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Patient Case Study - Mental Health Clinical

Ashley J. Walton

Nursing Department, Youngstown State University

NURS 4842L: Mental Health Nursing Lab

Mrs. Phyllis Jean Defiore-Golden

March 19, 2021

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Abstract

This case study will look at a patient diagnosed with Bipolar 2 disorder and post traumatic stress

disorder (PTSD). The patient indicator being used is P.M. It will include multiple part;

illustration the objective date, summary of the psychiatric diagnoses, identification of the

stressors and behaviors, discussion of patient and family history of mental illness, description of

the psychiatric evidence based nursing care provided, analysis of ethnic, spiritual and cultural

influences, evaluation of the patient outcomes, summary of the plans for discharge, prioritization

of all actual diagnoses, a list of potential nursing diagnoses and a conclusion. This case study

will also use several references for further detailed information and to back up statements.

Keywords: Bipolar 2 disorder, PTSD, nursing care, stressors, behaviors, mental illness
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Objective data:

The patient P.M. was admitted on February 24, 2021. I provided care two days later on

February 26, 2021. This was not the patient’s first psychiatric hospitalization; there were five

previous documented hospitalizations in the last five years. She has two documented psychiatric

diagnoses. They consist of Bipolar 2 disorder and post traumatic stress disorder (PTSD). The

laboratory results for this patient were normal all normal, except for her creatinine level. It was

slightly elevated at 1.3, which makes sense because the patient has a history of acute kidney

injury and atrophic kidney. In the toxicology lab results it also indicated that the patient was

positive for both benzodiazepines and oxycodone. Before admission the patient had to receive

several doses of Narcan to treat an overdose by the EMTs that brought her to the emergency

department. The EMTs stated that the Narcan had minimal effect on the patient. Upon admission

the patient was in a depressive state and stated “she just wanted to sleep and be left alone”. The

patient was also refusing to answer questions during her admission assessment pertaining to

suicidal ideation and homicidal ideation. On the day of care the patient was still depressed,

however she was more cooperative in answering questions by the nurse and myself. She was

insistent that she did not want to hurt herself and that it was an “misunderstanding”. She stated “I

am not supposed to be here, you do not have the right to keep me here, I don’t need to be here”.

On the day of care she also refused to participate in group therapy or leave her room for anything

else. The patient is currently medically cleared and does not have any current issue, however she

does have a history of hypertension and acute kidney injury. The safety and security measures

that are in place include taking the patients personal belongings that include everything that can

be used as a weapon or something that can be used to hurt themselves and checking on each

patient visually every 15 minutes to ensure that they are safe and no one has made an attempt on
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their life. The patient has been prescribed librium to help with both her anxiety and also the

alcohol withdrawal she was experiencing. Another prescription is catapres which will help with

the opiate withdrawal that was also present. The last medication is prozac, which is used for her

depression that is related to her Bipolar 2 disorder diagnosis.

Summarize the psychiatric diagnoses:

● Bipolar 2 disorder can be described as “a pattern of depressive episodes and hypomanic

episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder”

(Bipolar Disorder, 2020). The common symptoms include; feelings of worthlessness,

helplessness, and sadness, difficulty sleeping or changes in the sleep pattern, weight gain,

changes in appetite, difficulting concentrating and making decisions, have little to no

interest in activities that once brought them joy, all of this could lead to thoughts of

suicide or self harm (Bipolar Disorder, 2020).

● PTSD occurs in “people who have experienced or witnessed a traumatic event such as a

natural disaster, a serious accident, a terrorist act, war/combat, or rape or who have been

threatened with death, sexual violence or serious injury” (Torres, 2020). It is defined as

an “intense, disturbing thoughts and feelings related to their experience that last long after

the traumatic event has ended. They may relive the event through flashbacks or

nightmares; they may feel sadness, fear or anger; and they may feel detached or estranged

from other people” (Torres, 2020). The common signs and symptoms include intrusive

memories that are recurrent or upsetting, avoidance of thinking or talking about the

trauma or avoiding people, places or activities, a change in thoughts or mood in a

negative way, and changes in reactions both physical and emotional (Post-traumatic stress

disorder, 2018).
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● The patient stated that her PTSD resulted from “seeing my first fiancee being killed and

then my second one died in bed with me. It’s very hard to get over that and be happy”.

This was well documented in the chart so this can be corroborated. She said that this is

“the reason that I have trouble sleeping every night”.

Identity the stressors and behaviors:

Before the hospital admission the patient stated that she was celebrating with her

significant other because they had just moved into a new apartment together. She stated that she

was “happy to be with her girlfriend and she was not doing anything to hurt herself”. After

having several alcoholic beverages the patient took her “sleeping pills” that are prescribed due to

her PTSD. She said she took a couple extra out of “habit” and she was just “trying to get a good

night's sleep”. She also has a history of cocaine use, however it did not show up on the

toxicology report. The girlfriend stated to the EMTs that the patient was “sad but no more than

usual and they were just trying to have a good time tonight and then I found her unresponsive

and she would not answer me”.

Discuss patient and family history of mental illness:

The patient has had multiple previous psychiatric hospitalizations in the last five years.

When it comes to her family history it is documented that she has a lengthy history. It is reported

and documented that her maternal grandfather, maternal grandmother, father, mother and sister

all have some type of diagnosed mental illness. The chart did not go into depth with the specific

diagnoses and the patient did not want to discuss her family.

