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Comprehensive Case Study

Trevor N. Gump

Youngstown State University: Centofanti School of Nursing

Mental Health Nursing 4842

Mrs. Teresa Peck

Due April 8, 2021

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Abstract

A nineteen-year-old Male of African American decent was brought into the St. Elizabeth
Youngstown Emergency Department by local police after the patient’s mother reports him
vomiting and acting extremely out of character upon returning home from a party. The patient
presented to the emergency room in an agitated and combative state. To ensure personal safety
and the safety of hospital staff, the patient was sedated for the remainder of his stay in the
emergency department. Upon admission to the Behavioral Acute Care Unit on the seventh floor
of St. Elizabeth’s, the patient received a diagnosis of Bipolar I Disorder with psychotic features
to accompany his already existing Attention Deficit Hyperactivity Disorder diagnosis from his
childhood. Of the psychotic symptoms experienced, the most evident were delusions of
grandeur, religious delusions, flight of ideas, and circumstantiality. The patients frequently
expressed verbal agitation, homicidal ideation targeted at specific individuals and/or discomfort
during the interview but did not display any intentions of acting on his thoughts besides the
homicidal remarks.
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Objective Data

On March 25, 2021, I had the opportunity to participate in the interview of a nineteen-

year-old African American male at the St. Elizabeth’s inpatient behavioral/psychiatry unit. He

will be referred to as EH from this point forward. The patient’s diagnosis was Bipolar Disorder I

with psychotic features and concomitant attention deficit hyperactivity disorder. EH had no other

medical diagnoses listened within the electronic health record; however, it was noted that the

patient has a history of combative and violent behavior.

The patient’s date of admission was March 10, 2021. He had been brought into the St.

Elizabeth’s Emergency Department by the local police department. He has since been held under

an involuntarily police hold with all unit restrictions implemented. Upon arrival to the

Emergency Department, the patient had become agitated, belligerent, and violent. After

numerous warnings and redirections, the patient’s behavior warranted involuntary sedation. EH

received what is known as a B-52 while in the emergency department. The mixture contained

50mg of Benadryl, 5 mg of Haldol, and 2mg of Ativan injected intramuscularly in order to

sufficiently sedate the patient to sleep.

EH most recent psychiatric diagnosis was Bipolar I Disorder with psychotic features. He

received this diagnosis upon arrival to the ED and admission to the behavioral floor. The

Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) outlines the criteria

for a Bipolar I Disorder diagnosis and are as follows: The patient must meet the criteria for a

manic episode that may or may not be followed or preceded by an episode of hypomania or

depression. The manic episode must be a period of unexplainable and persistent elevation in

mood or irritability. The episode must last at least seven days and exist for most of each day, if

not everyday entirely. Symptoms so severe that they require hospitalization also maintain
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eligibility for diagnosis. Manic episodes must meet 3 or more of the following criteria, unless

irritability is the only characteristic, then 4 categories must be met. The criteria for a manic

episode are as follows, inflated self-esteem or grandiosity, decreased need for sleep (feeling

rested after 3 hours of sleep), more talkative or feeling pressured into talking more, flight of

ideas or subjective ques that thoughts are racing, increased distractibility whether it be observed

or reported, increase in goal-directed activities whether socially, at school/work, or sexually, and

increased involvement in risky behavior with increased potential for painful consequences

(increased spending, sexual promiscuity, or dangerous behavior). The mood disturbances

involved in episodes in mania must also be severe enough to mark impairment in social and/or

occupational settings or severe enough to warrant hospitalization to prevent harm to the patient

or others. Lastly, the episode of mania must not be attributed to the effects of another substance

or such as drugs or medications or another medical condition such as hypo/hyperglycemia,

hypo/hyperthyroidism, lack of sleep, malnutrition, and/or poor oxygenation (Bipolar Disorder,

NIH, 2021).

After an extended stay in the Behavioral unit of the Emergency Department, EH was

transferred to the inpatient Behavioral Health unit where he began to receive care and treatment

specific to his Bipolar I diagnosis as well as safety precautions to keep himself and the other

patients around him safe. EH underwent preliminary blood work which yielded the following

abnormal results:
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Lab Value Result Reason

Potassium 3.3 Malnutrition
Chloride 92 Malnutrition
Magnesium 2.9 (High) Malnutrition
WBC 18,000 (High) Unknown, may alter LOC
*Glucose 73 (Low) Rule out, may alter LOC
*Hematocrit 44.9 (WDL) Rule out, may alter LOC
*Hemoglobin 15.2 (WDL) Rule out, ay alter LOC
*T4 1.6 (WDL) Rule out, may alter LOC
*TSH 1.470 (WDL) Rule out, may alter LOC
*ALT 34 (WDL) Rule out, may alter LOC
*AST 33 (WDL) Rule out, may alter LOC
**QTc interval 412 (WDL)  509 (High) Baseline EKG for

antipsychotic use.
* indicates the Lab is drawn to rule out the possibility that the psychosis experienced may not be

related mental illness and rather alterations in level of consciousness as a result of the

abnormality or imbalance.

