11.4 Applying the Nursing Process to Schizophrenia

The focus of the nursing process for a client with a thought disorder should center on providing client-centered care that addresses the individual’s unique needs and experiences. This includes a holistic approach that considers emotional, cognitive, and social factors, while ensuring safety and minimizing risks of self-harm or harm to others. The actions taken by the nurse will differ depending on which phase of the illness the client is in: acute, stabilization, or maintenance.

Assessment (Recognizing Cues)

Assessment includes several components, such as a mental status examination, psychosocial assessment, cultural assessment, spiritual assessment, screening with validated tools, reviewing laboratory testing results, and including lifespan considerations.

Mental Status Examination

The nursing assessment adapts to the client’s phase of illness, with a focus on acute symptom management in the acute phase, treatment response and stabilization in the stabilization phase, and long-term functional and psychosocial support in the maintenance phase.

During the acute phase, the assessment focuses on identifying and managing positive psychotic symptoms such as hallucinations, delusions, and disorganized speech or behavior. Assessing the severity and impact of these symptoms on the client’s functioning, as well as assessing for any immediate safety concerns, including risk of harm to self or others.

In the stabilization phase, the assessment shifts towards monitoring the reduction of acute symptoms and the emergence of any residual symptoms. This phase often involves evaluating the client’s response to treatment, adherence to medication, and the presence of any side effects. The focus is also on assessing the patient’s cognitive function, mood, and overall ability to engage in daily activities.

During the maintenance phase, the assessment is more comprehensive and long-term, focusing on the management of residual symptoms, particularly negative symptoms such as social withdrawal, apathy, and flat affect. the assessment should include evaluating the client’s support systems and any potential stressors that could trigger a relapse.

Common findings during a mental status examination for a client with schizophrenia who experiencing an acute psychotic episode are described in Table 11.4a. Review information about performing a mental status examination and psychosocial assessment in the “Application of the Nursing Process in Mental Health Care” chapter. It is also important to assess for suicide risk for clients with psychosis. Review how to assess for suicide risk in the “Foundational Mental Health Concepts” chapter.

Table 11.4a Common Findings During a Mental Status Examination for Individual With Schizophrenia Experiencing an Acute-Psychotic Episode^[1]

When assessing hallucinations, do not imply the perceptions are real. For example, a nurse should ask the client, “What do you hear?” not “What are the voices saying?” It is important to assess for command hallucinations, such as, “Are you hearing a voice that is telling you to do something,” followed by, “Do you believe what you hear is real?” If the answer is “Yes,” the client is at increased risk for acting on the command. Assess when the hallucinations began, their content, and the manner in which the client experiences them (i.e., Are they supportive or distressing? In the background or intrusive?). Ask what makes them worse or better, how the client responds, and what they do to cope with the hallucinations.^[2]

When assessing delusions, determine if the client is capable of reality testing (i.e., questioning their thoughts and determining what is real). Ask the client if they believe there is any danger related to the delusion.^[3]

Countertransference, which refers to the nurse's or health care professional's emotional reactions to a client, can be particularly complex when working with individuals diagnosed with schizophrenia. These reactions can be intense and multifaceted. Understanding and managing countertransference is crucial for effective interventions with this population, as it can significantly impact the nurse-client therapeutic relationship and the client's progress.

Psychosocial Assessment

As previously discussed in the “Application of the Nursing Process in Mental Health Care” chapter, a psychosocial assessment obtains additional subjective data that detects risks and identifies treatment opportunities and resources.^[4],[5]:

• Reason for seeking health care (i.e., “chief complaint”)
• Thoughts of self-harm or suicide (both current and historical)
• Cultural assessment
• Spiritual assessment
• Family dynamics
• Current and past medical history
• Current medications
• History of previously diagnosed mental health disorders
• Previous hospitalizations
• Educational background
• Occupational background
• History of exposure to psychological trauma, violence, and domestic abuse
• Substance use (tobacco, alcohol, recreational drugs, misused prescription drugs)
• Family history of mental illness
• Coping mechanisms
• Functional ability/Activities of daily living

After identifying the reason the client is seeking health care, additional focused questions are used to obtain detailed information used to plan care. The mnemonic PQRSTU can be used to ask questions in an organized fashion. See Table 11.4b for a sample PQRST assessment for a client with schizophrenia and sample responses.

