CASE STUDY ON SCHIZOPHRENIA DISORDER
Coverage Date: April 2, 2022
Instructions:
● This case study is equivalent to one whole day of Related Learning Exposure.
● Read the case provided below thoroughly and answer all questions and activities below.
● Use a short bond paper when answering the activities in this case study.
● Upload the activities to your Group Google Drive at the prescribed time by your Clinical
Instructor
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 aggressive
behaviour 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 complaint of
academic decline and experienced to have auditory hallucination for over a year.
His educational history revealed that he had declined in his academic performance with
handwriting deterioration, and irritable, sad behaviour was noted. He engaged in fights at school and
oftentimes his teacher would suggest individual meetings to her mother with undesirable behaviour was
noted. He also preferred solitary activities and resented eating with the rest of the family.
He was on sodium valproate up to 400 mg./day for nearly 2 months which declined in his irritability and
aggression.
After a year, he manifested worsened 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 behaviour worsened and he sought for his mother for further
consultations, And now he was diagnosed with Schizophrenia and treated with Risperidone 3mg. and
Carbamazipine 300 mg./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 behaviour 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
List down significant mental health assessment findings and provide brief discussion of each finding.
You may add more spaces if you believe there are more assessment findings in the case.
ASSESSMENT FINDINGS
DISCUSSION
Child Abuse
Research does support the idea that social stress and
family stress may play a role in development of
schizophrenia – especially for people who are
biologically or genetically predisposed to developing
schizophrenia. Therefore it is reasonable to suspect
that child abuse could significantly increase the risk of
schizophrenia (and certainly child abuse – including
neglect and physical abuse – is very harmful and has a
lasting impact on a child).
Source: http://crimepsychblog.com/?p=1060
Auditory Hallucinations
Auditory hallucinations, or hearing voices, is a common
symptom in people living with schizophrenia. In fact,
an estimated 70% to 80% of people with schizophrenia
hear voices. These voices can call your name, argue
with you, threaten you, come from inside your head or
from outside sources, and can begin suddenly as well
as grow stronger over time.
Source: https://tinyurl.com/mnyn4nna
Handwriting deterioration
Schizophrenia, tremors, depression, autism and
Asperger’s syndrome all end in a gradual deterioration
Patient preferred solitary activities; poor
socialization and lack of motivation to
participate in activities
Poor compliance to medication treatment
in handwriting. Experts hold that thorough and
intelligent investigation of handwriting can locate
damages in neuromuscular coordination. Handwriting
is an instruction from the brain as electric impulses
transmitted through our nerves to fingers which
actually deliver the writings. Any obstacle to the path
or any impairment to the source (brain) would sure to
show up in the quality of writing delivered.
Source: https://tinyurl.com/bdzcmey5
Asociality refers to lack of motivation to partake in
social interactions accompanied by the preference for
solitary activities. This is common among introverts
and people with schizoid personality disorder. In
schizophrenia, this symptom can make the person
want to avoid socialization.
Source:
https://mentalhealthdaily.com/2014/04/01/ne
gative-symptoms-of-schizophrenia/
Non-compliance to medication in schizophrenia is a
common problem. It leads to frequent recurrence of
psychosis which has a negative impact on individuals
and their families. Understanding and reducing nonadherence is therefore a key challenge to quality care
for patients with schizophrenia.
Source: https://tinyurl.com/nju79c68
C. PSYCHOSOCIAL THEORY
Discuss the particular psychosocial stage where the client is in. Highlight either the positive resolution
or negative resolution findings provided in the case and expected in the client.
