I.

Introduction
Paranoid schizophrenia (paranoia) is a subtype of schizophrenia
and is the most common example of this mental illness. Schizophrenia
is not “split personality”. Although the word schizophrenia means
“splitting of the mind”, it refers to the disconnect between thought and
language that occurs in this disease. The precise cause and
pathogenesis of schizophrenia with paranoia is still unknown. However,
abnormalities in brain structure that are characteristics of this disorder
are present at the first episode and in unmedicated persons. This
suggest that the anatomic alterations are not the result of progressive
brain deteriorations due to repeated psychotic episodes or to effects of
psychotropic drugs, but rather caused by abnormalities in the
neurodevelopment in intrauterine and early postnatal life. The onset of
the disorder typically occurs between 20 and 35 years of age. Men and
women seem to be affected equally, but the age of onset for the
paranoid schizophrenia subtype is 3 to 4 years later in women than in
men.
Risk factors for schizophrenia include having a close relative with
schizotypal personality disorder or schizophrenia, second trimester
prenatal influenza infection and brain abnormalities. Paranoid
schizophrenia is characterized by predominantly positive symptoms of
schizophrenia, including delusions (e.g. that one is being controlled by
an outside force), mostly hallucinations (seeing things that is not real
and hearing voices is the most common), disorganized thinking and
speech that commonly lead to problems such as inability to
communicate properly, altered thought process, confusion, risk for
injury and violence. It also includes disorganized catatonic or abnormal
motor behavior. Frequently, persons with schizophrenia lose the ability
to appropriately sort and interpret incoming stimuli, which impairs the
ability to appropriately respond to the environment. An enhancement
or a blunting of the senses is very common in the early stages of
schizophrenia. In addition, the person with schizophrenia often
experiences sensory overload owing to a loss of the ability to screen
external sensory stimuli. These debilitating symptoms blur the line
between what is real and what is not, making it difficult for the person
to lead a typical life.

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 For a diagnostic test of schizophrenia to be made, according to
the DSM-IV classification, two or more of the following symptoms
must be present for a significant portion of 1 month: delusions,
hallucinations, disorganized speech, grossly disorganized or catatonic
behavior. In addition, one or more areas of functioning must be
significantly impaired compared with premorbid abilities, and
continuous signs of the disturbance must persist for at least 6
months. Physical exam may be done to help rule out other problems
that could be causing symptoms and to check for any related
complications.Tests and screenings include tests that help rule out
conditions with similar symptoms, and screening for alcohol and
drugs. The doctor may also request imaging studies, such as an MRI
or CT scan. Psychiatric evaluation is done to checks mental status by
observing appearance and demeanor and asking about thoughts,
moods, delusions, hallucinations, substance use, and potential for
violence or suicide.

Once the patient has been diagnosed with schizophrenia, the

goal of treatment is to induce a remission, prevent a recurrence, and
restore behavioral, cognitive, and psychosocial function to premorbid
levels. The positive symptoms of schizophrenia are most likely to
respond to drug therapy, particularly with the typical anti psychotic
drugs. The negative symptoms of schizophrenia respond more
favorably tho the atypical antipsychotic drugs (e.g clozapine). Often
antipsychotic are combined with benzodiazepines during the acute
phase of treatment to reduce the risk of extrapyrimidal effects from
large doses of antipsychotic agents.

Schizophrenia is fairly common, found in approximately 1% of

the general population and affects more than 21 million people
worldwide. According to the study conducted by Dr. Tomas Bautista,
about 42% of the 2,562 patients with mental illness suffer from
schizophrenia, making it the most common mental illness in the
Philippines—with it making up roughly 1% of the country’s total
population. Baguio General Hospital and Medical Center (BGHMC)
Psychiatry division consultant Dr. Lowell Rebucal said that mental
health problems like Schizophrenia are rarely being discussed in
public because of stigma. He said that based on their statistics of

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 2013. there are 9.802 consultations and 50% of this are the people
with mild Schizophrenia. He added that the rest are the people who
are undergoing depression and bipolar disorder.

Sources:
http://www.who.int/mental_health/management/schizophrenia/e n/

https://today.mims.com/the-4-most-common-mental-health-illnesses-
among-filipinos

http://www.nordis.net/2014/10/mental-health-month-focuses-on-
schizophrenia/

Pathophysiology Concepts of Altered Health States by Lippincott

Williams and Wilkins 6th edition

II. Statement of Objectives

A. General Objectives

The main goal of the group is to be able to present the case of

our patient in a comprehensive discussion of the definition, signs

and symptoms, pathological mechanism of the disease to yield

significant information for the case study including Nursing Care

Management.