Describe the psychiatric evidence based nursing care provided:

● Cognitive behavioral therapy is used to treat multiple mental health illnesses including

anxiety, depression, other mood disorders, and substance abuse disorder. Cognitive
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behavioral therapy is described “as a therapy that helps individuals discover the

relationships that exists between self-destructive behaviors and negative thoughts and

feelings” (Evidence-based treatment practices). Cognitive behavioral therapy is used in

different capacities at the hospital. This includes the different group therapies that are

offered and treatment teams.

● Treatment teams are where the patient meets with the doctor, nurse, social worker and

any other necessary team member to discuss the patients progress, effectiveness of

treatment, concerns had by the patient or family, discharge planning, etc.

● Rounding every 15 minutes on each patient is a practice that is done to maintain the

safety of all the patients on the unit due to suicidal ideation that is evident in multiple

patients. Laying eyes on each patient every 15 minutes ensures that no patient has made

an attempt on their life.

Analyze ethnic, spiritual, and cultural influences:

The patient is caucasian, she states that she does not belong to any religion and “does not

believe in God”. The highest level of education completed by the patient is high school. She is

currently unemployed “due to the pandemic”. She is in a domestic partnership and lives with her

partner. She is chronically mentally ill and has had frequent hospitalizations throughout the last

several years due to ongoing episodes. She states that she is compliant with her treatment at

Compassionate Care, however on most of her admissions she has misused her prescribed

benzodiazepine.

Evaluate the patient outcomes:

During my time of care the patient continued to refuse to leave her room. She did

participate in the daily assessment and allowed me to talk with her and assess her on my own and
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answered several of the additional questions I had. However, after so many questions she asked

that I leave because she was “done talking about something that is not a problem and I should not

even be in here”. She did not participate in any of the group activities or therapies while I was on

the floor because “she has been here before and would not talk about things with other people

that did not apply to her and her situation”. She did comply and take her medication, but

continued to insist that this was “all a mistake”. She did not show any signs of self harm. So, on

the positive side she complied with medication and assessment. On the negative side, she has yet

to accept the reason that she was admitted and will not participate in group therapies.

Summarize the plans for discharge:

The patient was involuntarily admitted and was on a pink slip by the police department

until March 1, 2021. The primary nurse for her care that day discussed the plans of discharge

with me. She stated that the goal was to get the patient stabilized and for her to begin to

participate in group therapy and activities. Upon discharge the patient will return to

Compassionate Care for continued treatment. It was also a goal to start the patient in a drug and

alcohol treatment because this is not the first overdose that the patient has experienced that led to

psychiatric hospitalizations. Ultimately, the goal is for the patient to agree that there was grounds

for her admission and that there is a problem that needs to be addressed. As of my day of care

with her she was refusing to cooperate with treatment and acknowledge why she was at the

hospital. Due to the patient being discharged it is also necessary that the doctor must examine her

and to determine if she is stable enough to leave or if they need to ask her to sign in voluntarily

to receive more treatment.

Prioritized list of all actual diagnoses:

● Risk for self directed violence related to neurologic imbalances and depressive acts
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● Social isolation related to past experiences of difficulty in interaction with others

● Powerlessness related to lifestyle of helplessness

● Deficient knowledge related to misuse of prescribed medication

● Ineffective individual coping related to ineffective problem solving skills/strategies

● Fear related to physiological symptoms, mental/cognitive behaviors

● Anxiety related to actual or perceived threat to biologic integrity

List of potential nursing diagnoses:

● Risk for injury

● Impaired social interaction

● Interrupted family process

● Total self care deficit

Conclusion:

In conclusion, the patient, P.M., suffers from two mental illnesses, PTSD and bipolar 2

disorder. She was admitted after being transported to the emergency department because of an

overdose on alcohol and benzodiazepines. She was pink slipped by the police department and

involuntarily admitted to the psychiatric floor. When she was first brought onto the unit she was

uncooperative and denied that there was any reason that she should be admitted. On my day of

care, which was two days after the admission, the patient was now cooperating and answering

questions, however she was still denying that she should be admitted. She is unwilling to

participate in any of the cognitive behavioral therapy. She is however complying with

medication. She has a large family history of mental illness and is chronically mentally ill

herself. She is being treated with medication for alcohol withdrawal, opiate withdrawal and

depression. She needs to acknowledge the problem that brought her to the hospital. After her
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discharge is approved she will need further continued treatment at Compassionate Care and

possibly a substance abuse counselor.

References

Bipolar disorder. (2020, January). Retrieved March 15, 2021, from

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml#:~:text=Episodes%20of%2

0depression%20with%20mixed,typical%20of%20Bipolar%20I%20Disorder.

Evidence-based treatment practices. (n.d.). Retrieved March 15, 2021, from

https://dualdiagnosis.org/treatment-therapies-for-dual-diagnosis-patients/evidence-based-treatme

nt-practices/#:~:text=The%20National%20Alliance%20on%20Mental,than%20one%20investiga

tion%20or%20study.

Post-traumatic stress disorder (ptsd). (2018, July 06). Retrieved March 15, 2021, from

https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes

/syc-20355967

Torres, F. (2020, August). What is posttraumatic stress disorder? Retrieved March 15,

2021, from https://www.psychiatry.org/patients-families/ptsd/what-is-ptsd

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