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Case Study

Connor Dennison

Youngstown State University

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Abstract

The patient I was able to talk to this visit was suffering from a combination of bipolar

disorder, mild schizophrenia, and a more predominate case of obsessive compulsive disorder.

We were able to pick these disorders out of the patient in the form of different ways the patient

communicated with us, like how the patient was always talking about how much he noticed how

dirty the place was and how he needed to clean over and over again. Also how his demeanor

would change in a moment’s notice from happy and calm to slightly irritated and fidgety without

any causative factors. They were involuntary admitted to the floor because the wife was very

concerned for the patient’s wellbeing and the patient kept saying that the wife is out to get him

and that she isn’t really trying to help him at all.

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Objective Data

The patient is a 32 year old, relatively good shape, white male with a shaved head and

brown eyes. They were admitted to the unit a few days prior to me interacting to the patient

because they were having a violent outburst in their home towards his wife by yelling and

screaming at her because he said she was out to get her and make him do things he didn’t want to

do. The wife then ended up calling the police while the patient was out at a home goods store,

picking up a few things where he was willing to cooperate and go peacefully with the police.

The patient had previously been diagnosed with bipolar affective disorder, which is what

is causing the severe changes in mood and attitude in a moment’s notice. There were no other

prominent medical diagnoses for the patient and all other physical signs and vitals were within

the normal range that they are supposed to be. For their disorder, they are currently taking one

medication a day that is required and is prescribed four others for as needed purposes. The

medication that he takes regularly is Cogentin 2mg twice a day for an outburst of agitation or

acute dystonia that the patient may be experiencing for their diagnosis of bipolar disorder. Other

medications that were prescribed to the patient but were just used on an as needed basis were

Depakote 500mg, Haldol 5mg, Vistaril 50mg, and Ativan 1mg. These medications were ordered

on the chance that the patient was becoming more and more agitated or anxious and no other

interventions were helpful to return him to a previous normal functioning. These meds overall

appeared to help keep the patient in a state of calmness and have good demeanor about

themselves with visible episodes of OCD still present by cleaning the area over and over again.

Safety measures that were in place were of the normal ones available on any normal psych unit

with no extra precautions put on the patient where they may cause self-harm or harm others and

was free to roam the unit without constant watch needed.

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On the date of care, the patient was wearing sweat pants and a long sleeve shirt instead of

a hospital gown and was well kept by having showered daily and the clothes he was wearing

were clean and in neat order. The patient themselves was very open to talking to me about their

reasons that may have proceeded to them arriving to the hospital. Their speech was clear and

concise with no stuttering or any form of speech impediment that could make it difficult to

understand the patient during the conversation. The patient also had a kind attitude to me the

whole time I was talking to him and appeared to be truthful with everything they were telling me

about their childhood but wasn’t so much truthful about the reason that had brought him into the

hospital today.

Summarization

The patient had been diagnosed with bipolar affective disorder which is a disorder that is

associated with episodes of mood swings, which range from a very depressive state of being too

high levels of mania where they may make rash decisions and become agitated very easy. The

patient themselves states they admit having spells of being depressed and not wanting to do

anything productive or even leave the house, then at times they state they have to keep

everything as clean as he possibly can to satiate a habit that the patient has because of the mood

they are in at the time. Depression isn’t something the patient states they suffer from as much as

they do the manic episodes. They state that whenever they are at work that they can work and

keep working until the job is done as efficiently and effectively to the point of staying over late

at night to make sure the job is done to perfection in his eyes. The manic episodes would cause

this patient to have this type of work ethic or demeanor toward other aspects of his life like

having to clean things over and over again and make things how he likes them in an orderly

fashion. The patient also makes impulsive decisions that may not always be the best for the
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patient or for anyone around the patient who may be affected and the patient is also in denial that

there is specifically wrong with him and that they are just acting this way because it’s who they

are.

The patient also shows other symptoms of the disorder with a few examples being that

they have difficulty sleeping almost every night and it wasn’t just because they were in the

hospital and it was happening in their home life as well. He had said he only gets as much as five

hours of sleep per night and is perfectly fine with it but others are able to notice a level of fatigue

in the patient that he might not see because of the increased energy from the manic episodes.

They also have racing thought because of how much the patient was talking to me during the

interview, I had interviewed the patient for an hour and a half and he was talking the whole time

about a whole range of different topics like his past, work, and other parts of his life without

breaks in between.

Identify Stressors

The patient describes the situation of being brought to the emergency as his wife is out to

get him and made the call to get at him. The call he was referring to was his wife had called the

police not because he was physically hurting himself or her but because she was very concerned

that he would and didn’t want it to escalate to that before it was too late. The patient did not see

it that way and just kept saying that there was nothing wrong with him and that she is the crazy

one who is trying to take his things. He thinks she also did this because she wanted to take is

belongings which the wife had also responded to saying she didn’t know what he was talking

about because she wasn’t out to do any such thing and just wanted to see him get better and be as

safe as possible.
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The patient also told us of another stressor that may have been a predisposing factor to

them coming to the hospital was they did not like when someone moved his things without

telling him and put them in an unruly manor. This made the patient very agitated and angry to a

point of being very angry and yelling at the person responsible for this which also made the wife

very afraid for what he might do.

