Case study on PARANOID SCHIZOPHRENIA

Submitted to: Mr Eluamlai

Submitted from: Student Nurse Melisa Eleuthere
Date: 06/7/19
 Acknowledgement

The success of any project depends largely on the encouragement and guidelines of many people
who have directly or indirectly worked on the project. We sincerely acknowledge our gratitude
to a host of personalities with those support, guidelines and encouragement, the present final
thesis has been materialized.
Firstly, I would like to thank the Almighty God, for providing me with the knowledge and
strength required for carrying out the project.
Our sincere thanks to my guide Mr. Elumalai and the staff of Mental wellness who helped me at
every stage of my training .
I also owe a debt of gratitude to my family and staff of Aimu for encouraging me for completion
of this project.
Last but not the least, a big thank to my family members and friends for being supportive and
being instrumental in the successful completion of this project.
 Introduction

Paranoid schizophrenia 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, and perceptual disturbances.
Disturbances of affect, volition, and speech, and catatonic symptoms, are not prominent.
With paranoid schizophrenia, your ability to think and function in daily life may be better than
with other types of schizophrenia. You may not have as many problems with memory,
concentration or dulled emotions. Still, paranoid schizophrenia is a serious, lifelong condition
that can lead to many complications, including suicidal behavior.
Patients who have paranoid schizophrenia that has thought disorder may be obvious in acute
states, but if so it does not prevent the typical delusions or hallucinations from being described
clearly. Affect is usually less blunted than in other varieties of schizophrenia, but a minor degree
of incongruity is common, as are mood disturbances such as irritability, sudden anger,
fearfulness, and suspicion. "Negative" symptoms such as blunting of affect and impaired volition
are often present but do not dominate the clinical picture.
The course of paranoid schizophrenia may be episodic, with partial or complete remissions, or
chronic. In chronic cases, the florid symptoms persist over years and it is difficult to distinguish
discrete episodes. The onset tends to be later than in the hebephrenic and catatonic forms.
 Table of contents

Acknowledgement 1
Introduction of condition 2
Personal data 3,4
Physical and mental Assessment 5,6
PSYCHOPATHOPHYSIOLOGY 7,8,

Drug study 9,10

Nursing care plan 11,13
Conclusion & references 14
Personal Data
Name of the Patient: Mr. M
Age: 35 years old
Gender: male
Address: Morne Du Don
Civil Status: Single
Nationality: ST. LUCIAN
Religion: Pentecostal
Birthday: Date admitted: June 18, 2019
Admitting Diagnosis: Paranoid Schizophrenia
Chief Complaints:

According to the Father, the client was hostile and showing untoward behaviors. He was
claiming that he was a prophet and speaks most often about Satan. The informant also added that
the client often says that he was not accepted by their church because of his mother who sold
herself to Satan when they went to a tour around the world.

History of Present Illness

Patient has previous admission at Mental Hospital. He was discharged from male ward on
December, 2016.He had 1-2 consultations with physicians. Upon discharge he resumed smoking
and after few months she resumed alcohol intake and she became suspicious and verbally
assaultive when not giving cigarettes. After few hours upon admission, she heard his female
cousin and a neighbor talking to each other and felt rejuvenated. He went down the house and
with carrying an ice pick. He stabbed at his cousin who sustained several abrasions in
the forearm and she got a scar on the head and on her right lower quadrant of abdomen. The
neighbor placed him in restraints and informed his father who was out in the farm.
History of Previous Illness
The patient was first admitted on October 4, 2014 at the Mental Hospital with chief complaints
of poor appetite, cannot able to sleep and hears a female voice on his ear. A year prior to
admission, the patient used illegal drug such cocaine. After using cocaine, few months prior to
admission he was engaged to abused substances like alcohol and
cigarettes. He started to become violent and shouts to his parents. Few hours uponadmission, he
was saw laughing by him only, becomes aggressive and always shouting. Her father took him to
mental hospital hence the reason for his admission remissions, or chronic. In chronic cases, the
florid symptoms persist over years and it is difficult to distinguish discrete episodes. The onset
tends to be later than in the hebephrenic and catatonic forms. His condition becomes better and
he was discharged on August 19, 2014. But he was then readmitted on November 15, 2015 for
the reason of he took things from the stores and insisted that it was his property. On the nest
seven succeeding years, he was in and out of MMH with an admitting diagnosis of
Undifferentiated Schizophrenia. But early this
year, January 9, 2017, he was again readmitted with a new diagnosis of Paranoid Schizophrenia.

