MENTAL HEALTH: CASE

STUDY
Youngstown State Fall 2020

NURS 4842

Mackenzie Hawk | October 29, 2020

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Mackenzie Hawk Mental Health: Case Study

Objective Data:

The following case study is based on a patient identified as J.H for these

purposes, who was admitted to the St. Elizabeth’s Hospital Mental Health unit on

October the 19th. She is a 35 year old woman who presented to the psychiatric

emergency room with polysubstance abuse and suicidal attempt by controlled

substances and alcohol intoxication. Labs were drawn on this patient to reveal a

positive result for marijuana, benzodiazepines, and a blood alcohol level of 0.28.

The patient initially refused to be swabbed for COVID, which is required for

psychiatric admission, but later tested negative. She also ripped out her

intravenous line and tried to leave against medical advice. To this, the police

responded by redirecting the patient back to her treatment room, resulting in the

patient becoming verbally and physically aggressive. It was noted that she shoved

a couple nurses and was walking down the hallway in her underwear yelling

profanities. After this escalation, security and the nurses put the patient in four

point restraints for the safety of her and the staff. Haloperidol (Haldol) 5 mg dose

was ordered as needed for agitation every six hours. Chlordiazepoxide (Librium)

25 mg was also ordered as needed every six hours to control symptoms of

substance and alcohol withdrawal. The patient reports being prescribed

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Mackenzie Hawk Mental Health: Case Study
lurasidone (Latuda) 60 mg twice daily, oxcarbazepine (Trileptal) 150 mg twice

daily, bupropion (Wellbutrin) 150 mg twice daily, and hydroxyzine (Vistaril) 50 mg

as needed for anxiety. In the hospital, trazodone (Desyrel) 50 mg as needed was

prescribed to help with sleep at night.

Psychiatric diagnoses:

The main psychiatric diagnosis involved in this hospital admission is

polysubstance abuse and cluster B personality. Cluster B personality is

characterized by dramatic, overly emotional, or unpredictable thinking or

behavior. It can include borderline personality disorder, histrionic personality

disorder and narcissistic personality disorder. Polysubstance abuse is the use of

multiple drugs at the same time. The patient also had a diagnosis of bipolar 1

disorder which is defined as a mental health condition that causes extreme mood

swings that include emotional highs called mania and lows called depression.

People with bipolar 1 disorder tend to live most of their days in the manic phase

of the disorder. Some behaviors associated with this disorder typically are mood

swings and possibly suicidal ideation. Going along with the bipolar diagnosis,

depression is a mood disorder that causes a persistent feeling of sadness and loss

of interest that can interfere with daily function. Some symptoms are lack of

motivation to do basic self-care, social withdrawal from friends and family, and
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Mackenzie Hawk Mental Health: Case Study
can include physical symptoms such as headaches, chest pain, and sleep

problems. Mania are periods of great excitement, euphoria, delusions, and

overactivity. Symptoms exhibited during mania include abnormally upbeat or

wired, increased energy or agitation, decreased need for sleep, racing thoughts,

unusual talkativeness, or distractibility.

Stressors and Behaviors:

The background to this admission was precipitated by the recent event of

her boyfriend/life partner of the last eight years being unfaithful in the

relationship. This reportedly is not the first time that he has been unfaithful to

her, and claims they did not agree on an open mannered relationship. She also

told the providers in the emergency room that her 12 year old son had been

giving her a hard time, and the two were stressing her out immensely. She

clarified that her son was not her boyfriend’s son, but that her boyfriend had

been closer than the child’s father throughout his life. The patient identified her

stress coping mechanisms as taking hits from her marijuana vape pen, and going

out to do fun things with her son. In this particular instance, her son was not

home, so she used alcohol to “numb her pain.” Once that proved to be ineffective

in drowning her pain, she resorted to taking a Xanax that her mom had previously

given her to cure anxiety over an upcoming airplane flight. Once that didn’t work,
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Mackenzie Hawk Mental Health: Case Study
she took more and more until she finally felt escaped from her sorrows. The

providers in the emergency room listed her as a danger to herself due to the

ingestion of a toxic amount of drugs and alcohol, but she told them that she had

no reason that she wanted to kill herself, especially since her son was waiting for

her to come home (see Tadros et al, 2020.) This led to her being “pink slipped”, or

involuntarily admitted. She reported most of stress coming from the toxic

relationship, two full time jobs, and unruly son. At this time, I do not believe that

this patient had suicidal ideations or attempt, but I do agree that she was involved

in the depression cycle of her bipolar disorder. Smaller triggers the patient

discussed included things like anxiety when the phone rings too often at work and

other coworkers not pulling their weight. She claimed that she feels pressured to

take over projects if she wants the result to be to her standards.

