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MENTAL HEALTH CASE STUDY

Mental Health Nursing Case Study

Brian Nash

Youngstown State University


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MENTAL HEALTH CASE STUDY


Abstract
The completion of a successful and legitimate case study requires the collection of

objective data from the subject to better understand the situation that lead them to an inpatient

psychiatric hospital stay. It is imperative to have a baseline understanding of the psychiatric

diagnosis to lend to the ability to gather important data effectively. The subject of the study in

this case suffered from bipolar disorder which led to periods of crippling depression and the

eventually led to the desire to take his own life. During the interview I was able to gather a

condensed family history which is important because many mental illnesses are genetic in nature.

A safe environment or milieu is imperative for all patients on a psychiatric unit and especially

when the client is in a state of potential suicidal behavior. The use of nursing diagnosis allow

nurses to assess and implement a plan of care for the patient for the length of stay.
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Objective Data

The patient presented to Trumbull Memorial Hospital's emergency department on

November 11th, 2017. Upon arrival the patient told the staff that he had planned to commit

suicide earlier and that he was currently withdrawing from the use of heroin. Due to his claims of

suicidal ideation with a plan he was then admitted to the psychiatric unit for observation. Upon

claiming suicidal ideation, patients are admitted for a three day hold in which they are unable to

leave, however in this case the patient did not want to leave until he was feeling better. Upon

evaluation he was diagnosed with the following psychiatric diagnosis; Bipolar type 2 major

depressive, Cluster B personality disorder (borderline), and generalized anxiety disorder. The

only medical diagnosis was heroin dependence. All important labs were within normal ranges

including thyroid stimulating hormone which is drawn to rule out biologic causes of depression.

The only other lab value worth noting was Valproic Acid levels which were 28.8, which is low

and would normally indicate non-adherence to drug regiment; in this case the drug had just been

started and low levels were expected.

The gathering of data occurred on the day of care when we received our morning report

from the charge nurse, Debbie. The date of care was the morning of the fifth day of the patient's

admission. Report included the information that he was a 27 year old male with a history of

bipolar disorder and that he was very quiet and excessively sad. She suggested that he may have

a developmental delay as he was social maladjusted and spent most of his time completing

puzzles rather than socializing. She relayed that he had been attending groups, and stating a score

of 9/10 depression and 5/10 anxiety.


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I approached my patient with a degree of trepidation, I was wanted to be careful not to

upset him any further and so after allowing him to eat his breakfast I asked if it would okay to sit

and speak to him while we both worked on a puzzle together since that is what I was told he

enjoyed doing. The fact that he was preferring to be alone and working on puzzles also indicated

moderate depression as it exhibits social isolation with focus on self (Townsend 2015). I sat

down and introduced myself and stated why I was there and asked him if he had any objections

to me asking him some fairly personal questions, to which he consented. One thing I noticed

straight away was that he made eye contact for only a very short period of time which is an

indicator of social maladjustment. He was dressed appropriately for someone of his age,

although he was careless in his actual appearance and his personal hygiene was adequate. He sat

to my left and was slouching throughout the entire encounter. When speaking he did so very

quietly and with little to no tone changes, and with little emotion. It was clear the patient was

exhibiting a flat affect a common and expected sign of bipolar type 2 (Townsend 2015).

I opened the conversation by asking how he was feeling that day to which he replied

"good", and I then probed into why he was there. He gave me an account of how he had been

driving to his mother's house to get a gun and shoot himself in the head. It was at that point that

he realized he need to be admitted to the hospital because he did not truly want to die. I listened

to him the entire time trying to remain objective and judgment free. I asked what events had led

him to feel as though he wanted to kill himself and he said that he was recently let go from his

job and as a result was kick out of his apartment where he had been living with some friends for

a few months. I recognized at this point that my patient may have had a personality disorder that
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we discussed in class, borderline personality. Planning suicide and then seeking help before the

plan go into full effect is an indicator as is the manipulation of people around you to cause drama

and create unrest. I suspect that is what his chart was referring to when I found he was diagnosed

with cluster "B" personality disorder. He was clearly very upset by these developments in his life

and with good reasons these are life altering and jarring events with someone of sound mind and

adequate resources, unfortunately for this patient he did not have the luxury of these resources.

