A Case Study On:

SCHIZOPHRENIA DISORDER

Student: Ma. Charis Anne M. Indanan

Section: BSN 3A
Clinical Instructor: Mr. Anthony Joseph C. Mercado
Subject Code: NUR 220
Date Submitted: June 1, 2021
A. CASE
A 15-year-old male, belongs to a middle socio-economic status, the child attained
developmental milestones as per to age. From his early childhood he was too young to be exposed
to an aggressive behavior by his father, who often attempted to discipline him in this pursuit at
times was abusive and aggressive toward him. Marital problems and domestic violence since
marriage lead to divorce of parents when he was 10 years old. He was brought for consultation a
week ago brought with complain of academic decline and experienced to have auditory hallucination
for over a year.
His educational history revealed that he was declined in his academic performance with hand
writing deterioration, and irritable, sad behavior was noted. He engaged in fight at school and often
times his teacher will suggest for an individual meeting to her mother with undesirable behavior was
noted. He also preferred solitary activities and resented to eat with the rest of the family.
He was on sodium valproate up to 400 mg./day for nearly 2 months which to decline in his
irritability and aggression.
After a year, he manifested worsen hearing hallucination and even his family members
believe it was done to tease him. Seen awake late at night, muttering to self, shouting at
person as if a person existed, self-care deterioration noted. His behavior worsen that sought for
his mother for another consultations, and now he was diagnosed with Schizophrenia and treated
patient with Risperidone 3mg and Carbamazepine 300mg/day with some improvement of his
symptoms.
After 3 months since he was discharged, it was revealed that there is a relapse of his
symptoms due to a poor compliance of his medication that leads to a multiple hospital admission of
his acute exacerbation of symptoms. He was admitted for diagnostic clarification and rationalization
of his medications. Non –cooperation for mental state examination and aggressive behavior were
still noted. A schedule of activities in the institutions was also conducted. However, poor
socialization and lack of motivation to participate was noted. The family was psycho educated
about the illness and mother’s expressed emotions and over involvement was addressed by
supportive psychotherapy.

B. MENTAL HEALTH ASSESSMENT FINDINGS

ASSESSMENT FINDINGS DISCUSSION

Exposure to an aggressive behavior by his father who Childhood trauma is also thought to be a contributing
attempted to discipline him in this pursuit at times factor in developing schizophrenia. Some people with
was abusive and aggressive toward him schizophrenia experience hallucinations related to
abuse or neglect they experienced as children.

Broken Family: Solitary activities and resented to eat People from broken homes may be at a significantly
with the rest of the family greater risk to develop psychotic illnesses such as
schizophrenia.

Academic Decline with handwriting deterioration, and People with schizophrenia experience psychosis, which
irritable, sad behavior was noted means they can have serious problems with thinking
clearly, emotions, and knowing what is real and what
is not such as hallucination and delusion.
Aggressive behavior & irritability Psychotic symptoms, such as delusions and
hallucinations, with subsequent suspiciousness and
hostility, may result in aggressive behavior. Patients
with schizophrenia may show dysfunctional impulsivity
and impulsive aggression.

Hearing/Auditory Hallucinations Auditory hallucinations, or “hearing voices,” is one of

the most prevalent symptoms of schizophrenia.

Muttering to self, shouting at a person as if a person Some people with schizophrenia appear to talk to
existed themselves as they respond to the voices. People with
schizophrenia believe that the hallucinations are real.
Disordered thoughts. Thoughts may become jumbled
or blocked.

C. PSYCHOSOCIAL THEORY

Psychosocial Stage: Stage 5: Identity vs. Confusion Age Range: Adolescence (12 to 18 years)

Discussion:
The fifth psychosocial stage takes place during the turbulent teenage years. This stage plays an essential role
in developing a sense of personal identity which will continue to influence behavior and development for the
rest of a person's life. Teens need to develop a sense of self and personal identity. Success leads to an ability
to stay true to yourself, while failure leads to role confusion and a weak sense of self.

