A Case Study on

SCHIZOPHRENIA PARANOID
Submitted to:
Aida Bautista RN, MAN
Clinical Instructor

Submitted by:
MENDOZA, STEFANI
OBEDOZA, ESTHER
ODRADA, ELIZABETH
PEROL, MAE
SUNGA, KAREN
TAN, JEANETTE
VALEROS, JAYSON
VICENCIO, DIOSSA
VILLANUEVA, KERSTINE

BSN 3Y2-2D
TABLE OF CONTENTS:
1

Learning Objectives......3
Introduction.....4
Patients Profile......6
Physical Assessment and MSE...7
Psychosocial Theory and Development.9
Gordons Functional Health Pattern..13
Course in the Ward.....15
Psychotherapies...20
Anatomy and Physiology........21
Pathophysiology.......23
Laboratory.....25
Drug Study....27
Nursing Care Plan.........................31
Recommendation............34

General Objectives

This case study aims to identify and determine the general health problems and needs
of the patient with an admitting diagnosis of Paranoid Schizophrenia. This study also
intends to help us promote health and medical understanding of such condition through
the application of the nursing skills.
Specific Objectives
After the completion of this case study, the students will be able to:

Define Paranoid Schizophrenia

Enumerate the risk factors, different signs and symptoms and to trace the
pathophysiology of Paranoid Schizophrenia
Identify and understand the different psychotherapies
To understand the role of drug therapy in managing the client
Formulate appropriate nursing care plan and provide nursing care

Rationale for choosing the case

We chose this as our case study to enhance knowledge and acquire more information
to understand the mental disorder better. It has been observed to be the most common
psychotic diseases accounting for high costs in mental health care. It is therefore
important for us student nurses and vital for the community to be knowledgeable and
skillful in caring patient with Schizophrenia, its symptoms and how best to handle
patients suffering from the disorder in order to ensure that such individuals will be lead
to a better and fulfilled lives and will become a functional member of the society.

Scope and Limitation:

This is a case of 57 year old female diagnosed with Paranoid Schizophrenia. The
patient was admitted in National Center for Mental Health, Mandaluyong. Treatment,
laboratory results and other significant data are included for interpretations. Reliability
of information from patient is 80%.

INTRODUCTION

Schizophrenia causes distorted and

bizarre thoughts, perceptions, emotions,
movements, and behavior. It cannot be
defined as a single illness; rather,
schizophrenia is thought of as a syndrome
or as a disease process with many
different varieties and symptoms, much
like the varieties of cancer. For decades,
the
public
vastly
misunderstood
schizophrenia, fearing it as dangerous and uncontrollable and causing wild disturbances
and violent outbursts. Many people believed that those with schizophrenia needed to be
locked away from society and institutionalized. Through prolong and in-depth research
Only recently has the mental health industry come to learn and educate the community
at large that schizophrenia has many different sign and symptoms and presentations
and is an illness that medication can control. Clients whose illness is medically
supervised and whose treatment is maintained often continue to live and sometimes
work in the community with family and outside support.
The word "schizophrenia" comes from the Greek roots schizo (split) and phrene (mind) to
describe the fragmented thinking of people with the disorder. The symptoms of
schizophrenia and divided into two major categories: positive or hard symptoms, which
include delusions, hallucinations, and grossly disorganized thinking, speech, and behavior
and negative or soft symptoms, which include flat affect, lack of volition, and social
withdrawal or discomfort.

Paranoid schizophrenia, also called schizophrenia, paranoid type is a sub-type of

schizophrenia as defined in the Diagnostic and Statistical Manual of Mental Disorders,
(DSM-IV) is the most common type of schizophrenia in most parts of the world. The
clinical picture is dominated by relatively stable, often paranoid, delusions, usually
accompanied by hallucinations, particularly of the auditory variety.

Affect is usually less blunted than in other varieties of

schizophrenia, but a minor degree of incongruity is common, as
are mood disturbances is also common which are described as
irritability, sudden anger, fearfulness, and suspicion.

Causes
The causes of schizophrenia are not fully known. However, it
appears that schizophrenia usually results from a complex interaction between genetic
and environmental factors.
Epidemiology
Schizophrenia in Southeastern Asia
Country
Number of Cases
East Timor
8,243
Indonesia
1,928,663
Laos
49,080
Malaysia
190,255
Philippines
697,543
Singapore
35,215
Thailand
524,647
Vietnam
668,596
According to the record of Cagayan Valley Medical Center psychiatry department from
Jan. July of 2010, there were 43 patients admitted in female ward, and among those
patients there were 26 cases of schizophrenia. There are 697,543 cases of
schizophrenia in the Philippines, 75% are males and the rest are females. And 51
million people worldwide suffer from schizophrenia in which males have the highest
percentage. (2014, searchcure)