Table 11.4b Sample PQRSTU Questions for Assessing Depression

Suicide and Self Injury Screening

Clients with schizophrenia may have hallucinations commanding them to commit suicide or self harm or injure others.  The Patient Safety Screener (PSS-3) is an example of a brief screening tool to detect suicide risk in all client presenting to acute care settings.^[6]

Non-suicidal self-injury (NSSI) refers to intentional self-inflicted destruction of body tissue without suicidal intention and for purposes not socially sanctioned. Common forms of NSSI include behaviors such as cutting, burning, scratching, and self-hitting. It is considered a maladaptive coping strategy without the desire to die. NSSI is a common finding among adolescents and young adults in psychiatric inpatient settings.^[7]

Review information about suicide screening, the Patient Safety Screener, and screening for non-suicidal self-injury (NSSI) in the "Assessment" section of the Applying the Nursing Process to Mental Health Care" chapter.

Cultural Assessment

Cultural Formulation Interview (CFI) questions help nurses understand a client’s cultural background and how it influences their experience of mental health symptoms, including psychosis.^[8] Sample CFI questions focused specifically on understanding depression within a cultural context include the following:

• Cultural Definition of the Problem
  • “How would you describe the problems you are having with your thoughts or experiences?”
  • “Are there any names or terms your family or community use for these experiences?”
  • “How do other people in your culture view experiences like hearing voices or seeing things?”
• Cultural Perceptions of Cause, Context, and Support
  • "What do you think is causing you to hear voices?”
  • “Do you have any cultural or spiritual beliefs that help explain what you’re going through?”
• Cultural Factors Affecting Coping and Help-Seeking
  • “What kinds of things have you done to cope with hearing these voices?”
  • “Are there any traditional remedies, rituals, or religious practices you use to feel better?”
  • “Have you tried to talk to anyone about these experiences, like family members, friends, religious leaders, or traditional healers?”
• Cultural Features of the Nurse–Client Relationship
  • "“Is there anything I should know about your background or beliefs that would help me better understand you?”
  • “Do you have any concerns or hesitations you have about seeing a mental health professional?”
  • “What kind of help do you think would work best for you?”

Findings from the cultural formulation interview are used to individualize a client’s plan of care to their preferences, values, beliefs, and goals.

Spiritual Assessment

The FICA Spiritual History Tool is a widely used assessment model for evaluating a client’s spiritual beliefs and how they may influence health, illness, and coping.  FICA© is a mnemonic for the domains of Faith, Importance, Community, and Address in Care.^[9] The data obtained from a FICA assessment can be helpful in understanding how clients with schizophrenia draw on spirituality or religion for support. Addressing a client’s spirituality and advocating spiritual care have been shown to improve clients’ health and quality of life.^[10],[11]

Table 11.4c summarizes a sample spiritual assessment questions and sample responses from a client with schizophrenia.

Table 11.4c Sample FICA Spiritual Assessment Questions For Clients With Schizophrenia

Clients with schizophrenia may expresses religious delusions or spiritual distress. They may express a desire for clarity and connection. Nurses may recognize cues of spiritual distress and offer to connect the client with a chaplain or spiritual care services. Spiritual goals may be included in the nursing care plan if the client finds them valuable.