** indicates peculiar finding explained below.

 Upon arrival EH QTc reading was 412 but later jumped to 509. This anomaly may be

a result of the use of the antipsychotic Haldol in the sedative medication used in the

emergency room to calm EH as he became combative and violent.

During the interview with EH he appeared to be fit, well groomed, and was dressed in

two hospital gowns to prevent exposure. His facial expressions were angry in nature his

movements were agitated and mildly restless. Tactilely, the patient was exhibiting fine tremors in

his hands. Patient knocked over a water cup as well as fumbled items in his hands on multiple

occasions. EH denied having any thoughts of suicide or harming himself; however, he admitted

to having some homicidal ideations targeted towards his doctor for “not listening” to the patient
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about his ADHD diagnosis, and a nurse whom he claimed “disrespected” him during a routine

medication pass. EH had a psychotic thought process. He experienced multiple delusions of

grandeur, stating he was a “made-man” referencing the term for a well-known member of the

Italian Mafia. He also stated that he had been given the powers and intelligence from God to read

people and their pasts, indicating the presence of religious delusions. The patient spoke

circumstantially as well. He would often begin to answer a question and trail off down a loosely

related rabbit-hole that would ultimately need redirection to maintain focus. His thought process

was rapid, and his words would tangle or struggle to keep up at points indicating flight of ideas

as well.

After assessment from the physician, EH received orders to receive the following

psychiatric medications.

Generic Name Trade Name Class/Category Dose/Freq Reason for Rx

Clonazepam Klonopin Benzodiazepine 1mg BID Anxiety/agitation
Lorazepam Ativan Benzodiazepine 2mg BID Anxiety/agitation
Ariprazole Abilify Atypical 10mg daily Bipolar management

antipsychotic
Oxcarbazepine Trileptal Mood stabilizer 450mg daily Mood swing control
The patient expressed disapproval of the use of his mood stabilizer as he felt that it made

it harder for him to think and made him feel not himself. He also expressed discontent with his

current medication regime as he believes he required an ADHD medication and not a medication

to treat bipolar disorder. EH also expressed disagreement with his bipolar diagnosis as a whole.

He stated that he was simply angry that no one was listening to him at that he was nearing his

“breaking point”. Since admission, EH has maintained a steady irritable mood, however he was

not as violently agitated as he was while in the Emergency Department.

Bipolar I Disorder Psychiatric Diagnosis

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Bipolar I Disorder is the term now used to refer to Manic Depressive Disorder. With this

disorder the patient experiences manic episodes that manifest as elevated mood, irritability, and

decreased need for sleep. Other symptoms include jumpy/wired/reckless behavior, racing

thoughts, loss of appetite, and feelings of higher importance. Manic episodes must last at least 7

days to warrant a Bipolar 1 diagnosis. These manic episodes may or may not be accompanied by

counteracting depressive episodes. Here, the patient will experience an overall down mood,

apathy, anhedonia, hypo/hypersomnia, loss of interest in previous interests, as well as increased

or decreased appetite, feelings of hopelessness, suicidal ideation, and decreased to absent sex

drive. Hypomania may also be experienced. In hypomania, the patient experiences slight

elevations in mood and motivation that may or may not eb noticed by the patient themselves.

Here, the patient may have an easier time getting started in the morning, pleasant increases in

mood, increases in energy, and other slightly more positive changes that others living amongst

the patient may notice a pattern in.

The manic patient will likely exhibit increased pace of speech, flight of ideas,

partake in risky behavior, survive prolonged periods of time without sleep, and go a few days

without eating. The patient is usually unaware of the fact that their mood has swung to the

extreme of a manic episode resulting in behavior that may negatively impact the patient much

more than they understand at that given moment. For example, patients experiencing a known

manic episode have been known to drink and drive, have affairs, and spend entire life savings. If

left untreated manic patients may approach a manic crisis where their grip on reality begins to

slip. Patients experiencing a manic episode with psychotic features will likely exhibit

hallucinations (visual and auditory are most common) as well as delusions of various types

concurrently. The most common delusions are delusions of grandeur, where the patient thinks
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they are of higher importance, persecutory delusions where the patient believes a larger group is

after them or attempting to hurt them, and religious delusions where the patient believes that god

works through them or speaks to them (Truschel, 2020).