During adolescence, children explore their independence and develop a sense of self.2 Those who receive
proper encouragement and reinforcement through personal exploration will emerge from this stage with a
strong sense of self and feelings of independence and control. Those who remain unsure of their beliefs
and desires will feel insecure and confused about themselves and the future.

Erikson claims that the adolescent may feel uncomfortable about their body for a while until they can
adapt and “grow into” the changes. Success in this stage will lead to the virtue of fidelity.

Fidelity involves being able to commit oneself to others on the basis of accepting others, even when there may
be ideological differences.

Source:
Mcleod,S. (2018). Erik Erikson's Stages of Psychosocial Development. Retrieved from
https://www.simplypsychology.org/Erik-Erikson.html.

Susman,D. (2020). Erik Erikson's Stages of Psychosocial Development. Retrieved from https://www.verywellmind.com/erik-
eriksons-stages-of-psychosocial-development-2795740.
D. DIAGNOSIS

Diagnosis: Schizophrenia

Source: Sarzlasco. (2010). Pathophysiology of Schizophrenia. Retrieved from

https://www.scribd.com/document/37048164/Pathophysiology-of-Schizophrenia
E. MEDICATION REVIEW (DRUG STUDY)

Medication Indication Mechanism of Contraindication Adverse Effects Nursing Responsibilities

Action

Generic Name: Refractory seizure Mechanism of Contraindicated with CNS: Disturbance 1. History: Hypersensitivity to
Carbamazepine disorders: Partial action not hypersensitivity to of coordination, carbamazepine or TCAs;
seizures with understood; carbamazepine or TCAs, confusion, visual history of bone marrow
complex symptoms antiepileptic history of bone marrow hallucinations, depression; concomitant use of
Brand Name: (psychomotor, activity may be depression, concomitant use depression with MAOIs; history of adverse
Apo-Carbamazepine temporal lobe related to its of MAOIs, lactation, agitation, hematologic reaction to any
(CAN), Atretol, epilepsy), ability to inhibit pregnancy. behavioral drug; glaucoma or increased
Carbatrol, Epitol, Novo- generalized tonic- polysynaptic changes in IOP; history of cardiac,
Carbamaz (CAN), clonic (grand mal) responses and Use cautiously with history children, hepatic, or renal damage;
Tegretol, Tegretol-XR seizures, mixed block post-tetanic of adverse hematologic talkativeness, psychiatric history; lactation;
seizure patterns or potentiation. reaction to any drug symptoms of pregnancy
other partial or Drug is (increased risk of severe cerebral arterial
Dosage: generalized chemically hematologic toxicity); insufficiency, 2. Physical: Weight; T; skin color,
300mg/day seizures. Reserve related to the glaucoma or increased IOP; peripheral lesions; palpation of lymph
for patients tricyclic history of cardiac, hepatic, neuritis and glands; orientation, affect,
unresponsive to antidepressants or renal damage; psychiatric paresthesia, reflexes; ophthalmologic exam
other agents with (TCAs). patients (may activate tinnitus, (including tonometry,
seizures difficult to latent psychosis). hyperacusis, fundoscopy, slit lamp exam);
control or who are blurred vision, P, BP, perfusion; auscultation;
experiencing transient diplopia peripheral vascular exam; R,
marked side and oculomotor adventitious sounds; bowel
effects, such as disturbances, sounds, normal output; oral
excessive sedation. nystagmus, mucous membranes; normal
Trigeminal scattered urinary output, voiding
neuralgia (tic punctate cortical pattern; CBC including platelet,
douloureux): lens opacities, reticulocyte counts and serum
Treatment of pain conjunctivitis, iron; hepatic function tests,
associated with ophthalmoplegia, urinalysis, BUN, thyroid
true trigeminal fever, chills; function tests, EEG
neuralgia; also SIADH. 3. Use only for classifications
beneficial in CV: CHF, listed. Do not use as a general
glossopharyngeal aggravation of analgesic. Use only for epileptic
neuralgia. seizures that are refractory to
Unlabeled uses: other safer agents.
Neurogenic hypertension, 4. Give drug with food to prevent
 hypotension,
diabetes insipidus syncope and GI upset.
(200 mg bid–tid); collapse, edema, 5. Do not mix suspension with
certain psychiatric primary other medications or elements
disorders, thrombophlebitis, —precipitation may occur.
including bipolar recurrence of 6. Reduce dosage, discontinue, or
disorders, thrombophlebitis, substitute other antiepileptic
schizoaffective aggravation of medication gradually. Abrupt
illness, resistant CAD, arrhythmias discontinuation of all
schizophrenia, and and AV block; CV antiepileptic medication may
dyscontrol complications. precipitate status epilepticus.
syndrome Dermatologic: 7. Suspension will produce higher
associated with Pruritic and peak levels than tablets—start
limbic system erythematous with a lower dose given more
dysfunction; rashes, urticaria, frequently.
alcohol withdrawal Stevens-Johnson
(800–1,000 syndrome,
mg/day); restless photosensitivity
leg syndrome reactions,
(100–300 mg/day alterations in
hs); non-neuritic pigmentation,
pain syndrome exfoliative
(600–1,400 dermatitis,
mg/day); alopecia,
hereditary or diaphoresis,
nonheriditary erythema
chorea in children multiforme and
(15–25 nodosum,
mg/kg/day). purpura,
GI: Gastric
distress,
diarrhea,
anorexia, dryness
of mouth or
pharynx,
glossitis,

