SCHIZOPHRENIA

Introduction

Eugen Bleuler (1857–1940) was a Swiss psychiatrist who coined the term schizophrenia and contributed to the understanding of the disorder. Schizophrenia is a major public health problem throughout the world. It is always severe and is usually long lasting. The onset is before age 25 and persists throughout life. It affects persons of all social classes. Diagnosis is based entirely on psychiatric history and mental status examination.

Definition

Schizophrenia is a chronic brain disease that affects the way a person behaves, thinks, and sees the world, characterized by often altered perception of reality i.e., may see or hear things that don’t exist, speak in strange or confusing ways, believe that others are trying to harm them, or feel like they’re being constantly watched or schizophrenia is a chronic mental disorder characterized by “split off” from reality.

Prevalence

Worldwide prevalence rate of Schizophrenia stands at 1% of the world population. In Zambia hospital-based figures suggest a prevalence rate of 1.8 per 10 000 (Mwape et al, 2010). It accounts for 30% of readmissions at Chainama Hospital (Bash, 2015).

Incidence rate

The chances of one suffering from schizophrenia when exposed in the following instances is as follows.

• In Monozygotic twin if one twin has schizophrenia the chances of the other twin suffering from it too is 47%.

• In Dizygotic twins- if one has schizophrenia, chances that the other twin will suffer from schizophrenia is 12%

• If one parent has schizophrenia- chances of a child suffering from schizophrenia is 12%.

• If both parents have schizophrenia the chances of a child having schizophrenia is 40%

• If a First-degree relative- incidence rate is 12%

• If a Second-degree relative- incidence rate is 5-6%

Causes and Risk factors of Schizophrenia

The aetiology of schizophrenia is unknown; however, the following are known to as risk factors:  

High levels of Dopamine; 

The dopamine hypothesis, posits that schizophrenia is due to hyperactivity in brain dopaminergic pathways. 

This theory is consistent with the efficacy of antipsychotics (which block dopamine receptors) and the ability of drugs (such as cocaine or amphetamines) that stimulate dopaminergic activity to induce psychosis.

Conflicting parental messages; The Double-bind Theory states that when Children are receiving conflicting ideas about their behaviour, attitudes, and feelings. The may end up suffering from schizophrenia.

                   iii.        Viral origin; Influenza, Rubella are viruses that are capable of crossing the blood brain barrier are cause some alterations in the functions of the brain cells resulting in Schizophrenia.

                   iv.        Low socio-economic status; The downward Drift Theory, explains that people with low social economic status are at higher risk of suffering from schizophrenia than those with a good social economic status.

                    v.        Inheritance; Genetic theories explain that Schizophrenia may be genetic (about 1 in 3 cases). Twin and family studies show that schizophrenia is inheritable. The closer one’s relative is, the higher the possibility of inheritance. People with a ‘lighter’ genetic load may require environmental triggers, for instance, Perinatal trauma, family stresses, whilst those with greater genetic predisposition may develop schizophrenia on a genetic basis alone or with minimal environmental triggering.

NOTE: There is a clear inheritable component, but familial incidence is sporadic and schizophrenia does occur in families with no history of the disease.

                   vi.        Psychological life events; Emotionally arousing or threatening experiences, (Brown and Birley 1968), For example: Moving house, having visitors to stay, witnessing an accident, Separation – from close friend or relative can trigger schizophrenia.

More recent studies have focused on structural and functional abnormalities through brain imaging of schizophrenics and control populations. No one finding or theory to date is adequate in explaining the aetiology and pathogenesis of this complex disease.

Cardinal Signs and symptoms

Schizophrenia is a disorder characterized by what have been termed positive and negative symptoms, a pattern of social and occupational deterioration, and persistence of the illness for at least 6 months.

Positive symptoms are characterized by the presence of unusual thoughts, perceptions, and behaviours (e.g., hallucinations, delusions, agitation); Whereas negative symptoms are characterized by the absence of normal social and mental functions (e.g., lack of motivation, isolation, anergia). The

positive versus negative distinction was made in a nosologic attempt to identify subtypes of schizophrenia and because some medications seem to be more effective in treating negative symptoms. Clinically, patients often exhibit both positive and negative symptoms at the same time.

