OUR LADY OF FATIMA UNIVERSITYVALENZUELA CAMPUSCollege of Nursing

CASE STUDY OF PARANOID SCHIZOPHRENIAPresented to:Ms. Aida BautistaPresented by:Floidas L. FernandoBSN 3Y2-2 Group B

General Objectives:General Objective:This case study aims to gain a comprehensive knowledge about F20.0 Paranoid Schizophrenia including the practical exercise about the health problem and the practica. experience working with the patient having the disease in order to provide holistic care to patient.Specific Objectives To describe F 20.0 Paranoid Schizophrenia To determine the causative factor of the disease To recognize the clinical sign and symptoms of the disease To know and understand the medical management To determine appropriate nursing care for F 20.0 patient.

Introduction:Schizophrenia is a mental disorder characterized by the disturbances in thoughts, sensory perception and deterioration in psychosocial functioning. It is also characterized by a weak ego. The common defense mechanisms used by individual are regression, projection, withdrawal and denial. There are four As to acknowledge in having schizophrenia, first, the associative looseness, the blunted affect, ambivalence and the autistic thinking.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 particular auditory variety, and perceptual alterations. Disturbances of affect, volition and speech, and catatonic symptoms are not prominent. Paranoid Schizophrenia is manifested primarily through impaired thought processes, in which the central focus is on distorted perceptions or paranoid behavior and thinking. Delusions are in most cases grandiose, persecutory or both. (WHO 2005)With paranoid schizophrenia, the ability to think and function in daily life is better compare with other types of schizophrenia. It may not have as many problems with memory, concentration or dull emotions. Still, paranoid schizophrenia is a serious, lifelong condition that can lead to many complications, including suicidal behavior.Those individuals who diagnosed with paranoidschizophreniaare not especially prone to violence; often prefer to be alone. Studies show that if people have no record of criminal violence prior to develop schizophrenia and are not substance abusers, then they are unlikely to commit crimes after they become ill. Most violent crimes are not committed by people with paranoid schizophrenia, and most people with schizophrenia do not commit violent crimes. Substance abuse always increases violent behavior, whether or not the person has schizophrenia.If someone with paranoid schizophrenia becomes violent, their violence is most often directed at family members and takes place at home. These individuals may spend an extraordinary amount of time thinking about ways to protect themselves from their persecutors.In the US paranoid schizophrenia reports issued by Centers for Disease Control and Prevention (CDC) for 2000 revealed 121,000 diagnoses of paranoid schizophrenia in non-Federal, short-stay hospitals (73,000 men and 47,000 women). Most individuals (62,000) were between the ages of 15 and 44; none were under age 15; 37,000 were between 45 and 64; and 21,000 were 65 or older. According to geographic distribution, the highest prevalence is in the South and Northeast regions of the US with the lowest prevalence in the West and Midwest are almost equal. (Medical Disability Advisor, 2010)The onset of the disorder is usually later than catatonic or disorganized schizophrenia. Men have earlier onset, and more frequent than women. Women have a bimodal onset with peaks in their 20s and early 40s. One study demonstrated within subtype age of institutionalization gender differences only for paranoid schizophrenia (Salokangas et al., 2003).The present etiology of the paranoid schizophrenia are the following, genetics it is known because people believed that mental disorder can be inherit. Other causes are decreased dopamine, stress, alcohol abuse and substance abuse.

Prognosis of the disease is good when there is no familial history of the disease, the patient has good social and professional adjustment prior to onset of symptoms, if the disease come suddenly and the disorder is treated early, quickly, consistently. And onset symptoms occur at later years of life and there is an absence of symptoms between psychotic episodes.Paranoid schizophrenia is usually treated with a combination of therapies, tailored to the individual's symptoms and needs. Anti-psychotic medications can reduce hallucinations and disordered thinking, but do not affect the social withdrawal that is common among those with paranoid schizophrenia. Failure to take medication even during remission periods can result in a relapse. Psychotherapy is used to address the emotional and social issues that result from paranoid schizophrenia. Group therapy can be especially helpful, because it creates opportunities for socialization for individuals with paranoid schizophrenia.

The reason of choosing paranoid schizophrenia as study is to add knowledge, and to know different contributing factors in developing the said illness. Perhaps to correct the misconception of not all people who have mental illness are violent and dangerous. While this may be true in some cases, the generalization has been made far too widely.These attitudes contribute to a significant amount of prejudice against the mentally ill, which may prevent people from seeking help. Stigma may also affect peoples recovery, contributing to low self-esteem and decreased social contact. In contrast to physical health issues, most people in our community avoid even discussing the subject of mental illness, dancing around the issue in the shadow of these pervasive misconceptions.Moreover, the preferred client had a superficial manifestations which seen directly to the clients experiencing the said mental illness. And the client was cooperative and provided primary information that we needed in conducting this study.

