Paranoid schizophrenia, what must the nurse assess? How do they go about assessing? Upon assessing, how will the nurse manage the outcomes of the assessment? These important questions are what this paper will resolve. Through review of recent literature into the assessment and management of individuals affected by paranoid schizophrenia, this paper will discuss in detail how the nurse goes about assessing the patient, why assessment is vital, common outcomes of the assessment and finally go into detail on how the nurse manages a patient with paranoid schizophrenia.
Stein-Parbury (2009) discuss the importance of providing an environment without distractions for an assessment to occur in, as this enhances the ability of both the patient and nurse to listen and understand. This can assist with patients with paranoid schizophrenia, experiencing perceptual disturbances or delusions. It is also important to provide a space that is private, thus giving the patient a sense of safety in disclosing personal information. Snyderman and Rovner (2009) highlight the importance of using a Mental State Examination (MSE), to assess the patients’ mental state and to aid in diagnosing a patients’ mental illness through identifying a range of sections including thought form, content and mood. It also enables the treating team to formulate a plan individualised to the patients needs.
The following areas should be assessed in a mental state examination (MSE). Appearance including the physical characteristics, age, the way in which the patient is appropriately dressed according to weather or environment and how they have attended to their personal hygiene (Shives, 2008). Patients suffering acute periods of illness resulting from their paranoid schizophrenia commonly have poor attention to their self care and grooming, their general appearance is can be identified as dishevelled or unkempt (Edward, Munro, Robins & Welch, 2011). Affect refers to how patients emotionally respond at that present time (Shives, 2008). Patients with paranoid schizophrenia may appear to look perplexed or restricted, due to distraction caused by perceptual disturbances and/or the delusional thought processes, resulting in a restricted range of emotional expressions (Barling, 2009). Mood refers to how the patient describes their feelings or how they are feeling (Shives, 2008). Mood may vary depending on what the current symptoms are that the patient is experiencing (Bradford, Perkins & Lieberman, 2003), For example, individuals affected by psychotic symptoms are likely to become agitated and frustrated. Delusional material may cause patients to have a suspicious mood (Bradford, Perkins & Lieberman, 2003). Assessment of behaviour and/or motor activity looks at the level of cooperativeness and compliance whether it is as an inpatient or outpatient in the community, looking at any change in motor activity in regards to bizarre movements or psychomotor agitation (Shives, 2008). Psychotic symptoms of paranoid schizophrenia can contribute to the type of behaviour assessed, such as minimal eye contact due to auditory hallucinations and the inability to concentrate or particular medication like clozapine which often causes side effects such as tardive dyskinisia (Walther, Horn, Razavi,Koschorke et al, 2009). Speech assessment and observation of rate, tone and volume, allows the manner in which the patients have difficulties in thought processing or communication (Shives, 2008). Thought processes and content is an area that needs to be assessed during the processes of communication with patients. Thought processes can be identified through how patients put their ideas together. (Shives, 2008). Patients with paranoid schizophrenia often have delusions that can vary in type, such as of a persecutory nature, believing that people, types of people or groups of people are out to get them or are talking about them (McMurran, Khalifa & Gibbon, 2008). Thought content is another important area the nurse must assess. Delusions of a paranoid nature are common in patients with psychotic illnesses, causing an impairment in their ability to comprehend and understand people or the environment around them, which can lead them to behaving impulsively due to the lack of awareness of what’s going on around them (Bentall, Rowse, Shryane, Kinderman , Howard et al, 2009). It is important to ascertain if patients are having any suicidal thoughts, plans or intent, as this is an aspect of care when assessing patient’s level of risk (Edward, Munro, Robins & Welch, 2011). Perceptual disturbances is an element that requires assessment during and MSE, to ascertain symptoms that may assist the treating team in diagnoses, patient response to treatment and risks. (McMurran, Khalifa & Gibbon, 2008). Auditory hallucinations being a common form of perceptual disturbance in someone with paranoid schizophrenia comprise of such things like a patient reporting voices that are like running commentary, voices expressing their thoughts out loud to everyone or voices discussing the patient among themselves (McMurran, Khalifa & Gibbon, 2008), other forms of perceptual disturbance include: visual, tactile and olfactory. MSE’s also entail assessment of patient’s orientation and memory. Orientation often refers to time, place and person, meaning if they are able to establish where they are, who they are and the time and/or date (Shives, 2008). Patients with paranoid schizophrenia often have difficulties with memory and orientation due to their cognitive functioning being impaired, whether this is predominantly the illness or partially due to side effects of treatment (Aubin, Stip, Gélinas, Rainville & Chapparo, 2009). Judgement is an aspect of an MSE that can be assessed by how well the patients decision making is, with awareness of consequences of their actions and anything that may be affecting their judgement such as medication, illicit substances, withdrawal from drugs and/or alcohol or psychotic symptoms (Corcoran, Cummins, Rowse, Moore, Blackwood et al, 2006). Delusions of a certain nature frequently play a role in impaired judgement of patients with paranoid schizophrenia. Assessment of a patients insight who has paranoid schizophrenia, is to establish the patients full, partial or nil awareness of their illness, treatment and necessary ongoing management for them to stay healthy (Shives, 2008).
