Schizophrenia Case Study on a 35-Year-Old Male

URDANETA CITY, PANGASINAN
COLLEGE OF NURSING
A CASE STUDY ON
SCHIZOPHRENIA
Submitted to:
Ms. Maribel Murillo RN, MAN
Clinical Instructor
Submitted by:
Kristin Abee E. Guarin
SN Batch 2014

I. PATIENT ASSESSMENT DATABASE
A. Personal Data
 Name: Mr. MP
 Address: Las Pinas, Philippines
 Age: 35
 Sex: Male
 Birthday: June 5, 1976
 Birth Place:
 Civil Status: Single
 Nationality: Filipino
 Religion: Roman Catholic
 Educational Attainment: 3rd year college, BS Management
 Occupation: None
 Physician: Dr. Cortez
 Date of Admission: July 14, 2004
 Admitting Diagnosis: Schizophrenia
 Hospital Name: Mother Theresa A Home that Cares
B. CHIEF COMPLAINT
 N/A (he doesn’t cooperate upon interview)
C. HISTORY OF PRESENT ILLNESS
 N/A(he doesn’t answer my question about his present illness)
D. PAST HEALTH HISTORY
 N/A (he doesn’t recall his past health history)
E. FAMILY ASSESSMENT
Name Relation Age Sex Occupation Educational Attainment
Mr. MP Patient 35 Male None 3rd year college
Mr. CP Father 78 Male Doesn’t recall Doesn’t recall
Mrs. DP Mother 68 Female Doesn’t recall Doesn’t recall
F. SYSTEM REVIEW
1. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

 Not assess because patient doesn’t answer my questions about health perception and health management
2. NUTRITIONAL – METABOLIC PATTERN
 N/A
3. ELIMINATION PATTERN
 Patient usually urinates 6 times a day and defecates 2 times daily
4. ACTIVITY- EXERCISE PATTERN
0-Feeding 0 -Dressing 0-Grooming
0-Bathing 0 -Toileting ____others
Legend:
0- Full Care
I- Requires use of assistance
II- Requires assistance and supervisions by others
III- Requires assistance or supervisions from another and equipments and devices
IV – Dependent, doesn’t participate
5. COGNITIVE – PERCEPTUAL PATTERN
 Hearing: she doesn’t have any hearing problems
 Vision: she’s having blurred vision and she use reading glass
 Sensory: our patient is responsive and is able stimulated by closing her eyes and instructed to point what have been pointed on her
skin. There is no problem with sense of taste and smell.
 Learning Styles: my patient doesn’t answer my question and sometimes not cooperative
6. SLEEP- REST PATTERN
 According to my patient he sleeps at 9pm to 6am. He also stated that sometimes he had problems in sleeping.
7. SELF- PERCEPTION AND SELF- CONCEPT PATTERN
 N/A
8. ROLE- RELATIONSHIP PATTERN
 N/A
9. COPING- STRESS TOLERANCE PATTERN
 N/A
10. VALUE- BELIEF PATTER

