Mental Health Case Study

Jessica Chaney

Youngstown State University

CASE STUDY 2

Abstract

This case study looks at a young adult female patient that has been diagnosed with bipolar and

anxiety disorder who has discontinued her medications. With this we can see how important

medication compliance is and how it had an impact on her mood and even daily life.

Precipitating factors are discussed and how they have affected her by increasing her anxiety and

depression with suicidal thoughts. The important criteria for being diagnosed with bipolar and

anxiety disorder are pointed out and what signs and symptoms she exhibits. Her past mental

illnesses and hospitalizations are observed and their impact over the years are discussed. With all

the information obtained from the client a proper plan of care could be put into place as well as

planning for discharge.

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Objective Data: Describe the patient using date of admission data, date of care data, psychiatric

diagnosis criteria, laboratory results. Include behaviors observed on admission and the day(s) of

care, medical conditions and treatments, safety and security measures maintained, prescribed

psychiatric medications and reasons:

The patient, a young female discontinued her medications and stopped attending her

appointments four months ago when she moved to Bellaire OH. In those past four months she

stated she’s been feeling down with an increase in her depression and suicidal thoughts. Due to

these feelings she felt that it was best to bring herself to the hospital so that she could not get

back onto her medications. Upon admission to the hospital she voiced multiple suicidal thoughts

and said her anxiety and stress are increased due to frequent arguments with her mother while in

her current living situation. She is currently living in one room with her mother and father at the

Salvation Army. Then her depression was increased due to her son being taken away from her

five months ago. The patient said her mood fluctuates and she has racing thoughts, feels very

impulsive, has trouble falling asleep sometimes and rated her depression an eight out of ten and

her anxiety a nine out of ten. She also stated that she gets images of hurting other people. It was

noted that she has bilateral scars from cutting and has not been caring for herself. She ended up

being diagnosis with diabetes which has been uncontrolled. Studies show “The prevalence of

diabetes in patients with anxiety disorders was higher than that in the general population” (Chien

2016 p. 49).

When I spoke with the patient personally, I didn’t hear the exact same story that was in

her H&P notes. She told me she brought herself to the emergency room because she was “wasn’t

feeling right and was depressed” and that she knew she needed to get back on her medications.
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Then she proceeded to tell me that her, her son, her mother and father all lived together in the

same home but left out that it was actually a room at the Salvation Army and that her son was

taken away. When I asked her if she had thoughts of suicide she denied and said she has never

felt that way before and would never want to kill herself. She did tell me that things are rough

with her mom and that her anxiety and depression have increased since being off her

medications. She also voiced that she didn’t like her son’s father and that she would like to

“drown him just for a minute, but not kill him.” Some information she told me lined up with her

notes while other pieces of information did not.

She has been diagnosed with bipolar disorder and anxiety disorder. Bipolar disorder is

defined in the DSM 5 as an individual that has at least one hypomanic episode (a less serious

form of mania) and at least one major depressive episode (American Psychiatric Association,

2013). While anxiety disorder is defined as “the presence of excessive anxiety and worry about a

variety of topics, events, or activities. Worry occurs more often than not for at least 6 months and

is clearly excessive. The worry is experienced as very challenging to control. The anxiety and

worry are accompanied with at least three of the following physical or cognitive symptoms:

edginess or restlessness, tiring easily; more fatigued than usual, impaired concentration or feeling

as though the mind goes blank, irritability, increased muscle aches or soreness, and/or difficulty

sleeping (American Psychiatric Association, 2013).

When the patient arrived at the hospital labs were drawn on her to check her CBC, urine

and toxicology report. Almost all of her labs were normal. The only ones that differed where

creatinine which was slightly elevated at 0.42 (0.52-1.04) and could be due to a decrease in her

kidney function. Her glucose was elevated as well at 287 (74-106) which takes in account for her

uncontrolled diabetes. Then she was positive for THC which she stated she uses occasionally.
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Behaviors upon admission were appropriate especially since she voluntarily committed

herself so that she could get help. She answered all the questions staff asked her and wants to be

a part of her own care. On the day I spoke with the patient she was calm and held a good

conversation, but her eye contact was poor. This is due to poor social skills and insecurity with

telling a stranger all about herself. She was dressed in an acceptable manner and her hair and

nails were kept neat and clean. She was being treated for her diabetes as well as learning how to

take care of it on her own. All safety and security measures were maintained, two staff members

were with the patients at all times in the rec room and they were not given items they were not

allowed to have.