Family history
The client belongs to a well to do family. They were five siblings in their family and have
already their own families respectively and she was the only one who has the condition. Her
father was businessman and so with his wife. The client has three children and they were
studying at the University of the West Indies.
According to him, their family fond of going into different places in the country and also abroad.
On both paternal and maternal side, they do not have a history of schizophrenia and she was the
first to have the condition. The client has a mean father and he never speak to much about his
mother.

PAST PERSONAL HISTORY

The client was a graduate of College Degree at the University of the West Indies. He was
married and has three children. He has been affiliated religiously at their church as a member and
he has been active to their church activities. He spends most of his time on his affiliation and has
a normal state dealing with his colleagues.
Past Clinical History: Schizophrenia, cocaine abuse
Past Surgical History: Nil known
Family History: Works in his garden, nil history of psychiatry illness in family
Social History: Lives on his own. Use of cocaine. But denies use of cocaine
Medications: Artane 2mg PO bid, Haldol 5mg PO bid, Valium 10mg Nocte
Allergies: Nil known allergies
Diet: Normal diet

Review of Systems:
General Appearance: alert, fully conscious, self-ventilating, nil apparent/ painful distress,
afebrile, nil cardiopulmonary distress, well-nourished
Vital Assessment: BP: 124/91 P: 97 Resp: 20 T: 37.4°C SPO2: 100%

HEENT:
Head: normocephalic, hair clean, normal texture
Eye: PERRLA – not assessed, vision intact
Ear: tympanic membrane not assessed, hearing intact
Nose: normal, no nasal secretions
Throat: nil exudates from the throat, teeth and gingiva in good general condition
Mucous membrane pink and moist
Respiratory System: Self ventilating, respiratory sounds not assessed.
Cardiovascular System: BP and pulse are within acceptable range. Heart sounds not
assessed
Abdomen: flat, no emesis, bowel sounds not assessed, bowel pattern normal
Genitourinary: Spontaneously passing urine, no detailed assessment done
Skin: warm to touch, appears well-hydrated, no signs of pallor, acyanotic, skin intact
Musculoskeletal: ambulant, ROM normal, normal gait.
Mental Status: alert, oriented to person, place, time and event, fully conscious, calm
GCS: 15/ 15 ; E4, V5, M6
Psychiatry Assessment
Appearance: healthy, clean appropriately dressed, calm and cooperative, normal gait and
posture
Psychomotor activity: nil tremor, nil tics, nil psychomotor retardation
Speech: coherent, normal tone and rate
Thought Process: irrelevant
Delusion: Grandiose
Perceptual Disturbances: admits to auditory hallucinations, paranoid beliefs he is a pastor
and can heal people
Affect: congruent
Mood: flat to neutral
Insight and Judgment: Complete denial of illness
Intelligence: average
Suicidal/Homicidal Ideation: Nil
Cognitive Status (Orientation and Memory): oriented to person, place and time. Not
knowledgeable of illness. Remote and recent memory intact
PAST FAMILIAL HISTORY

The client belongs to a well to do family. They were five siblings in their family and have
already their own families respectively and he was the only one who has the condition. His father
was businessman and so with his wife. The client has three children and they were studying at
the Castries Comprehensive Schools.
According to him, their family fond of going into different places in the country and also abroad.
On both paternal and maternal side, they do not have a history of schizophrenia and she was the
first to have the condition. The client has a mean father and he has never spoke too much about
his mother.