 N/A
G. DEVELOPMENTAL HISTORY
Theory Age Sex Description
Erickson’s Psychosocial Theory 35 years old Male
Intimacy vs Isolation
Mr. MP doesn’t answer my questions sometimes and doesn’t participate to the
activities because he doesn’t trust me as his nurse.
H. PHYSICAL ASSESSMENT
A. General Survey
1. Overall appearance and grooming: upon assessment patient is neat and clean, he manifested a good grooming.
2. Actual height and weight vs. ideal body weight: n/a
3. Symptoms of distress: he is not answering my question mostly and he prefer to be alone sometimes
4. Posture and gait: upon assessment her posture and gait are well coordinated.
5. Affect and mood: he is not answering my question mostly and he prefer to be alone sometimes.
B. Regional exam- utilize IPPA technique
1. Hair: Upon inspection, his hair is evenly distributed, thick, its texture is silky and resilient hair and there is no presence of infestation
(lice) and variable in amount.
Head and face: his head is round, smooth skull contour, symmetric in size and consistent while her face is symmetric in facial
movement.
2. Eyes: Upon inspection of the client’s eyes, its eyebrows and eyelashes are symmetrically aligned, curled slightly outward and hair is
evenly distributed.
3. Nose: Upon inspection, client’s nose is symmetrical, no discharges, uniform in color, he breaths properly through the nares.
4. Ears: Through inspection, client’s ears are symmetrical; the auricle is aligned with the outer canthus of the eyes and same with the
color of facial skin.
5. Mouth and throat: Through inspection, client’s lips and buccal mucosa is pink in color. No retraction of gums, with incomplete
teeth. Tongue moves freely.
6. Neck and lymph nodes: The client’s neck muscles are equal in size, no enlargement of nodules or masses upon palpation. Head
movement is coordinated and smooth movement with no discomfort.
7. Skin: Brown in color, warm to touch and equally distributed by hair.
8. Nails: fingernail plate has convex curvature and an angle of nail plate about 160˚, smooth texture, finger nail and toenail bed color is
pale, with intact epidermis.
9. Thorax and lungs: Chest is symmetric, spine vertically aligned, spinal column is straight, right and left shoulder are at same height.
10. Breast and axilla: not assessed
11. . Abdomen: not assessed

12. Extremities: there is no presence of edema or abnormal findings
13. Genitals: not assessed
14. Rectum and anus: not assessed
15. Neurological/Cranial nerves: not assessed.

INTRODUCTION
Schizophrenia is a psychotic disorder (or a group of disorders) marked by severely impaired thinking, emotions, and behaviors. Schizophrenic
patients are typically unable to filter sensory stimuli and may have enhanced perceptions of sounds, colors, and other features of their environment.
Most schizophrenics, if untreated, gradually withdraw from interactions with other people, and lose their ability to take care of personal needs and
grooming.
Clinical Manifestations
The symptoms of schizophrenia are divided into two major categories:
A. The positive symptoms include:
 delusions and its types,
 hallucinations,
 loose associations and
 bizarre or disorganized behavior
B. The negative symptoms includes:
 restricted emotions,
 anhedonia,
 avolition,
 alogia,
 catatonia and
 social withdrawal.
Diagnostic Test
 Clinical diagnosis is developed on historical information and thorough mental status examination.
 No laboratory findings have been identified that are diagnostic of schizophrenia.
 Routine battery of laboratory test may be useful in ruling out possible organic etiologies, including CBC, urinalysis, liver function tests,
thyroid function test, RPR, HIV test, serum ceruloplasmin ( rules out an inherited disease, wilson’s disease, in which the body retains
excessive amounts of copper), PET scan, CT scan, and MRI.
 Rating scale assessment:
 Scale for the assessment of negative symptoms.
 Scale for the assessment of positive symptoms.
 Brief psychiatric rating scale

Treatment
A comprehensive treatment program can include:
 Antipsychotic medication
 Education & support, for both ill individuals and families
 Social skills training
 Rehabilitation to improve activities of daily living
 Vocational and recreational support
 Cognitive therapy
Nursing Interventions:
A. Strengthening Differentiation
 Provide patient with honest and consistent feedback in a non threatening manner.
 Avoid challenging the content of patient’s behavior
 Focus interactions on patient’s behavior.
 Administer drugs as prescribed while monitoring and documenting patient’s response to drug regimen.
 Use simple and clear language when speaking with the patient.
 Explain all procedures, test and activities to patient before starting them
B. Promoting Socialization
 Encourage patient to talk about feelings in the context of a trusting, supportive relationship.
 Allow patient to reveal delusions to you without engaging in power struggle over the content or the entire reality of the delusions.
 Use supportive, emphatic approach to focus on patient’s feelings about troubling events or conflicts.
 Provide opportunities for socialization and encourage participation in group activities.
 Be aware of personal space and use touch judiciously.
 Help patient to identify behaviors that alienate significant others and family members.
C. Ensuring Safety
 Monitor patient for behaviors that indicate increased anxiety and agitation.
 Collaborate patient to identify anxious behaviors as well as causes.
 Establish consistent limits on patients behavior and clearly communicate these limits to patients, family member, and health care providers.
 Secure all potential weapons and articles from patients room and the unit environment that could be used to inflict injury.
 Determine the need for external control, including seclusion or restraints. Communicate the decision to patient and put plan into action.
 Frequently monitor the patient within guidelines of facility’s policy on restrictive devices and assess the patients level of agitation.
 When patient’s level of agitation begins to decrease and self control regained, establish a behavioral agreement that identifies specific
behaviors that indicate self control against are escalation agitation.

