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Perpetual Help College of Perpetual Help College of PangasinanPangasinanMalasiquiMalasiqui,, PangasinanPangasinan

National Center for Mental Health AffiliationNational Center for Mental Health Affiliation

(S. Y. 2010(S. Y. 2010--2011)2011)

A caseA case study onstudy onPARANOID SCHIZOPHRENIAPARANOID SCHIZOPHRENIA

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INTRODUCTIONINTRODUCTION

A severe and prolonged mentaldisturbance manifested as a wide range of

disturbed behavior. This should be more

appropriately considered as a group of

disorders rather than a single diseaseentity. The cause of which is uncertain but

with similar clinical pictures, which

includes disturbances in thought, feelingsand mood and with such characteristics

symptoms as hallucinations, delusions,

bizarre behavior and deterioration in the

general level of functioning.

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Schizophrenia, paranoid type is

characterized by persecutory (feeling

victimized or spied on) or grandiosedelusions, hallucinations, and occasionally,

excessively religiosity (delusional focus) or

hostile and aggressive behavior.Paranoidschizophrenia is the most common type of

schizophrenia in most parts of the world.

The course of paranoid schizophrenia may

be episodic, with partial or completeremissions, or chronic. In chronic cases, the

florid symptoms persist over years and it is

difficult to distinguish discrete episodes.

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OBJECTIVESAfter the case presentation, each one should be

able to:

K ² to understand what paranoid schizophrenia is

- to identify the positive and negative symptoms

of paranoid schizophrenic patient - to know when does the symptoms starts

S ² to perform verbal and nonverbal therapeutic

communication to the client in order to help

them to cope with their stress and anxiety

A ² to appreciate the importance or uniqueness

of every individual without labelling them as a

psychiatric client

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PATIENT·S PROFILEPATIENT·S PROFILE

Name: Mr. T.M.

Age: 25

Sex: M ale

Date of birth: January1, 1985

Birthplace: Oriental MindoroCivil status: Single

Religion: Roman Catholic

Pavilion: 1, ward 6Education attainment: High school level

Admission date: September 9, 2009

Admitting diagnosis: Paranoid schizophrenia

Medical dia nosis: Paranoid schizo hrenia

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ADMITTING COMPLAINTSADMITTING COMPLAINTS

ACCORDING TO INFORMANTACCORDING TO INFORMANT

� Nagsasalita mag-isa

� Nagkukulong sa kwarto

� Takot sa lahat ng tao

� Nang-aaway ng ibang tao

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MEDICAL HISTORYMEDICAL HISTORY

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PAST MEDICAL HISTORYPAST MEDICAL HISTORY

Mr. T.M was mentally ill since 2006 and theprevious admission was August 28-

September 3, 2006. He was semi functional

at home with on and off relapses but wastolerated

FAMILY HISTORYFAMILY HISTORY

There is no history of mental illness in the

family. (-) Hypertension, (-) Asthma and (-)

DM were also noted in the family.

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SOCIAL HISTORY

He had a childhood friend andeventually turned into an intimate

relationship during their high

school times but it did not workout and lead to separation. After

the incidence, he was often to

solitary activities in his bedroom,and would avoid socializing with

friends and family.

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HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

2 weeks prior to admission, the patient

was noted to be talking to self and

talking irrelevantly. Sometimes he was

noted to be not sleeping at night. He

was noted to be frightened to other people. As days pass by, Mr. T.M.

noted to be agitated looking for bolo

and easily irritated to his other siblings.He was noted to be frightened when he

sees other inside their house. The

patient was also noted to be alcoholic.

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PATIENT ASSESSMENTPATIENT ASSESSMENT

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PHYSICAL ASSESSMENTPHYSICAL ASSESSMENTPatient is conscious, coherent, ambulatory

and not in Cardiopulmonary distress.

Skin: Hypopigmented patch bellow and medial

to left nipple and several wheal in the

abdomen

(+) scaling lesion and healed cuts on ® legand foot

(+) whitish scaly lesion on both upper and

lower extremities

(+) avulsion & hypopigmented plaque onright foot

NEUROLOGIC EXAM

Orientation: Oriented to X3

�

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Activities of daily living

(As of November 12, 2010)

� I- independent

� D- dependent

� A- assisted

� Feeding ² I

�

Bathing - I� Dressing ² I

� Grooming ² A

�

Toileting ² I

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ANATOM Y AND PH YSIOLOGY

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Neurotransmitters -Approximately 100 billion

brain cells form groups of neurons or nerve cells

that are arranged in networks. These neurons

communicate information with one another bysending electrochemical messages from neuron to

neuron, a process called neurotransmission.

