Running head: PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Mental Health Case Study

Nicholas Boyce

Youngstown State University

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Abstract

This case study was formed for the duel purposes of enhancing my knowledge of mental

health, and applying all the concepts of mental health that we learn in clinical. This narrative

document was structured using several headings required in our course packet. The subjects are

objective data, psychiatric diagnoses, stressors and behaviors, patient and family history of

mental illness, psychiatric evidence based nursing care, ethnic, cultural, and spiritual influence,

patient outcomes, plans for discharge, actual nursing diagnoses, potential nursing diagnoses, and

conclusion. The subject or patient of this case study will be addressed as D. for the purpose of

protecting private health information. Information on this patient has been collected through

reading the patients chart, observation, and conversation with the patient. This case study

summarizes the patients mental health status, history, influences, and goals moving forward.
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Objective Data:

D. was admitted on October 3, 2020 and was cared for on October 6, 2020. He is a

thirteen year old male who was voluntarily admitted by his foster parents for threatening to kill

his foster mother, foster brother, and dog with a rock. This patient has previously hit his mother

with an umbrella, and his dog with a large rock. He also has a history of stealing, cruelty to

animals, lying, and has attempted to set his house on fire with a gas stove.

D. is diagnosed with a few psychiatric disorders. These disorders are: pervasive

development disorder, disruptive mood dysregulation disorder (DMDD), and bipolar disorder

without psychotic features. D. has also been diagnosed with attention-deficit/hyperactivity

disorder (ADHD), and was previously diagnosed with autism. His only medical diagnosis is

hypothyroidism.

His lab results were mostly within normal range with no notable values except for a

glucose of 119. He is currently taking three psychiatric medications which are: Seroquel for

bipolar disorder, Intuniv for ADHD, and Depakote XR for bipolar disorder.

Behaviors observed on date of admission could not be noted since this patient arrived

before date of care. However the patients behaviors on the date of care were assessed mainly

during conversation. D. stated that he felt "worried" because he was going to be discharged home

soon. His behavior was congruent with his mood as he appeared to be a little restless,

continuously adjusting his seating position, and playing with his hands. He hid face with his

hands and moved around more when discussing certain topics like his past animal abuse and

misbehaving; showing he was uncomfortable and perhaps ashamed or embarrassed. D. acted

friendly and was open to discussion. His tone was calm and candid, and his facial expression was
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animated. D. did not display any unusual motor activity, akathisia, akinesia, tardive dyskinesia,

or acute dystonic reactions. He also did not display any disturbance in thought processes, thought

content, or perceptual content.

D. was kept on the psych floor with the other adolescents which is suicide proof. Safety

checks are performed regularly. This patient should be assessed for self harm since he reports

"pulling hair out my skin" and "picking his fingers".

Psychiatric Diagnoses:

As mentioned earlier D. has three psychiatric diagnoses. One of them is pervasive

development disorder. Pervasive developmental disorder is defined as "a group of disorders

characterized by delays in the development of socialization and communication skills." (National

Institute of Neurological Disorders and Stroke, 2019). DMDD is a psychiatric diagnosis used to

"describe children with chronic mood irritability and behavioral outbursts in multiple settings."

(Floyd, Balta, & Kaur, 2020). The third psychiatric diagnosis to note is bipolar disorder without

psychotic features, a mood disorder that causes unusual shifts in mood, energy, and

concentration. (National Institute of Mental Health, 2020).

Precipitating Stressors and Behaviors:

As mentioned earlier D. was voluntarily admitted by his foster parents after making

hostile threats against his adoptive mother, foster brother, and dog. His biggest stressor seems to

be his foster mother, but his foster brother is also a major source of stress. The client stated that

this is because his foster brother reports his misbehavior at school and home to their adoptive

mother. D. stated that this makes him feel angry. The client claims "I get anxious about my

family because of trauma." D. had been slapped by his foster father multiple times before being
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reported, but the patient claims that this abuse no longer occurs. D. understands his expectations

and knows when he is misbehaving, but becomes angry whenever his mother confronts or

discusses his misbehavior. This has been identified as a trigger for his threats and aggression. It's

possible his hypothyroidism can contribute to his irritability. However, D. also stated during

discussion that he sometimes uses threats to achieve a desired outcome such as getting away

from his family and staying at a psych hospital. D. stated that he does not always mean what he

threatens, but sometimes he does.

Patient and Family History of Mental Illness:

Since D. is adopted, not much is known about his biological mother's health history. It is

known however, that D.'s biological mother smoked during pregnancy. D. was previously

diagnosed with autism but this diagnosis no longer seems to be valid.