Another reason that could have contributed to hospitalization was that the patient was not

adhering to their medication plan that was given to him outside of the hospital. A study done to

show the average adherence of patients with this disorder showed that “The majority reports

satisfaction with information received regarding the medication and its effectiveness, though

there were reports of collateral effects, doubts and lack of motivation to keep up the treatment,”

meaning that the patients may need a different method to help them to maintain their medication

compliance and make sure that they are aware of the helpfulness of the medications and are not

suspicious for any reason that they be harming the patient.

Discuss Family/Patient History

The patient’s family didn’t have any history of mental illness but what the patient had

told us happened to him was more than likely what contributed to him having the mental disorder

they have today. The patient had told us that he and his parents had a great relationship when he

was growing up. He stated that the parents would argue once in a while but never escalated it to

screaming or physical violence toward the other parent, him or brothers and sisters whom he had

two brothers and an older sister. Then one night when he was about eight years old, the patient

was sound asleep as well as his siblings and his father had come home very late because of work

and had come home to a horrible scene. The patient’s mother was found in her bed where she
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was raped and murdered by someone who had broken into the house to rob the place. He told me

that he didn’t really understand what had happened because he was so young but he saw how

upset his father and other siblings were and knew that he would never be able to talk to his

mother again. For years after that, he stated he attended therapy for what had happened and was

doing relatively well for the situation that had happened until he was about sixteen years old. He

was at school when he got called down with a phone call from his older brother that his sister

was in a car accident. He was picked up by the brother and was taken to the scene of the accident

where the sister was unfortunately was thrown from the car and did not survive the impact. This

really affected the patient even more so because he understood what had happened and

completely devastated for years after the even had taken place and was not attending therapy for

it because he didn’t want to and thought it wouldn’t help with everything that happened to him in

his life.

Describe Psychiatric Evidence

The floor where the patient was admitted had an array of different helpful RNs and LPNs

on the floor for the direct care of the patient. There were also a few doctors that would rotate

days of care and would have one on the floor to help with patient care and either have a plan for

the patient or give them resources they can use when they are discharged from the unit. There are

also a few milieu therapists that are very involved with the patients with anything that they might

need to talk about. They lead groups where the patients can feel safe to speak about anything that

might be on their mind and create a safe environment where they might tell about something they

had not previously told anyone about which could be helpful to their care for the future.
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The equipment on the floor is also made for the reason of keeping the patients as safe as

they can possibly be and the staff safe as well. The beds are locked in the lowest position on the

floor with no ability to tie a bed sheet or blanket around the bed or anything else in the room.

The bathroom is also very empty with only a toilet and sink, with a reflective mirror that isn’t

actually glass so the patients can’t break it and cut themselves. These small but simple safety

measures are put there to help keep the patient as safe as possible from harming themselves and

keep a safe environment for treatment.

Analyze Influences on Patient

Growing up the patient faced very little adversity in life being a white male and was not

bullied because he was friends with everybody and did not see the point of making fun of

someone or being mean to someone for no reason. The patient also stated that they were a very

religious person with Christianity being their religion of choice. He had showed me a few videos

on YouTube of Christian singers that he really liked and they are very helpful to him to listen to

when he is feeling like he doesn’t matter or that he is in a very depressive state. He also states

that he likes to read as much as he can because it helps him focus on something other than the

problems that might be affecting him in his head at the time.

Evaluate Patient Outcomes

The patient could very easily help themselves if they are more willing to take care of

themselves and actually adhere to their medication regimen for as long as it too even it was for

their whole life. He could also use the resourced that are available to them for helping people

with his disorder and help them to function better in society without others fearing what he might

do to them or himselves. If he were able to have the motivation and want to take care of himself,
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then he will be more than able to have a normal life with his wife and if he were to have an

episode again, he would be better prepared for it and know how to approach the situation in a

much better manner.

Summarize Discharge Plan

As was stated previously, the patient will be put on a medication plan that adherence to

said plan will help his disorder and help him better manage it. He will also have a follow up

appointment with and outpatient doctor that can help him to better organize any other plans that

he wanted to try and help better him with. They also state that they really want to get back to

working because it helps them focus on one thing and keeps their mind at ease during the task at

hand.

Prioritize List of Actual Diagnoses

 Risk for self-harm related to manic episodes.

 Risk for injury related to repetitiveness of everyday tasks. (washing hands too much,

scrubbing floor on knees to much)

 Risk for inadequate nutritional intake related to suppressed hunger from manic episodes.

 Inability to cope with disorder related to frequent episodes of mania

 Family knowledge deficit related to no knowledge of the disorder or how is could affect

the patient.

List of Potential Nursing Diagnosis

 Decreased medication regimen compliance with regards to patient not thinking something

is wrong with them

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 Risk for disturbed sleeping pattern related to episode of mania

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References

- Bipolar Affective Disorder Treatment & Management. (2017, November 30). Retrieved

December 06, 2017, from https://emedicine.medscape.com/article/286342-treatment

- BIPOLAR AFFECTIVE DISORDER. (December 05). Retrieved December 06, 2017, from

http://www.obad.ca/information_bipolar#spectrum

- Lam, P. D. (2003, February 01). A Randomized Controlled Study of Cognitive Therapy for

Relapse Prevention for Bipolar Affective Disorder. Retrieved December 06, 2017, from

https://jamanetwork.com/journals/jamapsychiatry/fullarticle/207181

- Miasso, A. I., Monteschi, M., & Giacchero, K. G. (n.d.). Bipolar affective disorder: medication

adherence and satisfaction with treatment and guidance by the health team in a mental health

service. Retrieved December 06, 2017, from https://www.ncbi.nlm.nih.gov/pubmed/19820864