stomatitis;
abnormal liver
function tests,
cholestatic and
 hepatocellular
jaundice,
hepatitis,
massive hepatic
cellular necrosis
with total loss of
intact liver tissue.
GU: Urinary
frequency, acute
urinary retention,
oliguria with
hypertension,
renal failure,
azotemia,
impotence,
proteinuria,
glycosuria,
elevated BUN,
microscopic
deposits in urine.
Hematologic:
Hematologic
disorders (severe
bone marrow
depression).
Respiratory:
Pulmonary
hypersensitivity
characterized by
fever, dyspnea,
pneumonitis or
pneumonia.

Source: Api. (2008). Carbamazepine. Retrieved from https://www.scribd.com/document/6981967/Carbamazepine.

Medication Indication/s Mechanism of Contraindication/s Adverse Effects Nursing Responsibilities

Action

Generic Name: Treatment of Mechanism of Contraindicated with CNS: Insomnia, 1. History: Allergy to risperidone,
 Risperidone schizophrenia action not fully hypersensitivity to anxiety, agitation, lactation, CV disease,
understood: risperidone, lactation. headache, pregnancy, renal or hepatic
Delaying relapse in Block’s dopamine somnolence, impairment, hypotension
Brand Name: long-term and serotonin Use cautiously with aggression, 2. Physical: T, weight; reflexes,
Risperdal, Risperdal M- treatment of receptors in the cardiovascular disease, dizziness, tardive orientation; P, BP, orthostatic
TAB schizophrenia brain, depresses pregnancy, renal or dyskinesias BP; R, adventitious sounds;
the RAS; hepatic impairment, CV: Orthostatic bowel sounds, normal output,
OFF-LABEL: Bipolar anticholinergic, hypotension. hypotension, liver evaluation; CBC,
Dosage: disorder; treatment antihistaminic, arrhythmias urinalysis, liver and kidney
3mg of patients with and alpha- Dermatologic: function tests
dementia-related adrenergic Rash, dry skin, 3. Maintain seizure precautions,
psychotic blocking activity seborrhea, especially when initiating
symptoms. may contribute to photosensitivity therapy and increasing dosage.
some of its GI: Nausea, 4. Mix oral solution with 3–4 oz of
therapeutic and vomiting, water, coffee, orange juice, or
adverse actions. constipation, low-fat milk. Do not mix with
abdominal cola or tea.
discomfort, dry 5. Monitor patient regularly for
mouth, increased signs and symptoms of
saliva diabetes mellitus.
Respiratory: 6. Monitor T. If fever occurs, rule
Rhinitis, coughing, out underlying infection, and
sinusitis, consult physician for
pharyngitis, appropriate comfort measures.
dyspnea 7. Advise patient to use
Others: Chest contraception during drug
pain, arthralgia, therapy.
back pain, fever,
neuroleptic
malignant
syndrome,
diabetes mellitus

Source: Api. (2008). Risperidone. Retrieved from https://www.scribd.com/document/6982864/Risperidone.