PAST SOCIAL HISTORY

The client was an active member of her Religious affiliation. He was dedicated and goes along
with his colleagues religiously and acts accordingly. He’s fond of dealing with her co-members.
The client always remembers that he was singing at their church with other group members. The
client’s social atmosphere changed when one day he was not already a member of their church.
He always claimed that he was rejected due to the wrong doing of her mother. He became
socially withdrawn, suspicious and later became hostile and has disorganized behavior.
PHYSICAL AND MENTAL ASSESSMENT

GENERAL APPEARANCE
The client appears stated with her age of 48 years old, wearing a pink dress with a face towel at
her back, well groom and with good personal hygiene. He’s taking a bath every day with a good
daily routine. The client has a good posture, gait and coordination. During interaction, she has a
good eye to eye contact and an appropriate affect or facial expression with regards to a certain
situation. He was well nourished and has a fair skin as evidenced by his good body built and has
no sleeping difficulties by the absence of dark circles under her eyes. He was well oriented with
time, place, date and reality. The client considered the interview the interview as a normal thing
and he was guided accordingly with no harsh or offending questions thrown to him during the
interview. He was cooperative with consistency of speech and behavior.
GENERAL BEHAVIOR AND ACTIVITY
The client sometimes lethargic and catatonic stupor during interactions. There are also times that
he was restless where he can’t remain still. He has also hand tremors which were involuntary,
purposeless rhythmic movements.

ORIENTATION
The client was well oriented on date, time, place and reality. He can relate to past experiences
and able to organized ideas and thoughts related to her present condition. He know and aware
that he was at the National Center for Mental Health.

AFFECT AND MOOD

The client show appropriate affect with regards to a certain situation. But sometimes, he
suddenly change in expression of mood and this makes hard to identify whether he was on stated
condition and willing to cooperate and interested with the interaction. Sometimes, there was an
alteration of the affective state of the client which was inappropriate and contrary to her feelings
and emotions.

THOUGHT PROCESS AND CONTENT

Even the client was at the center, he has a normal and logical thought process. What he uttered
was meaningful and with sense. He didn’t use confabulation nor circumstantial. He can easily
catch up what the interviewee mean and answer relevant to the questions.
DEFENSE MECHANISM
In the case of my client, he used denial as a defense mechanism. In the reason why he was at the
center, he elaborated that he only wanted to rest because he was already tired and exhausted, but
in fact, he’s been hostile and doing unacceptable manner. In some of the activities that were
done, the client never excels in such, but became a winner in the play therapies; therefore he was
compensating on her actions that was not succeeded on her part.
And one thing also that I noticed was that, he tend and often said that his attitude of mumbling
and rattling of speech was due to limited visitation by his family. He’s blaming and concluding
that her physical handicap was due to that event and it was a defense mechanism called
conversion.

PSYCHOPATHOPHYSIOLOGY

PSYCHODYNAMICS

According to Freud, schizophrenia is a form of regression, back to the oral stage

of development. The oral stage is the first stage of psychosexual development.

A baby is born a bundle of id; ID is self-indulgent and concerned only with a satisfaction of
his/her needs. There is a need to gratify these impulses but their experiences in the real world
result in conflict. People with schizophrenia are overwhelmed by anxiety because their egos are
not strong enough to cope with id impulses. In schizophrenia, this can lead to self-indulgent
symptoms such as delusions of grandeur, Jesus Christ. As the patient is still living in the real
world, this may result in further delusions such as hearing voices which may have an ultimate
authority such as God.
This explanation suggests that schizophrenia has a psychosomatic cause the origin is solely in the
mind. At best it could only be a partial explanation of some symptoms, e.g. delusions. In reality,
Freud is denying the very experience of patients with schizophrenia. Itis unscientific and
extremely difficult to test. Concepts such as repression are difficult to observe and measure,
although this difficulty does not invalidate the theory. The theory is based on unrepresentative
samples, case studies, from which it is difficult to generalize. And it involves poor
methodology. The theory fails to account for gender differences - the onset for males is around
20 years, and for females 30 years. Nor does the theory explain why, prior to diagnosis, their
behavior has appeared normal. Furthermore, it excludes a consideration of the environment.

Dysfunctional Families
This explanation suggests that schizophrenia is the result of dysfunctional families. In contrast to
the biological or medical approach which may be regarded as more humane, attaching no blame
to the individual, this model by implication is attaching blame to the family. Bateson (1956)
claimed that parents predispose their children to schizophrenia by communicating in double
binds. Double binds are a no-win situation for the child, e.g. a parent might complain about a
child, lack of affection, but when the child does give affection, s/he is told that s/he is too old for
that. Bateson used the term double bind to explain these ideas of contradictory messages.

