IDENTIFICATION DATA

NAME – Miss. Farhana

AGE – 18 years
FATHER NAME- Mohd. Haseen
DATE OF ADMISSION – 06 March 2017
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 Ri L Cerebellar Ri L
System g e Signs g e
ht f ht f
t t
Pain √ √ Finger Nose √ √
Touch √ √ Dysdiadocho √ √
kinesia
Temper √ √ Tendem √ √
ature Walking
Pressur √ √ Rombergs √ √
e
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 Schizophrenia This category is diagnosed either
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 Depression Depressive features develop in the
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:

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

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

Potential for criticism
Disturbed Self care deficit
thought process violence

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

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

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

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 4 th;

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
TEERTHANKER MAHAVEER UNIVERSITY, COLLEGE OF NURSING

CASE STUDY
ON
SCHIZOPHRENIA
SUBMITTED TO: - SUBMITTED BY: -

Dr. NAGESHWAR MAHIMA ELIAZER

T.M.C.O.N M.SC 1ST YEAR
T.M.C.O.N