Family Dynamics

Family dynamics are included in a psychosocial assessment, especially for children, adolescents, and older adults. Family dynamics refers to the patterns of interactions among relatives, their roles and relationships, and the various factors that shape their interactions. Because family members rely on each other for emotional, physical, and economic support, they are primary sources of relationship security or stress. Family dynamics and the quality of family relationships can have either a positive or negative impact on an individual’s health. For example, secure and supportive family relationships can provide love, advice, and care, whereas stressful family relationships can be burdened with arguments, unhealthy relationships, and a lack of support.^[12] When possible, assess family members and significant others' knowledge of the client’s illness and their response. Are they overprotective, frustrated, or anxious? Are they familiar with family support groups, respite, and other community resources?^[13]

Unhealthy family dynamics can cause children to experience trauma and stress as they grow up. This type of exposure, known as adverse childhood experiences (ACEs), is linked to an increased risk of developing physical and mental health problems.^[14] Review information about adverse childhood experiences (ACEs) in the "Mental Health and Mental Illness" section of Chapter 1.

Assessment of Activities of Daily Living

Assess the client’s ability to perform activities of daily living. Are they getting adequate food, fluid, sleep, and rest? Are they completing daily hygiene tasks and dressing safely for weather conditions? Are they able to control their impulses and make safe decisions?^[15] Nursing interventions related to the physiological symptoms of schizophrenia are discussed in the "Implementation" section.

Current Medications and Adverse Effects

During the assessment, nurses assess if the client is taking their medications as prescribed, their effectiveness, and if they are experiencing side effects. Are there any barriers to medications or other treatment, such as cost, stigma, or mistrust of health care providers?^[16]

Nurses also assess for adverse effects of medications, such as involuntary movements associated with the use of antipsychotic medications (e.g., extrapyramidal side effects or tardive dyskinesia). Clients are routinely assessed for these adverse effects using scales like the Abnormal Involuntary Movement Scale.

Laboratory Testing

The potential laboratory tests and diagnostic procedures for a client with schizophrenia vary depending on whether the client is in the acute phase, stabilization phase, or maintenance phase. During the acute phase, the focus is on identifying any immediate medical issues that could be contributing to the psychotic symptoms and ensuring the client's safety. Ensure the client has had a medical workup for other potential causes of psychosis. For example, dehydration, infection, electrolyte imbalances, abnormal blood glucose level, substance use, or withdrawal from substances can cause psychosis. Concurrent medical disorders are common and should be treated in addition to treating schizophrenia.

In the stabilization phase, the focus shifts to monitoring the client's response to treatment and managing any side effects of medications. During the maintenance phase, the goal is to ensure long-term stability and prevent relapse. If the client is currently taking psychotropic medications, therapeutic drug levels of some types of medications are required. As always, review current information from a medication reference before administering medications.

Life Span Considerations

Life span considerations influence how the client is assessed, as well as the selection of appropriate nursing interventions. It is important to individualize all interventions to the age and developmental level of the client. Review developmental stages in the “Application of the Nursing Process in Mental Health Care” chapter.

Children and Adolescents

Onset is  of schizophrenia is rare before age 13, but incidence increases in late adolescence and early adulthood. It may be preceded by years of social withdrawal, academic decline, or odd behavior. Children may experience hallucinations (especially auditory), delusions, and disorganized speech/behavior. They may exhibit poor school performance, sleep disturbances, social isolation, or irritability. There is an increased risk of substance use, self-injury, and suicide in adolescents with schizophrenia.

Older Adults

New-onset schizophrenia after age 45 is uncommon. Symptoms may be attributed to delirium, dementia, or sensory impairment (e.g., hearing loss). Polypharmacy and comorbidities complicate diagnosis. In addition to hallucinates, older adults with schizophrenia may include persecutory ideation (e.g., believing a family member is stealing from them or poisoning their food).

Diagnosis (Analyzing Cues)

Mental health disorders like schizophrenia are diagnosed by mental health providers using the DSM-5. Nurses create individualized nursing care plans based on the client’s responses to their mental health disorders. See Table 11.4d for a list of common nursing diagnoses and human responses related to schizophrenia.

