Mental Health: Case Study 1

Mental Health: Case Study

Harlie Silberman

Youngstown State University

Mental Health: Case Study 2

Abstract

J.B. a 36-year-old female was admitted to the behavioral unit on September 15th, 2019.

The patient suffers from bipolar 1 disorder and schizophrenia. J.B. threatened to kill herself

while in the ED for RUQ stomach pains. J.B. lives in a long-term care facility, and has a limited

support system. The patient is noncompliant with medication therapy. Patient is convinced

prescribed medicine and group therapy will not work for her, as she has tried it before. Patient

has a long mental illness history especially with substance and physical abuse.
Mental Health: Case Study 3

Objective Data:

J.B. is a 36-year-old Caucasian women. She was admitted to the inpatient behavioral unit

at Mercy Health St. Elizabeth Youngstown Hospital on September 15th, 2019. The date of care

for J.B. was September 19th, 2019. She was involuntarily admitted. J.B. has known allergies to

amoxicillin, moxifloxacin, bacitracin, clindamycin, cephalexin, neomycin, lidocaine and

sulfadiazine.

Patient was admitted with multiple psychological diagnoses including bipolar 1 disorder,

and schizophrenia. J.B. does have history of rape, drug abuse and suicidal attempts. Patient was

pink slipped after making threats in ED to harm herself. Originally, J.B. was transported to St.

Elizabeth Youngstown ED via ambulance after calling 911 on the evening of September 14th,

2019 about the complaint of RUQ stomach pain that began about a week prior. Later, the ED

staff also found out the patient hadn’t been taking any medications during this period. Patient

resides in a long-term care facility and has a legal appointed guardian.

Bipolar 1 disorder also known as manic depression, it is a disorder related to periods of

highs and lows. Bipolar 1 disorder consists of two major concepts: mania & major depressive

episodes. According to the DSM 5 criteria for diagnosis of bipolar 1 disorder, it includes manic

episodes which must last for at least seven days. Symptoms of mania can include feelings of

euphoria, insomnia, racing thoughts, increased sexual desire, impulsive risk behaviors, delusions,

and hostility (Purse, 2019). Depressive episodes usually occur but are not required for formal

diagnosis. Depressive episodes include symptoms such as hypersomnia, malaise, lack of

concentration, self-harm ideations and loss of interest in daily activities (Purse, 2019).
Mental Health: Case Study 4

The DSM 5 criteria states diagnosis of schizophrenia involves two or more symptoms

such as disorganized or withdrawn behavior, and flat affect over the period of a month or longer,

and at least one of the symptoms must include delusions, hallucinations and/or disorganized

speech (Hurley, 2019). Other factors to look at may be symptoms of disturbed sleep pattern,

disconnection with the self and the people around them, and anger/aggression (Hurley, 2019).

On the night of the patient’s ED encounter, the patient was exhibiting illogical thought

processes, and was very confrontational to all staff trying to help her. After being pink slipped,

the patient’s demeanor did not change on the morning of September 15th. Patient still was

uncooperative, hostile, paranoid, and often argumentative towards other patients and the staff.

On September 19th, 2019, the day of care, the patient seemed cooperative regarding the interview

taking place. However, the patient did show signs of restlessness, and decreased attention span.

Patient was apprehensive at first to talk about herself, however portrayed feelings of grandiosity

about her psychological history throughout the discussion. Patient refused to participate in group

therapy on admission through date of care.

The patient’s treatment and safety measures upon admission to the behavioral unit

consisted of 24-hour observation along with milieu standards of care, medical management,

group therapy, and routine suicide precautions such as no weapons or sharp objects in a patient’s

possession, while admitted on the unit. Along with her psychological issues, the patient suffers

from other comorbidities including Hypertension and ADHD. Due to an unsuccessful suicide

attempt in 2012 and later contracting MRSA, J.B. was forced to have a below the knee

amputation on her left lower extremity. Patient’s labs upon ED encounter came back within

normal limits expect for alkaline phosphatase level which was 111 IU/L and normal is 35-104

IU/L. This could indicate some impaired liver function possibly secondary to Hypertension.
Mental Health: Case Study 5

Also, patient’s drug screen was clear of any abnormalities. Patient is on an anticholinergic,

Cogentin 2 mg IM BID for acute dystonia related to bipolar 1 disorder. Zyprexa (5 mg PO q 4

hrs. PRN & 10 mg IM Daily) & Seroquel (200 mg Nightly PO & 100 mg Daily PO) are

prescribed antipsychotics to help patient deal with symptoms of schizophrenia & bipolar 1

disorder. Desyrel, an antidepressant, is prescribed as 50 mg nightly PRN to help with sleep. The

patient also take melatonin nightly 3 mg PO.

