URDANETA CITY, PANGASINAN

COLLEGE OF NURSING

A CASE STUDY ON
SCHIZOPHRENIA

Submitted to:
Ms. Maribel Murillo RN, MAN
Clinical Instructor

Submitted by:
Kristin Abee E. Guarin
SN Batch 2014
I. PATIENT ASSESSMENT DATABASE

A. Personal Data
 Name: Mr. MP
 Address: Las Pinas, Philippines
 Age: 35
 Sex: Male
 Birthday: June 5, 1976
 Birth Place:
 Civil Status: Single
 Nationality: Filipino
 Religion: Roman Catholic
 Educational Attainment: 3rd year college, BS Management
 Occupation: None
 Physician: Dr. Cortez
 Date of Admission: July 14, 2004
 Admitting Diagnosis: Schizophrenia
 Hospital Name: Mother Theresa A Home that Cares

B. CHIEF COMPLAINT
 N/A (he doesn’t cooperate upon interview)

C. HISTORY OF PRESENT ILLNESS

 N/A(he doesn’t answer my question about his present illness)

D. PAST HEALTH HISTORY

 N/A (he doesn’t recall his past health history)

E. FAMILY ASSESSMENT
Name Relation Age Sex Occupation Educational Attainment
Mr. MP Patient 35 Male None 3rd year college
Mr. CP Father 78 Male Doesn’t recall Doesn’t recall
Mrs. DP Mother 68 Female Doesn’t recall Doesn’t recall

F. SYSTEM REVIEW
1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN
  Not assess because patient doesn’t answer my questions about health perception and health management
2. NUTRITIONAL – METABOLIC PATTERN
 N/A
3. ELIMINATION PATTERN
 Patient usually urinates 6 times a day and defecates 2 times daily
4. ACTIVITY- EXERCISE PATTERN

0-Feeding 0 -Dressing 0-Grooming

0-Bathing 0 -Toileting ____others

Legend:
0- Full Care
I- Requires use of assistance
II- Requires assistance and supervisions by others
III- Requires assistance or supervisions from another and equipments and devices
IV – Dependent, doesn’t participate

5. COGNITIVE – PERCEPTUAL PATTERN

 Hearing: she doesn’t have any hearing problems
 Vision: she’s having blurred vision and she use reading glass
 Sensory: our patient is responsive and is able stimulated by closing her eyes and instructed to point what have been pointed on her
skin. There is no problem with sense of taste and smell.
 Learning Styles: my patient doesn’t answer my question and sometimes not cooperative
6. SLEEP- REST PATTERN
 According to my patient he sleeps at 9pm to 6am. He also stated that sometimes he had problems in sleeping.
7. SELF- PERCEPTION AND SELF- CONCEPT PATTERN
 N/A
8. ROLE- RELATIONSHIP PATTERN
 N/A

9. COPING- STRESS TOLERANCE PATTERN

 N/A
10. VALUE- BELIEF PATTER
  N/A

G. DEVELOPMENTAL HISTORY

Theory Age Sex Description

Intimacy vs Isolation
Erickson’s Psychosocial Theory 35 years old Male Mr. MP doesn’t answer my questions sometimes and doesn’t participate to the
activities because he doesn’t trust me as his nurse.

H. PHYSICAL ASSESSMENT
A. General Survey
1. Overall appearance and grooming: upon assessment patient is neat and clean, he manifested a good grooming.
2. Actual height and weight vs. ideal body weight: n/a
3. Symptoms of distress: he is not answering my question mostly and he prefer to be alone sometimes
4. Posture and gait: upon assessment her posture and gait are well coordinated.
5. Affect and mood: he is not answering my question mostly and he prefer to be alone sometimes.