Updates
Research has found a tentative benefit in using minocycline (antibiotic) to treat
schizophrenia. The addition of minocycline to atypical antipsychotic drugs in early
schizophrenia had significant efficacy on negative symptoms but had a slight effect on
the attention domains of patients with schizophrenia. the mechanism of action of
minocycline would include affecting glutamate pathways in the central nervous system,
blocking nitric oxide-induced neurotoxicity, or inhibiting microglial activation in the brain,
5

causing inflammation. It may be considered as a new adjunct treatment for negative

symptoms of schizophrenia.
Nidotherapy or efforts to change the environment of people with schizophrenia to
improve their ability to function, is also being studied; a collaborative treatment involving
the systematic assessment and modification of the environment to minimise the impact
of any form of mental disorder on the individual or on society'. However, there is not
enough evidence yet to make conclusions about its effectiveness.
Patients Profile
Patients name: Mrs. P
Gender: Female
Date of Birth: June 06, 1957
Admitting diagnosis: Paranoid Schizophrenia
Civil status: Married
Age: 57 y/o
Hospital #:055565
Educational attainment: Grade 4
Religion: Catholic
Address: Sabong Tabok, Lavezares, Northern Samar
Citizenship: Filipino
Birthplace: Samar
Date of admission: December 15, 2014 (5:03 pm)

Chief Complaint:
According to the patient: Pinag-kakaisahan ako ng mga pulis, nakamanman sila sa
akin

History of Present Illness:

The patient came from Bgy. Tabok, Northern Samar who was known to be
frequently involved in fights with the neighbors. She was apprehended by NAPOLCOM
last July 2012. She filed a case against policemen battering her and was then referred
to DOH by a television program of Tulfo and Attorney Persida Acosta. She was then
referred to NCMH to acquire a medical certificate attesting that she is capable to stand
trial against the policemen who allegedly abused her. She came alone and was
irritable, furious, cursing and was physically violent hence admission in NCMH.

Past medical history:

Patient has no known history of HPN, DM, PTB and other medical disease.
No previous hospital confinement.
Family health history:
No known family health history of HPN, DM, PTB and other medical disease.

ysical Examination
PHYSICAL EXAM ( NO IDENTIFIED PHYSICAL ABNORMALITIES )
normocephalic, symmetrical facial
HEAD
-movements, smooth without
masses or depressions and
symmetrical facial movements
NECK

no abnormal

swelling or masses
no discharge and pink
conjunctiva

EYES
EARS
no lesions or discoloration

nasal flaring

NOSE
MOUTH
dry mouth, cracked lips

Incomplete

TEETH
CHEST
equal chest expansion, clear breath sounds

ABDOMEN

Flat, soft, normoactive, no

tenderness

EXTREMITIES

full and equal

pulses

Mental Status Exam

Patient seen and examined an adult female of average height and weight. She has
brown skin with shoulder length black hair. She was clad in red hospital gown, fairly
groomed. She has fair sustained eye contact. She was cooperative. With psychomotor
agitation noted. Mood is labile. Speech is spontaneous, hyperproductive, audible and
clear. Patient denied any perceptual disturbances. She denied any homicidal and
suicidal thoughts. She still has persecutory delusions. She became teary eyed when
asked about what happened at the police station in the province. Nakamanman ang
mga pulis pero wala na naman sila. Patient is alert and oriented. She has poor insight
with impaired judgment and impulse control.

Neurological Exam
conscious, coherent, hyperproductive speech, oriented to time and place, able to do simple
commands
Cranial Nerves
CN I- smell intact
CN II- pupils equally round and reactive to light
CN III, IV, VI- intact EOM
CN V- can clench teeth
CN VII- no facial asymmetry
CN VIII- intact hearing
CN IX, X- uvula at the midline
CN XI- shrugs shoulders

CN XII- tongue is midline, no atrophy

Psyschosocial Theories of Development

Erikson's stages of psychosocial development, as articulated by Erik Erikson, is a
psychoanalytic theory which identifies eight stages through which a healthily developing
human should pass from infancy to late adulthood. In each stage, the person confronts,
and hopefully masters, new challenges. Each stage builds upon the successful
completion of earlier stages. The challenges of stages not successfully completed may
be expected to reappear as problems in the future.

LIFE STAGE

Infancy (birth to 1 1/2

years old)
Central Task: Trust vs
Mistrust

INDICATIONS
OF POSITIVE
RESOLUTION

INDICATIONS
OF NEGATIVE
RESOLUTION

Learning
how to
trust others

Mistrust,
withdrawal,
enstrangemen
t

Centers on the infants

basic needs being met
by the parents. The
infant depends on the
parents, especially the
mother, for food,
9

ASSESSMENT

JUSTIFICATION

Mistrust

Her mother did not

breastfeed her.
She was taken
care of by her
grandmother for a
year while her
mother worked.
Lola ko ang nagpalaki sa akin.
Madalas ako iwan
ng nanay ko kasi

nagtrabaho siya.

sustenance and comfort.

