation and recovery, and family therapy. Emerging evidence indicates that a comprehensive, patient-centered approach offers hope for a recovery process and improved quality of life in this population. 214
373 Escalona, & Keith, 2017). This chapter explores various theories of predisposing factors implicated in the development of schizophrenia. Symptomatol- ogy associated with different diagnostic categories of the disorder is discussed. Nursing care is pre- sented in the context of the six steps of the nursing process. Various dimensions of medical treatment are explored. Nature of the Disorder Movie Connections list films that demonstrate relevant conditions and behaviors. Schizophrenia is a disabling psychological disorder. Characteristically, disturbances in thought processes, perception, and affect invariably result in a severe deterioration of social and occupational functioning. The lifetime prevalence of schizophrenia is about 1% in the general population (Sadock, Sadock, & Ruiz, 2015). Symptoms generally appear in late adolescence or early adulthood, although they may occur in middle or late adult life. Early-onset schizo- phrenia refers to symptoms that begin in childhood and adolescence before age 18 years. This condition, although rare, is recognized as a progressive neurode- velopmental disorder with a chronic and severely A severe mental condition in which there is disorgani- zation of the personality, deterioration in social function- ing, and loss of contact with, or distortion of, reality. There may be evidence of hallucinations and delusional thinking. Psychosis can occur with or without the presence of organic impairment. CORE CONCEPT Psychosis
Communication Exercises 1. Hal, a patient on the psychiatric unit, has a diagnosis of schizophrenia. He lives in a halfway house, where last evening he began yelling that “aliens were on the way to take over our bodies! The message is coming through loud and clear!” The residence supervisor became fright- ened and called 911. As Hal was being admitted to the psychiatric unit, he told the nurse, “I’m special! I get mes- sages from a higher being! We are in for big trouble!” How would the nurse respond appropriately to this statement by Hal? 2. The nurse notices that Hal is sitting off to himself in a cor- ■ Recognizes distortions of reality ■ 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 ner of the dayroom. He appears to be talking to himself and tilts his head to the side as if listening to something. How would the nurse intervene with Hal in this situation? 3. Hal says to the nurse, “We must choose to take a ride. All alone we slip and slide. Now it’s time to take a bride.” How would the nurse respond appropriately to this statement by Hal? Communication Exercises let students practice their communication skills with vignettes and questions that prepare them for clinical and practice. The following section presents a group of selected nursing diagnoses, with short- and long-term goals and nursing interventions for each. In general, nursing interventions should be directed toward establishing trust, because suspiciousness is a common symptom in this disorder. Use of a passive rather than a directive the selection of appropriate nursing diagnoses is determined. Table 24–1 presents a list of patient behaviors and the NANDA nursing diagnoses that correspond to those behaviors, which may be used in planning care for patients with psychotic disorders. Outcome Criteria The following criteria may be used for measure- ment of outcomes in the care of the patient with schizophrenia. The patient: ■ Demonstrates an ability to relate satisfactorily to others
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Unit 2 ■ Psychiatric Mental Health Nursing Interventions
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Social Determinants of Health highlights non-medical factors that affect health outcomes. The majority of people who die by suicide diagnosable mental illness with numbers 10 times that of the general population. O without a diagnosable mental illness, many are related to crises associated with financ tionships, discrimination, violence, terror, a (Bachman, 2018). The mental illnesses mo monly associated with suicide include dep bipolar disorder, or substance use disorder. In the latest edition of the Diagnostic and S Manual of Mental Disorders, Fifth Edition, Text (DSM-5-TR) a new section, “Association with Ethnicity Ethnic/racial groups with disproportionately rates of suicide include non-Hispanic Native can and non-Hispanic White people (CDC, Within the Native American community, adults are the highest-risk age group, and the suicide is 2.5 times higher than the national (National Indian Council on Aging, 2024). One study examining suicide trends school-age children younger than age 12 et al., 2015) found that suicide rates for Bla dren 5 to 11 years of age nearly doubled o period from 1993 to 2012, while the overall rate in this age group remained relativel during the same period. The use of hanging o cation as a means of taking one’s own life also cantly increased in this population. A more study (Sheftall et al., 2022) found that from 2017 Black youth experienced a significant trend in suicide with the largest annual per change among girls in the 15- to 17-year age As of 2018, suicide became the second-leadin of death in Black children ages 10 to 14, third-leading cause of death in Black ado ages 15 to 19 (Gordon, 2020). The contribu tors to these trends are not well understood require further research, including a review impact of health-care disparities for select co ties or populations. Other Risk Factors
