MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Birgitte Kammerdiener

November 29, 2022

Mrs. Mackenzie Kriss

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

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Abstract

EB is a 22 year old female admitted to the psychiatric until after being brought to the Emergency

Department that followed a suicide attempt by hanging herself. The patient stated thinking about

self harm a few weeks prior to her suicide attempt; but denied any event triggering her attempt.

The patient has been diagnosed with major depressive disorder. EB has been placed on an

antidepressant to help with her symptoms. The patient is also taking anticonvulsants for a history

of seizures. Patient has a one-to-one sitter and has been attending group therapy.
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Objective Data

Patient Identifier EB

Age 22

Sex Female

Date of admission November 14, 2022

Date of care November 15, 2022

Psychiatric diagnosis Major depressive disorder, recurrent episode with anxious disorder

Other diagnoses seizure, Iron deficiency anemia

Behaviors on admission EB had been found in her garage by her uncle while attempting suicide

by hanging. The patient was cut down and brought to the Emergency Department where she

stated “I just wanted everything to be quiet.” She was calm and able to answer questions in the

ambulance and in the ED.

Behaviors on day of care EB was very willing to speak. The patient has been participating in

group since her arrival. EB was not experiencing any anxiety, depression or suicidal ideation

during the interview. The patient stated that she was glad to be alive and her affect was congruent

with her mood. EB did not experience any delusions or hallucinations. The patient's speech was

clear and there were no signs of flight of ideas or word salad. Every now and then she would

have small mannerisms to add emphasis to her story of what brought her into the hospital.

Overall, she was very willing to speak and explain how she was feeling before she came in,

when she got into the Emergency Department, and how she was feeling after being on the floor.

Safety and security measures Patient is not permitted off the unit at any time. EB also has a

one-to-one sitter with her at all times while the nurses would lay eyes on her every 15 minutes as
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part of safety checks. EB is on precautions for Suicide and Elopment. Any objects that can cause

harm to the patient are removed from the rooms and the person themselves; ex: belts, scarves,

shoe-laces or drugs.

Laboratory results

Lab Value Result

Potassium 3.5

sodium 138

Glucose/A1C 184/5.1

Blood Urea Nitrogen 9

Creatinine 0.91

Red Blood Cells 4.11

Hemoglobin/Hematocrit 12.5/38.4

White Blood Cells 12.9

AST/ALT 15/18

TSH/T4 1.69/0.91

Drug Toxicity Negative

UA.Alcohol Level Negative

QTC/ECG 465/Sinus Rhythm

Psychiatric medications

Generic Name Trade Name Classification Dose/Frequency Reasoning

lamotrigine Lamictal Anticonvulsant 425 mg Q12H Seizures

ethosuximide Zarontin Anticonvulsant 250 mg BID Seizures

sertraline Zoloft Antidepressant 50 mg daily Depression

acetaminophen Tylenol NSAID 650 mg Q6H Mild Pain (1-3)

PRN
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Summary of psychiatric diagnosis

EB was diagnosed with Major Depressive Disorder. This can involve feeling hopeless,

sad, and even lead to suicidal ideation and effect that patient ability to function in everyday life.

In the text, Major depressive disorder is:

typically 2 weeks or more of a sad mood or lack of interest in life activities, with at least

four other symptoms of depression such as anhedonia and changes in weight, sleep,

energy, concentration, decision-making, self-esteem, and goals (Videbeck, 2020).

Major depressive disorder can affect people for a short period of time or for the rest of their lives.

When someone is placed on some form of an antidepressant, it is not always going to be life

long. Major depressive disorder can be brought on by many things: a loss of a loved one, many

losses in a short amount of time, loss of a pet, a major life changing event, or it can be due to a

change in brain chemistry such as a decrease in serotonin.

In recent years there has been new criteria for Major Depressive Disorder as it has been

separated from bipolar disorder in the DSM-5. The criteria that needs to be met in order to be

diagnosed with Major Depressive Disorder is:

One or more major depressive episodes (MDE) and the lifetime absence of mania and

hypomania (Uher, Payne, Pavlova, & Perlis, 2014).

