COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Brooke T. Carroll

James and Coralie Centofanti School of Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

Mrs. Phyllis Jean Defiore-Golden

19 February 2023
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Abstract

R.B is a 34 year old male admitted to the inpatient psychiatric unit following having

auditory hallucinations at his home after being off of his medications. He has a mental health

diagnosis of schizoaffective disorder and bipolar type 1 and often experiences auditory

hallucinations. With medication treatments including antipsychotics and antidepressants, the

symptoms have become somewhat manageable and RB has been able to resume activities of

daily living and actively searching for a job. Nursing care provided on the unit is focused on

getting to know the patient now that he is stable and symptom management through both

pharmacological and nonpharmacological methods such as group therapy sessions. Numerous

medical journals will be reviewed and referenced within this case study.
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Objective Data

Patient Identifier: RB

Age: 34

Sex: Male

Date of Admission: February 11, 2023

Date of Care: February 17, 2023

Psychiatric diagnosis: Schizoaffective disorder

Other diagnoses: Bipolar type 1

Behaviors on Admission: RB voluntarily admitted himself to the unit because he was having

auditory hallucinations telling him to kill himself and his loved ones. The patient had been off of

his medication for about a week after running out. He was actively suicidal with a plan and the

means to carry out his plan.

Behaviors on the day of Care: RB was calm, cooperative and willing to talk to me openly. He

participated in group therapy and also psychotherapy throughout the day and was very social

with the other patients on the unit. When I asked, RB exclaimed he had no suicidal or homicidal

ideation. He also displayed no signs or symptoms of depression or anxiety. RB was going to be

discharged later that day. RB was no longer experiencing auditory hallucinations and was not

delusional. RB was in an appropriate state of mind and said he “used God to overcome his

hallucinations”. RB had a clear pattern of speech and didn’t display a flight of ideas. RB

answered all questions appropriately and even cracked a few jokes here and there. RB had an

appropriate affect and facial expression matched what was being said. The mannerisms displayed

were expected and RB did not display any signs of mania.

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Safety and Security Measures: Throughout the inpatient unit at Mercy Health Youngstown

there are various safety and security measures. RB was allowed to roam freely throughout the

unit at his leisure but was not allowed off the unit or in the nurses station. RB also maintained his

boundaries and did not intrude on anyone's personal space. Hazardous items such as weapons,

shoelaces and hoodie strings are not permitted on the unit. Breakfast, lunch and dinner trays are

served on styrofoam with plastic utensils and patients are permitted to wear their own clothing

after it has been washed by hospital staff and strings have been removed. Personal belongings are

kept in a locker until the time of discharge, and no cell phones are permitted. All medications

including nicotine gum are administered by either a RN or LPN and they are verified by both the

nurse and pharmacist.

Laboratory results:

Lab value Result

Potassium 4.1

Sodium 139

BUN 6

Creatinine 1.0

Red blood cells 5.12

White blood cells 10.8

Hemoglobin 15.8

Drug toxicology Negative

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Psychiatric Medications:

Generic name Trade name Class/category Dose/frequency Reasoning

atorvastatin Lipitor Antihyperlipide 40mg daily High cholesterol

mic

oxcarbazepine Trileptal Anticonvulsants 300mg BID Bipolar disorder

quetiapine Seroquel Antipsychotics 50mg BID Schizoaffective

disorder

Summary of Psychiatric Diagnosis

Schizoaffective disorder is a disorder characterized by a combination of schizophrenia

symptoms, such as hallucinations or delusions and mood disorder symptoms such as mania or

depression. A hallucination is defined as seeing or hearing something that is not really there and

a delusion is defined as a false, fixed belief that is held regardless of contradictory evidence.

These symptoms negatively impact a person’s thinking, emotions, perceptions of reality and

interactions with others. Another marked characteristic of schizoaffective disorder is

disorganized thinking (Wesseldijk-Elferink et al., 2021).

Schizoaffective disorder involves mood fluctuations, such as mania and depression with

psychotic events. Patients with schizoaffective disorder are often hesitant toward pharmaceutical

treatment, because of the fear of adverse effects. This reluctant behavior reflects a loss of

metacognitive and communication capacities, and is harmful when a person is not properly

treated which might lead to hospitalization in long-term mental healthcare (Wesseldijk-Elferink

et al., 2021).