Table1.1: Clinical features of Schizophrenia

POSITIVE

NEGATIVE

DELUSIONS

Often described by content; persecutory, grandiose, paranoid, religious; ideas of reference, thought broadcasting, thought insertion, thought withdrawal

AFFECTIVE FLATTENING/ BLUNTING: Unchanging facial expression, Paucity of expressive gestures, Poor eye contact

HALLUCINATIONS

Auditory, visual, tactile, and/or olfactory hallucinations; voices that are commenting

ALOGIA:

Poverty of speech, Poverty of content of speech, Blocking, Increased latency of response

DISORGANIZED/BIZARRE BEHAVIOUR

Aggressive/agitated, odd clothing or appearance, odd social behavior, repetitive-stereotyped behavior

AVOLITION-APATHY:

Grooming and hygiene, Impersistence at work or school

POSITIVE FORMAL THOUGHT DISORDER

ANHEDONIA-ASOCIALITY:

Recreational interests and activities, Sexual activity, Relationships with friends and peers

INAPPROPRIATE AFFECT

ATTENTION:

Social inattentiveness

Table 1.1: the table above represents.

Clinical features of Schizophrenia explained.

A.   Hallucinations: 

Hallucinations are the most common feature of schizophrenia. These involve hearing, seeing, smelling, tasting, and feeling touched by things in the absence of stimuli. An example is hearing voices that command the patient to do certain things, usually abusive and self-destructive. Excessive dopamine activity is linked to hallucinations, agitation, and delusion.

Types of hallucinations

                i.        Auditory: these are the commonest type of hallucinations in schizophrenia. A patient will hear voices, music or noises without an external stimulus. These voices could be; Amusing, Threatening, Abusive and insulting, Commanding or Neutral. In second person Auditory hallucinations the patient will be hearing a voice or voices talking to him, these voices can be persecutory, highly critical, complimentary or issue commands to the patient. In third person auditory hallucinations the patient hears voices talking about him. This may take a form of two or more voices arguing or discussing the patient among themselves; or one or more voices giving a running commentary on the patient’s thoughts or actions. Types of Auditory hallucinations are;

a)        Second & Third person Hallucinations: Voices talking, Voices arguing or discussing the person among themselves or voices giving a running commentary on the persons behaviour are pathognomonic of Schizophrenia.

b)   Audible thoughts: patient hearing owns thoughts as if they were projected by an inner voice.

c)   Extra Campine hallucination: patient claiming to hear voices from remote places. For example, patient is in Zambia and claiming to hear voices coming from Kenya. “Extra” means outside; “Campine” means immediate location.

d)   Functional hallucination: The patient hears voices alongside an identifiable noise. For example, when a radio is on, a patient hears a voice with clear words for as long as the radio is on, the voice stops as soon as the radio is turned off.

              ii.        Visual hallucination: The patient will be seen images without stimulus. i.e., images that are not seen by others.

            iii.         Tactile hallucination:  The patient will have an abnormal or false sensation of touch or perception of movement on the skin or inside the body.

            iv.         Gustatory hallucination: The patient will have a sensation of taste without having tasted or eaten something. It is common in epilepsy.

              v.         Olfactory hallucination: also known as phantosmia, the patient detects smells that aren't really present in the environment. The odours detected in phantosmia vary from person to person and may be foul or pleasant

B.   Delusions

A delusion is a firmly held idea that a person has despite clear and obvious evidence that it isn’t true.

Delusions are extremely common in schizophrenia, occurring in more than 90% of those who have the disorder.

Often, these delusions involve illogical or bizarre ideas or fantasies.

Common schizophrenic delusions include:

·         Delusions of persecution – Belief that others, often a vague “they,” are out to get him or her. These persecutory delusions often involve bizarre ideas and plots (e.g., “Martians are trying to poison me with radioactive particles delivered through my tap water”)

·         Delusions of reference – A neutral environmental event is believed to have a special and personal meaning. For example, a person with schizophrenia might believe a billboard or a person on TV is sending a message meant specifically for them.

·         Delusions of grandeur – Belief that one is a famous or important figure, such as Jesus Christ or Napoleon. Alternately, delusions of grandeur may involve the belief that one has unusual powers that no one else has (e.g., the ability to fly).

·         Delusions of control – Belief that one’s thoughts or actions are being controlled by outside, alien forces. Common delusions of control include thought broadcasting (“My private thoughts are being transmitted to others”), thought insertion (“Someone is planting thoughts in my head”), and thought withdrawal (“Someone is robbing me of my thoughts”).

