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Running head: COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Valerie N Jeffery

Bitonte College of Health and Human Services

Youngstown State University


COMPREHENSIVE CASE STUDY 2

Abstract

This study gives an in-depth analysis of a psychiatric mental health inpatient at Mercy

Health – St. Elizabeth’s Hospital in Youngstown, OH. Many facets of the patient’s care include,

but are not limited to, a DSM-IV-TR diagnosis, precipitating factors for hospitalization,

treatment orders, medication schedule and an evaluation of outcomes. The study dissects the

patient’s past medical and psychiatric history, analyzes spiritual influences pertaining to the

patient’s hospitalization, and provides a prioritized list of nursing diagnoses as well as a list of

potential nursing diagnoses.


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Objective Data

KM is a 56 year-old inpatient that was involuntarily admitted to Mercy Health St.

Elizabeth’s Youngstown Hospital, Behavioral Health Institute on November 11, 2017. This

patient was diagnosed with the DSM-IV-TR Axis I #296.0–296.89 criteria of “Severe Bipolar

Affective Disorder with Psychotic Features” (Pini et al., 1999). Upon admission, the patient

stated she was “feeling overwhelmed and concerned that she hasn’t taken her medical test to

become a doctor, even though she already is one.” KM presented with a rapid flight of thoughts

with occasional points of clarity. Her physical manifestations included flushed skin, diaphoresis,

a rapid heart rate and enlarged pupils. The patient was irritable and not easily consoled. She was

put on self-harm precautions due to her combativeness when consolation was attempted. KM

also presented with acute kidney injury the day she was admitted to the ER, as evidenced by

elevated BUN and creatinine levels. Her past medical history consists of hypernatremia, acquired

hypothyroidism, nephrogenic diabetes insipidus, thyroid disease, cervical cancer and

endometriosis. The patient was put on q15minute safety checks, as well behavior counseling and

group therapy sessions. Her current scheduled medications:

 Benztropine (1 mg, 1 tablet PO BID for EPS symptoms)

 Divalproex (1000mg, 2 tablets PO HS for seizures)

 Quetiapine (400mg, 4 tablets PO HS for agitation)

Her current as needed medications:

 Chlorpromazine (100mg, PO/IM Q8H PRN for agitation)

 Diphenhydramine (50mg, PO/IM Q4H PRN for agitation)

 Haloperidol (5mg, PO/IM Q4H PRN for agitation)

 Lorazepam (1mg, PO/IM Q4H PRN for anxiety)


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Summary

“Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes

unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks”

(NIMH, 2016). Bipolar disorders are placed in between depressive disorders and psychotic

disorders due to the “recognition of their place as a bridge between the two diagnostic classes in

terms of symptomatology, family history and genetics” (Parker, 2014). In the manic stage, a

patient is likely to experience “three or more of the following symptoms: low self-esteem,

decreased sleep, pressured speech, racing thoughts, activity at heightened levels, goal agitation,

risk-taking behaviors, and symptoms severe enough to cause marked impairment” (McCormick,

Murray, McNew, 2015). Upon admission, and throughout her stay at the BHI, KM presented

with decreased sleep, pressured speech, racing thoughts and activity at heightened levels. In the

major depressive stage, a patient is likely to experience “five or more of the following symptoms

over a 2-week period: depressed mood, loss of interest or pleasure, weight loss/gain,

insomnia/hypersomnia, agitation, fatigue, worthlessness, lack of focus, suicidal ideation and

significant distress or impairment” (McCormick, Murray, McNew, 2015). Throughout KM’s

stay, she has also presented with at least five of these symptoms, which include depressed mood,

insomnia, agitation, lack of focus, and significant distress or impairment.

Psychotic features “are also part of this disorder, which can severely impact a person’s

ability to function” (Ffrench, 2017). There can be two types of psychotic features: congruent or

incongruent. “Mood-congruent psychotic symptoms are delusions, which are false beliefs, or

hallucinations, which are false sensory perceptions, that are consistent with the person’s current

or most recent mood episode” (Ffrench, 2017). KM experienced these types of psychotic features

as evidenced by her delusions of religion and grandiosity.


