Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Sydney Hurd

November 20, 2022

Mrs. Elizabeth Sanford MSN, RN, CEN

NURS 4842L Mental Health Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Objective Data

Patient Identifier: TE

Age: 26

Sex: Male

Date of Admission: 10/03/2022

Date of Care: 10/06/2022

Psychiatric Diagnosis: Bipolar II Disorder, Major Depressive Disorder

Other Diagnoses: None

Behavior on Admission: TE was admitted into Teen Challenge to get rehabilitation for drug

addiction. He stated that, immediately upon entry, he felt that the staff was strict and mean.

When the staff attempted to take his cell phone and vape, he got angry and proceeded to say, “I

don’t want to be alive anymore!” Subsequently, the Teen Challenge facility wanted to transfer

TE to St. Elizabeth’s Hospital for suicidal ideations. He entered the Mental Health ER

voluntarily and said that he did not mean what he said. He claimed he stated he did not want to

be alive in “the heat of the moment” and was in a manic episode. It was also documented that the

patient said he had a fear of blood when labs were being draw in the ER.

Behaviors of the Day of Care: During my patient interview, I noticed that TE seemed slightly

manic, rather than depressed. He said he was excited to go home, as he was going to be

discharged that day. TE approached the table and climbed over the back of the chair and crossed

his legs. He seemed very comfortable, friendly, cooperative, and open to conversation. When

asked what he was admitted for, TE quickly said “Oh! I’m a drug addict!” and started to laugh.

He said that he began smoking when he was 13 and is now addicted to Fentanyl, Percocet, and

cannabis. TE did acknowledge that he has an addictive personality and plans to continue
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treatment and stay sober after discharge. He currently lives with his mother and had a job at Bob

Evans before being admitted. However, it was documented that he lost that job because he called

off too much. The patient said he has two children, both of which he does not take care of.

TE was well groomed and an average height and weight. He maintained adequate eye

contact and did not present with tics or tremors. He spoke quickly but at normal volume and no

speech impediment. TE had a congruent affect and mood. There were no signs of mood swings

or lability. The patient also did not present with delusions, hallucinations, paranoia, magic

thinking, or suicidal ideas. He was alert and oriented to person, place, and time.

Safety and Security Measures: TE was put on suicide precautions and was not permitted off

the unit. Safety checks were ordered every 15 minutes and staff was present in all areas of the

unit. The patient was not allowed to have objects such as shoelaces, pens, and belts. For most of

the clinical day, TE remained in the common area and interacted with the other patients.

Lab Data:

Lab Collected Normal Value Range Patient’s Value

Potassium 3.5 – 5.0 4.3 (Normal)

Sodium 132 - 146 140 (Normal)

Blood Glucose 70 - 99 108 (High)

Blood Urea Nitrogen 6 - 20 8 (Normal)

Red Blood Cells 3.8 – 5.8 5.6 (Normal)

Hemoglobin 12.5 – 16.6 16.7 (High)

Hematocrit 42 - 52 49.8 (Normal)

Lab Collected Normal Value Range Patient’s Value

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White Blood Cells 4.5 – 11.5 12.5 (High)

AST/ALT 0 – 39/0 - 39 21 (Normal)/22 (Normal)

Lithium/Depakote/Tegretol 0.6 – 1.2/50 – 125/ 4 - 12 N/A

Drug Toxicity Negative Positive for fentanyl and

cannabinoids
QTC 350 - 450 389 (Normal)

Prescribed Psychiatric Medications:

Drug Route Dose/Frequency Classification Reasoning

Depakote PO 250mg BID antiepileptic mania

(divalproex)

Zyprexa PO 2.5mg nightly antipsychotic mania

(olanzapine)

Nicorette PO 4mg Q2H PRN smoking nicotine

cessation aid addiction
(nicotine
polacrilex)

PO 3mg nightly endogenous sleep aid

Melatonin hormone
MENTAL HEALTH COMPREHENSIVE CASE STUDY 5

Summary of Psychiatric Diagnosis

Bipolar II Disorder is defined as a “mental health condition that causes extreme mood

swings that include emotional highs and lows” (Mayo Clinic, 2021). The ‘highs’ are caused by

mania. Mania manifests in symptoms such as euphoria, excitability, and the inability to sleep.

Within the article “Bipolar II Disorder: CNS Drugs”, Franco Benazzi states that “Hypomania,

according to DSM-IV, requires elevated (euphoric) and/or irritable mood, plus at least three of

the following symptoms (four if mood is only irritable): grandiosity, decreased need for sleep,

increased talking, racing thoughts, distractibility, overactivity (an increase in goal-directed

activity), psychomotor agitation and excessive involvement in risky activities.” (Benazzi, 2012).

