CASE STUDY

ON

PARANOID SCHIZOPHRENIA

SUBMITTED TO SUBMITTED BY
MS. VIJYEYTA BHASIN SADIA SALEEM
ASSISTANT PROFESSOR M.Sc N 1STYEAR
SOCIO DEMOGRAPHIC DATA

Name: Ms Priyanka Singh

Age: 37 years
Sex: Female
Ward- Psychiatric Ward B2
Education- B.A

Occupation- Home Maker

Socio Economic Status (Income) – 60,000rs/month
Marital Status-married
Religion-sikh
Language- Punjabi , Hindi
Nationality-Indian
Address – Jalandhar
Date of Admission- 11th Nov 2023
Date of Assessment- 15th Nov 2023
Identification Marks-not significant
Diagnosis: Paranoid Schizophrenia
Description of living area- client is living in rural area in pucca house and there are good sanitation conditions. Good ventilation and
surrounding area is clean.
1. INFORMANT

S.no. Name Relationship Reliability Adequacy

1. Mr. Hardeep Singh Father Reliable Inadequate

PRESENTING CHIEF COMPLAINTS:-

According to patient:
Mujhe neendh nahi aati thi * 4 months
Bhook nhi kagtinthi* 4 months
Gussa ata tha * 4 months
Rone lag jati thi har baat pai * 4 months

According to informant:
Neendh nahi ana * 4 months
Shq har kisi pai* 4 months
Gussa ana * 4 months
Awazein sunayi dena * 4 months
Rone lag jati hai * 4 months
Bhook nahi lagna * 4 months

HISTORY OF PRESENT ILLNESS:

Onset of Illness- acute

Course of Illness-continuous
Predisposing Factors- Marital issue
Precipitating Factors- not significant
 HISTORY OF PRESENT COMPLAINTS:

➢ Ms Priyanka singh was apparently well 4 months back when her family noticed change in patient’s behavior. Patient started
remaining aggressive. She remains aggressive all the time. Patient said that she used to hear voices and was very much
suspicious .patients had marital issues Patient was not able to get proper sleep. Patients did not went to any medical practitioner.
Then she was bought to Mindplus with complaints of excessive anger, disturbed sleep , eat less food. Then she got admitted in
psychiatric ward and now she is admitted in ward with diagnosis of Paranoid Schizophrenia

➢ PAST PSYCHIATRIC HISTORY

There is no significant past history of psychiatric illness.

PAST MEDICAL HISTORY

There is no significant medical history of headache, fever, infection and Epilepsy, head injury, Trauma, Accident etc
FAMILY HISTORY:

FAMILY TREE

KEYS

MALE

FEMALE

PRESENT
PATIENT
 MEDICAL AND PSYCHOLOGICAL HISTORY

There is no history of medical illness and Psychiatric Illness in the family.

5. PERSONAL HISTORY

PRENATAL/NATAL HISTORY:-
• Mother had no history of febrile illness
• No history of medication use
• no history of alcohol use
• No history of trauma to abdomen during antenatal period.
• He was a wanted child.
• Delivery was normal and client was born in house.
• No history of birth defects
• Immunization: Done

BIRTH HISTORY:-
• Primary care giver: Father and mother.
• Breast feeding was adequate
• Weaning: started on 6th month of age.
• No history of maternal deprivation.
• Milestones: were normal

INFANCY/EARLY CHILDHOOD HISTORY:-

• Developmental milestones: developmental milestones were said to be normal.

• Physical health: client was physically healthy.
• Immunization: immunization was completed as per age.
• Behavioural/emotional problem: no behavioural or emotional problem like enuresis, encopresis, nail biting etc.
MIDDLE CHILDHOOD/SCHOOLING HISTORY:-

• Age of starting schooling: 5 years

• Performance at school, scholastic achievements: good
• Extracurricular activities/achievement: uneventful
• Popularity in the class: uneventful
• Any groupism/gangsterism/type of group: no groupism or gangism
• Relationship with teachers and friends: good
• Discipline in the class: maintained
• Any problems at school: not significant

ADOLESCENT AND LATE CHILDHOOD:-

• Appearance of secondary sexual characteristics:13 years

• Attitudes: Positive
• Any emotional problem during adolescence: not significant
• Knowledge about sex: client was having less knowledge about sex.

OCCUPATIONAL HISTORY
Patient is a homemaker

MARITAL HISTORY
• Age of marriage: client got married at the age of 23 years.
• Type of marriage: Arrange marriage
• Satisfaction in marital life: not satisfied
• Quality of marital relationship: not good
 • Quality of sexual relationship: not good

• Responsibilities: client is not responsible and beat his wife

• Financial support from spouse: client is having no financial support from spouse

PREMORBID PERSONALITY

Attitude to Self :

• Self Confidence level is good

• Self Criticism not present in patient.
• Positive self-consciousness
• Self Centered behavior
• Hopes/plan for self: hope was present and future plans was there.
• Problem solving/decision making: The client is having good ability for problem solving and decision making.