The patient is on two psychiatrist prescribed medications. One is called Cariprazine and it

is given orally in 1.5mg PO daily. This is an atypical antipsychotic that is used for her bipolar

disorder, it helps restore the balance of natural substances in the brain. She also takes

Propranolol and it is given orally in 10mg PO BID. This is a beta-blocker and it is used to help

with her anxiety, it works by slowing down the body.

Summarize the psychiatric diagnosis and expected/common behaviors, with citations:

According to Townsend and Morgan (2017) “Bipolar Disorder is characterized by mood

swings from profound depression to extreme euphoria (mania) with intervening periods of

normalcy” (p.419). There are two different sets of symptoms that go along with bipolar disorder.

Mania causes more noticeable problems at work, school and social activities as well as

relationship difficulties. They also may experience a break from reality (psychosis) and require

hospitalization. Symptoms could include the following; abnormally upbeat, jumpy or wired,

increased activity, energy or agitation, exaggerated sense of well-being and self-confidence,

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decreased need for sleep, unusual talkativeness, racing thoughts, distractibility, and poor decision

making (Bipolar Disorder 2018).

According to Townsend and Morgan “Anxiety Disorder is characterized by persistent,

unrealistic, and excessive anxiety and worry, which have occurred more days than not for at least

6 months and cannot be attributed to specific organic factors” (p.450). Symptoms can vary from;

persistent worrying, overthinking plans and solutions to all possible worst-case outcomes,

perceiving situations and events as threatening, difficulty handling uncertainty, indecisiveness

and fear of making the wrong decision, inability to set aside or let go of worry, inability to relax,

feeling restless, and difficulty concentrating. Some physical signs and symptoms include;

fatigue, trouble sleeping, muscle tension or aches, trembling, feeling twitch, nervousness or

being easily startled, sweating, nausea, diarrhea or irritable bowel syndrome, and irritability

(Generalized Anxiety Disorder 2017).

Identify the stressors and behaviors that precipitated current hospitalization:

The patient has been encountering a number of stressors over the past several months that

lead up to this current hospitalization. One of the first and largest stressors she encountered was

about five months ago when her son was taken away from her. He would have been about one

year old at the time her son was given to his father’s grandparents and she doesn’t have a great

relationship with either the father or his parents. She has been increasingly depressed since he

was taken away and argues with her sons’ father about the correct way to raise him. She stated

he is a womanizer and doesn’t take care of their child the way an adult should. During this time,

she also became homeless and was placed with the Salvation Army. “Based on perceptions of the

individual, beginning and sustaining metal health recovery may be more difficult for people who
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have had a more extensive history with homelessness” (Castellow, Kloos & Townley 2015, p.

681)

Not only is she homeless but her mother and father are as well, and they are all living

together in one room. This small living space increases stress and anxiety for the patient because

she is constantly fighting with her mother about things. The only source of income the family has

is the fathers SSI checks and none of the family members have a job. On top of all of that her

father is in end stage kidney disease and he has to attend dialysis four days a week.

Discuss patient and family history of mental illness:

The patient has a history of violence, self-harm, hospitalizations and more that she

believes stem from an event that happened when she was only nine years old. When she was

nine, her grandmother passed away on Thanksgiving and her grandmother was a very important

figure in her life. This had a very traumatic effect on her and may have caused some of her

depression and anxiety at such a young age. She began self-harm habits of cutting around the age

of twelve and was hospitalized multiple times. It was also noted that she did overdose once but it

did not state what she overdosed on or what age. Moving on later into life at the age of sixteen

she spent fifteen days in Juvey because she became violent towards her mother.

When asked if she had any suicidal thoughts, she stated “they have been coming and

going for the past few months.” She provided information that she had though of a few different

plans that included cutting herself, jumping into oncoming cars on the highway, overdosing on

pills or that she would hang herself. It was determined that she did not have any weapons at

home but that she could carry out a number of these plans. She stated that she sometimes she just

wants to hurt people and gets images of ways to hurt others. She has some physical aggression
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that includes punching people. Before this hospitalization she was at Trinity East approximately

7 months ago and also was seeking health through Coleman professional service when she lived

in Steubenville.

Her family history of mental health consist of two family members on her mother’s side

of the family. Her Aunt has been diagnosed with Bipolar disorder and her cousin has been

diagnosed with schizophrenia. It could be possible that the patient has some type of genetic risk

factor of mental illness that runs in her family, but it could also just be because it is very

common in the general population. It’s hard to say what the exact cause of mental illness is.

