Psychiatric Mental Health Comprehensive Case Study

Psychiatric Mental Health Comprehensive Case Study

Jordan Dickey

November 18, 2021

Mrs. Teresa Peck, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

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Abstract

LW is a 46- year-old female patient admitted to the inpatient psychiatric unit following

an increase of psychotic episodes, highly disorganized thought process, and a potential suicide

attempt. She has a mental health diagnosis of schizoaffective with bipolar episodes and is

experiencing persecutory and somatic delusions and auditory and olfactory hallucinations.

Symptoms have become more manageable after restarting an atypical antipsychotic medication.

LW resumed connection with her case manager and started participating in her care. Nursing

care provided on the unit was providing safety and focused on re-orientation to reality and

symptom management as well as group therapy and individual therapy sessions. LW started to

slowly resume grooming and hygiene and was able to focus on conversations.
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Objective Data

Patient identifier: L.W.

Age: 46 yo

Sex: Female

Date of admission: November 02, 2021

Date of care: November 04, 2021

Psychiatric diagnosis: Paranoia, Schizoaffective

Other diagnoses: Bipolar, Depression, PTSD, Hypertension, Diabetes, Herpes Simples Virus,

Syphilis

Behaviors on admission: LW believed that her boyfriend that she lived with was sexually

assaulting her, then drugging her at night, and then her boyfriend would traffic her. Upon

presentation to the emergency department, LW was assessed by the SANE nurse due to her

complaints of a sexual assault. LW reported scabs on her right forearm and left antecubital were

due to injections of drugs, that she smelled the men on her, was hearing “things” from the

basement and felt like cameras are watching her around her house. LW stopped taking her

medications due to thinking she was getting drugged by her boyfriend. Then she reported that

she took a handful of “sleeping” pills to overdose but changed her story to wanting to sleep.

Behaviors on day of care: LW was calm and cooperative on the surface. She was very willing

to speak but as soon as the conversation was focused on her illness she would start asking about

me being a nursing student. She was very open to talking to other patients and participated in

group after she got off the phone with her case manager. LW had a very positive outlook on her

admission to the unit due to her positive discharge plan. LW was having somatic delusions,

auditory hallucinations, and was extremely paranoid. On the day of care these delusions and
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hallucinations seemed to of resolved but she was still very paranoid about her boyfriend and

family at home. LW had poor grooming and poor hygiene, rapid speech at times when she was

uncomfortable talking about a topic. She had a very blunted affect and only showed emotions

when the topic was switched to me. LW was oriented to person and place but believed it was

2019 and that she was there to get placement for a domestic violence shelter.

Safety and security measures: For the inpatient admission setting there were safety checks

every 15 minutes around the clock. All hazardous items were removed from each patient upon

admission and patients were allowed to keep their safe clothing during their stay. There were

“sally port” areas between two locked doors to reduce the chances of an escape and patients were

not permitted off the unit at any point. Medications were administered by the medication nurse,

and the nurse verified the patient took all the medications at that time.

Laboratory results

Lab Value Result

Potassium 3.5
Sodium 139
Glucose 92
BUN/Crea. 12 / 0.86
RBC 4.69
Hbg/Hct 13.4 / 41.8
WBC 6.3
TSH 1.79
QTc 433
Toxicology + for TCH
Hcg level Negative
Syphilis Positive
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Psychiatric medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

Olanzapine Zyprexa Atypical 2.5 mg daily Mood
antipsychotic stabilization
Cephalexin Keflex Anticonvulsant 500 mg Q 8 hrs Infection in
finger
Gabapentin Neurontin Anticonvulsant / 300 mg Q 12 hrs Chronic pain
GABA inhibitor
Valacylovir Valtrex Antiviral 500 mg daily HSV
suppression
Benzotropine Cogentin Antiparkinsons 1 mg PRN EPS symptoms
agent
Haloperidol Haldol Typical 5 mg PRN Aggression
antipsychotic
Hydroxyzine Vistaril Antihistamine 50 mg PRN Anxiety
Tramadol Ultram Narcotic agonist 50 mg PRN Severe pain (7-
10)

Summary of psychiatric diagnosis

Schizoaffective disorder is a mental health diagnosis that includes a major mood episode

of bipolar or depression with addition to schizophrenia symptoms. It must include two or more of

delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior or

negative symptoms the following for at least one month at a time. Hallucinations and delusions

are present for two weeks or more without a mood episode. There has to be at least two weeks or

more of only psychotic symptoms but majority of the duration of the illness includes mood

symptoms (P. Wy and Saadabadi, 2021).