Relations

• Social relationship- Poor relationship with society.

• Relationship with Parents- Poor relationship with family.

Extrovert/introvert-introvert
• Shy/ easily makes friendships-easily makes friends
• Relationships with the members of opposite sex-normal
• Tolerance to criticism- she cannot tolerate criticism.

Standards
• Moral standards/ value system- good moral standards.
• Religious standards-maintained
• Attitude towards health/ health standards- positive
Leisure
• she uses her leisure time in reading
• Hobbies/ interest-client is having hobby of watching cooking channels on tv

Mood
• Predominant mood- happy
• Optimistic/pessimistic:optimistic
• Stable/fluctuations: fluctuations
• Emotional control: good

Habbits
• Sleeping pattern: disturbed (3 hrs per night)
• Eating pattern: good
• Excretory functions: no disturbance in excretory functions.
• Substance abuse: beedi smoking (2 bundles of beedi per day), alcohol sometimes 2-3 peg
2 times in a week.

Fantasy life
• Day dreaming: not significant.
 MENTAL STATUS EXAMINATION

GENERAL APPEARANCE AND BEHAVIOUR:

Appearance- looking apparent to age

Level of grooming- normal

Level of cleanliness- adequate

Level of consciousness- fully conscious and alert

Mode of entry- came willingly

Cooperativenes- cooperative

Eye to eye contact- established and maintained

Rapport- spontaneous

Facial expression- angry

Gesturing- normal

Posturing- normal

Psychomotor activity- normal

Other movements- not significant

Catatonic phenomena-not significant

 ➢ SPEECH

Initiation- spontaneous

Rate- decreased

Reaction time- decreased

Verbal output- increased

Tone of speech decreased

Relevance- relevant

Coherence- coherent

Disorder of speech- no disorder of speech like stuttering, stammering, circumstantiality, tangentiality etc.

Sample of speech:-

Q: Aap muje apne bare mein kuch btaiye.

Ans: mera naam Priyanka hai,

Inference:- Initiation is spontaneous. Rate, verbal output, tempo, tone of speech are decreased , reaction time is decreased. Speech is
reliable and coherent and no speech disorder.

➢ THOUGHT

Stream of thought- pressure of thought is present and no poverty of thought/autistic thinking/deristic thinking/thought block.

Form of thought- no any formal thought disorders like circumstantiality, tangentiality, neologism, verbigeration, flight of ideas etc.
Inference-In stream of thought, pressure of thought is present and form of thought is normal.

Content of thought-

Delusion:

Delusion of grandiosity:

Q: kya apko esa lgta hai ki aap mahaan hein?

Ans: nhi esa kuch nhi lagta.

Inference:Delusion of grandiosity is not present.

Delusion of persecussion:

Q: Kya apko kisi par shaq hai ki koi aapko nuksaan phunchana chahta hai?

Ans: haan mere sasural wale

Inference: Delusion of persecussion is present.

Delusion of reference:

Q: Kya apko kbi ese lgta hai ki jase 2 log aapas mein baat kr rhe hein,vo aapke bare mein baat kar rhe hein?

Ans: nahi.

Inference: delusion of reference is not present.

Delusion of control:

Q: kya apko esa lgta hai ki aapko kisi ne control kia hua h,vhi apko chala rha hai?

Ans: nhi
 Inference: delusion of control is not present.

Somatic delusion:

Q: kya apko lgta hai ki apke sharer ka koi hissa kaam ni kar rha?

Ans: nahi

Inference: somatic delusion is not present.

Obsession:

Q: kya aapko baar baar ek hi vichaar ate rehte hein kya?

Ans: nahi ji.

Inference: obsession is not present.

Suicidal ideas:

Q:kya apke mann me kbi aatamhatya k vichaar ate h?

Ans: nahi,bilkul nahi

Inference:suicidal ideas are not present.

Phobic ideas:

Q: kya apko kisi chiz se had se jyada darr lgta hai?

Ans: nahi

Inference:phobic ideas are not present.

Inference:- pressure of thought is present and form of thought is normal, no speech disorders, and in content of thought there is
somatic delusion present and obsession, phobic ideas and suicidal ideas are not present.

MOOD AND AFFECT

Subjective mood-

Q:apka mann kaisa hai ab?

Ans: mein thik nhi hu, ghar jana chaheti hu

Objective mood: client is looking unhappy.

Inference-affect is appropriate to mood.

PERCEPTION

Hallucination-

• Auditory

Q: kya apko kbi kuch awaazein sunai deti hein jo auro ko sunai nhi deti?

