KMC COLLEGE OF NURSING, MEERUT

Advance Nursing Practice

CASE STUDY
ON
SCHIZOPHRENIA

Submitted to: - SubmittedBy:-

Mrs Zeba Azam Tyagi Mrs Jyoti Katiyar

Assistant Professor M.Sc. (N) 1st Year
KMC College Of Nursing
ENTIFICATION DATA
NAME – Miss. Farhana
AGE – 18 years
FATHER NAME- Mohd. Haseen
DATE OF ADMISSION – 06 jan 2020
MARITAL STATUS- Unmarried
RELIGION- Muslim
IPD No. – 170306023
ADDRESS- Moradabad
DOCTOR NAME – Dr. Azfer Ibrahim
DIAGNOSIS- Schizophrenia
CHIEF COMPLAINS
Miss. Farhana complains of
 Self Talking
 Suddenly start crying
 Headache Since last 5 Days
 Insomnia
 Loss of appetite

HISTORY OF PRESENT ILLNESS

Suddenly from last 5 days my client started saying that she is having a
heavy headache and was unable to had food and proper sleep . During the
night time she start shouting and was talking to self and unable to be
comfortable. She is not talking to anyone in the family and not sharing
any information with them.

LIFE CHART

HOSPITAL

Admitted on TMH &RH

D.O.A- 06/03/2017
Rx-
 Tb. Risdil 1mg – BD
 Tb. Ativan 500mg – BD
 Syp. Valence Sol 250mg/500-BD
PAST MEDICAL AND SURGICAL HISTORY
She is not having any past medical and surgical history .
 FAMILY HISTORY

Mohd. Haseen Mrs. Fatima

47 yrs, Farmer 44yrs, Housewife

Ms. Sukhesa Mr. Salim Ms. Nidha Miss. Farhana

25 yrs, Job 22 yrs 20yrs 18 yrs

KEY WORDS
Male
Female
Death Male

Death Female

Female patient

SOCIO ECONOMIC FACTORS

She belong to a lower middle class family .They live in a nuclear family.
In family member father and brother are the earning member . The
personal hygiene and sanitation is proper .
PERSONAL HISTORY
She is non – vegetarian in nature . She sleep for 5-6 hours in a day. And
she is not addicted to any substance abuse.

MENTAL STATUS EXAMINATION

1. General appearance
• Physique and body build:-Moderate body built
• Physical appearance:- good
 • Height:- 5’1
• Weight:-43 kg
• Appearance:- Good
• Looks:- Uncomfortable
• Level of grooming: - Normal
• Hygiene:- Good
• Dressing :-Normal
• Attitude towards the examiner:- Co-operative
• Comprehension:- Intact
• Gait and posture:- Normal
• Motor activity:- Lethargic
• Social manner and non-verbal behavior:- Decreased
• Eye contact :- Not maintained
• Rapport:- Not Established
• Hallucinatory behavior:- Present

2.Speech
• Rate and quantity of speech
• Speech:- decreased
• Initiation:- When required
• Productivity:- Poor
• Rate:- Decreased
I .Volume and tone of speech:-
• Volume:- Decreased
• Tone:- Normal
II. Flow and rhythm of speech: Normal with lethargic state.

3. Mood and affect

Mood
Subjective: - Data on subjective mood are obtained by answers to
question such as

 Question: - How do you feel?

 Answer: - Sahi lag raha hai, par sir me dard ho raha hai
 Question: - What part of the day is most pleasant?
 Answer: - Jab mjhe sir me dard na ho
 Question: - What part of the day most difficult?
 Answer: - Jab me soo nhi pati sir dard ki wahja se.
 Question: - Do you become angry, depressed, irritable,
frightened? When? Why?
 Answer: - Uljhan hoti hai jab sir me dard hota hai.
Objective: (by examination)
• Stability of mood (over a period of time):- irritable because of that
throbbing headache.
• Reactivity of mood (variation in mood with stimuli):- depressed
and lethargic.
• Persistence of mood (length of time the mood lasts):- till the
headache goes.

Affect:-
• Affect was normal to the situation and to the emotion.
• Depth or intensity of affect :- normal
• Appropriateness of affect : (it was in relation to thought and
surrounding environment)
Inferences: mood and affect is congruent.
4. Thought: -
Stream and form of thought:
• Initiation:-Delayed
• Productivity:-Decreased
• Flight of ideas:- Not significant
• Word salad :- Not significant
• Thought block:- Not significant

Content thought:
• Any preoccupation: - no any idea was pre-occupied.
• Obsessions/Compulsions:-By observing the patient I found that
she is not having any obsession and compulsion.
Contents of phobias:-
 Question: - Do feel afraid of being alone, fear of closed space or
height, or any kind of phobia.
Answer: - No

Inference: - phobia and obsession is absent in my client.

