Schizophrenia in the Clinical Setting

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As a nurse, you’ll be caring for patients with mental health conditions regularly, even if you’re not working in a psychiatric environment. And that’s simply because people with conditions such as bipolar disorder, schizophrenia, OCD, depression, and anxiety also require medical care. One of the more complex conditions you’ll be faced with is schizophrenia, which I review here.

In this lesson, we’re exploring how three patients with schizophrenia can present in the clinical setting. Granted, these are generalities meant to familiarize you with the key signs and nursing implications. All patients are unique and some don’t even experience overtly obvious signs and symptoms when their condition is effectively managed. 

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Jacob is a 38-year-old male with a known history of schizophrenia. He is brought to the emergency department by his concerned sister, Lucy. According to Lucy, Jacob has been isolating more over the past three weeks and neglectful of his personal hygiene. When she couldn’t reach him by phone, she visited the group home where he resides and noticed a foul-smelling wound on his lower leg, which also appeared red and swollen. 

Upon arrival at the ER, Jacob is visibly agitated and mistrustful of the medical staff. He is heard muttering to himself and occasionally responding to auditory hallucinations, saying, “No, I won’t let them trap me.” His eyes dart around the room, and he flinches when anyone comes too close, clutching a worn-out backpack as if it contained something precious. His appearance is unkempt, hair is disheveled and doesn’t appear to have been washed recently. He is wearing dark purple pants that are several sizes too large and cinched at the waist with rope. He is also wearing a long sleeved black shirt and a bright red jacket despite the warm spring weather.

When approached by the nurse, Jacob is initially resistant, pulling away and whispering, “They’re trying to take my secrets” as he clutches his backpack. Lucy provides some background information, stating that Jacob often expresses fears that people are conspiring against him. With a calm demeanor, you explain to Jacob that you’re not going to take away his backpack and that Lucy can stay with him during the examination. With gentle coaxing, you finally get Jacob to consent to having his wound examined.

The MD confirms that the wound on his leg is infected. The wound is cleaned and dressed which can be painful, though Jacob declined analgesic medication due to his suspicions. Treatment options are discussed with Jacob and Lucy at length, and Jacob repeatedly questions the purpose of medications, suggesting they are part of a plot to harm him. It is ultimately decided that Jacob will be admitted to ensure adherence to antibiotic therapy. 

The physician also orders a psychiatric consultant. The psych NP comes to see Jacob and recommends adjusting his antipsychotic medications while emphasizing the importance of follow-up with his outpatient psychiatric provider. Since Jacob is being admitted, you will need to search his backpack to ensure it doesn’t contain any weapons or items that could cause harm. You enlist the expertise of the psych NP to navigate this potentially difficult situation. You ensure Jacob can see everything you are doing as you look through his backpack and catalog his belongings and he is ultimately safely transferred to his room on the Med Surg floor.

To summarize: An individual with paranoia related to schizophrenia will display positive symptoms in the form of delusions that are paranoid in nature. He will be unreasonably suspicious and may have auditory hallucinations as well. Negative symptoms often present as an inability to find pleasure in life or show appropriate emotional responses. This is the most common display of schizophrenia.

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Daniel, a 42-year-old male with a diagnosis of schizophrenia with catatonic manifestations, is brought to the hospital by his caregiver due to a concerning shift in behavior. According to the caregiver, Daniel had exhibited increased, purposeless movements for several days, but had suddenly become completely immobile for the past 10 hours. She states, “He was just pacing and repeating everything I said last week, and now… he won’t move at all.”

Upon arrival, Daniel is found sitting rigidly in a wheelchair, his gaze fixed and unblinking. Despite the activity around him, he remains completely still. His caregiver is deeply worried, explaining that Daniel hasn’t had anything to eat or drink since becoming immobile, and that his intake prior to that was minimal due to his increased purposeless movements. She tells you he has not responded to any verbal cues or physical touch since early that morning when the shift in behavior was noticed.