Emotions and Environments

Support for this view comes from the work of Brown (1966) who examined the progress of
patients with schizophrenia discharged from hospital. Brown found that those patients who came
from families characterized by high expressed emotion (high conflict, constant interference)
were more likely to return to hospital in a shorter period of time. 58%of patients returned to high
EE families experienced a relapse compared with 10% returning to low EE families. The
implications of this research are that the environment has a significant role to play in the course
of the development of schizophrenia. However, the direction of causation is unclear, it may be
that living with a person with schizophrenia is causing hostility and high expressed emotion
within the family.
Alternatively, it may be the family that is causing the relapse. The effects of stress on the
immune system and on the incidence of disease and illness are well-known. If stress has a role in
physical illness, it may well have a role in mental illness.

Cognitive Deficits
Also, it may be noted that schizophrenia is characterized by cognitive deficits, disorganized
speech, hallucinations, delusions, and a cognitive model focuses more tightly on these
deficits. Deficits in information processing may leave people vulnerable to the behaviors
typically seen as symptoms of schizophrenia. The cognitive approach tends to be descriptive
rather than explanatory and tend to use the biological model to explain the origin of
schizophrenia. Research does suggest that people with cognitive deficits are highly susceptible to
stress.

Diathesis-Stress Model
The diathesis-stress model combines biological and genetic factors with levels
of stress. Diathesis refers to a predisposition (innate) and the stress is environmental
(nurture).This model suggests that mental disorders are the result of an interaction between
nature and nurture. Finnish study revealed that none of the adopted children raised in healthy
families developed schizophrenia, but 11% in severely disturbed families went on to do so. The
bio- psycho-social approach is a more eclectic approach to studying and understanding
schizophrenia. The idea that schizophrenia is the result of schizophrenogenic families is based on
retrospective studies and may be unhelpful and highly destructive. Today, high express
edemotion families which are hostile, critical, and over-involved, are seen as maintaining
schizophrenia rather than causing it. However, it should be noted that many patients with
schizophrenia are estranged from their families. It does seem as if there is a role for attributions
of relatives. Weisman ( (1998) found that relatives who tend to attribute positive symptoms and
delusions to a person mental illness do not hold them accountable. Relatives attributing negative
symptoms tend to become angry and critical. There are higher relapse rates in families with
highly critical attribution.

PSYCHOPATHOLOGY
Schizophrenia is a group of psychotic reactions that affect multiple areas of an individual
functioning including thinking and communication, perceiving and interpreting reality, feeling
and demonstrating emotions and behaving in a socially accepted manner. This condition causes
distortion and bizarre behavior, thoughts, movements, emotions and perceptions. This condition
is usually diagnosed in late adolescence or early adulthood and rarely manifest in child hood. In
relation to the predisposing and precipitating factors, the client cause of illness is severe
religiosity, parenting (family relationships and attitudes towards other), low frustration tolerance
and the nature of work. The onset of the symptoms usually occurs in the adolescence or early
adulthood and the onset can be gradual or sudden. Course of schizophrenia is variable and
remissions may occur. Some clients may recover completely. Some have chronic, unremitting
disorder. Schizophrenic clients have difficulty in perceiving reality and disturbances on
ego. These individuals have poor sense of identity as well as lowered self esteem. The signs and
symptoms which manifested by the client when admitted were delusions (grandiose, jealous,
persecution and reference), hallucinations (auditory and visual), hostility, loose associations,
disorganized behavior, social withdrawal and restricted emotions.