Summarize psychiatric diagnoses & their expected behaviors:

J.B., as stated above, has the diagnosis of bipolar 1 disorder. Bipolar 1 disorder is a mood

disorder than causes unusual shifts in mood, energy, and ability to carry out day-day tasks. There

are 4 types of bipolar disorder. Moods can be described as “up”, or elated and energized behavior

known as manic episodes. Moods can also vary to the total opposite extreme to “down” or

hopeless periods called depressive episodes. These patients will exhibit very opposite symptoms

regarding if they are experiencing a manic or depressive episode (Purse, 2019). Common

behaviors seen with a manic episode may include insomnia, increased activity, irritable, agitated,

feel as though they cannot shut their brain or thought processes off, very ambitious to start

different tasks or projects, and often they will take part in risky behaviors such as gambling or

reckless sex when in this energized state (McCormick, U., Murray, B., & McNew, B., 2015).

These episodes of mania are not attributed to a physiological effect of medications, substance or

another medical condition. A full mania episode will happen during antidepressant therapy, but

continues at a fully syndromal level beyond effect of that treatment is enough evidence for a

manic episode or therefore to be diagnosed with bipolar 1 disorder (Essentials of Psychiatric

Mental Health Nursing, p. 420). Common behaviors with a depressive episode may include
Mental Health: Case Study 6

hypersomnia, malaise, experience feelings of hopelessness, sadness, and emptiness. Also, these

depressive episodes inhibit ability to concentrate, and effective memory cognition. Many of

times these episodes can even progress to feelings and thoughts about death or suicide. These

different episodes can really influence the patient’s ability to function within a family dynamic

and marital relationships, so not only will the patient need individual therapy, but family therapy

as well (Essentials, p. 433).

Another diagnosis J.B. has is schizophrenia. “Schizophrenia is a severe and chronic

mental disorder characterized by disturbances in thought, perception and behavior” (Hurley,

2019). This disorder is characterized by psychosis or experiencing a loss of reality. These

patients may exhibit hallucinations or altered sensory process; sensory input occurs when no

external stimuli exist. Delusions or altered thought processes, (false belief that persists despite

evidence on the contrary) may occur along with hallucinations at the same time. Hallucinations

can be auditory or visual, meaning no one else can hear or feel what the patient can. Other

behaviors include disorganized speech, and/or catatonic behavior with diminished emotional

expression. Schizophrenia prognosis is difficult to predict but a full recovery from this disease is

not common. About 5-6% of schizophrenics die by suicide (Hurley, 2019). Suicidal behavior is

often secondary to the delusions and hallucinations the patient experiences, and the risk for

suicide can be a lifelong battle when living with this mental illness.

Identify stressors & behaviors that precipitated current hospitalization:

On the evening of September 14th, 2019, J.B. was rushed to Mercy Health’s St. Elizabeth

Youngstown Hospital with compliant of RUQ pain that had been persistent for the past week.
Mental Health: Case Study 7

After the hospital performed diagnostic tests such as a CT of abdomen, and pelvis with contrast

did the patient admit to not taking any of her medication for the past week. Patient further

explained during the interview, that the long-term care facility she lives at was giving her lithium

and were not performing proper lithium therapeutic toxicity levels. The patient explained she

understood the risks of lithium destroying the liver so the patient felt it was better to not take the

medication at all. J.B. expressed her unhappiness about the facility she is living in. Patient

explained she didn’t threaten to kill herself; she believes her legal guardian twisted the story and

purposefully put her in the behavioral unit because the guardian is out to get her.

Discuss patient & family history of mental illness:

Patient had claimed she has had prior behavioral unit involuntary holds. Patient even

discussed of serving in the Navy, as being one of the root causes she began her abuse with drugs.

Patient explained as of 2008, she was heavily abusing benzodiazepines while purposefully was

overdosing with intent to commit suicide. J.B. further explained that in 2012, she jumped off a

bridge and broke her leg. Patient states multiple reasons why she jumped off the bridge. She

stated her mother told her to jump. Patient also stated she felt as though she had a parachute on

her back and jumped to reach out to catch something. Patient has long history of mental illness

and suicidal attempts that go along with her psychiatric diagnoses of bipolar 1 disorder &

schizophrenia. Patient also stated that she was raped and it was the best thing to happen to her

because she became a mother to a baby girl. Patient was adopted at age 5, and stated she doesn’t

know much about her maternal and paternal parent’s mental or physical history.
Mental Health: Case Study 8

Describe the psychiatric evidence base on nursing care provided:

The St. Elizabeth Youngstown Hospital behavioral unit provides resources to patients in

a psychiatric emergency. Whether the admission is based on a patient risk for being a harm to

themselves, others and/or so gravely ill they are unable to take care of themselves. Staff

members including nurses, doctors, and aides on this unit provide 24-hour care for the treatment

of mentally ill patients. The staff and patients are acquainted to one another to allow for

therapeutic relationships and open communication for proper healing or overall growth of the

patient. This unit offers a structured schedule including social and work related activities in the

treatment plan. The unit is very safe following all proper procedural safety precautions including

no curtains, or plastic trash bags, weighted chairs, steel mirrors, and weapons or anything a

patient could harm themselves with taken away. This also includes suicide precautions and not

leaving a suicidal patient alone. Each patient’s discharge is overseen by a social worker to ensure

proper resources are used post-hospitalization to encourage healing and prevent readmission to

the unit.

Analyze ethnic, spiritual and cultural influences:

J.B. did mention of spiritual influences as she was brought up in the catholic church. The

patient explained when growing up in Kentucky, she lived a on a farm and was raised by old-

school type disciplining parents. Although she didn’t mention specific cultural influences, the

patient did explain how she wanted to move back to Kentucky with her family. Sadly, all her

family still resides in Kentucky and has no one here in Ohio other than her legal guardian as her

support system.
Mental Health: Case Study 9

Evaluate the patient outcomes:

Patient centered outcomes regarding care on inpatient unit:

1. Develop two coping mechanisms specifically to help with feelings of mania &

episodes of hallucinations and delusions by discharge.

2. Reduce feelings of suicidal thoughts and feelings of hopelessness by

discharge.

3. List three reasons why patient should take medication by discharge

4. Go to at least three group therapy sessions by discharge.

Plans for Discharge:

Patient J.B. said she thought was planning on leaving the psychiatric unit on September

19th, 2019, the same day of care. J.B. explained she didn’t know what was next for her other than

going back to the long-term care facility she resided in before admission. J.B. explained she

didn’t understand the whole reason she had been admitted and has learned nothing from her

experience. Patient explained she was still feeling the stomach pains she experienced at the ED

on that September 14th evening. At the end of the interview, the patient became upset after asking

plans or new goals developed while being admitted. After reinforcing to the patient about taking

their medication and the positives that would come, she still refused repeatedly to follow this

recommendation. Patient explained medication she has been prescribed in the past has not

worked and it won’t work this time. The patient further explained no desire to go to group

therapy sessions as they are a “trigger” for her.

Mental Health: Case Study 10

Nursing Diagnosis (Actual):

Based on diagnoses upon admission to behavioral unit on September 15th, 2019, patients

interview, and mental history, there are many nursing diagnosis relevant to this case. The most

important ones include:

- Risk for falls related to impaired physical mobility as evidence by left below the knee

amputation.

- Risk for suicidal behavior related to bipolar 1 depression as evidence by patient

threatening to harm herself in the ED.

- Pain related to somatic symptoms secondary to refusal to taking medication as

evidence by RUQ stomach pain and normal diagnostic workup in the ED.

List of Potential Nursing Diagnoses:

- Risk for violence: self-directed or others directed related to manic and depressive

episodes as evidence by delusion thinking, and provocative behaviors such as

declining to work on her mental health by not going to group.

- Ineffective Individual Coping related to altered mental status as evidence by presence

of delusions that she has her PhD in Computer Science.

- Impaired social interaction related to inadequate emotional responses as evidence by

appearing content when discussing sexual abuse and stating it was the best thing that

ever happened to the patient.

- Ineffective coping related to inadequate support system as evidence by lack of goal-

directed behavior and family living in another state.

Mental Health: Case Study 11

- Deficient Knowledge related to decreased motivation to learn as evidence by

verbalizing refusal to take psychiatric medications.

Conclusion:

J.B. a 36-year-old female was admitted to the St. Elizabeth Youngstown Hospital on

September 15th, 2019. After threatening to kill herself in the ED while waiting on tests for her

initial RUQ stomach pain, she was involuntarily admitted upon her statement and admitted to not

taking medications for the past week. With a lack of support system, and altered mental status

secondary to refusal of medications, the patient has yet to understand her illness. She has a long

history of mental hospitalizations and abuse of substances such as benzodiazepines. Patient is in

a stage of denial as she doesn’t believe she needs her medication. The patient’s lack of coping

skills and impulse control has led her to be wheelchair bound due to a BKA after jumping off a

bridge in 2008. The patient explained that she had not learned anything during her admission to

the unit.