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CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Sara R. Ciletti Youngstown State University

NURSG 4842L: Mental Health Nursing Lab

Mackenzie Kriss

November 30, 2021

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CASE STUDY
Abstract

The patient of this case study presented is a 25-year-old Caucasian female admitted to

Trumbull Regional Medical Center with suicidal ideations and a plan to overdose on pills. She

has a boyfriend she has been with for one year and has four children with no custody. Her

boyfriend works late nights and she said she would harm herself by overdosing on pills and

cutting her wrists. She is an everyday drinker and cigarette smoker. Her urine drug screen came

back positive for marijuana and cocaine. Her current occupation is a dancer, and she works at a

flea market in Niles. She has a family history of mental illness and a history of physical and

sexual abuse. She has a baby doll that she refers to as a ‘reborn’ and carries the baby doll around

with her on the unit. This patient was friendly and cooperative and has plans for receiving help

for her drug and alcohol addiction upon discharge.

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Objective Data

The patient is a 25-year-old Caucasian female admitted to Trumbull Regional Medical

Center on October 21st, 2021. The patient presented in the emergency department via EMS with

thoughts of harming herself by overdosing on pills and scratching her wrist, because her

boyfriend had to work, and she did not want to be alone. According to the boyfriend she got

angry in the car and swung the door open almost hitting a mailbox and tried to jump out of the

car while it was moving. The boyfriend called 911 after she texted him that she overdosed on

pills and sent him pictures of her wrists bleeding. The boyfriend also mentioned that she is

physically and verbally abusive towards him.

I took care of the patient five days after her admission on October 26th, 2021. I first

observed the client in group therapy actively participating and listening. The patient was asking

the nurse on ways she can follow up with NA/AA meetings upon discharge. When I approached

the patient to talk, she was socializing with the other patients. The patient collected her baby doll

from another patient and sat down at a table to talk with me. The patient was friendly,

cooperative, and had a smile on her face. She was well groomed, had brown hair with one side

shaved, tattoos and appeared her age. The patient spoke with a calm tone and had normal

volume. She had a normal affect and both recent and remote memory. The patient has good

impulse control with hostility, guilt, affection, and sexual feelings, but her ability to control her

aggression and fear are poor. She became physically aggressive with her boyfriend before

admission and is very fearful of her boyfriend leaving her. The patient however, has poor

judgement and insight with problem solving and decision making. For example, she has poor

decision making with drugs and alcohol and says she uses them because she is a stripper. While

talking to the patient she appeared to be very open with me. She currently lives with her
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boyfriend who is married but going through a divorce. She stated that she met her boyfriend at

the strip club while she was working. She said her and her boyfriend have plans to get married

next year on Halloween. The patient told me how she has four kids but lost custody to all of them

due to postpartum depression. The daughter lives in Las Vegas with the dad and her three sons

live with their dad in Salem. She told me about her baby doll that she refers to as a reborn and

how the baby doll helps her cope. The patient even let me hold her baby doll while we sat and

talked. The patient got a phone call from her boyfriend during our interview. When she returned

from the phone call, she said that her boyfriend asked how the baby doll was doing which she

said makes her happy. The patient realizes that the baby doll can trigger unwanted feelings and

emotions for women who have had a miscarriage. She said she asked the other patients if it

bothered anyone that she had the baby doll, and nobody had an issue with it.

The patient’s primary psychiatric diagnosis is bipolar affective disorder, current episode

hypomanic. According to Townsend and Morgan (2020), “A bipolar disorder is characterized by

mood swings from profound depression to extreme euphoria (mania) with intervening periods or

normalcy” (p. 422). The textbook also states, “The bipolar 2 diagnostic category is characterized

by recurrent bouts of major depression with episodic occurrence of hypomania” (Townsend and

Morgan, 2020, p. 423). The patients past medical conditions are GERD, ulcer disease, obesity,

tobacco use, and right wrist pain from punching a wall before admission. The patient reports that

she has a history of seizures. Her laboratory results were normal other than a high glucose level,

which can be due to stress and anxiety, and a positive urine drug screen for cocaine and

cannabinoids. The patient has a history of polysubstance abuse, and she is currently an everyday

drinker and tobacco smoker. The patient is currently being prescribed Aripiprazole (Abilify) for
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CASE STUDY
her bipolar disorder. She is also prescribed lithium carbonate for her mania related to her bipolar

affective disorder. The patient is being prescribed vitamins due to her alcohol abuse.