If the parents expose the
child to warmth and
dependable affection,
the infants view of the
world will be one of trust.
But if the caregivers are
neglectful, the infant
instead learns that the
world is unpredictable
and unsafe place.
Early childhood (1 -3
years old)
Central Task:
Autonomy vs Shame
and Doubt
If caregivers encourage
self-sufficient behavior,
child develops a sense
of autonomy- a sense of
being able to handle
things on their own. But
if caregivers demand too
much too soon, refuse to
let children perform
tasks of which they are
capable; they may
instead develop shame
and doubt about their
ability to handle things.
Late Childhood (3-6
years old)
Central task: Initiative
vs Guilt
The child learns to take
initiative and get ready
for leadership and goal
achievement roles.

Self-co
ntrol
without loss
of self
esteem;
ability to
cooperate
and
express
oneself

Compulsive
self-discipline
or
compliance;
willfulness and
defiance

Autonomy

The client was

potty trained when
she was 2 years
old.

Over
restriction of
own desired
activity

Guilt

The client did not

engage much in
childhood play. Her
mother did not
allow her to play
outside and
compelled her to
go fishing with his
father on a regular
basis to earn a
living.

Bowel control:
1 years old
Daytime
bladder
control:
2 years old

Learning
degree of
assertivene
ss and
purpose
influence
the
environmen
t ; begins to
evaluate
ones own

10

behavior
Di ako
pinapayagan maglaro sa labas,
nagagalit nanay
ko. Pinapasama
ako mangisda
kasama ang tatay
ko kasi doon kami
kumikita.
School Age (7-12 years
old)
Central Task: Industry
vs Inferiority

Developing
sense of
competenc
e and
perseveran
ce

Sense of
being
mediocre;
withdrawal
from peers
and school

Inferiority

Sense of self
and plans to
actualize
ones abilities

Feelings of
confusion,
pressure,
hesitancy

Role
Confusion

Children are eager to

learn and accomplish
more complex skills;
reading, writing, telling
time.

Adolescence (12-21
years old)
Central Task: Identity
vs Role Confusion
Concerned with how
they appear to others.
The sense of central
identity appears through
sexual, emotional,

11

Displayed poor
performance in
school due to
absences. She
withdraws herself
with her
classmates. She
only has a few
friends due to lack
of interaction with
them. She dropped
out of school in 4th
grade due to
financial reasons.
Hindi ako
masyadong
nakakapasok sa
eskuwela kasi kapos
at nangingisda kami
ng tatay ko at
tumutulong din magtinda sa palengke.
At the age of 14, her
mother had arranged
marriage for her to be
exchanged for a cow.
Gusto kasi ng nanay
ko ng malaking baka.
Naglalaro pa nga ako
noon nung sinundo
ako sa bahay ng
magulang ng
magiging asawa ko.

educational, ethnic,
cultural and vocational
discovery.

Early Adulthood
(21-35 years old)
Central Task: Intimacy
Vs Isolation

Forming adult, loving

relationships and
meaningful attachments
to others.

Una akong nagkaanak nung 16 pa

lang ako at sunod
sunod na yung
dalawa ko pang
anak, isang taon pa
lang ang pagitan
Intimate
relationship
with another
person and
has a sense
of
commitment
to work and
relationships

Avoidance of
relationship,
career or
lifestyle
commitments

12

Isolation

Her spouse worked

abroad in Dubai for 8
years as a
construction worker.
She stayed at home
and took care of her
children and had a
small sari-sari store.
She had a rough
relationship with her
inlaws regarding
financial matters.
Matagal kaming nagkawalay ng asawa
ko, kasi nagtrabaho
siya sa Dubai.
Hinuhuthutan sya ng
biyenan ko at
pinakulam pa ako ng
mga kamag anak ng
asawa ko para
makuha nila mga
anak ko. Itinali at
ginapos. Nung
nalaman ng
magulang ko kinuha
nila ako. Nag-hiwalay
na rin kami ng asawa
ko pag-kauwi niya
kasi natatakot ako sa
pamilya niya baka
gawan nila ako ulit ng
masama.

Middle Adulthood (3565 years old)

Central Task:
Generativity vs
Stagnation

Working
towards the
betterment of
society;
being
productive

Lack of
productivity, not
helping society
to move forward

Contributing to society
and helping to guide
future generations.
When a person makes a
contribution during this
period, perhaps by
raising a family or
working toward the
betterment of society- a
sense of productivity and
accomplishment.