Ans: haan kuch ajeeb si awazein

Inference- auditory hallucination is present.

• Visual

Q: kya apko kuch esa dikhai deta hai jo auro ko dikhai nhi deta?

Ans: nhi

Inference- visual hallucination is not present.

 • Olfactory

Q: kya apko koi alag si smell mehsoos karte hein?

Ans: nahi

Inference- olfactory hallucination is not present.

• gustatory

Q: kya apke muh mein koi ajeeb sa swaad rehta hai?

Ans: nahi,bas bhukh nhi lagti

Inference- gustatory hallucination is not present.

• Tactile

Q: kya apko apne sharer pr kuch ajeeb si sansani mehsoos hoti hai?

Ans: nahi toh.

Inference- tactile hallucination is not present.

Illusion-

Q:kya apko chizon ko dekhte samay koi galatfehmi hoti hai?

Ans: nhi

Inference- illusion is not present.

Deja-Vu and Jamais-Vu- Deja-Vu

Q: kya apko kisi anjaan jgah pr pehli baar jane pr esa lgta hai jase aap pehle bhi vhan gye hein?

Ans: nhi

Inference- Deja-Vu is not present.

Jamais-Vu

Q: kya apko kisi jgah pr jhan aap pahle bhi ja chuke hein vha pr jane pr esa lgta hai jase aap pehle vhan kbhi nhi gye?

Ans :nahi

Inference- Jamais-Vu is not present.

Depersonalization and derealization

Depersonalization

Q: kya apko esa lgta hai aap iss duniya ke nhi ho?

Ans : ji nahi

Inference- depersonalization is not present.

Derealization

Q:kya apko esa lgta hai ki ye duniya nakli hai?

Ans: nhi,duniya to hoti hi hai.

Inference-derealization is not present.

Inference- hallucination is not present, illusion is not present, déjà vu jamais vu not present, depersonalization and derealization is not
present.
COGNITIVE FUNCTION

• Attention-

Q: number 16977 ko sidha and ulta boliye?

Ans: 16977, 77961

Inference- Attention is normally aroused.

• Concentration-

Q: 100 mein se 7 ko 5 baar ghata k batein?

Ans- remains silent

Q: 40 mein se 3 ko 5 baar ghata k batein?

Ans- 25

Inference- sustained.

• Orientation-

Time

Q:aap muje bataiye aaj kya tareekh hai?

Ans-21.

Q:aap muje bataiye ab kya mahina chal rha hai?

Ans-february

Place
Q: aap abhi khan pr hein?

Ans: mindplus mein.

Person

Q: vo kaun hein (pointing toward nurse)

Ans- nurse

Inference- Client is oriented to time, place and person.

• Memory-

Immediate memory

Q: aap 1,2,3,4,5 ko sidha aur ulta boliye?

Ans- 1,2,3,4,5 aur 5,4,3,2,1

Recent memory

Q: apko yaad hai aapne kal raat khane mein kya kahaya tha?

Ans:aloo gobhi ki sbji aur roti

Remote memory

Q: apka janamdin kab aata hai?

Ans-10 march

Q: ap kaunse school mein pdhte the?

Ans: stephens school

Inference- client’s immediate, remote and recent memory is intact (after confirming with family members about recent memory)

• Intelligence-

Q: apko pta hai hamare desh ka azadi ka din kab manate hein?

Ans:hanji,15 august

Q: aap muje 10 mein 20 jama krke btaein?

Ans: 30

Inference- Adequate

• Abstract thinking-

Proverb testing

Q:apko koi muhavra(kahawat) ata hai?

Ans:hnji, UNCHI DUKAAN FEEKA PAKWAN.
Q:acha aap muje iska mtlb btaein?
Ans: bahar se acha ander se bekaar
Similarity and dissimilarity test-
Q: seb(apple) aur aam(mango) mein kya ek jasa hai aur kya alag hai?
Ans- dono fal hein nd rang aur swaad alg h dono ka.

Inference- Abstract thinking present.

• Judgement-

Personal judgement
Q: aap yha se ghr janek baad kya kreinge?
Ans: apni transfer ki koshish krunga nhi hui to vhi kaam krunga.
Social judgement

Q: agar ap sadak par jarhe hein to vha lal(red) light ati hai,to kya karna chahie?

Ans: hme ruk jana chahie.

Test judgement

Q: maan lo agar apke ghar mein aag lag jae aur aap ghr par akele ho to ap kya kreinege?

Ans: aag bujha dunga

Inference- social, personal and test judgement is intact.

