SCHIZOPHRENIA,RELAPSES SCHIZIOPHRENIA

1. 3/1/2018 SCHIZOPHRENIA
CASE –STUDY
MALE PSYCHIATRIC WARD C2
BROWN SEQUARD MENTAL
HEALTH CARE CENTRE
O6TH MARCH 2018
MENTAL HEALTH NURSING
AUTHORS SHAILEND SINGH SUMMAH , DANIRAO
RAJJOO, GIRISH SAURTY, SHAMTALLY TANWIR
,ROSOOL YASINE

2. 1
SCHIZOPHRENIA
This project is submitted for the partial fulfilment of the programme of studies of the diploma in
general nursing
Date 06th
march 2018
Module name: - mental health nursing
Team leader: Rajjoo Danirao
Co- authors :- shailend singh summah. Girish saurty, shamtally tanwir, rosool yasine
Cohort :- 09th
march 2015 group 2

3. 2
SCHIZOPHRENIA
Acknowledgement
We want to express our profound gratitude to our programme coordinator Mr Takun, to whom we
are indebted for helpful guidance, efforts, patience, keen interest, devotion, encouragements and
considerations throughout the concretisation of this project.
We are equally grateful to the staff of the male psychiatric C1 and C2 of Brown Sequard Mental
Health Care Centre, who have put forward their skills and experiences for the achievement of this
project.
We also would like to thank the administration of the mental health care centre for providing full
support and informational requisite write this project.

4. 3
SCHIZOPHRENIA
Table of content
Abstract................................................................................................................4
Introduction..........................................................................................................4
Case presentation..................................................................................................4
Demography..........................................................................................................4
Objective data........................................................................................................5
Mode of referral......................................................................................................5
History of present complaint..................................................................................5
Forensic history.......................................................................................................6
Substance abuse history..........................................................................................6
Family psychiatric history..........................................................................................6
Medical history..........................................................................................................6
Current neurovegetative signs and symptoms............................................................7
Past psychiatric history...............................................................................................7
Mental state examination by psychologist................................................................8
Mental state examination by registered medical officer.............................................8.
Mental state examination by psychiatrist...................................................................8
Cognition.....................................................................................................................8
Social history................................................................................................................8
Interview with the patient............................................................................................9
Premorbid personality.................................................................................................9
Physical examination.....................................................................................................9
Prognosis /diagnosis & differential diagnosis .............................................................10
Treatment plan by specialists.....................................................................................10
Medication & pharmacological management..........................................................10
Nursing diagnosis .....................................................................................................11
Nursing care plan...................................................................................................11
Nursing process.....................................................................................................11
Rehabilitation...........................................................................................................12.
Discussion / conclusion................................................................................................12
References....................................................................................................................13

5. 4
SCHIZOPHRENIA
ABSTRACT
Schizophrenia is a major mental disorder. It is the most common of the psychotic disorders.
Schizophrenia is a common disease prevalent in all cultures and in all parts of the world. About 1
percent of the general population stand the risk of this disease in their lifetime. The disease is most
common in the lower social classes. Schizophrenia development remains a puzzle despite extensive
research. Nevertheless, schizophrenia aetiology was breakdown by three sets of factors, namely
biological, psychological and social.
A delusion is a mistaken belief that is held with strong conviction even when presented with superior
evidence to the contrary. As a pathology, it is distinct from a belief based on false or incomplete
information, confabulation, dogma, illusion, or some other misleading effects of perception.
They have been found to occur in the context of many pathological states (both general physical and
mental) and are of particular diagnostic importance in psychotic disorders including schizophrenia,
paraphrenia, manic episodes of bipolar disorder, and psychotic depression.
Introduction
This case illustrates the complexity of diagnosis in a person with a first presentation of psychotic
symptoms, unpredictable behaviour, morbid jealousy and perhaps some borderline personality traits
and a comprehensive psychosocial rehabilitation assessment and strong treatment alliance in a man
with approximately twenty-year history of schizophrenia. In this context of matter, we will show to
you that non-compliance to medication can lead to a relapse in schizophrenia and affect disorders.
Case presentation
37-year-old man with a history of depression, delusions, morbid jealousy and borderline personality
traits.
When the patient was age 29, he was diagnosed and was suffering from a severe form of
schizophrenia and morbid jealousy. The patient was also reported having a history of depression,
anxiety and post- traumatic stress disorder.
On admission the patient was alert and oriented, with willingness to get admitted. The father of the
patient reported to the casualty officer that he has not eaten or drinking tap water, as he believes
that these are poisoned and his father and siblings may be conspiring to cause him harm.
The patient reported to the casualty officer that he has not slept, eaten and drinking anything for the
past one week. He also reported some euphoric mood and racing thoughts
When we were first introduced ourselves to this patient, he was very restless and was facing away
from us, staring at the wall.
Demography
Mr John Smith is a 37 years old Asian divorcee who is currently working as handy man in a five-star
hotel situated in the south of Mauritius.
Mr smith lives with his parents and two children.