ANATOMY AND PHYSIOLOGY
I. Structures
A. The neurologic system consists of two main divisions, the central nervous system (CNS) and the peripheral nervous system (PNS). The
autonomic nervous system (ANS) is composed of both central and peripheral elements.
1. The CNS is composed of the brain and spinal cord.
2. The PNS is composed of the 12 pairs of the cranial nerves and the 31 pairs of the spinal nerves.
3. The ANS is comprised of visceral efferent (motor) and the visceral afferent (sensory) nuclei in the brain and spinal cord. Its peripheral
division is made up of visceral efferent and afferent nerve fibers as well as autonomic and sensory ganglia.
B. The brain is covered by three membranes.
1. The dura matter is a fibrous, connective tissue structure containing several blood vessels.
2. The arachnoid membrane is a delicate serous membrane.
3. The pia matter is a vascular membrane.
C. The spinal cord extends from the medulla oblongata to the lower border of the first lumbar
vertebrae. It contains millions of nerve fibers, and it consists of 31 nerves – 8 cervical, 12 thoracic, 5
lumbar, and 5 sacral.
D. Cerebrospinal fluid (CSF) forms in the lateral ventricles in the choroid plexus of the pia matter.
It flows through the foramen of Monro into to the third ventricle, then through the aqueduct of
Sylvius to the fourth ventricle. CSF exits the fourth ventricle by the foramen of Magendie and the two
foramens of Luska. It then flows into the cistema magna, and finally it circulates to the subarachnoid
space of the spinal cord, bathing both the brain and the spinal cord. Fluid is absorbed by the
arachnoid membrane.
II. Function
A. CNS
1. Brain
The cerebrum is the center for consciousness, thought, memory, sensory input, and motor activity; it consists of two hemispheres (left and
right) and four lobes, each with specific functions.
 The frontal lobe controls voluntary muscle movements and contains motor areas, including the area for speech; it also contains the centers for
personality, behavioral, autonomic and intellectual functions and those for emotional and cardiac responses.
 The temporal lobe is the center for taste, hearing and smell, and in the brain’s dominant hemisphere, the center for interpreting spoken
language.
 The parietal lobe coordinates and interprets sensory information from the opposite side of the body.

 The occipital lobe interprets visual stimuli.
The thalamus further organizes cerebral function by transmitting
impulses to and from the cerebrum. It also is responsible for primitive
emotional responses, such as fear, and for distinguishing between
pleasant and unpleasant stimuli.
Lying beneath the thalamus, the hypothalamus is an automatic
center that regulates blood pressure, temperature, libido, appetite,
breathing, sleeping patterns, and peripheral nerve discharges associated
with certain behavior and emotional expression. It also helps control
pituitary secretion and stress reactions.
The cerebellum or hindbrain, controls smooth muscle movements,
coordinates sensory impulses with muscle activity, and maintains muscle
tone and equilibrium.
The brain stem, which includes the mesencephalon, pons, and
medulla oblongata, relays nerve impulses between the brain and spinal
cord.
2. The spinal cord forms a two-way conductor pathway between the brain stem and the PNS. It is also the reflex center for motor activities that do
not involve brain control.
B. The PNS connects the CNS to remote body regions and conducts signals to and from these areas and the spinal cord.
C. The ANS regulates body functions such as digestion, respiration, and cardiovascular function. Supervised chiefly by the hypothalamus, the ANS
contains two divisions.
1. The sympathetic nervous system serves as an emergency preparedness system, the “flight-for-fight” response. Sympathetic impulses
increase greatly when the body is under physical or emotional stress causing bronchiole dilation, dilation of the heart and voluntary muscle blood
vessels, stronger and faster heart contractions, peripheral blood vessel constriction, decreased peristalsis, and increased perspiration. Sympathetic
stimuli are mediated by norepinephrine.
2. The parasympathetic nervous system is the dominant controller for most visceral effectors for most of the time. Parasympathetic
impulses are mediated by acetylcholine.