Delusions
 Question: - Are you considered yourself friendly and popular?
Answer: - No
 Question: - Do people like you? Treat you well?
Answer: - Yes
 Question: - Do they talk about you?
Answer:-No
 Question: - Are you suspicious towards others like they are
conspiring against you?
 Answer: - No
Inference: - Delusions are not significant in my client.

Thought insertion / withdrawal / broadcasting

 Question: - Do you think others are able to influence you? How?

Answer: - No, they can’t influence me.
 Question: - Do you think that some people can read minds? Can
they read yours? Control you? How?
Answer: - no one can read, it’s not possible.

Inference: - thought insertion, withdrawal is absent.

5.Perception
• Hallucination:- Present
• Visual: flash of light?
• No visual hallucination
 Question: when you stay alone that time do you listen unknown
voices or seeing something different?
Answer: - Yes

Illusion

 Question: - Do television gives you special message which it not

known to others?
Answer: No it’s not like that.
Inference: Absence of illusion and present of auditory hallucination.
6. Cognition ( neuropsychiatric) assessment

Consciousness
• Level of consciousness: She is conscious
• Patient is responding to voice:- Patient is responding
Inference: - Patient is fully conscious and provided the answer in
normal voice.
Orientation:-

 Time: Question: - what is the time now according to you.

Answer: - This must be near to 11 o’clock.
 Place: Question: - Do you know where you are now, and what is
the name of this city you know? And who I am?
Answer: - She is aware of the present location hospital and also
aware about the city, and about student nurse.
Inference: - Client is fully oriented about the time, place and person.

7. Attention and concentration

 Question: If you have 20 chapatti in your house and 4 are eaten

by your elder daughter and 2 by your younger daughter, then how
many are left.
Answer: Able to reply
 Question: Can you name the week days
Answer: - Able to name
Inference: Her attention and concentration is good.

8. Memory

Immediate retention and recall (IR and R)

 Question: - As your mother told that which sabji you prepare very
tasty that she likes the most.
Answer: - She is able to answer.

Recent memory:
 Question: - So what you had last night in dinner?
Answer: - She replied

Remote memory
 Question: - What was your best friend name who is your
neighbour.
Answer: - She was able to answer.

Inference: - immediate recent memory and remote memory is good.

9. Intelligence:

 Question: - This season of which Crop?

Answer: - She replied
 Question: - Which is the National Flower?
Answer: - She Replied.

Similarities and differences?

 Question: - What is the Similarity between Pen and Pencil?
Answer: - both are used for writing.
 Question: - Difference between cooker and bowl?
 Answer – Cooker is used for cooking food and in bowl we keep
the bowl.

Inference: - Intelligence of the client is good.

10.Insight
 Question: - Do you have any Illness, or why you came here?
Answer: - yes, I have headache which is very intense.
 Question:- What is the cause of illness
Answer: - I don’t know why it is happening to me.
 Question: - Do you want to free from this illness, want to be
happy?
Answer:-Yes I want to be free from illness.
Inference: - Patient has awareness about to sick, but she does not know
that it is psychiatric illness.

11.Judgment
Social judgment:-

 Question: - If this whole ward getting burn and all clients

sleeping what will you do?
Answer:- I will make the patients awake and tell them to run.

Personal judgement:-

 Question:- if you find letter in the road what will you do?
Answer:- what I should do with that I simply go.

Inference :- Social and Personal Judgment of the client is good.

TREATMENT PLAN
Sl. Trade Dose/Route Freq. Side Effect
No Name

1 Tb. Risdil 1 Mg / Oral BD Headache, Akathisia,

Parkinsonism
 2 Tab. Ativan 500mg /Oral BD Agitation, Sedation,

3. Syp. Valance 250mg/5ml BD Loss of appetite,

Sol Oral Nausea, Hair loss,
Tremor

PHYSICAL EXAMINATION
GENERAL INFORMATION :-
Name Ms. Shama Date/Time –
06/12/2016
Age 17 years C R No.–--------
Gender Female Unit –Psychiatry ward

IDENTIFICATION MARKS:-
1. Mole on the neck

GENERAL PHYSICAL EXAMINATION

Pulse 76beats/min Pallor Absent
Bp Supine Icterus Absent
Temp. 98.8’F Cyanosis Absent
Respiratory Rate 24breath/min Clubbing Absent
Level Of Fully Lymphadenopathy Absent
Consciousness consciousness
Orientation Oriented Edema Absent
Pupils Fundus Absent
Height 5’1 Oral Examination:-
Weight 53kg Lips –
Tongue- .
 Teeth –

SYSTEMIC EXAMINATION:-
Cardiovascular System
Heart Rate 76beats/min Heart Sounds Normal
Murmurs Absent
Other Positive Findings (If Any):-

Respiratory System
Air Entry Normal Adventitious Sounds Scratching
sound
Breath Normal heard Grating sound
Sounds
Other Positive Findings (If Any):-

Per Abdomen
Inspection Normal Organomegaly Not
significant
Palpation Not organomegaly
Other Positive Findings (If Any):-
MUSCULOSKELETAL SYSTEM:-
Body alignment- Body alignment is good.
Movement – Movements are normal
Joint – Joints are normal pain.
NERVOUS SYSTEM:-
Speech: Normal
Posture: Normal
Note: - posture is normal, verbal responses are normal. And she
responded to stimuli.

