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Mental Health Case Study

Kayle Augustine
October 8th 2017
Youngstown State University
Mr. Criscione

KT is a 23-year-old female that arrived on the mental unit some time

approximately before midnight on September 25th, 2017 due to severe episodes of

recurrent major depressive disorder but without psychotic features. Due to many life

stressors, that will be explained in this case study, KT stated she tried to take her life and

had suicidal thoughts. She did not ingest anything and was driven to Trumbull Memorial

hospital by her boyfriend. She was then transferred to St. Elizabeth Youngstown by the

hospital. The date of care of this case study was taken on the 28th of September 2017

where she was given a discharge time of noon that same day. In this case study, the

patients life stressors, DSM axes I to IV and behaviors during her stay will be discussed

along with plans of discharge and care for the patient after she is off the unit.

Objective Data
On September 25th 2017 KT, a 23 year old female from Warren, Ohio was taken

to Trumbull Memorial Hospital ER by her boyfriend where she was then transferred to

St. Elizabeth Youngtown Mental unit. Patient stated that she got there a little before

midnight that day and was scared and nervous for what it would be like on the unit, but

willing to participate in group activities and was actively trying to get better. Patient

explained that she was having suicidal thoughts and tried to take her life by ingesting the

rest of her anti-depressant pills (did not know approximately how many) but nothing was

ever ingested when her boyfriend found her crying in the kitchen. KT was very complaint

with nursing care and obtaining any information. When discussing information with her

on the 28th of September, KT had stayed approximately 3 days. KT also stated that her

doctor would discharge her that day and she would be able to leave by noon. Patient

stated that she feels much better than when she first came in and she had learned many

new coping skills from the staff and other patients on the unit. Overall, KT admitted that

she was glad that she had come. Her demeanor that day was calm and happy, she looked

nice and well-kempt. She was diagnosed with ‘severe episodes of recurrent major

depressive disorder, without psychotic features.

DSM Axes I-IV:

I: a major depressive episode

II: no personality or other mental disorder

III: no medical or neurological disorders


IV: bereavement overload (that started at 13 years old) with stroke of older

brother, death of friend and death of cousin; too many hours at work and

not enough time to do school work

Security and safety measures were obtained for the whole unit. The unit made

sure that the doors were locked, any objects that could be hazardous for these patients

have been assessed thoroughly along with watching them closely. Activities likes

drawing and reading were utilized by KT in order to keep herself busy and calm. The

patient’s PRN medication are many that are hospital protocol (ex. Haldol when agitated)

but no PRN medications were given during her stay in the unit. She received buspirone

(Buspar) 10mg tablet 3 times a day for anxiety and Paroxetine (Paxil) 20mg capsule

daily, an SSRI for depression, and will be going home on both of those medications after

discharge. KT has no other medical conditions stated by herself or in her chart.


Different than depression, Major Depressive disorder is a very common mood

disorder in many. Losing interested in activities that once gave pleasure, problems with

sleeping and a general negative outlook on life are the common manifestations of this

disorder due to a mix of stressors and imbalances in the brain (American Accreditation

HealthCare Commission, 2017). The American Accreditation HealthCare Commission

(also known as URAC) has a list of symptoms that may also affect the patient. The

patient may be feeling hopeless, helpless, guilty and over all self-hating. Theese moods

can also affect sleep and cause fatigue and loss of energy. It can also affect their appetitie

and cause weight gain/loss (URAC, 2017). These feelings can stay throughout a person’s

whole lifetime with high rates of reoccurring. Research suggests that patietns with

chronic MDD benefit best when on long-term treatment to maintain their depression

(Keller, 2013). The cause of depression and MDD is unknown but studies show that

synaptic and structural alteration in the brain may prevent the brain from adapting to

certain stimuli, causing a mood disorder than is very hard to change back without

medication help and compliance (Hindawi, 2013).


KT stated that she began feeling depressed when she was 13 years old when her life

stressors began all the way up to the present. KT believes that a lot of her anxiety and

nervousness comes from her past and current life stressors had made it hard to cope. At age 13,

her brother had a stroke at age 35 and had to move back in with her and her parents. KT’S

brother had no control over his right side, so he has been in a wheelchair for the rest of his life.

The family was very supportive, including the patient, to help him live his life but it also caused

some strain. KT explains that she would help her brother with fixing and working on his car ( an

activity he enjoyed doing) but there was a lot of strain and fighting when she would do

something wrong. She began cutting herself on her arm to relieve stress and pain she was having.

