OUR LADY OF FATIMA UNIVERSITY

VALENZUELA CAMPUS
College of Nursing

CASE STUDY OF PARANOID

SCHIZOPHRENIA
Presented to:
Ms. Aida Bautista
Presented by:
Floidas L. Fernando
BSN 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 paranoid schizophrenia are 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 History
Patients Profile:
Patients Name:

PATIENT EG

Ward Rm:

Pavillion 3 Female

Age:

51 years old

Sex:

Female

Civil Status:

Single

Birth Place:

Tacloban

Nationality:

Filipino

Religion:

Catholic

Admission Date:

December 3, 2013

Physicians 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

Brain
The 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:

Cerebrum
The 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.
Cerebellum
The 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 stem
The 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 thirst

Cranial nerves emerge from the brainstem. These nerves control facial sensation, eye
movement, hearing, swallowing, taste and speech.
Other important parts of the brain
NEUROTRANSMITTERS
NEUROTRANSMITTERS are 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 Neurotransmitters
SEROTONIN is 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.
GABA is 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.
DOPAMINE is 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 Neurotransmitters
DOPAMINE is 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.
NOREPINEPHRINE is 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.
EPINEPHRINE is 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 Schizophrenia
Psychosocial
Stressor and
(Theoretical Based)
interpersonal
events
Stimulated by
different factors

Modifiable
Factors:

Non-Modifiable:

Lifestyle
Alcohol
Smoking
Substance
abuse

Failure in
development or
a subsequent
loss of brain
tissue
Diminished
glucose meta,
and oxygen in
frontal cortical
Decrease brain
volume and
abnormal brain
function in
frontal and
temporal lobe

Transmission of signal
requires a complex
series of biochemical
events

Malfunctioning
of transmission
of electrical
impulses

Actions of:
Dopamine
Serotonin
Norepiephrin
e
Acetylcholine
Glumate

Drug increases
dopaminergic
system activity
Drug blocking
post synaptic
dopamine
receptors
Three separate symptoms
complexes/syndromes:
Hallucinations/delusions
Disorganized thoughts and
behavior

Age
o
o

Male (15-25)
Female (2535)
Gender

Enlarged
ventricles
and
cortical
atrophy

Induced
paranoid
psychotic
symptoms
Reduce
psychotic
symptoms

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
cyanosis
Skin: Brown, dry, visible skin lesions on lower extremities, no cyanosis
Neck: Normal in size, symmetrical no mass, normal muscle development and tone, no
palpable lymph nodes
Lung/Chest: Symmetrical chest expansion, clear breath sounds
Heart: 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 Examination

General 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 Gannaban
Evaluation: 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 comfortable
d. Nutritional Therapy: they ate and we gave them their prizes after the activities.
Assisted by: Floidas Fernando
Evaluation: 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 Fernando
Evaluation: 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 Fernando
Evaluation: 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 Fernando
Evaluation: 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 Fernando
Evaluation: 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/Class

Action

Haloperidol

Blocks
postsynaptic
dopamine
receptors in the
brain

Antipsychoti
c
10-20mg/tab
BID

Biperiden
HCL
AntiCholinergic
2mg
PRNxEPS

Risperidon
e
Antipsychotic
4mg

Synthetic
anticholinergic
drug that blocks
cholinergic
response in the
CNS

Blocks
dopamine and
serotonin
receptors in
the brain,
depresses the
RAS;
anticholinergic,
antihistaminic,
and alphaadrenergic
blocking activity
may contribute
to some of its
therapeutic and
adverse actions.

Contraindic
ated

Adverse
Effect

Intervent
ion

Management of
psychotic
symptoms

Sub-cortical
brain
damage

Short-term
treatment of
hyperactivity

u/c epilepsy,
PUD, allergy
to aspirin

Drowsine
ss, EPS,
urinary
retention,
urticarial

Advised
to avoid
prolonged
sun
exposure

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

Untreated
narrow angle
glaucoma,
intestinal
stenosis or
obstruction,
mega colon,
prostatic
hypertrophy

skin
rashes,
dyskinesi
a,
twitching,
impaired
speech,
fatigue

Use
cautiously
with
cardiovascul
ar disease,
pregnancy,
renal or
hepatic
impairment,
hypotension.

Insomnia
, dry
mouth,
rash, dry
skin,

Indication

Treatment for
Schizophrenia

Advised
on
bladder
emptying
before
giving the
drug
Assess
for Parkin
sonism,
EPS

Assess
for allergy
to
risperidon
e,
lactation,
CV
disease,
pregnanc
y, renal or
hepatic
impairme
nt,
hypotensi
on

Nursing Care Plan

Assessment
Subjective:
Lagi akong na
ngangati,
nahawa na ako
sa loob
Objective:
(+) dry skin
(+) itchiness
(+) skin rash
(+) disruption of
skin surface

Nursing
Diagnosis

Planning

Impaired Skin

After 3
Integrity related to
hours of nursing
mechanical trauma
intervention the
as manifested by
patient will
patients report of dry
demonstrate
skin, itchiness, skin
understanding of
rash and disruption
plan to heal and
of skin surface
prevent presence
of current skin
condition.

Nursing Intervention &

Rationale
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.

Evaluation
After 3
hours of nursing
intervention the
patient
demonstrated
the
understanding
of plan to heal
and prevent
presence of
current skin
condition.