My patient was only on several scheduled medications of my day of care, including;

valproic acid (Depakote) 250 mg/BID orally, sertraline (Zoloft) 200mg/daily orally and clonidine

(Catapres) 0.1mg/q4hrs orally, quetiapine (Seroquel) 200mg/daily orally, Trazodone 200mg/TID

orally. The list of PRN medications included; haloperidol (Haldol) 5mg/IM during acute

agitation episodes and hydroxyzine (Vistaril) 50mg/IM for agitation. Valproic acid is an anti-

seizure medicine that is used off label for mood stabilization for patients with bipolar disorder

and is especially usually in the mania phase. Sertraline is a SSRI which works in the brain to

help regulate the levels of serotonin and works to improve symptoms of depression. Clonidine is

a sedative and anti-hypertensive drug which in this case is being used to treat the physical and

mental symptoms associated with withdrawal. Quetiapine is an anti-psychotic medication that is

used to treat bipolar disorder (manic depression). Lastly Trazodone is an antidepressant that is

used primarily in major depressive disorder.

Summarize the Psychiatric Diagnoses and Expected/Common Behaviors

"Bipolar II disorder is characterized by recurrent bouts of major depression with episodic

occurrence of hypomania. The individual who is assigned the diagnosis may present with

symptoms (or history) of depression or hypomania. The client has never experienced a full manic

episode. The diagnosis may specify whether the current or most recent episode is hypomanic,
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depressed, or with mixed features. If the current syndrome is a major depressive, psychotic or

catatonic features may also be noted" (Townsend, 2015. pg 501). Those afflicted with bipolar

disorder type 2 have mood swings that tend to remain on the depressive side with occasional flair

ups of a lesser form of manic episodes. Someone with this disease will exhibit signs of moderate

to severe depression with symptoms potentially including; feelings of utter despair,

worthlessness, slowed thinking processes, difficulty concentrating, anorexia or overeating,

insomnia, sleep disturbances, generally portraying pessimism and negativism, verbalizations and

behavior reflecting suicidal ideation (Townsend, 2015.)

Indentify the Stressors and Behaviors that Precipitated Current Hospitalization

There was a cacophony of events that led to the hospitalization of my patient. The most

obvious and blunt reason was his suicidal ideation with a plan, which is what led him into the

emergency department that day. He had several big stressors that lead to this hospitalization, the

loss of his job and his eviction from his apartment by his friends. The latter event served as a

devastating blow because not only did he lose a place to live, but he also says he lost those

friends with which he was living. The event that caused him to lose his job was when they asked

him to take on more routes at work and he agreed, but eventually the stress of taking on more

work caught up to him and he had what he described as a nervous breakdown and required him

to be admitted to the same facility earlier this year. These situations are a reason that many

people with bipolar disorder are unable to hold longer term jobs (O’Donnell et al., 2017). Due to

the loss of that job and thus the income it provided he was no longer able to afford rent and that

was a issue for his roommates. The actual reasons for his eviction at the hands of his friends is

actually unknown because he did not want to discuss it. The patient did mention that his
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roommates were also doing heroin in large amounts and that he thought that perhaps it was for

the best since he believed them to be enabling him.

Discuss Patient and Family History of Mental Illness

I inquired into the patients family history to get a better understand of his illness.

Unsurprisingly, his mother had been diagnosed with generalized anxiety disorder which he said

she has been medication for. When I asked about his father he said his dad does not discuss his

emotions with him and he has never complained of anything being wrong with him. The family

history in the chart only mentioned peripheral vascular circulation as a medical problem. The

patients sister also suffers from depression which she is also medicated for. The patient told me

that growing up he and his sister got along well and used to discuss their issues with one another,

but since she is out of state now they don't talk as much which is something I find to be

significant.

Describe the Psychiatric Evidence Based Nursing Care & Milieu Activities Provided

For a patient whom is experiencing suicidal ideation with intent and a plan, there is no

better milieu than the psychiatric nursing unit. On admission the personal belongings of the

patient are screened to ensure nothing of harm can be brought into the patient population as to

protect other patients. They also conduct a cavity search in order to ensure no illicit drugs are

being brought into the unit. The unit itself is designed with no sharp edges, shatterproof glass,

rounded door frames, specially made light posts, and a variety of other safety precautions to

ensure that a patient that is having suicidal thoughts will have a very difficult time trying to take

their own life. It is positively essential for the patient to take an active role in their care and

participate in all therapeutic activities throughout their stay (Freeland et al., 2015). There is a
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structured schedule posted on the unit and reminders when activities are going to commence

announced over the PA system. There is also several group therapy sessions to be utilized

throughout the day where staff attempt to teach various coping mechanisms, discuss medications,

and offer their assistance in any possible way to assist the patients toward feeling well again. The

overall goal of these interventions are to assist the patient to return to a higher level of daily

functioning in anticipation of discharge.

