Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Shereif Bynum

November 18, 2020

Mrs. Teresa Peck, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

This psychiatric mental health case study will be describing the disease process and treatment

of a patient with Bipolar I disorder and Schizophrenic Affective disorder. The initials of the

patient are “RM”. RM is a 57-year-old Caucasian male who was admitted to Generations

Behavioral Health Facility in Trumbull County on October 18, 2020. Patient arrived via pink slip

after police discovered the patient on a sidewalk yelling, highly agitated, and rambling illogical

and disorganized thoughts. RM has a medical diagnosis of obesity and hypertension. This case

study looks to highlight and analyze RM mental disorder, nursing diagnoses/care, outcomes,

treatments and discharge during his hospitalization. Varies academic journal articles were

utilized to create this case study.

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Objective Data

Patient Identifier: RM

Age: 57

Sex: Male

Date of Admission: October 18, 2020

Date of Care: October 23, 2020

Psychiatric Diagnosis: Bipolar I Disorder (Schizophrenic Affective)

Medical Diagnoses: Obesity and Hypertension

Behavior on Admission: RM reported that he was brought in for his own protection. He was

experiencing some trouble at home in regard to the ownership of his “house”. The patient

reported that his “family” was trying to take the house away from him. Police arrived to pick

him up, who he expressed being familiar with, and take him away for safety purposes. Per the

patient’s charts, RM was picked up by police because he was disturbing the peace. RM was

yelling illogical and disorganized thoughts on the sidewalk and was highly agitated. He was

pinked slipped with a 72 hour hold and then signed a voluntary stay.

Behavior on Day of Care: RM was rather oblivious to his surrounding environment. He was

preoccupied with his breakfast. It is important to note that he had two breakfast boxes

compared to the normal serving of one per patient. The breakfast consisted of eggs, hash

browns, breaks meats, and toast. He ate in a very aggressive manor as if he had not eaten in

while. Near completion of his breakfast a conversation ensued in which the patient expressed a

very relaxed and calm demeanor. His main focus continued to be on his food with small

interjecting comments between bites. His appearance and hygiene were visually poor. He had
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unkempt hair that was longer in length and dyed a greenish, pink color. When asked about his

hairstyle he responded with “he wanted to do something new and fresh”. He looked

overweight with a round fat abdomen which is confirmed with his obesity diagnosis. This is

contrary to what the patient believes because he states he is in “great physical health”. Upon

standing to walk his food containers to the garbage, one can observe an uneven ambulator gait.

He favored his right foot. The uneven gait was a result of some discoloration to his left foot,

primarily his greater toe that was blackened in color. Furthermore, his lower extremities were

edematous bilaterally with a reddish pigment. With his breakfast being finished a more in-

depth conversation revealed that RM had some disturbances in thought process and content.

He had slight slowed to process responses over the course of the conversation. A difficulty to

find the right words or thoughts he wanted to use, but eventually expressed his ideas to

completion. When questioned about his occupation and finances RM shared that he was

financially stable with no need for any state or community assistance such as (food stamps,

S.N.A.P., and/or food banks). He stated being unemployed currently but is able to make ends

meet with random “handyman” type of jobs. In addition, he is working with an organization to

help get some assistance with his house utilities because his power and water are currently

shut off. The lack of power and water is also a source of frustration for him because his “family”

is trying to take his house away from him. Further investigation into the patient’s record

revealed that he is in fact homeless. The “house” RM is referring to his most likely an

abandoned building which coincides with the lack of power and water. The “family” he is

referring to is the state or private entity that is probably going to demolish the house soon. RM

is experiencing some delusions about his life and state of well-being. Towards the end of the
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day some other disturbances in cognition came to light during a group therapy session. RM

demonstrated flight of ideas, tangentiality, and circumstantiality when participating in group.

He was very active in group, so much so that he was easily identified as a Monopolizer. This

behavior was reduced after a while when it was brought to his attention that other people

wanted to comment on the topic being discussed.