Table 11.4d Common Nursing Diagnoses Related to Schizophrenia^[18],[19]

Outcome Identification (Generate Solutions)

Outcomes should be consistent with the recovery model and emphasize hope, resilience, living a full and productive life, and recovery from illness. Expected outcomes are identified based on the client’s current phase of their illness: acute, stabilization, or maintenance^[20]:

• Acute: The overall goal in the acute phase of schizophrenia is client safety and stabilization. An example of an expected outcome is, “The client will consistently be able to label their hallucinations as ‘not real’ and a symptom of their illness by discharge.”^[21]
• Stabilization: Goals during the stabilization phase focus on understanding the illness and the prescribed treatment plan, as well as controlling and/or coping with symptoms using an optimal medication and psychosocial treatment regimen. Outcomes typically target negative and cognitive symptoms of schizophrenia during this phase because these symptoms respond less well to initial medication treatment than do positive symptoms.^[22] An example of an expected outcome during the stabilization phase is, “The client will establish two goal-directed activities by the end of the shift.”
• Maintenance: Goals during the maintenance phase focus on maintaining and increasing symptom control and optimal functioning. Factors include treatment adherence, increasing independence, and a satisfactory quality of life.^[23] An example of an expected outcome during the maintenance phase is, “The client will identify advantages for taking medications by the end of Week 2.”

Planning (Generate Solutions)

Safety

Clients with command hallucinations require close monitoring for suicide, homicide, and other violence risk. Implement interventions to reduce risk of suicide as described in the “Application of the Nursing Process in Mental Health Care” chapter.

Interpersonal conflict, paranoia, delusions, impaired judgment, limited impulse control, fear, and disagreement with unit rules increase the risk for aggressive behavior.^[24] Nursing interventions addressing increased risk for violence to self and others are described in the following box. Read more about recognizing signs of crisis and crisis interventions in the “Stress, Coping, and Crisis Intervention” chapter.

Acute Phase of Schizophrenia

Hospitalization is indicated during the acute phase of schizophrenia if the client is considered a danger to self (e.g., refuses to eat or is too disorganized to function in the community) or to others (e.g., is behaving in a threatening manner to others).^[26] During this phase, planning focuses on selecting interventions that focus on client safety and management of acute symptoms.

During the acute phase of schizophrenia, hospitalization provides safety, structure, and support. As discussed earlier, anosognosia may impair the client’s ability to recognize their mental illness. In this case, court-ordered hospitalization may be required.^[27] Read more about court-ordered hospitalization in the “Legal and Ethical Considerations in Mental Health Care” chapter. Nursing interventions focus on providing safety, promoting hygiene and nutrition, improving socialization, encouraging hope and self-esteem, preventing falls, using specific therapeutic techniques, addressing physiological needs, and implementing collaborative interventions.

Stabilization and Maintenance Phases

During the stabilization and maintenance phases, planning focuses on education, support, and skills training for the client and family. It also addresses how and where these needs can be met within the community. As explained previously in this chapter, relapse prevention efforts are vital. Each relapse can increase residual dysfunction and deterioration and can contribute to despair, hopelessness, and suicide risk. Additionally, recognizing early signs of relapse (e.g., reduced sleep, social withdrawal, and worsening concentration) and implementing intensive treatment are needed to minimize the disruption of the client’s life.^[28]

Implementation (Take Action)

Acute Phase

Promote Hygiene and Nutrition

Promote hygiene in clients experiencing psychosis by concisely and explicitly stating expected hygiene tasks. Break tasks into smaller, more manageable tasks and assist when needed. Use visual cues to prompt hygiene tasks, such as putting clean clothes on the bed or clean towels and a toothbrush in the bathroom. Share potential benefits of improved hygiene such as improved socialization with others. Reinforce progress in performing hygiene with verbal praise or concrete rewards like additional privileges on the unit.^[29]

Clients who are experiencing catatonia require assistance with nutrition, as well as other activities of daily living.

