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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Amber Ortiz

November 7, 2021

Mrs. Teresa Peck, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
Abstract

AB is a 34-year-old African American male admitted onto the inpatient psychiatric unit due to

increased suicidal ideations with visual hallucinations. AB has been diagnosed with multiple

mental disorders including depression, bipolar disorder and psychosis. AB has a health condition

with seizures as well. With medication treatments of anticonvulsants, antipsychotics, antianxiety,

and antidepressant medications the goal is to decrease seizure activity, help with moods and

depression, and decrease the hallucinations he is experiencing. The patient has experienced a

great deal of losses in the past two years, so grieving teaching is needed as well as offering

assistance to support groups. Nursing care is to provide care, reorient he patient to reality,

distract from hallucinations, manage health status with pharmacological measures, and provide

support.
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY

Objective Data:

Patient Identifier: AB

Client’s age: 34 years-old

Sex: Male

Admission date: 10/19/2021

Date of Care: 10/21/2021

Psychiatric Diagnosis: Suicidal Ideation with visual hallucinations; Psychosis

Other Diagnosis: Depression and Bipolar Disorder

Behaviors on admission AB reported with chronic pain from a previous fall and breaking his

tailbone and increasing suicidal ideation with hallucinations. Patient stated, “I am feeling terrible

and not wanting to live anymore.” He reports having a history of self-harm and suicide attempts.

He stated, “I have tried to stab myself, intentionally overdose on mediations, and had thoughts of

using available firearm near me.” His hallucinations were seeing all the ways to kill himself.

Behaviors on day of care AB was stand offish when we came in and asked to speak to people

and ended up leaving the room. Eventually, he returned and was open to talking to the nursing

instructor and I then became included in the conversation. He became more open and

cooperative to talk about what he has been going through. He expressed his stress and depression

from the seven recent losses he has experienced in the past two years, two of them being two

very important people to him. AB was not having any hallucinations during this time and was

hoping to get his self together and return to his home in Cleveland, Ohio. His affect was

appropriate, speech and tone were normal, but he was anxious and fearful about what is to come
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
next in his life. His posture was hunched over sitting in the chair, discussing all the recent trauma

in his life, but he maintained eye contact while discussing.

Safety and security measures Throughout the inpatient stays on the psychiatric unit, there are

safety checks implanted every 15 minutes around the clock to every patient. AB is on suicide

precautions and general unit precautions. The patient is not permitted off the unit and requires

staff monitoring at all times. Items such as shoelaces, razors, pens or pencils have been

confiscated as a safety precaution; only markers are allowed to be used for drawing and during

group sessions. Medications have been arranged and discussed with the patient to start/continue

regime upon admission, and currently a medication for seizures are still being identified to find

one that works.

Medications

Levetiracetam 1,000mg PO- tablet 1BID Used for

(Keppra) seizures

*Anticonvulsant

Nicotine 21mg/24hr Transdermal 1QD Treat nicotine

*Nicotine patch dependence

replacement

Olanzapine 10mg PO-tablet 1HS Treat psychosis

(Zyprexa) and moods

*Antipsychotic

Olanzapine 2.5mg PO- tablet 1QD Treat psychotic

(Zyprexa) symptoms

*Antipsychotic
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
Cyclobenzaprine 5mg PO-tablet 1TID PP Treat for pain as

(Flexeril) needed for

*Muscle broken tailbone

Relaxant

Hydroxyzine 50mg PO- capsules 1Q6h PRN Help treat

Pamoate anxiety

(Vistaril)

*Antihistamine

Trazodone 100mg PO- tablets 1HS PRN Improve sleep,

(Desyrel) help depression

*Antidepressant and anxiety

and Sedative

Labs

Potassium- 4.0 (normal 3.5-5.0)

Sodium- 137 (normal 135-145)

Glucose- 82mg/dL (normal 74-100) (want to keep an eye one because the patient is taking an

antipsychotic and those can increase blood sugars)

BUN- 15 mg/dL (normal 6-23)

Creatinine- 1.20 mg/dL (normal 0.50-1.30)

RBC- 4.07 (normal 4.50-5.90)

Hemoglobin- 13.1 (normal 13.5-17.5)

Hematocrit- 40.0% (normal 41.0-52.0%)

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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
WBC- 6.7 (normal 4.4-11.3)

AST/ALT- tried to find, not drawn yet for the patient.

Lithium/ Depakote/Tegretol level- Patient is not taking either of these medications, but it was

considered so QTC level was drawn

TSH/T4- tried to find, was not drawn on patient yet.