Another common occurrence in schizophrenic patients is suicidal, homicidal ideation and

suicidal behavior. RB had suicidal and homicidal ideation on the day of admission.
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Identification of stressors and behaviors precipitating current hospitalization

Prior to admission, RB was noncompliant with his medications. He lives at home with his

brother and aunt but said they have a “good” relationship and rarely argue. RB did not identify

any home stressors, but did express concern that he needs to find a job because disability does

not pay enough for his preferred way of life. RB stated that he knows the auditory hallucinations

reoccur when he is off his medications, but also said the voices are what makes him not take the

medications in the first place. RB stated he uses “God” to combat suicidal and homicidal ideation

but did not elaborate on who or what his “God” is. On the day RB was brought to and admitted

into the hospital, he was experiencing auditory hallucinations that told him to kill himself and the

one’s around him. RB realized that the voices were fake and called 9-1-1 for help. EMS arrived

at the scene and RB was standing in the front yard waiting for them. Per the EMS report, RB was

talking to himself. RB signed himself into the psychiatric unit and was therefore deemed

voluntary.

Patient and family history of mental illness

RB stated he was diagnosed with schizoaffective disorder as well as bipolar type 1 about

15 years ago when he was the tender age of 20. RB stated his diagnosis came about when he was

struggling to hold a job and experiencing hallucinations. RB graduated from highschool and was

on track to obtain his bachelor’s degree when the hallucinations started to interrupt his daily life

functions. There was no family history on file in the patient's electronic medical record and when

asked where his parents were, he did not know. RB stated neither his aunt or brother had any

history of mental illness and were contributing members of society. When asked if he had any

siblings, he said he was not sure and quickly changed the conversation.
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Psychiatric evidence-based nursing care provided

During his stay in the inpatient psychiatric unit, RB received care from the mental health

nursing staff, such as Registered Nurses, Social Workers and Nurse Practitioners. RB was

assigned a nurse each shift which changed approximately every 12 hours. RB built a relationship

with each nurse he had and brought any concerns he had to them. The nurse used the nursing

process to assess, plan, implement and evaluate RB daily. The nurse also administered daily

medications as well as “as needed/PRN” medications to the patient while following the 5 rights

of medication administration. RB was prescribed an antipsychotic and an anticonvulsant. The

nurses that provided care for RB were well aware of the purpose, side effects, and

contraindications for the medications. For the antipsychotic, the nurses were aware of the signs

of neuroleptic malignant syndrome, a rare but serious condition that can occur when taking this

class of medication or when abruptly stopping, characterized by severe mental status changes,

muscular rigidity and autonomic dysfunction.

For patients experiencing auditory hallucinations, we as healthcare professionals are

taught now to explore the voices and what they entail with the patient. Dismissing the

hallucinations and telling the patient they are wrong is not backed by evidence and is frowned

upon today. This will only cause the patient to be defensive and untrustworthy toward staff

members and people in general. Although RB was not experiencing any hallucinations on the

day I participated in his care, I have seen other staff members display this new practice.
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Ethnic, spiritual and cultural influences

RB is a caucasian, single man from a lower-middle class family in Campbell, Ohio. RB is

not employed and is collecting disability due to losing all 8 of his fingers and both of his thumbs

following severe frostbite around 10 years ago. When asked what happened, RB explained that

the voices made him stay outside in extremely cold temperatures for hours until someone found

him and alerted emergency services. I could not exactly piece together if this is what prompted

his diagnosis, but he expressed that he was adapted to his way of life. RB practices Christianity

as a religion but said he does not attend church. RB was not willing to elaborate on his spiritual

beliefs but stated that he is content where he is at now with “God”.

Evaluation of patient outcomes

Outcomes for a patient with schizoaffective disorder vary greatly and are individualized.