B. Specific Objectives

Specifically, this case analysis aims to:

1. Define Paranoid Schizophrenia and its effects to the

body as a whole

2. Illustrate the pathophysiology of Paranoid Schizophrenia

and in relation to the signs and symptoms specifically

observed in the client

3. Describe and identify the common signs and symptoms

of Paranoid Schizophrenia

4. Formulate appropriate nursing care plans suited for the

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 client based on the assessment findings

5. Differentiate types of medical treatment necessary for

Paranoid Schizophrenia

III.Client’s Profile

Name: Patient X

Age: 23 years old

Gender: Male

Address: La Trinidad

Nationality: Filipino

Ethnic Group: Kankanaey

Civil Status: Single

Religion: Roman Catholic

Occupation: None

Date of Admission: December 26, 2017

Admitting Physician: Doctor X

Admitting Diagnosis: Paranoid Schizophrenia

Final Diagnosis: Paranoid Schizophrenia

Date Handled: January 29-31, 2018; 7-3 Shift

Hospital and Ward: Baguio General Hospital and Medical

Center, Psychiatric Ward

IV. Chief Complaint

According to the informant: “Wala siyang ganang kumain at tumakas

siya sa bahay.”

V. History of Present Illness

The patient was a diagnosed case of Paranoid Schizophrenia

since 2014. Recent confinement was June 28,2017 and was discharged

on July 14,2017.

3 days prior to admission the patient was noticed of having loss

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of appetite and always being quiet. He also stated to his mother about

visiting the hospital in Baguio.

1 day prior to admission the patient escaped from their house

after eating lunch. Few hours prior to admission, the patient was seen

wandering at the BGH Emergency Room then suddenly became

physically assaultive. The patient was brought to the Psych-OPD, he

was observed to have labile mood and was unresponsive to asked

questions, hence admitted.

VI. Past History Illness

Immunizations and childhood illness were unrecalled. There is

one episode of seizure when the patient was 1 year old. Patient has no

known allergies to foods or drugs. No history of accidents or past

surgeries.

Psychiatric History: Past Admission at BGHMC

1st Admission (2014): Severe depressive episode, without psychotic

symptoms, dehydration, secondary to major depressive disorder, single

episode, severe, without psychotic symptoms. Managed Accordingly.

2nd Admission (June 28, 2017): Paranoid Schizophrenia, Managed

Accordingly.

VII. Family Health History

The patient’s grandfather in the mother’s side has a family history of

behavioural problem. The patient’s mother is hypertensive and takes

Amlodipine 5mg since 2010. There is no known other familial diseases

such as psychiatric disorders, diabetes, arthritis or cancer.

VIII. Developmental History

Patient X is 23 years old who falls under Erik Erikson’s Psychosocial

stage

Of Intimacy vs. Isolation. This occurs during young adulthood wherein

young adults explore relationships leading toward longer-term

commitments with someone other than family. The patient manifests

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isolation

IX. Social and Environmental History

Patient X has a good interpersonal relationship with parents and

siblings. His Patient X is an undergraduate of Computer Science.

Developmental milestones were at par with other children of the same

age.He was described to be active in class.

X. Lifestyle and Health Practices

X. Health Assessment

A. General Survey

Patient X was received awake, sitting on bed. With normal body

posture appeared, relaxed, erect, and with coordinated body

movements. Patient X also moves very slowly and his pace is not as

active as that of how a normal person of his age moves about.

B. Head to Toe Assessment

1. Head Norm cephalic. Hair is short, black

and evenly distributed. No
presence of masses and nodules
upon palpation. Dry scalp and
dandruff noted with no presence
of parasite.
2. Eyes No i of vision. Pupils equally round
and reactive to light and
accommodation.

3. Ears Auricles are symmetrical and

have the same color as the facial
skin. No lesions observed; no
palpable nodules and masses,
minimal cerumen discharges

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 noted.

4. Nose and Sinuses No presence of lesion, nodules,

nasal flaring and discharges
noted.

5. Mouth Oral mucosa dry and pink, no

lesions noted, tonsils are not
inflamed, and uvula located
midline. Lips appear to be dry,
symmetrical and colored brown to
dark red. Cavities on his front
teeth noted.
6. Neck Able to change direction of head
slowly without complains of pain;
no jugular distension noted. No
palpable superficial lymph nodes.
Thyroid gland not inflamed.
7. Chest No difficulty of breathing
observed
8. Cardiac No noted abnormal heaves, and
thrills felt over the apex upon
auscultation.

9. Breast Equal in color. No presence of

mass and lumps. No pain upon
palpation
10. Abdomen No lesions, bruise, and incision
noted.

11.Genitalia No presence of rashes and lesions

around the inguinal area. No foul
odor noted.

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12.Musculoskeletal Both extremities are equal in size.
No involuntary movement. Can
counter act gravity and resistance
on ROM. No tremors noted

13.Integumentary Skin is dry and warm to touch.