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Identification

The patient presented in the emergency department with flank pain coupled with mental

confusion. After a comprehensive metabolic panel was completed, results pointed to acute

kidney injury as evidenced by elevated BUN and creatinine levels, 30mg/dL and 1.5mg/dL

respectively. It was unclear how KM arrived at St. Elizabeth’s, or where she came from. She was

involuntarily admitted, but I could not find who accompanied her to the ED. She stated in my

patient interview with her that she “lives in mansion with my cats,” and her “LPN takes care of

me.” When prompted to explain the events that led up to her arrival, the patient stated “I’ve been

here forever and my LPN made me come here because she wants me sick.” Again, it was unclear

if KM had been in a harmful environment to begin with, or if a stressful event took place that

triggered her manic episode. However, her flank pain was real and manifested in the lab results

thereafter. When asked about any problems with past medical diagnoses, KM stated “I’ve been a

diabetic all my life, but that hasn’t stopped me from being the best cadet in the Navy. I once did

500, one-armed push-ups for my drill sergeant and I never quit for a second to rest.” It’s unclear

if the patient had actually served time in the Navy, but if true, would explain possible PTSD

manifestations in her speech and stream of consciousness.

Discussion

Unfortunately, KM was unable to coherently describe her family or any past mental

illnesses they could have potentially had. However, KM has had two previous psychiatric

hospitalizations, both pertaining to her bipolar disorder with psychotic features. It appeared she

had been diagnosed with this mental illness approximately five years ago. It was unclear if she

had any previous psychiatric hospitalizations other than at St. Elizabeth’s. KM frequently
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presents to the emergency department at St. Elizabeth’s roughly three to four times a month

regarding a medical complaint.

Description

Throughout her stay, KM was provided with extensive patient education and support of

her thoughts and feelings. During medication passes, the staff LPN consoled her when she felt

too anxious to take them, which increased compliance and was a step toward better management

of her diagnosis. KM was encouraged to attend group therapy sessions, which allowed her to

witness good behavior modeling. She was also exposed to different viewpoints during group

discussions, which could have promoted better listening skills. Being out in the milieu

environment could have potentially escalated her manic behaviors, since most episodes occurred

in the common area. However, the space also allowed her to interact with new people, possibly

alleviating her depressive episodes whenever she felt alone.

Analysis

KM stated she was “Polish and a little bit of German, but I know I have some African in

me because my great grandfather was 100% black.” Due to her diagnosis, it was unclear how

valid that statement was. KM talked extensively how much she loved God, but how “sometimes

the Devil tells my cats that I need to get up at 1:30 in the morning to check out my mansion

because burglars are sneaking around trying to steal my stuff.” She appeared to have many

delusions of religion, saying how she went to Catholic school when she was younger, but joined

the Navy later in life, and “it was God who got me through basic training.” It seemed that her
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religion must have been an important part of her life, considering the amount of praise she gave

God and the expression of hatred she had toward the Devil.

Evaluation

In regards to KM’s outcomes, the patient remains hospitalized due to ongoing events and

interactions with the staff and other patients. Dr. Jason Rock states “patient has ongoing

symptoms of mania and psychotic features. Patient has not been improving as expected.”

Throughout the patient’s progress notes regarding nursing diagnoses and outcomes met, there are

a few ongoing outcomes and a few outcomes that are consistently met every day of care. For

example, “Risk of Self-Harm” with the intervention of “absence of self-harm” has been met

every day of her care. An ongoing outcome example would be “Altered Mood; Manic Behavior”

with the intervention of “ability to sleep.” This outcome has yet to be met.

Summary for Discharge

As of November 28, 2017, KM’s guardian (Steve) contacted the Behavioral Health

Institute and asked that KM would be transferred to the state hospital and be put on Lithium.

However, Dr. Rock had consulted with the treatment team and they concluded that the patient

was “not sick enough to be transferred to a state hospital” and that he “would like to see her go

on a step-down unit for medical treatment.” Dr. Rock believes that a state hospital “is not an

option at this moment in time.” He also stated, again, “patient has not been improving as

expected.” It appears plans for a prolonged stay is taking precedence over discharging KM as of

today.
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Prioritized List of Nursing Diagnoses

1. Risk for self- or other-directed violence related to delusions and manic/psychotic state.

a. Goal: Patient will identify 2 factors contributing to aggressive behavior by the end

of the shift.

b. Intervention: Assess the patient for risk factors of violence, including those in the

following categories: personal history, psychiatric disorders, neurological

disorders, medical disorders, and coping difficulties.

2. Sleep deprivation related to hyper-agitated state as evidenced by pacing around the floor

and talking with a flight of ideas.

a. Goal: Patient will verbalize 2 actions that can be taken to improved quality of

sleep.

b. Intervention: Keep the sleep environment quiet by avoiding use of the intercoms,

turn off the television, and speak in a low-toned voice on the unit.

3. Impaired nutrition: less than body requirements related to constant movement as

evidenced by pacing around the floor and complaining about being “too skinny because

you people don’t feed me enough.”

a. Goal: Patient will gain 2 pounds within one week of care.

b. Intervention: Monitor food intake; record percentages of served food eaten, and

keep a food diary to determine actual intake.