Generativity

She worked as a
house servant for 10
years and saved up
her earnings. She
then started a small
ukay-ukay business
back in the province
which was doing well
for 3 years until she
was apprehended by
policemen and was
detained and
subsequent
admission at NCMH.

Lumuwas ako ng
Manila at namasukan
ng sampung taon.
Nakapag ipon at
umuwi ng probinsya
upang mag-umpisa
ng ukay ukay.
Malakas ang benta
ng mga paninda ko.
Pagkatapos ng
tatlong taon bigla na
lang akong hinuli ng
mga pulis at kinulong
na walang
kadahilanan.

GORDONS FUNCTIONAL HEALTH PATTERN

13

HEALTH PERCEPTION AND

MANAGEMENT

NUTRITIONAL-METABOLIC

PRIOR TO ADMISSION
No regular check up
with the doctor
Goes to Albularyo
when sick
Takes otc drugs for
mild fever and colds
and use of herbal
medicines

ELIMINATION

ACTIVITY-EXERCISE

COGNITIVE-PERCEPTUAL

Eats 3x a day (there

are times that she
skipped meals
because of her work)
Drinks 5-6 glasses of
water everyday
Good appetite
Fish and vegetables

UPON EXAMINATION
Willing to listen to
health teachings
Compliance with
medication regimen
According to patient
Malusog naman ako
kaya lang nag iisip ako
kung kelan ako
makakalabas.
Eats 3x a day meal
Drinks 4-5 glasses of
water everyday

Urinates 5-6 times

daily without any pain
or difficulty
Normal daily bowel
movement in the
morning

Could perform ADL

Works almost
everyday

Could do simple
calculations
Intact memory and has
good fund of
knowledge
Responds
appropriately to
physical and verbal
stimuli

14

Voids yellow turbid

colored urine at least
3-4 times a day
Defecates formed
stool once every two
days
Stays in the corner
inside the ward
Avoid social interaction
with others
Patient denied suicide
and homicidal thought
Denied any perceptual
disturbances

SLEEP-REST

SELF-PERCEPTION/
SELF CONCEPT

ROLE-RELATIONSHIP

Normal 5-6 hours of

sleep daily and no
naps during the day

Sees herself with good

personality
Describes herself as
Masayahin ako tao at
matulungin noong
araw
Married but separated
for almost 30 years
With 4 children(has not
seen them since 2005)

According to patient
Matanda at mahina na
ako Diyos nalang
nakakaalam sa buhay
ko

No contact with her

family
Has not seen her
children since 2005
Absent of support
system

SEXUALITYREPRODUCTIVE

Not sexually active

COPING/STRESS
TOLERANCE

Does not drink alcohol

Does not smoke
Keeps problem to
herself

VALUE-BELIEF

Roman Catholic
Attends Sunday mass

15

Average of 5 hours of
sleep daily
Frequent awakenings
due to noises and
difficulty of going back
to sleep

Separated with
husband for 30 years
Not sexually active
Social isolation
Preoccupation with
unjustified doubts
about trustworthiness
of friends
No restrictions in any
treatments brought by
religion

COURSE IN THE WARD

DAY 1

March 3 2015
8:00am 12:00 noon

Nurses Notes

Assisted in administration of medications (Risperidone 2 mg

BID, multivitamins 1 tab OD, biperiden 2mg PRN,)

Received patient in clean hospital gown, fairly groomed, and

wearing slippers
Brought client out from the ward to the activity area
Explained roles as a student nurse
Conducted nurse patient interaction: Orientation phase
Gathered pertinent data about the client
Discussed duration and limitations of the relationship
are defined
Discussed nurse and patient interaction from each
other
Rapport is built by demonstrating acceptance and
non-judgmental attitude
Established trust
Asked client about the positive benefits of regular exercise
Facilitated dance exercise (Spaghetti)
Stated Nakakabuhay ng dugo

Games conducted(physical and mental games)

Refused to participate (showed discomfort and was
uncommunicative with team members)

Served snack and drink (refused to eat)

Game prizes given

Assisted with hygiene care

Assisted patient back to ward

DAY 2

March 4 2015
8:00am 12:00noon

Nurses Notes
Assisted in administration of medications (Risperidone 2 mg
BID, multivitamins 1 tab OD, biperiden 2mg PRN,)
Received patient in clean hospital gown, fairly groomed, and
wearing slippers
Brought client out from the ward to the activity area
Asked client about the positive benefits of regular exercise
Facilitated dance exercise (Spaghetti)
Stated Nakakapagpalakas

Games conducted (physical and mental games)