Hair is evenly distributed; nails
are firm and no signs of clubbing.
No visible lesions on the body.
Capillary refill of 1-2 seconds.

A. 13 Areas of Assessment

1. Psychosocial Status:

Patient X, is 23 year old a filipino male who stands around

5’6” and weighs fairly average based on his appearance. According to

Eric Erickson psychosocial theory, Patient X is in the development

stage of intimacy vs. isolation (18-40 years old). In this stage, adult

begin to be intimate with others, exploring relationship leading toward

longer term commitments with someone other than a family member.

2. Environmental status:

Patient X was admitted at the Baguio General Hospital in the

Psychiatric Ward. The male ward is separated from female ward, it is a

little bit congested and has 2 windows. There are approximately 10

beds with just enough space for visitors walk by and watchers to sit in.

Patient X has a bed and under the bed is the storage of food, water

and other essential belongings.

3. Mental and emotional status:

Patient X is oriented to time, place and person. He can identify

things or names being asked. He can recall recent and remote

memories. He is aware that he is more than a month in BGHMC. He is

able to answer direct questions. He is able to speak in Ilocano and

kankanaey. Patient X is unresponsive to some questions, calm and

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relaxed during the interview.

4. Sensory status:

a) VISUAL: Patient X has no difficulty in opening and closing his eyes.

He is not wearing eyeglasses. He can distinguish objects such as

alcohol and pillows. He was instructed to follow the direction of a finger

with His eyes following six cardinal signs, and his eyes were able to

move in full range of motion. With the use of penlight the pupils

constrict when struck with light. Patient’s eyes are symmetrical and

round, sclera is white in color, while her conjunctiva is pale in color.

Patient X has a full stare at something but never on the person or

nurse he is relating to.

b) AUDITORY: His ears are symmetrical with minimal discharges

observed. No lesions and tenderness upon palpation. Patient was

instructed to repeat the words that were whispered at a distance of

two feet away on on both ears and was not able to hear the exact

words. He mumbles to himself and talking to someone else not visible

(“May tumatawag ba sa akin?”) it falls as an illusion or auditory and

visual hallucinations.

c) OLFACTORY STATUS: His nose is symmetrical, no nasal flaring and

no discharges observed. No tenderness and lesions upon palpation.

Patient X is able to distinguish odors that are given to him such as

alcohol.

d) GUSTATORY STATUS: Lips are able to open when eating and able

to articulate sound and speech. Prior to hospitalization, he was able to

eat and taste different flavors such as sweet, sour, and salty. His hair is

black in color. His conjunctiva is slightly pale, and sclera is whitish in

color.

5. Motor status: The patient did not have a difficult time flexing or

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extending his elbows and abducting his fingers. Also, no pain or

intolerance was noted when the patient was asked to flex his hips

against negative pressure. This shows that the patient has a rating

scale of 5/5 on the muscle strength. The rating scale of 5/5 explains

that the patient has active motion against full resisitance.

6. Thermoregulatory:

Time January 29, January 30, 2018 January 29, 2018

2018
6 am 36.5 °C 36.5 °C 36.6 °C

2 pm 36.4 °C 36.6°C 36.4 °C

10 pm 36.4 °C 36. 5°C 36.6 °C
The patient’s skin is warm to touch with the temperature of 36.3-

36.6 degrees Celsius. The normal axillary temperature is within 36.5-

37.5 Celsius (WebMD). The patient did not experience hypothermia or

hyperthermia.

7. Respiratory Status:

Respirations were normal in pattern. Table below shows the

respiratory rate of the patient.

Time January 29, January 30, 2018 January 31, 2018

2018
6 am 18 19 19

breaths/minute breaths/minute breaths/minute

2 pm 19 19 19

breaths/minute breaths/minute breaths/minute

10pm 17 18 19

breaths/minute breaths/minute breaths/minute

The patient’s respiratory rate ranged from 17-19 breaths/minute.

Normal respiratory rate for adults is 12-20 cpm. Average is 18. In term

of pattern, normal respirations must be regualar and even in rhythm.

8. Circulatory

Time January 29, January 30, January 31,

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 2018 2018 2018
6 am 81 bpm 82 bpm 80 bpm
2 pm 98 bpm 76 bpm 76 bpm
10 pm 100 bpm 88 bpm 80 bpm
The patient’s heart rate ranged from 76-100 bpm. The normal

value for pulse is 60-100 bpm.

Time January 29, January 30, January 31,2018

2018 2018
6 am 120/90 mmHg 110/80 mmHg 120/80 mmHg
2 pm 120/80 mmHg 120/70 mmHg 110/80 mmHg
10 pm 110/80 mmHg 130/80 mmHg 120/80 mmHg

The patient’s blood pressure ranged from 110/80-130-80 mmHg.