The patient is on SI precautions, elopement, and seizure precautions. SI precautions are

very important on a psychiatric floor. Patients on a psych unit with SI precautions usually have

visual checks every 15 minutes but, these can differ depending on the patient’s mental health

crisis. The psychiatric floor is designed so that people cannot harm themselves. The unit has

different doorknobs then a usual floor, and they are also not permitted to have strings. On this

unit, it is important to keep all doors locked so that patients are not able to leave the unit.

Psychiatric diagnoses

To be diagnosed with Bipolar affective disorder, current episode hypomanic, the patient

must meet certain criteria according to the DSM-5. The American Psychiatric Association (2013)

states, “For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a

current or past hypomanic episode and the following criteria for a current or past major

depressive episode:” (p. 132). According to the American Psychiatric Association (2013),

diagnostic criteria for someone who is having an episode of hypomania is stated as:

A. A distinct period of abnormally and persistently elevated, expansive, or irritable

mood and abnormally and persistently increased activity or energy, lasting at least 4

consecutive days and present most of the day, nearly every day. B. During the period

of mood disturbance and increased energy and activity, three (or more) of the

following symptoms (four if the mood is only irritable) have persisted, represent a

noticeable change from usual behavior, and have been present to a significant degree:

1. Inflated self-esteem or grandiosity. 2. Decreased need for sleep (e.g., feels rested

after only 3 hours of sleep). 3. More talkative than usual or pressure to keep talking.
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4. Flight of ideas or subjective experience that thoughts are racing. 5. Distractibility

(i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as

reported or observed. 6. Increase in goal-directed activity (either socially, at work or

school, or sexually) or psychomotor agitation. 7. Excessive involvement in activities

that have a high potential for painful consequences (e.g., engaging in unrestrained

buying sprees, sexual indiscretions, or foolish business investments). C. The episode

is associated with an unequivocal change in functioning that is uncharacteristic of the

individual when not symptomatic. D. The disturbance in mood and the change in

functioning are observable by others. E. The episode is not severe enough to cause

marked impairment in social or occupational functioning or to necessitate

hospitalization. If there are psychotic features, the episode is, by definition, manic. F.

The episode is not attributable to the physiological effects of a substance (e.g., a drug

of abuse, a medication, other treatment)” (p. 124).

Her axis II diagnosis is borderline personality disorder and polysubstance abuse.

Borderline personality disorder is a cluster B personality disorder. It is characterized by

impulsiveness, erratic emotions, and extreme intensity. People with cluster B personality

disorders are usually manipulative and can be dishonest. Borderline personality disorder usually

derives from a fear of abandonment, and it is apparent, my patient has a fear of her boyfriend

leaving her.

Stressors and Behaviors

Upon admission to the hospital the patient became angry when her boyfriend said he

would be home late from work that night. He works as an Amish carrier and can be out late at

night. Once the patient found out that he would be home late, she became angry and threatened
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to overdose on pills and slit her wrists. The patient reports her anxiety a 5/10 when she is not

with him. She was questioned as to why this event triggered her present response. The patient

stated she said it out of anger because she is tired of being alone. She also mentioned that

stressors made her angry but did not specify what those stressors were.

Patient and Family History of Mental Illness

The patient has an extensive history of mental illness and hospitalizations related to her

mental illness. The patient was last admitted to Trumbull Regional Medical Center in August of

2021. She was discharged home on Wellbutrin and Trileptal. Upon discharge her boyfriend kept

her in a motel with a friend and when she returned to her boyfriend’s house, she saw that his wife

packed up her belongings and got rid of them. Prior to her admission in August of 2021, she was

admitted to St. Elizabeth’s in January of 2021 for attempting to overdose on Depakote.

