Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Kaitlyn Goss
March 22, 2023
Ms. Elizabeth Sanford, BSN, RN
NURS 4842L Mental Health Nursing Laboratory
Youngstown State University
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract
EO is a 32-year-old female patient admitted to the psychiatric unit after being found in Barnes &

Noble wondering around making absurd statements after being noncompliant with her

medication for approximately one year. She has a mental health diagnosis of severe manic

bipolar 1 disorder with psychotic behavior. EO is still having delusions and hallucinations after

being on the psychiatric unit for several weeks. She is currently prescribed Valproic Acid,

Haloperidol, Lorazepam, and Risperidone. Nursing care for EO has been focused on

reorientation for delusions and hallucinations.

Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 3

Objective Data

Patient identifier EO

Age 32

Sex Female

Date of admission February 07, 2023

Date of care February 23, 2023

Psychiatric diagnosis Severe Manic Bipolar 1 Disorder with Psychotic Behavior

Other diagnoses Schizophrenia and ADHD

Behaviors on admission EO was brought to the emergency room after three run-ins with the

police that day. The final run-in happened at Barnes & Noble after employees called when they

found her walking around making absurd statements about being the CEO of Apple and about

the Queen of England. The patient was having delusions and hallucinations and appeared to not

have showered in many days. Family members stated she had not been home in three days and

was walking the streets.

Behaviors on day of care EO was friendly and calm, but slightly guarded and suspicious on the

day of care. She was very willing to talk and answered any questions I had for her. She is very

suspicious of her family, stating growing up her dad had cameras around the house and her

parents have not been honest to her about where she comes from. She stated that she comes from

the royal family and is the CEO of apple. She also stated that her parents have kept her from

reaching her full potential because she is not the daughter they wanted. She talked about her

plans for the future, such as going to film school in New York City upon discharge (she stated

she had already been accepted to school here). When asked to participate in group therapy, she

replied that “she has found God and will be studying the Bible in her room” but that she is “sure
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 4

others will benefit from it.” EO was still having auditory and visual hallucinations, as well as

grandiose, persecutory, reference, and religious delusions. She was oriented to time, person,

place, but not circumstance. Her volume was loud and she exhibited slightly pressured speech.

EO also experienced moderate anxiety on the day of care, as evidenced by frequently looking

around and shaking her leg. She had a blunt and flat affect with labile mood. She appeared well-

groomed.

Safety and security measures EO was not permitted off the unit and was on elopement

precautions. No hazardous items are not permitted on the unit. Chairs and tables are heavy so

they cannot be thrown at others.

Laboratory Results

Potassium 3.3 (slightly decreased)

Sodium 138

Glucose 101

BUN 14

Creatinine 0.7

RBC 4.41

Hemoglobin/Hematocrit 13.2/39.5

WBC 11.7 (slightly elevated)

AST/ALT 31/28

Drug Toxicology Negative

UA Alcohol level Negative

QTC 435

Psychiatric Medications
Drug Pt. Route Frequency Classification Reason Pt. Receiving
Dose
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 5

Valproic 750 mg Oral 2x daily Anticonvulsant Bipolar

Acid
Haloperidol 5 mg IM Q6h Antipsychotic Hallucinations/delusions
Lorazepam 1mg IM Q6h Benzodiazepine Anxiety
Risperidone 120mg SubQ Q30d Antipsychotic Schizophrenia

Psychiatric Diagnosis Summary

Bipolar 1 Disorder is defined by manic episodes that last for at least 7 days (nearly every

day for most of the day) or by manic symptoms that are so severe that the person needs

immediate medical care. Usually, depressive episodes occur as well, typically lasting at least 2

weeks. Symptoms of a manic episode include: feeling unusually important, talented, or powerful;

having excessive appetite for food, drinking, sex, or other pleasurable activities; feeling able to

do many things at once without getting tired; racing thoughts; talking fast about a lot of different

things (flight of ideas); decreased need for sleep; feeling jumpy or wired; feeling very up, high,

or elated. Symptoms of a depressive episode include: feeling very down or sad; feeling slowed

down or restless; having trouble falling asleep, waking up too early, or sleeping too much;

talking very slowly, feeling unable to find anything to say, or forgetting a lot; having trouble

concentrating or making decisions; feeling unable to do even simple things; having a lack of

interest in almost all activities; feeling hopeless or worthless or thinking about death/suicide.