Participation and cooperation noted

Music and art therapy provided

Asked to explain her drawing (Wrote Nakakalungkot ang
kanta and drew a small flower)

Served snack and drink

Awarded game prizes

Assisted with hygiene care

Conducted nurse patient interaction: Orientation phase

Gathered pertinent data about the client
Discussed duration and limitations of the relationship
are defined
Discussed nurse and patient interaction from each
other
Rapport is built by demonstrating acceptance and
non-judgmental attitude
Established trust
Assisted patient back to ward

DAY 3

March 9 2015
8:00am 12:00noon

Nurses Notes

Assisted in administration of medications (Risperidone 2 mg

BID, multivitamins 1 tab OD, biperiden 2mg PRN,)

Received patient in clean hospital gown, fairly groomed, and

wearing slippers
Brought client out from the ward to the activity area
Asked client about the positive benefits of regular exercise
Facilitated dance exercise (Spaghetti)

Games conducted
Participation and cooperation noted
Remotivation therapy provided
Stimulated social skills and interest in their environment
Asked to explain her drawing (Wrote Nakakalungkot ang
kanta and drew a small flower)
Served snack and drink
Awarded game prizes
Assisted with hygiene care
Conducted nurse patient interaction: Working Phase
Maintained relationship and trust
Encouraged client in self-disclosure
Promoted a positive self-concept
Evaluated and redefined goals as appropriate

Assisted patient back to ward

DAY 4

March 10 2015
8:00am 12:00 noon

Nurses Notes

Assisted in administration of medications (Risperidone 2 mg

BID, multivitamins 1 tab OD, biperiden 2mg PRN)

Received patient in clean hospital gown, fairly groomed, and

wearing slippers
Brought client out from the ward to the activity area
Asked client about the positive benefits of regular exercise
Facilitated dance exercise (Spaghetti)
Stated Nakakapagpalakas

Games conducted
Participation and cooperation noted

Bibliotherapy provided
Stimulated patient to explore the real world
Asked to reflect on what was read
Served snack and drink
Awarded game prizes
Assisted with hygiene care

Conducted nurse patient interaction: Working Phase

Maintained relationship and trust
Encouraged client in self-disclosure
Promoted a positive self-concept
Evaluated and redefined goals as appropriate

Assisted patient back to ward

DAY 5

March 11 2015

Nurses Notes

8:00 12:00 noon

Assisted in administration of medications (Risperidone 2 mg

BID, multivitamins 1 tab OD, biperiden 2mg PRN)

Received patient in clean hospital gown, fairly groomed, and

wearing slippers
Brought client out from the ward to the activity area
Asked client about the positive benefits of regular exercise
Facilitated dance exercise (Spaghetti)
Stated Nakakapagpalakas

Games conducted
Participation and cooperation noted

Bibliotherapy provided
Stimulated patient to explore the real world
Asked to reflect on what was read
Served snack and drink
Awarded game prizes

Assisted with hygiene care:

Conducted nurse patient interaction: Termination Phase

Assessed client emotional stability
Talked about progress of the relationship

Assisted patient back to ward

PSYCHOTHERAPIES
Activity / Goals
Aerobics and Exercise
-To promote physical and
mental health
-To let client dance actively

Student-Nurse
Facilitated Spaghetti morning
exercise dance

Client
Coordinated movements and
stated Nakakabuhay ng
dugo

Recreational Therapy

Facilitated various individual

and team games. Provided
rewards for the winners and as
well as consolation prizes.

During the first day she

showed discomfort
interacting and was
uncommunicative with team
members. The following day
she participated and was
more cooperative.

Provided go, grow, and glow

light meals

Displayed good appetite.

Facilitated the reading and

objective explanation of a
poem entitled, Ang gulay

She provided variety of

different examples of
vegetables and their different
uses.

Facilitated the reading and

reflection on a short story
called, Ng Dahil Sa Pera

Attentive; when asked about

what she learned, she
stated, Ng dahil sa pera sila
ay naghirap

Instructed to draw using

crayons while listening to a
slow song Thousand Years in
the background

Wrote Nakakalungkot ang

kanta and drew a small
flower.

-To help the client achieve a

balance of work and play in
her life
-To help client socialize with
others
-Enhance memory
-Encourage participation and
cooperation
Food and Nutrition
-To provide the necessary
nutritional needs of the client
Remotivation Therapy
-To stimulate communication,
vocational, and social skills
and interest in their
environment
Bibliotherapy
-Develop ability to reflect on
what was read
-To stimulate patients to be
fellow and explore the real
world
Music and Arts Therapy
-To enable the client identify
and work on resolving issues

through music and arts

-To express ideas and feelings
-To help client express her
thoughts

ANATOMY AND PHYSIOLOGY

The brain is one of the most complex and magnificent organs in the human body. Our
brain gives us awareness of ourselves and of our environment, processing a constant
stream of sensory data. It controls our muscle movements, the secretions of our
glands, and even our breathing and internal temperature. Every creative thought,
feeling, and plan is developed by our brain. The brains neurons record the memory of
every event in our lives.The brain controls thoughts, memory and speech, arm and leg
movements, and the function of many organs within the body. It also determines how
people respond to stressful situations (i.e. writing of an exam, loss of a job, birth of a child,
illness, etc.) by regulating heart and breathing rates. The brain is an organized structure,
divided into many components that serve specific and important functions.