Analyze Ethnic, Spiritual, and Cultural Influences that Impact the Patient

The client denied and religious and or ethnic affiliation. Culturally it is clear that the

patients struggles to fit in. His use of heroin seems to be a result of hanging out with his friends

and he used that as a negative coping technique. The patient also claimed to struggle where the

other sex is concerned and his attempts to communicate always seem to fail which leads to

anger. Due to the heavy emphasis our society puts on relationships and sex it is clear he is

frustrated and that only further contributes to his depression. I also believe that his coping

mechanism of cutting is another way of seeking attention from others. When I asked him why it

was that he cut he said because people respond to him doing it. This is an example of a learned

behavior that receives attention from others something he clearly desires.

Evaluate the Patient Outcomes Related to Care

To me there are several nursing outcome that must be met before this patient should leave

the facility. Obviously his depression needs better control and that is why they started him on

valproic acid, a therapeutic level should be met and then evaluate the patients mood before going

any further. Additionally this young man would benefit from someone to talk to, and it was a

role I felt very comfortable fulfilling. It appears to me as thought he is wrapped up in his own
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head and he needs a medium for him to express himself. Positive reinforcement and sense of

purpose should also be established; perhaps a token economy where he is rewarded for

participating in group, or simply a compliment when he takes a shower and dresses appropriately

(“Bipolar Disorder,” 2017). Lastly teaching the usage of coping techniques and positive in nature

is crucial as he was implementing a vast array of negative coping techniques; and he would

certainly benefit from this kind of instruction.

Summarize the Plans for Discharge

Once a therapeutic level of valproic acid has been reached and he is able to maintain it

(indicating medication program adherence) discharge should be considered. An important aspect

of discharge for this patient would be a living situation that is free of the type of enablers that

lead to unacceptable exacerbations of depression. Ensuring that the gun that the patient was

going to use be locked away where it would be difficult for him to access should also be

established. Should all of these criteria be met the discharge of this patient should go smoothly

and he should be able to return and be a functional member of society once again.

Nursing Diagnoses

Nursing diagnoses are an important part of patient care as they help to identify and care

for problems the patient is likely to encounter. The following are nursing diagnoses which could

apply to the patient that I interviewed. Impaired social interaction related disturbed thought

processes as evidenced by inability to develop satisfying relationships. Ineffective individual

coping related to ineffective problem solving skills as evidenced by destructive behavior toward

self. Risk for injury related to self harm behaviors as evidenced by impaired judgment.

Interrupted family processes related to situational crisis or transition as evidenced by inability to


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deal with traumatic or crisis experiences constructively. Self-care deficit related to severe anxiety

evidenced by observation or valid report of inability to eat, bathe, toilet, dress, and/or groom self

independently.
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Works Cited

Ackley, Betty J., and Gail B. Ladwig. Nursing Diagnosis Handbook: an Evidenced-Based Guide

to Planning Care. Elsevier, 2014.

Bipolar Disorder: Implications for Nursing Practice. (2017). ISNA Bulletin, 43(4), 12–15.

Freeland, K. N., Cogdill, B. R., Ross, C. A., Sullivan, C. O., Drayton, S. J., Vandenberg T., A.

M., … Garrison, K. L. (2015). Adherence to evidence-based treatment guidelines for

bipolar depression in an inpatient setting. American Journal of Health-System Pharmacy,

72, S156–S161. https://doi.org/10.2146/sp150023

O’Donnell, L. A., Deldin, P. J., Grogan-Kaylor, A., McInnis, M. G., Weintraub, J., Ryan, K. A.,

… O’Donnell, L. A. (2017). Depression and executive functioning deficits predict poor

occupational functioning in a large longitudinal sample with bipolar disorder. Journal of

Affective Disorders, 215, 135–142. https://doi.org/10.1016/j.jad.2017.03.015

Townsend, M. C. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based

Practice. Philadelphia, PA: F.A. Davis Company, 2015.