Safety and Security Measures: Per Generations policy for inpatient admission they implement

visual patient checks every 15 minutes. Patient are not permitted off the property for the

duration of treatment. Staff is present at all times in the milieu. Any potential hazardous items

are restricted from the unit such as shoelaces, pens, pencils, ties of any kind, razors, belts,

headphones or wires, and jewelry. In addition to the items listed above Generations Behavioral

Facilities do not allow any personal items such as MP3 players, personal TVs, cellphones,

laptops, electric fans, cameras or other electronic devices. All TVs or electronic devices present

on the unit are behind a plexiglass case so that the cords nor the devices can be used to harm

themselves or others. Medications are administered by a nurse to patients during scheduled

times. Nurses verify that each patient is receiving the correct type and amount of medication

prescribed along with verifying the medication was consumed properly.

Laboratory Results

Lab Value Results

Drug/Toxic + Marjiauna
Glucose 83 (Normal)
BUN 10 (Normal)
Creatinine 0.94
WBC 5.6
TSH 0.45
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Alcohol Negative
Valproic Acid (Unavailable)
Psychiatric Medications:

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

Divalproex Sodium Depakote Anticonvulsant 250 mg Mood Stabilizer
Olanzapine Zyprexa Antipsychotic 10 mg Mood Stabilizer

(Atypical)
Benztropine Cogentin Antiparkinson 1 mg EPS
Haloperidol Haldol Antipsychotic 5 mg Agitation
Hydroxyzine Vistaril Antianxiety 50 mg Anxiety

Pamoate
Melatonin Sedative 9 mg Sleep aid
Summary of Psychiatric Diagnosis

Bipolar disorder (formerly known as manic-depressive illness) is a mental disorder that

causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out

daily activities. There are three types of bipolar disorders all which effect and individual’s mood,

energy, and activity level. Episodes of mania are characterized by manifestations of euphoria,

extreme “up”, elated, irritable, and/or energized behavior. Episodes of depression are

characterized by manifestations of extreme “down”, sad, indifferent, and/or hopelessness.

Sometimes individuals experience symptoms that do not fall under either category and those a

referred to as “other specified and unspecified bipolar and related disorders”. A person with

bipolar disorder cycles between depressive episodes and normal behavior (bipolar depressive)

or mania episodes and normal behavior (bipolar manic). Bipolar is typically diagnosed during

late adolescence or early adulthood and has a higher prevalence in males. Symptoms may vary

over time but usually require lifelong treatment with adhering to a prescribed treatment plan
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to control symptoms and improve overall quality of life (National Institute of Mental Health

2020).

Schizophrenia is a mental disorder that causes distortions in one’s thought process,

perceptions, emotions, movements and behaviors. Schizophrenia is not a singular illness but

rather a syndrome or disease process with varied symptoms, much like a variety of cancers.

People who are affected display positive and negative symptoms. Positive symptoms are

referred to as “hard symptoms”. They include delusions, hallucinations, disorganized

thinking/speech and behavior. Negative symptoms are referred to as “soft symptoms”. They

include flat affect, lack of volition and social withdrawal or discomfort. An individual can

experience psychotic symptoms mixed with the mood swings, that person is then labeled with

schizoaffective disorder. A person must have signs and symptoms of schizophrenia and a mood

disorder such as depression or bipolar disorder. Symptoms may manifest simultaneously or

alternate between psychotic and mood disorders symptoms. Onset of symptoms can be abrupt

or insidious with negative symptoms usually manifesting first like social withdrawal or lack of

interest. Schizophrenia diagnosis is usually given after the presence of active positive symptoms

(Videobeck 2020).

Stressors and Behaviors that Precipitate Hospitalization

As stated earlier the patient was brought in because he was found yelling and highly

agitated. He was yelling disorganized thoughts and was pinked slipped. Per the patient

interview it was concluded that he is in fact homeless living out of an abandon building. RM

states that he has no running water or electricity and that the building is condemned. The living

conditions are not suitable to sustain life properly. Before being picked up by police he
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expressed some frustration about his housing security because someone was trying to take his

“home” away from him. RM showed heighten concern about the status of his house and

maintaining his living space. This event is a substantial reason why his schizophrenic symptoms

manifested the day he was picked up off the street.

Poverty and mental health have an extremely high correlation. The topic of poverty’s

effect on mental status is discussed in medical journal Psychiatric Times: Addressing Poverty

and Mental Illness. The definition of poverty varies with social, cultural, and political systems. It

is a multidimensional social phenomenon that is a primary social determinant of mental health.