Medication Mechanism of Contraindication/s Adverse Nursing Responsibilities

Indication/s Action Effects
 Generic Name: Used to treat all Sodium valproate Hypersensitivity to valproate Weight gain, 1. Monitor patient alertness
Sodium Valproate types of epilepsy in is a weak blocker sodium; thrombocytopenia, Tremor, Hair especially with multiple drug
adults and children. of sodium ion patient with bleeding loss, GI therapy for seizure control.
channels; it is also disorders or liver dysfunction disorders, Evaluate plasma levels of the
Used to calm or a weak inhibitor of or disease; cirrhosis, Hematological adjunctive anticonvulsants
Brand Name: stabilize the enzymes that pancreatitis; congenital disorder, periodically as indicators for
Depakote, Epilim, electrical activity in deactivate GABA metabolic disorders, those Leucopenia, possible neurologic toxicity.
Episenta the brain of patients such as GABA with severe seizures, or on bone marrow 2. Monitor patient carefully during
with epilepsy. transaminase. It multiple anticonvulsant depression, dose adjustments and
may also stimulate drugs; AIDS; pregnancy nocturnal promptly report presence of
Treatment of manic the synthesis of (category D), lactation; child enuresis, adverse effects. Increased
Dosage: episodes in bipolar GABA, but the <2 y; children <18 y for curly hair dosage is associated with
400mg/day disorder. direct mechanism treatment of mania. development, frequency of adverse effects.
is not known. 3. Lab tests: Perform baseline
Because of its platelet counts, bleeding time,
many mechanisms and serum ammonia, then
of action, sodium repeat at least q2mo,
valproate has especially during the first 6
efficacy in all mo. of therapy.
partial and 4. Monitor for therapeutic
generalized effectiveness achieved with
seizures including serum levels of valproic acid.
absence seizures.

Source: Guerrero,P.P.(2014). DRUG SODIUM VALPROATE (Depakote, Epilim, Episenta). Retrieved from
https://www.scribd.com/document/247848172/DRUG-SODIUM-VALPROATE-Depakote-Epilim-Episenta
F. PROBLEM LIST

Problem Rationale

Disturbed Sensory Perception related to neurologic The patient manifested worsen hearing
changes as evidenced by hallucinations and hallucinations and seen awake late at night,
inability to concentrate muttering to self, shouting at person as if a person
existed.

Impaired Social Interaction related to impaired He engaged in fight at school and often times his
thought processes as evidenced by inadequate teacher will suggest for an individual meeting to
emotional responses her mother with undesirable behavior was noted.
He also preferred solitary activities and resented to
eat with the rest of the family.

Interrupted Family Process related to situational From his early childhood he was too young to be
crisis as evidenced by communication pattern exposed to an aggressive behavior by his father,
changes who often attempted to discipline him in this
pursuit at times was abusive and aggressive toward
him. Marital problems and domestic violence since
marriage lead to divorce of parents when he was
10 years old.