➢ Insight-
Q: kya apko pta hai aap yha kyu aye ho?
Ans: gussa ata tha, bhukh nhi lgti, neend bhi nhi ati.
Inference: insight is absent(level-3)
Physical examination
General appearance- client is conscious, having normal posture, looking anxious, cooperative
Integumentry system- colour of skin is fair, temperature is normothermic, moist skin, turgor is good, elastic skin, no lesions and no
scars
Head-shape of head is round, normal distribution of hairs, colour of hairs is black healthy bony prominences, dandruff is present, no
pediculosis, oily scalp

Face-
Eyes-properly aligned, healthy eyebrows and eyelashes, colour of conjunctiva is pink, colour of sclera is slight yellow, no conjutivitis,
no extra watery discharge from eyes, color of eyes is red, eyes look lathargic
Ears-properly aligned, normal recoiing of ears, no discharge from ears

Nose- no deviated septum, nasal patency is normal, no discharge from nose

Mouth- teeth are of white colour, gums are light brown in colour, no bad smell from mouth, cavities are not present, toungue is
coated
Neck-no enlarged lymph nodes, no abnormal mass, no enlarged thyroid gland

Chest – heart sounds are normal(lub-dub), no lump in breast, symmetrical and healthy
Abdomen-bowel sounds are present, no ascites, no tightness of abdomen
Genitals- healthy

Extremities- normal range of motion, no abnormality seen.

Conclusion- Result of physical examination reveals that all organs of client Ms.Priyanka are healthy but there is dandruff present in
hairs, eyes are looking lethargic and red in color.
INVESTIGATIONS
Sr. no. Investigations Patient’s value Normal value Remarks
1. Blood sugar fasting 88 mg/dl 70.00-110.00 mg/dl Normal
Lipid profile
2. Total cholesterol 120mg/dl Desirable <200 mg/dl Normal
Borderline
290-239 mg/dl
High >240 mg/dl
3. Triglycerides 145mg/dl 35.00-160.00 mg/dl Normal
4. HDL cholesterol 47 mg/dl 35.30-79.50 mg/dl Normal
5. LDL cholesterol 23.3 mg/dl <130 mg/dl Normal
6. VLDL 41 mg/dl <40 mg/dl Normal
MEDICATIONS
MEDICATION

DRUG DOSE INDICATIONS/ MOA CONTRAINDICATIONS

PLASMA LIFE AND PRECAUTIONS
Antipsychotics 10–20 mg C/ 21–54 hr/ Effi cacy in schizophrenia is Hypersensitivity, children,
Olanzapine 6/25–12/50 • Schizophrenia achieved through a lactation. Caution with
Mg
(Zyprexa • Acute manic combination of dopamine hepatic or cardiovascular
episodes and serotonin type 2 (5HT2) disease, history of seizures,
• Management of antagonism. comatose or other CNS
bipolar disorder Mechanism of action in the depression, prostatic
treatment of mania is
• Agitation associated hypertrophy, narrow-angle
unknown.
with schizophrenia or glaucoma, diabetes or risk
mania factors for diabetes,
Unlabeled uses: pregnancy, elderly and
•Obsessivecompulsive debilitated patients
disorder
Anti parkinsons Benztropine is a selective
1-8mg/day Drug induced
Anti cholinergic Ma muscarinic acetylcholine
extrapyramidal
Benztropine receptor antagonist. It It is
symptoms and the
(Cogentin) able to discriminate between
prevention of dystonic
the M1 (cortical or neuronal)
reaction
and the peripheral muscarinic
subtypes (cardiac and
glandular). Benztropine
partially blocks cholinergic
activity in the CNS, which is
responsible for the symptoms
of Parkinson's disease. It is
also thought to increase the
availability of dopamine, a
brain chemical that is critical
in the initiation and smooth
control of voluntary
muscle movement.
Contraindicated for use in
patients with
prostatic hypertrophy or
bladder neck obstruc
tions, myasthenia gravis
and in children under
three years of age. Use
with caution in pregnant
women and in patients
with tachycardia,
prostatic hypertrophy or
angle-closure glau
coma. Use caution in
patients exposed to hot
weather. Paralytic ileus has
occurred when
benztropine has been used
concomitantly with
phenothiazines or other
anticholinergics.
Patients should be advised
to report gastroin
testinal complaints
promptly. Pregnancy
Category C.
 PHYSICAL EXAMINATION:

SUBJECTIVE DATA OBJECTIVE DATA

1.General appearance- ❖ Weight : 80 kg

❖ Height :170 cm
❖ Temperature: 37 degree centigrade
❖ Respiration : 20 breaths /min.
❖ Blood pressure: 120/80mmhg.
 ❖ Moderately nourished and is moderately built.

2. Head to toe examination- ❖ Hair is black in color and is equally distributed.

i. Head ❖ No dandruff and pediculosis present.
❖ No alopecia present.

ii. Eyes. ❖ Visual acuity: Normal.

