As we have seen the symptoms or rather the results, of Schizophrenia can be life disheartening, depressing and take an emotional toll on the patients and their family. The person is unable to interact within the community and family, express him or herself well and hence unable to continue with his work and social life. Since this is likely to be a life-long condition it is important that every family has, ample schizophrenia education to enable them to detect early symptoms, seek early medical intervention, and be well adapted to help the patient cope with the condition. Just like any other health condition, early diagnosis implies that the condition is less severe and the medical intervention is likely to work better and faster. Currently, though there is no cure, there are successful treatments to ensure that many schizophrenic patients lead satisfying and independent lives.
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An approximate 2.4 million United States adults, or basically 1.1%, of the U.S. population aged 18 years and above are diagnosed with schizophrenia each year. In men, it manifests itself in their early twenty’s while in women it manifests itself in their late twenties or early thirties. However, both men and women are equally affected. Being a mental disorder that is usually characterized by the disintegration of the thinking process and emotional responsiveness, Schizophrenia is among the most chronic and severe lifelong brain disorders, especially if not diagnosed early enough. It leads to both occupational and social. (NHMI, 2010).
The complexity of schizophrenia does not make it any easier for the patients. Unlike most mental diseases, schizophrenia is not synonymous with multiple or split personality disorder and most people with it are not violent or dangerous. They simply reside with families, on their own, or in group homes. Schizophrenia diagnosis is dependent on the person’s observed behavior and self-reported experience. However, most people living with a schizophrenic person barely notice that they have a serious mental condition and hence dismiss their symptoms as being paranoid, bizarre delusions, mere hallucinations, disorganized thinking or speech or bizarre delusions. Schizophrenia interferes with a person’s ability to manage emotions, distinguish reality from fantasy, think clearly, relate to others, and make decisions. Nevertheless, just like many mental conditions, schizophrenia has no cure and it is therefore important that all Americans are well versed with the causes, symptoms, diagnosis, prognosis and management of schizophrenia so that they are well aware of the hazardous health, social, and occupational effects that the disease causes and pay attention to the persons living around them to ensure that steps towards earlier medical intervention which can inhibit the progression of the disease and save a patient’s life are taken (NHMI, 2010).
The client (M.J) which I cared for was a 52 year old female. She was unemployed, single, under weight and staying alone in her apartment. She smokes cigarettes, one pack per day. Her sister staying in Maryland was supportive to her. Moreover, her sister was a source of support after discharge. Her mother was bipolar. She also had a history of Asthma. She is also a Hepatitis C carrier.
Causes
Although researchers have not yet been able to identify specific causes of schizophrenia they have been able to ascertain that a combination of various factors such environmental factors, hormonal changes, and genetic factors altering brain chemistry and psychological, places people at a higher risk of having schizophrenia.
Abnormalities in brain structure, chemicals and circuitry:
Using the Magnetic Resonance Imaging (MRI), brain scans have shown a number of abnormalities within the brain structure associate with the condition. Such problems cause damages that cause nerve disconnection and damage in the brain chemical pathways. These problems show up on brain scans of persons with chronic schizophrenia more often than newly diagnosed ones. Schizophrenia is also associated with neurotransmitter imbalances and brain chemicals such as glutamine, dopamine over activity, reelin and others. In abnormal circuitry brain structure abnormalities are reflected in disrupted connection in the schizophrenic patients. This impairs information processing and mental functions coordination which are symptoms in schizophrenic patients (UM, 2010).
Genetic factors
Undoubtedly, research has proven that schizophrenia has genetic components such as OLI2 gene, neuregulin-1 gene, and the COMT gene. The genetic components exhibit a risk of 10% of inheriting the condition if one immediate family member has it and 40% if an identical twin or both parents have it (UM, 2010).
Psychological factors
External pressures and influences play a psychological role in a person’s development. Prefrontal lobes which are the brain areas that lead to the condition are usually extremely responsive to environmental stress. With the fact that schizophrenic symptoms naturally elicit negative responses from a patient’s family circle and acquaintances, negative feedback can intensify deficit in the vulnerable brain and trigger or exacerbate the existing symptoms (UM, 2010).