The medical team quickly obtains a set of vital signs, which are: HR 128, BP 88/57, RR 28, SpO2 95% on RA, Temp 98.5. A quick assessment reveals dry mucous membranes and poor skin turgor, which further support a diagnosis of dehydration secondary to the patient’s schizophrenia. 

You attempt to start an IV, but it is difficult due to Daniel’s rigid posture and resistance to being moved. You take care to approach Daniel gently and speak in a calm, reassuring way to minimize any distress he may be feeling. With the help of another nurse, you’re able to start the IV and initiate fluid therapy to address the dehydration.  You obtain a blood glucose level and are relieved to see Daniel is not hypoglycemic, though he is on the lower end of normal. Labs are drawn to assess electrolyte levels and renal function, which you suspect to be impaired due to his hypovolemic status and poor nutritional intake. Daniel is admitted to the Med Surg floor for continued hydration therapy and support.

As you prepare to transfer Daniel to his room, you know his care is going to present some challenges to the nursing staff: 

• Communication Difficulties: Daniel’s catatonia presents significant barriers to communication. His lack of verbal response and immobility will require the staff to use alternative methods to assess his comfort and pain levels. For example, the nurses will need to rely on physiological cues such as changes in vital signs to determine if Daniel could be experiencing pain.
• Physical Management: To prevent injury, Daniel must be handled carefully. Because he is resistant to movement, it’s important the staff don’t use excessive force, which could cause harm and create an environment of distrust. To preserve mobility, passive range-of-motion will be necessary which can be especially challenging with a patient displaying catatonia symptoms.
• Pressure Ulcer Prevention: The risk of pressure ulcers from prolonged immobility is high for Daniel so he will require regular repositioning.
• Nutrition and Hydration: Since Daniel is not responsive, he’ll require IV fluids for hydration and will likely also require enteral nutrition. If this is ordered, the nurse will need to insert a nasogastric tube and initiate tube feeding to provide Daniel with adequate calories.
• Blood Glucose Management: Daniel is at high risk for impaired blood glucose so it will be important to monitor this routinely. Since he will likely be on continuous tube feeds, his blood glucose will likely be measured every four hours to ensure his levels are stable.

To summarize: A patient experiencing signs and symptoms of catatonia could have either a significant decrease in movement to the point of being immobile and resist being moved, or significantly increased movement that lacks purpose. This increased movement may be seen as echopraxia (mimicking the movements of others), bizarre posturing, rocking or echolalia (repeating what others say). Many times patients with catatonic schizophrenia will remain immobile for hours, and avoid eating and drinking. If this condition persists long enough, it is a medical emergency.

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Emma, a 59-year-old woman diagnosed with schizophrenia, has been residing in a mental health hospital for the past two weeks due to an increase in symptoms while her medications are being adjusted. Her symptoms recently intensified further, necessitating her transfer to the intensive care area of the facility.

As you review the nursing notes, you notice that Emma’s disorganized speech and behavior have been pronounced:

• Emma has been observed pacing back and forth in her room, occasionally stopping to mumble or laugh without any apparent stimulus. 
• Her speech has been largely incoherent, characterized by “word salad,” making it difficult for the staff to understand her needs or emotions. 
• At times Emma exhibits a flat affect, showing little to no emotional response, and her interactions lack appropriate facial expressions.
• Emma occasionally uses rhyming saying nonsensical things such as, “It’s time for lunch, crunch the flump stump.” Or “The sun is out, spout the snout, that’s what it’s about.”
• Emma has been extremely distrustful of staff, especially anyone new. This has resulted in a core team being involved in her care. 
• Yesterday, Emma started screaming in the common room, shouting “snake snake snake” over and over while pointing to a tree branch that was just outside the window.
• Emma began laughing uncontrollably when another patient fell in the common room and injured her leg.
• On more than one occasion, Emma has invited staff members to the White House where she serves as Press Secretary and has stood in the front of the common room to issue press briefings that are an amalgamation of grandiose statements, word salad and tangentiality.

Some key nursing interventions employed during Emma’s hospitalization include: 

• Constant Supervision: Emma has been under constant supervision in the intensive care area, ensuring immediate intervention if she engages in behavior that could lead to harm.
• Safe Environment: Emma was moved to the intensive care area to minimize risks as there are fewer potentially harmful objects and a more structured environment.