B. Regional exam- utilize IPPA technique

1. Hair: Upon inspection, his hair is evenly distributed, thick, its texture is silky and resilient hair and there is no presence of infestation
(lice) and variable in amount.
Head and face: his head is round, smooth skull contour, symmetric in size and consistent while her face is symmetric in facial
movement.
2. Eyes: Upon inspection of the client’s eyes, its eyebrows and eyelashes are symmetrically aligned, curled slightly outward and hair is
evenly distributed.
3. Nose: Upon inspection, client’s nose is symmetrical, no discharges, uniform in color, he breaths properly through the nares.
4. Ears: Through inspection, client’s ears are symmetrical; the auricle is aligned with the outer canthus of the eyes and same with the
color of facial skin.
5. Mouth and throat: Through inspection, client’s lips and buccal mucosa is pink in color. No retraction of gums, with incomplete
teeth. Tongue moves freely.
6. Neck and lymph nodes: The client’s neck muscles are equal in size, no enlargement of nodules or masses upon palpation. Head
movement is coordinated and smooth movement with no discomfort.
7. Skin: Brown in color, warm to touch and equally distributed by hair.
8. Nails: fingernail plate has convex curvature and an angle of nail plate about 160˚, smooth texture, finger nail and toenail bed color is
pale, with intact epidermis.
9. Thorax and lungs: Chest is symmetric, spine vertically aligned, spinal column is straight, right and left shoulder are at same height.
10. Breast and axilla: not assessed
11. . Abdomen: not assessed
12. Extremities: there is no presence of edema or abnormal findings
13. Genitals: not assessed
14. Rectum and anus: not assessed
15. Neurological/Cranial nerves: not assessed.
INTRODUCTION

Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic
patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment.
Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and
grooming.

Clinical Manifestations
The symptoms of schizophrenia are divided into two major categories:
A. The positive symptoms include:
 delusions and its types,
 hallucinations,
 loose associations and
 bizarre or disorganized behavior
B. The negative symptoms includes:
 restricted emotions,
 anhedonia,
 avolition,
 alogia,
 catatonia and
 social withdrawal.

Diagnostic Test
 Clinical diagnosis is developed on historical information and thorough mental status examination.
 No laboratory findings have been identified that are diagnostic of schizophrenia.
 Routine battery of laboratory test may be useful in ruling out possible organic etiologies, including CBC, urinalysis, liver function tests,
thyroid function test, RPR, HIV test, serum ceruloplasmin ( rules out an inherited disease, wilson’s disease, in which the body retains
excessive amounts of copper), PET scan, CT scan, and MRI.
 Rating scale assessment:
 Scale for the assessment of negative symptoms.
 Scale for the assessment of positive symptoms.
 Brief psychiatric rating scale
Treatment
A comprehensive treatment program can include:
 Antipsychotic medication
 Education & support, for both ill individuals and families
 Social skills training
 Rehabilitation to improve activities of daily living
 Vocational and recreational support
 Cognitive therapy

Nursing Interventions:
A. Strengthening Differentiation
 Provide patient with honest and consistent feedback in a non threatening manner.
 Avoid challenging the content of patient’s behavior
 Focus interactions on patient’s behavior.
 Administer drugs as prescribed while monitoring and documenting patient’s response to drug regimen.
 Use simple and clear language when speaking with the patient.
 Explain all procedures, test and activities to patient before starting them

B. Promoting Socialization
 Encourage patient to talk about feelings in the context of a trusting, supportive relationship.
 Allow patient to reveal delusions to you without engaging in power struggle over the content or the entire reality of the delusions.
 Use supportive, emphatic approach to focus on patient’s feelings about troubling events or conflicts.
 Provide opportunities for socialization and encourage participation in group activities.
 Be aware of personal space and use touch judiciously.
 Help patient to identify behaviors that alienate significant others and family members.