Psychosocial Stage:
Age Range: 12-18 yrs. old
Identity vs. Role Confusion (Fidelity)
Discussion:
In adolescence (ages 12–18), children face the task of identity vs. role confusion. According to
Erikson, an adolescent’s main task is developing a sense of self. Adolescents struggle with questions
such as “Who am I?” and “What do I want to do with my life?” Along the way, most adolescents try
on many different selves to see which ones fit; they explore various roles and ideas, set goals, and
attempt to discover their adult selves. Adolescents who are successful at this stage have a strong
sense of identity and are able to remain true to their beliefs and values in the face of problems and
other people’s perspectives. When adolescents are apathetic, do not make a conscious search for
identity, or are pressured to conform to their parents’ ideas for the future, they may develop a weak
sense of self and experience role confusion. They will be unsure of their identity and confused about
the future. Teenagers who struggle to adopt a positive role will likely struggle to find themselves as
adults.
Source: https://courses.lumenlearning.com/wm-lifespandevelopment/chapter/erikson-andpsychosocial-theory/
D. DIAGNOSIS
Discuss the pathophysiology/progression of the diagnosis of the specified case
Diagnosis: Schizophrenia
The underlying pathophysiology of schizophrenia involves dysregulation of different pathways in the
brain function. The pathway involves abnormalities in neurotransmission with either excess or
deficiency in neurotransmissions (Uher et al., 2019). There are three main theories that explain the
pathophysiology including dopamine, serotonin, and glutamate. Positron Emission Tomography (PET)
studies show evidence of dopaminergic hyperactivity in nucleus accumben and in the dopaminergic
hypofunction in frontal temporal regions.
In the dopamine theory, the main culprit is dopamine, although other neurotransmitters like
glutamate, aspartate, glycine, and GABA (gamma aminobutyric acid) are also implicated (Uher et al.,
2019; van Santvoort et al., 2015). As in many other brain disorders, schizophrenia is associated with
abnormal activities at the dopamine receptor site, mainly D2 (Sandstrom et al., 2020). Evidence
shows increased density of D2 receptors in nucleus accumbens which leads to positive symptoms.
Evidence also shows decreased densities of D1 receptors in the prefrontal cortex which leads to
negative activities . Four major pathways that are involved include dopaminergic pathways,
mesolimbic pathway, mesocortical pathway, and the tuberoinfundibular pathway.
The serotonin theory is based on the activities of lysergic acid diethylamide (LSD) that enhances the
effect of serotonin on the brain hence the effect is on serotonin receptors (Sandstrom et al., 2020).
The glutamate theory is based on excitatory neurotransmitters through the action of phencyclidine
and ketamine, both glutamate antagonists (Sandstrom et al., 2020).
Diagnosis
DSM Criteria for Schizophrenia
DSM outlines the following Criteria:
1. Two or more of the following conditions for at least a month:
● Delusions
● Hallucinations
● Disorganized speech
● Grossly disorganized or catatonic behavior
● Negative symptoms, such as diminished emotional expression
Source: Onuchukwu, Chimezie, "Pathophysiology of Schizophrenia" (2020). Nursing Student Class
Projects (Formerly MSN). 427. https://digitalcommons.otterbein.edu/stu_msn/427
E. MEDICATION REVIEW (DRUG STUDY)
Create a Medication Review for all medications provided in the case. Use the format provided below:
Medication
Generic
Name: sodium
valproate
Brand Name:
Depakote
Dosage
Dosage is expressed
as valproic acid
equivalents. Initial
dose is 10–
15 mg/kg/day PO,
increasing at 1-wk
intervals by 5–
10 mg/kg/day until
seizures are
controlled or side
effects preclude
further increases.
Maximum
recommended
dosage is
60 mg/kg/day PO. If
total dose >
250 mg/day, give in
divided doses.
 Migraine: 250 mg
PO bid; up to
1,000 mg/day has
been used
(Divalproex
DR tablets);
500 mg ER tablet
once a day.