The cerebral hemispheres of the brain are divided into pairs of lobes as follows:

Frontal the largest lobe, located in the front of the brain. The major functions of this
lobe are concentration, abstract thought, information storage or memory, and
motor function. It contains Brocas area which is located in the left hemisphere and is

critical for motor control of speech. The frontal lobe is also responsible in large part
for a persons affect, judgment, personality, and inhibitions.

Parietal a predominantly sensory lobe posterior to the frontal lobe. This lobe analyzes
sensory information and relays the interpretation of this information to other cortical
areas and is essential to a persons awareness of body position in space, size and
shape discrimination, and right-left orientation.

Temporal located inferior to the frontal and parietal lobes, this lobe contains the
auditory receptive areas and plays a role in memory of sound and understanding -

Occipital located posterior to the parietal lobe, this lobe is responsible for visual
interpretation and memory.

Neurotransmitters:
Dopamine- Plays important roles in motor control, motivation, arousal, cognition, and reward.
Serotonin- Responsible for maintaining mood balance, food intake control, sleep and
wakefulness and temperature regulation
Glutamate- Major mediator of excitatory signals in the central nervous system and is involved in
most aspects of normal brain function including cognition, memory and learning.

PSYCHOPATHOLOGY

Etiology

Individual
-Age 57
-(Onset 26)
-Life
experience
s

Interpersonal

Social Factors

-Separation
from
children/spou
se

-Poverty
Migration

-health
beliefs

Stress

Activates flight or fight response

Release of hormone adrenaline, noradrenaline,

cortisol

Adaptive energy is drained out

Decrease blood supply in the

brain

Frontal lobe hypometabolism

Malfunction of
transmission in
electrical impulses

Persecutory delusion

difficulty
concentrating

hostile

suspiciousness

hypervigilant

Actions of:
-dopamine
- serotonin
-glutamate

LABORATORY RESULT

Hematology
Hematology

Result

Normal Values

RBC

4.8

4.6 X 1012 /L

WBC

6.6

5.10 X 109 /L

Hemoglobin

125

120-160 g/L

Hematocrit

0.38

0. 36 -0.42

Neutrophil

0.60

(0.45-0.65)

Lymphocyte

0.25

(0.20-0.35)

Monocyte

0.05

(0.02-0.06)

Eosinophil

0.02

(0.02-0.05)

Platelet Count

333

(150 -450 X 109 /L)

RDW

0.13

(0.10 -0.18)

MCV

88

80-100

MCH

29.2

27-31 g/L

MCHC

332

330-370 g/L

Differential Count

Red Cell Indices

Urinalysis
Gross Examination

Microscopic findings

Color:

WBC:

25 -28

RBC:

3-6

Yellow

Transparency:

Turbid

Specific gravity: 1.020

Epithelial cells:

Moderate

pH:

Mucus Threads:

Few

Acidic

Protein: Positive(++)
Sugar: negative

Amorphous urates:

Moderate

DRUG STUDY
Drug Name

Generic
Name:
Risperidone

Brand Name:
Risperdal

2 mg BID

Drug Class

Atypical
Antipsycho
tics

Drug
Rationale
is used to
treat certain
mental/mood
disorders
(such as
schizophreni
a, bipolar
disorder,
irritability
associated
with autistic
disorder).
This
medication
can help you
to think
clearly and
take part in
everyday life.

Action
Blocks
dopamine
receptors in
the brain.

Side Effects

Nursing Consideration
-Explain the importance and action of the drug

(non observed)
- Monitor patient for tardive dyskinesia, which may occur after
prolonged use. It may not appear until months or years later
and may disappear spontaneously or persist for life, despite
stopping drug.

-weight gain
-drowsiness
-dizziness
-drooling
-nausea
-muscle
spasms
-tremors
-insomnia

Generic
Name:

Anticholine
rgic

biperiden

Brand Name:

Prevent EPS
secondary to
neuroleptic
drug therapy
side effects
before they
actually
occur.