Three months later after the stroke accident, a family friend shot himself. KT stated that she had

no clue that he was suicidal with any plans of suicide and feels guilty for not noticing sooner. A

few months after this death, a friend of her brother moved in. He was like an older brother and

she opened up to him with a lot of her depression issues. Two weeks later after moving in,

they’re was a 4-wheeling accident and he broke his back instantly. Patient stated she was very

distraught because she felt a bad feeling about them going out 4-wheeling but didn’t say

anything. She also had the same feeling when she had 3 friends staying over at her house. KT

and another friend warned a mutual friend that she should not go out in the middle of the night

because KT had another bad feeling. KT’s friend went anyways and got into a car accident.

Patient stated she felt guilty and friend was angry that they let her go but later apologized for

blaming it on KT and her friends. This car accident happened approximately. 2 weeks before KT

was admitted into the hospital. KT admits that stress from working too many hours at work has

also caused issues. She has put school on hold for now while she works as a manager at a store

but she often works hours where she does not have any time to see her friends and socialize. The

patient believes that work, putting school on hold and the car accident has all contributed to the

change of KT’s mental state


Patient stated that there is no history or her parents, grandparents or siblings with

depression nor has she seen any signs or symptoms of the disorder in any of her relatives. Her

family and friends are very supportive of her history with depression and have reached out to

help her to be treated.


The unit at St. Elizabeth Youngstown utilizes the evidence based practices of staying on a

schedule day to day to ensure the patients have a steady and predictable routine. They have 2

group sessions that allow the patients to learn different coping mechanisms and talk about how

they are feeling. Each team member of the health care is utilized, the doctor and social worker

makes their rounds along with a nurse who plans the group sessions. Medications are given by

the LPN’s and they are to check up on the patients every 15 minutes. They allow an open room

for drawing, watching TV and socializing. There is a library for reading and each patient has a

room with a roommate so they do not have to be constantly around others. The unit’s floor is

mainly white and bright. If a patient is agitated to the point they need to be medicated, they have

protocols for medication that can be given PRN and an isolation area to prevent other patients

around them to get nervous or agitated to be affected.


When talking to the patient about god and religion, the patient stated that she has a much

more agnostic outlook on life. KT believes that there is a higher being of life but is unknown of

who is may exactly be. She gets much of her support from her friends and boyfriend. Patient

stated that she had a hard time talking to her parents about issues but they are more than willing

to support her after she is discharged.


The patient stated that she has learned new coping skills along with beneficial

relationships in and out of the unit. She met many people who have influenced her in a positive

way and here stay in the unit has strengthened her bond with her family and her boyfriend. Her

co-workers are also supportive and willing to work with her to lower her stress level. KT was

very nervous and scared when first admitted in the report but she is much more relaxed and

ready to use better coping mechanisms and use the support around her to stay positive.

Summary of discharge

Patient’s boyfriend had planned to come by and visit around noon, KT stated that her

doctor will discharge her and she wants to surprise her boyfriend when he gets there. While on

the unit, she talked to family members and parents and she and her boyfriend plan on moving in

with her parents. Over the course of the week she and her boyfriend are going to move out of the

house they rent with their roomates and move in with her parents and her brother. She plans on

seeing a therapist after discharge thought she did not specify who. The patient was suggested

Turning Point and she plans on looking into this organization after discharge.

List of Nursing Diagnoses

- Risk of Injury d/t depression EAB feelings of hopelessness, tempted suicide, history of

self-harm, feelings of sadness and loss of pleasure

- Caregiver role strain d/t stroke patient relative EAB history of strain between family


- Disturbed thought process d/t depression EAB anxiety, panic attacks and problems

sleeping and long days of work with little rest

- Impaired social interaction d/t depression EAB withdrawal from social activities, pt

states she never has time for friends or family while working

- Altered grieving process d/t bereavement overload EAB brother has stroke, death of 3

family/friend all within the same year, evidence of still grieving for lost ones that passed

away 10 years ago and patients states she is still grieving. feelings of guilt concerning

friend in recent car accident.



American Accreditation HealthCare Commission. (2017, June 28). Major depression.

Retrieved October 11, 2017, from

Hindawi. (2013, October 09). Neurobiology of Major Depressive Disorder. Retrieved

October 11, 2017, from

Keller, M. (2013, September 10). Clinical & Research. Retrieved October 11, 2017, from