PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Ashley Ventimiglia

NURS 3721: Mental Health Nursing

Dr. Peck

April 3, 2023
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Abstract

The following case study describes the disease process of a patient with psychosis along with

treatments and interventions provided for the patient. The subject of this case study is A.L., a 62

year old caucasian female that was involuntarily admitted to the psychiatric floor for a psychotic

episode. A.L. also has diagnoses of hypothyroidism, hyperlipidemia and hypertension that may

be attributed to her disease or compile on top of her list of symptoms. Numerous academic

journals were utilized to complement the patient data. This paper highlights the manifestations of

psychosis and those factors that may lead to periods of exacerbations and remissions.
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychosis: Case Study

Objective Data:

A.L. is a 62 year old female. She was admitted to the inpatient psych floor at Trumbull Regional

Medical Center on March 20th, 2023 involuntarily related to a violent threat to blow up her

neighbor’s home. A.L. has a long standing history of admissions to psychiatric units since the

age of 18, as well as a family history of mental illness. Her mother has bipolar disorder and her

sister also has a history of mental health disorders that was unspecified by the patient.

Currently A.L. is experiencing an episode of psychosis. Throughout the patient interview,

she displayed many characteristics of a psychotic patient. Examples of these are as follows. The

patient displayed a prevalence of religious and paranoid delusions. She believes that God speaks

directly to her and shares that God often tells her people's fate, what to do, and even gives her

signs in her physical environment. She believes that, related to these religious delusions, that

God has given her a few signs that the world is going to end in the very near future. These signs

included the storm that happened in Ohio a few weeks ago, and that it signifies Noah’s Ark, a

beauty mark on the bottom of her foot that is in the shape of an “e”, that to her,stands for end,

that claiming that you have a disease (she used the example of diabetes) is claiming the devil, so

she does not claim her diseases and she does not welcome the devil inside of her body. She also

exclaimed many times that “this is God's revolution”, which, to A.L. means that the end of the

world is near. Finally, she said that God woke her up one night as a sign to trust the nurse , and

he also told her to bring a bible into work and give it to her manager at work because he needed

to be healed.
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A.L. also experiences persecutory and paranoid delusions. The first one that she shared

was that she felt that the other students on the floor were taking notes on her, when these

students really were minding their own business. This was the first clue that she was

experiencing paranoid delusions. Later in the interview she was explaining why she lost her

previous job. She shared that her coworkers and bosses were all ganging up against her and that

they all wanted her fired. She exclaimed that they were all trying to make her look crazy, so

before they fired her she quit. She also said multiple times that she believes people in the

community know where she lives and that she believes that they want to harm her, so she

barricaded herself in her own home out of fear of persecution. She has conspiracies with

healthcare workers covering up crimes and that they are trying to poison her with drugs she does

not take so that they end up making her drowsy. A.L. therefore has a huge distrust with

healthcare workers, coworkers and her community.

A.L. presented with flight of ideas where she talked about many things all at once that did

not correlate together, and were unrelated to the topic of discussion. The patient showed an

instance of impulsivity when she claims that she randomly spent 600 dollars of chocolate, and

claims that this is why her sugar had spiked. She also displayed both tangentiality and

circumstantiality. A lot of the time when a question was asked, she would go off on a tangent

about something completely different and would never get to the answer. There were very

scattered instances of circumstantiality when she would finally get to the answer, but most of the

time she needed to be redirected to receive an appropriate answer to the question.

A.L. has a medical history of hypertension, hypothyroidism, hyperlipidemia, type 2

diabetes, vitamin D deficiency, obesity, and bipolar disorder.

PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Treatments for A.L. include Clonazepam/ Klonopin which treats her anxiety, Depakote/

Valproic Acid which is a mood stabilizer, Haloperidol/ Haldol for acute psychotic behavior,

Hydroxyzine/ Atarax for anxiety, Paliperidone/ Invega for psychosis symptoms and Trazodone

for sleep. She also takes hydralazine for her blood pressure, vitamin D supplements, and

synthroid for her thyroid

The patient's labs were monitored during her visit. Any abnormal labs must be addressed

as they can have a negative impact on the patient. ALT and AST, are monitored with depakote

along with BUN and creatinine because depakote is nephro and hepatotoxic. Depakote can also

drop white blood cells. Haldol and Depakote also raise the QTC, so this is also checked on

admission and throughout the patient's stay to ensure that the patient will not go into torsades,

which may be fatal. The patient is taking Invega which can raise blood sugar, so this lab value is

monitored as well. The patient may have platelets drawn because Depakote can decrease

platelets, and finally will have a cholesterol level drawn because Haldol can increase a patient’s

cholesterol.