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Potential Nursing Diagnoses

1. Ineffective coping related to situational crisis

2. Disturbed personal identity related to manic state

3. Self-neglect related to manic state

4. Anxiety related to change in role function

5. Non-compliance related to denial of illness

6. Social isolation related to ineffective coping

7. Ineffective activity planning related to unrealistic perception of events

8. Risk for loneliness related to depression

9. Risk for caregiver role strain related to unpredictability of condition

10. Risk for spiritual distress related to depression

11. Risk for powerlessness related to inability to control changes in mood

12. Risk-prone health behavior related to low state of optimism


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References

T. (2016, April). Bipolar Disorder. Retrieved November 30, 2017, from

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

DeepDiveAdmin, W. D. (2015, December 2). DSM IV. Retrieved November 30, 2017, from

http://www.psyweb.com/DSM_IV/jsp/dsm_iv.jsp

Ffrench, D. K. (2017, August 14). Bipolar 1 Disorder With Psychotic Features. Retrieved November

30, 2017, from https://www.livestrong.com/article/127995-bipolar-disorder-psychotic-features/

McCormick, U., Murray, B., & McNew, B. (2015, July 14). Diagnosis and treatment of patients

with bipolar disorder: A review for advanced practice nurses. Retrieved December 07, 2017,

from http://onlinelibrary.wiley.com/doi/10.1002/2327-6924.12275/full

Parker, G. F. (2014, June 01). DSM-5 and Psychotic and Mood Disorders. Retrieved November 30,

2017, from http://jaapl.org/content/42/2/182#sec-9

Pini, S., Dell'Osso, L., Mastrocinque, C., Marcacci, G., Papasogli, A., Vignoli, S., . . . Cassano, G.

(1999, November 01). Axis I comorbidity in bipolar disorder with psychotic features. Retrieved

November 30, 2017, from http://bjp.rcpsych.org/content/175/5/467


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Case Study Comment Sheet 4842

Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

__________ Style, spelling, grammar, clarity, organization, APA format


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Criteria 1 Poor Basic Proficient Distinguished


10 % Constructs a unique
patient case study and Does not Discusses a Constructs a Creates and correlates a unique
determines an appropriate construct a unique patient unique patient patient case study with previous
description for patient and unique patient case study and case study and clinical experience and provides a
setting case study and properly determines an thorough description for patient
determine an generalizes an appropriate and setting
appropriate appropriate description for
description for description for patient and
patient and patient and setting
setting setting from
experience
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Criteria 2 Poor Basic Proficient Distinguished


30 % Summarizes a
detailed patient history and Does not Describes a basic Summarizes a Constructs a detailed patient
a complete physical summarize a patient history detailed history and determines a
assessment detailed patient and lists physical patient history probable complete physical
history and assessment and a assessment description
complete findings complete
physical physical
assessment assessment

Criteria 3 Poor Basic Proficient Distinguished


25 % Identifies and Does not identify Identifies and Identifies and Identifies and describes nursing
describes nursing theory or describe describes describes theory and correctly correlates
nursing theory nursing theory nursing theory and defends nursing
and correctly correlates and does not and discusses and correctly interventions with theory
nursing interventions correlate interventions’ correlates
interventions correlation with nursing
with theory with theory theory interventions
with theory

Criteria 4 Poor Basic Proficient Distinguished


20 % Determines
discharge needs Does not Identifies and Discusses and Distinguishes and prioritizes
determine describes explains discharge needs
discharge needs discharge needs discharge
needs

Criteria 5 Poor Basic Proficient Distinguished


10 % Communicate
through writing that is Does not Communicates Communicates Consistently communicates
concise, balanced, and communicate through writing through through writing that is concise,
logically organized through writing that is writing that is balanced, organized, flows with
that is concise, inconsistent in concise, smooth transitions between ideas
balanced, and its concision, balanced, and
logically balance, and logically
organized logic organized

Criteria 6 Poor Basic Proficient Distinguished


5 % Communicate through Does not Communicates Communicates Consistently communicates
writing that applies APA communicate through writing through through writing that
6th Edition style and through writing that is writing that demonstrates level appropriate
formatting and conforms to that applies APA inconsistent in applies APA mastery of APA 6th Edition style
all assignment instructions. 6th Edition style its use of correct 6th Edition and formatting and follows all
and formatting APA 6th Edition style and assignment instructions
and/or does not style and formatting and
conform to formatting conforms to all
assignment and/or assignment
instructions inconsistently instructions
follows
assignment
instructions
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