Drug Toxicity- negative

Alcohol Level- negative

QTC/ ECG- EKG had a range from 354-430

Summary of Psychiatric Diagnosis

Psychosis is a condition that affects the way your brain processes information and it

causes you to lose touch with reality. Psychosis may cause you to see, hear, or believe things that

aren’t real. It is a symptom, not really an illness. This can be triggers from a mental illness such

as depression or bipolar, a physical injury or illness, substance abuse, or extreme stress or trauma

(Bhandari, 2021).

Causes of Psychosis can be a variety of reasons. Genetics, for example, you can have the

genes for it, but not necessarily mean you’ll get it. Some prescription medications or abuse of

alcohol or drugs like marijuana, LSD, and amphetamines can be triggers for psychosis. Traumas

such as death of loved ones, sexual assault, or PTSD from war can lead to psychosis as well.

More important, the trauma and the age you experienced it play a huge role in psychosis. Injuries

and/ or illnesses such as traumatic brain injuries, brain tumors, strokes, Parkinson’s disease,

Alzheimer’s disease, dementia, and HIV can all trigger the symptoms of psychosis (Bhandari,

2021).
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
Hallucinations are sensory experiences that appear real to the patient but are created by

their mind. They can affect all five senses: auditory, visual, tactile, olfactory, and gustatory.

Auditory is the first most common, while visual is the second most common hallucination. In

auditory hallucinations you might hear commands from someone telling you to do things and the

voice may be angry, neutral, or warm. These commands are usually telling the patient to harm

themselves or others (Legg, 2019).

Suicidal Ideation is common in patients who experience psychosis symptoms such as

hallucinations and patients who have depression. Suicidal ideation means wanting to take your

own life or thinking about suicide, however, there are two types of suicide ideation. Passive

suicidal ideation is when you just wish you were dead and not living, but not actively attempting

to kill yourself. Active suicidal ideation is when you not just thinking about it but having the

intent to commit suicide and thinking about plans on how you can do it (Purse, 2020).

Identify the Stressors and behaviors precipitating current hospitalization

AB is a previous smoker of marijuana for years but stopped four years ago. He likes

alcohol and likes to drink currently to help relieve stress and cope with stressful events. He used

to be a heavy drinker and drink daily as well. He has an 8-year-old son who lives with his sons

mother and he sees him every other weekend, but he is not fond of the mother’s boyfriend

disciplining his son; he believes him, and his son’s mother should be the only people to

discipline his son. Unfortunately, there is not much he can do about that situation, but he states

he is going to talk with his child’s mother about it to see what can be done. AB has experienced

multiple deaths in the past 2 years and witnessed the one right in front of him. The problem is, he

has not had time for grieving so that is taking a toll on his mental health. AB witnessed his best
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
friend get shot in the head during a basketball game they were playing due to a fight breaking out

and lost his grandfather, which was his best friend and went everywhere with. AB is employed at

a car shop in Cleveland, but due to his depression and traumatic events lately, he has not been

able to work.

Discuss patient and family history of mental illness

The only family history discussed was diabetes, no other history was provided. The

patient does have mental disorders of depression, psychosis, and bipolar disorder. Patient has a

history of suicide attempts, self-injurious behaviors, alcohol abuse, smoking ½ pack per day, and

seizures. The patient had a background check ran on him prior to admission to the facility and it

came back as him being a previous tier 2,3 sex offender. The facility can run these checks to see

if there is a specific patient they may not want to take. AB did not bring this aspect up during the

interview, so this can be a possible stressor that he is ashamed of or something that has been

dropped.

Describe the psychiatric evidence-based nursing care provided and milieu activities

attended

During the inpatient stay on the unit, AB received care from the mental health nursing

staff, and they were assigned a nurse for the hours 7am-7pm then a new nurse for the 7pm-7am

shift. Rapport was made between the nurse and AB and he was able to be open and honest and

bring up concerns or thoughts he was having. The nursing process is used to assess the patients

status and needs, diagnosis the patient based on their signs and symptoms, create a plan that is

beneficial to the patient and will have their best interest at heart, implement your daily
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
interventions, and then evaluate the patient’s progress. Their assigned nurse would pass

medications and ensure that the patient is taking their meds to improve their condition. The nurse

should be aware of all the medications prescribed for AB and the possible side effects they can

cause. Reassessments should be performed after administering medications to ensure they are

working and they patient is not rejecting or having adverse reactions to them.

The patient was experiencing hallucinations upon admission and a new approach to look

into these more is to help the patient explore what their voices they are hearing. This helps the

nursing staff put together more information for documentation on the patient’s progress. Another

aspect of treatment if encouraging the patient to attend group sessions because this helps build

social interaction, communication skills, opening up about personal matters, and helps

progression throughout their stay.