Some general outcomes for a patient with schizoaffective disorder include remaining free from

suicidal or homicidal thoughts, performing self care activities independently and recognizing

their distorted reality. On the day of care for RB, he was appropriately performing self care

activities and took a shower between group therapy sessions. RB was also appropriately dressed

and did not have any odor or signs of neglect. RB asked for a snack around 10am and ate this

appropriately with adequate table mannerisms. I did not see him eat breakfast or lunch but the

staff exclaimed he had adequate intake. RB also remained free of any suicidal or homicidal

thoughts while on the inpatient unit and did not express any concerns regarding her well-being.

During the medication pass, RB was observed taking his medications without any trouble or

disagreement toward the medication nurse.

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Plans for discharge

RB was being discharged later on that day that I participated in his care. RB will return to

his home where he resides with his brother and aunt. Staff felt that RB was appropriate to return

home and did not need an extended stay or long-term psychiatric placement after discharge from

the inpatient unit. RB will be discharged with a 30-day supply of the Sertraline and will receive

the 30-day intramuscular shot for his other medications. The intramuscular shot is something

new and ensures patients at least are on their medication for 30 days. RB also had multiple

outpatient counseling sessions scheduled even before leaving the inpatient unit. The outpatient

counseling sessions are held at a community agency. RB is encouraged to regularly attend group

therapy sessions within the community and with his psychiatrist. Another big teaching moment

for discharge was the importance of medication compliance because when he was admitted, he

was noncompliant with his medications at home. This is another reason why RB is now

prescribed the 30-day long acting intramuscular injection for his antipsychotic medications.

Educational material will be provided to both the patient and his brother on things such as

suicidal ideation, medication compliance and possible side effects/adverse reactions.

Transportation was set up on behalf of the social worker and RB will be using public

transportation to return home.

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Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for RB:

1. Risk for violence related to delusions and hallucinations as evidenced by the patient

saying he heard voices.

2. Disrupted sensory perception related to psychological stress as evidenced by auditory

hallucinations and an altered communication pattern.

3. Impaired verbal communication related to altered perceptions as evidenced by difficulty

communicating thoughts verbally.

4. Risk for suicide related to suicidal auditory hallucinations as evidenced by suicidal

ideation.

5. Anxiety related to discharge as evidenced by restlessness and forgetfulness.

6. Interrupted family processes related to patient being hospitalized as evidenced by holding

a family meeting on the unit.

Potential nursing diagnoses

1. Acute confusion

2. Fear

3. Hopelessness

4. Impaired memory

5. Ineffective coping

6. Ineffective health maintenance

7. Self-care deficit

8. Impaired social interaction

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9. Risk for situational low self-esteem

10. Risk for loneliness

Conclusion

Schizoaffective disorder and Bipolar type 1 disorder are both complex disease processes

and affect both the mind and body. Exacerbation and remission of symptoms is common, and

medication compliance is absolutely necessary for daily life functions. During the exacerbations,

patients can become suicidal or homicidal so inpatient care with direct supervision is the best

treatment option, with intense outpatient therapy being second. Once in remission, patients often

resume daily life functions without trouble while on their medications.

RB had severe auditory hallucinations which told him to kill himself and the others

around him. RB was at an increased risk for suicide during this time and he recognized this and

voluntarily admitted himself to the inpatient unit. RB has been dealing with this for 10+ years so

it was easy for him to recognize and attack what was happening.

RB was a great patient and deeply broadened my knowledge on schizoaffective disorder

and was very helpful to have as a nursing student. I believe RB can thrive and meet his goal of

getting a job with the right support from family and his psychiatrist. Medication compliance is

something RB has to work on and he now has the skills and support to do so.
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References

DW;, M. J. N. B. (2019, February). Schizoaffective disorder: A Review. Annals of clinical

psychiatry : official journal of the American Academy of Clinical Psychiatrists. Retrieved

February 22, 2023, from https://pubmed.ncbi.nlm.nih.gov/30699217/

Videbeck, S. L. (2019). Psychiatric-Mental Health Nursing (Eighth). LWW.

Wesseldijk-Elferink, I. J. M., Hendriks, A. W., & Heuvel, S. (2021, July 2). October 2021. Table

of Contents page: Archives of Psychiatric Nursing. Retrieved February 22, 2023, from

https://www.psychiatricnursing.org/issue/S0883-9417(21)X0005-2