C.   Disorganized speech

Common signs of disorganized speech in schizophrenia include:

Loose associations – Rapidly shifting from topic to topic, with no connection between one thought and the next.

Neologisms – Made-up words or phrases that only have meaning to the patient.

Perseveration – Repetition of words and statements; saying the same thing over and over.

Clang – Meaningless use of rhyming words (“I said the bread and read the shed and fed Ned at the head").

D.   Disorders of thought

Derailment - ideas slip off track onto ideas obliquely related or unrelated.

Thought blocking – Sudden cessation in the flow of thought so that the topic of conversation is lost and a new thought arrives.

Thought withdrawal- outside force removing thoughts  

Thought insertion – something dictating patient’s thoughts

Thought broadcasting – thoughts accessible to everyone

Phases of schizophrenia

i.        Prodromal

The prodromal stage occurs before hospitalization or within a year. It is Characterized by a clear decline from his previous level of functioning. It occurs before noticeable psychotic symptoms appear. During this stage, a person undergoes behavioural and cognitive changes that can, in time, progress to psychosis. May withdraw from friends and families and hobbies and interests, exhibit peculiar behaviour, and deterioration in work and school performance.

This phase can last from weeks to years. Some people with schizophrenia never go past this point, but most do.

ii.        Active

(Sometimes called “acute”). This phase is commonly triggered by a stressful event. It is Characterized by presence of acute psychotic symptoms (e.g., hallucinations, delusions, incoherence, and catatonic behaviours). Prognosis worsens with each acute episode. This phase usually lasts from 4 to 8 weeks. Acute schizophrenia is typically associated with severe agitation, which can result from such symptoms as frightening delusions, hallucinations, or suspiciousness, included are more profound negative, withdrawal symptoms like flattened affect, reduced productivity (alogia), and decreased initiation of goal-directed behaviour (avolition).

iii.        Residual

This final stage occurs when a person experiences fewer, less severe symptoms of active schizophrenia. At this point illness pattern is established, disability level may be stabilized, and late improvements may occur.

Types of schizophrenia

 i.   Paranoid: This is the type of schizophrenia in which a patient is typically preoccupied with one or more delusions and/or hallucinations, usually involving grandeur or persecution. Patients are often uncooperative and difficult to deal with and may be aggressive, angry, or fearful. Develops later (in the 30s or 40s) than other forms of schizophrenia. Personality is well integrated.

ii.    Disorganized (aka Hebephrenic)

The onset of schizophrenia is in adolescence or early 20s. Patients often appear silly and childish in their behaviour. Affective symptoms (flattened affect and incongruity) and thought disorder are prominent. Delusion is common and not highly organized. Hallucinations also are common, and are not elaborate.

Though onset is usually insidious, some cases begin suddenly, with marked depression and anxiety.

iii. Catatonic

Involves psychomotor disturbances, ranging from severe retardation to excitement. The patient presents with Extreme negativism and Mutism, Peculiarities of voluntary movements: posturing, waxy flexibility. Medical care may be necessary because of exhaustion, malnutrition, self-inflicted injury, or hyperpyrexia. There are different types of Catatonias some of which include:

•      Catatonic stupor or mutism: Patient does not appreciably respond to the environment or to the people in it.

•      Despite appearances, these patients are often thoroughly aware of what is going on around them.

•      Catatonic negativism: Patient resists all directions of physical attempts to move him or her.

•      Catatonic rigidity: Patient is physically rigid.

•      Catatonic posturing: Patient assumes bizarre or unusual postures.

•      Catatonic excitement: Patient is extremely active and excited.

•      Delusions, hallucinations, and affective symptoms occur, but are usually less obvious.

iv. Undifferentiated

This is a mental illness in which a person has symptoms of schizophrenia that cannot be classified into a particular type.