6. 5
SCHIZOPHRENIA
Objective data
Vital signs: oral temperature 36.7 degrees Celsius, non-invasive blood pressure 120/80 via right arm,
heart rate 72bpm and noted to be in sinus rhythm, oxygen saturation 99% on room air, respirations
18bpm and non-laboured.
Patient is awake, alert and oriented to self-place, and time.
Socially, the patient denies consuming alcohol or illicit drug use. He previously smoked 10 cigarettes
per day for approximately 10 years
Family history is contributory, and was found that the patient has no predisposing factors leading to
proneness of developing non communicable or mental illnesses.
The patient denies any allergies to food and medication.
Mode of referral
Mr John Smith has been a client of Mahebourg hospital for the past decades receiving treatment for
schizophrenia. The latter was referred to the liaison psychiatric service yesterday on the 21/02/2018
by his father and police who were sole concerned about his bizarre and unpredictable behaviour.
and due to his frequent visit to his nearest police post where he lives.
History of present complaint
The police and father reported to the casualty officer that the patient was keeping offensive
weapons with him, and frequently visit his nearest police post for no valid reason.
The latter was also complaining of insomnia, auditory hallucination, with false beliefs that food and
water is poisoned.
According to the case sheet, the patient was diagnosed and following treatment at Mahebourg
hospital for schizophrenia.
It was also being pinpointed that the patient has a poor compliance to medication.
The casualty officer advised to admit the patient in a male acute psychiatric ward C2 on a provisional
diagnosis of relapse schizophrenia, to be reassess latter by psychiatric specialist.
The patient was placed on a number of medication following his admission such as IM Phenergan
25mg prn, IM Serenace 5mg prn. Tab olanzapine 10mg nocte, Tab Phenergan 25mg Nocte and cap
pothiaden 50mg nocte..
John had at least ten hospitalisations over the last six years with what sounds like an exacerbation of
his schizophrenias. On one occasion the father reported that he had a suicide attempt by hanging
himself to the ceiling of the fan of the living room.
He told the casualty officer that he was on medication and denies to be mentally sick.
The patient was placed on a number of medication such as tab ozitas 10mg nocte,tab largactil 75mg
nocte, the patient also shows poor compliance to medication and admitted to us that he is taking
medication ever since his last appointment three months back at Mahebourg hospital.
He also describes serious side effects to medication such as tremor, fatigue, sleepiness.
He believes that medication is not useful to cure his disease condition.

7. 6
SCHIZOPHRENIA
John believes that his relatives is interfering with his thoughts and that everybody is conspiring to
give him schizophrenia.
John always keep a long knife with him in response to his belief and he poses an ongoing risk to his
parents and children.
it was also reported that Mr John is a serious risk regarding his personal safety as he frequently
wanders the street in a confused state, walks in front the traffic and forgets his home address.
Forensic history
in relation to the past psychiatric history, the patient has not committed any crime, nor arrested,
and had never been convicted to court or to be convicted following admission.
Substance abuse history
The patient denies taking drugs and alcohol.
He admits to be a smoker and smokes a packet of cigarette daily.
He has also confessed to have consume drugs and alcohol for experimentation purposes, and had
recur to these substances once in his life following peer pressure.
Family psychiatric history
Following an inquiry done to conceal out the family contextual situation in which the patient is
evolving, it came out that none of his parents and siblings have been suffering or diagnosed from a
mental illness.
Later, we have found that the patient parental grandmother was suffering from paranoid
schizophrenia and was long back following treatment at the BROWN SEQQUARD MENTAL HEALTH
CARE CENTRE.
The late grandmother of the patient was also a long stay patient at the mental asylum and
incarcerated in the high security unit for about 20years.
Medical history
Illnesses: the patient do not suffer from any ailments and is not on any medication apart from
schizophrenia.
Hospitalisation in a general hospital: - none
Surgeries: - none
Allergies: - no drug allergies
Medication used: - tab ozitas 10mg nocte,tab largactil 75mg nocte for psychiatric issues.
Treating specialist: - Dr Jack sparrow for mental disorder.
The last visit to treating specialist was three months back.