Cranial Right Left Motor system

nerve
1 √ √ Right Left
2 √ √ Bulk √ √
3 √ √ Power √ √
4 √ √ Tone √ √
5 √ √ Reflexes
6 √ √ Right Left
7 √ √ Biceps √ √
8 √ √ Triceps √ √
 9 √ √ Supinator √ √
10 √ √ Knee √ √
11 √ √ Ankle √ √
12 √ √ Corneal √ √

Sensory Righ Left Cerebellar Signs Righ

System t t
Pain √ √ Finger Nose √
Touch √ √ Dysdiadochokinesi √
a
Temperature √ √ Tendem Walking √
Pressure √ √ Rombergs √
Position √ √ Stereognosis √

DISEASE PROCESS
INTRODUCTION:-
The word “Schizophrenia” was coined in 1908 by the Swiss psychiatrist
Eugen Bleuler. It is derived from the Greek Words Skhizo ( split) and
Phren (mind).
DEFINITION:
Schizophrenia is a psychotic condition characterized by a disturbance in
thinking, emotions, volitions and faculties in the presence of clear
consciousness ,which usually leads to social withdrawal.
ETIOLOGY
  Schizophrenia etiological factors are not known exactly , but some are
found such as – Genetic predisposition
 Biological factors - Such as alterations in neurotransmitters, like
endocrine, or inflammatory mediators
 Chronic stress - Particularly with feelings of hopelessness and/or
helplessness
 Chronic medical illness
 Ruminative coping strategies - These, as opposed to problem solving or
cognitive restructuring strategies.
CLASSIFICATION ACCORDING TO ICD X
(F20-F29) Schizophrenia, schizotypal and delusional disorders
(F20) Schizophrenia
(F20.0) Paranoid Schizophrenia
(F20.1) Hebephrenic Schizophrenia
(F20.2) Catatonic Schizophrenia
(F20.3) Undifferentiated Schizophrenia
(F20.4) Post- Schizophrenic depression
(F20.5) Residual Schizophrenia
(F20.6) Simple Schizophrenia
(F21) Schizotypal disorder

CLINICAL TYPES
S.no CLINICAL TYPES CHARACTERSTIC
1. Paranoid Schizophrenia It is the most common type of
schizophrenia .It is characteristic
by. Delusions of persecution ,
Delusion of jealously, Delusion of
Grandiosity, Hallucinatory
voices .
It has a good prognosis if treated
early.
2. Hebephrenia Schizophrenia It has an early and insidious onset.
Its features like marked thought
disorder, severe loosening of
association and extreme social
impairment.
It has a worst prognosis .
3. Catatonic Schizophrenia It has characterized by marked
disturbance of motor behavior.
This may take the form of
catatonic stupor, catatonic
 excitement and catatonic
alternating between excitement
and stupor
4. Residual Schizophrenia It include emotional blunting ,
eccentric behavior , illogical
thinking, social withdrawal and
loosening of association.
5. Undifferentiated This category is diagnosed either
Schizophrenia when features of no subtype are
fully present or features of more
than one subtype are exhibited
6. Simple Schizophrenia It is characterized by an early and
insidious onset, progressive
course and presence of
characterstic negative symptoms,
vague hypochondriacal
features,and aimless activity
7. Post-Schizophrenic Depressive features develop in the
Depression presence of residual or active
features of schizophrenia and are
associated with an increased risk
of suicide.

SIGN AND SYMPTOMS: -

 Delusions
 Hallucinations
 Excitement or agitation
 Hostility or aggressive behavior
 Suspiciousness, ideas of reference
 Possible suicidal tendencies
 Attentional impairment
 Alogia
 Anhedonia

PSYCHOPATHOLOGY :-
 Stansky (1914), using a metaphor from neurology , proposed ‘
intrapsychic ataxia’ as the basic symptoms of schizophrenia. He
described a lack of co-ordination between emotions and thinking ,
which is now generally accepted and referred to as incongruity of
affect.
  Bleuler said loosening in the association of ideas was the primary
and fundamental disturbance. Through the loosened links in the
chain association instinctual desired and unconscious wishes can
intrude into the consciousness of the patient, his repressed
complexes gain the upper hand and can entirely rule his life and
behavior . The result is the disruption of his personality.
 Berze (1914) thought that insufficient and lowering of psychic
activity , based on organic damage of unknown nature , is the
primary symptoms of schizophrenia. The lowered mental activity
may prevent the making of a clear distinction between what is real
and what is imaginary causing the schizophrenic to indulge in
delusional ways of thinking and behaving.