Signs and symptoms to receive the diagnosis include hallucinations which is a false

perception, this can present as an auditory, visual, tactile, olfactory, and gustatory. Abnormal

content of thought is also included, this can be a persecutory, grandiose, reference, religious, or

somatic delusion (Videbeck, 2020). Mood disorders can be a bipolar type or depression type.
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Depression would only include depressive episodes between psychosis episodes. Bipolar type

would include dramatic highs and manic lows between episodes. LW exhibited symptoms of

psychosis at the time of admission but she stated many times of manic episodes while with her

boyfriend. While this visit was an exacerbation she showed delusions and hallucinations, rapid

speech, flight of ideas, and had highly disorganized thought process.

Delusions are “fixed, false beliefs with no basis in reality” (Videbeck, 2020). The clients

believe these delusions with total certainty. LW presented with persecutory delusions, she stated

that she believed that her boyfriend was trafficking her and that cameras were watching her in

her house, she also had somatic delusions and believed that scabs on her arms were where her

boyfriend was injecting drugs into her to drug her for compliance. Hallucinations are false

perceptions that could include seeing or hearing things that aren’t there. LW presented with an

auditory hallucination of believing that there were voices coming from the basement and an

olfactory hallucination believing that she smelled “men” on her.

According to the National Alliance of Mental Illness, bipolar type behavior is when they

experience symptoms of mania through inflated self-esteem, decreased sleep, increased activity

and excessive speech and symptoms of depression through sadness, emptiness, hopelessness and

worthlessness (Schizoaffective disorder, NAMI). LW potentially attempted to overdose on

sleeping pills before coming to the hospital to receive help which showed her feelings of

hopelessness. LW presented with rapid speech and euphoric mood with extreme disorganized

thinking.

Identification of stressors and behaviors precipitating current hospitalization

Prior to admissions, LW was non-compliant with her medication even though she told me

she was taking them. She lives with her boyfriend who she believed was drugging and raping
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her. LW believes that when her boyfriend drugs her that he also traffics her to his friends. She

was experiencing auditory hallucinations from hearing people in her basement, olfactory

hallucinations due to smelling “men” on herself. LW felt like she had several scabs on her arms

from injection sites and also believed that there were video cameras around her house watching

her. She stated that she stopped eating, drinking, and taking her medications due to believing she

was being drugged. LW told the SANE nurse in the emergency department that she tried to take

a handful of pills to overdose but then changed her story to she was trying to get some sleep. The

physician in the emergency department pink slipped her due to an increase of psychotic episodes

and highly disorganized ideas.

Patient and family history of mental illness

LW stated that she was diagnosed with Schizoaffective at the age of 33 after her mother’s

funeral when she started experiencing somatic delusions. She stated that she had no other

relatives with the same diagnosis that she was aware of. LW lives with her boyfriend of five

years who she reports is very physically and sexually abusive. She has two daughters that she is

not close with. LW was not willing to talk about her family and her family’s health history.

Psychiatric evidence-based nursing care provided

LW was assigned a nurse each shift that presented time to talk and ask questions if

needed which she was able to build a relationship with. The medication nurse would administer

daily medication and ensure all medications were taken at the time of observation and didn’t

pocket pills to use for harm later. LW was placed on an atypical antipsychotic to stabilize her

mood. Although LW was on this medication prior to arrival, the nursing staff ensured she was

aware of why she was on the medication, side effects to look for, and what to tell the psychiatrist
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when she went back for her appointment. LW also was on an antiparkinsons agent to prevent any

extrapyramidal symptoms.

The nurse also provided distractions to help LW if she was to start experiencing any

hallucinations or delusions while on the unit. Throughout her stay on the unit, LW was

encouraged to attend group therapy sessions that would promote different techniques that she

could use after discharged. She was very excited to attend these groups and was able to tell me

her coping techniques, how she learned to meditate, and how she learned to communicate her

feelings. LW had received lots of outside resources for more group therapy sessions in Cleveland

and she had reconnected with her case manager to meet with weekly.

