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Psychiatric Mental Health Case Study

Madison Scrocco

Nursing Department, Youngstown State University

NURS 4842: Mental Health Nursing

Mrs. Teresa Peck, MSN, RN

March 19, 2020

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Abstract

On February 18, 2020, A.S. was admitted to the Adult Behavioral Health Unit of St. Elizabeth’s

Hospital in Youngstown. He is a young male with an extensive history of mental illness and

many psychiatric hospitalizations. This admission was due to suicidal ideation and an attempt to

kill himself one week prior to seeking medical attention in the emergency department. A.S. was

stabilized on a medical floor of St. Elizabeth’s before his transfer to the psychiatric unit for a

mental health evaluation and treatment. Overall, his objective patient data, psychiatric

diagnoses, stressors leading up to hospitalization, and his prior history will be discussed in great

detail. In addition to this data, the nursing care, influences, evaluations of outcomes, and

existing/potential nursing diagnoses will be covered for this admission.

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Psychiatric Mental Health Case Study

Objective Data

A.S. is a 23-year-old male who was admitted to the emergency department of St.

Elizabeth’s in Youngstown with an involuntary hold on February 11, 2020. He was then

medically stabilized on a general floor before his transfer to the Adult Behavioral Health Unit on

February 18, 2020. The date of care was February 20, 2020; therefore, it was the patients second

day of psychiatric care. He presented to the ED with two self-inflicted stab wounds to the right

side of his neck after a fight with his father. A.S. states that he was about to leave his house for a

date when his father told him he was not allowed to go, and that he would call the police if A.S.

tried to leave the house. A.S. became very stressed out due to the fact that he has multiple

outstanding warrants with the court system, and thought he had no other way to cope besides

killing himself. He has a history of suicidal ideation with attempts, major depressive disorder

without psychosis, cluster B personality disorder, impulse control disorder, and opiate

dependency. In the past, he has sought out psychiatric help at Paramount Advantage, opiate

addiction treatment with Meridian Services, and has been admitted to the Adult Behavioral

Health Unit at St. Elizabeth’s in Youngstown seven times in the last 12 months.

On admission, A.S. had no support system at the bedside. He was depressed, impulsive,

and wanting to self-harm. On the date of care, he was relaxed, but when it came to the

discussion of his past and the stressors that led to his admission he became quite restless. A.S.

had an otherwise neat appearance, with a large scar over the right side of his forehead which he

stated was from his ex-girlfriend hitting him in the face with a broken bottle. He also had

multiple scars on his arms from drug use and self-harm, and the two self-inflicted stab wounds

on the right side of his neck were mostly healed and open to air.
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A.S was friendly and acted in a socially appropriate manner on the date of care but stated

that he was “more emotional than usual” and “depressed and angry” about his multiple court

dates and warrants, which we will discuss further in the stressors and behaviors precipitating

hospitalization section. Overall, he had a pleasurable affect with moments of depression and

anxiety throughout the conversation. A.S. was alert and oriented to person, place, time, and

situation, and displayed an excellent memory of his past with plenty of detail.

As far as lab work, his toxicology screen resulted positive for marijuana and methadone

on admission. Prior to admission he was receiving methadone treatment at Meridian Services for

opiate dependency and continued that treatment in the hospital to prevent withdrawal. He had a

blood alcohol concentration of <.10 on admission which is an insignificant or negative finding.

A.S. had a valproic acid level of 29 mcg/mL on the date of care which is below the therapeutic

level of 50-125 mcg/mL, indicating that he has either been non-compliant with his medication

regimen or it has not yet built up within his system. His white blood cells were low, resulting at

3.7 k/uL, which indicates a high risk for infection. A.S. also had a TSH level of 1.46 mU/L and

a T4 of 6.2 mcg/dL drawn on admission which are both within normal range, ruling out any

thyroid issues that could be causing his anxiety and depression. His blood urea nitrogen (BUN)

level was 25 mg/dL which is higher than normal, indicating kidney impairment likely due to his

history of drug use. A.S. did not have an ALT or AST drawn, so liver function was unable to be

assessed via lab work.

Furthermore, A.S. has an extensive list of prescribed psychiatric medications. For mood

stabilization he is on two anticonvulsant medications, twice a day for each-- both divalproex

(Depakote) and topiramate (Topamax). A.S. has been prescribed the antihistamine hydroxyzine

(Vistaril) three times a day for his anxiety, and the Selective Norepinephrine Reuptake Inhibitor
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venlafaxine (Effexor) daily for depression. To facilitate sleep, A.S. is prescribed the Selective

Serotonin Reuptake Inhibitor trazodone (Desyrel) every night. A.S. is being treated for opiate

dependency with methadone (Dolophine) every day. He also has the typical antipsychotic

haloperidol (Haldol) as needed, either intramuscular or orally, in the event of acute agitation.