These electrochemical messages pass from the

dendrites (projections from the cell body), through

the soma or the cell body, down the axon (long,

extended structures) and across the synapses

(gaps between cells) to the dendrites of the next

neuron. In the nervous system, the

electrochemical messages cross the synapses

between neural cells by way of special chemical

messengers called neurotransmitters.

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Neurotransmitters are the chemical substances

manufactured in the neuron that aid in the

transmission of information throughout the body.

They either excite or stimulate an action in thecells (excitatory) or inhibit or stop and action

(inhibitory). These neurotransmitters fit into

specific receptor cells embedded in the membrane

of the dendrite, just like a certain key shape fits

into a lock. After neurotransmitters are released

into the synapse and relay message to the

receptor cells, they are either transported backfrom the synapse to the axon to be stored for later

use (reuptake) or are metabolized and inactivated

by enzymes, primarily monoamine oxidase (MAO).

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These neurotransmitters are

necessary in just the right

proportions to relay messageacross the synapses. Studies are

beginning to show differences in

the amount of some

neurotransmitters available in the

brains of people with certainmental disorders compared with

people who have no signs of

mental illness.

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� DOPAMINE

Dopamine, a neurotransmitter located

primarily in the brain stem, has beenfound to be involved in the control

complex movements, motivation,

cognition, and regulation of emotionalresponses. Dopamine is generally

excitatory and is synthesized from

tyrosine, a dietary amino acid.Dopamine is implicated in

schizophrenia and other psychoses.

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� Serotonin,

A neurotransmitter found only in the brain,

is derived from tryptophan, a dietary aminoacid. The function of serotonin is mostly

inhibitory, and it is involved in the control of

food intake, sleep and wakefulness,

temperature regulation, pain control, sexual

behavior, and regulation of emotions.

Serotonin plays an important role in anxiety

mood disorders and schizophrenia, it hasbeen found to contribute to the delusions

hallucinations, and withdrawn behavior

seen in schizophrenia.

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PATHOPHYSIOLOGYPATHOPHYSIOLOGY

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BIOLOGICAL FACTORSBIOLOGICAL FACTORS ENVIRONMENTAL ANDENVIRONMENTAL AND

PSYCHOSOCIAL FACTORSPSYCHOSOCIAL FACTORS

THE GROWTH ANDTHE GROWTH AND

DEVELOPMENTS OF THE DEVELOPMENTS OF THE

PATIENTS IS NORMAL UP TO PATIENTS IS NORMAL UP TO

LATENCY PERIODLATENCY PERIOD

DURING THE ADOLESCENT DURING THE ADOLESCENT

STAGE ROLE DIFFUSION TAKES STAGE ROLE DIFFUSION TAKES

PARTPART

STRESS, ANXIETY ANDSTRESS, ANXIETY AND

DECREASED COPING DECREASED COPING

MECHANISM THAT LEADS TO MECHANISM THAT LEADS TO

SLEEP DEPRIVATIONSLEEP DEPRIVATION

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AFFECTS THE BRAINAFFECTS THE BRAIN

INCREASED VENTRICULAR BRAIN VOLUMEINCREASED VENTRICULAR BRAIN VOLUME

DECREASED CEREBRAL BLOOD FLOWDECREASED CEREBRAL BLOOD FLOW

DECREASED BRAIN TISSUE AND CAPACITY THAT AFFECTS THE E DECREASED BRAIN TISSUE AND CAPACITY THAT AFFECTS THE E

ANATOMIC SYSTEMSANATOMIC SYSTEMS

CORTEX OF THE CORTEX OF THE BRAINBRAIN

BROCCA ANDBROCCA ANDWERNICK¶S AREAWERNICK¶S AREA

LIMBIC SYSTEMLIMBIC SYSTEM

IMBALANCE IN THE IMBALANCE IN THE NEUROTRANSMITTERNEUROTRANSMITTER

PARANOID SCHIZOPHRENIAPARANOID SCHIZOPHRENIA

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INCREASEDINCREASEDDOPAMINEDOPAMINE