SCHIZOPHRENIA

Sign & Sx: Sign & Sx Sign & Sx:

Talking Patient is Sign & Sx:
Patient is Self –
irrelevant unhygienic
becoming esteem
violence disturbance

Nsg Dx. Nsg Dx. Nsg Dx. Nsg Dx. Sensitivity

Disturbed Self care deficit Potential for to criticism
thought process violence

Nursing actions:- Nursing actions :- Nursing actions: - Nursing actions: -

- To assess the intensity, Assess the client ability to - Observe client behavior - Focus on strength and
frequency and duration of meet self care activities frequently accomplishments and
hallucination minimize failure.
Develop a structured Remove all the dangerous Provide simple and easily
To provide a safe and calm schedule for client routine objects from the client achievable activity
environment for hygiene environment Teach assertiveness and
coping skill
To encourage the client to Encourage the client to
express her feeling as perform independently as Talk with the client in the
much as possible many activities as possible low calm voice
Outcomes :- Outcomes :- Outcomes :- Outcomes :-

The thought Client is now Client is

process of the able to accept Client is now making the
client is now the grieving relax and calm task complete
normal process and and do not with positive
able to adjust getting involve attitude
0 in any violence

COMPARISON BOOK PICTURE AND PATIENT PICTURE

ETIOLOGY
BOOK PICTURE PATIENT PICTURE
1 Genetic predisposition X

2 Biological factors - Such as X

alterations in neurotransmitters, like
endocrine, or inflammatory
mediators

3 Chronic stress - Particularly with √

feelings of hopelessness and/or
helplessness

4 Chronic medical illness √

5 Ruminative coping strategies -

These, as opposed to problem solving √
or cognitive restructuring strategies.

CLINICAL FEATURES

BOOK PICTURE PATIENT PICTURE

1 Delusions No
2 Hallucinations Yes
 3 Excitement or agitation Yes
4 Hostility or aggressive behavior Yes
5 Suspiciousness, ideas of No
reference
6 Possible suicidal tendencies No
7 Attentional impairment Yes
8 Anhedonia Yes

DIAGNOSTIC CRITERIA
BOOK PICTURE PATIENT
PICTURE
1 Physical examination
Physical exam and ask in-depth questions Done- patient is not
about your health to determine what may be having any physical
causing your dissociative. In some cases, it problem only
may be linked to an childhood neglect and dissociative
childhood abuse.. disorder.

2 Lab tests
Lab tests are done to rule out any physical No any positive
disorder, but there wasn’t any physical disorder findings
or any associating problem to physical illness.

3 Psychological evaluation. This includes After talk to patient

discussing your thoughts, feelings and behavior Patient having
and it may include a questionnaire to help dissociative
pinpoint a diagnosis. This evaluation can help disorder.
determine whether you have dissociative
disorder order or any physical problem. like
physical problem shows significant finding but
this client has not any significant problem.
Patient is not having psychological illness like
anxiety disorder, or any other mood disorder
 MEDICAL MANAGEMENT

BOOK PICTURE PATIENT PICTURE

1 Anti-psychotics √
SSRIs X
Atypical neuroleptics X
2 Benzodiazepines √

NURSING MANAGEMENT

BOOK PICTURE PATIENT PICTURE

1 Promote physical safety by making him Provided
aware about his personality changes.
2 Provide for clients basic needs, Provided
promoting highest possible level of
independent functioning.
3 Provide best copying strategies to the Provided
client.

4 Support client/family participation in Done

follow-up care/community treatment.

5 Provide information about condition, Provided

prognosis, and treatment needs.

CONCLUSION:-
Schizophrenia , a severe and persistent mental illness with an onset in
early adulthood, is not usually associated with older adults. The
prevalence was thought to decline with aging as a result of early
mortality, decreased symptom severity and recovery.

BIBLIOGRAPHY

 Townsend mary c; psychiatric mental health nursing concepts of

care in evidence-based practive; 7th edition; published by jaypee
brothers; page no. 609 to 615.

 R sreevani; a guide to mental health and psychiatric nursing; edition

4th; published by jaypee brothers; page no. 254 to 268.
  http://www.myoclinic.com, dissociative.disorder.educ.exis.sem.

http://www.study on
incidence of dissociative

disorder,pubmed,2010,17,September:56(5): 533-9