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Clinical Consultations: Facilitating a Connection with a Rehabilitation Patient Who Has Schizophrenia
Situation: Mrs. Johnson is a 50-year-old patient on the rehabilitation unit. She has a fractured right hip and a diagnosis of paranoid schizophrenia. The symptoms of her schizophrenia have presented problems for the staff. She accuses staff members of plotting against her and refuses to interact with them. Mrs. Johnson is often overheard speaking loudly when no one is with her. She refuses to take her olanzapine (Zyprexa(r)), an antipsychotic medication, and is not sleeping. Staff members are becoming increasingly frustrated trying to connect with Mrs. Johnson and question whether her goals for recovery can be met.
Schizophrenia has been described as both a sentence and a diagnosis (Torrey, 2001). This mental illness “attacks the very core of what makes us human—the capacities for intimacy, communication, and thought” (Selzer, Sullivan, Carskey, & Terkelson, 1989, p. 33). Nurses are likely to provide care for someone with schizophrenia over the course of their careers. Over 2 million people in the United States suffer from schizophrenia. Patients with schizophrenia have a higher morbidity rate than the general population and are more likely to develop conditions such as diabetes and hypertension (Lambert, Velakoulis, and Pantelis, 2003). In addition to the medical and psychiatric aspects of treatment, healthcare professionals must be mindful of the human being behind the illogical thoughts and bizarre behavior.
Consultation: Susan V. Brammer, PhD RN, is an assistant professor at the University of Cincinnati Raymond Walters College. Address correspondence to her at 9555 Plainfield Road, Cincinnati, OH 45236 or firstname.lastname@example.org.
Mrs. Johnson is exhibiting common symptoms of paranoid schizophrenia, including hallucinations and delusional thinking. Symptoms usually improve if the patient adheres to a regimen of antipsychotic medication. The rehabilitation nurses who care for Mrs. Johnson must find out why she is not taking her medication, which could be for a number of reasons: she may be bothered by side effects, she may not believe that she is ill, she may think that her medication is part of a plot to harm her, she may be accustomed to a different medication.
Nurses should become familiar with the desired and untoward effects of antipsychotic medications. Olanzapine (Zyprexa) is one of the newer, or atypical, antipsychotics. Examples of other drugs of this type are risperidone (Risperdal(r)) and quetiapine (Seroquel(r)). Common side effects of this class of drugs are somnolence, dizziness, and headache. Many of these medications are associated with weight gain and hyperglycemia. A rare but potentially fatal condition associated with antipsychotic medications is neuroleptic malignant syndrome, with symptoms including fever, muscle rigidity, autonomic instability, and altered consciousness (Trigoboff, 2005). Such drug effects underscore the importance of a psychiatrist or psychiatric nurse practitioner managing Mrs. Johnson’s psychiatric medications.
Denial of illness and fixed delusions cannot be quickly treated. Nurses can make inroads, however, by listening, empathizing, and finding common ground with Mrs. Johnson about her health care (Amador, 2000).
Medication, however, is not always effective in controlling symptoms. Twenty-five to 30% of people continue to have auditory hallucinations despite taking medication (Shergill, Murray, & McGuire, 1998). Delusions may also be unresponsive to antipsychotic medications. There are, however, strategies that nurses can utilize with Mrs. Johnson to deal with these symptoms. In the case of auditory hallucinations,
If the voices are telling her to harm herself, do not leave her alone. Clear the environment of potentially dangerous objects. Contact the psychiatrist or psychiatric nurse practitioner immediately. Provide reassurance.
If the voices are telling her to harm someone else, ask who is at risk for harm. Ensure the safety of staff and other patients. Contact the psychiatrist or psychiatric nurse practitioner immediately. Check agency policy for notifying potential victims.
The nurses must first determine what Mrs. Johnson is experiencing. Some people with schizophrenia talk to themselves to rehearse for conversations that they plan to have (Frese, 1993). Mrs. Johnson may respond to a nonthreatening statement such as “you look like you’re hearing voices other than mine right now.” She is also more likely to answer if the nurses don’t argue with her about whether the voices are real. Identify and respond to the feeling behind the hallucination. A statement such as “it must be frustrating to hear voices” sends a message of understanding and empathy. If Mrs. Johnson admits to hearing voices, a direct line of questioning to determine whether there is a safety risk is appropriate.