If a patient has had a history of mania, whether it is hyper or hypo, it will not qualify as Major

Depressive Disorder. Instead it would be recognized as Bipolar Disorder. EB has stated that she

has had no other inpatient psychiatric hospitalizations and has no other history of a psychiatric

diagnosis. Therefore, she qualifies for Major Depressive Disorder rather than Bipolar Disorder

because she has had no history of mania.

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While the DSM-5 was able to split Major Depressive Disorder and Bipolar disorder into

different groups, there is still a broad category that falls under Major Depressive Disorder. Not

all patients go into severe depression because of a loss and not all patients recover from

depression at the same rate. There need to be a stronger differentiation between mild and severe

because:

Eliminating all distinctions between the various types of depression supports treatment

options that do not distinguish between conditions that respond to medication from those

that do not (Paris, 2014).

Without the differentiation in how long symptoms last and the severity of someone's depression,

it can affect the way a patient receives treatment and how effective it is.

While some patients may have the depression go away, it may come and go for others.

According to the texbook:

An untreated episode of depression can last from a few weeks to months or even years,

though most episodes clear in about 6 months. Some people have a single episode of

depression, while 50% to 60% will have a recurrence of depression. Approximately 20%

will develop a chronic form of depression (Videbeck, 2020).

Even though someone's depression may only last a few months, the severity of it can

depend on the person and the situation. With mild depression a patient may still be able to

function in everyday life but they may lack the energy, have lost interest in hobbies and they may

even have a flat affect. Severe depression can cause a patient to lose all ability to function in

everyday life. A patient may lay in bed all day not simply because they are tired but because they

lack any energy to even get themselves out of bed. Patients in the severe stage will possibly need
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more help performing everyday tasks, which can involve showering, changing clothes and even

brushing their teeth.

Treatment for these patients can be a lengthy process. Antidepressants can take between 4

and 6 weeks to begin working. In this amount of time providers need to watch for an increased

risk of suicide due to the first neurotransmitter increase being norepinephrine. This allows the

patient to have a spike in energy, while their mood may not change their energy to follow

through with their plan to attempt suicide might increase. There are many factors that go into

deciding what medication will work best for the patient. In the text, these factors include:

Client’s symptoms, age, and physical health needs; drugs that have or have not worked in

the past or that have worked for a blood relative with depression; and other medications

that the client is taking (Videbeck, 2020).

The providers will consider each one of these factors to find the most effective treatment for their

patient. Providers can also look at what dose will be most effective and potentially a combination

of low dose medications to prevent tolerance from occurring as quickly as giving one medication

at a higher dose.

Identification of stressors and behaviors precipitating current hospitalization

Before being admitted to the Psychiatric unit, the patient stated that she was not feeling

like herself for a while and there was a presence of anxiety and depression. EB states that there

was an amount of frustration that she was letting build up because none understood her. The

patient was in constant arguments with her aunt and began thinking of self harm. The patient is

more isolated as she is not allowed to drive or work due to her seizures and has had many losses

within her family. EB stated feelings of hopelessness, and low energy.

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Patient and family history of mental illness

EB has not had any other inpatient admissions to a psychiatric unit. The patient stated

that she has had past panic attacks and some small amounts of depression which could be largely

due to bullying. EB has not attempted suicide or had any plan of self harm in the past. The

patients mother has been diagnosed with Bipolar Disorder and her aunt has attempted suicide in

the past.

Psychiatric evidence-based nursing care provided

During the patients stay group therapy was attempted and completed successfully. While

the patient does state that she is antisocial and has social anxiety in larger groups, she was able to

push herself outside of her comfort zone and attend each group therapy session. The patient was

also placed in the common area where she could speak with others and go outside her comfort

zone. Within the common area she was also able to do activities by herself in a non stimulating

environment involving coloring, puzzles and watching TV.

Ethnic, spiritual and cultural influences

EB is a single, Caucasian female. She is unemployed due to her epilepsy. The patient

currently lives with her aunt and uncle. When asked about social support, the patient stated that

her support group is her online friends. She has mentioned that she is antisocial and has some

social anxiety when it comes to large groups of people. EB states that she grew up going to

church, attending for about the first 19 years of her life. She explained that she is not religious

but she does believe that there is some higher being. EB has graduated with a GED after she had
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flunked out of highschool. She explained that it is difficult for her to learn in a normal setting.