M.J doesn’t have a good relationship with her father and brother. Her father was abusive to her for not being employed. She was living with her parents; but because of her father’s behavior she was kicked out of her parent’s house by her mother.
Infectious factors
Research has identified that infections such as viruses increases the risk of the condition. The risk of the condition is usually 5-8% higher for persons born in winter and spring when colds and viruses are prevalent. Pregnant mother’s exposure to viral infections such as measles, chicken pox, and rubella among others while the infant is still in the womb increases higher chances of developing schizophrenia. Researchers have also identified that viruses belonging to the HERV-W retrovirus family are found in 30% of schizophrenics, a clear indication that infections play a major role (UM, 2010).
M.J was born in winter on December 2, 1957. According to research the chance for her getting schizophrenia increases up to 8% because she was born during a winter month.
Positive symptoms
These are behaviors not exhibited in healthy persons and even they usually come and go, sometimes they can be hardly noticeable or severe depending on whether the individual is receiving medication or not. Schizophrenics suffer from hallucinations whereby they hear, smell, feel and see persons or things that no one else can. Many hear voices which may order a person to do things, warn them of danger and talk to them about their behaviors. Schizophrenics might hear voices for a long period of time before anyone can notice them. They also suffer from delusions; false beliefs that do not change or are not part of a person’s culture. They believe in delusions even after people prove to them that these beliefs are not logical or true. Their delusions such as; having the belief that neighbors are controlling them through magnetic waves, people on television are directing messages to them, radio stations are broadcasting their thoughts to others, they are a famous historic figure, others are trying to harm them, cheating, poisoning, harassing, plotting and spying on them. Schizophrenics might also experience thought disorders whereby they may experience disorganized thinking. They have trouble connecting their thoughts logically, talk in a garbled way, and experience ‘thought blocking’ whereby they feel that their thoughts has been taken out of their heads. They may also have agitated body movements, repetitive motions, and may even become catatonic.
M.J has an array of positive symptoms like auditory and visual delusions and hallucinations. She was being paranoid from her neighbor. She complains that her neighbors make weird noises so she started to sleep outside. She also tried to commit suicide by jumping into a river. At the time she was not staying at her house. She was frequently found living out on the streets.
Negative symptoms and cognitive symptoms
These are symptoms associated with normal behavior and emotional disruption. They are hard to recognize and often mistaken for depression. They include ‘flat affect’ whereby a person shows no emotions, speaks little, lacks pleasure in everyday life, has an inability to sustain and begin planned activities. Such people neglect the basics of personal hygiene and are often mistaken for being unwilling and lazy. Cognitive symptoms are usually subtle and are barely recognized as part of the condition. They include poor ‘executive function’, inability to focus and pay attention, and poor working memory.
M.J also has negative symptoms which include depression. She lost 34 lbs drastically, without trying, in two month. She refuses to eat an appropriate amount of food and goes days without eating. She does not sleep well. She cannot take care of herself. Layers of unwashed clothes covered in feces and urine drops were found on her body. The client has irregular contact with an assigned case manager, counselor, co-worker, and nurses. In activity group she sits alone in the corner without answering a single question. When somebody sits beside her she walks away immediately. She has very poor concentration. Upon admission she scores 10 on Axis V. M.J stopped taking her medicine. She always says that she doesn’t felt better after she has taken her medicine. M.J was not ready to accept the decision of the treatment even though she was on a very low score of 10. In the court room she always says no to each and every question regardless of the content.
Diagnosis and Treatment
Diagnosis
Diagnosis is based on the self reported experiences and any abnormalities reported by family members, co-workers, or friends. This is followed by a clinical assessment by a social worker, clinical psychologist, mental health nurse, psychiatrist, or any other mental health professional. Psychiatric assessment involves mental status evaluation and a psychiatric history. However, the American Psychiatric Association Diagnostic and Statistical Manual of Mental Health provides a standardized criteria, version DSM-IV- TR to diagnose schizophrenia. Three diagnostic criteria must be met for a person to be declared schizophrenic including; a continuous disturbance with signs persisting for at least six months, evidence of social and occupational dysfunction, and characteristic symptoms of the condition (NHMI, 2010).