Patient says “I’m able to see the objects ❖ No stys or ptosis present.
from far.” ❖ Pupils are round, and reacting to light and accommodation.
❖ Sclera is red in color.
❖ Conjunctiva: pink in color.

iii. . Ears. ❖ External ears symmetrical,

Patient says “I’ve no hearing problems.” ❖ Hearing acuity: normal.
❖ No wax collection or abnormal discharges from ears.

iv. Nose. ❖ No septal deviation present

❖ No nasal discharge or nasal polyp present.

v. Mouth.
o Tongue ❖ No lesions present.
 o Lips ❖ No cracks and stomatitis present.
o Teeth ❖ Reddish discoloration present. No dental carries present.

o Gums ❖ No gingivitis or gum bleeding present.

o Buccal cavity ❖ No infection.

o Uvula. ❖ Centrally placed.
o Tonsils ❖ No tonsillitis present.

vi. . Neck. ❖ No lymph node and thyroid enlargement present.

❖ Complete range of motion possible.

3. Systemic Examination-
a. Respiratory system. ❖ Respiratory rate: 20 breaths/ min
❖ Depth of respiration: normal.
❖ Inspection : Normal chest symmetry.
❖ Palpation : liver was palpable.
❖ Auscultation: breath sounds: normal.
❖ Percussion: resonance sound heard over the lungs.

b. Cardiovascular system. ❖ S1 S2 sound heard. No murmur heard.

❖ Pulse :80/min
 ❖ BP :120/80mmHg
❖ No cyanosis or clubbing.
❖ Capillary refill normal.

c. Abdomen. ❖ Inspection: No distension, lesion or hernia.

❖ Palpation : No liver or spleen enlargement present.
❖ Auscultation: Bowel sounds heard and is normal.
❖ Percussion: No fluid or gas accumulation felt.

d. Muscular skeletal system. ❖ Normal range of motion present.

e. Skin. ❖ White patches present all over the chest.

f. Nervous system. ❖ Patient is oriented to time, place and person

❖ He is conscious and co- operative.
❖ Speech normal.
❖ All nerve functions are normal.

g. Motor control ❖ Gait: normal

❖ Hand tremors not present
h. Genito- urinary system ❖ No Dysuria or Hematuria present.
❖ Urine out is normal.
 DESCRIPTION OF THE CASE

PARANOID SCHIZOPHRENIA

Paranoid schizophrenia is characterized mainly by delusions of persecution, feelings of passive or active control, feelings
of intrusion, and often by megalomanic tendencies also. The delusions are not usually systemized too much, without tight
logical connections and are often combined with hallucinations of different senses, mostly with hearing voices.
Disturbances of affect, volition and speech, and catatonic symptoms, are either absent or relatively inconspicuous.

CLASSIFICATION OF PARANOID SCHIZOPHRENIA

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

F20.8 Other schizophrenia

F20.9 Schizophrenia, unspecified

 Etiology:

Book Picture Patient Picture

1)Neurotransmitter and Structural Hypothesis: Family problems.

Glutamate and dopamine has attained a key theoretical role in the hypothesized Lack of adequate support system.
pathophysiology of schizophrenia, of positive symptoms of psychosis in general

2) Genetic Considerations:
Those with a family history may have a higher risk. 
Medical: These may include poor nutrition before birth and some viruses.  Not present
 CLINICAL MANIFESTATION

BOOK PICTURE PATIENT PICTURE

Alogia -
Affective flatteing -
Apathy ✓
Anhedonia ✓
Attention impairment -
Delusions ✓
Hallucinations ✓
 PSYCHOPATHOLOGY

Precipitating Event
(any event sufficiently stressful to threaten
an already weak ego)

Predisposing Factors
Genetic Influences
Family history of schizophrenia
Possible biochemical alterations
Possible birth defect

Past Experiences: Prenatal exposure to viral infections

Existing Conditions: abnormal brain structure

Physical condition , such as
epilepsy , huntingtons disease ,
brain tumor , parkinsonism,

Cognitive Appraisal

Primary
(perceived threat to self concept or physical integrity )

Secondary
 Because of weak ego strength, patient is unable to use coping mechanism effectively.
Defence mechanisms utilized: denial, regression, projection, identification , religios

Quality of response

Adaptive Maladaptive

initial or exacerbation of schizophrenia symptoms

Hallucinations inappropriate affect

Delusions bizzare behavior
Social isolation apathy
Violence autism
DIAGNOSTIC EVALUATION

BOOK PICTURE PATIENT PICTURE

• History taking ✓

• Mental Status Examination ✓

• Mini Mental Status Examination ✓

MANAGEMENT
TREATMENT MODALITIES:- The specific goals of treatment are to decrease the frequency, severity & psychosocial
consequences of episodes & to improve psychosocial functioning between episodes.