Sometimes, manic and depressive symptoms can happen in the same episode. When this

happens, it is called an episode with mixed features. Sometimes people who have severe manic

or depressive episodes also have symptoms of psychosis, which may include hallucinations or

delusions. This is what EO was experiencing. The psychotic symptoms a person exhibits will

usually go hand in hand with the person’s extreme mood. For example, the text stated that

“someone having psychotic symptoms during a manic episode may falsely believe they are
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 6

famous or have special powers” (National Institute of Mental Health, 2023). This was true for

EO, as she mentioned she was made for much greater things and was related to the royal family.

She also believed she was dating someone famous. She also believed in deeply spiritual things

and mentioned having important duties to fulfill and that she was chosen to do things that she

could not talk about yet, but that we would know about it one day.

According to a study of 1342 bipolar type 1 patients, it was found that 73.8% of these

patients presented a history of psychotic symptoms including delusions, hallucinations, formal

thought disorder, mood incongruent, and Schneiderian symptoms (Abramovic et al., 2019). EO

presented with many of these psychotic symptoms. Medication compliance can greatly decrease

these symptoms, however, EO had been off of her medications for more than one year prior to

admission.

Precipitating Stressors and Behaviors

Prior to admission, EO was living with her boyfriend of many years. Right before

precipitating events, she stated she had moved back in with her parents because “strange things

began happening at her boyfriend’s house” and she could no longer trust him. She then stated

that strange things began happening at her parents’ house upon moving back in with them as

well. She would not elaborate much, only that her parents were not being truthful about things

and something about their laptops being connected to other people of higher power. She also

believed her dad had cameras set up around their house and was very suspicious of him. EO had

been noncompliant with her medications for more than one year because she stated she does not

think she needs them. She stated she sees and hears paranormal activity and ghosts as well. She

stated that she has evidence of this on her phone. The patient was found in Barnes & Noble on
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 7

the day of admission wondering around loudly making delusional statements about being the

CEO of Apple.

Psychiatric Evidence-Based Nursing Care Provided

EO received care from multiple members of the nursing staff at St. Elizabeth Hospital in

Youngstown. Each nurse assigned to her assessed her on a daily basis and administered her

medications. EO was encouraged to attend group therapy during her stay, but would only attend

sometimes. When she did attend, she would talk about these grand plans she had for the future

and would talk very highly of herself. When she refused to attend group therapy, she would

usually state that she needed to study her Bible in her room or that she did not need to go to

group therapy because there is nothing wrong with her. EO was also allowed to have visitors

daily when visitation hours were happening, and on the day of care she did have her mom there.

She talked very loudly with her mom about her past and how her parents were never honest with

her. She spoke to her about how she did not want them in her life any longer because they do not

treat her well. When having hallucinations and delusions, nursing staff would try to reorient EO

once, and then distract after.

Ethnic, Spiritual and Cultural Influences

EO is a single woman of Caucasian ethnicity. She comes from a middle-class family and

grew up an only child. She stated that because of this, she felt a lot of pressure from her parents

to be something she was not. EO stated that her parents wanted her to be their “perfect little

angel” and because she was not and did not turn out to be how they envisioned that she feels that

she was a disappointment to them. EO practices Christianity and says she has found God more
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 8

since being on the psychiatric unit. She spends a lot of time studying her Bible and believes there

is something bigger out there for her, but cannot disclose what that is at this time.

Evaluation of Patient Outcomes

Some of the outcomes that are desired for a patient with bipolar disorder include

remaining free from harming themselves or others, performing self-care activities appropriately,

remaining free of delusions and hallucinations, cooperating with unit rules without aggression or

inappropriate behavior, and that the patient will take short voluntary rest periods throughout the

day.

EO was dressed well on the day of care and had just taken a shower prior to us having a

conversation. She was overdressed if anything, wearing a velvet purple long sleeve dress. She

cooperated with unit rules and was not aggressive or acting inappropriately toward others on the

day of care. She took voluntary rest periods to talk to me and was also in her room for quite

some time resting. The only outcome EO did not meet on the day of care would be remaining

free from delusions and hallucinations. She was having many delusions on the day of care,

saying she was related to the Queen and that she was “made for things much bigger than this”

but that she could not tell us what yet. She seemed to be delusional about her childhood as well

and her stories were inconsistent. She claimed to have videos of ghosts and demons on her phone

as well.