AGITATEDAGITATED

PERSECUTORY PERSECUTORY

DELUSIODELUSIO

DECREASEDDECREASEDDOPAMINEDOPAMINE

SOCIALSOCIAL

ISOLATIONISOLATION

AFFECT AFFECT

DIST

URB

ANCES

DIST

URB

ANCES

IMBALAN

CED

IMBALAN

CEDSEROTONINSEROTONIN

DISTURBEDDISTURBED

SLEEP WAKE SLEEP WAKE

CYCLECYCLE

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MEDICALMEDICAL

INTERVENTIONSINTERVENTIONS

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Haloperidol (Haldol)

Drug classification:

Antipsychotic drug

Dosage: 10 mg b.i.d. p.o.

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Mechanism of Action-May block postsynaptic

dopamine receptors in

brain.

Therapeutic Effect:

-decrease psychoticbehaviours

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SIDE EFFECTS

CNS: severe extrapyramidal

reactions, tardive dyskinesia, sedation,drowsiness, lethargy, headache,

insomnia, confusion, vertigo, seizures,

neuroleptic malignant syndrome.CV: tachycardia, hypotension,

hypertension, ECG change.

EENT: blurred visionGI: dry mouth, anorexia, constipation,

diarrhea, nausea, vomiting, dyspepsia.

GU : urine retention

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NURSING CONSIDERATIONSNURSING CONSIDERATIONS

1. Protect drug from light. Slight, yellowingof injection or concentrate is common an

does not affect potency. Discard

markedly discolored, solution.2. When switching from tablets to

decannoate injection, (maximum 100 mg).

3. Dilute oral dose with water/ beverage,such as orange juice, apple juice,

immediately before administration.

4. Monitor patient for tar dive dyskinesia,

which ma occur after rolon ed use.

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Biperiden Hydrochloride

Drug Classification:

Antiparkinsonian

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Mechanism of Action:

Anticholinergic activity in theCNS that is believed to help

normalize the hypothesizedimbalance of cholinergic and

Dopaminergic

neurotransmission in thebasal ganglia in the brain.

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Side Effects:

Excitement, dizziness, urinaryretention, dry mouth,

tachycardia, agitation,

disturbed behaviour may been

seen, blurred vision, elevated

temperature and muscularcramping.

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� Give with caution, and reduce dosage inhot weather. Drug interferes with

sweating and ability of the body to

maintain equilibrium.� Give with meals if GI upset occurs

� Give before meals to patient with dry

mouth� Give after meals if drooling and nausea

occurs.

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Chlorpromazine(Thorazine)

Drug Classification:

Antipsychotic drug,Dopaminergic Blocking drug,

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Mechanism of Action:Antipsychotic drugs block

postsynaptic dopaminereceptors in the brain;

depress those parts of thebrain involved with

wakefulness and emesis.

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SIDE EFFECTS:Tardive dyskinesia (a movement disorder) may

occur and may not go away after you stop usingthe medicine. Signs of tardive dyskinesia include

fine, worm-like movements of the tongue, or

other uncontrolled movements of the mouth,

tongue, cheeks, jaw, or arms and legs. Otherserious but rare side effects may also occur.

These include severe muscle stiffness, fever,

unusual tiredness or weakness, fast heartbeat,

difficult breathing, increased sweating, loss of bladder control, and seizures (neuroleptic

malignant syndrome).

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� Dilute the oral concentrate just beforeadministration in 60mL or more of tomato juice or

fruit juice.

� Do not give by subcutaneous injection, give by deep

IM injection into upper outer quadrant of buttocks.

� Avoid skin contact with oral concentrates and

parenteral drug solutions due to possible contact

dermatitis.

� Keep patient recumbent for 30 minutes after

injection to prevent orthostatic hypotension.

� Be alert to potential for aspiration because of cough

reflex.

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Fluphenazine Decanoate

Drug Classification:Antipsychotic,

Dopaminergic-blockingdrug

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Mechanism of Action:�

Antipsychotic drugs blocks postsynapticdopamine receptors in the brain, depress

the RAS, including the parts of the brain

involved in wakefulness and emesis.