Treatment
The causes of schizophrenia are still unknown and therefore treatment focuses on eliminating the disease symptoms with antipsychotic medications such as Thorazine, Haldol, perphenazine, Fluphenazine, paliperidone, and ziprasidone among others. They eliminate hallucinations, psychotic symptoms, and breaks with reality. However, the medications have side effects such as rapid heartbeat, skin rashes, dizziness, tremor, rigidity, restlessness, drowsiness, menstrual problems, and blurred vision. Sometimes, persons need to try several medications to find the right one and hence, doctors need to work together with patients to find the right medication combination. The treatment is administered once or twice a month as an injection and symptoms such as hallucinations and agitation go away within days and symptoms like delusions after a few weeks. Within six weeks many people are able to see a lot of improvement. People have relapses when they stop taking medication or do not follow doctor’s orders making the symptoms get worse, hence, patients should never skip or stop taking the medication on their own (NHMI, 2010).
After being admitted to MCES medicine was given to M.J on a regular basis which shows continuous improvement in her mental functioning. After three weeks of being admitted in MCES she began to take part in some activities. She also began giving her feedback in the activity room. She still suffers from symptoms of disorganized thinking.
Patients also need psychosocial treatment such as cognitive behavioral therapy and coping mechanisms to help them communicate, work, care for themselves and keep relationships. They may also get rehabilitated and join self help groups to help them learn social and vocational skills that will help them cope with the community (NHMI, 2010).
From my experience with schizophrenic clients, the nursing process for schizophrenic patients is complex because of the wide range of symptoms that patient’s exhibit. During diagnosis I usually avoid ambiguity in use of words and phrases. I use words that can be understood by the patient to avoid misinterpretations that can have adverse effects. However, due to compelling circumstances, at times I forget and touch or cuff the patient before explaining reasons for this. This is often adversarial especially when the patients I am attending to are agitated or suspicious. While I understand that such patients need to be helped to carry out certain duties as stipulated by Edwards, Peterson and Davis (2006), I take measures to minimize dependence but help out with activities I know schizophrenic patients cannot execute individually. In order to encourage quick recovery I reward patients who exhibit good behavior. This has even been encouraged by Coatsworth- Ruspoky, Forchuk and Ward-Griffin (2006) who assert that rewarding patients encourages improved functioning.
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My priority nursing diagnosis was Risk for violence: related to prior suicide attempt after reviewing her chart and speaking with her. My intervention was to ask direct questions about any specific plan for suicide. Assess for any sharp instruments she could possibly carry with her. I observed closely for any signs of physical abuse. I assessed her potential to harm others. I taught her healthy coping mechanisms to deal with her feelings. I encouraged her to attend group therapy. My second nursing diagnosis was self care deficit: related to cognitive impairment. My intervention was to give her instruction in small steps to avoid confusion. I encouraged her to bathe every morning to promote independence in daily care. I instructed her to keep journaling about her daily schedule.
In addition to the standard care of schizophrenic patients, the nursing care which I provided to my client was different and was more specific. I allowed her sufficient time to express her feelings verbally. I listened to my client attentively while maintaining eye contact. I built a therapeutic relationship with my client. Sometimes she did not want to talk, but I still spent some time with her sitting in silence. By doing this I tried to establish rapport with her. I encourage her to participate in self care to her fullest extent possible to reduce feelings of helplessness. Moreover, I encourage my patient to establish a self care schedule to enhance feelings of usefulness and control. I also told her that the social worker, case worker, co-worker, nurses and doctor are her support groups I recommended she listen to them and follow their guidelines. Talk with them and express her feelings about sadness, guilt, anger, and depression. I advised her to write the goal a day and try to fulfill it. Moreover, I instructed her to keep a daily activity log to help her achieve a more objective view of her behavior. I encouraged the client to be a part of each and appropriate activity group.
I assessed my client’s personal strengths, including coping and problem solving abilities and her participation level during activities. I encouraged my client to use healthy coping skills to overcome stressful situations, similar to ones in the past, to bolster clients’ confidence in her ability to manage current situations and explore ways to apply coping strategies before she became overwhelmed. I advised her that the use of healthy coping skills would increase her self esteem and could reduce her feelings of dependence. I encouraged my client to identify enjoyable diversions and to participate in them to decrease negative thinking and enhance self-esteem. I strongly encouraged thinking positively which conveys a sense of confidence in her ability to cope with illness and to promote an optimistic outlook. I encouraged my client to continue practicing her spiritual beliefs. I also asked her to keep a sleep log describing any sleep disturbances and their impact on daytime functioning, such as with cognition, mood and coping skills.