Presenting complaints meet criteria for schizophrenia but do not meet criteria for paranoid type, catatonic type or disorganized type.

v. Simple Schizophrenia

The onset is in adolescence. The condition is characterized by insidious development of eccentric behaviour, apathy, a shallow affect, social withdrawal, a lack of drive and initiative, and declining performance at work. Delusions and hallucinations are uncommon. Prognosis is very poor since clear schizophrenic symptoms are absent, simple schizophrenia is difficult to identify reliably.

vi. Residual

Met criteria for schizophrenia, now resolved, i.e., no hallucinations, no prominent delusions, etc., but residual negative symptoms or attenuated delusions, hallucinations, or thought disorder

Diagnostic criteria for schizophrenia

A diagnosis of schizophrenia is made based on a full psychiatric evaluation, medical history, physical exam, and lab tests, only when the patient meets any one or all of the following criterions;

                i. The presence of two or more of the following symptoms for at least 30 days:

•      Hallucinations

•      Delusions

•      Disorganized speech

•      Disorganized or catatonic behavior

•      Negative symptoms (emotional flatness, apathy, lack of speech)

            ii.        Significant problems functioning at work or school, relating to other people, and taking care of oneself.

           iii.        Continuous signs of schizophrenia for at least six months, with active symptoms (hallucinations, delusions, etc.) for at least one month.

           iv.        No other mental health disorder, medical issue, or substance abuse problem is causing the symptoms.

Management of a patient with Schizophrenia

The management of this patient encompasses both Medical and Nursing care. Medical care is the care that focuses on screening, patient examination, establishment of a proper diagnosis and prescription of appropriate medications for the patient. Nursing care, focuses on all nursing services provided to the patient from admission to discharge. We can better understand this management with an example, therefore let us look at the scenario below.

Medical management

Aims/Objectives of medical care:

To prevent complications from arising

To establish a diagnosis through screening and history taking

To undertake laboratory investigations

To stabilise the patient through appropriate medications

Note: During NMCZ exams, 3 aims are enough

History of presenting illness (HPI)

Assess William for symptoms of current illness, that is; date of onset, duration and course of symptoms. Assess Willian for recent psychosocial stressors: stressful life events that may have contributed to his current presentation.

This section provides evidence that supports or rules out relevant diagnoses. Therefore, documenting the absence of pertinent symptoms is also important.

Past psychiatric history

Assess William for previous psychiatric diagnoses. Find out if he suffered from mental illness before, assess history of psychiatric treatment, including outpatient and inpatient treatment. Assess for history of psychotropic medication used. Also assess for history of suicidal attempts and potential lethality.

Medical history
Assess for any current and/or previous medical problems the patient may have suffered from. Assess for any type of treatment, including prescription, over-the-counter medications, home remedies the patient may have taken. Find out if patient has

Family history.
Find out if there are any relatives with history of psychiatric disorders, suicide or suicide attempts, alcohol or substance abuse to determine whether patient’s condition is familial.        

Social history

Assess for patient’s occupational status and source of income to find out how he fends for himself. Also record his level of education, relationship history (including marriages, sexual orientation, number of children); and individuals that currently live with patient.
Assess for the current alcohol or illicit drug usage. 

Mental Status Exam.

The mental status exam is an assessment of the patient at the present time. Historical information should not be included in this section.
The patient should be assessed focusing on the Affect, Mood, thought process, thought Content, insight and his judgment.

Physical Examination

Assess patient’s physical status, to rule out any injuries that may call for attention and also, assess the patient’s general appearance which may review whether he is taking good care of himself or not.

Investigations.

•      Usually none are required for diagnosis.

•      Tests to rule out organic causes of psychosis.

•      Baseline full blood count, blood sugar, lipids, liver, and kidney function tests, for purposes of guiding treatment

•      For Olanzapine and Risperidone, ensure that fasting blood sugar, lipid profiles, liver and kidney function test are carried out at least twice a year.

Diagnosis:

After a thorough history taking, a diagnosis is established to properly treat William. In this case William has a diagnosis of Schizophrenia.

Drug therapy for Schizophrenia:

Drug therapy is important. Remember that some of the drugs may not be specific to the condition but given only to deal with the devastating clinical features the patient may have. As nurses, we should have knowledge of these drugs, including their side effects and nursing considerations. Patients should be given full information concerning drugs and allow them make an informed choice if they can.