8. 7
SCHIZOPHRENIA
Current neurovegetative signs and symptoms
Schizophrenia is a complex syndrome that is defined by a collection of symptoms that are dominated
by psychosis. However, symptoms also include deficits in thinking, behavior, and affect and are
typically grouped into
(1) positive symptoms such as hallucinations, delusions, or paranoia;
(2) negative symptoms that include a loss of motivation, apathy, asocial behavior, loss of affect, and
poor use and understanding of speech and language;
(3) cognitive symptoms such as impaired working memory, dissociated thought processes, and
impaired executive function.
Past psychiatric history
Mr John Smith was transferred from Jawarhal Nehru Hospital to Brown sequard mental health care
centre on the 23/04/2010.
At Jawarhal Nehru Hospital he was in an acute phase of psychotic disorder.
He was suspecting that his wife was having an affair somebody else.
He was provisionally diagnosed and suffering from paranoia and delusion.
Following his transfer to Brown Sequard mental healthcare centre, his treating specialist diagnosed
patient to be suffering from an acute form of morbid jealousy and have intense psychotic episodes.
The first line of treatment for this disorder was to put the patient in a number of medication namely
tab laroxyl 10mg mane & 25mg nocte, tab Xanax 0.25mg nocte and finally B complex once daily.
On the 12 November 2012, Mr John Smith was brought again to the mental health care centre by
this wife, he reported to be hearing voices and her wife tells us that he leaves home at very odd
hours.
The latter was diagnosed to be schizophrenic and place under medication such as Olanzepine 150mg
nocte.
Following a profound examination, it came about that the patient was talkative, have auditory
hallucinations, deluding, but fortunately no suicidal ideation.
Latter on the patient was permanently diagnosed schizophrenia and place for lifelong medication
namely olanzapine 10mg, vitamin B complex, and referred to his nearest locality healthcare centre
for continuing treatment and rehabilitation.
22 December 2014 was brought again to the mental health care centre for relapse schizophrenia,
due to poor drug compliance.
Mr John Smith was admitted in a male psychiatric ward and under close supervision and behavioural
monitoring to prevent acute psychotic episodes.

9. 8
SCHIZOPHRENIA
Mental state examination by psychologist
Patient is a muscular fair complexion man, and appears to be younger than his age. He has tattoos
draw in both arms, he was dressed casually wearing a black jeans and a black shirt. Patient appears
to be well groomed, with no sign of injury or bodily injuries.
During the interview the patient appears to a bit restless and wants to go home. He remained curled
into the corner of the chair and avoided eye contact. Rapport was difficult to establish as he seems
to be persecuted by the environment and the experiences he was going through.
When he was asked question, the answer given was not coherent, relevant and goal directed. He
seems to be very talkative and paranoid toward father, his mood seems to disturbed and anxious.
He denies to hallucination and suicidal thoughts.
Mental state examination by registered medical officer
Following, his relapse the patient mental state was reassessed to ensure effectiveness of treatment.
The medical officer has noticed a great improvement since admission, during the interview the
patient is calm cooperative. He answers question with great cohesiveness and logic ability.
Nevertheless, the patient seems to a bit suspicious and seem to be on his guard refraining from
revealing some fact and no delusional symptoms was perceived during the assessment.
Mental state examination by psychiatrist
During the interview, patient was irritable, his positive mental attitude increases during probing, by
showing sign of delusion of grandiose and religiosity. The assessment proves to be very
argumentative as the latter shows denial to take medication and appears to be hiding facts. In ward
otherwise, when not questioned, remains calm, buts appear to be unpredictable with some
characteristic pf a psychopath. The doctor conclude that patient was suffering from psychopathy
schizophrenia.
Cognition
Vocabulary is consistent with level of education.
Calculations: was able to calculate simple addition, subtraction, division and multiplication.
Abstractions: was able to interpret proverbs and similarities in an abstract fashion.
Constructional ability: Was able to copy a three dimensional figure accurately.
Insight is not good as is evidenced by unrecognising that he is suffering from depression. Judgment
is intact.
Social history
John smith was the oldest of two sons. Due to some socioeconomic issues he was forced to live with
his grandmother, while his parents and brother were living together apart in another locality. He
studied till standard 6 and quite often receive the visit of his parents, since he was a school drop out
with two unsuccessful attend to pass standard 6. His father oriented him to a prevocational field,
and finally he became an apprentice barber. After some years of practice as a barber, he left this
profession to join an industry working as a handy man by performing odd tasks. While working in the
industry he finally found his life mate and have face lots of family issues before being able to get
married, as family was against this relationship because both being in different ethnic group. They