Ethnic, spiritual and cultural influences

LW is an African American woman belonging to the lower-class economy. She has been

enrolled in social security income since 2011. LW believes in Presbyterian views but does not

actively go to church. LW stated that she believes she needs to go through her diagnosis alone

and doesn’t want to involve her daughters in caring for her.

Evaluation of patient outcomes

Some outcomes for a patient with schizoaffective disorder include remaining free

from harming self, believing that delusions and hallucinations are false, controlling inappropriate

behaviors, teaching the client and family about the diagnosis, and keeping up with performing

self-care activities appropriately. Due to this only being the second day on the unit, LW still

hadn’t completely met these outcomes. LW did meet remaining free from harming self, she now

had a positive outlook on her discharge due to knowing she was safe and had an out from her

boyfriend. Her only concern was how she was able to get her cat to the shelter.
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When talking to LW she was able to tell me her history with her diagnosis and how she

was able to control everything prior but stated that her family believed her symptoms were her

trying to get attention instead of it being an illness. LW did not talk about her delusions and

hallucinations when asked but was still very clear about her boyfriend abusing her.

LW stated that her anxiety was better due to knowing she was able to get help and was

compliant to agreeing to counseling when she was discharged. She stated that she felt like she

had a clearer mind. LW was taking her medications appropriately, was out in the common areas

most of the day talking to other patients and was eating all of her meals. LW changed into clean

clothes for the day but still did not shower. She stated that she was going to call her daughters to

update them about the situation and invite them to come to a therapy session with her to learn

more about her diagnosis.

Plans for discharge

When LW is discharged, she will go to a domestic violence shelter alone. LW will continue

having support from social security income and will try to reconnect with her daughters. She is

ready to get help to get out of her relationship and continue to follow up with her case manager.

LW made an agreement to follow her medication regime until she can finally get in with her

established psychiatrist. She has an appointment made and transportation already planned for

her. LW has agreed to get her schizoaffective disorder back under control by visiting with her

psychiatrist as often as possible and keep a journal about her emotions leading up to her

appointment. Educational material has been provided on her medications and LW listed known

side-effects to look out for.

Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for LW:

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1. Disturbed sensory perception related to chemical alterations as evidenced by active

delusions and hallucinations.

2. Risk for suicide related to previous suicidal ideation and attempt.

3. Risk for relocation stress syndrome related to discharge planning to domestic violence

shelter.

4. Impaired social interaction related to impaired thought processes as evidence by lack of

eye contact.

5. Self-neglect related to psychiatric disorder of Schizoaffective disorder as evidence by

lack of grooming and hygiene.

Potential nursing diagnoses

1. Acute confusion

2. Ineffective coping

3. Sleep deprivation

4. Bathing self-care deficit

5. Hopelessness

6. Risk for disturbed personal identity

7. Chronic low self-esteem

8. Ineffective relationship

9. Fear

10. Decisional conflict

11. Chronic sorrow

12. Labile emotional control

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Conclusion

Medical professionals do not know much about treatment and management of

schizoaffective which makes it very difficult for patients. Many times, these patients know they

have to get help but do not like following medication regime. Due to self- care deficits, extreme

paranoia, different hallucinations and delusions, these patients can be a harm to self during times

of exacerbations requiring hospitalizations.

LW exhibited severe psychosis upon arrival to the hospital. LW had a history of being in

a manic episode usually but due to paranoia she had stopped taking her medications. LW was

feeling hopeless and took a handful of medications and just wanted out of her situation at home.

With her story sounding very truthful about being raped and trafficked at home, she was placed

somewhere safe upon discharge where she can concentrate on her health first. The goal for LW

is to stay compliant with her medications and start to follow up with counseling to talk about her

feelings. With her exacerbations being controlled prior, LWs prognosis of returning to normal

function is very good with the help of medications and counseling.

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References

P. Wy, T. J., & Saadabadi, A. (2021, August 6). Schizoaffective disorder. StatPearls [Internet].

Retrieved November 15, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK541012/. 

Schizoaffective disorder. NAMI. (n.d.). Retrieved November 15, 2021, from

https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-

Disorder. 

U.S. National Library of Medicine. (2020, August 18). Schizoaffective disorder: Medlineplus

genetics. MedlinePlus. Retrieved November 15, 2021, from

https://medlineplus.gov/genetics/condition/schizoaffective-disorder/. 

Videbeck, S. L. (2020). Chapter 16. In Psychiatric-Mental Health Nursing. book, Wolters

Kluwer.