Improve Socialization

Regularly engage with the client. Initially interact briefly about low-anxiety topics like the weather and gradually increase the duration and frequency of interactions as they become more comfortable. Encourage clients to participate in unit activities without pressure, such as “We would like to see you at the morning meeting.” Reinforce the client’s control in their choices, such as, “If you become uncomfortable in the group, you can leave and try again on another day.” Provide positive reinforcement for attempts at socialization, such as, “It was nice to see you in the morning meeting today.”^[30]

Encourage Hope and Self-Esteem

Convey unconditional acceptance, empathy, and support. For example, say, “Sometimes it can feel very discouraging when experiencing a mental health disorder. I am wondering how you are feeling?” If the client cannot identify their feelings, suggest words that may apply, such as, “Sometimes it is hard to say what you are feeling. Do you feel sad, frustrated, or anxious?” Validate the client’s feelings and assure them they are not alone. Help the client identify their positive traits or previous accomplishments. Suggest coping strategies such as journaling and attending a support group. Teach stress management techniques and coping strategies as outlined in the “Stress, Coping, and Crisis Intervention” chapter.

Prevent Falls

Fall risk may be increased due to orthostatic hypotension, impaired balance, bradykinesia, or other movement disorders. Assess the client’s gait and for orthostatic hypotension. Teach the client to slowly change position from lying to sitting to standing and encourage the use of handrails or seeking assistance when feeling unsteady. Implement additional fall precautions as needed according to agency policy.

Use Therapeutic Techniques for Cognitive Impairments, Delusions, and Hallucinations

Recall that clients with schizophrenia may have memory and attention impairments. Repetition with visual and verbal reminders is helpful to promote task completion. Additionally, short but frequent interactions may be less stimulating to the client and better tolerated.^[31] Additional techniques for helping clients who are experiencing delusions and hallucinations are described below.

Helping Clients Who Are Experiencing Delusions

Delusions feel very real to the client and can be frightening. Nurses should acknowledge and accept the client’s experience and feelings resulting from the delusion while conveying empathy. They can provide reassurance regarding their intentions to help the client feel safer.

Avoid questioning the delusion. Until the client’s ability to test reality improves, trying to prove the delusion is incorrect can intensify it and cause the client to view the staff as people who cannot be trusted. Instead, focus on the fear and what would help the client feel safer. For example, if a client states, “The doctor is here. He wants to kill me,” the nurse could respond, “Yes, the doctor is here and wants to see you. They talk with all of the clients about their treatment. Would you feel more comfortable if I stayed with you during your meeting with the doctor?” Focusing of events in the present keeps the client focused on reality and helps them distinguish what is real.^[32]

If a client is exhibiting paranoia and is highly suspicious, it is helpful to maintain consistent staff assignments. Staff should avoid laughing, whispering, or talking quietly where the client can see these actions but cannot hear what is being said. Staff should ask permission before touching the client, such as before taking their blood pressure.

Helping Clients Who Are Experiencing Hallucinations

Hallucinations feel very real to the person experiencing them and can be distracting during their interactions with others. Hallucinations can be supportive or terrifying, faint or loud, or episodic or constant. For example, listen to simulations of auditory hallucinations in the following box. The nurse should focus on understanding the client’s experiences and responses and convey empathy. Command hallucinations, suicidal ideation, or homicidal ideation requires safety measures as previously discussed in the “Provide Safety” subsection.

Categorizing Nursing Interventions According to the APNA Standard of Implementation

Interventions for clients experiencing psychosis previously discussed in this chapter can also be categorized by the standard of Implementation by the American Psychiatric Nursing Association (APNA). Read more about this standard in the “Application of the Nursing Process in Mental Health Care” chapter. See Table 11.4e for categorization of nursing interventions by this standard.