In order for the nursing process on schizophrenic patients to yield beneficial results there should be effective and open communication between the patient and nurse. This forms the basement upon which viable relationships are established. When the client is brought in to the medical facility they are taken through the orientation stage. This marks the onset of the client- nurse relationship and nurses assume the responsibility of explaining to the patient why they are in the facility. According to Edwards et al (2006), schizophrenic patients at this particular stage might not be able to express themselves effectively due to anxiety and emotional distress. To help the patient to relax, nurses expose them to palliative measures such as administering painkillers and promoting rest. Patients that exhibit extreme aggression are secluded to prevent them from injuring others (Coatsworth-Ruspoky et al, 2006). Nurses at this point avoid arguing with the clients but exercise empathy by assisting them to carry out certain difficult duties. Also, they keep the levels of noise minimal and clear the environment of objects that may be harmful to the safety of the client.
During the exploration phase that comes after orientation the problems of clients are identified; solutions sought, applied, and evaluated (Edwards et al, 2006). The nurse employs unambiguous communication techniques such as using simple phrases to help the patient cope. For instant, instead of saying ‘Can you pick the spoon up from the floor’, the nurse can say ‘please help me get that spoon’. Elimination of the word floor would be imperative as patients can misinterpret this to mean lie on the floor. Nurses also encourage independence by letting the clients perform most of the tasks (Coatsworth- Ruspoky et al, 2006). At this stage, clients are able to undertake self care tasks such as bathing, eating, cleaning and so forth. Nurses become stricter with the written schedules and lay particular emphasis on the feelings of the patients.
Finally, Edwards et al (2006) indicates that the resolution phase constitutes termination of the nurse-client relationship. Nurses at this stage help make the vital decision of either discharging the patient or transferring them to another facility or department within the same facility. Clients in some instances become anxious and may be hostile or aggressive. In particular, they may not wish to leave the institution and can refuse to speak to anybody. They experience anorexia and sleeplessness as a result of being separated from their nurse (Edwards et al., 2006). Nurses usually intervene by providing patients with their contacts and addresses. In addition, they assure the client that the relationship has not actually ended and that they are welcome at any given time. Encouraging words such as ‘congratulations on recovering’ can also go a long way in helping the client to accept the conditions.
During my initial meeting with the client, I introduced myself and told her that I would like to talk with her. I also assured her that our conversation would be kept confidential. The client refused to speak with me and made no eye contact. I continued to sit with my client but didn’t insist that she talk to me. After 10 minutes she just stood up and walked away. I accepted her behavior and didn’t take anything personal. In our next meeting, I re-introduced myself and continued to approach her with a gentle voice and asked a couple of brief open-ended questions. The client responded positively to me. She answered a few of my questions and began to express her paranoia. I used active listening to encourage her to trust me and open up more emotionally. I continued this method every week. Eventually she started to make eye contact and sat facing towards me. At one meeting I accompanied her to court where she refused treatment. After the hearing was over I sat down and talked to her about her further treatment. As a student nurse I told her that, “I know that you are anxious and frightened.” I am here to help you. Please tell me why you do not want to accept the treatment; they are trying to help you out in getting better. She didn’t respond verbally but nodded her head and left. After that, I didn’t talk about the court meeting again because I did not want to lose her trust. The non-therapeutic technique which I used was providing her pamphlets from the facility; I reviewed them with her and encouraged her to read them again by herself. During the termination phase she expressed her feelings of gratitude and acknowledged my help. This final meeting made me feels like all my patience had paid off and that I was able to assist her with her treatment.