and other psychotic disorders has been identified. These include (on a gradient of psychopathology from least to most severe): schizotypal personal- ity disorder, delusional disorder, brief psychotic disorder, substance-induced psychotic disorder, psychotic disorder associated with another medi- cal condition, catatonic disorder associated with another medical condition, schizophreniform dis- order, schizoaffective disorder, and schizophrenia. ■■ Nursing care of the patient with schizophrenia is ac- complished using the six steps of the nursing process. ■■ Nursing assessment is based on knowledge of symptomatology related to thought content and processes, perception, affect, volition, interper- sonal functioning and relationship to the external world, and psychomotor behavior. ■■ Symptoms of schizophrenia are categorized as posi- tive (an excess or distortion of normal functions) or negative (a diminution or loss of normal functions). ■■ Antipsychotic medications remain the mainstay of treatment for psychotic disorders. Atypical antipsy- chotics have become the first line of therapy and treat both positive and negative symptoms of schizo- phrenia. They have a more favorable side-effect pro- file than the conventional (typical) antipsychotics. ■■ Individuals with schizophrenia require long-term integrated treatment with pharmacological and other interventions. Some of these include indi- vidual psychotherapy, group therapy, behavior therapy, social skills training, milieu therapy, fam- ily therapy, and assertive community treatment. For the majority of clients, the most effective treat- ment appears to be a combination of psychotropic medication and psychosocial therapy. ■■ Some clinicians are choosing a course of therapy based on a model of recovery, somewhat like that which has been used for many years with prob- lems of addiction. The basic premise of a recovery model is empowerment of the consumer. The re- covery model is designed to allow consumers pri- Suicide rates are higher in rural areas and with a twofold greater use of firearms as the means (Ivey- Stephenson et al., 2017). Kim and associates (2016) studied the factors influencing a move from suicide ideation to suicide attempts and found that low edu- cation and unemployment significantly increased the Core Concepts listed at the beginning of each chapter and defined in boxes throughout the text emphasize important takeaways. Assessing religion’s role in risk for suicide is compli- cated by variables such as degree of affiliation, partic- ipation, religious doctrine, and others. Most studies identify religion as a protective factor; associated with lower risks for suicide (Gearing & Alonzo, 2018; Poorolajal et al., 2022; Vitorino et al., 2023). A system- atic review of the research on religion and suicide risk (Lawrence et al., 2016) found that although religious affiliation is not protective against suicide ideation , it is protective against suicide attempts, and religious ser- vice attendance is possibly protective against suicide. The authors of another study (Rasic et al., 2009) found that religious affiliation is associated with a decreased risk of suicide attempts in both the general population and in those with a mental illness, independent of the availability of social support systems. Among studies that identify religion as a possible risk factor for sui- cide, researchers note that associated distress (such as anger toward God or shaming and stigmatization from an individual’s significant support systems) may be influential (Gearing &Alonzo, 2018). Socioeconomic Influences although statistics reveal degrees of risk in certain age-groups, screening for risk of suicide should be conducted for all individuals regardless of demo- graphic characteristics. Religion Financial strain and unemployment have often been identified as risk factors for suicide. To what extent these factors act alone (as opposed to a complex interaction of several variables) requires fur- ther study. In addition, the CDC (2022) identifies loss (including loss of employment), and lack of access to health care as risk factors for suicide that may be asso- ciated with socioeconomic influences.
CHAPTER 15 ■ Schizophrenia Spectrum and Other Psychotic Disorders
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MOVIE CONNECTIONs I Never Promised You a Rose Garden (Schizophrenia) • A Beautiful Mind (Schizophrenia) • The Fisher King (Schizophrenia) • Bennie & Joon (Schizophrenia) • Out of Darkness (Schizophrenia) • Conspiracy Theory (Paranoia) • The Fan (Delusional disorder) • The Soloist (Schizophrenia) • Of Two Minds (Schizophrenia) Quality and Safety Education for Nurses (QSEN) Activities help students attain the knowledge, skills, and attitudes required to fulfill the initiative’s quality and safety competencies. decisions about activities, treatment goals, and other aspects of care, helps establish trust while incorporat- ing a patient-centered approach. For example, saying, “Would you like to attend group now?” is a less directive approach than saying “You need to go to group now.”
Summary and Key Points ■■ Of all of the mental illnesses, schizophrenia un- doubtedly results in the greatest amount of per- sonal, emotional, and social costs. It presents an enormous threat to life and happiness. ■■ For many years, there was little agreement as to a definition of the concept of schizophrenia. The
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