10. 9
SCHIZOPHRENIA
finally get married and have two children one daughter and a son both aged 15 and 4 years old
respectively, john’s wife was a little bit introvert has little contact outsides the fundamentalist
church she attends regularly with family. Latter on the wife of Mr Smith left him because the latter
was suffering from mental illness. So Mr Smith with his two children have seek asylum to his parents’
place.
Interview with the patient
The interviewing process was carried out in a closed room by using open and closed ended
questions.
The rapport with the patient was difficult to establish as he seems to get irritated easily.
The patient was made at ease by use of diversional therapy.
The patient seems to be very anxious and indulge in deep thought before answering any question.
He has paranoid thoughts toward family with a strong sense of being persecuted.
He has not consumed food and tap water for one week, a he believes it is poisoned and has a
strange taste.
He is not aware of this illness, and believes that his family is conspiring against him to make him
mentally sick.
Answers to question was incoherent, no use of logic with indulgence toward religiosity.
Communication with the patient was difficult as he is argumentative and hiding facts.
The history obtained from patient is very paradoxical and may be originated from a fairy tale.
He denies consuming alcohol and drugs.
He is a smoker consumes a packet of cigarette daily
He works as a barber and handy man in a five-star hotel.
Premorbid personality
Mr john smith has features (traits) of a borderline personality. He was describing by father as having
impulsive and self-destructive behaviour, with intense emotional swings and unpredictability
behaviour. He has a fear of being abandoned by family and had an immense anger buried inside
within himself. Patient has unclear or unstable self- image of himself and chronic feeling of
emptiness. The father reported that he maintains an unstable relationship to his kin and family,
sometimes conflictual and argumentative. But nevertheless he is not a violent person and has no
history of physically assaulting someone or recur to violence.
Physical examination
Height: 1m68
Weight: 67kg
Temp: 36.6 C.
RR: 16
BP: 110/62
Pulse: 82 BPM

11. 10
SCHIZOPHRENIA
Appearance: muscular tall male, slightly pale, fair complexion, appearing younger than stated age, in
moderate agitation, neatly dressed and groomed.
Skin: soft dry skin, no lesions. Nailbeds pink with no cyanosis or clubbing.
Hair fine, scalp without lesions
Eyes: Visual acuity 20/20 without corrective lenses.
ENT: Hearing grossly intact.
Mouth: Dentition without lesions.
Neck: Full range of motion.
Abdomen: No scars, inspection unremarkable. Bowel sounds norm active.
Prognosis/diagnosis and differential diagnosis
Specialist diagnosis: -psychopathy schizophrenia
Provisional diagnosis: -paranoia, delusion, morbid jealousy, acute psychiatric episode
Early diagnosis by specialist: paranoid schizophrenia
Type of delusion: -grandiose, religiosity, persecution.
Personality: - borderline personality disorder.
Characteristics trait- unpredictable, tendency to hide facts
Treatment plan by specialist
The patient was admitted to male psychiatric ward C2, since he was not acutely suicidal at present,
and he is facing acute psychotic episode. Patient need hospitalisation to treat his acute psychotic
disorder as his mental condition is not stable enough to be treated in the outpatient department.
1. The patient is admitted in a male psychiatric ward.
2. The vital signs of patient are taken and charted
3. Provisional diagnosis laboratory analysis is sent such as FBC.U&E, SERUM CREATININE &
random glucose.
4. Behaviour of patient is being monitored and recorder in a nursing report.
5. Ensure safety of patient by giving a one to one nursing supervision.
6. Keep potentially harmful object out of reach of the patient
7. Observe for episode of acute psychotic disorder.
8. Restrained if he is hyperactive
9. Administer drugs as scheduled
10. Inform registered medical officer for any abnormalities.
Medication/ pharmacological management
The drugs used to reduce the symptoms the symptoms of schizophrenia are known as
antipsychotics. Some of the common drugs available at Brown Sequard Mental Health care centre
are
1. Conventional antipsychotics (haloperidol, trifluperazine, chlorpromazine)
2. Atypical antipsychotics (clozapine, risperidone, olanzapine)
Patient who was in acute phase of psychotic episode, was place under a number of medication to
reduce the symptomatic effect of schizophrenia.
The medication used in this context was;
1. Tab Olanzapine 10mg nocte: - to restore the balance of substances in the brain
2. Tab largactil 75mg nocte :-to relieve restlessness
3. Injection modecate 25mg/ml:- to reduce the level of dopamine in the brain.
4. Tab phernergan 25mg nocte:-it is used as sedative and induces sleep.
5. Cap pothiadem 50mg nocte:- is a tricyclic antidepressant and use to treat depression.