• Non-confrontational Interaction: Staff approach Emma in a non-threatening manner, maintaining a calm voice and non-threatening body language.
• Engagement in Activities: Emma was involved in simple, structured group activities that did not require complex social interactions but allowed some level of engagement with others. This approach also facilitated monitoring of her social behaviors and adjustment of treatment plans accordingly.

To summarize: A patient experiencing disorganized symptoms related to schizophrenia can have bizarre behavior as well as a flat or inappropriate affect. You may notice this patient has incoherent speech or talks in what is referred to as “word salad.” Behavior are disorganized as well, with an inability to act appropriately in social situations or start and finish tasks. A patient exhibiting these types of symptoms will likely be unable to make proper eye contact or display facial expressions. You may also see disorganized schizophrenia referred to as “hebephrenic schizophrenia.” Note that, like the other subtypes, disorganized schizophrenia is no longer listed as a subtype of schizophrenia in the Diagnositic and Statistical Manual of Mental Disorders (DSM).

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References 

American Psychiatric Association. (n.d.). What Is Schizophrenia? https://www.psychiatry.org/patients-families/schizophrenia/what-is-schizophrenia

Bitter, I. (2011, June 4). Pharmacological Treatment of Schizophrenia. TouchNEUROLOGY. https://touchneurology.com/pharmacological-treatment-of-schizophrenia/

Brazier, Y. (2017, December 22). Catatonic Schizophrenia: Causes, Symptoms, and Treatment. https://www.medicalnewstoday.com/articles/192263

Cagliostro, D. (2018). 5 Schizophrenia Subtypes. Psycom.Net – Mental Health Treatment Resource Since 1986. https://www.psycom.net/schizophrenia-5-subtypes

Caspi, A., Davidson, M., & Tamminga, C. (n.d.). Treatment-refractory schizophrenia – PMC. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181784/

Cleveland Clinic. (2018, November 7). What Are the 4 Types of Schizophrenia and How Do They Affect You? Health Essentials from Cleveland Clinic. https://health.clevelandclinic.org/what-are-the-4-types-of-schizophrenia-and-how-can-they-affect-you/

Cleveland Clinic. (2022a). Catatonic Schizophrenia: What It Is, Symptoms & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/23499-catatonic-schizophrenia

Cleveland Clinic. (2022b). Paranoid Schizophrenia: What It Is, Symptoms & Treatment. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/23348-paranoid-schizophrenia

Haghighi, A. S. (2022, June 29). What is residual schizophrenia? MedicalNewsToday. https://www.medicalnewstoday.com/articles/residual-schizophrenia

Hugdahl, K., Løberg, E.-M., Specht, K., Steen, V. M., van Wageningen, H., & Jørgensen, H. A. (2008). Auditory hallucinations in schizophrenia: the role of cognitive, brain structural and genetic disturbances in the left temporal lobe. Frontiers in Human Neuroscience, 1. https://doi.org/10.3389/neuro.09.006.2007

Hurley, K. (2023, March 1). Disorganized Schizophrenia (Hebephrenia): Symptoms & Treatment. HealthCentral. https://www.healthcentral.com/condition/schizophrenia/disorganized-schizophrenia-hebephrenia

Lintunen, J., Lahteenvuo, M., Tiihonen, J., & Tanskanen, A. (n.d.). Adenosine modulators and calcium channel blockers as add-on treatment for schizophrenia | Schizophrenia. Retrieved January 11, 2022, from https://www.nature.com/articles/s41537-020-00135-y

Lintunen, J., Lähteenvuo, M., Tiihonen, J., Tanskanen, A., & Taipale, H. (2021). Adenosine modulators and calcium channel blockers as add-on treatment for schizophrenia. Npj Schizophrenia, 7(1), 1–7. https://doi.org/10.1038/s41537-020-00135-y

Last Updated on March 29, 2026 by Maureen Osuna, MSN, RN