PATHOPHYSIOLOGY
Brain developmentfromconceptiontoearlyadulthood
Anatomicandfunctional disruptionin neural connectivity and communication
Impairmentinafundamental cognitive process
Impairmentinone ormore second-ordercognitive process
Predisposing factor
Stress
Low socioeconomics
Disturbance in neurotransmitter system
Looseness of ability in thinking
Impaired ability to perceive
Disorganized thought confusion
S/Sx:Delusionand hallucination
Social isolation

LABORATORY RESULT
Electrolytes
Urinalysis
RESULTS SIGNIFICANCE RESULTS SIGNIFICANCE
Color:
Yellow Within normal range
Sugar:
negative Within normal range
Transparency:
Clear Within normal range
Specific gravity:
1.010 Within normal range
Reaction: Microscopic:
Pusleukocytes:
Albumin:
Acidic Albumin Within normal range Erythrocytes:
Roentrogenological report
Findings:
There are hazy infiktrates at both suprahilar area heart is not enlarged diaphragm and sulci are intact
Impression
Suprahilar pneumonitis, bilateral koch's etiology not ruled out
Result Normal Values Significance
Sodium 136 135-145 Within normal range
Potassium 3.98 3.5-5.0 Within normal range

DRUG STUDY
Generic Name: Haloperidol
Brand Name: Haldol
Drug Classification: Antipsychotic
Dosage: 20mg 1/4 tab OD
Indication: Management of manifestations of psychotic disorders
Mechanism of Action Adverse Effects Contraindications Side Effects Nursing Considerations
Anti-psychotics block
postsynaptic dopamine
receptors in the brain,
depress the RAS,
including those parts of
the brain involved with
wakefulness and emesis.
 Vertigo, headache
 Nasal congestion
 Polyuria
 Cerebral edema
 Tremor
 Ataxia
 Orthostatic
hypotension
 Cardiomegaly
 SIADH
 Eosinophilia
 Leucopenia
 Jaundice
 Urticaria
 Coma
 Severe CNS
depression
 Bone marrow
depression
 Blood dyscrasia
 Circulatory collapse
 Subcortical brain
damage
 Cerebral
arteriosclerosis
 Coronary disease
 Severe hypotension
or hypertension
 Drowsiness
 Blurring of vision
 Dry mouth
 Nausea and vomiting
 Tachycardia,
bradycardia
 insomnia
 Provide safety to the patient
 Maintain fluid intake and use
precautions against heatstroke or
heat weather
 Monitor electrolytes level
 Monitor Vital Signs continuously
 Provide rest and comfort
 Monitor CBC, BUN, Creatinine
 Gradually withdraw drug when
patient has been on maintenance
therapy

Generic Name: Diphenhydramine hydrochloride
Brand Name: Benadryl
Drug Classification: Antiparkinsonian
Dosage: 50mg cap HS
Indication: Parkinsonism (including drug induced parkinsonism and extrapyramidal reactions), in the elderly intolerant of more potent drugs, for
milder forms of disorder
Competitively blocks the
effects of histamine at
h1 receptor sites, has
atropine-like, anti-
pruritic and sedative
effects
 Fatigue
 Confusion
 Blurred vision
 Headache
 Diplopia
 Tremors
 Palpitations
 Bradycardia
 Diarrhea
 Constipation
 Urinary frequency
 Anorexia
 Dysuria
 rash
 Third trimester of
pregnancy
 Lactation
 Used cautiously
with:
 Narrow angle
glaucoma
 Asthmatic attack
 Bladder neck
obstruction
 Pregnancy
 Stenosing peptic
ulcer
 Symptomatic
prostatic
hypertrophy
 Drowsiness
 Sedation
 Dizziness
 Disturbed
coordination
 Assist patient in ambulation
heat weather
 Administer these drugs with food
if GI upset occur
therapy