 Bipolar
mania: 750 mg
Indication
 Sole and
adjunctive
therapy in simple
(petit mal) and
complex absence
seizures
 Depakote
ER: Treatment of
epilepsy in
children > 10 yr
 Adjunctive
therapy with
multiple seizure
types, including
absence seizures
 Divalproex
DR: Treatment of
bipolar mania
 Divalproex DR
and ER
tablets: Prophylax
is of migraine
headaches
 Divalproex, sodiu
m valproate
injection:
Treatment of
complex partial
seizures as
monotherapy or
with other
antiepileptics
 Unlabeled uses:
Adjunct in
symptom
management of
schizophrenia,
Mechanism of
Action
Mechanism of action
not understood:
antiepileptic activity
may be related to
the metabolism of
the inhibitory
neurotransmitter,
gammaaminobutyric acid
(GABA); divalproex s
odium is a compound
containing equal
proportions
of valproic acid and
sodium valproate.
Contraindication
Adverse Effects
 Contraindicated
with
hypersensitivity
to valproic acid,
hepatic disease or
significant hepatic
dysfunction.
 Use cautiously
with children < 18
mo; children < 2
yr, especially with
multiple
antiepileptics,
congenital
metabolic
disorders, severe
seizures
accompanied by
severe mental
retardation,
organic brain
disorders (higher
risk of developing
fatal hepatotoxicit
y); pregnancy
(fetal neural tube
defects; do not
discontinue to
prevent major
seizures;
discontinuing such
medication is
likely to
precipitate
status epilepticus,
hypoxia and risk
to both mother
 CNS: Sedation, tr
emor (may be
dose-related),
emotional upset,
depression,
psychosis,
aggression,
hyperactivity,
behavioral
deterioration,
weakness
 Dermatologic: Tr
ansient increases
in hair loss,
rash, petechiae
 GI: Nausea,
vomiting,
indigestion, diarrh
ea, abdominal
cramps,
constipation,
anorexia with
weight loss,
increased appetite
with weight
gain, lifethreatening pancr
eatitis, hepatic
failure
 GU: Irregular
menses,
secondary
amenorrhea
 Hematologic: Sli
ght elevations in
AST, ALT, LDH;
increases in
Nursing
Responsibilities
 Give drug with
food if GI upset
occurs;
substitution of the
enteric-coated
formulation also
may be of benefit;
have patient
swallow SR tablet
whole; do not cut,
crush, or chew.
 Monitor ammonia
levels, and
discontinue if
there is clinically
significant
elevation in level.
 Monitor serum
levels
of valproic acid
and other
antiepileptic drugs
given
concomitantly,
especially during
the first few
weeks of therapy.
Adjust dosage on
the basis of these
data and clinical
response.
 Discontinue drug
at any sign
of pancreatitis.
 Evaluate for
therapeutic serum
PO daily in divided
doses; do not
exceed
60 mg/kg/day
(Divalproex
DR tablets only).
treatment of
aggressive
outbursts in
children with
attention-deficit
hyperactivity
disorder, organic
brain syndrome
and fetus);
lactation.
serum bilirubin,
abnormal changes
in other liver
function tests,
altered bleeding
time;
thrombocytopenia
;
bruising; hemato
ma formation;
frank
hemorrhage;
relative lymphocyt
osis; hypofibrinog
enemia; leukopeni
a, eosinophilia,
anemia, bone
marrow
suppression
Source:
http://download.lww.com/downloads/thePoint/9780781760331_Videbeck/Drug_Monograph/mg/valproic_acid.htm
levels—usually
50–100 mcg/mL.
Medication
Generic
Name:
carbamazepine
Brand Name:
Tegretol
Dosage
Adults and children
over 12 years of age
- Initial: Either 200
mg b.i.d. for tablets
and XR tablets, or 1
teaspoon q.i.d. for
suspension (400
mg/day). Increase at
weekly intervals by
adding up to 200
mg/day using a
b.i.d. regimen of
Tegretol-XR or a
t.i.d. or q.i.d.
regimen of the other
formulations until
the optimal response
is obtained. Dosage
generally should not
exceed 1000 mg
daily in children 1215 years of age, and
1200 mg daily in
patients above 15
years of age. Doses
up to 1600 mg daily
have been used in
adults in rare
instances.