Plans for Discharge

The plan for discharge is unknown at this time. EO shut down all of her bank accounts

prior to being admitted and does not trust her family or her now ex-boyfriend. EO has lived in
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 9

group homes in the past, so she may return to one of these until she is more stable. EO did state

to me that she was only taking her medications on the unit so she would get discharged but did

not plan to stay compliant upon discharge because she does not think she needs them. The goal

would be for EO to stay compliant on her medications, attend therapy sessions regularly, and

work on her financial status upon discharge (getting a job, opening her bank accounts back up,

etc.). Upon discharge, EO will be educated by physicians, nurses, social workers, and therapists

on her medication side effects, importance of compliances, and given information on resources

she may need.

Prioritized List of all Diagnoses

The following are prioritized nursing diagnoses for EO:

1. Disturbed sensory perception related to psychological stress as evidenced by auditory

and visual hallucinations

2. Disturbed thought processes related to bipolar disorder as evidenced by hallucinations

and delusions.

3. Alteration in thought process related to bipolar disorder

4. Ineffective coping related to paranoia

5. Risk for suicide related to hallucinations

6. Risk for violence related to delusions and hallucinations

7. Risk for self-harm related to delusions and hallucinations

8. Risk for nutritional imbalance related to manic episode

Potential Nursing Diagnoses

The following are potential nursing diagnoses for EO:

Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 10

1. Anxiety

2. Impaired verbal communication

3. Disturbance of self-esteem

4. Self-care deficits

5. Sleep pattern disturbances

6. Fatigue

7. Risk for spiritual distress

8. Social isolation

9. Impaired cognition

Conclusion

Bipolar disorder is a lifelong mental illness that can be managed effectively through the

use of medications and therapy. Compliance with treatment is a huge factor in whether or not

mental illness is manageable. According to a survey from eight European countries, it is

estimated that 57% of bipolar patients were partially or non-compliant to medication, which

leads to higher rates of relapse and hospitalization (Averous et al., 2018). The article states that

when it comes to medication compliance, the main obstacles are usually difficulty with

medication routines, worry about medication side effects, and denial of illness severity. In EO’s

case, denial of illness severity is huge. She stated many times how she does not think she needs

to take the medication because she truly believes everything she is paranoid about and all of her

delusions/hallucinations are real. So, in order for EO to get better long term, she is going to need

to somehow understand the severity of her illness or she will revert to noncompliance upon

discharge and it will be a never-ending cycle of hospital readmissions.

Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 11

If compliant with medications and other forms of treatment, people can live a happy and

successful life with bipolar disorder. It is important for people to get the help they need to live

their lives to the fullest potential. Mental illness is just like having a physical illness and should

not be associated with a negative stigma. You would not tell a diabetic they do not need their

insulin, so we should not be telling those with mental illness to live their lives without treatment.

Although bipolar disorder can cause many challenges in a person’s life, with the right treatment,

people can live very successful normal lives with bipolar disorder. My hope for EO is that she

gets on the right treatment path and stays compliant upon discharge so she can get her symptoms

under control.
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 12

References

Abramovic, L. et al. (2019). The characteristics of psychotic features in bipolar disorder.

Psychological Medicine, 49(12), 2036-2048. https://doi.org/10.1017/S00332917
18002854

Averous, P., Charbonnier, E., Dany, L., Lagouanelle-Simeoni, M. C., Prosperi, A. (2018). Illness
perceptions and adherence in bipolar disorder: An exploratory study. Comprehensive
Psychiatry, 80, 109-115. https://hal-amu.archives-ouvertes.fr/hal-01648422

National Institute of Mental Health. (2023). Bipolar Disorder. U.S. Department of Health and
Human Services, National Institutes of Health. https://www.nimh.nih.gov/health/topics/
bipolardisorder#:~:text=Bipolar%20I%20disorder%20is%20defined,lasting%20at%20lea
st%202%20weeks.