Psychosis, Mania and Personality Disorders

Caring for Clients Experiencing Psychosis

Psychosis is a clinical state in which an individual experiences an altered perception of reality. Two key features of psychosis are hallucinations and delusions. A hallucination is a sensory perception occurring in the absence of an external stimulus, such as hearing voices or seeing objects that are not present. A delusion is a fixed, false belief firmly held despite contrary objective evidence, such as believing one possesses extraordinary hidden identities or that outside forces are controlling one's thoughts. The practical nurse performs focused data collection by observing both verbal statements and nonverbal indicators of hallucinations, which include unprovoked laughter, head tilting as if listening to someone, or conversing with empty space.

Communication with a client experiencing active psychosis requires a delicate balance of empathy, safety assessment, and reality testing. When a client reports hearing voices, the practical nurse asks the client directly what the voices are saying, paying special attention to whether they give commands. Command hallucinations instructing self-harm or violence toward others present an extreme safety risk and require immediate reporting to the registered nurse along with close safety observation. When speaking with a hallucinating client, the practical nurse validates the client's feelings while clarifying that the nurse does not perceive the sensory stimulus. For example, the nurse might say, 'That sounds very frightening, but I do not hear any voices.' When dealing with delusions, the practical nurse presents reality gently without arguing, debating, or attempting to disprove the client's beliefs. At the same time, the practical nurse must never agree with or validate delusional content, because doing so reinforces the false belief and is completely non-therapeutic.

Managing the clinical environment is essential for keeping a psychotic client safe and comfortable. Reducing noise and other excessive stimuli can help a psychotic client feel less overwhelmed by their surroundings. Practical nurses should also maintain enough light in the room to avoid shadows that may be misinterpreted by the client as threatening figures or shapes. Touching a paranoid or actively hallucinating client without warning can be perceived as an imminent threat and should be avoided entirely. The practical nurse can offer reality-based, structured activities to help the client shift attention away from hallucinations or distress, without expecting the activity to eliminate delusional beliefs. The practical nurse remains vigilant and reports sudden behavioral changes, progressive paranoia, or escalating agitation immediately to the registered nurse.

Pharmacological management of psychosis frequently involves antipsychotic medications, which are commonly prescribed to manage positive psychotic symptoms such as hallucinations, delusions, and thought disorganization. The practical nurse performs focused checks for extrapyramidal symptoms, which include dystonia, akathisia, and pseudoparkinsonism, and reports these findings promptly to the registered nurse. Additionally, the nurse must monitor for neuroleptic malignant syndrome, a life-threatening complication of antipsychotic therapy manifested by high fever, severe muscle rigidity, altered mental status, and autonomic instability. If neuroleptic malignant syndrome is suspected, the practical nurse withholds the antipsychotic, obtains vital signs, initiates the facility's emergency response as indicated, and immediately notifies the registered nurse.