PREDISPOSING AND PRECIPITATING FACTORS

The relationship between members of the family has a big relationship in the development of the
condition. Parenting in the early stage of life which the child seen during those years, she may
manifest and carried until shed grow up.
As to the blaming of others for problems and maybe a problem with authority figures. In this
case, the person may be able to be withdrawn and may not develop interpersonal or social
relationships, she may also vulnerable to stress as she never know what were the alternatives for
the coping of her problems. Nature of work also predispose the development of the condition, if
the person is always ridiculed even she thinks that she did her best and her work is good but it
has no effect on his boss, feeling of guilt a and inadequacy and inferiority begins. That’s why,
the person maybe have fascinating effects that someday her boss would be please on what she
had done or maybe think of hostility against her boss.
Drug study
DRUG CARDS

Generic Brand Name: Haloperidol/ Haldol

Classification: Antipsychotic
Mechanism of Action: Albutyrophenone that probably exerts antipsychotic effects by blocking
post synaptic dopamine receptors in the brain.

Contraindication: Hypersensitivity to drug and those with Parkinsonism coma or CNS depression

Side and Adverse Effects: CNS: severe extra pyramidal reactions, dyskinesia, seizure, lethargy
CV: hypotension, tachycardia GI: anorexia, constipation, dry mouth
Nursing Implications;
- Monitor patient for tardive dyskinesia which may occur after prolong use.
- Watch for signs and symptoms of extra pyramidal effects
- Tell client to relieve dry mouth with sugarless candy.
Dosage: 5mg tablet once daily
Indication: Psychotic disorders
Therapeutic Effects: exerts antipsychotic effects to the client.
Precaution: Use cautiously in elderly clients, those with history of seizures, CV disorders and
those using lithium.
Drug study

Generic Name: Chlorpromazine

Classification: Antipsychotic
Mechanism of Action: Apiperidone phenothiazine that may block post synaptic dopamine
receptors in the brain.
Contraindications: Hypersensitivity to drug and those with Parkinsonism, coma or CNS
depression
Side and Adverse Effects: CNS: severe extra pyramidal reactions, dyskinesia, dizziness,
drowsiness CV: tachycardia GI: nausea constipation, dry mouth
Nursing Implications: Monitor blood pressure regularly.
- Watch for orthostatic hypotension
-Monitor for tardice dyskinesia
-Watch for signs and symptoms of neurolyptic malignant syndrome-
Advise client not to chew extended release capsule before swallowing

Dosage: 100mg capsule once a day

Indication: psychotic disorders
Theraperutic Effects; Exerts antipsychotic effects to the client
Precaution: Use cautiously in elderly clients, those with history of seizures, CV disorders and
respiratory disorders.
Care plans
Nursing diagnosis

Disturbed sensory Disturbed sensory perception related to loneliness and isolation as evidenced
by talking to self frequently, leaves suddenly without explanations, poor concentration and has
difficulty in maintaining conversations.

Anxiety related to prolong rehabilitation as evidenced by grimacing, poor eye contact at times,
hand tremors and restlessness.

Social Isolation related to sadness, poor eye contact at times, absent of significant others and
isolation of self in room most of the time.
 Nursing plan of care