Treatments for this patient include medication administration, wound care, and group

therapy sessions multiple times a day. There are many opportunities for group therapy, including

spiritual groups, music therapy, trivia questions, and more. Safety measures are maintained by

visual checks on A.S. every 15 minutes per protocol and removing all objects/belongings from

the patients’ room that could be used to harm himself or others. The unit itself has many safety

features as well, such as slanted doors to the bathroom, pressure sensors on top of the doors,

polished steel for the mirrors, and more. On admission, A.S. had two stab wounds in his neck

paired with a low white blood cell count, so monitoring for infection is crucial.

Summary of Psychiatric Diagnoses

A.S. has several psychiatric diagnoses, many of which he manifested on the date of care.

For starters, he has a diagnosis of Major Depressive Disorder (MDD) without psychosis. He

stated that he had been feeling more emotional than usual on the date of care because of the

discussion regarding his recent charges and court dates. According to the National Institute of

Mental Health, Depression “causes severe symptoms that affect how you feel, think, and handle

daily activities, such as sleeping, eating, or working” (2018). Common symptoms include

persistent sad, anxious, or empty feelings, hopelessness, decreased energy, irritability, and

pessimism. Depression is one of the most common mental disorders in the United States, and
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current research suggests that causes include genetic, biological, environmental, and

psychological factors (2018).

In addition to Major Depressive Disorder, A.S. has a diagnosis of Cluster B personality

disorder. According to the Mayo Clinic, “Cluster B personality disorders are characterized by

dramatic, overly emotional or unpredictable thinking or behavior. They include antisocial

personality disorder, borderline personality disorder, histrionic personality disorder and

narcissistic personality disorder” (2016). Each of the four personality disorders that make up

Cluster B have their own subset of symptoms, ranging anywhere from recurring problems with

the law, to unstable/irresponsible behavior, to emotional lability.

Lastly, A.S. has a diagnosis of Impulse Control Disorder which correlates directly with

his Opioid Dependence. Due to the addictive nature of opioids, most patients who are dependent

upon these substances will do just about anything to get their fix, regardless of the repercussions.

Generally speaking, impulsiveness is a “hasty reaction to an internal or external stimulus without

considering the consequences” (Peters & Soyka, 2018, p. 74). This neuropsychobiology study

also “confirmed that patients with opioid dependence have impaired impulse control which

appears to be related to depressive symptoms” as well (p. 80).

Stressors and Behaviors Precipitating Hospitalization

Before his admission to the hospital, A.S. got into a fight with his father over whether or

not he was allowed to leave the house to go on a date. His father threatened to call the police if

A.S. left the house, and because he is not currently in good graces with the law, he became very

stressed out. A.S. felt that he had no other option than to kill himself, so he stabbed himself in

the right side of his neck twice with a kitchen knife. Last year, A.S. was charged with a second-
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degree felony for felonious assault after getting into a fight with a man who stabbed him. He

served several months in jail and was released on parole. In December he did a 40-day stint in a

drug rehabilitation center, only to relapse for 20 days after he got out. During this relapse A.S.

was charged with Operating a Vehicle while Impaired (OVI), and with possession of drug

paraphernalia, both of which he has court dates for. It is because of all of these outstanding

charges and court dates that A.S. was afraid if his father called the police, they would arrest him

and throw him in jail. A.S. states that if they put him in jail he would get “dope-sick”, which

means he would have to withdrawal from Methamphetamines and methadone with no other

treatments available—in that moment, he thought killing himself was the only way out. His

probation officer is recommending he goes back to a drug rehabilitation facility; however, A.S.

states that he “already learned all of the steps” so it “does not make sense” for him to go back to

rehab. A.S. feels that these recent charges and court dates are the main cause of his stress at the

moment because he wants to sort everything out. His father is also currently battling stage four

Multiple Myeloma, so A.S. is upset about that as well.

Patient and Family History of Mental Illness

A.S. has an extensive history of mental illness dating back to his childhood. Growing up,

A.S. lived in a house with his parents, his aunt, and his two older cousins. His mother has a

history of depression and anxiety, one of his cousins has been a Heroin addict since the age of

16, and his other cousin is a severe alcoholic. A.S. believes that this sort of home environment

“made drug and alcohol abuse seem like a hobby” rather than an addiction. When he was

discussing his drug use and the positive toxicology screen on admission, A.S. says that he was

positive for methadone because he has been a Methamphetamine user for the past few years and
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is trying to stay clean without going through withdrawal. He also “smokes a lot of weed” but did

not seem to think that marijuana was much of a drug.

Psychiatric Evidence Based Nursing Care and Milieu Activities

Nursing care provided for A.S. on the date of care included administration of many

different psychiatric medications, therapeutic group sessions, safety precautions, monitoring of

lab work, and wound care. The medications administered were prescribed for mood

stabilization, anxiety, agitation, and sleep. The group sessions A.S. attended promoted the use of

effective coping skills, and the safety precautions in place protect the patient against potential

self-harm. Wound care is performed as needed for the two stab wounds on the patients’ neck,

and the multiple wounds on his arms from drug use and self-harm in the past.

