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COLLEGE OF NURSING
Lucinda Campus
Tarlac City
A CASE STUDY
On
PARANOID
SCHIZOPHRENIA
Presented by:
Chapter 1 …………………………………………………………….
Introduction
Theoretical Framework
Personal Data
History of present Illness
Past Personal History
Family History
Chapter 2 ……………………………………………………………
General appearance
Motor behavior
Sensorium and Cognities
Perception
Attitude and Behavior
Defense Mechanism
Affective State
Speech
Thought Process and Content
Chapter 3 …………………………………………………………….
Psychopathology
Related Literature and Studies
Drug Study
Chapter 4 …………………………………………………………….
Process Recordings
Prioritized Psychiatric Nursing Diagnoses
Chapter 5 ……………………………………………………………
Psychotherapies Implemented
CHAPTER 1
Introduction
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.
(http://www.mayoclinic.com/health/paranoid-schizophrenia/DS00862)
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.
Schizophrenia affects men and women with equal frequency. Schizophrenia often
first appears in men in their late teens or early twenties. In contrast, women are generally
affected in their twenties or early thirties.
In the U.S., mental disorders are diagnosed based on the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition (DSM-IV).
(http://www.howstuffworks.com/framed.htm?parent=schizophrenia.htm&url=http://www
.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america.shtml)
In the Philippine setting, the disability survey done in 2000 by the National
Statistics Office (NSO) found out that mental illness was the 3rd most common form of
disability in the country. The prevalence rate of mental disorders was 88 cases per
100,000 population and was highest among the elderly group. This finding was supported
by a more recent data from the Social Weather Station Survey commissioned by DOH in
2004. It reveals that 0.7 percent of the total households have a family member afflicted
with mental disability. The Baseline Survey for the National Objectives for Health in
2000 stated that the more frequently reported symptoms of an underlying mental health
problem were sadness, confusion, forgetfulness, no control over the use of cigarettes and
alcohol, and delusions.
The most recent study on the prevalence of mental health problems was
conducted by the National Epidemiology Center (DOH-NEC) in 2006 which showed
revealing results though the target population was limited only to government employees
from the 20 national agencies in Metro Manila. Among 327 respondents, 32 percent were
found to have experienced a mental health problem at least once in their lifetime. The
three most prevalent diagnoses were: specific phobias (15 %), alcohol abuse (10%),
depression and schizophrenia (6%). Mental health problems were significantly associated
with the following respondent characteristics: ages 20-29 years, those who have big
families, and those who had low educational attainment. The prevalence rate generated
from the survey was much higher than those that were previously reported by 17 percent.
(http://72.14.235.132/search?q=cache:sGh-NeA_KcUJ:home.doh.gov.ph/ao/ao2007-
0009.pdf+epidemiology+of+schizophrenia+in+the+philippines&cd=6&hl=tl&ct=clnk&g
l=ph)
This introduced psychiatric case was chosen primarily because it is the most
interesting amongst the cases that were encountered by the group members. It posts
relevant manifestations that are psychiatric in nature and the entire case is highly possible
to be studied comprehensively within the limited time available.
Theoretical Framework
The patient was first admitted on October 4, 200 at Mariveles 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 as shabu. After using
shabu, 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 upon
admission, he was saw laughing by him only, becomes aggressive and always shouting.
His father took him to MMH hence the reason for his admission.
His condition becomes better and he was discharged on August 19, 2001. But he
was then readmitted on November 15, 2002 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, 2009, he was again readmitted with a new diagnosis of
Paranoid Schizophrenia.
A. General Appearance
During nurse-patient interaction, the patient’s grooming was not good prior to
morning care but on the later part he improves and shows good grooming. Most of the
time, he exhibited appropriate facial expressions and posture during interactions. At first,
he cannot display eye contact which may show lack of focused and interest on the topic.
As days passes by student nurse established trust on the patient and he maintains good
eye contact.
B. Motor Behavior
D. Perception
From the 1st up to 4th day of nurse-patient interaction, the patient manifest
presence of delusions wherein he always claims that he was the husband of Sheryl
Cosim. Other perceptions were not noted.
F. Defense Mechanism
G. Affective State
H. Speech
Speech refers to the processes associated with the production and perception of
sounds used in spoken language.
During the interaction, the patient does not show any alteration in his speech
pattern. He did not experience verbigeration, aphasia, other speech problems.
During the first part of our nurse-patient interaction, the patient shows delusion.
He also manifested obsession wherein he keeps on insisting that his wife is Sheryl Cosim
who is a famous news anchor.