The feeling behind Mrs. Johnson’s delusion is fear. The nurses can use the following strategies to increase her sense of security:
The more predictable her environment, the safer Mrs. Johnson will feel. The safer she feels with the staff, the more likely she will be to connect with them (Wichowski, 2004).
Sometimes nurses become so engrossed in psychiatric symptoms that they overlook physical needs. The staff must find out why Mrs. Johnson is not sleeping and manage the causes. She should be in a private room, if at all possible, with the door at least partially shut to block out noise. She may not be sleeping because she is in pain. People with schizophrenia have the same need for pain control as everyone else. Mrs. Johnson may be reluctant to report pain, so the staff must be alert for nonverbal cues. The fact that she refuses her antipsychotic medication does not mean that she will refuse pain medication. The staff must also consider the fatigue associated with physical therapy sessions. The sessions may have to be shorter or less frequent until her sleep pattern improves.
An important factor in connecting with Mrs. Johnson is to affirm her humanness (Brammer, 2000). People with schizophrenia have the universal needs of safety and security, love and belonging, and a positive self-esteem. Fostering positive self-esteem is as simple as being kind, respectful, and treating her as a person rather than a diagnosis.
Even though Mrs. Johnson rebuffs staff members’ attempts to interact with her, they must keep trying. The following strategies may help facilitate interactions:
Mrs. Johnson may have a hobby, such as crocheting, that is an important part of her life. She may have children and grandchildren whose pictures she’d like to show off. Current or historical events are possible topics of conversation. Staff members won’t know any of this unless they ask her. Although family members may provide background information about Mrs. Johnson’s interests, staff members should be cautious of such information. Mrs. Johnson may think that such conversations are part of a plot; they may also be a violation of confidentiality.
It is important for the rehabilitation treatment team to consult any case managers, therapists, or psychiatrists who were working with Mrs. Johnson before her hospitalization to help guide expectations by describing Mrs. Johnson’s baseline functioning. Mrs. Johnson may hear voices even when at her very best. The outpatient healthcare professionals are also needed to make realistic plans for discharge. Other resources for the treatment team are groups such as the National Alliance on Mental Illness (NAMI) and the Mental Health Association (MHA). NAMI provides information and support to patients, healthcare professionals, and family members.
Patients with schizophrenia may present many challenges to those providing care. Rehabilitation nurses can optimize communication and interactions by attending to all aspects of their patients’ needs. Taking measures such as controlling pain, providing safety reassurance, and talking about outside interests help the nurse establish a connection with the patient with schizophrenia. Once a connection is established, the nurse and patient can formulate a mutual plan of care and goals for recovery.
Amador, X. (2000). I am not sick I don’t need help! Peconic, NY: Vida.
Brammer, S. (2000). How people with schizophrenia experience connecting with mental health care professionals. Unpublished doctoral dissertation, University of Cincinnati, Cincinnati, OH.
Frese, F. (1993). Twelve aspects of coping for persons with schizophrenia. Innovations and Research, 2(3), 39–46.
Lambert, T. J. R., Velakoulis, D., & Pantelis, C. (2003). Medical comorbidity in schizophrenia. Medical Journal of Australia, 178 (suppl.), S67–S70.
Selzer, M. A., Sullivan, T. B., Carskey, M., & Terkelson, K. G. (1989). Working with the person with schizophrenia: The treatment alliance (p. 33). New York: New York University.
Shergill, S. S., Murray, R. N., & McGuire, P. (1998). Auditory hallucinations: Review of psychological treatment. Schizophrenia Research, 32, 137–150.
Torrey, E. F. (2001). Surviving schizophrenia (4th ed.). New York: Quill.
Trigoboff, E. (2005). Psychiatric drug guide. Upper Saddle, NJ: Prentice Hall.
Wichowski, H. C. (2004). Your patient has schizophrenia—handle with care. Nursing, November 2004. Retrieved October 10, 2005, from http://www.findarticles.com/p/articles/mi_qa3689/is_200411/ai_n9471343.