Patient and Family History of Mental Illness:

The patient’s electronic medical record listed her past psychiatric history as

depression and suicidal thoughts. This history was obtained from one previous

admission back in 2017, and from her continuous outpatient therapy. When

talking to the patient, she mentioned that she had been “in and out of these

places all the time,” but no such history was evident in the Mercy Health record
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Mackenzie Hawk Mental Health: Case Study
system. She, nor the medical record, had any information on her family history of

mental illness.

Evidence Based Nursing Care:

In the emergency room, the nurses attempted to establish a therapeutic

relationship with the patient in order to plan care more efficiently. Unfortunately,

due to the intoxicated state of the patient, this was unsuccessful and she became

a danger to herself and others. Chemical and physical restraints were applied to

the patient to maintain a save environment until the patient could come to a

clearer state of judgement. Once the medications had worn off (both prescribed

and unprescribed) the patient was remorseful of her rowdy behavior. When

admitted to the unit, all patients must undergo a full body search and personal

item inventory to ensure no unsafe contraband is presented to the unit. On the

unit, constant monitoring was put in place to ensure the patient’s safety at all

times. The patient was much more agreeable to the proposed holistic plan of care

once she had withdrawn from the various substances. She participated in all of

the group therapies hosted on the unit, and made daily goals for herself. Her goal

on day of care was to take a step back from her situation to see it for what it

realistically was. A referral to social work was put in place in order to connect the
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Mackenzie Hawk Mental Health: Case Study
patient with resources that would help her with recovery after her discharge. The

patient’s medication were also adjusted by the care providers to better manage

her day to day symptoms of the various mental disorders.

Ethnic, Spiritual, and Cultural Impact:

The patient did not verbalize any ethnic, spiritual, or cultural influences that

impact her or her decision-making process. These do not obstruct or add to the

processing of her mental diagnoses.

Discharge Plans:

As for this patient’s discharge plans, the nurses and doctors did a wonderful

job of care planning for her to lead her in the right direction once she was out on

her own again. For one, the patient was educated thoroughly about any changes

to her medications, and she demonstrated great acceptance of these changes in

conversation. Patients are much more likely to adhere to their treatment regimen

if they are in an active decision-making role, and have adjusted to their

medications prior to being released. Also included was a safety plan for the

patient regarding the assessment of her suicidal behaviors. The patient was

educated on relaxation techniques to help manage and cope with stressors in her

life that cause her anxiety, and was given the suicide prevention hotline as a

resource in the even that she find herself in the same sort of precipitating events
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Mackenzie Hawk Mental Health: Case Study
prior to the present hospitalization. A medication safety plan was advised by

suggesting the patient give her medications to someone responsible she could

trust to ensure that she does not take a toxic amount of them again. The patient

verbalized understanding of the plan of care, although she did express some

concern that she would have to be on these medications lifelong (see Ostrow et

al, 2017.) She was to be discharged to her home once her involuntary hold time

was complete.

Relevant Nursing Diagnoses:

1. Risk for Suicide related to loss of important relationship as evidenced by

suicide behavior and statements of despair.

2. Ineffective Coping related to intense emotional state as evidenced by

anger, hostility, dishonesty, extreme distrust to others, and failure to

achieve an optimal sense of control.

3. Chronic Low Self-esteem related to substance abuse, shame/guilt, avoidant

patterns as evidenced by seeking reassurance, chronic self-negating

verbalizations, and evaluation of self as unable to deal with events.

4. Interrupted Family Processes related to addictive personality, lack of

problem-solving skills, and substance abuse as evidenced by anxiety, social

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Mackenzie Hawk Mental Health: Case Study
isolation, ineffective spousal communications, and disruption of family

roles.

5. Denial of substance abuse related to previous ineffective coping skills with

substitution of drugs as evidenced by refusal of healthcare attention to

detriment of health and the patient not willing to admit impact of condition

on life pattern (see Taylor et al, 2006.)

Conclusion Statement:

In conclusion, the patient was a good fit for a case study, as she had a

multifaceted psychiatric history. Despite this history, here cognition was

sufficiently intact to gain insight into her perspective of her illnesses. While I feel

that the historian who provided her history in the medical chart may have skewed

a few things or perhaps her cognition during the assessment was impaired, most

of it matched up. I wish her well, and hope that the plan of care set by the

multidisciplinary team was developed with enough care that may set a better

tone for the rest of her psychiatric history.

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Mackenzie Hawk Mental Health: Case Study
References

Ostrow, Laysha, et al. “Discontinuing Psychiatric Medications: A Survey of Long-Term

Users.” Psychiatric Services, vol. 68, no. 12, 2017, pp. 1232–1238.,
doi:10.1176/appi.ps.201700070. 

Tadros, Allison, et al. “Coexistence of Substance Abuse among Emergency Department Patients
Presenting with Suicidal Ideation.” BioMed Research International, vol. 2020, 29 Sept.
2020. 

Taylor, Jeannette, et al. “Disinhibitory Trait Profile and Its Relation to Cluster B Personality
Disorder Features and Substance Use Problems.” European Journal of Personality, 20
Mar. 2006, doi:10.1002/per.585.