Chapter 3
Psychopathology
Book-Based
Client-Based
Related Literature and Studies
What is Schizophrenia?
The onset of illness may be rapid, with acute symptoms developing over several
weeks, or it may be slow, developing over months or even years. During onset, the person
often withdraws from others, gets depressed and anxious and develops extreme fears or
obsessions.
These include changes in the chemistry of the brain, changes in the structure of
the brain, and genetic factors. Viral infections and head injuries may also play a
role....finally, schizophrenia is probably a group of related diseases, some of which are
caused by one factor and some by another." (p. 222).
There are billions of nerve cells in the brain. Each nerve cell has branches that
transmit and receive messages from other nerve cells. The branches release chemicals,
called neurotransmitters, which carry the messages from the end of one nerve branch to
the cell body of another. In the brain afflicted with schizophrenia, something goes wrong
in this communication system.
In some, the illness may develop into what is known as chronic schizophrenia.
This is a severe, long-lasting disability characterized by social withdrawal, lack of
motivation, depression, and blunted feelings. In addition, moderate versions of acute
symptoms such as delusions and thought disorder may be present in the chronic disorder.
• Loss of drive - where often the ability to engage in everyday activities such as
washing and cooking is lost. This lack of drive, initiative or motivation is part of
the illness and is not laziness.
• Blunted expression of emotions -where the ability to express emotion is greatly
reduced and is often accompanied by a lack of response or an inappropriate
response to external events such as happy or sad occasions.
• Social withdrawal - this may be caused by a number of factors including the fear
that someone is going to harm them, or a fear of interacting with others because of
a loss of social skills.
• Lack of insight or awareness of other conditions - because some experiences such
as delusions and hallucinations are so real, it is common for people with
schizophrenia to be unaware they are ill. For this and other reasons, such as
medication side-effects, they may refuse to accept treatment which could be
essential for their well-being.
• Thinking difficulties - a person's concentration, memory, and ability to plan and
organise may be affected, making it more difficult to reason, communicate, and
complete daily tasks.
No single cause has been identified, but several factors are believed to contribute to the
onset of schizophrenia in some people:
Genetic factors
Biochemical factors
Certain biochemical substances in the brain are believed to be involved in this condition,
especially a neurotransmitter called dopamine. One likely cause of this chemical
imbalance is the person's genetic predisposition to the illness.
Family relationships
No evidence has been found to support the suggestion that family relationships cause the
illness. However, some people with schizophrenia are sensitive to any family tension
which, for them, may be associated with relapses.
Environment
It is well recognised that stressful incidents often precede the onset of schizophrenia.
They often act as precipitating events in vulnerable people. People with schizophrenia
often become anxious, irritable and unable to concentrate before any acute symptoms are
evident. This can cause relationships to deteriorate, possibly leading to divorce or
unemployment. Often these factors are then blamed for the onset of the illness when, in
fact, the illness itself has caused the crisis. It is not, therefore, always clear whether stress
is a cause or a result of illness.
Drug use
The use of some drugs, especially cannabis and LSD, is likely to cause a relapse in
schizophrenia.
Source: www.mental-health-matters.com
Paranoid Schizophrenia
People with paranoid schizophrenia, the most common form of the disorder,
mainly experience hallucinations. They tend to believe that others are poisoning,
harassing, or plotting against them. They may also hear voices, which order them to do
things. Contrary to popular belief, people suffering from this type of schizophrenia are
actually not prone to violence; in fact, they generally prefer to be left alone.
For people with paranoid schizophrenia, the primary symptoms are delusions or
auditory hallucinations. People with paranoid schizophrenia usually do not have thought
disorder, disorganized behavior, or affective flattening.
People with paranoid schizophrenia have grandiose delusions. For example, they may
believe that others are deliberately:
• Cheating them
• Harassing them
• Poisoning them
• Spying on them
• Plotting against them or the people they care about.
People with paranoid schizophrenia are not especially prone to violence and often
prefer to be left alone. Studies show that if people have no record of criminal violence
before they develop schizophrenia and are not substance abusers, 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 almost always increases violent behavior, whether or not the
person has schizophrenia.
Source: http://schizophrenia.emedtv.com
Drug Study
NURSING RESPONSIBILITIES:
BEFORE:
• Explain the importance and action of the drugs.
• Tell the possible reaction or side effects of the drugs.
• Monitor patient for any adverse reaction.