Stressors and Behaviors Prior to Hospitalization

The night of EH admission to the emergency department, he had been out at a party

where he allegedly ingested psychedelic mushrooms containing psylocibin. The patient left the

party and went to his mother’s house where he was reported to vomiting multiple times as well

as acting out of character. He had been exhibiting signs of irritability, anxiety, agitation, and

emotional lability. Ultimately the patient’s mother was required to contact local police services

to help control her son as he became increasingly agitated. EH mood continued to worsen, and he

became increasingly agitated to the point that he began to become belligerent and combative. It

was ordered that he receive an IM injection of Benadryl, Haldol, and Ativan to medicinally

sedate the patient to avoid any harm to himself other members of the hospital staff.

Prior to this hospitalization, EH does not have any history of mental illness or aggressive

behavior. His family is said to have described him as easy going and well mannered. That is why

his abnormal behavior was so evident when the patient arrived at his mother’s house. The patient

lived with his girlfriend and two young children. EH states, “I have a one-year-old baby girl, and

a two-year-old son that can tuck himself in at night”. He graduated high school and was working

to become an independent autobody mechanic prior to the pandemic; however, he is unemployed

at the moment.

Patient and Family History of Mental Illness

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The patient reported to having a history of mental illness in his family. He stated that his

older sister also struggles with Bipolar Disorder and that he has a younger brother who struggles

with a “delusional complex”. There was not too much information regarding the patient’s family

history of mental illness beyond what was verbally shared with us. If the patient does in fact have

a blood relative sibling diagnosed with Bipolar Disorder, it will only strengthen the likelihood

and probability that he too has the disorder for sure.

EH also reported having been ADHD from a young age. He adamantly expressed that his

feelings of anger and agitation stemmed from the fact that he believed that he was not bipolar

and that he simply needed to be medicated for his currently untreated ADHD. The physician that

was managing the care of EH reportedly did not bother to consider or validate any of the

thoughts or concerns that EH had regarding his Bipolar I Disorder diagnosis. In response to the

care given, the patient expressed homicidal ideation directed towards the doctor in charge of his

case. In addition to the homicidal ideation targeted towards his doctor, EH also expressed

homicidal ideation towards another nurse whom he claimed disrespected in the middle of a

routine medication pass.

Psychiatric Evidence Based Nursing Care

The nursing care provided to this patient was relatively routine. EH came to the

floor and was mildly malnourished. Care for him included the use of a calm environment with

minimally intense stimuli, routine medication administration and management, safety

management and monitoring, rehydration therapy via an IV that EH favorite part of care, group

therapy participation, individual therapy, and regular meals.

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Manic patients have a difficult time remembering to eat while experiencing

mania. They are too busy frantically pacing or otherwise preoccupied to notice that they have not

eaten. To combat this, manic patients are given finger foods that they can eat while they are on

the move to avoid furthering their nutritional deficit. Manic patients tend to burn excess calories

on a daily basis due to their increased activity as well, so they need to eat more calorie dense

foods more often to adequately provide their bodies with enough nutrition to maintain their

health.

EH was also prescribed a medication regimen to help control his mood and mania. The

primary medications used for that were ariprazole (Abilify) and oxcarbazepine (Trileptal).

Abilify is an atypical antipsychotic commonly used as the first medication to control psychotic

symptoms in Bipolar patients and schizophrenic patients. It is a common first choice because

Abilify is not believed to have an effect on the QTc interval of the patient. Prolonging the QTc

interval can be dangerous in the elderly as well as patients who also have heart issues,

particularly electrical issues, because farther prolongation of the electrical conduction may cause

sudden cardiac death.

Ethnic, Spiritual, and Cultural Influences

EH was of African American decent and he was a follower of the Christian faith.

Member of both communities are known to be incredibly culturally and group oriented.

Members of the African American community still face many barriers to health care to this day.

