Mental Health Case Study

Alaina Lytle

Youngstown State University

Abstract

D.C. is a schizophrenic patient brought into the emergency department multiple times

with suicidal ideations and attempts. He has been in and out of psychiatric facilities

since the age of 11. He has history of substance abuse, hypotension, bipolar 1, obesity,

insomnia and dyslipidemia. He is seen for the noncompliance of his medications, leading

him to have hopelessness and depression. During both admissions, we see two different

sides of him.
1. Objective Data

D.C. is a 48 year old male diagnosed with schizophrenia. D.C. was brought into the

emergency department on February 17th, 2021 for a suicide attempt. According to the

patient, he did not want to live anymore and took 136 pills to end his life, instead he

ended up in the emergency department and put onto the psychiatric floor. Once he was

brought onto the floor he was lethargic, going in and out of consciousness. From there he

was sent to a medicine floor to detox before being put back on the psychiatric floor.

When on the floor, the patient attended group therapy sessions, socialized with other

patients and grew his relationship with God. He used this as a coping mechanism and a

way to redirect his thoughts. His medical history includes, hypotension, AKI, Bipolar 1,

obesity, insomnia, dyslipidemia and PYSD. While talking to the patient he appeared

ready to move on with his life and live a better life while helping others. He had a plan to

go back to school for ministry and use that education to help those in the prison systems

in the Warren area. He thought that by being in prison in the past, it would help him get

through to the men and women he preached to. While on the floor the nurses put him

under the unit restrictions and patient self harm precautions for his suicide attempt. When

being put on medications he stated that he wanted to start over and none of them were

working, so the doctor started him on multiple new medications. He was put on buspirone

10 mg three times a day for anxiety, clozapine 25 mg per day for schizophrenia,

duloxetine 30 mg two times a day for depression, famotidine 2 mg a day for acid reflux,

haloperidol 2 mg as needed for an acute psychotic break and chlordiazepoxide 25 mg a

day for withdrawal symptoms. When it comes to his medications it is important to check

the patients WBC because buspirone is know to tank WBC. For this visit, D.C. was on
 the floor until February 23, 2021 where he was discharged home on the current

medications. His Lithium level was also to be checked to ensure he was not in the toxic

level. The normal levels for Lithium are 0.6 to 1.2.

Following the previous admission, D.C. was brought in again to the emergency room on

March 1, 2021 for a suicidal ideation. He sent multiple texts to his friend stating that he

needed to get out of Ohio or he was going to end his life. From the emergency

department he was voluntarily committed to the psychiatric floor. Unlike he previous

admission, he would not talk to anyone. When one would try to talk to him he would

stray away from the conversation. His body language was completely changed from

engaged to leaning away, not answering questions while carrying a careless look. He also

refused to talk to the doctor about his goals for treatment. The doctor discontinued all of

his medications and because of him refusing to speak to anyone he was not started on any

new medications. On this admission he was positive for benzodiazepines, cocaine and

cannabis. This admission he appeared homeless, whereas last admission was telling

nurses he had an apartment on Park Ave.

2. Summarize the psychiatric diagnoses and the expected/common behaviors with citations.

Schizophrenia is a mental illness that affects a persons thought process, their feelings and

how they behave. These patients have lost touch with reality and “causes significant

distress for the individual, their family members and friends” (National Institute of

Mental Health). It is normally diagnosed from ages 10-30 but can come on at any time.
 Symptoms one would expect to see would be altered perceptions including hallucinations

or delusions, loss of motivation, socially withdrawn and a flat affect.

Bipolar 1, another disorder D.C. was diagnosed with is defined as a “mental health

condition that causes extreme mood swings that include emotional highs and lows”

(Mayo Clinic). Symptoms include having a manic episode followed by a major

depressive episode. The manic stage can be seen as abnormally upbeat with extreme

energy and racing thoughts. The depressive stage is where the patient has no interest or

pleasure. We can see insomnia, sadness, fatigue or worthlessness. This stage can lead to

suicidal ideations.

3. Identify stressors that may have lead to current hospitalization

Leading up to both of D.C.’s hospitalizations he had experienced a lot of loss. In the past

year he lost an Aunt and his father along with loosing his job. A week before his first

hospitalization his truck broke down and he was unable to fix it. He stated that there was

just too much going on in his life at once. After he was discharged, it was suspected that

another patient on the floor was planning on going to live with him. A couple days before

he was brought back in, it was brought to our attention that the patient he was close with

overdosed and passed away. This could have been the reason for him being brought back

in within a couple days of leaving.

His history that was discussed in his first admission was him being in and out of

psychiatric facilities since the age of 11. He claims that during college he had a sponsor
 who helped him stay sober. This sponsor happened to be his paster. When D.C. got

divorced, the sponsor dropped him because it was against his religion to get a divorce.