Nursing HistoryPatients Profile:Patients Name: PATIENT EGWard Rm: Pavillion 3 Female Age: 51 years oldSex:FemaleCivil Status: SingleBirth Place: TaclobanNationality: FilipinoReligion: CatholicAdmission Date: December 3, 2013Physicians Diagnosis:F 20.0 Paranoid Schizophrenia

Chief Complaint:According to the informant ( brother ): nanghahabol ng kitchen knife at biglang nagagalit.According to the patient: wala po akong sakit

History of Present Illness:The present illness started 12 years prior to admission when the patient got her heart broken which caused poor sleep and she preferred to be left alone. She became irritable and had poor self care. She was not brought for consult and was tolerated. Nine years prior to admission still of above symptom the patient was brought for a consult and was given Risperidone. Patient was non-compliant a and had tolerable relapses. She was semi-function at home.One month prior to admission patient became very irritable and was getting poor sleep. Patient was suspicious to her relatives so she chased them with kitchen knife. Patient would not take any medication. Three days prior to addmission the patient was getting poor sleep, shouting spells, suspicious to relative and would not take any medication. She started collecting garbage and brought at home.

History of Past Illnesss:Patient denies any seizure, no suicidal attempts, no hypertension, no diabetes, no asthma, no heart problem and no thyroid disease.

Family History:Patient denied history of psychiatric illlness.

Anatomy and Physiology

BrainThe brain is a spongy organ made up of nerve and supportive tissues. It is located in the head and is protected by a bony covering called the skull. The base, or lower part, of the brain is connected to the spinal cord. Together, the brain and spinal cord are known as the central nervous system (CNS). The spinal cord contains nerves that send information to and from the brain. The CNS works with the peripheral nervous system (PNS). The PNS is made up of nerves that branch out from the spinal cord to relay messages from the brain to different parts of the body. Together, the CNS and PNS allow a person to walk, talk, throw a ball and so on.

The brain has 3 main parts: CerebrumThe cerebrum is the largest part of the brain. It is divided into 2 parts (halves) called the left and right cerebral hemispheres. The 2 hemispheres are connected by a bridge of nerve fibres called the corpus callosum.CerebellumThe cerebellum is the next largest part of the brain. It is located under the cerebrum at the back of the brain. It is divided into 2 parts or hemispheres and has grey and white matter, much like the cerebrum.Brain stemThe brain stem is a bundle of nerve tissue at the base of the brain. It connects the cerebrum to the spinal cord and sends messages between different parts of the body and the brain.The brain stem controls: breathing body temperature blood pressure heart rate hunger and thirstCranial nerves emerge from the brainstem. These nerves control facial sensation, eye movement, hearing, swallowing, taste and speech.Other important parts of the brainNEUROTRANSMITTERSNEUROTRANSMITTERSare the brain chemicals that communicate information throughout our brain and body. They relay signals between nerve cells, called neurons. The brain uses neurotransmitters to tell your heart to beat, your lungs to breathe, and your stomach to digest. They can also affect mood, sleep, concentration, weight, and can cause adverse symptoms when they are out of balance. Neurotransmitter levels can be depleted many ways. Inhibitory NeurotransmittersSEROTONINis an inhibitory neurotransmitter which means that it does not stimulate the brain. Adequate amounts of serotonin are necessary for a stable mood and to balance any excessive excitatory (stimulating) neurotransmitter firing in the brain. If you use stimulant medications or caffeine in your daily regimen it can cause a depletion of serotonin over time. Serotonin also regulates many other processes such as carbohydrate cravings, sleep cycle, pain control and appropriate digestion. Low serotonin levels are also associated with decreased immune system function.GABAis an inhibitory neurotransmitter that is often referred to as natures VALIUM-like substance. When GABA is out of range (high or low excretion values), it is likely that an excitatory neurotransmitter is firing too often in the brain. GABA will be sent out to attempt to balance this stimulating over-firing.DOPAMINEis a special neurotransmitter because it is considered to be both excitatory and inhibitory. Dopamine helps with depression as well as focus, which you will read about in the excitatory section.Excitatory NeurotransmittersDOPAMINEis our main focus neurotransmitter. When dopamine is either elevated or low we can have focus issues such as not remembering where we put our keys, forgetting what a paragraph said when we just finished reading it or simply daydreaming and not being able to stay on task. Dopamine is also responsible for our drive or desire to get things done or motivation. Stimulants such as medications for ADD/ADHD and caffeine cause dopamine to be pushed into the synapse so that focus is improved. Unfortunately, stimulating dopamine consistently can cause a depletion of dopamine over time.NOREPINEPHRINEis an excitatory neurotransmitter that is responsible for stimulatory processes in the body. Norepinephrine helps to make epinephrine as well. This neurotransmitter can cause ANXIETY at elevated excretion levels as well as some MOOD DAMPENING effects. Low levels of norepinephrine are associated with LOW ENERGY, DECREASED FOCUS ability and sleep cycle problems.EPINEPHRINEis an excitatory neurotransmitter that is reflective of stress. This neurotransmitter will often be elevated when ADHD like symptoms are present. Long term STRESS or INSOMNIA can cause epinephrine levels to be depleted (low). Epinephrine also regulates HEART RATE and BLOOD PRESSURE.Psychopathology of SchizophreniaModifiable Factors: Lifestyle Alcohol Smoking Substance abuseThree separate symptoms complexes/syndromes: Hallucinations/delusions Disorganized thoughts and behavior Negative symptomsReduce psychotic symptomsInduced paranoid psychotic symptomsDrug blocking post synaptic dopamine receptorsDrug increases dopaminergic system activityActions of: Dopamine Serotonin Norepiephrine Acetylcholine GlumateTransmission of signal requires a complex series of biochemical eventsPsychosocial Stressor and interpersonal eventsStimulated by different factorsFailure in development or a subsequent loss of brain tissueDiminished glucose meta, and oxygen in frontal cortical structures of the brainDecrease brain volume and abnormal brain function in frontal and temporal lobeMalfunctioning of transmission of electrical impulses