Psychiatric Evidence Based Nursing Care:

Walking could be a good therapy for D. in the case that he is being hostile and is

escalating. Walking can help him burn off some excess energy and provide a therapeutic outlet

for his anger. There are other methods used in de-escalation and anger management such as

talking down. Identifying triggers is an important intervention, because identifying what sets the

patient off can prevent it from happening in the first place. Another example of evidence based

care is the administration of psychiatric medications. In this patients case one of the medications

is Seroquel which has shown to be effective in treating bipolar disorder. Yet another example is

the formation of a complete safety crisis plan in the event that the patient does escalate at home

after discharge.

Ethnicity, Spiritual, and Cultural Influences:

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It's difficult to evaluate what ethnic influences may be present since the client is adopted,

and has no ties to his biological family. While the clients parents are spiritual and encourage him

to go to church and pray, the client seems to feel conflicted about their spirituality. The client

seems to view spirituality as another expectation of his parents rather than a beneficial source of

support. The client also states that they have not prayed in a long time. It's also difficult to see

what cultural factors influence the patient outside of their hospitalization. D. is in seventh grade

and it's likely that school and other kids his age have some amount of influence on him although,

it has been noted that D. struggles with peer relationships. D. claims that his foster parents

carefully monitor what he is exposed to including television shows such as Spongebob. He also

is not allowed to have social media or a cell phone. Because of this his influence from media is

likely greatly limited when compared to other kids his age.

Patient Outcomes Related to Care:

Several goals have been put in place for the patient to achieve. One goal is that D. will

list two consequences of his actions. On the opposite side of this another goal is D. will list two

rewards he wants for good behavior. Yet another goal is D. will use two ways/coping

mechanisms to remain in control of self when angry. A final goal is D. will explore positive

alternatives to threats.

Discharge:

Several outcomes are required to be met prior to D.'s discharge. To be more precise four

outcomes have been set and they are: no acts of aggression, no suicidal thoughts or homicidal

thoughts, improved mood, thinking and behavior, and finally a verbal commitment for aftercare
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and an appointment with a psychiatrist or therapist. D. will return home once he is discharged

from the hospital.

Actual Nursing Diagnoses:

Ineffective coping related to insufficient sense of control as evidenced by destructive

behaviors toward others and self. 287

Labile emotional control related to emotional disturbance, fatigue, and mood disorder as

evidenced by emotional outbursts of hostility.

Dysfunctional family processes related to ineffective coping skills as evidenced by

disturbance in family dynamics and escalating conflict.

Fatigue related to endocrine disorder as evidenced by tiredness.

Ineffective impulse control related to mood disorder as evidenced by temper outbursts

and violent behavior.

Relocation distress syndrome related to move from one environment to another as

evidenced by anger, anxiety, and concern about relocation.

Self-mutilation related to disturbance in interpersonal relationships, impulsiveness, and

living in nontraditional setting, as evidenced by picking at fingers and plucking hair.

Impaired social interaction related to disturbance in self concept as evidenced by

dysfunctional interactions with others.

Potential Nursing Diagnoses:

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Risk for impaired skin integrity related to mechanical factors as evidenced by self-

mutilation.

Risk for trauma related to history of trauma and emotional disturbance as evidenced by

previous physical abuse from foster father.

Risk for infection related to alteration in skin integrity as evidenced by client picking at

fingers.

Risk for unstable glucose level related to alteration in mental status and excessive stress

as evidenced by slightly elevated glucose level.

Conclusion:

D. has mental health issues that trace back to his early years and biological mother,

(substance abuse during pregnancy), and these issues will persist with him through life due to

their biological nature. Bipolar disorder, DMDD, ADHD, and pervasive development disorder

all contribute to his inability to control emotional outbursts, aggression, and impulsivity. This

places a strain on his relationship with his peers, siblings, father, and especially mother. It's

critical for D. to practice coping mechanisms, take prescribed medications, and cooperate with

outpatient mental health care to control his psychiatric disorders and behavior. D. understands

right from wrong, but often acts on impulsivity and emotional outbursts. It's possible there is

genetic influence on D's. mental health but without a family history this cannot be known. Even

with hypothyroidism his labs were insignificant other than blood glucose. D. has several nursing

diagnoses that raise concern and should receive intervention in order to achieve positive client

outcomes.
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Resources

Ackley, Betty J., et al. Nursing Diagnosis Handbook: an Evidence-Based Guide to Planning

Care. Elsevier, 2017.

“Bipolar Disorder.” National Institute of Mental Health, U.S. Department of Health and Human

Services, Jan. 2020, www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml.

Floyd, Augustus, et al. “12.2 The Functional Anatomy And Neurochemical Basis For Dmdd.”

Journal of the American Academy of Child & Adolescent Psychiatry, vol. 59, no. 10, 1 Oct.

2020, doi:10.1016/j.jaac.2020.08.170.

“Pervasive Developmental Disorders Information Page.” National Institute of Neurological

Disorders and Stroke, U.S. Department of Health and Human Services, 27 Mar. 2019,

www.ninds.nih.gov/Disorders/All-Disorders/Pervasive-Developmental-Disorders-

Information-Page.