Falls risk can be of great concern for patients being treated on in a psychiatric inpatient service. Assessment of these risks can be accounted for, for several different reasons. Medications may contribute to increased falls risks due to side effects such as dizziness, hypotension and alertness (Edmonson, Robinson & Hughes, 2011). Patients diagnosed with paranoid schizophrenia may have altered judgement and inability to interpret environmental hazards, either due to their psychotic symptoms or through lack of sleep due to psychotic symptoms (Edmonson, Robinson & Hughes, 2011).
Risk assessments are an important aspect of assessing any patient with a mental illness. In a patient with paranoid schizophrenia, they may be suffering with positive symptoms such as command auditory hallucinations of an aggressive nature, increasing the likely risk of becoming violent (Balaratnasingam, 2011). Many different tools are used to formulate a risk assessment. Different services may have different policies and procedures to formulate a risk assessment. Risk assessments are utilised to focus on the patient’s individual needs. Risk assessments are also designed to manage and identify areas of concern, either to the patient or health professional’s involved in the care of the patient. Areas of risk assessment may include suicide or self harm, absconding, aggression or violence, substance use, vulnerabilities and neglect, non adherence or compliance. These areas of assessment may include past risk and current risk factors (Edward, Munro, Robins & Welch, 2011). Risk assessment of the patient is important but also risk towards others. Patients with paranoid schizophrenia are more opportunistic in behaving aggressively or violently towards co-patients and/or staff, which is why implementation of such assessment tools have been put in place (Langan, 2008).
Upon completion of regular risk assessment screening tools the nurse must implement measures to minimize risks which have been identified. Good examples of this on an inpaitent unit are increased visual observations, the use of PRN medication, utilising the low stimulus environment of the acute management area, increased one-on-one time with the patient to deescalate the situation.
Substance use is of particular importance for the mental health nurse to assess. It enables the treating team to have an understanding of contributing factors to the patients relapse, helps identify if there are any risks which need to be controlled due to withdrawal whilst an inpatient, and also helps to identify any areas in which the treating team can work with the patient to resolve substance abuse issues, if the patient is willing to do so (Saddichha, Sur, Sinha & Khess, 2010). In order to assess whether or not a patient is willing to address their substance use, the nurse can utilise the stages of change model. This model includes stages such as pre-contemplative, contemplative, preparation, action, maintenance and relapse. It is a circular model, which individuals can work their way around, often several times ending in relapse and beginning again when they feel ready. With dual diagnosis playing such an integral role on modern day mental health it is vital that the nurse assesses both substance use and patients willingness to address these issue, and refer on to drug and alcohol services as appropriate (Mental Illness Fellowship Victoria, 2005).
The vast majority of patients being treated for schizophrenia will likely be managed with antipsychotic medication, based on the presenting and ongoing symptoms and the severity. With this being the case, antipsychotic medications often have side effects that need to be monitored regularly by the health professionals (Young et al, 2011). Compliance is often a challenge with patients either because of the unmanageable side effects they experience or through limited insight. It is a role of the health professionals involved in the care to closely monitor this behaviour, as the effectiveness of the treatment may be affected (Young et al, 2011). Keller, Drexler &Lichtenberg (2009) discuss the benefits of treating paranoid schizophrenia with atypical antipsychotic medication clozapine and Electroconvulsive Therapy (ECT). However both forms of treatment are linked with harsh side effects. As a nurse it is important to manage these side effects as best possible . Thus relieving anxiety related to treatment, ensuring healthy outcomes for the patient, this is making physical health an important aspect of management (Keller, Drexler &Lichtenberg, 2009).
Physical health is an area that is of equal importance to a patient’s mental health. With the treatment of schizophrenia frequently resulting in antipsychotic medication, this brings about the need to manage patient’s physical status, as such side effects as increased weight gain may hinder the recovery process, through patients becoming non-compliant, poor self esteem resulting in further social isolation and further lowered mood (Dunbar, Brandt, Wheeler & Harrison, 2010).
Psycho education for patients with paranoid schizophrenia improves adherence to treatment and medication compliance, also giving them a sense of empowerment into their illness and treatment. This also enables the patient to begin to take responsibility of their own mental illness, through being able to identify triggers of relapse themselves, this reducing the admissions to hospital, through patients being able to seek help before the become acutely unwell (The Royal Australian & New Zealand College of Psychiatrists, 2004). Also involving the family or people who are in regular close contact with the patient, gives not only the patient a stronger support system, but allows close family and friends to be involved and educated in the treatment and management process, and often helps families to gain a deeper understanding of their loved ones illness (The Royal Australian & New Zealand College of Psychiatrists, 2004).
Another form of management mental health nurses must use is the use of psychotherapy, such as Cognitive Behavioural Therapy. Brabban, Tai & Turkington (2009) discusses the benefits of Cognitive Behavioural Therapy (CBT) in patients with paranoid schizophrenia.CBT has been linked to improve socialisation, improvement of communication skills, significant behavioural modification and changes in patients emotional response to situations which in the past would bring about distress. Developing a therapeutic relationship is an important aspect in nursing management, with this being achieved through empathy and goal setting, whilst maintaining professional boundaries, are seen to assist in developing a therapeutic relationship in patients with paranoid schizophrenia (Evans-Jones, Peters & Barker, 2009).
Paranoid schizophrenia can be a debilitating illness, however with continual consistent management, it is something that can.....CONCLUSION

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