C. Ensuring Safety
 Monitor patient for behaviors that indicate increased anxiety and agitation.
 Collaborate patient to identify anxious behaviors as well as causes.
 Establish consistent limits on patients behavior and clearly communicate these limits to patients, family member, and health care providers.
 Secure all potential weapons and articles from patients room and the unit environment that could be used to inflict injury.
 Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action.
 Frequently monitor the patient within guidelines of facility’s policy on restrictive devices and assess the patients level of agitation.
 When patient’s level of agitation begins to decrease and self control regained, establish a behavioral agreement that identifies specific
behaviors that indicate self control against are escalation agitation.
ANATOMY AND PHYSIOLOGY

I. Structures
A. The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The
autonomic nervous system (ANS) is composed of both central and peripheral elements.
1. The CNS is composed of the brain and spinal cord.
2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves.
3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. Its peripheral
division is made up of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia.

B. The brain is covered by three membranes.

1. The dura matter is a fibrous, connective tissue structure containing several blood vessels.
2. The arachnoid membrane is a delicate serous membrane.
3. The pia matter is a vascular membrane.
C. The spinal cord extends from the medulla oblongata to the lower border of the first lumbar
vertebrae. It contains millions of nerve fibers, and it consists of 31 nerves – 8 cervical, 12 thoracic, 5
lumbar, and 5 sacral.

D. Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroid plexus of the pia matter. It
flows through the foramen of Monro into to the third ventricle, then through the aqueduct of Sylvius
to the fourth ventricle. CSF exits the fourth ventricle by the foramen of Magendie and the two
foramens of Luska. It then flows into the cistema magna, and finally it circulates to the subarachnoid
space of the spinal cord, bathing both the brain and the spinal cord. Fluid is absorbed by the arachnoid
membrane.

II. Function

A. CNS
1. Brain
The cerebrum is the center for consciousness, thought, memory, sensory input, and motor activity; it consists of two hemispheres (left and
right) and four lobes, each with specific functions.
 The frontal lobe controls voluntary muscle movements and contains motor areas, including the area for speech; it also contains the centers for
personality, behavioral, autonomic and intellectual functions and those for emotional and cardiac responses.
 The temporal lobe is the center for taste, hearing and smell, and in the brain’s dominant hemisphere, the center for interpreting spoken
language.
 The parietal lobe coordinates and interprets sensory information from the opposite side of the body.
  The occipital lobe interprets visual stimuli.

The thalamus further organizes cerebral function by transmitting

impulses to and from the cerebrum. It also is responsible for primitive
emotional responses, such as fear, and for distinguishing between pleasant
and unpleasant stimuli.

Lying beneath the thalamus, the hypothalamus is an automatic

center that regulates blood pressure, temperature, libido, appetite,
breathing, sleeping patterns, and peripheral nerve discharges associated
with certain behavior and emotional expression. It also helps control
pituitary secretion and stress reactions.

The cerebellum or hindbrain, controls smooth muscle movements,

coordinates sensory impulses with muscle activity, and maintains muscle
tone and equilibrium.

  The brain stem, which includes the mesencephalon, pons, and

medulla oblongata, relays nerve impulses between the brain and spinal
cord.

2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do
not involve brain control.

B. The PNS connects the CNS to remote body regions and conducts signals to and from these areas and the spinal cord.

C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function. Supervised chiefly by the hypothalamus, the ANS
contains two divisions.
1. The sympathetic nervous system serves as an emergency preparedness system, the “flight-for-fight” response. Sympathetic impulses
increase greatly when the body is under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood
vessels, stronger and faster heart contractions, peripheral blood vessel constriction, decreased peristalsis, and increased perspiration. Sympathetic
stimuli are mediated by norepinephrine.
2. The parasympathetic nervous system is the dominant controller for most visceral effectors for most of the time. Parasympathetic
impulses are mediated by acetylcholine.
PATHOPHYSIOLOGY

Predisposing factor
Stress
Low socioeconomics

Brain development from conception to early adulthood

Anatomic and functional disruption in neural connectivity and communication

Disturbance in neurotransmitter system

Impairment in a fundamental cognitive process

Impairment in one or more second-order cognitive process

Looseness of ability in thinking

S/Sx: Delusion and hallucination

Impaired ability to perceive

Disorganized thought confusion

Social isolation
LABORATORY RESULT

Electrolytes
Result Normal Values Significance
Sodium 136 135-145 Within normal range
Potassium 3.98 3.5-5.0 Within normal range