Although A.S. was brought into the psychiatric unit on an involuntary hold, he had

complied with the active plan of care and seemed to thrive in the structured milieu environment.

A.S. was very social with other patients and nursing students on the date of care, and his basic

physiologic needs seemed to be met. He had a healthy appetite, snacking on graham crackers

during the interview, and also was one of the first people in line when the nurse began passing

out dinner trays.

Moreover, A.S. was an active participant in the music therapy group session. He was

very talkative and involved, and even shared a few songs that help him decompress during

stressful times. He was also not hesitant to express how the songs that other patients had

requested made him feel. A.S. also stated that he was aware of his maladaptive coping skills, i.e.

drug use and violence, and has been working on more positive ways to deal with his stress. He

states that he often does push-ups and works out in his room while in the hospital, but he
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thoroughly enjoys doing yoga and would like to return to classes once he is discharged. A.S.

also revealed that he does not have a counselor outside of the hospital, but that he would

appreciate if his case manager would assign him to one.

Ethnic, Spiritual, and Cultural Influences

A.S. is influenced by ethnic, spiritual, and cultural influences, although his is family is

not necessarily involved in the same practices as him. His nationality is Indian, which he states

is why he enjoys yoga so much. He does not speak any languages other than English and does

not have any dietary restrictions or special clothing needs. A.S. states that his family practices

Hinduism; however, he is not as religiously involved as his family. Instead of strong religious

beliefs, A.S. states that he is more of a spiritual person. More specifically, he believes in the

metaphysical concept of a “conscious universe”.

Evaluation of Patient Outcomes

In regard to medication management for A.S.’s depression, one possible outcome is that

he will verbalize an improvement in mood this shift. This outcome was not met due to the fact

that A.S. stated he felt “more emotional than usual” during our conversation, citing specific

feelings of depression and anger. Another outcome related to safety would be that the patient

verbalizes no thoughts of self-harm this shift. This outcome was met. As for group therapy, one

outcome could be the patient demonstrates understanding of positive coping techniques. This

outcome was met. In addition, an outcome of no signs or symptoms of infection this shift is

necessary because of the self-inflicted wounds on A.S.’s neck. This outcome was partially met,
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because although his white blood cells were low, his stab wounds were well approximated, with

no redness, drainage, or foul odor.

Discharge Plan

A.S. plans to discharge home to his father’s house. It is critical that he follows up with

his primary care physician and complies with his medication treatment, as an abrupt

discontinuation of psychiatric medications can put the patient at risk for increased suicidal

ideations. A.S. must also comply with his methadone treatments at Meridian Services so that he

does not withdrawal from opioids. A.S. states that he is very upset with the path he went down

in life and knows that he needs to focus more on his mental and physical health, therefore he

plans to return to college in pursuit of a chemistry or physics degree to “get his life back on

track”.

Prioritized List of All Actual NANDA Nursing Diagnoses

1. Self-mutilation related to Major Depressive Disorder as evidenced by two self-inflicted

stab wounds to the right side of the neck.

2. Disturbed thought process related to Major Depressive Disorder as evidenced by suicidal

attempt.

3. Ineffective coping related to negative role modeling as evidenced by substance abuse.

List of Potential Nursing Diagnoses

1. Risk for low self-esteem related to Cluster B personality disorder

2. Risk for suicide related to Major Depressive Disorder

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3. Risk for self-care deficit related to Major Depressive Disorder.

Conclusion

A.S. is a male psychiatric patient who has been diagnosed with Major Depressive

Disorder (MDD) without psychosis, Cluster B Personality Disorder, Impulse Control Disorder,

and Opioid Dependency. He is at a high risk for suicide due to his depression and past history of

self-harm. His outpatient care will need to be carefully managed, so that future hospitalizations

can be less frequent or avoided entirely. This case study has explored his objective data,

psychiatric diagnoses, stressors leading up to hospitalization, and history of mental illness.

Furthermore, nursing care on the psychiatric unit, influences, evaluation of outcomes, and

nursing diagnoses were also covered in depth. All in all, A.S.’s mental health has shown little

improvement from admission. Hopefully he will comply with his medications and treatment

upon discharge, as well as utilize the effective coping techniques he learned in group therapy.
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References

Depression. (2018, February). Retrieved from https://www.nimh.nih.gov/health/topics/

depression/index.shtml

Personality disorders. (2016, September 23). Retrieved from https://www.mayoclinic.org

/diseases-conditions/personality-disorders/symptoms-causes/syc-20354463

Peters, L., & Soyka, M. (2018). Interrelationship of Opioid Dependence, Impaired Impulse

Control, and Depressive Symptoms: An Open-Label Cross-Sectional Study of Patients in

Maintenance Therapy. Neuropsychobiology, 77(2), 73–82. https://doi.org/10.1159/

000494697