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Schizophrenia

Psychotic

Positive Symptoms

  • Delusions: Fixed, false beliefs (persecutory, grandiose, referential, somatic)
  • Hallucinations: Sensory experiences without external stimulus (auditory most common)
  • Disorganized speech: Loose associations, derailment, word salad, neologisms
  • Disorganized behavior: Catatonia, agitation, inappropriate affect

Negative Symptoms (5 A's)

  • Affective flattening (reduced emotional expression)
  • Alogia (poverty of speech)
  • Anhedonia (inability to experience pleasure)
  • Asociality (lack of interest in social relationships)
  • Avolution (lack of motivation)

Diagnostic Criteria (DSM-5)

  • Two or more of the following for at least 1 month:
    • Delusions
    • Hallucinations
    • Disorganized speech
    • Grossly disorganized or catatonic behavior
    • Negative symptoms
  • Social/occupational dysfunction
  • Continuous signs for at least 6 months

Types of Schizophrenia

  • Paranoid type: Preoccupation with delusions or auditory hallucinations; preserved cognitive function
  • Disorganized type: Disorganized speech and behavior; flat or inappropriate affect
  • Catatonic type: Marked psychomotor disturbance (stupor, rigidity, excitement, posturing)
  • Undifferentiated type: Mixed symptoms that don't fit other types
  • Residual type: Continued evidence of disturbance without prominent positive symptoms

Nursing Interventions

  • Establish trust: Be consistent, honest, and reliable
  • Safety first: Assess for risk of self-harm or harm to others
  • Manage hallucinations: Don't argue; focus on feelings; redirect to reality-based activities
  • Address delusions: Don't challenge directly; present reality gently; focus on underlying feelings
  • Promote medication adherence: Educate about antipsychotics; monitor for side effects
  • Support activities of daily living: Provide structure; use step-by-step instructions
  • Involve family: Provide education and support; refer to support groups

Antipsychotic Medications

ClassExamplesSide Effects
Typical (1st generation)Haloperidol, chlorpromazine, fluphenazineEPS, tardive dyskinesia, sedation, anticholinergic effects
Atypical (2nd generation)Risperidone, olanzapine, quetiapine, clozapineMetabolic syndrome, weight gain, diabetes, agranulocytosis (clozapine)

Extrapyramidal Symptoms (EPS)

  • Acute dystonia: Muscle spasms (eyes rolled back, neck torsion) - treat with anticholinergics
  • Akathisia: Restlessness, inability to sit still - treat with beta-blockers or benzodiazepines
  • Parkinsonism: Tremor, rigidity, bradykinesia - treat with anticholinergics
  • Tardive dyskinesia: Involuntary movements (tongue, lips, face) - may be irreversible

📝 NCLEX Priority Points

  • Priority: Safety - command hallucinations, aggression risk, self-harm
  • Don't argue with delusions; focus on feelings, redirect to reality-based activities
  • Monitor for EPS: acute dystonia (muscle spasms), akathisia (restlessness), parkinsonism, tardive dyskinesia (irreversible)
  • Medication adherence is critical; educate about side effects to improve compliance
  • Establish trust through consistent, honest communication

💊 Key Medications

  • First-generation antipsychotics (FGA): haloperidol (Haldol) - higher EPS risk; treat EPS with anticholinergics (benztropine)
  • Second-generation antipsychotics (SGA): risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel) - lower EPS, higher metabolic risk
  • Clozapine (Clozaril): for treatment-resistant schizophrenia - requires weekly WBC monitoring for agranulocytosis
  • Long-acting injectables: for non-adherent patients - monitor for injection site reactions

🩺 Therapeutic Communication Techniques

  • Using silence: Allows patient to organize thoughts and feelings
  • Active listening: Pay attention to both verbal and nonverbal cues
  • Clarifying: "I'm not sure I understand. Tell me more."
  • Focusing: "Let's talk more about that feeling."
  • Restating: "You're saying that you feel alone."
  • Exploring: "What happened before you felt that way?"
  • Validating: "I can see this is difficult for you."
  • Reality orientation: "I don't hear voices, but I understand that's frightening for you."
  • Distraction: Redirect to reality-based activities when hallucinations occur

⚠️ Safety Considerations

  • Command hallucinations: assess if commanding self-harm or harm to others
  • Delusions: don't challenge directly; focus on underlying feelings
  • Monitor for medication non-adherence leading to relapse
  • Assess for tardive dyskinesia using AIMS scale regularly

Source: DSM-5-TR, NCLEX-RN Test Plan. For educational purposes only. Always follow facility protocols and current clinical guidelines.