Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Taylor Coy
March 28, 2023
Dr. Teresa Peck
Nurse 4842L Mental Health Nursing Laboratory
Youngstown State University
MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

The following case study follows the patient C.S. who is a 20-year-old male whom students

interviewed twice. C.S. has a psychiatric diagnosis of bipolar disorder with psychotic features as

well as other medical diagnoses such as polysubstance abuse, major depressive disorder, and

social anxiety disorder. C.S. is a single, white Caucasian male who lives at home with his mother

and brother. C.S. is a poor historian due to having psychotic features both times he was admitted

to the inpatient psychiatric unit and has no recollection of why. The information below is from

C.S’s electronic medical record with information of his history mostly given by the patient’s

mother.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 3

Objective Data

Patient identifier: C.S

Age: 20

Sex: Male

Dates of admission: January 17, 2023, & March 08, 2023

Dates of care: January 31, 2023, & March 14, 2023

Psychiatric Diagnosis: Bipolar with psychotic features

Medical Diagnoses: Polysubstance abuse, self-harm behavior, major depressive disorder, social

anxiety disorder, tobacco abuse

Behaviors on admission: When C.S. was admitted to the inpatient psychiatric unit on January

17, 2023, the patient was brought in by Warren PD being found in his neighbor’s attic after

breaking into her house. When he was found he was described as acting bizarre, delusional, and

becoming aggressive towards his family. Once brought to the ER pt. was described as being

extremely bizarre, manic, and agitated. A little over a month after that admission, on March 08,

2023, the patient was once again brought in by the Warren PD this time the patient's mother

called and said the patient was threatening to kill her and the six voices in his head were telling

him to do so.

Behaviors on days of care: Upon interviewing the patient on January 31, 2023, C.S. was very

friendly, cooperative, calm, and very willing to talk to students. Pt. stated that he was feeling a

lot better than he was and was happy to be getting discharged later that day. The patient

described his stay as being helpful as he learned some new positive coping mechanisms and he
 MENTAL HEALTH COMPREHENSIVE CASE STUDY 4

stated that enjoyed spending time with the other patients on the psychiatric floor. The patient’s

affect was congruent with his mood, he had a normal speech volume and pattern, displayed

appropriate eye contact when speaking, and was appropriately groomed and dressed. Upon visual

assessment, C.S. had one tattoo on his right wrist and multiple scars on his left forearm from

self-harm. C.S. was very open to talking about why he self-harms and he stated it was so his

family knew he was feeling sad because he felt as though he couldn’t communicate his emotions

with them any other way.

While interviewing C.S. on March 14, 2023, he appeared more depressed than the first-time

students interviewed him. C.S. stated that this was because he was not getting discharged today

and that his anxiety level was a 10/10. The patient stated that he experiences this anxiety all of

the time but cannot pinpoint an exact cause. C.S. was appropriately dressed and groomed, his

affect matched his mood, and he was calm and cooperative but displayed apathy while being

interviewed. C.S. stated he was extremely tired and ended the interview early to go back to bed.

Psychiatric Medications (for both admissions):

Generic Name Trade Name Classification Dose/Frequency Reason pt. is receiving

Benztropine Mesylate Cogentin Anti-cholinergic 0.5mg & 1mg/ BID Treats EPS symptoms
(1/31/23 & 3/14/23 caused by
Respectively) antipsychotics
Buspirone HCL Buspar Anxiolytic, sedative 10mg/ BID & TID Used to treat anxiety
(1/31/23 & 3/14/23 disorder
Respectively)
Clonidine HCL Catapres Antihypertensive 0.1mg/ Q4H PRN Withdrawal symptoms
Divalproex Sodium Depakote Dr Anticonvulsant 500mg BID Stabilizes mood
Haloperidol Haldol Antipsychotic Q6H PRN Treats acute psychosis
Hydroxyzine HCL Atarax Anxiolytic 25mg & 50mg/ Q6H Treat anxiety
PRN
(1/31/23 & 3/14/23
Respectively)
Risperidone Perseris Atypical 120mg/ Q 30 days Used to treat
 MENTAL HEALTH COMPREHENSIVE CASE STUDY 5

Antipsychotic schizophrenia
Trazadone Trazadone Antidepressant 50mg/ QHS Sleep
Nicotine NicoDerm Smoking cessation 14mg/ daily Smoking cessation
agent
Laboratory results:

January 31, 2023 March 14, 2023

Lab value Result Lab Value Result
Glucose 108 (slightly elevated) Glucose 107 (slightly elevated)
TSH 2.35 (normal) TSH 2.49(normal)
T4 0.73 (normal) T4 0.75 (slightly low)
RBC 4.94 (normal) RBC 5.15 (normal)
Hgb/Hct 14.3 (normal)/ 42% Hgb/Hct 14.9 (normal)/44.3% (normal)
(normal)
WBC 5.5 (normal) WBC 7.3 (normal)
BUN/ Creatinine 8 (normal)/0.85 BUN/ Creatinine 6 (low)/ 0.82 (normal)
(normal)
QTC 419 (normal) QTC 414 (normal)
Plt. Count 277 (normal) Cholesterol 156 (normal)
Toxicology Negative Toxicology positive for Amphetamines &
Cannabinoids
Depakote Level 53.5 (therapeutic) Depakote Level 93.1 (therapeutic)

Safety & Security Measures:

There are several safety and security measures taken when a patient is admitted to an inpatient

psychiatric unit. The patient is closely monitored, and any dangerous objects are removed from

them when they are admitted. These items include but are not limited to pens, pencils, any item

with glass in it, belts, etc... If patients were in group therapy and needed to write something down

or were drawing or journaling, they were given markers to do so since they are not sharp. If staff,

students, and visitors had a pen or pencil, they needed to have them always concealed in their

hands or their pockets, never laying around where the patients can grab them. The doors are

locked at all times and have to be badged into to open, staff are trained that once they open a

door, they are supposed to walk backwards through it so a patient does not try to run out. All the
MENTAL HEALTH COMPREHENSIVE CASE STUDY 6

chairs in the psych unit are extremely heavy so they are not able to be picked up and thrown at

staff or other patients. Medication administration was done only by the nurse and the nurse

verified that all the medications given were taken by the patient when given to them, this was to

prevent patients from pocketing the medications and possibly using them to make a suicide

attempt. Some psychiatric medications can cause adverse effects such as raised blood sugar,

cholesterol, elevated AST and ALT, can lower platelet count, and can prolong a patient's QTC

which can cause a dysrhythmia called Torsade de pointes. Some medications also require a

therapeutic level to be drawn such as Lithium, Depakote, and Tegretol. C.S was on Depakote so

he needed to get his blood work drawn to see if his Depakote levels were in a therapeutic range,

too much of the drug can cause toxicity and too little of the drug would be subtherapeutic so it

would not work as well. So, blood work and ECGs were done to see if C.S. was experiencing

any adverse effects from his medications.

Summary of Psychiatric Diagnosis

According to Miller (2020), “bipolar disorder is a chronic mood disorder characterized by

manic or hypomanic episodes alternating or intermixed with episodes of depression. The 12-

month prevalence of DSM-IV bipolar disorder in the USA was estimated at 0.6%, with a lifetime

prevalence of over 1% of the world’s population, irrespective of nationality, ethnic origin, or

socioeconomic status” (p.1). During his January 2023 admission, the patient had only a diagnosis

of bipolar disorder, however, he was displaying some psychotic behaviors that were noted during

the first interview. During his March 2023 admission, his psychiatric diagnosis was changed

from "bipolar disorder" to "bipolar disorder with psychotic features.” C.S. is starting to show

signs of schizophrenia as he is at the age that it tends to present itself, however, due to his young

age it is believed that they are holding off on fully diagnosing him yet. It is believed that he may
MENTAL HEALTH COMPREHENSIVE CASE STUDY 7

be starting to develop schizophrenia due to him having auditory command hallucinations from

the six voices he hears in his head telling him to harm others. The voices in his head also told

him to hold his bowels for an entire week. The patient also has bizarre behaviors when being

brought into the ED. The command hallucinations and bizarre behaviors are considered positive

signs of schizophrenia. The patient also shows some negative signs of schizophrenia such as

anhedonia (does not feel enjoyment), avolition (little to no motivation or initiative), and anergia

which means a lack of energy. The negative symptoms of schizophrenia are what make it hard

for these patients to keep a job and function to their full potential. According to Correll, C. U., &

Schooler, N. R. (2020), “Negative symptoms are a core component of schizophrenia that account

for a large part of the long-term disability and poor functional outcomes in patients with the

disorder. The term negative symptoms describe a lessening or absence of normal behaviors and

functions related to motivation and interest, or verbal/emotional expression” (p. 519).

Identification of Stressors and Behaviors Precipitating Current Hospitalization

When C.S. was first admitted after being brought in by Warren PD on January 17, 2023,

it was due to breaking into his neighbor's house where PD found him in the attic. The ER note

stated that the patient was acting "extremely bizarre, manic, and agitated." When C.S was

interviewed on January 31, 2023, he expressed his next-door neighbor as a "crazy old lady who

was out to get him" he had no recollection of being in his neighbor's attic when asked about

being in his neighbor’s attic he stated, “why would I be in the neighbor's attic?" C.S. believed

that the cops came and arrested him for no reason.