(Theoretical Based)Enlarged ventricles and cortical atrophyNon-Modifiable: Age Male (15-25) Female (25-35) Gender

General Survey: Patient is an adult female appearing as stated age. Of medium height and built. She is wearing red dress, fairly groomed. Patient is attentive and cooperative and also maintains good eye contact. Patient seems depressed with appropriate affect. She talks spontaneously and responds to question. Patient is oriented to time, place and person. Patient claims that she is not sick.HEENT: Normocephalic, symmetric short black hair, no visible scalp/lesions, no cyanosisSkin: Brown, dry, visible skin lesions on lower extremities, no cyanosisNeck: Normal in size, symmetrical no mass, normal muscle development and tone, no palpable lymph nodesLung/Chest: Symmetrical chest expansion, clear breath soundsHeart: Dynamic precordium, normal rate, regular rhythm, no murmur Abdomen: Flat, symmetrical, Normo-active bowel sounds, soft, non-tender and no palpable mass Extremities: No gross deformities, full and equal pulses. No edema

Mental Status ExaminationGeneral Assessment:Client is seen, an adult female of petite height and small frame she has brown skin and dark hair, wearing red hospital gown with good grooming, she has good eye contact and was cooperative. No psychomotor agitation noted.

Speech: is spontaneous, normoproductive and at usual rate and with no latency.Mood and Affect: is Euphymic with appropriate affect.Perception: Client denies any perceptual disturbances. Thought Process: Client denies any suicidal and homicidal thoughts, client wants to go out of the hospital, doesn't want to be in the ward. Cognitive: Client is alert, and is oriented to 3 spheres, has intact memory and good function of knowledge.Insight is Fair, has good judgment

Course in the Ward:Day 1

a. Aerobic exercise to stretch the muscles and bones (we named the exercise Laba-dami Dance).By: Linton Dela Cruz and Kevin Evangelista.Evaluation: after performing exercise, the patient feels alive, energetic and cooperative.b. Then the Recreational therapy (games prepared are Calamansi relay & Hep-Hep Hooray).By: Jessica Garcia and Efren GannabanEvaluation: the patient is well cooperative and increased her level of functioning.c. Proper hygiene (facial wash, tooth brushing, cleaning ears, giving them powder and lotion, cutting nails, etc.)Evaluation: patient feels comfortabled. Nutritional Therapy: they ate and we gave them their prizes after the activities.Assisted by: Floidas FernandoEvaluation: the patient is happy and feels satisfied.

Day 2

a. Aerobic exercise to stretch the muscles and bones (we named the exercise Laba-dami Dance).By: Linton Dela Cruz and Kevin Evangelista.Evaluation: after performing exercise, the patient feels alive, energetic and cooperative.b. Occupational therapy (our group teach them how to make a salted egg)Evaluation: the patient is cooperative, maintains the daily living and improved her work skills.c. Nutritional Therapy: they ate and we gave them their prizes after the activities.Assisted by: Floidas FernandoEvaluation: the patient is happy and feels satisfied

Day 3

a. Aerobic exercise to stretch the muscles and bones (we named the exercise Laba-dami Dance).By: Linton Dela Cruz and Kevin Evangelista.Evaluation: after performing exercise, the patient feels alive, energetic and cooperative.b. Occupational therapy (our group teach them how to make a salted egg)Evaluation: the patient is cooperative, maintains the daily living and improved her work skills.c. The Remotivation therapy (our group presented a poem about the environment).Evaluation: the patient shows willingness to listen and stimulates interest in the environment.d. Nutritional Therapy: they ate and we gave them their prizes after the activities.Assisted by: Floidas FernandoEvaluation: the patient is happy and feels satisfied