4. Identify family history of psychiatric illness

To my knowledge there was no family history of mental illness.

5. Describe the psychiatric evidence based nursing care provided and milieu activities

attended.

Over the course of D.C.’s first admission, he attended many of the group therapy

activities. Here he learned about coping skills, how to manage anger and how to

communicate with others in a stressful situation. Milieu activities include using a low

stimulating environment. On the psychiatric floor the walls are a nude color and low

stimulating games are placed on the tables such as cards and puzzles.

On D.C.’s second admission he was not participating in any of the activities that were

offered to him. He also was not a part of the social interaction on the floor. he came out

of his room to eat and then immediately returned when he was finished.

There are many evidence based practices that are used to help those with schizophrenia

disorder. A recent study has shown that using a mirror therapy has helped patients who

suffer from chronic hallucinations. The nurses used a series of patients and gave them a

mirror to look at themselves. This helped “the patient suppress her visual hallucinations

by enhancing a different visual stimulus” (Shu-Ling, 2018). This is another way to

redirect the patients focus. We have learned that in patients with a lost sense of reality we

have to reorient them. Normally this is done with words, but with this study we can see

that using a mirror to represent what the actual reality is helps patients visually see it.

many times when we disagree with schizophrenic patients they could become paranoid

and think we are out to get them. This idea allows them to physically see what we are

seeing and bring them back to reality.

Milieu therapy is seen as the use of “environmental modification and structuring ward

activities, establishing interaction with patient and teaching caregivers on managing

conflict behavior of patient” (Bhat, 2020). Milieu is a way of providing the patients with

a calming environment to promote healing, mentally and physically. When it comes to a

schizophrenic patient, supplying them with milieu therapy rather than being placed on a

traditional hospital floor allows them to advance in their treatment faster. An experiment

was done that placed schizophrenic patients in a psychiatric floor with milieu therapy and

a traditional floor to see how it compared. The results showed that the “experimental

group participants showed decrease in aggressive behavior, self-harm behavior and

general rule breaking behavior at baseline and 2nd, 3rd and 15th day” (Bhat 2020). The

experimental group was the group that was experiencing milieu therapy. This shows that

with the calming affect of milieu it allows the patient to feel reality faster and be a calmer

and less aggressive patient for the staff to take care of. When these patients are placed in

a traditional hospital room with no interaction with others, they become aggressive and

agitated because they have nothing else to do but think about the voices in their heads,

which in a schizophrenic may not be reality.

6. Analyze ethnic, spiritual and cultural influence that impact the patient

D.C. states that he is a Christian. He uses his religion to ground him and bring him back

to reality. His first admission, he stated that whenever things were hard, he took out his

coin with Jesus’ face on it. He claimed that having this brought him back to the reason for

living and that he had a purpose in life and that was to be fulfilled with Jesus. On the first

admission he used his religion to inspire him to go back to school so he could preach in

the prison systems and help people that were in the same situation he had previously been

in.

Using Christianity as a coping skill allows the patients to take their mind off of the past

and future and reminds them to remember the right now. As a Christian, you are not to

focus on what happened in the past or what is going to happen because that is all out of

your control. Christians believe that God is in charge of everything that happens in their

life and that they should cast all of their cares to him and not worry about them. 1 Peter 5:

6-7 states, “Therefore humble yourself under the might hand of God, that He may exalt

you in due time, casting all your care upon Him, for He cares for you”(1 Peter 5: 6-7). In

other words, casting all of ones stress and anxiety on God allows that person to focus on

the present and not have stress about what is yet to come. In a study, Christians are used

and placed in a series of traumatic events which included natural disasters, car accidents,

the death of loved ones, assault and abuse (Knabb 2019). They found that using God,

refocused the adults minds from the typical “why” and “what if” questions (Knabb 2019).

It allowed them to have mindfulness skills such as attention, present focus, awareness and
 acceptance (Knabb 2019). Therefore, as Christians believe, they should “set their minds

on things above” (Colossians 3:2).

A cultural component of D.C. that could impact him would include his tattoos. He

presents with tattoos covering his whole body including his face. He stated that he lost his

job recently and that it had been hard to find another job since then.

7. Evaluate the patients outcomes related to care

During the first admission, the patient met all the desired outcomes that were needed for

discharge. He was taking his medications, going to group therapy and stating that he had

goals in life and that he wanted to live. He was able to talk to the nurses about his

feelings and the events that lead him to the emergency room with an attempted suicide.

He understood all of his medications and the importance of compliance with the

medications to further his treatment.