Maintenance: Adjust
dosage to the
minimum effective
Indication
 Tegretol is
indicated for use
as an
anticonvulsant
drug.
 Tegretol is
indicated in the
treatment of the
pain associated
with true
trigeminal
neuralgia.
 This drug is not a
simple analgesic
and should not be
used for the relief
of trivial aches or
pains.
 Beneficial results
have also been
reported in
glossopharyngeal
neuralgia.
Mechanism of
Action
Tegretol has
demonstrated
anticonvulsant
properties in rats
and mice with
electrically and
chemically induced
seizures. It appears
to act by reducing
polysynaptic
responses and
blocking the posttetanic potentiation.
Tegretol greatly
reduces or abolishes
pain induced by
stimulation of the
infraorbital nerve in
cats and rats. It
depresses thalamic
potential and bulbar
and polysynaptic
reflexes, including
the linguomandibular
reflex in cats.
Tegretol is
chemically unrelated
to other
anticonvulsants or
other drugs used to
control the pain of
trigeminal neuralgia.
The mechanism of
action remains
unknown. The
principal metabolite
of Tegretol,
carbamazepine10,11-epoxide, has
anticonvulsant
Contraindication
Adverse Effects
 Tegretol should
not be used in
patients with a
history of
previous bone
marrow
depression,
hypersensitivity to
the drug, or
known sensitivity
to any of the
tricyclic
compounds, such
as amitriptyline,
desipramine,
imipramine,
protriptyline,
nortriptyline, etc.
 Before
administration of
Tegretol, MAO
inhibitors should
be discontinued
for a minimum of
14 days, or longer
if the clinical
situation permits.
 Coadministration
of carbamazepine
and nefazodone
may result in
insufficient
plasma
concentrations of
nefazodone and
its active
metabolite to
achieve a
therapeutic effect.
Coadministration
 Hemopoietic
System: Aplastic
anemia,
agranulocytosis,
pancytopenia,
bone marrow
depression,
thrombocytopenia
, leukopenia,
leukocytosis,
eosinophilia,
acute intermittent
porphyria.
 Skin: Toxic
epidermal
necrolysis (TEN)
and StevensJohnson
syndrome (SJS)
(see BOXED
WARNING),
pruritic and
erythematous
rashes, urticaria,
photosensitivity
reactions,
alterations in skin
pigmentation,
exfoliative
dermatitis,
erythema
multiforme and
nodosum,
purpura,
aggravation of
disseminated
lupus
erythematosus,
alopecia, and
diaphoresis. In





Nursing
Responsibilities
Observe for
confusion and
agitation in older
people.
Observe for
changes in mental
state.
Observe for
allergic reactions
such as rashes,
purpura.
Leucopenia which
is severe,
progressive or
associated with
clinical symptoms
requires
withdrawal.
When the patient
is in a more
upright position,
check his or her
blood pressure
(lying to standing,
sitting to
standing, lying to
sitting). When
systolic BP goes
below 20 mm Hg
or diastolic BP
falls below 10 mm
Hg, document
orthostatic
hypotension and
notify your doctor.
level, usually 8001200 mg daily.
activity as
demonstrated in
several in vivo
animal models of
seizures. Though
clinical activity for
the epoxide has been
postulated, the
significance of its
activity with respect
to the safety and
efficacy of Tegretol
has not been
established.
of carbamazepine
with nefazodone
is contraindicated.
certain cases,
discontinuation of
therapy may be
necessary.
Isolated cases of
hirsutism have
been reported,
but a causal
relationship is not
clear.
 Cardiovascular
System:
Congestive heart
failure, edema,
aggravation of
hypertension,
hypotension,
syncope and
collapse,
aggravation of
coronary artery
disease,
arrhythmias and
AV block,
thrombophlebitis,
thromboembolism
, and adenopathy
or
lymphadenopathy.
 Liver:
Abnormalities in
liver function
tests, cholestatic
and hepatocellular
jaundice,
hepatitis; very
rare cases of
hepatic failure
 Respiratory
System:
Pulmonary
hypersensitivity
characterized by
fever, dyspnea,
pneumonitis, or
pneumonia.