There are two main classes of antipsychotics namely Typical or first generation and Atypical or Second-generation antipsychotics. These drugs can be used under first-line or Second-line treatment. [refer to Appendices p--- for information on antipsychotics]

According to MOH treatment guidelines for mental disorders (2022) treat schizophrenia as follows:

Acute treatment:

 i.    Diazepam:

a)   Adults: 5-10 mg PO 6-12 hourly in the first 24 hours

b)   Children: 12 -18 years; 10 mg 12 hourly, 5 - 12 years; 5 mg 12 hourly

OR

ii.     Diazepam:

a)   Adults: 5-10 mg I.V slowly over 2-3 minutes, to a maximum of 20mg/day

b)   Children: 200-300 microgram/kg slowly over 2-3 minutes. This may be repeated after 10 minutes if there is no response.

OR

iii.     Haloperidol:

a)   Adults: 2-5 mg I.M stat. Then: Repeat 6-8 hourly according to response, to maximum of 10 mg daily

b)   Children: 6-12 years; 1-3 mg 6-8 hourly as required in the first 24 hours, < 6 years (not recommended) OR

iv.     Haloperidol:

a)   Adults: 0.5-5 mg PO 8-12 hourly in the first 24 hours. Then: 5-10 mg 8-12 hourly (max. of 20 mg)

b)   Children: > 12 years; 0.5-5 mg 8-12 hourly daily. Then: 5-10 mg 8-12 hourly (max. of 15 mg/day), 3-12 years or body weight 15-40 kg; 0.25-0.5 mg daily.

Then:

Increase by 0.5 mg every 5-7 days.

b.    < 3 years; not recommended.

OR

v.        Chlorpromazine: Adults: 25-50 mg I.M. 6-8 hourly, adjusting to max. of 200 mg daily

a.    Children: 12-18 year; 25-50 mg 6-8 hourly, adjusting to max. of 200 mg daily

b.    6-12 years; 500 microgram/kg 6-8 hourly to max. of 75 mg daily

c.    1-6 year; 500 microgram/kg 6-8 hourly to max. of 40 mg daily OR

vi.        Chlorpromazine: 25 mg PO OD or 75 mg at night. Then adjust according to response to 75-300 mg daily

Children: > 12 years; 25 mg OD or 75 mg at night. Then adjust according to response to max. of 75-200 mg daily 6-12 years: 10 mg OD. Then adjust according to response to max. of 75 mg daily 1-6 years: 500 microgram/kg 4-6 hourly. Then adjust according to response to max. of 40 mg daily.

Maintenance treatment

 i. Risperidone: Adults: 1-2 mg OD PO, then can increase to a maximum of 4mg/day (start at low dose and adjust daily according to patient response)

Children: > 12 years; 5-10 mg, max. 10 mg daily, < 12 years (not recommended)

OR

ii.    Haloperidol: Adults: 2-5mg OD PO, then can adjust to maximum daily dose of 10 mg

Children: 12-18 years; 1-3 mg PO OD, adjusted to maximum daily dose of 10 mg

3-12 years; 500 micrograms 12 hourly, adjust up to a maximum of 5 mg 12 hourly

OR

iii.    Chlorpromazine: Adults: 25 mg PO OD or 75 mg at night, adjust to maximum of 200 mg/day

Children: 12-18 years; 25 mg OD or 75 mg at night, adjust to maximum of 200mg/day, < 12 years (not recommended)

Maintenance treatment with depot preparations for patients with poor drug compliance and recurrent or chronic illness

                            i. Fluphenazine decanoate: Adults: 12.5mg-25mg I.M monthly; test dose at 12.5mg. Children: (not recommended)

 Nursing Management of a patient with Schizophrenia

The nursing care of the patient begins on admission, here we will discuss the nursing services that will be given to William during his hospitalisation. It is very important to take note of how your patient is presenting and what he is straggling with before initiating nursing care.  Nursing management is about attending to the patient’s needs, therefore, identify these needs and help the patient meet them. For William these will be some of his needs. He will need to be in a safe environment, he needs to feed, psychological care, assertiveness training, cognitive-behavioural therapy, group therapy, family therapy.

Aims:

The aims for nursing patient with schizophrenia are.

• To Reduce severity of psychotic symptoms

• To Prevent recurrence of acute episodes

• To Meet patient’s’ physical and psychosocial needs

• To Help patient gain optimum level of functioning.

• To Increase client’s compliance to treatment and nursing plan

Establish trust and rapport. 