Synthetic
anticholinergic
drug, blocks
cholinergic
responses in the
CNS

Dry mouth

-Advise patient to increase fluid intake to avoid dry mouth and

constipation

-dry mouth
-blurred
vision
-drowsiness

Akineton

-urinary
retention
2 mg PRN
-postural
hypotension
-constipation
-agitation
Drug Name

Generic
Name:
multivitamins

1 tab OD

Drug Class

Multivitamin
s and
minerals

Drug
Rationale

Action

-used to
provide
vitamins that
are not taken
in through
the diet
-also used to
treat vitamin
deficiencies

Promotes
normal
biochemical
reactions,
strengthens
the immune
system,
supports
normal growth
and
development
and helps

Side Effects

Nursing Consideration

(non observed) Avoid taking more than one vitamin/mineral product at the
same time unless your doctor tells you to. Taking similar
vitamin products together can result in a vitamin overdose.

-stomach
upset
-headache
-unpleasant

prevent growth
retardation in
children and
young adult

taste in the
mouth

ASSESSMENT
Subjective:
Pinag-kakaisahan ako
ng mga tao. Tatlong
beses na akong hinuli ng
mga pulis at kinulong.
Wala akong ginawang
masama, minaltrato nila
ako at linagay sa
bartolina as verbalized
by the client.

Objective:
-hypervigilance
-suspiciousness
-easily distracted
-apprehensive (uneasy)
-always on guard
-socially withdrawn

DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Disturbed thought
process: persecutory
delusion related to
impaired cognitive
function secondary to
mental illness as
manifested by delusional
thinking and
hypervigilance.

Short term:
Within 1 day of nursing
interventions, the client
will converse about
concrete happenings in
the environment for at
least 15 minutes or more
during nurse patient
interaction.

Avoided laughing,
whispering, or talking
quietly where client can
see but not
hear what is being said
Being sincere when
communicating. Avoided
vague or evasive remarks
Encouraged to participate
in ward activities and
taught client coping skills
that minimize worrying
thoughts. (talking to
someone, singing, reading)

Suspicious clients often

believe others are talking
about them, and
secretive behaviors
reinforce the paranoid
feelings
Evasive comments or
hesitation reinforces
mistrust or delusions.
When thinking is focused
on reality based
activities, helps focus
attention externally and
not on the delusions

Short term:
After 1 day of
nursing
interventions,
goal was met.
The client
conversed about
concrete
happenings in
the environment
for at least 15
minutes during
nurse patient
interaction.

Long term:
Within 2 weeks of
nursing interventions,
the client will be able to
demonstrate that the
disturbed thoughts are
less intense and less
frequent

Consistent in setting
expectations, enforcing
rules
Recognized the clients
delusions as the clients
perception of the
environment
Did not argue with the
client or try to convince the
client that the delusions are
false or unreal
Interacted with the client on
the basis of real things; did
not dwell on the delusional
thoughts
Recognized and support
clients accomplishments
(projects completed,
interactions initiated)
Showed empathy
regarding clients feelings;

Clear, consistent limits

provide a secure
structure for the client
Recognizing the clients
perceptions can help
understand the feelings
shes experiencing
Logical argument does
not dispel delusional
ideas and can interfere
with the development of
trust
Interacting about reality
is healthy for the patient

Recognizing the clients

accomplishments can
increase clients self
concept and trust on
others
Empathy conveys caring,

Long term:
After 2 weeks of
nursing
interventions,
goal was partially
met. The client
demonstrated
disturbed
thoughts are less
intense and less
frequent as
evidenced by:
-Delusions were
not observed
during activities
-Participated
more on group
activities

reassured of presence and

acceptance
Collaborative: Assisted in
the administration of
Risperidone 2 mg (BID)

DAY 1

ASSESSMENT
Subjective:
Ayoko makihalubilo
sa iba, pakiramdam ko
kasi sasaktan at
lolokohin lang nila ko.
as verbalized by the
patient.
Objective:
- Social Withdrawal
- Prefers to be alone
- Reluctance to
involve in group
activities
- Poor eye contact
during interaction
- Uncommunicative
with others
- Pre-occupation with
own thoughts
- Sense of discomfort
with others.

DIAGNOSIS

PLANNING

Social Isolation
related to disturbed
thought process as
manifested by evident
discomfort in social
situation

Short Term:
Within 8 hours of
nursing interventions,
the patient will
understand causes
and techniques to
correct isolation.
Long Term:
Within 2 weeks of
nursing interventions,
the patient will
participate willingly in
therapeutic activities
and involve self in
social interaction.

interest and acceptance

of the client.
Blocks dopaminergic
receptor sites therefore
decreasing delusional
thoughts of the client.

INTERVENTIONS

RATIONALE

Develop a therapeutic
nurse-patient
relationship through
frequent brief
contacts and an
accepting attitude.

Acceptance and
conveyance
enhances feelings of
self-worth and
facilitates trust.