A. Psychiatric Management:-
The general goals of management are to assess & treat acute exacerbation prevent recurrence improve inter episode functioning &
provide assistance, insight & support to patient & family.
The specific goals of psychiatric management include establishing & maintaining a therapeutic alliances, monitoring the patient’s
psychiatric status, providing education regarding their illness, prognosis & treatment, enhancing treatment compliance.
Pharmacological Treatment:-
BOOK PICTURE PATIENT PICTURE
✓ DRUGS: olanzapine, Chlorpromazine , Clozapine ✓ Benztropine, olanzapine,
Benztropine

NON-PHARMOCOTHERAPY-

ECT- ECT is useful for treating schizophrenia

B. PSYCHOTHERAPIES
BOOK PICTURE PATIENT PICTURE

• Interpersonal psychotherapy :- Interpersonal

therapy,developed by Gerald Klerman, focuses on one
or two of a patient's current interpersonal problems.
This therapy is based on two assumptions. First, current
interpersonal problems are likely to have their roots in
early dysfunctional relationships. Second, current
interpersonal problems are likely to be involved in ✓
precipitating or perpetuating the current depressive
symptoms. Controlled trials have indicated that
interpersonal therapy is effective in the treatment of
major depressive disorder and, not surprisingly, may be
specifically helpful in addressing interpersonal
problems. Some studies indicate that interpersonal
therapy may be the most effective method for severe
major depressive episodes when the treatment choice is
psychotherapy alone.
• Behavior therapy :- Behavior therapy is based on the
hypothesis that maladaptive behavioral patterns result in
a person's receiving little positive feedback and perhaps Not given
outright rejection from society. By addressing
maladaptive behaviors in therapy, patients learn to
function in the world in such a way that they receive
positive reinforcement. Behavior therapy for major
depressive disorder has not yet been the subject of many
controlled studies. The limited data indicate that it is an
effective treatment for major depressive disorder.
• Family therapy and marital therapy :- The ultimate
objectives in working with families of clients with mood
disorders are to resolve the symptoms and initiate or
restore adaptive family functioning. As with group ✓
therapy, the most effective approach appears to be with
a combination of psychotherapeutic and pharmaco
therapeutic treatments. Some studies with bipolar
disorder have shown that behavioral family treatment
combined with medication substantially reduces relapse
rate compared with medication therapy alone.
• Group therapy :- Once an acute phase of the illness is
passed, groups can provide an atmosphere in which
individuals may discuss issues in their lives that cause,
maintain, or arise out of having a serious affective
disorder. The element of peer support may provide a ✓
feeling of security as
troublesome or embarrassing issues are discussed and
resolved. Some groups have other specific purposes,
such as helping to monitor medication-related issues or
serving as an avenue for promoting education related to
 the affective disorder and its treatment.
• Cognitive behavior therapy :- In cognitive therapy,
the individual is taught to control thought distortions
that are considered to be a factor in the development Not given
and maintenance of mood disorders. In the cognitive
model, depression is characterized by a triad of
negative distortions related to
expectations of the environment, self, and future. The
environment and activities within it are viewed as
unsatisfying, the self is unrealistically devalued, and
the future is perceived as hopeless
• Supportive psychotherapy Not given
• Psychodynamic psychotherapy Not given

NURSING MANAGEMENT

Assessment

Assess the biological history, current symptoms and family history

Assess the person’s current mood and thought content

Assess the person nutritional status

Assess the person hygiene level

NURSING DIAGNOSIS

1. Risk for violence directed to self and others related to impaired cognitive process as evidenced by v e r b a l i z a t i o n b y

family members

2. Altered sleep and rest, related to assaultive behavior evidenced by difficulty in falling asleep.

3. Altered communication process related to less interest in talking with others as well as assaultive behavior.

4. Imbalanced nutrition Less than body requirements related to lack of appetite and excessive physical agitation, evidenced by

loss of weight.

5. Ineffective individual coping related to anxiety as evidenced by ritualistic behavior or obsessive thoughts.

6. Knowledge deficit of family members regarding the disease condition, its prognosis and management as evidenced by family

members asking doubts regarding the disease condition.

ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective Risk for Short-Term -Assess the client’s risk -Assessed the client’s -For preventing the Client remained
data: violence Goal: for harming others. level of anger and the client and the other free from the risk
Clients says that directed to self Agitation and reason for anger which is family members for violence
she use to feel and others hyperactivity at risk for harming others. from getting injury. directed to others.
anger and gets related to will be Her irritability and
irritated easily impaired maintained at anger outburst is
and is having cognitive manageable -Closely monitored the reduced to some
assaultive process as level with the - To Closely monitor client for any violent -Risk for hurting extent.
behavior evidenced by administration the client’s behavior. behaviors like hurting family is being
towards others. physical abuse of others and the using reduced by
on his family. tranquilizing abusive language. monitoring client.
medication.
Objective data: -Ensured that all sharp
Her father said Long-Term -To ensure that all objects, glass or mirrored -Preventing the
that gets she Goal: sharp objects, glass or items, belts, ties, client injury which
gets irritable Client will mirrored Items, belts, smoking materials have can also leads to
without any not harm self ties, have been been removed from sucide.
reason. or others removed from client client’s environment.
during environment.
hospitalization -Involved client in
-To redirect violent exercise and other -It will help in
behavior with physical activities like yoga. diverting the mind
outlets. and help the client
for relaxation.
-Administered Inj.
-To offer transquilizing Haloperidol 10mg -Transqulizer will
medication as per whenever the patient got help the client for
treating physician’s agitated as prescribed by controlling his
prescription. physician. aggressive behaviour
when client got
agitated
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective Altered sleep Short -Assess the level of -The level of altered -It is done for The thought
data: and rest, term altered sleeping pattern sleeping pattern of the improving the process of the
Patient says, related to goal: To of the client. client is assessed. why sleeping pattern of the patient is
“He is feeling assaultive provide patient is not able to sleep client. improved to some
restlessness.’ behavior adequate properly. extent as evidence
evidenced by resting by that the patient
Objective data: difficulty in hours to -Planning daytime -A time schedule is -It is done for is start
His father said falling asleep. the activities according to prepared for the patient. engaging the client in communicated and
that he didn’t . patient. the patient’s interests. And in that schedule, daily activities and discussing their
sleeped some activities are given diverting the mind as problem.
properly at last Long to the patient according to client gets frustrated
night and client term his intrest like- drawing, and shows anger.
looks dull. goal: -Ensure a quiet and playing games.
Get peaceful environment -Provided him quiet and -To help the client to
adequate when the patient is peaceful environment have adequate resting
sleep at preparing for sleep. when he want to sleep by time and sleeping
night removing all the hours when needed.
disturbing thing away
from client like mobile
-Do not allow the patient phone. -It will help the client
to sleep for long time -Avoided her excessive to engaged in some
during the day. day time sleep by task which is
engaging the client in provided to client
doing some task like which will avoid the
drawing and playing clients day time sleep.
ludoo
-Teach the family to give -For inducing the
some hot drink to client. -Mother is taught to give sleep of the client.
hot drink to child like
milk for drinking. Which
can induce sleep.
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Altered Short term -Planning of a non- -An active friendly -For making the The
DATA:- communication goal:- To help threatening approach is used while client comfort and communication
Patient relatives process related the client to environment. talk with patient. preventing the client process of the
say that “the to less interest interact with to get non patient is
patient not in talking with family and threatening improved to some
responding others as well others -Provide an -Listened the patient environment. extent as evidence
while they are as assaultive opportunity to actively by responding by that patient
interacting with behavior verbalize his feelings. such as by nodding and -As it will help the was start talking a
her.” Long term by using such words as patient to share his little with their
goal:- To help “yes, ok, continue”. feelings what he relatives
OBJECTIVE the patient to want to express.
DATA:- improve the -Plan certain teaching - Brief explanation is
It is observed communication and communication given while doing - This will taught
while process of the skills. conversation with the him to understand
communicating patient. patient regarding his the difference what
with the patient condition. he is saying and
-Encourage the patient feeling.
to develop relationship
with peoples with -Encouraged her to
whom a positive talking with their -Helped her to
conversation takes relatives in an effective know that
place avoid letting him manner. And by this non- expression of his
talk to elated patient verbal gestures of the anger did not harm
may feel more patient are also observed. anyone.
discouraged.
ASSESSMENT NURSING GOAL PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
Subjective Imbalanced Short-Term -Consult dietitian to -Diet chart of the patient -For helping the The client
data:- patient nutrition Less Goal: Client determine appropriate was prepared by the client to restore nutrition level is
family member than body will consume diet for Client to nurse to improve the nutrition and gain being maintained
verbalize that requirements sufficient restore nutrition and nutrition level and weight. to some extent
patient is not related to lack foods and meal gain weight. maintain the weight of and the clients
taking food at of appetite and snacks to meet the client. weight is gained
proper time and excessive recommended -It will help the i.e. 75 previously
adequately. physical daily -Ensure that her diet -Diet chart was prepared client to take food in that was 80.
agitation, allowances of includes foods that particularly according to time with interest.
evidenced by nutrients. he particularly likes. patient likes and dislikes.
Objective loss of weight.
data:- I Long-Term
observed this by Goal: -Maintain an accurate -Recording and reporting -It is maintained to
doing physical Client will record of intake, of the client intake, check the client
examination. begin to regain output, and calorie output, and about calorie input and output and
weight count. Obtain daily count is recorded timely. to obtain calorie
and exhibit no weights. level and revised the
signs or diet plan for the
symptoms of -Medicine like vitamin A client.
malnutrition. -Administer vitamin supplement is given to
supplement, as the client to maintain -It will help the
ordered by physician. vitamin level and during clients vitamin level.
Sit with Client during meal time check the
mealtime client have taken the
proper food and
medicine.
PSYCHOEDUCATION:-
• Educate the family about the impact of Paranoid schizophrenia on the individual’s life & functional ability.