Table 11.4e Nursing Interventions for Clients with Psychosis Based on the Categories of the APNA Implementation Standard^[39]

Nursing Interventions for Physiological Signs of Schizophrenia

While schizophrenia is a psychiatric condition, it frequently presents with or leads to physiological health concerns due to self-neglect, poor insight, medication side effects, and lifestyle disruptions.  Nursing interventions  target common physiological signs of schizophrenia and associated self-care deficits as described in Table 11.4f.

Table 11.4f Nursing Interventions Targeting Physiological Signs of Schizophrenia^[40]

Communication Tips for Clients With Schizophrenia

Helpful communication techniques for clients with schizophrenia are described in the following box.

Stabilization Phase

During the stabilization phase of schizophrenia, care is focused on ongoing medication therapy, education, and CBT therapy.^[41]

• Medication Management: Continue to monitor the effectiveness and side effects of antipsychotic medications. Adjust dosages as needed to minimize side effects and ensure therapeutic efficacy.
• Psychoeducation: Educate the client and their family about the illness, treatment options, and the importance of medication adherence.
• Therapeutic Interventions: Introduce cognitive-behavioral therapy for psychosis (CBTp) to help the client develop coping strategies and reduce the impact of psychotic symptoms.

Maintenance Phase

Effective long-term management of individuals with schizophrenia requires a comprehensive, multidisciplinary approach that extends beyond symptom control.

• Ongoing Monitoring: Regularly assess the client's mental status, medication adherence, and side effects. Monitor for signs of relapse and intervene early to prevent full-blown episodes.
• Supportive Services: Provide supported employment services and assertive community treatment to help the client maintain social and occupational functioning.
• Lifestyle and Wellness: Encourage healthy lifestyle choices, including regular exercise, a balanced diet, and smoking cessation. Monitor metabolic parameters, as antipsychotic medications can increase the risk of metabolic syndrome. Ongoing monitoring of the client's functional status, social integration, and quality of life.

Evaluation (Evaluate Outcomes)

A client’s progress is continually assessed using their individualized SMART outcomes and current status. Full recovery can take months. By setting small goals, it is easier to identify and recognize progress that may occur in small increments.^[42]

Acute Phase

During the acute phase of schizophrenia treatment, the primary focus is on symptom severity, safety, and the client’s immediate response to intervention. Clinicians assess changes in the Positive and Negative Syndrome Scale (PANSS) scores to determine whether there has been a reduction in the frequency and intensity of hallucinations, delusions, or other psychotic features. Monitoring for safety is also crucial—evaluating any shifts in the client’s risk of harm to self or others, and observing improvements in their ability to follow safety protocols within the treatment setting. In addition, the client’s immediate response to antipsychotic medications is closely observed. Providers track how quickly the symptoms respond to treatment and whether any side effects emerge that could impact further care decisions.^[43]

Stabilization Phase

In the stabilization phase, ongoing symptom monitoring helps ensure the client's progress continues. Updated PANSS scores are compared to both the baseline and acute-phase scores to evaluate trends. Clinicians identify any residual symptoms that persist and outline strategies for their management, such as medication adjustments or therapeutic interventions. Medication adherence becomes a central concern—providers assess whether the client is consistently following the prescribed regimen and address any side effects that may compromise adherence. This phase is key in solidifying gains made during acute care and building a foundation for long-term stability.^[44]

Maintenance Phase

The maintenance phase focuses on sustaining symptom remission and promoting recovery. Long-term tracking of PANSS scores helps clinicians evaluate symptom stability over time and detect early signs of relapse. Intervention strategies are adjusted accordingly to prevent deterioration. Equally important is evaluating the client’s quality of life using standardized tools like the Heinrichs-Carpenter Quality of Life Scale (QLS). Providers assess improvements in the client’s ability to engage in meaningful social relationships and maintain occupational or educational roles. Preventing relapse remains a central goal during this phase; clinicians monitor medication adherence rates and identify any new stressors or triggers that could threaten stability. Preventive measures, such as psychoeducation, structured routines, and early intervention strategies, are implemented to support ongoing recovery and well-being.^[45]