Describe the psychiatric evidence-based nursing care provided and milieu activities attended:

All of the care provided to the patient during her treatment is evidenced based nursing

care that will help her attain better outcomes in terms pf symptoms, functional status and quality

of life. Some of the most important factors of the nursing care provided is safety and acceptance.

In order to ensure a patient is safe from harming themselves there are certain measures that are

taken. Beds are low to the ground and fixated on the floor, bathrooms do not have glass mirrors,

trash cans contain paper bags and not plastic and there are no curtains. When a patient arrives,

their belongings are taken to a safe place for storage and anything they could use to harm

themselves with is taken away, like shoelaces and hoodie strings. All of these are precautionary

measures used for not only the patient’s safety but staff and visitor’s safety as well.

Other forms of evidenced-based nursing care that is provided is cognitive behavioral

therapy, this is used to change patterns of thinking or behavior in hopes of changing the way the

patient feels. This is very beneficial to the patient because she struggles with anxiety and

depression. This therapy can help her to work on and understand problems that bother her and
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allow her to develop new strategies for handling them. She does not have the best coping skills

and as long as she will continue to attend these session and meetings once she is released

(Coleman) then this can become very important to her.

One very important factor that goes into all of this evidenced base nursing care is having

a patient who not only understand their needs and problems but one that is willing to take control

of it. Once the patient knows what is going on and how to fix the problems it makes correcting

the issues much easier. A big factor in this is medication management and compliance. In order

for the medications to work and do exactly what they are supposed to a patient must take them

when ordered and make sure she is having routine checkups with her doctors in order to adjust

medications if needed.

On top of all the evidence-based nursing care there are milieu activities that can be used

to boost confidence and social skills. These activities include attending group meetings that

allow them to interact with other people and engage in conversation. They are able to voice their

opinions and ideas which can help them open up. Other therapies used may include art therapy,

music therapy, dietetics, and family therapy. All of these are important aspects to recovery for an

individual and can impact their overall mental health.

It was stated that the patient had attended daily group meetings/activities and engage in

every single one. She always took part when able to and never gave staff problems. She told me

that she was also very happy because since she had been in the facility, she had made a new

friend that she planned on staying in contact with. She also reported how she knew she needed to

follow up with a counselor and even get a social worker to help her out. It seems that all of the

nursing care and activities provided during her stay have been a tremendous impact on her.
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Analyze ethnic, spiritual and cultural influences that impact the patient:

The patient identifies as a Caucasian female who is from Steubenville Ohio. She is

catholic but states she has no spiritual needs and doesn’t affiliate with a specific church. When

going through a crisis situation she doesn’t turn to a higher power for emotional support. She has

experienced cultural bias from a number of people including her mother and this has a large

impact on her mental health. Her mother belittles her and makes her feel as if she is not an adult

who can do as she pleases. When she did have custody of her child, she tried to control what she

did with her son and questioned her every move. This made the patient feel as if she was

constantly being watched and criticized for her decisions. All of this pressure from her mother

just intensifies their unhealthy relationship. Not only does she experience her mother’s cultural

bias, but she deals with very low self-esteem.

Her social skills are poor as she doesn’t make eye contact regularly during a

conversation. She becomes very anxious easily and gets stressed out about things not being done

the way she believes they should be. It was found that people with bipolar disorder have

impairments in the ability to cope with neutral and adverse social situations (Rocca 2008 p. 690).

She completed up through 11th grade but never graduated high school and doesn’t have the

greatest writing abilities. She only enjoys listening to music as a coping skill and it was

suggested to try coloring/drawing. Some negative coping skills she uses are smoking cigarettes

(10 a day) and marijuana on the occasion. She denied any use of alcohol. When it comes to a

support system, the patient is definitely lacking in that department due to her mother’s inability

to help her daughter in positive ways and her father being sick. It was stated that she made some

new friends and will be turning to them in times of need.

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On a positive note the patient does have a great self-efficacy. She is very motivated to get

her mental illness under control with the use of medications and appointments so that she can

better herself in life. Even though others try to bring her down she is still trying to remain

positive during it all. She aspires to go back to school and get her GED so that she can further

her education by going to culinary school. It’s great for her to have a plan in place that she would

like to follow and an understanding of what is going on with her health. Without this she would

not be able to progress further in life and could end up stuck in the same spot she is now.