12. 11
SCHIZOPHRENIA
Nursing diagnosis
Schizophrenic patients may become acutely ill, mostly during the initial stage of the illness or they
may get acute exacerbations during their long-term course of the illness. Acute excitements are
most common in paranoid types.
The main nursing concern is controlling his impulsive behaviour, when he hears voices and responds
to them. He will be verbally abusive to staff.
It may be difficult to communicate with someone who is psychotic, but it is important to obtain
valuable data on how severe the thought disorder is.
These data can be obtained by the nurse who can establish some degree of trust with the patient.
Nursing care plan
1. Appropriate nutrition –regular diet and supervision of his diet.
2. Taking care of personal hygiene-regular bath and cleanliness.
3. Improve his communication and also his social contacts by encouraging the relatives/friends
to visit him often
4. To prevent institutional neurosis, patient is given routine task at ward level.
5. Medication and therapeutic group meetings is done to fulfil the psychosocial needs of
patient to prevent relapse.
6. Ensure safety of patient, in order to prevent physical injury.
7. Ensure that the spiritual needs of patient are met, by ensuring privacy or providing requisite.
8. A discharge plan is assessed by the nursing staff to ensure continuity of care at community
level.
Nursing process
The nurse should understand the general principle of management of schizophrenic patients.
Schizophrenia is a chronic illness, hence, the maintenance of long term treatment is essential.
Total cure is not possible in this context.
The aim of the nursing assessment and care plan should aim is to give an improvement and concise
regular, appropriate treatment to client.
Therefore, it is important to obtain valuable data on the patient illness and disease condition.
These data can be obtained by the nurse by data acquisitions system of observation and interview
(open and close ended question).
This data will allow the nurse to establish a rapport or gained some degree of trust with the patient.
In this context of matter as the client is refusing taking oral medication, on request of same doctor
has periodically change this line of treatment by administering medication to him via injection.
During the acute state, the client is avoided from getting sustained injury, during intense moment of
excitement.
The aim of the nursing process is to prevent relapse of patient health to disease condition, to
achieve this the latter is given small tasks, encourage to support other patient. Ensuring all his needs
is me and giving him a sense of appreciation on fulfil task. This allow the client to feel that he is not
rejected and he is accepted in society wholeheartedly as he is, and thus promoting remission.

13. 12
SCHIZOPHRENIA
Rehabilitation
After one week of in-patient treatment at Brown Sequard Mental Health Care Centre the patient is
allow home as acute phase of psychotic episode has lapse. Now the client is allowed home with
the following discharge plan.
Management included:
1. Patient is referred to outpatient department nearest to his locality.
2. Once every month the patient will be required to attend his nearest health care centre for
injection of modecate 25mg/ml
3. Drug treatment prescribed on discharge are tab olanzapine 10mg nocte, tab largactil 75mg
nocte.
4. Counselling, psychotherapy, and family therapy is done, to allow smooth re-insertion of
patient to society.
5. Family is advised that patient is not totally cure and should adhere to strict behavioural
monitoring and compliance to medication.
6. Despite his mental condition the patient is allowed home and may get back to work to lead a
active life.
Discussion /conclusion
After a thorough study into this controversial issues, it is crystal clear evidence that people of
ongoing mental illness the quality of their relationship with family and society relates to their ability
to maintain wellness in the community.
It is proved that for a schizophrenic patient that compliance to medication protocol is crucial to
prevent relapse or progression of disease condition.
A major criticism of mental health services has been lack of communication with family members.
Family members are not only a valuable source of information but are often a major support in the
individual’s therapy.
Families may experience their own stress from seeing a member unwell and community
organisations.
Patients having 37 years’ old with a long history of relapse schizophrenia, which appears to have
impacted his life in a significant way, leading to the curtailment of his development educationally,
socially and occupationally.
Hopefully as a service has changed and work with numerous stakeholders to find the best possible
line of management and re-insertion to society.
Nowadays schizophrenics are able to lead a near to normal and active lifestyle.

14. 13
SCHIZOPHRENIA
References
Psychiatric for nurses first edition ISBN 978-93-5152-379-6