RUNNING TITLE HEAD: Mental Health Nursing 1

Mental Health Nursing Case Study

Vanessa Gonzalez
Youngstown State University
Mental Health Nursing
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Abstract

During my clinical shift at Trumbull Memorial Hospitals Psychiatric unit, I took care of a

46-year-old female who was admitted for severe manic bipolar disorder, Manic with Psychotic

Features. In this paper I will identify objective data that describes the date of admission, date of

care, psychiatric diagnosis, and behaviors observed on admission and day of care. I will discuss

medical conditions, treatments, safety and security measures, and prescribed medications and the

reason for those medications. Next, I will go into detail about the psychiatric diagnosis, expected

behaviors and common behaviors. Following I will identify the stressors that precipitated the

current hospitalization, discuss patient and family history of mental illness, describe psychiatric

evidence based nursing care provided, analyze ethnic, spiritual and cultural influences, evaluate

patient outcomes related to care, summarize the plans for discharge, prioritize list of diagnosis

using NANDA format and finally prioritized list of potential nursing diagnosis.
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Objective Data

My patient AY is 46 year old Caucasian women, who is living with her husband and 7

year old daughter. She was involuntary admitted on 11/20/2017, date of care was on 10/3/2017.

The following are her diagnosis according to DSM IV, Axis I: Severe Manic Bipolar Disorder

with manic and psychotic features. Axis II: unkown Axis III: Depression, Anxiety, and PTSD.

Axis IV: recent move, medication changes, arguing with husband. Axis V: unknown. Upon

admission patient was manic with psychotic features, she was obsessing about the “red head

from down the street” and had unpleasant affects. Patient was hyper manic, pacing, hallucinating

and experiencing racing thoughts.

On the date of care the patient took a bit longer to come out for breakfast, she was taking

a long shower. Patient was in the common area of the unit interacting with others eating her

breakfast. Patient seemed calm and comfortable. She was dressed neatly and appropriately and

was willing to talk about her precipitating events and her illnesses. Patients affect was

appropriate and did not show any inappropriate or unpleasant affect. Her speech and

communication were relaxed, friendly, and her cognitive thoughts were filled with racing

thoughts, circumstantiality, and tangentiality. She was oriented to time and memory and was

experiencing disturbances in thought content with obsessions of the red headed lady from down

the street. However, she did have insight on her condition and understands her not taking her

medications, stressors and lack of sleep led up to her relapse. There were no abnormal

movements such as akathisia, akinesia, and or tardive dyskinesia.

The patients’ medical history is unknown she recently moved from Delaware and is

unaware of how many previous hospitalizations she has had.

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Safety and security measures were upheld throughout the day of care. Pts are checked on

every 15 minutes or as ordered. Pts are checked for contraband upon admission and if staff feels

a visitor might have snuck contraband they can be checked as well. They keep a milieu

environment to keep the patients protected from harm, have optimal healing, and health. Locking

of entrances to regulate those entering and leaving. Patients are physically assessed, and vitals

are taken daily and as needed. Every interaction is an opportunity for therapeutic intervention.

The patient owns her own environment and owns her own behavior. Basic physiological needs

are fulfilled, given clean clothes, food, a warm place to sleep, and a safe place to stay.

My patients scheduled meds include 30 mg daily of Ariprazole (Abilify) PO, taken as a

mood stabilizer, 600 mg BID Oxcarbazeoine (Trileptal) PO taken for mood, 200 mg at bedtime

Desyrel (Trazadone) PO, it is an anti-depressant used as a sleep aid. The patient has PRN

medications that include 50mg PO or IM q6h for anxiety. 5mg PO/IM Olanzaprine (Zyprexa)

Antipsychotic for agitation. Halopperidol (Haldol) 5 mg PO or IM for agitation.