 Genitourinary
System: Urinary
frequency, acute
urinary retention,
oliguria with
elevated blood
pressure,
azotemia, renal
failure, and
impotence.
Albuminuria,
glycosuria,
elevated BUN, and
microscopic
deposits in the
urine have also
been reported.
Sources:
https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/016608s101,018281s048lbl.pdf
F. PROBLEM LIST
Based on the case provided above, cite the top 3 Nursing Diagnosis of the identified client. Provide
your rationale/discussion on your choice and discuss briefly about the Nursing Diagnosis.
Problem
1. Disturbed Sensory Perception:
Auditory/Visual related to psychologic
stress as evidenced by mumbling, talking
or laughing to self
2. Interrupted Family Process related to
situational crisis or transition as
evidenced by inability to meet the needs
of family and significant others
3. Impaired social interaction related to
impaired thought processes (delusions or
hallucinations) as evidenced by spending
time alone
Rationale
Changes in the amount or patterns of incoming
stimuli
accompanied
with
a
reduced,
exaggerated, distorted, or impaired reaction to
those stimuli are referred to as disturbed sensory
perception.
A situational crisis occurs when an unforeseen
occurrence occurs that is out of the individual's
control. Natural disasters, job loss, assault, and
the unexpected death of a loved one are all
examples of situational crises. When a person is
unable to cope with the natural process of
development, a maturational crisis occurs.
A
distressing
experience
can bring
on
hallucinations. If you put a healthy person with
no history of mental illness under a lot of stress,
their cortisol (stress hormone) levels will
skyrocket, impacting their capacity to mentally
interpret information. Basically, you're not
reading what's going on correctly and are simply
reacting to your trauma with projections of
yourself in the form of forms, sights, or sounds.
F. NURSING CARE PLAN
Formulate an NCP for each of the 3 Nursing Diagnosis in your Problem List which applicable for the client using the format below:
Defining
Characteristics
Subjective
Data:
Objective Data:
Nursing Diagnosis
Scientific Analysis
Goals of Care
Impaired social
interaction related to
impaired thought
processes (delusions
or hallucinations) as
evidence by spends
time alone by self.
Hallucinations can be
triggered by a
traumatic event. If
you take a healthy
person with no
history of mental
health disorders and
put them under
great stress, their
cortisol levels (the
stress hormone)
would be
astronomical,
affecting their ability
to psychologically
interpret stimuli.
Basically, you’re not
reading what’s
actually happening
correctly and are just
reacting to your
trauma with forms,
visions, or sounds
that are a projection
of yourself.
Short-term Goal:
 Patient will attend
one structured
group activity
within 5-7 days.
Nursing
Intervention
 Assess if the
medication has
reached
therapeutic levels.
Long-term goal:
 After a month
Patient will
improve social
interaction with
family, friends,
and neighbors.
 Identify with client
symptoms he
experiences when
he or she begins
to feel anxious
around others.
 Keep client in an
environment as
free of stimuli
(loud noises,
crowding) as
possible.
 Avoid touching
the client.
Rationale
 Many of the
positive
symptoms of
schizophrenia
(hallucinations,
delusions, racing
thoughts) will
subside with
medications,
which will
facilitate
interactions.
 Increased anxiety
can intensify
agitation,
aggressiveness,
and
suspiciousness.
 Client might
respond to noises
and crowding with
agitation, anxiety,
and increased
inability to
concentrate on
outside events.
 Touch by an
unknown person
can be
misinterpreted as
a sexual or
threatening
gesture. This
particularly true
for a paranoid
client.
Collaborative
 Contact a
psychiatrist to
arrange for crisis
counselling.
Activate links to
self-help groups.
 Coordinate with
co-psychiatric
nurse for group
activity.
Collaborative
 Client needs
supervision and
counselling
especially at
his/her depression
attacks.