Encourage patient to
express feelings and
perceptions of
problems.

Helps identify and

clarify reasons for
difficulties in
interacting with other
people.

Assess patients use

of coping skills and
defense mechanisms.

Defense
mechanisms used to
protect the individual
that may contribute
to feelings of
isolation.

Show unconditional
positive regard.

Provide positive
reinforcement for
patients voluntary

This conveys a belief

in the patient as a
worth while social
being.

Positive
reinforcement

EVALUATION
Short Term:
After 8 hours of
nursing
interventions,
the patient was
able to
understand
causes and
techniques that
corrects isolation
as evidenced by
absence of
discomfort in
social situation.
Long Term:
After 2 weeks of
nursing
interventions,
the patient was
able to
participate
willingly in
therapeutic
activities and
involved self in
social
interaction.

ASSESSMENT
Subjective:
Uupakan na kita
dyan eh! Porket
matanda na ako
pinagkakaisahan
niyo
DAY 1
ako! as verbalized by
the patient in
response to another
client's statement.
Objective:

DIAGNOSIS
Risk for violence:
directed to others
related to disturbed
thought process and
rage reactions to
threatening situation
as delivered by
patient.

PLANNING
Short:
Within 30 minutes of
performing nursing
interventions, the
patient will learn to
assess situation
realistically before
taking action
Long term:
Within 2 weeks of
performing nursing
interventions, the
patient will
1.) Develop strategies
to control impulse.
2.) Refrain from
hurting others.

INTERVENTIONS

RATIONALE
EVALUATION
Short term: After
Anxietyenhances
level risesselfin a
esteem
and
it
stimulating environment 30 minutes of
encourages
thus increases
violent
nursing
repetition of desirable
behavior
interventions,
Provides
information
behaviors.
goal was met.

interactions
Maintained
low level of with
others.
stimuli in clients
environment.

-Assisted in identifying
situation
stimuli that
needed for problem
and
Encourage
the
The client learned
initiated angry outburst and
solving.
client can
ToThe
minimize
stimulito assess
patient in realitythe means of dealing with
alternative
oriented activities that then identify
that will
trigger
situation
stimuli, such as walking
responses.
involved human
symptoms of the realistically before
away or taking deep
contact
with
her
cocondition.
taking action as
breaths
patient.
-Provided safe
Removal of dangerous evidenced by
-Leaving the
environment by removing
objects prevents client
stimulus and
all dangerous objects from
in an agitated,
clients environment.
composed herself
confused state from

DAY 2

Remained calm and stated

limits on inappropriate
behavior in a firm manner.
Observed clients behavior
frequently.

Asked directly if client is

thinking of acting on
thoughts or feelings.
Reviewed with client the
factors (feelings and
events) that precipitate
violent behavior.

Discussed impact of
behavior on others and
consequences of action.

using them to harm

others.
To assist in controlling
behavior.

-Then explained
her feelings in a
nonconfronting
manner

Close observation is
important , because
appropriate
interventions can be
provided immediately
To determine violent
intent.

Longterm:
After 2 weeks of
performing
nursing
interventions, the
patient has
developed
strategies to
control impulse
and refrained
from hurting
others.

To provide opportunity
for client to understand
reason and techniques
to prevent violent
behavior.

To assist client to
accept responsibility for
impulsive behavior.

RECOMMENDATIONS

Medications:

Emphasize the importance of taking medications regularly and religiously

Explain the indication and side effects of the drug (lack of knowledge may result
to noncompliace of the drug)

Emphasize non-compliance to drugs results to relapse

Inform client to secure disability card from the local government and present card
at the pharmacy to avail discounted or free medications when discharged

Environment:

Provide a safe and secure environment.

Environmental sanitation is needed to provide a healthy mind and body

Treatment:

Family therapy (support group available for families relatives wherein they gather
once a month to help them deal with living with a family member with mental
illness)
Encouraged to ask questions (preparation of discharge)

Health Teaching:

Have adequate sleep and exercise everyday

Avoid alcohol. Alcohol interacts with medicine used to treat schizophrenia.
Continue participating in therapeutic activities
Promote self-care, personal hygiene and activities of daily living,

Instruct the family members to monitor the clients perception in reality.

Outpatient:

Follow-up check ups

Return if problems with sleep and eating pattern will be observed and have
questions or concerns about condition of care.

Diet and Nutrition:

Whole-grain carbohydrates, antioxidants (fruits) and niacin. Chicken, peanuts,

salmon, and turkey are rich sources of Niacin, which helps convert food into
energy, helping essential fatty-acid metabolism of the brain.
Reduce intake of sugar, refined carbohydrates, caffeine and stimulant drugs
Eat low glycemic load diet