Urinalysis
RESULTS SIGNIFICANCE RESULTS SIGNIFICANCE
Color: Sugar:
Yellow Within normal range negative Within normal range
Transparency: Specific gravity:
Clear Within normal range 1.010 Within normal range
Reaction: Microscopic:
Pusleukocytes:
Albumin:
Acidic Albumin Within normal range Erythrocytes:

Roentrogenological report
Findings:
There are hazy infiktrates at both suprahilar area heart is not enlarged diaphragm and sulci are intact

Impression
Suprahilar pneumonitis, bilateral koch's etiology not ruled out
DRUG STUDY

Generic Name: Haloperidol

Brand Name: Haldol
Drug Classification: Antipsychotic
Dosage: 20mg 1/4 tab OD
Indication: Management of manifestations of psychotic disorders

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Anti-psychotics block  Vertigo, headache  Coma  Drowsiness  Provide safety to the patient
postsynaptic dopamine  Nasal congestion  Severe CNS  Blurring of vision
receptors in the brain,  Polyuria depression
depress the RAS,  Cerebral edema  Bone marrow  Dry mouth  Maintain fluid intake and use
including those parts of  Tremor depression  Nausea and vomiting precautions against heatstroke or
the brain involved with  Ataxia  Blood dyscrasia heat weather
wakefulness and emesis.  Orthostatic  Circulatory collapse  Monitor electrolytes level
hypotension  Subcortical brain  Monitor Vital Signs continuously
 Cardiomegaly damage  Provide rest and comfort
 SIADH  Cerebral  Tachycardia,  Monitor CBC, BUN, Creatinine
 Eosinophilia arteriosclerosis bradycardia  Gradually withdraw drug when
 Leucopenia  Coronary disease  insomnia patient has been on maintenance
 Jaundice  Severe hypotension therapy
 Urticaria or hypertension
Generic Name: Diphenhydramine hydrochloride
Brand Name: Benadryl
Drug Classification: Antiparkinsonian
Dosage: 50mg cap HS
Indication: Parkinsonism (including drug induced parkinsonism and extrapyramidal reactions), in the elderly intolerant of more potent drugs, for
milder forms of disorder

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Competitively blocks the  Fatigue  Third trimester of  Drowsiness  Provide safety to the patient
effects of histamine at  Confusion pregnancy  Sedation  Assist patient in ambulation
h1 receptor sites, has  Blurred vision  Lactation  Dizziness
atropine-like, anti-  Headache  Used cautiously  Disturbed  Maintain fluid intake and use
pruritic and sedative  Diplopia with: coordination precautions against heatstroke or
effects  Tremors  Narrow angle  Nausea and vomiting heat weather
 Palpitations glaucoma  Monitor electrolytes level
 Bradycardia  Asthmatic attack  Administer these drugs with food
 Diarrhea  Bladder neck if GI upset occur
 Constipation obstruction  Monitor Vital Signs continuously
 Urinary frequency  Pregnancy  Provide rest and comfort
 Anorexia  Stenosing peptic  Monitor CBC, BUN, Creatinine
 Dysuria ulcer  Gradually withdraw drug when
 rash  Symptomatic patient has been on maintenance
prostatic therapy
hypertrophy
Generic Name: Fluoxetine hydrochloride
Brand Name: Prozac
Drug Classification: SSRI (Selective Serotonin Reuptake Inhibitor)
Dosage: initially 20mg/day tab
Indication: treatment of depression; most effective in patients with major depressive disorder