Avoid touching client without telling him first what you are going to do. Use an accepting, consistent approach; short, repeated contacts are best until trust has been established. Language should be clear and unambiguous. Maintain a sense of hope for possible improvement and convey this to the patient. Avoid making promises that you cannot fulfil. Respect client i.e., call him by his name.

Avoid crowding him physically or psychologically; he may strike out to protect himself. Respond neutrally to his condescending remarks; don’t let him put you on the defensive, and don’t take his remarks personally. If he tells you to leave him alone, do leave- but make sure you return soon. Spend time with the patient even if he’s mute and unresponsive, to promote reassurance and support.

q Environment

Nurse patient in a well dump dusted, infection free and well light environment. The environment should have isolation rooms in case the patient becomes violent he should be isolated easily. Patient should not be able to escape from the ward where he is been nursed from, doors should be lockable from outside. Environment should be secure and safe for both the patient and the health care providers.

q Promoting independence

Avoid promoting dependence by doing only what the patient can’t do for himself. Reward positive behaviour and work with him to increase his personal sense of responsibility in improving functioning.

q Promote social skills. 

Provide support in assisting him to learn social skills. This can be done through social skills training. The first level of this training begins with nurse patient interaction. You can also Let patients play simple games in which everyone will have equal chances of winning.

q Ensuring safety. 

Maintain a safe environment with minimal stimulation. Make sure there are no free items such as loose cords, chairs etc, that patient can use as a weapon. Patient should not have access to the drug locker because he may poison himself. Do not carry a nurse’ scissors in the patient’s room, because patient may steal it from you or grad it to stub you with it. Institute suicide and/or homicide precautions as appropriate.

q Ensuring adequate nutrition. 

Monitor patient’s nutritional status and if the patient thinks his food is poisoned, let him fix his own food if possible or offer him foods in closed containers that he can open. Allow and encourage relatives to bring food for the patient if he has special requests.

q Cognitive Therapy (keeping it real) 

Engage patient in reality-oriented activities that involve human contact (e.g., workshops, inpatient social skills training). Clarify private language, autistic inventions, or neologisms.

·        Deal with hallucinations by presenting reality. Explore the content of hallucinations. Avoid arguing about the hallucinations. Tell them you do not see, hear, smell, or feel it but explain that you know that these hallucinations are real to him.

·        Promote compliance and monitor drug therapy. Administer prescribed drugs and encourage the patient to comply. Ensure that patient is really taking the drug. Observe for manifestations that warrant hypersensitivity reactions and toxicity.

·        Encourage family involvement. Involve family in patient treatment and teach members to recognize impending relapse (e.g., nervousness, insomnia, decreased ability to concentrate). Suggest ways how families can manage symptoms.

q Psychotherapy

Encourage the client to ask all his questions and provide answers.

Explain every procedure been carried out on the patient

Explain the condition to the client in a simple language

as psychologist for more treatment.

MANAGEMENT OF SCHIZOPHRENIA

D. Discuss the management of Goma from admission to discharge (50 Marks)

1. At Admission (Initial Phase):

• Comprehensive Assessment

  • Mental status examination (MSE), history taking, physical examination.

• Risk Assessment

  • Evaluate suicidal or aggressive tendencies.

• Ensure Safety

  • Place Goma in a safe and calm environment; may require observation or seclusion.

2. Acute Phase Management:

• Pharmacological Treatment

  • Start antipsychotics (e.g., Risperidone, Olanzapine). Monitor for side effects.

• Monitor Compliance and Side Effects

  • EPS (extrapyramidal symptoms), weight gain, sedation.

• Therapeutic Communication

  • Use simple, non-confrontational language. Do not reinforce hallucinations.

• Psychological Support

  • Reassure Goma and explain that the voices are part of his illness.

3. Stabilization Phase:

• Psychoeducation

  • Educate Goma and family about schizophrenia, medication adherence, relapse signs.

• Occupational Therapy

  • Engage Goma in meaningful structured activities.

• Group Therapy

  • Facilitate socialization and communication skills.

• Monitor Progress

  • Regular reviews by psychiatric team.

4. Discharge Planning:

• Discharge Education

  • Inform Goma and his caregivers about medication, follow-up, and avoiding stressors.

• Outpatient Follow-Up

  • Schedule regular outpatient visits for medication refills and monitoring.

• Community Support Referral

  • Link with community mental health services or support groups.

• Relapse Prevention Plan

  • Identify early warning signs and action plan.