Summarize

Bipolar disorder is characterized by mood swings from profound depression to

extreme euphoria (mania), with intervening periods of normalcy. Delusions or

hallucinations may or may not be apart of the clinical picture, and onset of

symptoms may reflect a seasonal pattern. During a manic episode, mood is

elevated, expansive, or irritable. (Townsend, 2015, pg. 499)

Manic episodes are distinct periods of abnormal or persistently elevated expansive, or

irritable mood, lasting at least a week and is present most of the day, nearly every day. During

the period of mood disturbance and increased energy or activity, the following symptoms may be
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present to a significant degree. 3 or more must be present included is inflated self-esteem or

grandiosity, decreased need for sleep, more talkative than usual, flight of ideas, distractibility,

increase in goal-directed activity, and excessive involvement in activities that have high potential

for painful consequences, such as buying sprees, sexual indiscretions or foolish business

investments. (Townsend pg. 500) Major depressive disorder is characterized by depressed mood

or loss of interest or pleasure in usual activities and patient will experience impaired social and

occupational functioning that goes on for at least 2 weeks. (pg. 461)

Identify

My patient is a 46-year-old, married with a 7-year-old daughter. Patients past medical

history of anxiety, Bipolar Disorder, Depression, and PTSD. Presented to the emergency for

psychological evaluation. Her husband reports she has been “out of control” for the past 18

hours. Associated symptoms include sleep problems, severe constant manic flight of ideas.

Patient was obsessed with the red headed lady from down the street. States she keeps talking to

her husband. All she could think about is the red headed lady. Patient had to walk away and

when she came back red headed lady was on her porch talking to her husband. She then started

shouting for her to leave and when people were walking by the red headed lady was shouting

that the patient was Bipolar and had problems. This really triggered the patient since she felt that

was none of her business and doesn’t even know her like that. The husband then had to call the

ambulance because the patient was extremely manic and out of control. Other stressors include

med changes, patient was off her medication because she does not have insurance at the time and

recently moved from Delaware.

Discuss
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AY was born in Delaware where she lived with her parents and had one brother and

sister. She does not have any support from her family. Patient states she was physically abused

by her father and was raped twice when she was a younger girl. By different men at different

times. States the second time she was getting raped by a bridge and something came out of the

water and scared the man away. The patient states she cannot sleep at night due to flash backs

and nightmares from her trauma. According to Belleville, G. Guay, S. Marchand, A. (2009)

“Levels of sleep disturbances have been shown to strongly correlate with PTSD symptom

severity (Krakow et al., 2001,); such that the more severe the PTSD symptoms the more

disturbed is sleep expected to be.” (pg. 126) Patient suffers from anxiety, Depression, PTSD, and

recurrent relapses her Major depressive disorder with episodes of mania. AY states she receives

support from her in laws. Pt has been in and out of hospitalizations due to her Bipolar Disorder

but is unaware how many times in the past. She recently moved from Delaware so there was no

prior medical history in the system of prior hospitalizations, family history, or any chronic

conditions. The patient was not seeing any counseling services now. However, she will be set up

with services prior to discharge.

Describe

For this patient to have the best outcome, the patient has an individualized care plan. The patient

is educated about their illness and educated about how to properly take their medications. Also,

possible side effects associated with them and are monitored throughout the nurse’s shift. The

patient was given a long acting injection called Invega. Being that the patient does not have

insurance this is a better way to ensure compliance of the medication. The patient’s family

receives education on their illness as many times as needed. The nurse’s interaction is important

because through a good relationship trust is made. The patient is encouraged to attend group and
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goes to most. During group the patient was triggered and showed signs of anger and mood

change, by a statement made by the person running the group, so the patient had to get up and

take a walk to cool down.

Analyze

My patient is a 46 year old Caucasian female who was not able to finish high school and

currently does not work a job. According to McCormick, Murray, McNew, (2015):

Bipolar Disorder (BD) is a chronic illness associated with debilitating symptoms

that can have profound effects on both patients and their caregivers (miller, 2006).