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Acts as an antidepressant  Agitation  hypersensitivity to  Dizziness  Provide safety to the patient

by inhibiting CNS  Sedation fluoxetine and  Headednes  Teach patient about relaxation
neuronal uptake of  Seizure pregnancy  Nervousness technique
serotonin; blocks uptake  Abnormal gait  Increase fluid intake
of serotonin with little  Palpitations  Sweating and dry  Maintain fluid intake and use
effect on norepinephrine  Flatulence mouth precautions against heatstroke or
 Cystitis  Nausea and vomiting heat weather
 Impotence  Diarrhea  Monitor electrolytes level
 alopecia  Eat foods high in fiber
 Monitor Vital Signs continuously
 Provide rest and comfort
 constipation
 bradycardia
Generic Name: Fluphenazine decanoate
Brand Name: Modecate
Drug Classification: Antipsychotic
Dosage: initial dose, 12.5 – 25mg IM
Indication: Management of behavioral complication in patients with mental retardation

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Anti-psychotics block  Vertigo, headache  Coma  Drowsiness  Provide safety to the patient
dopamine receptors in  Nasal congestion  Severe CNS  Blurring of vision
the brain, depress the  Polyuria depression  Maintain fluid intake and use
RAS, including those  Cerebral edema  Bone marrow  Dry mouth precautions against heatstroke or
parts of the brain  Tremor depression  Nausea and vomiting heat weather
involved with  Ataxia  Blood dyscrasia  Monitor electrolytes level
wakefulness and emesis.  Orthostatic  Circulatory collapse  Monitor Vital Signs continuously
hypotension  Subcortical brain  Provide rest and comfort
 Cardiomegaly damage  Monitor CBC, BUN, Creatinine
 SIADH  Cerebral  Tachycardia,  Gradually withdraw drug when
 Eosinophilia arteriosclerosis bradycardia patient has been on maintenance
 Leucopenia  Coronary disease  insomnia therapy
 Jaundice  Severe hypotension
 Urticaria or hypertension
Generic Name: Clozapine
Brand Name: Ziproc
Drug Classification: Antipsychotic
Dosage: 100mg ¼ tab 2x/week HS
Indication: Management of severely ill schizophrenics who are unresponsive to standard psychotic drug

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Anti-psychotics block  Tremor  Severe CNS  Drowsiness  Provide safety to the patient
dopamine receptors in  Disturbed sleep depression  Sedation
the brain, depress the  Sedation  History of seizure  Dizziness
RAS, including those  Sweating  Granulocytopenia  Headache
parts of the brain  Dry mouth  Myeloproliferative  Nausea and vomiting  Maintain fluid intake
involved with  Urticaria disorders  Monitor electrolytes level
wakefulness and emesis.  Rash  Eat food rich in fiber
 leukopenia  Constipation  Tepid sponge bath
 Fever  Monitor Vital Signs continuously
 Tachycardia  Provide rest and comfort
 hypotension  Monitor CBC, BUN, Creatinine
 Gradually withdraw drug when
patient has been on maintenance
therapy
Generic Name: Biperiden
Brand Name: Akineton
Drug Classification: Antiparkinson
Dosage: 2mg/day ½ tab
Indication: Adjunct in the therapy of parkinsonism

Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations

Anticholinergic activity  Memory loss  Glaucoma  Disorientation  Provide safety to the patient
in the CNS that is  Agitation  Pyloric or duodenal  Confusion  Orient patient about time, place,
believed to help  Depression obstruction  Blurred vision event or things around her.
normalize the  Drowsiness  Stenosing peptic  Dizziness  Teach patient about relaxation
hypothesized imbalance  Tachycardia ulcer  Light-headednes technique
of cholinergic and  Palpitations  Achalasia  Nervousness  Maintain fluid intake and use
dopaminergic  Hypotension  Prostatic precautions against heatstroke or
neutransmission in the  Rash hypertrophy  Dry mouth heat weather
basal ganglia in the brain  Urticaria  Myasthenia gravis  Nausea and vomiting  Monitor electrolytes level
of a parkinsonism  weakness  Diarrhea  Eat foods high in fiber
patient.  Monitor Vital Signs continuously
 Provide rest and comfort
 Monitor CBC, BUN, Creatinine
 constipation  Gradually withdraw drug when
 bradycardia patient has been on maintenance
therapy

LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY

1. Disturbed thought processes related to inability to trust evidenced by delusional thinking.
2. Social Isolation related to alteration in mental status
3. Situational low self-esteem related to cognitive impairment
NURSING CARE PLAN

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective: Disturbed thought After 1-2 days of Be sincere and honest when Delusional clients are After 2 days of
processes related to rendering nursing communicating with the extremely sensitive about rendering nursing
Objective: inability to trust interventions, the client. Avoid vague or others and can recognize interventions, the
>inability to trust evidenced by patient will be able evasive remarks. insincerity. Evasive patient was
>lack of interest delusional thinking. to develop trusting comments or hesitation develop trusting
relationship with reinforces mistrust or relationship with
nurse delusions. nurse

Be consistent in setting Clear, consistent limits

expectations, enforcing rules, provide a secure structure
and so forth. for the client.

Do not make promises that Broken promises reinforce

you cannot keep. the client’s
mistrust of others.

Encourage the client to talk Probing increases the

with you, but do not pry for client’s suspicion and
information. interferes with the
therapeutic relationship.

Explain procedures, and try t When the client has full

o be sure the client knowledge of procedures, he
understands the procedures or she is less likely to feel
before carrying them out. tricked by the staff.

Initially, do not argue with Logical argument does not

the client or try to convince dispel delusional ideas and
the client that the delusions can interfere with the
are false or unreal. development of trust
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective: Social Isolation related After 1-2 days of >establish a >being emotionally After 1-2 days of
to alteration in mental rendering nursing therapeutic present and authentic rendering nursing
Objective: status interventions, client relationship by being fosters growth in interventions, client
>uncommunicative will identify feelings emotionally present relationships and will identify feelings
>seeks to be alone of isolation and authentic decrease isolation of isolation
> projects hostility
>sad/dull affect
>observe for barriers >adequate information
to social interaction should be gathered so
appropriate
interventions can be
planned

>provide positive >social support

reinforcement when contributes to positive
the client seeks out well being
others
>the individual’s
>discuss causes of experience of illness;
perceived or actual the circumstances of
isolation everyday living that
influence a quality of
life
 Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis

Subjective: Situational low After 2-3 hours of Encourage client to express Client may be fixed in anger After 3 hours of
self-esteem rendering nursing honest feelings in relation to stage of grieving process, rendering nursing
Objective: related to interventions, the loss of prior level of functioning which is turned inward on interventions, the
> lacking eye cognitive patient will the self, resulting in patient was
contact impairment verbalize diminished self-esteem. verbalized
>little interest in understanding of understanding of
activities things that Revise methods for assisting To explore the feelings of things that
>lack of social precipitate current client to express feelings the client thereby allowing precipitate current
interaction situation and properly. him to acknowledge his situation and
demonstrate own strength and weakness demonstrated
behaviors that behaviors that show
show positive self- Encourage client’s attempts to The ability to communicate positive self-esteem.
esteem. communicate. If verbalizations effectively with others may
are not understandable, express enhance self-esteem
to client what you think he
intended to say. It is necessary
to reorient client frequently.

Encourage reminiscence and Help client resume

discussion of life review
progression through the
grief process associated
with disappointing life
events and increase self-
esteem

Encourage to participate in Positive feedback from

activities group members will
 increase self-esteem

Offer support and empathy Focus on accomplishments

to lift self-esteem
DISCHARGE PLAN
 Medication:
 Instruct patient to continue taking her medications
 Do not stop abruptly taking the medications
 Report any complications or severe effects of drugs to your health care provider
 Exercise:
 Encourage patient to have regular exercise even he is at their home.
 Treatment:
 Instruct patient to continue taking her medications.
 Clinical Follow-up:
 Instruct patient to have her follow-up check- up after one week.
 Diet:
 Advise the patient to eat green leafy vegetables, rich in iron and vitamin C
 Danger signs:
 Instruct patient to seek medical advice to physician if she experiencing discomfort and complications