Source: Martin P. (2019) 6 Schizophrenia Nursing Care Plans Retrieved April 26,2021 from
https://nurseslabs.com/schizophrenia-nursing-care-plans
F. NURSING CARE PLAN

Nursing
Scientific Analysis Goals of Care Nursing Interventions Rationale
Defining Diagnosis
Characteristics

Subjective Data: Disturbed Sensory Disturbed sensory SHORT-TERM: Independent

Seen awake late at Perception related perception is a change in After 8 hours of 1. Accept the fact that 1. Validating that your
night, muttering to to neurologic the amount of pattering of nursing the voices are real to reality does not include
self, shouting at changes as incoming stimuli interventions, the the client but explain voices can help client
person as if a person evidenced by accompanied by a patient will be able that you do not hear cast “doubt” on the
existed, self-care hallucinations and diminished, exaggerated to: the voices. Refer to validity of his or her
deterioration noted. inability to distorted or impaired  learn ways to the voices as “your voices.
concentrate. response to such stimuli. refrain from voices” or “voices that
Auditory and visual responding to you hear”. 2. Might herald
hallucinations are the most hallucinations; hallucinatory activity,
Objective Data: common in schizophrenia.  state three 2. Be alert for signs of which can be very
 Auditory symptoms they increasing fear, frightening to client,
hallucinations recognize when anxiety or agitation. and client might act
 Altered their stress upon command
communication levels are high; 3. Explore how the hallucinations (harm
pattern.  identify two hallucinations are self or others).
 Aggressive stressful events experienced by the
behavior that trigger client. 3. Exploring the
hallucinations; hallucinations and
and 4. Help the client to sharing the experience
 state, using a identify the needs that can help give the
scale from 1 to might underlie the person a sense of
10, that “the hallucination. power that he or she
voices” are less might be able to
frequent and 5. Help client to identify manage the
threatening times that the hallucinatory voices.
when aided by hallucinations are
medication and most prevalent and 4. Hallucinations might
nursing frightening. reflect needs for anger,
intervention. power, self-esteem,
6. Stay with clients when and sexuality.
they are starting to
LONG-TERM: hallucinate, and direct 5. Helps both nurse and
After 2 weeks of them to tell the client identify
nursing “voices they hear” to situations and times
 interventions, go away. Repeat often that might be most
in a matter-of-fact anxiety-producing and
the patient will be manner. threatening to the
able to: client.
 maintain role Collaborative:
performance; 6. The client can
and 7. If voices are telling sometimes learn to
 state that the the client to harm self push voices aside when
voices are no or others, take given repeated
longer necessary instructions. especially
threatening, environmental within the framework
nor do they precautions. Notify of a trusting
interfere with others and police, relationship.
his or her life. physician, and
administration 7. People often obey
according to unit hallucinatory
protocol. If in the commands to kill self
hospital, use unit or others. Early
protocols for suicidal assessment and
or threats of violence intervention might save
if client plans to act on lives.
commands. If in the
community, evaluate
the need for
hospitalization.

Reference:
Martin P. (2019) 6
Schizophrenia Nursing Care
Plans Retrieved April
26,2021 from
https://nurseslabs.com/schizoph
renia-nursing-care-plans/3/

Defining Nursing
Scientific Analysis Goals of Care Nursing Interventions Rationale
Characteristics Diagnosis
Subjective Data: Impaired Social Impaired social interaction is SHORT-TERM: Independent:
He engaged in fight at Interaction related defined as a state in which After 8 hours of
school and preferred to impaired an individual participates in nursing 1. Assess if the 1. Many of the positive
solitary activities. thought processes either an insufficient or an interventions, the medication has reached symptoms of
as evidenced by excessive quantity of social patient will be able therapeutic levels. schizophrenia will
inadequate exchange, or with an to: subside with
Objective Data: emotional ineffective quality of social  engage in one 2. Identify with client medications, which will
 Irritability responses. exchange. activity with symptoms he facilitate interactions.
 Aggressive a nurse by the experiences when he or
behavior end of the day; she begins to feel 2. Increased anxiety can
 demonstrate anxious around others. intensify agitation,
interest to start aggressiveness, and
coping skills 3. Keep client in an suspiciousness.
training when environment as free of
ready for stimuli (loud noises, 3. Client might respond to
learning; and crowding) as possible. noises and crowding
 use appropriate with agitation, anxiety,
social skills in 4. 4.Structure activities and increased inability
interactions. that work at the client’s to concentrate on
pace and activity. outside events.