The patient stated that she first began to receive treatment for her mental health at ten

years old. The patient said she has a few previous suicide attempts but, her most serious one was

six years ago. She said her daughter was only three years old when the patient tried to overdose

on Seroquel. The patient said the last time she cut herself was three years ago but did not say

why. The patient has a substantial history of abuse. From age eight to sixteen years old, the

patient was sexually abused by her step grandfather and father. She reports that her ex-boyfriend

raped her and physically abused her by sitting on her stomach while she was pregnant. She also

reports that she was raped at a club in 2019 and was raped twice last year in 2020. She stated that

she was physically abused by her stepfather until the age of fifteen. According to the HPI, she

stated that she was raped at least five times, and her last rape was one year ago while she was

drinking, a male robbed and raped her. According to the HPI, the patient stated that she has

flashbacks when she drinks or when her and her boyfriend are intimate.
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The patient said throughout her lifetime she has been diagnosed with major depressive

disorder (MDD), insomnia, post-traumatic stress disorder (PTSD), post-partum depression,

attention deficit hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), and

borderline personality disorder. The patient’s family also has an extensive history of mental

illness. Her aunt committed suicide in 1968. The mother has a history of depression, post-

traumatic stress disorder (PTSD), and post-partum depression. The father has a history of bipolar

disorder and alcoholism.

Evidence-Based Nursing Care Provided

The most important aspect of caring for a patient with mental illness is creating a good

therapeutic relationship. “Effective establishment of the TR increases the effectiveness of any

nurse intervention in clinical practice in psychiatric units” (McAndrew et al., 2014, as cited in

Moreno‐Poyato et al., 2019, p. 1615). Many aspects make up a good therapeutic relationship, but

trust is an important aspect. The patient needs to be able to trust the nurse, and by doing so, the

patient may feel more vulnerable to share any negative feelings with the nurse. If the patient has

a poor therapeutic relationship with the nurse, then the patient may not be willing to share as

much information with the nurse. Keeping your word as a nurse is important in building the trust

in a therapeutic relationship. If you tell the patient, you are going to get them water, but then an

hour goes by and you never do, then the patient will no longer trust you. Being honest with the

patient is the best thing you can do to maintain a trusting therapeutic relationship.

Group therapies are an important practice of treating mental illness. Group therapies

allow the patients to be open and share their feelings with one another, if they feel comfortable

doing so. Group therapies also teach the patients how to interact with their peers. The patients
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CASE STUDY
usually remind one another with what is considered socially acceptable when speaking or acting

out in groups, and what is not.

Patients also need to be provided with education about their medications. For example,

my patient is currently taking a medication called Lithium. Lithium is an antimanic used to treat

patients experiencing mania. It is important to educate the patient about toxicity when taking

Lithium and the normal therapeutic range. The therapeutic range for Lithium is 0.60-1.20.

Lithium levels must be checked to ensure the patient is in the therapeutic range and not over or

below. My patient’s lithium level was 0.20 which is considered low and not therapeutic.

Ethnic, Spiritual, and Cultural influences

In the patients chart it denies any spiritual or cultural background. The patient also did

not mention any spiritual or cultural background. However, ethnicity, culture, and spirituality can

all have an impact on a person’s mental health and how the person decides to treat it. I learned a

few things in class and how a person’s culture may look at mental illness differently than another

culture. For example, Asian-Americans are known for denying mental illness or trying to hide it.

They believe if someone has a mental illness then they are weak, and it should not be talked

about. Some cultures believe that praying to a higher power may cure the person of that mental

illness.

