RUNNING HEAD: MENTAL HEALTH CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Andrew Makosky

Mental Health Clinical, Spring 2020

Mr. Michael Criscione

February 11, 2020

1
RUNNING HEAD: MENTAL HEALTH CASE STUDY

ABSTRACT

A.H. is an 18-year-old male patient transitioning to a female admitted to the psych unit from the

emergency department on an involuntary hold on 1/23/20. Parents brought A.H. to the

emergency room because A.H. had suicidal ideations with a plan to cut self. Patient stated, “I

wanted to take something sharp from school and hurt myself.” Patient was also labile. Patient

denies any hallucinations. She is a Junior in high school and spent 13 days in Windsor

Laurelwood Center for Behavior Medicine prior to this incident.

2
RUNNING HEAD: MENTAL HEALTH CASE STUDY

OBJECTIVE DATA:

A.H. is an 18-year-old male transitioning into a female who was admitted to the psych

unit from the emergency department on an involuntary hold on 1/23/20. On 1/24/20, the date of

care A.H. stated to me that she had a rough day yesterday which was the date of admission. She

was crying and severely depressed. She does feel better so far today. She can tell that she is

starting to think more positively. A.H. explained to me that she is a male but is transitioning to a

female. She prefers to be called by the female version of her name. She explained that she

doesn’t know why but she just feels right being feminine. Patient does not think parents

understand her feelings or they just don’t want to believe it. They are not very accepting of her

transitioning process.

After asking the patient why they came into the emergency room she stated wanted to

take something sharp from school and hurt herself. A.H. denies hallucinations. She has a

psychiatric doctor and was recently in Windsor Laurelwood Center for Behavior Medicine 13

days prior to turning 18. Patient was also at Belmont pines before. Patient reports no smoking,

no alcohol use, but does report using marijuana recreationally. Patient reports being depressed

for 3 years but only having suicidal ideations for the past few days. Patient has reported past

physical abuse that her mom hit her with objects, but this was never reported before. She

reported that she was raped last summer when she was 17. This was also never reported before.

She reports that she suffers from gender dysphoria, attention deficit disorder, attention deficit

hyperactivity disorder, post-traumatic stress disorder, and major depressive disorder. The gender

dysphoria was reported to be the main reason for wanting to self-inflict harm.

The behaviors that I observed by the patient were pleasant. A.H. was friendly and had a

soft tone of voice. She sates that she is very friendly and caring and is very open to any

3
RUNNING HEAD: MENTAL HEALTH CASE STUDY

questions. She just feels that people judge her without asking questions. She feels that people

just assume things about her. A.H. seemed to be cleaned up, bathed, and organized. A.H. also

tolerated food and drinks well. She reports that sometimes she feels sad and doesn’t want to eat

but other times she will eat food when she is stressed and use that as a coping mechanism. A.H.

has a depressed facial expression, relaxed posture and gestures, dresses neat, does not seem to be

restless, and has a friendly demeaner. She answers direct questions and has appropriate eye

contact.

A.H. takes multiple prescribed medications. Benztropine mesylate (Cogentin) is a

medication used to decrease tremors. Bupropion (Wellbutrin XL) is an antidepressant.

Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor used to treat depression and

generalized anxiety. Hydroxyzine (Vistaril) is used to treat anxiety. Olanzapine (Zyprexa) is an

antipsychotic used to treat mental disorders. Trazadone (Desyrel) is a sedative and

antidepressant.

SUMMARY OF PSYCHIATRIC DIAGNOSES:

A.H. presents with:

Depression (Major depressive disorder), Harvard Health defines as:

In major depression, the most prominent symptom is a severe and persistent low mood,

profound sadness, or a sense of despair. The mood can sometimes appear as irritability.

Or the person suffering major depression may not be able to enjoy activities that are

usually enjoyable.  Major depression is more than just a passing blue mood, a "bad day"

4
RUNNING HEAD: MENTAL HEALTH CASE STUDY

or temporary sadness. The symptoms of major depression are defined as lasting at least

two weeks but usually they go on much longer — months or even years. (Harvard, 2018)

Gender Dysphoria, American Psychiatric Association defines as:

Gender dysphoria involves a conflict between a person's physical or assigned gender

and the gender with which he/she/they identify. People with gender dysphoria may be

very uncomfortable with the gender they were assigned, sometimes described as being

uncomfortable with their body (particularly developments during puberty) or being

uncomfortable with the expected roles of their assigned gender. People with gender

dysphoria may often experience significant distress and/or problems functioning

associated with this conflict between the way they feel and think of themselves

(referred to as experienced or expressed gender) and their physical or assigned gender.

(Parekh, 2016)

STRESSORS AND BEHAVIORS:

A.H. presented with many stressors and behaviors during her current hospitalization.

A.H. stated she was crying and severely depressed on the date of admission. She felt that she

just couldn’t control her emotions. A.H. was more positive on the date of care but still seemed to

be depressed and down on herself. The main stressor that she had was going through a gender

transition from a male to a female. A.H. stated that this is the reason she feels depressed. She

feels that family and friends do not understand her feelings. She does not believe that they are

accepting of who she is. She just feels right being feminine and wants to remain that way. The

5
RUNNING HEAD: MENTAL HEALTH CASE STUDY

behaviors that were presented during current hospitalization were a depressed facial expression,

relaxed posture and gestures, dresses neat, is not restless, and has a friendly demeaner. She

answers direct questions and has appropriate eye contact.