Other nonpharmacological treatments include maintaining a safe environment free from

any hazards along with constant observation from staff. A.L. was also placed in the PICU where

she received B52 x3 to date related to being a danger to others during her angry outbreaks. The

patient also attends group therapy every day multiple times a day.

Stressors and Behaviors Precipitating Hospitalization:

A.L. has many stressors that may have contributed to her hospitalization. The patient

recognizes that she has had many admissions, so she has had these behaviors that brought her
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

into the hospital many times before. Throughout my interview with A.L. I gathered that all of her

hospitalizations were related to an anger outburst where she “flys off the handle”. She stated that

she is “like a grizzly bear when she is angry” and cannot control her actions or emotions in these

times. A.L. also has recently lost her job (in the last five years) and may be experiencing

financial difficulty. A.L. states that she has a distrust with medical professionals because she

thinks that they are trying to poison her. Due to this, A.L. is noncompliant with her medicine.

Prior to her hospitalization her depakote level was subtherapeutic, meaning that shye was not

receiving any treatment for her mood lability at the time of the outburst. Finally, A.L. is

extremely paranoid. This is a major stressor in her life because she is constantly in a state of fight

or flight with the anticipation that there is someone out to get her. This fact, along with her

medication noncompliance can lead to subsequent extreme fluctuations in mood for this patient.

Patient and Family History of Mental Illness:

A.L. states in her interview that her mother has a history of mental illness, specifically

bipolar disorder, as does her sister. A.L. states that her mother was uninvolved with her care and

brother was unsupportive of her throughout her childhood. A.L. also states that she has been in

and out of mental health facilities since she was 18, but due to psychosis diagnosis, does not

believe that there is anything wrong with her.

Summary of Psychosis:

“In their current conceptualization of psychosis, both the APA and the World Health

Organization define psychosis narrowly by requiring the presence of hallucinations (without

PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

insight into their pathologic nature), delusions, or both hallucinations without insight and

delusions. In both of these current diagnostic classification systems, impaired reality testing

remains central conceptually to psychosis” (Arciniegas, 2015). Because the specifications that

qualify a patient with psychosis are so broad, a patient with psychosis may fall under a wide

variety of other personality disorders or mental health conditions including and not limited to

bipolar disorder, and many other existing personality disorders. “Although psychosis is the

defining feature of the schizophrenia spectrum disorders (ie, schizophrenia, schizoaffective

disorder, delusional disorder, schizophreniform disorder, and brief psychotic disorder), it also

occurs in some people with bipolar disorder during either a manic or depressive episode as well

as in some individuals during a major depressive episode associated with major depressive

disorder” (Arciniegas, 2015). A.L. demonstrated religious and paranoid delusions during her

interview deeming her as part of the psychosis category, but I also believe she may have a

variety of other associated conditions. The patient seemed to have no remorse, mood lability, and

many types of delusional thinking. This further proves that her psychosis diagnosis may also

qualify her into the category of other mental health diagnoses.

Milieu Therapy and Evidence Based Nursing Care

Milieu therapy is a form of psychiatric treatment that focuses on the individual's

environment, including the physical, social, and psychological aspects, to promote healing and

recovery. The goal of milieu therapy is to create a therapeutic environment that supports the

individual's recovery and encourages positive behaviors. “Milieu therapy interventions are

simple, safe, cost-effective and can be used in any inpatient psychiatric setting. To implement

milieu therapy, nurses do not require any specialized training.” (Bhat et al., 2020). This fact
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

makes it easy to implement milieu therapy in the clinical setting. Patients arriving at the

psychiatric unit have all hazardous objects removed from the premise. Additionally, the lights

are kept dim in the patient's room and group therapies offer an ideal social opportunity for

discussion of feelings, goals, and thought processes.