When C.S. was admitted the second time after being brought in by Warren PD after being

pink-slipped on March 08, 2023, his mother called PD and stated he was making threats about

killing her. When C.S was asked what brought him into the psychiatric unit, he stated that his
MENTAL HEALTH COMPREHENSIVE CASE STUDY 8

mom was saying “stupid stuff to the cops,” he remembered telling his mother that he was going

to kill her, but stated he was not serious and would never do that, C.S stated it was something

that he said in the “heat of the moment.” When looking at the chart, it was discovered that the

mother told staff that the patient has voices in his head which told him to kill her. This is known

as a command hallucination. Videbeck (2020) states, “Command hallucinations are voices

demanding that the client take action, often to harm the self or others, and are considered

dangerous” (p.616). In the chart, C.S. stated that he has six different voices in his head, five of

which he talks to daily. C.S. was having a somatic delusion as he believes that these voices have

put a chip in his head. March 09, 2023, C.S. was placed in the psychiatric intensive care unit

(PICU) after a code violet was called on him, the patient wanted a B-52 but was unclear in his

chart whether he received one or not.

C.S. stated that he was not taking the medication that was given to him during his

previous admission in January. When further exploring this, the patient stated that he had trouble

with getting transportation to pick up his medications. The patient also stated that the

medications the hospital gives him do not work. C.S. talked about going to CVS to pick up his

injection which he is due for every 30 days and that his mom forgot about it after picking it up

and it never got administered to him. It is likely that the patient just never went to get his shot as

they do not just give the patient a shot to take at home and it would have likely been

administered whenever he went to get it. The patient is a poor historian, and it is unclear what the

true reasoning behind his noncompliance is or why he did not receive his scheduled injection.

Both times C.S. was interviewed, he stated that he wants some medication to calm him

down such as Xanax. The patient stated that the doctor never gives that to him though and feels

as though the doctor never listens to him. When drug screened for his March 2023 admission,
MENTAL HEALTH COMPREHENSIVE CASE STUDY 9

C.S. was positive for amphetamines, which these medications would amp him up more, so it is

unclear as to why he was taking them if he wants something to calm him down. It is a theory

that since the patient’s mother has ADHD that maybe he has it too, and taking amphetamines

used to calm him down when he was younger, but since he is now older, they more than likely

just don’t work anymore in the way he expects them to.

Patient and Family History of Mental Illness

C.S. has a history of juvenile charges for an assault where he threw a rock at his sister's

head, it is unclear if he is on probation or not. According to the patient’s mother, the patient was

sexually molested at approximately eight years old by mentally ill girls and believes that this

could have contributed to some of the patient’s mental health illness. In addition to these

admissions in January 2023, and March 2023, C.S. also has prior admission history in April

2022, July 2022, and August 2022.

C.S. stated that he believes he inherited his mental illnesses from his family. He did not

state what he believes his dad has but just stated that his dad takes Xanax. C.S. stated that his

mother has ADHD and takes medication for it. The patient also stated this his brother has severe

anxiety because he is older than the patient and has “seen more.” When asked to elaborate on

what he meant by his brother has "seen more" C.S. stated that his brother saw more of the abuse

that occurred between his parents. The patient stated that his father was abusive towards his

mother but not abusive towards them although his medical chart said otherwise. C.S. stated that

his mother was often abusive emotionally and physically towards him and his siblings because

their father was abusive toward her. When asked about his childhood he stated that he felt as

though his parents were neglectful of his emotional needs. C.S. stated that although his parents
MENTAL HEALTH COMPREHENSIVE CASE STUDY 10

took care of his physical needs, they would often just sit him in front of a television and never

pay attention to him.

Psychiatric Evidence-Based Nursing Care Provided

C.S. was cared for by many different staff members including nurses, social workers,

physicians, etc... Patients are always monitored by staff to make sure patients do not cause harm

to themselves or others. The nurses on the floor assess the patient's mental state daily and

administer the patient's prescribed medications. The nurse must watch the patients take the

medication to make sure they are not pocketing them to possibly make a suicide attempt with

them later. The nurse also provides patients with education on each medication during their

medication pass.

C.S. was also encouraged to go to the groups they had daily. These groups were to help

the patients interact better with others and to learn positive coping mechanisms. C.S. did not

attend any of the groups on either day of care. He stated that he felt going to the group sessions

did nothing for him and was just a "waste of time."