Generic Name: Fluoxetine hydrochloride
Brand Name: Prozac
Drug Classification: SSRI (Selective Serotonin Reuptake Inhibitor)
Dosage: initially 20mg/day tab
Indication: treatment of depression; most effective in patients with major depressive disorder
Acts as an
antidepressant by
inhibiting CNS neuronal
uptake of serotonin;
blocks uptake of
serotonin with little
effect on norepinephrine
 Agitation
 Sedation
 Seizure
 Abnormal gait
 Palpitations
 Flatulence
 Cystitis
 Impotence
 alopecia
 hypersensitivity to
fluoxetine and
pregnancy
 Dizziness
 Headednes
 Nervousness
 Sweating and dry
mouth
 Diarrhea
 constipation
 bradycardia
 Teach patient about relaxation
technique
 Increase fluid intake
heat weather
 Eat foods high in fiber

Generic Name: Fluphenazine decanoate
Brand Name: Modecate
Dosage: initial dose, 12.5 – 25mg IM
Indication: Management of behavioral complication in patients with mental retardation
dopamine receptors in
the brain, depress the
RAS, including those
parts of the brain
involved with
 Vertigo, headache
 Nasal congestion
 Polyuria
 Cerebral edema
 Tremor
 Ataxia
 Orthostatic
hypotension
 Cardiomegaly
 SIADH
 Eosinophilia
 Leucopenia
 Jaundice
 Urticaria
 Coma
 Severe CNS
depression
 Bone marrow
depression
 Blood dyscrasia
 Circulatory collapse
 Subcortical brain
damage
 Cerebral
arteriosclerosis
 Coronary disease
 Severe hypotension
or hypertension
 Drowsiness
 Blurring of vision
 Dry mouth
 Tachycardia,
bradycardia
 insomnia
heat weather
therapy

Generic Name: Clozapine
Brand Name: Ziproc
Dosage: 100mg ¼ tab 2x/week HS
Indication: Management of severely ill schizophrenics who are unresponsive to standard psychotic drug
dopamine receptors in
the brain, depress the
RAS, including those
parts of the brain
involved with
 Tremor
 Disturbed sleep
 Sedation
 Sweating
 Dry mouth
 Urticaria
 Rash
 leukopenia
 Severe CNS
depression
 History of seizure
 Granulocytopenia
 Myeloproliferative
disorders
 Drowsiness
 Sedation
 Dizziness
 Headache
 Constipation
 Fever
 Tachycardia
 hypotension
 Maintain fluid intake
 Eat food rich in fiber
 Tepid sponge bath
therapy

Generic Name: Biperiden
Brand Name: Akineton
Drug Classification: Antiparkinson
Dosage: 2mg/day ½ tab
Indication: Adjunct in the therapy of parkinsonism
Anticholinergic activity
in the CNS that is
believed to help
normalize the
hypothesized imbalance
of cholinergic and
dopaminergic
neutransmission in the
basal ganglia in the brain
of a parkinsonism
patient.
 Memory loss
 Agitation
 Depression
 Drowsiness
 Tachycardia
 Palpitations
 Hypotension
 Rash
 Urticaria
 weakness
 Glaucoma
 Pyloric or duodenal
obstruction
 Stenosing peptic
ulcer
 Achalasia
 Prostatic
hypertrophy
 Myasthenia gravis
 Disorientation
 Confusion
 Blurred vision
 Dizziness
 Light-headednes
 Nervousness
 Dry mouth
 Diarrhea
 constipation
 bradycardia
 Orient patient about time, place,
event or things around her.
 Teach patient about relaxation
technique
heat weather
 Eat foods high in fiber
therapy
LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY
1. Disturbed thought processes related to inability to trust evidenced by delusional thinking.
2. Social Isolation related to alteration in mental status
3. Situational low self-esteem related to cognitive impairment