Not only will EH be affected by the stigma surrounding a mental illness as severe as Bipolar

Disorder, but he will also have to climb the societal obstacles and socioeconomic disparities
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existing beyond his mental illness as well. According to the National Alliance, members of the

African American community are more likely to maintain a long-term struggle with mental

health and feelings of hopelessness or sadness, but only one out of every three adult African

Americans receive effective and adequate mental health care (Black/African American, 2021)

Evaluate Patient Outcomes

Up to the date of care, EH had not yet met any of patient outcomes selected for him.

Some of the most important outcomes that needed to be achieved were medication compliance,

decrease in overall anxiety, increased use of positive coping mechanisms, and decreased risk of

injury to self or others. EH had been making some progress in terms of levels of agitation as he

was able to maintain conversation and freely walk about the unit, however, more progress is

necessary to make EH a candidate for discharge.

Discharge Plans

Sadly, EH had been on the behavioral unit for over two weeks and there were not

discharge plans too far developed. EH was not showing too much progress in terms of

understanding his thoughts and emotions let alone his diagnosis. He was also reluctantly taking

his antipsychotic medication and mood stabilizer. He claimed that he did not require them as he

was not bipolar, he only needed medication to treat his ADHD. It was still believed that EH may

be a danger to himself or others if his involuntary hold was to be lifted and he were to be

discharged in his current condition.

If the overall condition or level of compliance exhibited by EH does not improve, he will

likely be placed in a more long-term inpatient care facility to help bridge the gap between EH

and his current condition involving mania, psychosis, and delusions to a more stable and
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manageable state that is safe to be amongst the community. The first step would be to ensure that

EH will maintain and adhere to a medication regimen to treat his bipolar disorder and prevent

another manic episode involving psychotic features such as the one he is currently in.

List of potential Nursing Diagnoses

1. Impaired Social interaction
a. Provide environment with minimal stimuli
b. Provide patient with opportunity to solitary activity
i. Patient will participate in group unit activities within 72 hours.
2. Ineffective Individual Coping
a. Administer medications to ensure patient safety
b. Monitor patient for destructive behavior targeted towards self or others
i. Patient will report decreased incidence of flight of ideas and anxiety while
on the unit within 24 hours.
3. Nutritional Imbalance (less than body requirement) r/t mania and paranoia.
a. Supply the patient with finger foods to be eaten while they are moving
b. Monitor patient body weight throughout inpatient care
i. Patient electrolyte values will return to within defined limits prior to
discharge.
4. Risk for Violence
a. Monitor patient for signs and symptoms of increasing agitation
b. Redirect violent behavior in increasing irritation with physical activity such as
walking
i. Patient will not harm anyone while staying on the unit
5. Risk for Suicide
a. Place patient under suicide precautions or an empty secluded room to ensure they
cannot harm themselves
b. Encourage patient to verbalize thoughts and emotions
i. Patient will express no intentions to harm self while staying on the unit.

Prioritized List of Diagnoses

1. Risk for Suicide

2. Risk for Violence

3. Nutritional Imbalance (less than body requirements)

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4. Ineffective Individual Coping

5. Ineffective Social Interaction

Conclusion

In conclusion, I am incredibly thankful for my opportunity to interview EH at St.

Elizabeth’s in Youngstown, Ohio. I am also very appreciative of EH as well for sharing with us

his struggles, trials, and temptations as he begins to navigate some very harsh waters in his early

adulthood years as he adapts to life with Bipolar I Disorder. Though he may have entered the

unit combative, angry, and likely incredibly scared, I believe that EH will begin to understand his

diagnosis and start down the path of recovery and maintenance in the near future.

It is not very often that we as nursing students get exposed to patients experiencing

severe mental illnesses especially those with psychotic features, let alone a patient willing to

speak with four individuals at one time while maintaining their composure. That is what made

this interview and project so useful. It was an experience that we would likely only be able to

experience one time as a nursing student. The lessons learned, insight gained, and understanding

developed now will benefit a struggling individual in the future.

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References

Bipolar Disorder. (n.d.). Retrieved April 05, 2021, from

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Black/African American. (n.d.). Retrieved April 05, 2021, from https://www.nami.org/Your-

Journey/Identity-and-Cultural-Dimensions/Black-African-American

Medically reviewed by: Henry A. Montero. Jessica Truschel. (2020, September 29). Bipolar
Definition and DSM-5 Diagnostic Criteria. Retrieved April 05, 2021, from
https://www.psycom.net/bipolar-definition-dsm-5/

What is Bipolar Disorder? (n.d.). Retrieved April 05, 2021, from

https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders
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Case Study Comment Sheet 4842

Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

__________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format