However, on D.C’s second admission a couple days later his progress did a turn. He was

not attending any group activities, he was not willing to talk to anyone about his

treatment or what brought him in and he was not taking any medications. This made the

doctors and nurses questioned his personality and how well he played along with

treatment in his first admission.

Noncompliance with medications is one of the biggest reasons for 30 day readmit in the

psychiatric hospitals. Most patients think that when they are not having symptoms

anymore they can discontinue their medications. Antipsychotics, used to treat

schizophrenia are known for the abundance of side effects they come with. They can

cause the patient to gain weight, sexual dysfunction and many more. Knowing these side

effects ahead of time may allow the nurses and doctors to observe the patients reaction

and predict noncompliance. Patients with schizophrenia have an even harder time

complying to their medication regimen. This is because these patients have a “lack of

illness awareness, the direct impact of symptoms, social isolation, comorbid substance

misuse, stigma and the increasing fragmentation of mental health services in many

countries” (Haddad 2014). In other words, the schizophrenic patient has a loss of reality

and is unaware that they have an illness and are unwilling to believe that they do. In a

study that looked at multiple schizophrenic case studies and noncompliance they found

“a mean rate of medication nonadherence in schizophrenia of 41.27%” (Haddad 2014).

This noncompliance is the reason for the multiple thirty day readmits in these patients.

When they stop taking their medications, they have an acute psychotic break leading

them to do harmful things to themselves or others, which brings them back into the

hospital. D.C. is a great example of this. His first admission he had a suicidal attempt.

When brought onto the psychiatric floor he talked to the doctor and told her to switch all

his medications because he did not like them. The doctor did this and got him back on his

feet and discharged him. Sometime in the next three days, he stopped talking his

medications and became severely depressed again and threatened suicide. This made

three trips to the psychiatric floor for D.C. most likely due to noncompliance of his

medications. Being able to find out why he is noncompliant with his medications would

be a good place to start. Knowing the side effects that he is facing can help the doctors

switch medications for him.

8. Summarize the plans for discharge

The plans for discharge for the patients first admission included being discharged to

home on the medications he was prescribed. He was supposed to have an appointment

with the resident on the case for a following up and to get labs drawn. He needed labs

drawn after the first admission because of the risk of buspirone significantly decreasing

his white blood cell count. He was educated on the signs and symptoms of this

happening, such as flu like symptoms, fever and fatigue.

As for his next admission, he did not have any plans for discharge in place since he

would not talk to anyone about his goals for treatments. There needed to be more

investigation in his home life because this admission he appeared homeless.

9. Prioritized list of all actual diagnoses using NANDA

1. Suicidal Attempt/Suicidal ideation

2. Schizophrenia

3. Bipolar 1

4. Hypotension

5. Obesity

6. PTSD

7. Insomnia

8. Dyslipidemia

10. List of potential nursing diagnoses

Disturbed Sensory perception: visual

Impaired Social Interaction

 Interrupted Family Process

Defensive Coping

Risk for Self-harm

Disturbed Thought Process

Hopelessness

11. Conclusion

Overall, D.C. is a 48 year old male with chronic schizophrenic in need of constant

medical care. His multiple admissions to the psychiatric floor for suicidal attempts and

ideations show his noncompliance with his medications. He also seems to be able to hide

his personality to the doctors and nurses on the floor leading to him being discharged.

Because of the medications he is on, such as buspirone, he needs to see a doctor once a

week for lab draws in order to make sure the medication does not drop his white blood

cell count. In order for this to happen he needs transportation, which should be set up by

social workers. They could also consider a group home for others with the same mental

illness as him. This could help with his feeling of hopelessness and know that he is not

alone in anything that he is going through. His main problem would be his disturbed

thought process and not using his coping skills. He is able to describe his coping skills,

but it seems as if he cannot use them to the fullest potential. He also seems to have no

support system in place besides the friend that he texted about ending his life. Having a

support person or system with a mental illness is very important. It gives the patient

someone to talk to about what they are feeling and gives an extra eye on medication

adherence.
 Resources

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“Bipolar Disorder.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 16 Feb. 2021,

www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955.

Haddad, P., Brain, C., & Scott, J. (2014, June 23). Nonadherence with antipsychotic medication in

schizophrenia: Challenges and management strategies. Retrieved March 11, 2021, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4085309/

Knabb, J., Vazquez, V., & Pate, R. (2019). “Set your minds on things above”: shifting from trauma-

based ruminations to ruminating on God. Mental Health, Religion & Culture, 22(4), 384–399.

https://doi-org.eps.cc.ysu.edu/10.1080/13674676.2019.1612336

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2020, www.nimh.nih.gov/health/topics/schizophrenia/index.shtml.

Shu-Ling LAN, Yu-Chi CHEN, & Hsiu-Ju CHANG. (2018). Nursing Experience of Using Mirror

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