The normal blood pressure is 120/80.

9. Nutritional:

Prior to hospitalization patient X’s appetite had decreased.

During hospitalization, patient X eats 3 times a day with snacks. He

was able to consume 100 percent of the food that was served, and

fluid intake of 4-5 glasses of water per day.

10. Elimination status:

Prior to hospitalization, the patient urinates 3-4 times a day, he

defecates once a day. During hospitalization he urinates 2-3 times a

day and he defecates once a day.

11. Fluid and Electrolyte

Prior to hospitalization patient drinks 3-4 glasses of water per

day and during hospitalization he drinks 4-5 glasses of water per day.

12. Sleep and Rest

Patient X usually sleeps 8-10 hours a day with naps. His sleep is

interrupted when doctors get vital signs and if agitated or if he has

mood swings.

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13. Integumentary status:

Patient X’s complexion is light brown the skin is pale, warm to

touch and slightly dry with no presence of lesions and rashes observed.

She has a short, black and thin hair with no presence of lice and

dandruff upon assessment. Hair is well distributed. Upon inspection

patient has a capillary 1-2 seconds.

MENTAL STATUS EXAMINATION

I. General Overall Appearance

Patient “X”, is a filipino male who stands around 5’6” and weighs fairly

average based o his appearance. He is fairly groomed, his hair cut

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short and his nails are cut short and clean. His behavior is sometimes

unpredictable. He has limited clothes and he wears the same jogging

pants and prefers to wear slippers. With normal body posture

appeared, relaxed, erect and with coordinated body movements.

He stays in his bed most often, if distracted he roams around the Male

ward. He cannot maintain a good eye contact for a period of time when

communicating, and with short attention span.

He is able to do activities of daily living independently. With regards to

his facial expressions, he usually has a blank face and an exaggerated

smile when “hi” is delighted. Patient also moves very slowly and his

pace is not as active as that of how a normal person of his age moves

about. Patient X has a full stare at something but never on the person

or nurse he is relating to. He presents vigil stare that are empty but

prolonged. He reflects his delight by smiling. Patient X observed to be

craving for a fatherly love and see a co-patient as his father figure

integrating the need for love and belonging by Maslows.

II. Speech

Patient’s volume of speech is described as hushed, and talks in a slow

manner. The patient’s reaction to the student nurse’s question is noted

as normal with frequent pause before answering. It is characterized by

non-verbal communication to sudden word without saying anything. He

only entertained questions being asked and sometimes refuses to talk

about personal things integrating trust vs. mistrust by Erick Erickson’s

psychosocial theory. Shows more non-verbal communication, poverty

of speech, and with a short span of attention as manifested by talking

less, reply briefly, nods and sudden stop in the middle of conversation,

stares blankly and walks away.

III. Socialization and Interpersonal Relationship

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He is often visited by his watcher. He sometimes interacts with the

other patients. He is conversant at times but he do have moods in

interaction and socialization. During OT activities he roams around, he

does not want to participate in doing art activities but enjoys ball

games.

IV. Pathological Content of Thought

No obsessions and suicidal thoughts noted. He mumbles to himself and

talking to someone else not visible (“May tumatawag ba sa akin?”) it

falls as an illusion or auditory and visual hallucinations.

V. Intellectual Areas

The patient is oriented to time, place, and person. He is aware that he

is more than a month in BGHMC. He is able to answer direct questions.

In giving instructions and asking questions, it should be kept simple

and should not overwhelm the patient to prevent mood swings.

VI. Mood Affect

The patient sustains varying moods from being happy, sad, irritable,

and flat. The patient has a blunt affect, showing very slow-to-respond

facial reactions. He also says “okay lang” well even if his facial

expressions would say otherwise. The patient shows evidence of

boredom and loneliness by isolating himself, not responding to anyone

and staying in bed most of the time and not often participating in OT

activities.

VII. Body Image

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 Patient seeks attention and mentions that he misses his mother and

father which is manifested by staying with Ernesto. He is sometimes

quiet and interpersonal and social relationship.

VIII. Ability to Stress Captivity

During interview, the patient used defense mechanisms such as

regression, resistance blocking, and showed limited affect, poverty of

speech which are indications of social isolation.

IX. Evaluation of How the patient react to the interview

During NPI, patient X was hesitant and reluctant to say something to

me due to uncertainty. He uses non-verbal communication and with

poverty of speech, and refuses to converse about personal things and

tends to block and walks away. Blocking tendency predisposes to

impairment of discussion about more important and significant topics.

Eventually his trust towards me gradually developed as we pursue with

our NPI. Although Patient X has a sense of hesitation, we learned to

deal with each other comfortably.

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