• Tell the client & family to report any worsening signs of Paranoid schizophrenia .

• Review common, uncommon & potentially dangerous side effects of medication; explain when the client should call the
prescriber about side effect.

• Inform the client that several strategies exist to manage uncomfortable side effects including reduced dosages, additional
medication, or switching to another medication.

• Tell client about the need to continue medication & discuss with their prescriber any desire to stop it.

• Help the client & family identify community resources such as suicide hotlines.
 METHOD OF APPROACH
Individual approach with active involvement of the family members and capacities to deal with the health problem and health
needs.
Frequency of visit- 3

FIRST VISIT(1st day)

OBJECTIVE:-

➢ To introduce myself to the family and the client.

➢ To establish good interpersonal relationship with the family members to get their co-operation & support.
➢ To take the history of the family.
➢ To identify the needs and problem
➢ To check the vital signs of the individual.

RECORD OF VISIT:-

Checked vital signs:

TIME TEMPERATURE RESPIRATION PULSE B.P

10:00am 980 F 22breaths/min 80 beats/min 120/80 mm hg
 SECOND VISIT(2nd day)

OBJECTIVE:-

➢ To develop the IPR with the family member and the patient
➢ To check the vital signs of the client
➢ To do physical examination of the client and mental status examination of the client.
➢ To provide the psycho education to the family member regarding BPAD.

RECORD OF VISIT:-

• Developed the IPR with the family member.

• General condition of client is good.
• To give the psycho education to the family member regarding care of the client.

PSYCHO EDUCATION:

• Advice on personal hygiene, including detailed instruction on fluid balance and on diet.
• To improve their knowledge, skills and confidence, enabling them to take increasing control of their own condition and
integrate effective self management into their daily living.
• Improves levels of physical activity
• Told the client to do exercise.
• To take their medication on time.
THIRD VISIT:-
OBJECTIVE:-
➢ Maintain the IPR with the patient
➢ To give the psycho education to the patient
➢ Tell about the follow to the client after discharge is planned

RECORD OF VISIT:-

The patient was cooperative

ADVICES:-
➢ Provide Privacy to the patient can share their feeling with one another.
➢ Implant the measures to facilitate patient adjustment to diseases and its effect .
➢ Improves the pattern of communication within the family
➢ Assist the family member to participate in client care.
➢ Assist the family member to identify goals and way to reach these goals.
➢ Give the explanation of the disease and condition of the client
➢ Encourage the client to pay attention for client diet
➢ Educate the family member to do physical activity.

RESPONSE AND VIEWS OF THE FAMILY:-

Family member responds to the advice and also showed the interest by asking the question.
PATIENT’S EVALUATION

Patient Ms. Priyanka Singh diagnosis with Paranoid Schzophrenia which was assigned to me. She is having various problem like
decreased sleep, loss appetite, excessive anger, and use of abusive language. I perform history taking, mental status examination, physical
examination to client. I provided nursing intervention to client. Now the client’s condition is improved to some extent and is having
controlled behavior with his family.

CONCLUSION

Myself Sadia saleem student of M.Sc Nursing 1st year. I am posted in psychiatry ward in Mindplus hospital Doraha . My patient Ms.
Priyanka singh diagnosis with Paranoid Schizophrenia which was assigned to me. I learned various thing about Paranoid Schizophrenia
and its management and how to deal with Psychiatric patient. I perform history taking, mental status examination, physical examination
to client and learnt about patient and psychotherapies like individual therapy, behavior therapy etc. It was a great learning experience
for me and I will apply this knowledge in my future.
REFERENCES
BOOKS:-

❖ Townsend, Townsend M, Davis FA. Package of psychiatric mental health nursing 6th & nursing diagnoses in psychiatric nursing 7th. F.
A. Davis Company; 2008.

❖ Sreevani R. Applied psychology for nurses. 4th ed. New Delhi, India: Jaypee Brothers Medical; 2021.

❖ Fountoulakis KN. Psychiatry: From its historical and philosophical roots to the modern face. 1st ed. Cham, Switzerland:
Springer Nature; 2022.