Age can also impact how people view and treat their mental illness. Clement et al., 2015

stated, “In addition, stigma is also commonly reported as a barrier to young people seeking help

and accessing mental-health related services” (As sited in Molloy et al., 2020, p. 16). Today,

younger people look at mental illness as having an issue or a problem. Unfortunately, people are

ashamed to say that they need help when it comes to mental illness and receiving treatment. I

feel like this can also apply to the older population as well.
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CASE STUDY
Patient outcomes

The patient revealed she feels much better taking the lithium, although her lithium levels

were low and not in the therapeutic range yet. Overall, the patient appeared to be in good spirits

and was excited about being nine days sober with plans to attend NA/AA meetings upon

discharge. According to the HPI, the patient has attended inpatient rehab at Ester house, but is

not interested in inpatient rehab at this time. The patient was able to talk about her sensitive past

without becoming tearful. The patient provided in depth details that matched with the HPI. The

patient wants to resume counseling when she is discharged. She said she used to attend a

counselor but had not gone for a while. The patient mentioned in group therapy that she wanted

to look for a new nurse practitioner. She said that the medications she had prescribed for her did

not help. The patient plans to go home to her boyfriend and meet his kids this weekend for the

first time. The patient stated that she was nervous she would lose visitation with her sons because

her drug screen came up positive for cocaine and pot. The patient said she would be quitting her

job as a stripper and working as a dispatcher for a tow truck company in Girard. She also wants

to continue to work at the flea market in Niles. The patient mentioned she was not sure how

going back to work at flea market would go. She said that there was a dispute between her and

another worker. This coworker and her boyfriend got into a fight in a front yard over an unknown

matter. I asked the patient how she plans to handle this situation and she said she was not sure

how it would go.

Prioritized Nursing Diagnoses

1. Risk for suicide related to feelings of loneliness as evidenced by verbal threats to

overdose on pills and self-harm.

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CASE STUDY
2. Risk for anxiety related to cessation of alcohol as evidenced by feelings of inadequacy

and increased tension.

3. Ineffective coping related to polysubstance abuse as evidenced by everyday drinking and

verbalization of using drugs to dance.

Listed Potential Nursing Diagnoses

1. Risk for withdrawal symptoms r/t polysubstance abuse

2. Risk for post-traumatic stress disorder r/t history of abuse

3. Risk for defensive coping r/t low self-esteem

4. Risk for insomnia r/t psychological stress

5. Risk for dysfunctional family process r/t alcohol abuse

Conclusion

Overall, I had a great interview with my patient. She came in with suicidal ideation and

participated in her treatment. During our interview she was respectful and answered any

questions I had. She was open about her current and past drug addiction and her work as a

dancer. The patient’s plans for discharge are appropriate, however, I think this patient would

benefit from inpatient rehab for her drug and alcohol addiction. I think my patient would really

benefit from counseling. She will be able to talk about her feelings of fear related to

abandonment and how she can overcome those fears. I also think she needs to be compliant with

her psychiatric medications especially, the lithium. The lithium will help control her manic and

erratic moods. For example, when she becomes angry with her boyfriend, instead of becoming

aggressive she will use appropriate actions. One thing I think I did well was get a thorough

history of my patient. Obtaining the history of your client is important when you go to interview

them so you can compare data with the HPI.

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References

Ackley, B. J., & Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide

to planning care (Ninth). Mosby/Elsevier.

American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental

Disorders: DSM-5 (5th ed.)

Molloy, L., Beckett, P., Chidarikire, S., Merrick, T. T., Guha, M., & Patton, D. (2020). Culture,

the Stigma of Mental Illness, and Young people. Journal of Psychosocial Nursing and

Mental Health Services, 58(11), 15–18. https://doi.org/10.3928/02793695-20201013-03

Moreno‐Poyato, A. R., Delgado‐Hito, P., Leyva‐Moral, J. M., Casanova‐Garrigós, G., &

Montesó‐Curto, P. (2019). Implementing evidence‐based practices on the therapeutic

relationship in inpatient psychiatric care: A participatory action research. Journal of

Clinical Nursing, 28(9-10), 1614–1622. https://doi.org/10.1111/jocn.14759

Townsend, M. C., & Morgan, K. I. (2020). Essentials of Psychiatric Mental Health Nursing:

Concepts of care in evidence-based practice (Eighth). F.A. Davis Company.

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Case Study Comment Sheet 4842 (Turn in with Case Study)

Student Name: Sara Ciletti

Pt Identifier: K.B.

Date(s) of Care: 10/26/2021

__________ Objective Data presentation the patient, treatments, medications

_________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format