Evaluate the patient outcomes related to care:

When it comes to evaluating the patient during her time of care, it is seen that she has met

or is going to meet all of her outcomes for bipolar disorder. These include; no harm to self or

others, no signs of physical agitation, eats a well-balanced meal, verbalizes that hallucination

activity has ceased, accepts responsibility for own behaviors, interacts with others and done so

appropriately, and is able to fall asleep and stay asleep. The patient voiced not wanting to harm

herself anymore and that she has been learning about her diabetes and how to control it.

As for the patient’s outcomes related to anxiety disorder these include; being able to

recognize signs of escalating anxiety, maintaining manageable levels of anxiety to make

independent decisions about life situations and, demonstrates more adaptive coping strategies.

The patient is still continuing to work on a lot of these outcomes and has expressed recognizing

stressful situations and how to decrease anxiety. She does need to find some more coping skills

to help manage and relieve stress.

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Summarize the plans for discharge:

Plans for discharge for the patient include being stabilized on her medications and once

that is achieved she will be released and referred back to Coleman professional services. The

main goal here is for her to remain compliant with her medication regimen and to not abruptly

discontinue her meds. Going to Coleman is only going to further benefit her in the long run, as it

was helping her before as well. She spoke of even getting a social worker to help her with

school, finding work, and they should be able to help with getting her son back as well. The

prognosis is very bright for this patient as long as she follows discharge orders and remains

aware of her mental illness and its needs.

Conclusion:

To summarize we looked at a patient who has been diagnosed with bipolar and anxiety

disorder and how it impacts her life. We see how medication compliance is a very important

factor and how easily going off of medications can impact a mental illness. The criteria for both

disorders were explained and how the patient fits the diagnoses. It is also discussed how events

in her life have negatively impacted her and how it will be beneficial for her to continue therapy

sessions as well as acquiring new coping techniques. The patients is showing a great interest in

her mental and physical health which gives a great amount of hope that she will continue on the

prescribed treatment regimen. Once discharged it will be up to her to keep up on her mental

health and prevention of further/future problems.

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Prioritize list of all actual diagnoses using NANDA format:

1. Sensory perceptual alteration related to bipolar disorder as evidenced by auditory

hallucinations to harm others.

2. Fatigue related to depression as evidenced by inability to fall asleep and/or stay asleep.

3. Disturbed thought process related to bipolar disorder as evidenced by hallucinations, and

inaccurate interpretation of internal stimuli.

4. Impaired mood regulation related to bipolar disorder as evidenced by consistent states of

depression with inability to cope.

5. Ineffective individual coping related to inadequate level of confidence in ability to cope

as evidenced by inability to make decisions, poor concentration, and sleep disturbances.

6. Interrupted family processes related to as evidenced by poor communication, and

inability to accept or receive needed help.

7. Impaired social interaction related to lack of support system as evidenced by

dysfunctional interaction with family and avoiding eye contact during conversation.
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List of potential diagnoses:

1. Risk for Injury

2. Risk for violence: self-directed or other directed

3. Risk for suicide

4. Risk for extrapyramidal symptoms

5. Risk for loneliness

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References

American Psychiatric Association. (2013). Anxiety Disorders. In Diagnostic and statistical

manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.dsm05

Bipolar disorder. (2018, January 31). Retrieved from https://www.mayoclinic.org/diseases-

conditions/bipolar-disorder/symptoms-causes/syc-20355955.

Castellow, J., Kloos, B., & Townley, G. (2015). Previous Homelessness as a Risk Factor for

Recovery from Serious Mental Illnesses. Community Mental Health Journal, 51(6), 674–684.

doi: 10.1007/s10597-014-9805-9

Chien, I.-C., & Lin, C.-H. (2016). Increased risk of diabetes in patients with anxiety disorders: A

population-based study. Journal of Psychosomatic Research, 86, 47–52. doi:

10.1016/j.jpsychores.2016.05.003

Comerford, Karen C. Nursing 2018 Drug Handbook. Wolters Kluwer, 2018.

Generalized anxiety disorder. (2017, October 13). Retrieved from

https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/symptoms-

causes/syc-20360803.
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Rocca, C. C. D. A., Macedo-Soares, M. B. D., Gorenstein, C., Tamada, R. S., Issler, C. K., Dias,

R. S., … Lafer, B. (2008). Social Dysfunction in Bipolar Disorder: Pilot Study. Australian &

New Zealand Journal of Psychiatry, 42(8), 686–692. doi: 10.1080/00048670802203426

Townsend, M. C., & Morgan, K. I. (2017). Essentials of psychiatric mental health nursing:

concepts of care in evidence-based practice. Philadelphia: F.A. Davis Company.