Analyze ethnic, spiritual, and cultural influences that impact this patient

AB is a 34-year-old African American male, who is from a lower-middle class family. He

has two brothers and lives with the one in Cleveland, Ohio. He is currently employed at a car

repair shop in Cleveland, but due to his mental state, he has not been working. When asked about

his religious preferences, he did not have any specifics, but that he believes in God. He has not

been baptized or go to church, but he did say, “I believe that everything God does, is for a

reason”. AB doesn’t discuss much more about religion.

Evaluate the patient outcomes related to care

One outcome for this patient was to decrease or eliminate the visual hallucinations AB

was experiencing and this is being met by providing medications and discussions with the
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
patient. Getting the patient redirected back to reality is important because this helps the patient

realize what they need to work before discharge. We may not ever really stop hallucinations, but

we can manage them. Another outcome was to make sure the patient is free from self-injury and

injury to others and perceiving themselves in a realistic manner; the patient was able to remain

free from injury and cooperative with others around him. Medication compliance for AB was a

priority because he had stopped his prescribed medications in the past, which possibly could

have started the psychosis symptoms again. AB has been complaint with his mediation during

his stay at inpatient and is raising concerns if he feels a medication is not working or alleviating

his symptoms.

AB was only able to partially meet his outcome with decreasing depression. Although he

is being cooperative and attending group sessions and complying with meds, his depression is

still there, and he still has an urge to drink to cope with stress. Offering him phone numbers and

information to outside sources such as AA meetings can help AB deal with his alcohol desires.

AB only partially met the outcome or controlling his seizures because upon admission, he has a

seizure the first night. The physician and nurses are still working with trying mediations to find

the one that will help correct the seizures the best.

Summarize the plan for discharge

The estimated length of stay is 5-7 days depending on the patient’s stability. AB has not

been discharged because he still needs to be regulated with his medications and needs to

decrease his depression a little more. AB will be encouraged to follow up with a PCP for

medication compliance and effectiveness. AB will be offered information on alcohol rehab

places or AA meetings to help decrease his need for alcohol in stressful situations. AB will need
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
a stabile support system upon discharge especially following all the recent losses and lack of

grieving time. Once some of these aspects are met and arranged, discharge will be discussed

upon the staff and with the patient.

Prioritized list of all actual diagnoses

1. Grieving related to seven recent losses within a 2-year time frame as evidenced by

depression.

2. Risk for suicide related to suicide ideations and attempts.

3. Risk for injury related to seizures, excessive alcohol use, and suicide attempts.

4. Disturbed thought processes related to stress as evidenced by auditory hallucinations.

5. Risk for violence related to auditory hallucinations

6. Risk for isolation related to depression as evidenced by suicidal thoughts and the loss

of grandfather and best friend.

Potential Nursing Diagnosis

1. Ineffective coping

2. Depression

3. Impaired social interaction

4. Interrupted Family Processes

5. Disturbed thought process

6. Grieving

7. Social isolation
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY
Conclusion

Psychosis can arise if a person’s mental condition worsens from non-compliance of

medications or if there are too many traumatic events or stress rising at once. Psychosis can

impact a person’s thought process and cause them to have suicidal thoughts or ideas and possibly

experience hallucinations and delusions. In this case, AB was having psychosis from all of the

stress from traumatic events happening at once which brought on auditory hallucinations during

his suicidal ideations. Patients can have an increase in depression and anxiety when these

exacerbations of a mental illness flare up which puts them at increased risk for suicide or another

suicide attempt since the previous one before. Prior to discharge, there should be a great amount

of education to the patient regarding new medications, side effects to expect and side effects to

report, therapy schedules, attending meetings with a therapist, and coping skills for coping with

stress. As nurses, we are going to teach to avoid self-harm and reach out for help to support

groups or support people when they feel stressed and overwhelmed. With the regular

maintenance and compliance of these aspects, the exacerbations of the mental illness can be

controlled.
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Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY

References

Bhandari, S. (n.d.). Psychosis: Definition, symptoms, causes, diagnosis, treatment. WebMD.

Retrieved November 8, 2021, from https://www.webmd.com/schizophrenia/guide/what-is-
psychosis.

Badii, C. (2019, July 11). Everything you need to know about hallucinations. Healthline.
Retrieved November 8, 2021, from https://www.healthline.com/health/hallucinations.

Purse, M. (2020, March 25). What is suicidal ideation? Verywell Mind. Retrieved November 8,

2021, from https://www.verywellmind.com/suicidal-ideation-380609.