LONG-TERM 5. If client is found to be 4. Client can lose interest

GOAL: very paranoid, solitary in activities that are too
After 2 weeks of or one-on-one ambitious, which can
nursing activities that require increase a sense of
interventions, the concentration are failure.
patient will be able appropriate.
to: 5. Client is free to choose
 attend one his level of interaction;
structured Collaborative: however, the
group activity concentration can help
within 5-7 6. As the client minimize distressing
days; progresses, provide the paranoid thoughts or
 seek out client with graded voice.
supportive activities according to
social contacts; the level of tolerance 6. Gradually the client
 improve social such as simple games learns to feel safe and
interaction with with one “safe” person competent with
family, friends, and slowly add a third increased social
and neighbors; person into “safe”. demands.
 and 7. Eventually engage 7. Client continues to feel
 state that he or other clients and safe and competent in
she is significant others in a graduated hierarchy
comfortable in social interactions and of interactions.
at least three activities with the client
structured (card games, ping
activities that pong, sing-a-songs,
are goal group sharing
directed. activities) at the
client’s level.

Reference:
Martin P. (2019) 6
Schizophrenia Nursing Care
Plans Retrieved April
26,2021 from
https://nurseslabs.com/schizophr
enia-nursing-care-plans/2/

Defining Nursing
Scientific Analysis Goals of Care Nursing Interventions Rationale
Characteristics Diagnosis
Subjective Data: Interrupted Family Interrupted Family Process SHORT-TERM: Independent:
Prefers solitary Process related to occurs as a result of the After 8 hours of
activities and situational crisis or inability of one or more nursing 1. Assess the family 1. Family might have
resented eating with transition as members of the family to interventions, the members’ current misconceptions and
the family. evidenced by adjust or perform, resulting Family and/or level of knowledge misinformation about
changes in in family dysfunction and significant others about the disease and schizophrenia and
communication interruption or prevention of will be able to: medications used to treatment, or no
Objective Data: patterns. development of the family.  recount in some treat the disease. knowledge at all. Teach
 Childhood detail the early client’s and family’s level
trauma signs and 2. Inform the client of understanding and
 came from a symptoms of family in clear, simple readiness to learn.
broken family relapse in their terms about
 Changes in ill family psychopharmacologic 2. Understanding of the
communication member, and therapy: dose, disease and the
patterns know whom to duration, indication, treatment of the disease
contact in case; side effects, and toxic encourages greater
and effects. Written family support and client
 state and have information should be adherence.
written given to the client and
information family members as 3. Rapid recognition of early
identifying the well. warning symptoms can
signs of help ward off potential
potential 3. Teach the client and relapse when immediate
relapse and family the warning medical attention is
whom to symptoms of relapse. sought.
contact before
discharge. 4. Provide information 4. Meet family members’
on disease and needs for information.
LONG-TERM: treatment strategies
After 2 weeks of at the family’s level of 5. Nurses and staff can best
nursing understanding. intervene when they
interventions, the understand the family’s
patient will be able 5. Provide an experience and needs.
to: opportunity for the
 meet with family to discuss 6. Schizophrenia is an
nurse/physician feelings related to ill overwhelming disease for
/social worker family member and both the client and the
the first day of identify their family. Groups, support
hospitalization immediate concerns. groups, and
and begin to psychoeducational
learn about Collaborative: centers can help access
neurologic/bioc caring, resources and
 hemical 6. Provide information support; develop family
disease, on client and family skills; improve quality of
treatment, and community resources life for all family
community for the client and members; and minimizes
resources; and family after isolation.
 be included in discharge: day
the discharge hospitals, support
planning along groups, organizations,
with the client. psychoeducational
programs, etc.

Reference:
Martin P. (2019) 6
Schizophrenia Nursing Care
Plans Retrieved April
26,2021 from
https://nurseslabs.com/schizophr
enia-nursing-care-plans/6/