BD typically begins in adolescence or early adulthood and can have life long

adverse effects on the patients mental and physical health, educational and

occupational functioning, and interpersonal relationships. (P. 530)

And rates are similar regardless of race, ethnicity, and gender. (2015) the patient’s spiritual belief

does not impact her. The only time she mentioned something spiritual is when she stated she was

being raped and something came out of the water, what she believes to be her “guardian angel”

and scarred the man that was raping her away.

Evaluate

Within the time the patient is hospitalized, the patient should be able to achieve short

term goals. The Patient will demonstrate a stable mood and practice self-care activities

throughout the shift. The patient will control thought processes and interact adequately with

others at least 2 twice a day. The patient will demonstrate a normal sleep pattern at least 4 times

out of a week. The patient will not refuse to take her medications more than 3 times in 7 days.

The day of care the patient slept 5 hours that night with the help of her sleep aid. Patient was not
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sleeping prior to hospitalization. AY was also able to stay in a stable mood, although she had a

slight mood change during group. Patient could interact adequately in group and in the common

area. According to Susman, J. L there are four main elements in collaboratively caring for

chronic illnesses:

(1) a collaborative definition of problems (that is, a definition that incorporates

both physician-perceived and patient-perceived problems); (2) joint goal setting

(which targets specific problems and creates an action plan); (3) the provision of

individualized patient training and support services, including educational

materials, emotional support, and structured programs; and (4) sustained follow-

up to monitor and reinforce progress, identify potential complications, or make

needed modifications to the patient's health care plan. (p.2)

Summarize

AY was admitted into Trumbull Memorials inpatient psychiatric unit to be stabilized and

treated. Prior to discharge the patient will have to be properly educated on the importance of

taking her medications. The patient will need to be set up with community resources and

outpatient counseling services and continued outpatient appointments with a physician since the

patient had recently moved from Delaware. The patient will like to go home to her daughter and

husband. The family needs to be properly educated on her medications and signs, symptoms and

possible triggers. Unfortunately, AY has had previous hospitalizations and chances are she will

be in out of the Psychiatric unit. According to Susman, J. L. (2009) a study was done on

improving outcomes in patients with bipolar disorder using an effective treatment team and

findings suggest a need to reorganize the current primary health care model that is focused more
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on acute care. Short patient visits that diagnose and treat symptoms, however there is little

patient education. (Susman, 2009, p.1)

Susman, J. L. (2009) suggests:

a planned approach to chronic care using evidence-based guidelines and

protocols to support patient participation and self-management was

recommended, along with incorporating information systems that support disease

registries, reminder systems, and continuity of care. (P.2)

Prioritized

- anxiety

-Disturbed thought processes

-Ineffective self-health maintenance

-Risk for other-directed violence

-Risk for injury- self violence

-impaired social interaction

-Ineffective individual coping

-Interrupted family process

-Ineffective coping

-Social isolation
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References

Belleville, G. Guay, S. Marchand, A. (2009). Impact of Sleep Disturbances on PTSD Symptoms

and Perceived Health. Journal of nervous and mental Disease. 2009 Feb;197(2):126-32.

doi: 10.1097/NMD.0b013e3181961d8e.

Susman, J. L. (2010). Improving Outcomes in Patients with Bipolar Disorder Through

Establishing an Effective Treatment Team. Primary Care Companion to The Journal of

Clinical Psychiatry, 12(Suppl 1), 30–34. http://doi.org/10.4088/PCC.9064su1c.05

Townsend, M. (2011). Psychiatric Mental Health Nursing: Concepts of care in Evidenced Based

Practice (8th edition). Philadelphia. F.A. Davis.

Ursula, M. Murray, B. McNew, B. (2015). Diagnosis and treatment of patients with bipolar

disorder: a review for advanced practice nurses. Journal of the American Association of

Nurse Practitioners, 530-542. http://doi.org/10.1002/2327-6924,12275