NURSING CARE PLAN
Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective:
Objective:
>inability to trust
>lack of interest
Disturbed thought
processes related to
inability to trust
evidenced by
delusional thinking.
After 1-2 days of
rendering nursing
interventions, the
patient will be able
to develop trusting
relationship with
nurse
Be sincere and honest when
communicating with the
client. Avoid vague or
evasive remarks.
Be consistent in setting
expectations, enforcing rules,
and so forth.
Do not make promises that
you cannot keep.
Encourage the client to talk
with you, but do not pry for
information.
Explain procedures, and try t
o be sure the client
understands the procedures
before carrying them out.
Initially, do not argue with
the client or try to convince
the client that the delusions
are false or unreal.
Delusional clients are
extremely sensitive about
others and can recognize
insincerity. Evasive
comments or hesitation
reinforces mistrust or
delusions.
Clear, consistent limits
provide a secure structure
for the client.
Broken promises reinforce
the client’s
mistrust of others.
Probing increases the
client’s suspicion and
interferes with the
therapeutic relationship.
When the client has full
knowledge of procedures, he
or she is less likely to feel
tricked by the staff.
Logical argument does not
dispel delusional ideas and
can interfere with the
development of trust
After 2 days of
rendering nursing
interventions, the
patient was
develop trusting
relationship with
nurse

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective:
Objective:
>uncommunicative
>seeks to be alone
> projects hostility
>sad/dull affect
Social Isolation related
to alteration in mental
status
After 1-2 days of
rendering nursing
interventions, client
will identify feelings
of isolation
>establish a
therapeutic
relationship by being
emotionally present
and authentic
>observe for barriers
to social interaction
>provide positive
reinforcement when
the client seeks out
others
>discuss causes of
perceived or actual
isolation
>being emotionally
present and authentic
fosters growth in
relationships and
decrease isolation
>adequate information
should be gathered so
appropriate
interventions can be
planned
>social support
contributes to positive
well being
>the individual’s
experience of illness;
the circumstances of
everyday living that
influence a quality of
life
After 1-2 days of
rendering nursing
interventions, client
will identify feelings
of isolation

Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
Subjective:
Objective:
> lacking eye
contact
>little interest in
activities
>lack of social
interaction
Situational low
self-esteem
related to
cognitive
impairment
After 2-3 hours of
rendering nursing
interventions, the
patient will
verbalize
understanding of
things that
precipitate current
situation and
demonstrate
behaviors that
show positive self-
esteem.
Encourage client to express
honest feelings in relation to
loss of prior level of functioning
Revise methods for assisting
client to express feelings
properly.
Encourage client’s attempts to
communicate. If verbalizations
are not understandable, express
to client what you think he
intended to say. It is necessary
to reorient client frequently.
Encourage reminiscence and
discussion of life review
Encourage to participate in
activities
Client may be fixed in anger
stage of grieving process,
which is turned inward on
the self, resulting in
diminished self-esteem.
To explore the feelings of
the client thereby allowing
him to acknowledge his
own strength and weakness
The ability to communicate
effectively with others may
enhance self-esteem
Help client resume
progression through the
grief process associated
with disappointing life
events and increase self-
esteem
Positive feedback from
group members will
After 3 hours of
rendering nursing
interventions, the
patient was
verbalized
understanding of
things that
precipitate current
situation and
demonstrated
behaviors that show
positive self-esteem.

Offer support and empathy
increase self-esteem
Focus on accomplishments
to lift self-esteem
DISCHARGE PLAN
 Medication:
 Instruct patient to continue taking her medications
 Do not stop abruptly taking the medications
 Report any complications or severe effects of drugs to your health care provider
 Exercise:
 Encourage patient to have regular exercise even he is at their home.
 Treatment:
 Instruct patient to continue taking her medications.
 Clinical Follow-up:
 Instruct patient to have her follow-up check- up after one week.
 Diet:
 Advise the patient to eat green leafy vegetables, rich in iron and vitamin C
 Danger signs:
 Instruct patient to seek medical advice to physician if she experiencing discomfort and complications

Schizophrenia Case Study on a 35-Year-Old Male

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