DURING:
• The client may sip small amount of water
• Stay with the client for at least 15-30 minutes after giving the drug
• Be alert for adverse reaction and drug interaction
Name of Date ordered/ Route/ General Indication Client’s
drug Date started/ Dosage/ action/mechanis / response to
Date changed Frequency of m of action Purpose medicine with
administration actual s/e
Generic Date Ordered: Route of Chemical Effect: This is Administratio
Name: January 31, 2009 Administration May block given to n of the drug
Date Started: : postsynaptic the patient was not
Haloperido January 31, 2009 Per Orem dopamine with actually
l receptors in brain. chronically observed
Date Ended: Dosage and Therapeutic psychotic
-------------------- Frequency: Effect: disorder
- 5mg tab tid Decreases who needs
psychotic prolonged
behaviors. therapy.
NURSING RESPONSIBILITIES:
BEFORE:
• Explain the importance and action of the drugs.
• Tell the possible reaction or side effects of the drugs.
• Monitor patient for any adverse reaction.
DURING:
• Stay with the client for at least 15-30 minutes after giving the drug
• Monitor patient for tardive dyskinesia, which may not appear until months or
years later and may disappear spontaneously or persists for life despite stopping
use of drug.
CHAPTER 5
PSYCHOTHERAPIES IMPLEMENTED
REMOTIVATION THERAPY
Definition: A simple group therapy which aims to bridge the fantasy- world of the
Psychotics to the real world. Is a technique of simple group therapy, objective in nature,
used with a group of patients in an effort to reach the “unwounded” areas of each
patient’s personality & to get them back into reality.
Goals:
To stimulate patients to be fellow explore the real world.
To develop their ability to communicated and share ideas and experiences with
the other people.
To develop feelings of acceptance.
To promote group harmony and identification.
NEWSPAPER THERAPY
Definition: Newspaper therapy is giving information to the clients about events and what
is happening outside
Newspaper therapy is cutting clippings from newspaper and sharing this information to
the clients and knowing their feelings and ideas about the information given. Providing
basic information about places/events may motivate the clients to follow the medical
regimen to be well. The facilitator let the clients to read the topic, then ask them
questions.
Goals:
To give information to the clients on what is happening outside and to give latest
news today.
To encouraged emotions and reactions about the news
Role of the Nurse:
PLAY THERAPY
Definition: A form of psychotherapy used to help them express or act out their
experiences, feelings, and problems by playing with dolls, toys, and other play material.
Procedure:
The clients are instructed to catch the ball with their respective partners.
Goals:
To establish rapport since it is the first recreational activity of the client
To encourage release/ express clients emotions
To let the client learn on how to cooperate
To let the client play freely and actively
DANCE THERAPY
Definition Dance is the most fundamental of the arts, involving direct expression through
the body. Dance /movement therapy effects changes in feelings, cognition, physical
functioning, and behavior.
Goals:
SONG THERAPY
Definition: A kind of recreational therapy under the music category, which connects us
with our creativity, innate wisdom and our vast inner resources for growth and well-
being. It has a soothing and pleasing effect and provides for emotion and release.
Procedure:
Using the visual aids that has the written lyrics, the patients read it first.
The nurse sings the song with the use of guitars.
Nurses, together with the patients, sing the song.
Lastly, let the patients sing to the tune of guitars.
Goals:
Develop patient’s ability to read and reflect.
Develop patient’s listening skill.
To encourage them to participate and cooperate.
Patients will learn to express emotions and feelings.
ART THERAPY
Role of Nurses:
Explain the procedure of the activity.
Provide the means of the therapy (crayons, papers).
Interrogate patients during post drawing phase.
Assessing and interpreting answers based on Buck’s HTP interpretation.
Develop a deeper nurse-patient relationship through building of trust.
OCCUPATIONAL THERAPY
Definition: Any activity, mental or physical, prescribed and guided to aid an individual’s
recovery from diseases or injury. This activity excludes competition and pressure. There
is opportunity for creativeness and produce something tangible out of patient’s own
thinking and imagination. Self confidence and personal achievements are also
experienced.
Role of Nurses:
To select the most useful activity.
To facilitate the activity successfully.
To assist the patients.
To promote positive personality growth
BIBLIOGRAPHY
7th Edition Nursing Diagnosis Handbook: A Guide to Planning Care by Betty J Auckley and Gail
B. Ladwig
http://www.answers.com/topic/psychosis
http://www.emedicine.com/med/byname/brief-psychotic-disorder.htm
http://www.hawaii.edu/hivandaids/Philippines_Mental_Health_Country_Profile.pdf
http://en.wikipedia.org/wiki/Psychotic_disorder