The client belongs to Hispanic culture, in which the father is the head of the family. Everyone should follow his rules and regulation. As she doesn’t have a good relationship with her father, I feel that her father may be major source for the client’s depression. He doesn’t allow the client to be independent in making decision for her own life. Because of mental abuse she got depressed and this led to dependency on others for her ADL’s. In an AA meeting she expressed her feelings of hopelessness and powerlessness and expressed she wanted help from a higher power. She looks up on the ceiling and said may be god will help me. She also said that she prayed to god every morning. According to Erikson’s developmental stage, she belongs to Trust Vs Mistrust. For example, I worked with her for four weeks; she sometimes talked with me and sometimes chose not to. Even after all the time I had spent building a trustworthy relationship with her. When I started to talk about her suicide attempt, she remained silent for a while. Her defense mechanism was to avoid my question and close up emotionally. After that I used a directive statement like “Look at me and listen; whatever you say to me, it will remain with me.” The client suddenly walked away from the activity room. Moreover, it was very hard to develop trust between the nurse-client relationships. For positive coping skills, I taught her that support groups help her to share feelings, prevent isolation, and to learn from others how to cope with difficult situations. Also, expressing her feelings can help her relax. This can be done by writing her thoughts down by keeping a journal. I also encourage her to use different distraction methods such as: talking with friends and/or family, yoga/exercise, arts and crafts, making collages, listening to music, reading, taking a walk, talking to therapist/doctor, breathing exercises, watching TV, and playing a game. As I observed she started to take part in activities. She began talking and playing games with her colleague. She started to make her daily goals and worked toward fulfilling them.
As a provider of care, I established a trusting relationship with my client. The building trust relationship allows my client to be more open. I assessed her feelings and anxiety level. I tried my best to talk with her. I listened to her carefully. I encouraged her to take part in each and every activity and also to seek help from her support group, spiritual direction, and journaling. The patient will strive to enhance coping skills using opportunities to which she feels best suited. I also encouraged taking an active part in setting goals for herself to facilitate independence and self esteem. For competence, I began my communication at my client’s level of comfort. I met my client regularly every week to assist in helping focus on her goals and evaluating her progress. I tried my best to recognize my client’s small attempts at successful coping which encourages patient to increase her efforts. I encouraged her to attend her therapy sessions, and allow my client to demonstrate new skills and abilities. I encouraged client independence helping her reach her maximum functional level. I encouraged the client to be as independent as possible in self care activities to enhance self-esteem and promote optimal functioning. I provided her emotional support by being available to answer questions and listened attentively. I referred her to available support groups to manage her depression by providing emotional support. I assured her that I was there for her treatment. For physical comforting, I monitored my client closely for signs of physical abuse to ensure safety and wellbeing. I helped my client recognize and feel good about her positive personal qualities and accomplishments. As self-esteem increases the patient will feel less need to manipulate others. I never forced her to sit with me but I sat with her for long periods when she allowed it. I felt positive about caring for my client by including all resources that could contribute to her comfort and well-being. I also feel happy by working with client to enhance her decision making capabilities which promote personal actions competence. By doing all this for my client I became more confident and also had a positive attitude towards my career.
As a manager of care, I conveyed a caring, nonjudgmental attitude when talking with my client about her suicide attempt. I asked her directly about any specific plan for suicide. I supervised my client when I was in my clinical rotation according to the protocol of the hospital. I also talked with her about the importance of continuing life. I also made sure she did not have any sharp material like a razor, belts, any glass objects, or unnecessary pills, to ensure her safety. I also encouraged her to take the advantage of the available support group. I also taught her how to follow the daily schedule of the facility and to try to attend each and every appropriate activity group. I also recommend that she read the material provided in the activity session. As an advocate I listened to my client carefully without challenging her statements. These communication techniques provide qualities like caring, support and understanding without reinforcing denial. Moreover, attentive listening also conveys empathy, recognition, and respect for a person.
As a member within my profession, I worked within my scope of practice. I maintained a therapeutic and professional client-nurse relationship. I protected my client’s dignity, autonomy, and rights by following HIPAA laws. I behaved professionally with my client, colleagues and staff members.
In conclusion, I enhanced my knowledge of this disease. I am confident I provided adequate care to my client when needed. People with this disease are often misunderstood in society and at times it is difficult to deal with a schizophrenic person without having enough education about the disease process. Hopefully, through more research and community mental health programs, healthcare providers and society together can improve the quality of life for people suffering with this disease.
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