Poverty affect a person mental state in an assortment of ways such as biological changes due to

chronic and acute stressful life events, cognitively due to lowered socioeconomic status with

reduced resources resulting in delayed speech and thought processing, and physiologically due

to lack of food resources. All these things are associated with higher rates of disorder such as

depression, anxiety, and suicide (Simon, Beder, & Manseau, 2018).

Along with the stress of possibly losing his living space RM reports that he self-

medicates with Marijuana. He states that “marijuana helps levels him out [mood]”. This self-

medication is often seen in bipolar along with schizophrenic patients because of marijuana’s

calming and relaxing effects. Bipolar patients mainly use it during mania stages to relax the

body and mind from racing thoughts and constant jitteriness. RM marijuana use could be

identified as a possible stressor because of its hypnotic effect which can exacerbate his

psychotic symptoms such as hallucination, delusions, and paranoia. It is possible that he was

either experiencing the effect of the marijuana or having a psychotic episode which was

increased with the effects of marijuana.

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Patient and Family History of Mental Illness

RM does not directly state in his interview that any of his family has been diagnosed

with a mental illness. There was no family history available in the patient charts.

Milieu Therapy and Evidence Based Nursing Care

Over the course of his care multiple interventions and milieu environment was

implemented in the plan of care. Firstly, the milieu was maintained as a safe and therapeutic

environment with the restrictions of all hazardous items during the admissions process. This

step is vital in creating a safe environment to promote healing and reduce stress of the patients

and staff. Patient have the option to turn off the lights within their rooms to promote a calm

personal area for relaxation and de-escalation. Diming the lights reduce the stimuli present in a

given area which is often beneficial for patients experiencing hyperactivity. Along with a safe

and comfortable environment patient interact in schedule group therapy sessions. In group

therapy varies skills are discussed focus on equipping patients with skills needed to maintain

control during the time in the facility and outside the facility as well. In group patients learned

about positive stress (eustress) and negative stress (distress). They discussed creating unique

techniques specific to them to help cope with stress. RM was very active in group monopolizing

majority of responses with displays of tangential or circumstantial thinking. Staff members

would use rounding techniques to correlate his ideas back to the main overall theme of the

group.

Pharmaceutical intervention was also utilized in the treatment of RM. Depakote an

anticonvulsant is used as a mood stabilizer that helps controls his bipolar symptoms. Zyprexa is

an atypical antipsychotic. It is used to control his positive schizophrenic symptoms. In

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conjunction with Zyprexa RM is on Cogentin, an Antiparkinson medication that targets

extrapyramidal symptoms (EPS). These are symptoms that can be a result of taking

antipsychotic medication. EPS symptoms include impaired motor activity such as tremors and

akathisia, akinesia, tardive dyskinesia, and acute dystonic reactions.

Ethnic, Spiritual, and Cultural Influences

RM is a 57-year-old Caucasian male that does not identify under a standard religion but

openly states his belief in spirits and divine intervention. He specifically states a connection

with the universe that may or may not be a result of fate or divinity. His life influences seem to

be connected with his experiences around being a handy man and repairing old electronics. RM

specifically states not being in a committed relationship and not having any children. Currently

he has many partners because he like to “keep is options open”. It can be concluded that RM is

a free spirit with traits similar to a nomad, just going with the flow.

Evaluate Patient Outcomes

RM revealed that he experienced a lot of positive outcomes during his time at

Generations. The most important being safety. He was free from injury or falls while on the

unit. During the interview he kept reenforcing that his main reason for being on the unit was

safety. The police brought him in for his safety so he could get better and return back home in a

better state physically and mentally. RM is no longer exhibiting any positive schizophrenic

symptoms such as delusions and hallucinations. There is some presence of disorganized

thought process, but he is able to eventually connect ideas back to main point with some

regularity. RM states being in a great physical health outside of preexisting medial issues. He

indicates his pleasure for being able to receive three meals a day which is sometimes difficult
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when he is at home. He verbalizes the need for assistance after being discharged from the unit.

The client is demonstrating appropriate judgment skills and being proactive about continuing

pharmacological treatment regimen along with therapy. He also expressed desire to work with

his social work to help with his housing security and basic resource. RM is demonstrating

appropriate thought processing needed to address stressors that can affect his mental and

physical health.

The use of supported housing is important for a permanent exit from homelessness.