PATIENT AND FAMILY HISTORY OF MENTAL ILLNESS

A.H. does have a history of a mental illness. She was previously in Windsor Laurelwood

Center for Behavior Medicine for 13 days prior to this incident. She previously went to Belmont

pines before turning 18. A.H. also is seen by a psychiatrist. Depression was found to be shown

in her family history. Mother was diagnosed with depression. No other family members were

found to have a history of mental illness.

PSYCHIATRIC EVIDENCE BASED NURSING CARE:

A.H. has attended all mandatory group sessions since admission to the mental health unit.

She states that she plans to keep attending all meetings going forward because she enjoys being

able to talk about her problems and relate to other patients. The mental health unit has many

different activities for the patient. The activities include television, board games, playing cards,

coloring pages, workout equipment, and a small library reading area. All of these activities aide

in maintaining the milieu environment. During group sessions the group leader will ask open

ended questions involving the patients struggles. This will lead to the patients conversating

about their problems. The group leader will also ask each patient their own personal goal for the

rest of the day. A.H. stated that her personal goal was to “keep thinking positively.” The nurses

also play a huge role in the health care team. The nurses are able to monitor patient behaviors,

administer medications, and provide medical treatments.

6
RUNNING HEAD: MENTAL HEALTH CASE STUDY

ETHICAL, SPIRITUAL, AND CULTURAL INFLUENCES:

A.H. is impacted by spiritual and cultural influences. She stated that she does not believe

in a religion currently. Her family is Catholic and believes that they do not accept her transition

process. A.H. believes that she is also influenced by her peers in high school. She feels that

people just judge her and assume things without asking.

PATIENT OUTCOMES:

After observing and communicating to A.H. for the day I believe she does suffer from

depression and gender dysphoria. She has not had any hallucinations or suicidal ideations during

admission and states she is going to comply with her new medication regimen in hopes to feel

better. When asked what plans they have when they get out of the hospital, she stated to me that

she plans to remain playing the trumpet in the marching band and finish high school. She would

like to attend college in state and study either writing, arts, music, or music technology. She

thinks that she will be leaning towards wanting to get a music technology job working with

producers and streaming services. Overall, she feels that she is thinking more positively than

before.

NURSING DIAGNOSIS:

Risk for self-directed violence related to depression as evidenced by wanting to take

something at school and cut herself. (Martin, 2019)

 Patient will seek immediate help from others when experiencing any self-

destructive impulses

7
RUNNING HEAD: MENTAL HEALTH CASE STUDY

 Patient will identify at least 2 to 3 people she can seek out for support or

emotional guidance

 Patient will demonstrate compliance with medication regimen

Chronic low self-esteem related to feelings of shame as evidenced by negative view of

self. (Martin, 2019)

 Patient will express belief in self

 Patient will identify 1 or 2 strengths by the end of the day

 Patient will identify 1 or 2 realistic goals by the end of the day

Disturbed thought process related to depression as evidence by impaired decision

making. (Martin, 2019)

 Patient will demonstrate an increased ability to make appropriate decisions when

planning with the nurse.

 Patient will show improved mood

 Patient will refrain from irrational thoughts

POTENTIAL NURSING DIAGNOSIS:

 Anxiety related to situational crisis as evidence by disorganized thought process.

(Vera, 2019)

 Social isolation related to past experience of difficulty in interaction with others

as evidence by insecurity in public. (Vera, 2019)

 Self-care deficit related to withdrawal as evidence by lack of interest. (Vera,

2019)

8
RUNNING HEAD: MENTAL HEALTH CASE STUDY

CONCLUSION:

After observing and communication with A.H. I believe it would be best for her to

continue receiving psychiatric therapy and to follow up with her psychiatrist. The main reason

she is here is for depression and risk for self-harm. She has not had any suicidal ideations since

the day of admission and is starting to think more positively about her current situation and

gender transition process. I believe that if she is able to learn healthy coping mechanisms and

maintain a scheduled antidepressant medication regimen that she will do much better at home

and school.

9
RUNNING HEAD: MENTAL HEALTH CASE STUDY

References

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: an evidence-based guide to

planning care. St. Louis, MO: Mosby/Elsevier.

Harvard Health Publishing. (2018, December). Major Depression. Retrieved February 11, 2020,

from https://www.health.harvard.edu/a_to_z/major-depression-a-to-z

Martin, P. (2019, November 4). Major Depression Nursing Care Plans - 9 Nursing Diagnosis -

Nurseslabs - Page 5. Retrieved February 11, 2020, from https://nurseslabs.com/major-

depression-nursing-care-plans/5/

Parekh, R. (2016, February). What is Gender Dysphoria? Retrieved February 11, 2020, from

https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-

dysphoria

Vera, M. (2019, April 11). 7 Anxiety and Panic Disorders Nursing Care Plans - Nurseslabs - Page

6. Retrieved February 11, 2020, from https://nurseslabs.com/anxiety-panic-disorders-

nursing-care-plans/6/

10