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Caring for the patient with schizophrenia

Iannaco, Dodi DNP, RN, APN-BC

doi: 10.1097/01.CCN.0000403405.34359.30
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Caring for a patient with schizophrenia includes ensuring that prescribed medications are administered as directed. You'll also monitor for adverse drug reactions, in addition to addressing the medical problem that brought the patient to the ICU.

Dodi Iannaco is a clinical advanced practice nurse in the medical-surgical, acute care for elders, and stroke unit at Virtua Hospital in Berlin, N.J.

Find out how to address the challenges of this condition in the CCU.

The author has disclosed that she has no financial relationships related to this article.

Figure

Figure

JT, a 38-year-old White male, is admitted to your ICU from the ED with a diagnosis of pneumonia. When he developed an acute cough, fever, and shortness of breath at the boarding home where he resides, the residence manager called 911. JT's past medical history includes schizophrenia, tobacco use, and hospitalization a year ago for ventilator-dependent respiratory failure. When he arrived in the ED, his SpO2 was 91% on 2 L/minute of supplemental oxygen via nasal cannula. After two nebulized albuterol treatments, his SpO2 is 94%. His serum electrolytes are within normal limits, but the complete blood cell (CBC) count reveals an elevated white blood cell count of 18,000 cells/mm3 (normal range for adults is 4,500 to 10,500 cells/mm3). A chest X-ray revealed patchy infiltrates at the left lung base. Because of his history of ventilator-dependent respiratory failure, he was admitted to the ICU for monitoring.

JT was prescribed olanzapine daily and alprazolam as needed for anxiety or agitation, but persons living at the boarding home are required to dispense their own medication without the oversight of a clinical staff member. Like many patients with schizophrenia, JT doesn't always take his medication, and told the admitting nurse that over the past few weeks he's taken his olanzapine sporadically, resulting in increased agitation and hallucinations. Nonadherance to medications is a significant problem in patients with schizophrenia and often leads to symptom relapse.1

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About schizophrenia

A mental illness that impairs both mental and social functioning, schizophrenia is characterized by positive symptoms that reflect an excess or distortion of normal functions, and negative symptoms that reflect a loss of normal functions.1,2

Positive symptoms can include hallucinations, voices that converse with or about the patient, and delusions that are often paranoid. Negative symptoms include flattened affect, loss of sense of pleasure, loss of will or drive, and social withdrawal.3 For a diagnosis of schizophrenia, the patient must have symptoms for at least 1 month, with some symptoms persisting for 6 months.2

Signs and symptoms of schizophrenia typically develop in the late teenage years or early 20s in men, and in the late 20s or early 30s in women.1 The most significant risk factor is a family history of the illness. Although not supported by evidence, additional risk factors may include poor maternal health during pregnancy, brain injury, and psychodynamic and social factors.3 Social and occupational dysfunction almost always accompany the illness, with the patient not being able to maintain stable relationships or jobs. The patient may need assistance with activities of daily living and encouragement to perform daily functions such as eating and bathing. Day programs or structured group programs can help patients maintain a regular schedule.

Medical therapy for schizophrenia typically includes an antipsychotic medication such as olanzapine, aripiprazole, ziprasidone, risperidone, or quetiapine.4 Adverse reactions to these newer atypical antipsychotic medications can include weight gain, type 2 diabetes, and metabolic syndrome.5 In inpatient psychiatric facilities, some of these medications may be given monthly as an I.M. injection in attempt to improve adherence.

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How to help

Caring for a patient with schizophrenia includes ensuring that prescribed medications are administered as directed. You'll also monitor for adverse drug reactions, in addition to addressing the medical problem that brought the patient to the ICU. Provide JT with information and support to help him make informed decisions about his care.3 Minimize stress and keep safety risks to a minimum.5 Maintain suicide precautions if indicated, and follow your facility's policy for handling a potentially violent patient.

When JT arrives in your ICU, he's awake and alert with stable vital signs. His SpO2 is 95% on 2 L/minute of supplemental oxygen. As you greet him, he answers simple questions appropriately but doesn't provide much information and appears guarded.

Resume his routine antipsychotic medications as soon as possible, to reduce symptom worsening and problematic behavior.5 If JT's routine antipsychotic medications weren't prescribed on admission, ask the healthcare provider to prescribe them as soon as possible. If the medication can't be given orally, check with the pharmacy to determine if it's available in I.V., I.M., or orally disintegrating tablet form.

Work to build and maintain a therapeutic relationship by establishing trust. Remain calm and unhurried and demonstrate acceptance through a nonjudgmental attitude.6,7 Sit down with JT and talk with him, using active listening. Clear communication of expectations, including explaining any procedures and asking permission before performing them, can help establish trust.

Maintaining structure in the patient's environment is essential, as is reality orientation as needed. If JT reports hallucinations, don't challenge him. Reorient him, for example, by saying, "I understand you see a tiger, but I don't see one."

If JT becomes agitated, don't turn your back on him. Remain calm, talk softly, and ask what he needs.6,7 Always be alert of exits and objects in the environment with any patient with a psychiatric illness. If you feel threatened, remove yourself from the situation if able and call security per hospital policy.

Consult psychiatry as soon as possible. A psychiatrist can evaluate JT and review his medication regimen. The psychiatrist also can ensure that JT receives appropriate psychiatric services after his discharge from the hospital.

As JT's condition improves and discharge is planned, talk with the hospital social worker to determine if JT has any needs for assistance upon discharge. If his symptoms are stable and he doesn't need oxygen or physical therapy, he should be able to return to the boarding home. The healthcare provider should complete comprehensive medication reconciliation when JT is discharged. Refer JT to a structured day program for ongoing support upon discharge, and give him information on when to follow up with his primary care provider and psychiatrist.

Schizophrenia is a chronic psychiatric illness that may be seen in various inpatient areas. By understanding the symptoms, common medications, and techniques to communicate and maintain a safe environment, you can feel more confident about caring for patients like JT.

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REFERENCES

1. Schultz SH, North SW, Shields CG. Schizophrenia: a review. Am Fam Physician 2007;75(12):1821–1829.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Arlington, VA: American Psychiatric Association; 2000.
3. Rigby P, Alexander J. Understanding schizophrenia. Nurs Stand. 2008;22(28):49–56.
4. Nurse Practitioners' Prescribing Reference. New York, NY: Haymarket Media; 2010.
5. Hoban S. Caring for a patient with schizophrenia. Nursing. 2010;40(1):44–48.
6. Gilbert SB. Psychiatric crash cart: treatment strategies for the emergency department. Adv Emerg Nurs J. 2009;31(4):298–308.
7. Stanley Hermanns M, Russell-Broaddus CA. But I'm not a psych nurse. RN. 2006;69(12):28–32.
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