Assessment Nursing diagnosis Outcome Implementation Rationale Evaluation

s
Subjective data Disturbed sensory Patient will Accept the fact that the Validating that your After Nursing
Client hears perception related learn ways to voices are real to the reality does not interventions, th
voices. to loneliness and refrain from client, but explain that include voices can client will
isolation as responding to you do not hear the help client cast demonstrate abil
Objective data evidenced by hallucinations voices. Refer to the “doubt” on the to hold conversa
talking to self voices as “your voices” validity of his or her without
talks to self frequently, leave Patient will or “voices that you voices hallucinating and
frequently suddenly without state that the hear”. ceases to talk to
> leaves area explanations, voices are no Might herald
suddenly poor concentration longer Be alert for signs of hallucinatory
without and has difficulty threatening, increasing fear, anxiety activity, which can
explanation in maintaining nor do they or agitation be very frightening
>poor conversations. interfere with . to client, and client
concentrations his or her life. Explore how the might act upon
>Has difficulty hallucinations are command
Maintaining Patient will experienced by the hallucinations (harm
conversations state, using a client self or others).
scale from 1 to
10, that “the
voices” are Exploring the
less frequent hallucinations and
and sharing the
threatening experience can help
when aided by give the person a
medication sense of power that
and nursing he or she might be
intervention able to manage the
hallucinatory voices
Assessment Nursing diagnosis outcomes implementation Rationale evaluation
Objective data Anxiety related Patient Recognize awareness Provide therapeutic
poor to prolong describes own of the patient’s anxiety Environment
eye contact rehabilitation as anxiety and _To gain client’s After Nursing
at times> evidenced by coping Use trust interventions,
grimacing> grimacing, patterns. presence, touch (with >Be available the client level
hand tremors> poor eye contact at permission), to client at all times of anxiety will
restless times, hand Patient verbalization, and _to make the client’ be lessened
tremors and demonstrates demeanor to remind feel valued and has
subjective data restlessness. improved patients that they are importance.
patient states concentration not alone and to >Stay at the clients
she miss all her and accuracy encourage expression and provide a
children of thoughts. or clarification of comfortable
needs, concerns, environment.
Patient unknowns, and _To make client’s
demonstrates questions feel valued and
ability to relieves the level of
reassure self. anxiety and releases
Patient Interact with patient in tension
maintains a a peaceful manner >Encourage client
desired level of to engage self in
role function activities
and problem- Help patient determine
solving precipitants of anxiety Activities helps the
that may indicate client divert
Patient interventions attention from
monitors signs anxiety and from
and intensity of undesirable behavio
anxiety. Avoid unnecessary rs.
reassurance; this may >Encourage client
Patient increase undue worry to acknowledge and
identifies express feelings
strategies to _To explore the
reduce anxiety. cause of feeling
of apprehension
Assessment Nursing outcomes implementation Rationale evaluation
diagnosis
Subjective Social to The patient Show the >Provide After nursing
data sadness, poor may acceptance by therapeutic interventions,
eye contact demonstrate conducting Environment the client
at times, a desire to frequent will be able
OBJECTIVE: absent socialize contacts, _To gain to engage
>sadness of significant with other but brief. clients trust self in all
> poor eye others and people social
contact at isolation . Rational: > Provide a activities
times of self in The patient Acceptance of positive actively and
>absent room most of can follow others will reinforcement verbalize
of significant the time. the group improve the when client willingness
others activity patient's self- makes moves to social
>isolates self without esteem and towards others. interactions
in room most prompting. facilitates a
of the time sense of trust _It encourages
The patient in others. continuation of
did efforts.
approach 2. Show a
the positive >Promote
interaction reinforcement participation in
with others to the patient. activities.
in a way
that is Rational: _This facilitates
appropriate Make the socialization
/ acceptable patient feel that
would be a >Engage other
useful. client to interact
with the client
3. Accompany
the patient to _this promotes
show support social skills in a
for group safe setting.
activities that
may be the >Help the client
case that scary seek out clients
or difficult for to socialize with
the patient. who have
rational: similar interest.

_Shared
common
interest promote
more enjoyable
socialization
which may be
repeated

.>Praise the
client for
attempts to seek
out others for
activities
and interactions

_Praises
promotes
repeated
positive
social behavior
 Summary and conclusion

Schizophrenia is a serious brain illness. People who have it may hear voices that aren't there.
They may think other people are trying to hurt them. Sometimes they don't make sense when
they talk. The disorder makes it hard for them to keep a job or take care of themselves.
Symptoms of schizophrenia usually start between ages 16 and 30. Men often develop symptoms
at a younger age than women. People usually do not get schizophrenia after age 45. There are
three types of symptoms:
 Psychotic symptoms distort a person's thinking. These include hallucinations (hearing or
seeing things that are not there), delusions (beliefs that are not true), trouble organizing
thoughts, and strange movements.
 "Negative" symptoms make it difficult to show emotions and to function normally. A
person may seem depressed and withdrawn.
 Cognitive symptoms affect the thought process. These include trouble using information,
making decisions, and paying attention.
No one is sure what causes schizophrenia. Your genes, environment, and brain chemistry may
play a role.
There is no cure. Medicine can help control many of the symptoms. You may need to try
different medicines to see which works best. You should stay on your medicine for as long as
your doctor recommends. Additional treatments can help you deal with your illness from day to
day. These include therapy, family education, rehabilitation, and skills training.
 References

www//.nurseslabs .com
www //medicinenet.com
www//. internet