Side Effects:� dry mouth, salivation, vomiting, nasal

congestion, fever, anorexia, pallor, ,

seizures, tremor, and bronchospasm.

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� Monitor liver and renal functionand CBC during long term

therapy.

� This medicine may not mix well

with other medicines which may

increase CNS depression suchas phenothiazines, opioids and

barbiturates


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NURSING CARE PLANSNURSING CARE PLANS

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Priority #1Priority #1

S> ´Kinakabahan ako palagi kasigusto nila akong patayin,µ as

verbalized by the patient

O> agitated

Restless most of the time

Poor eye contact

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NURSING DIAGNOSIS:

Anxiety related to perceive threat to physical safety as manifested

by persecutory delusion

PLANNING:

After 3 days of nurse patient

interaction, the patient maydescribe a reduction in the

presence of hallucination and

delusion.

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INTERVENTIONSINTERVENTIONS1. Acknowledge awareness of

the patient anxiety.

2. Reassure the patient that

he is safe. Stay with the

patient if this appears

necessary.

3. Maintain calm manner while

interacting with the patient.

RATIONALERATIONALE- Because a cause of anxiety

cannot always be identified,the patient may feel as

though the feelings bring

experienced are

counterfeit,acknowledgmen

t of the patient·s feelings

-Presence of a trusted person

may be helpful during the

anxiety attack.

-The patient feelings of

stability increases in a calm

and non-threatening

atmosphere

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4. Orient the patient in theenvironment and new

experiences for people as

needed.

5. Reduce sensory stimuli bymaintaining a quite

environment. Keep

threatening equipment out

of sight.

6. Administer medicines as

ordered.

RATIONALERATIONALE

-Orientation and awarenessof the surrounding

promote comfort and may

decrease anxiety.

-Anxiety may escalate withexcessive conversation,

noise and equipment

around the patient

-To help reduce or eliminate

the symptoms.

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EVALUATION:EVALUATION:

Goal partially met. The patientverbalizes a reduction in his anxiety

but still believes someone will kill

him.

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S> ´Di ako makatulogµ asverbalized by the patient

O> Irritability

RestlessnessMild fleeting nystagmus

Hand tremors

Acute confusion

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NURSING DIAGNOSIS

Sleep deprivation related to

environmental stimulation as

manifested by sleeplessness

PLANNING

After 2days of nurse patient

interaction, the patient will be ableto sleep well and verbalized feeling

of comfort


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1. Establish

therapeutic

relationship with the

client

2. Call the patient by

his name

3. Noteenvironmental

factors affecting

sleep

RATIONALERATIONALE

-To establish ordevelop trust

- Helpful in

establishing trust as well as reality

orientation

-To know what are

the possible ways

or action we can

do to help him

sleep


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4. Encourage

patient to

verbalize feeling

5. Evaluate for use

of medication

and or other drugaffecting sleep

RATIONALERATIONALE

-to know what is thereal reason why he

had sleep

deprivation

-To know the

mechanism of

action together

with adversereaction which

could affect the

sleep pattern of the

client

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EVALUATION

Goal partially met

The patient was not able to

sleep well but verbalizes

feeling of comfort

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SUBJECTIVE:´Nahihiya kasi ako baka hindi

maganda ang gawin koµ as

verbalized by the patient.

OBJECTIVES:

(+) tapping of foot

Observable social isolation

Poor eye contact

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DIAGNOSIS:

Social isolation related to negative

self concept as manifested by

report of fear of rejection

PLANNING:

After 2 days of nursing

interventions the client will

demonstrate an improvedwillingness to socialize with other

people

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1. Identify factors thatmay contribute in

progressing fear of

rejection

2. Plan for possible

reality-oriented

activities that involve

human contact

3. Provide positive

feedback to every

accomplishment

RATIONALERATIONALE

-To be able to identify

ways to overcome

these fears

-To encourage the

patient to involve

himself in group

activities

-To encourage the

patient in continuing

the activities

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4. Providesupportive group

if needed

5. Always provide

client for safety

RATIONALERATIONALE

-To minimize feeling

of rejection

-To prevent

aggravation of fear

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EVALUATION :EVALUATION :

The goal was partially met.The patient is able to socialize

with other people more

effectively during our shift butnot all the time.

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THANK YOUTHANK YOU

schizopres_2009.ppt2 (2)

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