Ethnic, Spiritual, and Cultural Influences that Impact the Patient

The patient is a white, single Caucasian male from a low-income family. C.S. lives with

his mother and brother, the mom is on disability and C.S. and his brother do not have jobs.

According to the patient, the brother often steals from their mother and spends most of the

money, so there are a lot of nights they go hungry or have the utilities shut off. C.S. dropped out

of high school in the tenth grade and is currently unemployed. When asked what he would be

interested in as a career he stated that he thought it would be cool to learn how to do glass
MENTAL HEALTH COMPREHENSIVE CASE STUDY 11

blowing. C.S. identifies his religion as Christianity and that he goes to church approximately

once a month.

Evaluation of Patient Outcomes

For the nursing diagnosis of disturbed sensory perception related to command auditory

hallucinations, a goal was given to C.S was that he would verbalize that the voices in his head

that were commanding the patient to kill his mother, were no longer threatening harm toward her

or others by the end of his hospitalization. This goal was not met as the patient did not state that

the voices were no longer threatening harm. Another goal for C.S. was that he would

demonstrate techniques that would help him from hearing the voices in his head. This goal was

not met as C.S. did not verbalize any distraction techniques against the voices in his head.

For the nursing diagnosis of risk for injury related to a history of self-harm behavior, a

goal given for C.S. was that he would not engage in self-harm behaviors during his stay at the

hospital. This goal was met as C.S. did not self-harm during his hospital stay. Another goal given

for this nursing diagnosis was that C.S. would be able to verbalize emotions to his family since

he feels as though he cannot and that is why he self-harms. This goal was not met, and C.S.

stated that he still felt as though he could not discuss his feelings with his family.

For the nursing diagnosis of risk to others related to manic excitement, a goal for C.S.

was given for the patient to remain calm and cooperative during the shift. This goal was met as

the patient remained calm, cooperative, and relaxed during the shift. Another goal given for this

nursing diagnosis was that C.S. would not harm others during the shift. This goal was met as the

patient did not harm others during the shift.

MENTAL HEALTH COMPREHENSIVE CASE STUDY 12

Plans for Discharge

When C.S. is discharged he stated that he will return home to where he lives with his

mother and brother. The patient has a history of medication noncompliance, so every 30 days he

will be scheduled to receive a long-acting injection to try to help with medication compliance.

Education will be provided to C.S. about the importance of medication compliance and will be

set up with a psychiatrist whom he will be encouraged to see frequently.

Prioritized Nursing Diagnoses

The following are prioritized nursing diagnoses for C.S:

1). Risk for injury related to a recent history of self-harm behaviors as evidenced by the scars on

his left forearm.

2). Risk to others related to manic excitement as evidenced by not remembering acting bizarre

and delusional.

3). Disturbed sensory perception related to command auditory hallucinations as evidenced by the

voices telling him to kill his mother.

4). Interrupted family process related to abusive father as evidenced by C.S. stating that the mom

would take it out on them when their father was abusive to her.

Potential Nursing Diagnoses

1). Impaired social interaction

2). Ineffective individual coping

3). Self-care deficit

MENTAL HEALTH COMPREHENSIVE CASE STUDY 13

4). Impaired thought process

Conclusion

In conclusion, C.S. was a good patient to do a case study on as he seems to have many

psychiatric diagnoses. The patient would benefit well from being compliant with his medication

and seeing a psychiatrist frequently. However, C.S. has a history of noncompliance and does not

seem to see that he has any problem so getting him to take his medication like he is supposed to

can be a challenge. So, it is vital that the patient’s family are involved in his plan of care so they

can help him remember to take his medications and help him do what he needs to do to function

to the best of his ability.

MENTAL HEALTH COMPREHENSIVE CASE STUDY 14

References

Miller, J.N., Black, D.W. Bipolar Disorder and Suicide: a Review. Curr Psychiatry Rep 22, 6

(2020). https://doi.org/10.1007/s11920-020-1130-0

Correll, C. U., & Schooler, N. R. (2020). Negative symptoms in schizophrenia: A review and

Clinical Guide for recognition, assessment, and treatment. Neuropsychiatric Disease and

Treatment, Volume 16, 519–534. https://doi.org/10.2147/ndt.s225643

Videbeck, S. L. (2020). Psychiatric Mental Health Nursing (8th ed.). Wolters Kluwer.  

MENTAL HEALTH COMPREHENSIVE CASE STUDY 15

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

Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________

__________ 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

___________ Patient education required (based on symptoms, diagnosis, medications, labs, safety, etc.)

___________ Priority patient needs (day of care and discharge)

__________ 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