 They need
socialization
activity so that
they can engage
and build
connection and
trust.
Source: https://nurseslabs.com/schizophrenia-nursing-care-plans/2/
Defining
Characteristics
Subjective
Data:
Objective Data:
Nursing Diagnosis
Scientific Analysis
Goals of Care
Disturbed Sensory
Perception:
Auditory/Visual
related to
Psychologic stress as
evidence by
Mumbling to self,
talking or laughing to
self
Disturbed Sensory
Perception: Change
in the amount or
patterning of
incoming stimuli
accompanied by a
diminished,
exaggerated,
distorted or impaired
response to such
stimuli.
Short-term goal:
 In 7 days the
patient will have a
social activities.
(Playing cards,
drawing, group
sharing)
Long-term goal:
 After a month,
patient will be
able to maintain
social relationship
and will
demonstrate
techniques that
help distract him
or her from the
voices.
Nursing
Intervention
 Accept the fact
that the voices
are real to the
client, but explain
that you do not
hear the voices.
Refer to the
voices as “your
voices” or “voices
that you hear”.
 Be alert for signs
of increasing fear,
anxiety or
agitation.
Rationale
 Validating that
your reality does
not include voices
can help client
cast “doubt” on
the validity of his
or her voices.
 Might herald
hallucinatory
activity, which can
be very
frightening to
client, and client
might act upon
command
hallucinations
(harm self or
others).
 Explore how the
hallucinations are
experienced by
the client.
 Help the client to
identify the needs
that might
underlie the
hallucination.
 Help client to
identify times that
the hallucinations
are most
prevalent and
frightening.
Collaborative
 Contact a
psychiatrist to
arrange for crisis
counselling.
 Exploring the
hallucinations and
sharing the
experience can
help give the
person a sense of
power that he or
she might be able
to manage the
hallucinatory
voices.
 Hallucinations
might reflect
needs for anger,
power, selfesteem, and
sexuality.
 Client need
supervision and
counselling
especially at
his/her depression
attacks.
Collaborative
 Client needs
supervision and
counselling
especially at
his/her depression
attacks.
Defining
Characteristics
Subjective
Data:
Objective Data:
Nursing Diagnosis
Scientific Analysis
Interrupted Family
Process related to
Situational crisis or
transition as
evidence by Inability
to meet the needs of
family and significant
others (physical,
emotional, spiritual)
Situational crises
involve an
unexpected event
that is usually
beyond the
individual's control.
Examples of
situational crises
include natural
disasters, loss of a
job, assault, and the
sudden death of a
loved one.
Maturational crises
occur when a person
is unable to cope
with the natural
process of
development.
Goals of Care
Short-term goal:
 In 7 days, the
family will be
provided
information on
disease and
treatment
strategies at the
family’s level of
understanding.
Long-term goal:
 Within a month,
the family will be
able to improve
and apply the
understanding of
treatment
strategies.
Nursing
Intervention
 Assess the family
members’ current
level of knowledge
about the disease
and medications
used to treat the
disease.
 Inform the client’s
family in clear,
simple terms
about
psychopharmacolo
gic therapy: dose,
duration,
indication, side
effects, and toxic
effects. Written
information
should be given to
the client and
family members
as well.
 Identify the
family’s ability to
cope (e.g.,
experience of
loss, caregiver
burden, needed
supports).
 Provide
information on
disease and
treatment
strategies at the
Rationale
 Family might have
misconceptions
and
misinformation
about
schizophrenia and
treatment, or no
knowledge at all.
Teach client’s and
family’s level of
understanding
and readiness to
learn.
 Understanding of
the disease and
the treatment of
the disease
encourages
greater family
support and client
adherence.
 Family’s need
must be
addressed to
stabilize the
family unit.
 Meet family
members’ needs
for information.
family’s level of
understanding
Collaborative
 Contact a
psychiatrist to
arrange for crisis
counselling.
Collaborative
 Client needs
supervision and
counselling for
family oriented.