Despite this, she took a few college courses but failed out of those, as the environment was not

one that she was able to learn in.

Evaluation of patient outcomes

From what was observed, EB had used the psychiatric floor and its resources to her

advantage. Her reason for admission was due to a suicide attempt. Upon ariving in the E,ergency

department she was asked what had gone through her mind when she had decided to attempt to

commit suicide. EB stated that she did not know what she was thinking but that she did not

believe she really wanted to kill herself. She stated that she is happy to be alive. When

interviewed and asked the same questions, the answers were the same, she was happy to be alive

and still did not know what was going through her mind when trying to hang herself. EB has

begun taking her medications and plans on being compliant. During the interview she even had a

smile on her face and seemed like she was improving in her mood. No harm came to the patient

while on the floor, whether self inflicted or brought on by another. All potential hazardous items

were removed upon admission to ensure that the patient did not have the ability to harm themself

or others. The patient is no longer stating ideas of wanting to harm or kill oneself.

Plans for discharge

Upon the date of the patient's discharge, she will go home with family. EB will return to

her aunt and uncle's house where she was living prior to her admission. The patient stated that

she will be compliant with all medications, anticonvulsants and antidepressants. Once discharged

home, EB plans to begin therapy so that she can talk through what she is feeling, learn new
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coping skills, and hopefully prevent another suicide attempt. EB stated that she would like to get

back into her schedule of helping around the house with chores. Her support system at home is

her online friends, and she states that she feels safe within her home environment and has no

concerns, besides her mental health, upon discharging back home.

Prioritize nursing diagnosis

1. Risk for self-directed violence related to severe depression as evidenced by previous

attempts of violence to self, suicidal behavior (attempts and ideation) and suicidal plan

(lethal method and available means).

2. Hopelessness related to losses, stressors, and the burdensome symptoms of depression as

evidenced by impaired decision making, suicidal thoughts and loss of interest in life.

3. Impaired social interaction related to lack of support system as evidenced by

dysfunctional interaction with family, peers and/or others, remains feelings of seclusion,

avoids contact with others, and states support system is only online friends.

Potential nursing diagnoses

1. Deficient knowledge related to unfamiliarity with signs and symptoms, and management

of depression

2. Risk for suicide related to history of prior suicide attempt

3. Hopelessness related to perceived hopelessness, helplessness

4. Risk for self-directed violence related to hopelessness

5. Disturbed thought processes related to depressed mood

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Conclusion

EB was fortunately a very talkative patient. She was able to understand the questions that

were asked and provide a clear answer that did not jump from topic to topic, rhyme or not make

a full sentence. EB is new to being diagnosed with Major Depressive Disorder and will need to

learn more about it, how it affects her and what to look for when things seem to worsen. She has

stated that she will be compliant with her medications and would like to start therapy upon

discharge. The hope is that she will follow through with her statements. Following through on

her states may result in an increase in mood due to the antidepressant, as well as, potentially

learning her signs and symptoms of Major Depressive Disorder from a therapist. EB could

improve her support system as it mainly consists of online friends. Unfortunately, she is unable

to work or drive due to her history of epilepsy which could be causing her to become more

isolated which in turn can lead to feelings of depression. Overall, EB seems involved in her care

and motivated to do what it takes to feel better.

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References

Paris J. (2014). The mistreatment of major depressive disorder. Canadian journal of psychiatry.

Revue canadienne de psychiatrie, 59(3), 148–151. https://doi.org/10.1177/070674371405900306

Uher, R., Payne, J. L., Pavlova, B., & Perlis, R. H. (2014). Major depressive disorder in DSM-5:

implications for clinical practice and research of changes from DSM-IV. Depression and anxiety,

31(6), 459–471. https://doi.org/10.1002/da.22217

Videbeck, Sheila L. (2020). Psychiatric-mental health nursing (8th ed). Philadelphia, PA: Wolters

Kluwe