Medical journal Psychiatric Times discusses the positive affect of supported housing on the

mental and physical health of the homelessness in an article titled “Reflections on Psychiatry in

Supported Housing”. To facilitate the permanent removal out of homelessness individuals, need

financial assistance and supportive service such as case management and linkage to healthcare.

Research has concluded that the use of supported housing has positive health and psychosocial

benefits. Individuals have increase days in a stable environment, decrease substance abuse,

increase perception of autonomy, decrease acute care (inpatient hospitalization and emergency

department use) and decrease interaction with law enforcement. Data shows that in

comparison to traditional housing programs supported housing programs housed clients 8

times faster, increased adherence to outpatient therapy regimens, and a demonstration of skills

that suggest that they can live independently within their community (Gabrielian 2018).

Discharge Plan

Before discharge RM will discuss appropriate housing options and local food resources

with social worker. They will also discuss continuing pharmacological therapy through his

Medicare and set up pick up from his local pharmacy. RM expressed interest in continuing
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group therapy so him and his social worker will work together to identify an accessible group

nearest him. Upon discharge a nurse will go over his medication regimen and education him on

EPS and associated symptoms he could develop while taking his antipsychotic medication.

Client is informed he should avoid alcohol. Depakote is contraindicated in patients with liver

disorder and can decrease WBC and platelet levels. RM needs to be aware of any developing

infections and attend follow up appointments.

Prioritized Nursing Diagnosis

Prioritized diagnosis from the Nursing Diagnosis Handbook: An Evidence Based Guide to

Planning Care:

 Disturbed Thought Process related to schizoaffective disorder evident by yelling and

disorganized thoughts

 Risk for Violence related to manic state

 Total Self Care Deficit related to obesity evident by homelessness

 Impaired Social Interaction related to schizoaffective disorder evident by tangential,

circumstantial, and flight of ideas thought processes

 Ineffective Coping related to disorder evident by drug use

Potential Nursing Diagnosis

 Risk for Substance Abuse related to homelessness

 Risk for Infection related to discolored foot and lower extremities

 Risk for Injury related to hyperactive state (mania)

Conclusion
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Bipolar is serious mental disorder that is characterized by changes in mood, energy and

activity. Individuals experience a variation of manic and depressive symptoms. Manic symptoms

are hyperactivity, elated, agitation, and euphoria. Depressive symptoms are lack of interest,

pleasure, sadness, and hopelessness. A person’s symptoms can be mainly manic, mainly

depressive, or cyclic through both. Along with mood symptoms a person can experience

psychotic symptoms of schizophrenia. Schizophrenia is a disease that causes distortions in a

person cognitive process. Patients experience bizarre thoughts, perceptions, emotions, and

behaviors. Both disorders require a lifelong requirement to regulated medication treatment.

Utilization of pharmacological intervention and cognitive behavioral therapy has been proven

to improve the symptoms associated with both disorders.

RM suffered from a period of mania along with schizophrenic symptoms. He was

brought in for his safety and to seek treatment. Since complying with his treatment his positive

schizophrenic symptoms have been reduce and he states being in a better state of mind. RM

expresses interest in continuing his therapy at outpatient appointments along with continuing

his medication regimen. Furthermore, RM is seeking assistance with his current living

arrangements to progress in his treatment and improve overall health.

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References

Ackley, B. J., Ladwig, G. B., Beth, M. F., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing

diagnosis handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.

Gabrielian, S., MD, MPH. (2018). Reflections on Psychiatry in Supported Housing. Psychiatric

Times, 35(6), 5-6.

doi:https://cdn.sanity.io/files/0vv8moc6/psychtimes/c9dcf2db20a301c59f4c80340b6f8

8b66ddd4d4d.pdf

The National Institute of Mental Health. (2020, January). Bipolar Disorder. Retrieved November

2, 2020, from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Simon, K. M., MD, Beder, M., MD, & Manseau, M. W., MD, MPH. (2018). Addressing Poverty

and Mental Illness. Psychiatric Times, 35(6), 7-9.

doi:https://cdn.sanity.io/files/0vv8moc6/psychtimes/c9dcf2db20a301c59f4c80340b6f8

8b66ddd4d4d.pdf

Videbeck, S. L. (2020). Psychiatric-Mental Health Nursing (8th ed.). Philadelphia, PA: Wolters

Kluwer.