During group therapy, the client was able to list potential positive coping mechanisms to

utilize upon discharge and interact with the other patients on the floor. “The outcome goals of

group therapy are applied to the patient's life outside of the group and include behavior

corrections, development of interpersonal and relationship skills, education, the installation of

preventative measures and coping skills, and an eventual return to normal functioning within

society” (Malhotra & Baker, 2022). Some other evidence-based nursing interventions may

include using cognitive-behavioral therapy or interpersonal therapy to treat specific mental

health conditions such as Psychosis. These interventions have been shown to be effective in

improving patient outcomes and may be integrated into milieu therapy to create a comprehensive

and evidence-based treatment plan. By using evidence-based nursing interventions within a

therapeutic milieu, nurses can help patients achieve better mental health outcomes.

Ethnic, Spiritual, and Cultural Influences:

A.L. is a caucasian female. She claims that she believes in God but did not specify a

specific religion or god that she identifies with. The patient has perseverance with discussing

religion and has a borderline obsession, as all of her answers in her interview connected to that

topic in some way. It could be deduced from the interview that A.L. was in a low socioeconomic

class because she is unemployed and stated that she does not have a car, and lives alone with no

caretaker to provide her with financial stability.

PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Evaluation of Patient Outcomes:

I was able to talk to A.L. two times during separate clinical experiences prior to this case

study, and noticed a very subtle change in A.L.’s progress. The only change that I noticed was

that physically, she had better hygiene and seemed to have taken a shower, whereas the first time

I saw her, she appeared very disheveled. She still had a noncompliance with her medications

besides Depakote because she stated that it makes her hair wavy, was not taking any of the other

antipsychotic medications she was prescribed, and was still having the same delusions along with

additional delusions on top of the ones from the first interview. She also stated that she does not

care if she ever leaves the floor because she has fear that she will be persecuted, and that she is

protected in that particular psychiatric facility. Alternatively, I do believe that she showed an

improvement in participation from the first week’s group therapy and even shared a few positive

coping mechanisms that she was taught in that session.

Discharge Plans:

Although A.L. displayed a clear desire to stay at the facility, the discharge plan for her is

currently to send her back to her home where she lives alone. If she were to return home, A.L. is

required to take all prescribed medications that she has been prescribed on the unit. This may

require a degree of medication teaching. Because the patient is on Depakote therapy, the patient

would be required to have regular levels drawn to be evaluated for therapeutic treatment and

compliance. A.L. is still refusing medications and has shown scarce signs of improvement and

may need to be considered for an alternate assisted living facility.

PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Prioritized List of Nursing Diagnoses:

Anxiety related to paranoid delusions as evidence by barricading self in home, perceiving that

students were taking notes on her, statements that people are “out to get her” ,

Risk for injury related to outbursts of uncontrolled emotion as evidenced by B52 injection,

restraint by police and injury to wrist.

Disturbed thought process related to biochemical alterations in the brain as evidenced by

disorganized thoughts.

Potential Nursing Diagnoses:

Risk for loneliness

Risk for spiritual distress

Ineffective impulse control

Ineffective health maintenance r/t ineffective diabetes management

Disturbed sensory perception

Self care deficit

Conclusion:

In conclusion, A.L. was an interesting patient and displayed many aspects of the

diagnosis of psychosis. If the patient follows the treatment plan as prescribed at the mental health

institution, and continues to be compliant with her regime in her personal life, she may be able to
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

be a functioning member of society. If she chooses not to follow the prescribed treatments, these

maladaptive behaviors will likely continue to keep A.L. in and out of mental health institutions.
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

References

Arciniegas, D. B. (2015, June). Psychosis. Continuum (Minneapolis, Minn.). Retrieved April 7,

2023, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455840/#:~:text=The%20DSM

%2D55%20allows,or%20negative%20symptoms%20(for%20schizophrenia

Bhat, S., Rentala, S., Nanjegowda, R. B., & Chellappan, X. B. (2020, February). Effectiveness of

milieu therapy in reducing conflicts and containment rates among schizophrenia

patients. Investigacion y educacion en enfermeria. Retrieved April 7, 2023, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7871472/

Malhotra, A., & Baker, J. (2022, December 13). National Center for Biotechnology Information.

Group Therapy. Retrieved April 7, 2023, from

https://www.ncbi.nlm.nih.gov/books/NBK549812/

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

nnnnnnnConcepts of care in evidence-based practice. F.A. Davis Company.