Day 4

a. Aerobic exercise to stretch the muscles and bones (we named the exercise Laba-dami Dance).By: Linton Dela Cruz and Kevin Evangelista.Evaluation: after performing exercise, the patient feels alive, energetic and cooperative.b. Occupational therapy (our group teach them how to make a salted egg)Evaluation: the patient is cooperative, maintains the daily living and improved her work skills.c. Bibliotherapy (uses books or reading materials for therapy). We do storytelling titled Ang Batang Pasaway.Evaluation: the patient shows willingness to listen and she learned a lot of things especially moral lessons.d. Nutritional Therapy: they ate and we gave them their prizes after the activities.Assisted by: Floidas FernandoEvaluation: the patient is happy and feels satisfied.

Day 5

a. Aerobic exercise to stretch the muscles and bones (we named the exercise Laba-dami Dance).By: Linton Dela Cruz and Kevin Evangelista.Evaluation: after performing exercise, the patient feels alive, energetic and cooperative.b. Occupational therapy (our group teach them how to make a salted egg)Evaluation: the patient is cooperative, maintains the daily living and improved her work skills.c. Music and Art therapy (we instructed our patient to hear and feel the background music then we asked them to draw in a sheet of paper about their feelings or ideas that comes in their mind while hearing the music)Evaluation: the patient explores her feelings, reduced anxiety, and developed her social skills.d. Nutritional Therapy: they ate and we gave them their prizes after the activities.Assisted by: Floidas FernandoEvaluation: the patient is happy and feels satisfied

Day 6 Socialization day

a. We started our program with a simple prayer followed by the national anthem.b. The patients performed that Laba Dami Dance c. Recreational Therapy, we prepared various games for the patients.d. Group 2B danced and sang a song for the patients.e. The patients ate and received their prizes.Evaluation: the patient is well cooperative and increased her level of functioning.

Drug Study:

Drug/ClassActionIndicationContraindicatedAdverse EffectIntervention

Haloperidol

Antipsychotic

10-20mg/tab BIDBlocks postsynaptic dopamine receptors in the brainManagement of psychotic symptomsShort-term treatment of hyperactivitySub-cortical brain damageu/c epilepsy, PUD, allergy to aspirinDrowsiness, EPS, urinary retention, urticarialAdvised to avoid prolonged sun exposureAdvised on bladder emptying before giving the drug

Biperiden HCLAnti-Cholinergic2mg PRNxEPS

Synthetic anticholinergic drug that blocks cholinergic response in the CNS

Parkinsonian syndrome especially to counteract muscular rigidity and tremor; extrapyramidal symptoms

Untreated narrow angle glaucoma, intestinal stenosis or obstruction, mega colon, prostatic hypertrophyskin rashes, dyskinesia, twitching, impaired speech, fatigue

Assess forParkinsonism, EPS

RisperidoneAnti- psychotic4mg

Blocks dopamine and serotonin receptors inthe brain, depresses the RAS; anticholinergic, antihistaminic, and alpha-adrenergicblocking activity may contribute to some of its therapeutic and adverse actions.

Treatment for Schizophrenia

Use cautiously with cardiovascular disease, pregnancy, renal or hepaticimpairment, hypotension.

Insomnia, dry mouth, rash, dry skin, Assess for allergy to risperidone, lactation, CV disease, pregnancy, renal or hepaticimpairment, hypotension

Nursing Care PlanAssessmentNursing DiagnosisPlanningNursing Intervention & RationaleEvaluation

Subjective:

Lagi akong na ngangati, nahawa na ako sa loob

Objective:(+) dry skin(+) itchiness(+) skin rash(+) disruption of skin surface

Impaired Skin Integrity related to mechanical trauma as manifested by patients report of dry skin, itchiness, skin rash and disruption of skin surface After 3 hours of nursing intervention the patient will demonstrate understanding of plan to heal and prevent presence of current skin condition. 1. Identified underlying condition/pathology involved to assess the causative factors.

2. Kept the area clean and dry to assess client with correcting condition.

3. Encouraged the client to maintain clean hands and shorts fingernails to reduce disruption of skin when there is itching.

4. Maintained strict skin hygiene, using mild non detergent soap, drying gently and thoroughly and lubricating with lotion as indicated to maintain skin integrity at optimal level.

5. Suggested to use ice or calamine lotion to decrease irritable itching.

6. Emphasized the importance of adequate nutritional/fluid intake to maintain good health and skin turgor. After 3 hours of nursing intervention the patient demonstrated the understanding of plan to heal and prevent presence of current skin condition.