The ‘lows’ stem from depression and can cause a patient to feel overly tired, antisocial, lonely,

and hopeless. These depressive episodes, often referred to as manic depression, can also cause

the inability to concentrate, lack of interest, and suicidal ideations. Patients with Bipolar II

Disorder can also endure a mixed episode, where they experience symptoms of mania and

depression at the same time.

Continuing, Bipolar II Disorder is unique in that a patient with this diagnosis mostly

experience depression and never reach full-blown mania, but rather experience a less intense

manic state called hypomania (WebMD, 2022). Bipolar II Disorder will manifest in a cyclic

pattern of mania and depression. A patient must have at least one hypomanic episode to be

diagnosed with this disorder.

Though there is not a cure for Bipolar II Disorder, there are many treatment options for

patients with this illness. Mood stabilizers such as Lithium are commonly used for mania, as well

as anticonvulsants (Depakote). Antipsychotics, benzodiazepines, and antidepressants may also be

prescribed. Mood stabilizers and atypical antipsychotics are the most used medications (National
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Institute of Mental Health, 2022). These patients can also benefit from counseling, therapy, and

support groups.

On the day of care, TE was mostly exhibiting signs of hypomania. He was observably

elated/happy and talked at a fast pace. He did not show signs of depression or suicidal ideations.

If TE is compliant to his medication regimen and continues to stay sober, I believe he will

improve in his Bipolar II symptoms.

Identification of Stressors/Behaviors That Precipitated Current Hospitalization

The patient, TE, had many stressors prior to his admission at St. Elizabeth’s. As stated

before, he got angry at Teen Challenge when staff tried to take his cell phone and vape. He felt

as though they were being way too strict and said suicidal things that lead to him being “pink

slipped.”

He also previously lived with a roommate but was kicked out for not paying rent. He did

state that he instead used the money for drugs and realized that was a bad decision. TE also felt

that his old roommate contributed to his drug addiction, as they continually offered drugs to him

and kept paraphernalia around the apartment. Therefore, he is planning to live with his mother

after discharge. I also recommended that TE try to make friends with people who are sober and

can encourage him to get clean.

TE recently lost his job at Bob Evans for frequent call offs linked to his drug abuse as

well. Financial responsibilities and unemployment seemed to be a stressor for the patient, and he

stated he wants to go back to school eventually and get a degree.

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With these stressors in mind, along with Bipolar II Disorder, it’s clear why TE was

admitted. He did state that he plans to stay sober and improve his quality of life. He also

expressed a desire to eventually build a relationship with his children.

Patient and Family History of Mental Illness

While TE does not have any family history of mental illness, he went into detail about

childhood experiences and trauma that may have caused the state of his current mental health.

TE claims he was physically, emotionally, and sexually abused by his father and uncle. He also

stated that he feels he was compared to his sisters when he was younger and that this still affects

him today. The constant comparison led the patient to feel like he isn’t good enough and have

low self-esteem.

TE stated that his father abandoned him when he was 13 and that this triggered his drug

abuse. He started smoking cigarettes and drinking alcohol. At 16, he decided to expand his drug

use and eventually became addicted to marijuana, methamphetamines, cocaine, Percocet, and

Fentanyl. The patient said that he feels cigarettes were a gateway to his further experimentation.

Aside from drug use, TE is generally healthy and does not have any comorbidities.

Psychiatric-Based Nursing Care Provided

In mental health nursing, it is vital that nurses use evidence-based care to treat patients.

The use of evidence-based care allows for beneficial treatment, adequate patient outcomes, and

overall good nursing practice. During admission, TE received many types of nursing care. These

include medication administration, referral to further treatment centers, education of drug abuse,

and the development of nurse-patient rapport.

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The patient was prescribed 250mg BID of Depakote (divalproex). Depakote, sometimes

called valproate, is an anticonvulsant medication used to treat mania (Johnson and Miklowitz,

2010). Zyprexa (olanzapine) was also ordered in a 2.5mg dose. This is an antipsychotic

mediation used to lessen the symptoms of bipolar disorder and manic episodes. These two

medications can cause many side effects and come with many precautions. Therefore, education

was provided to TE on Depakote and Zyprexa and what to expect during treatment with them.

Doing this can significantly decrease the risk of patient noncompliance to medications.

Depakote Side Effects: abdominal pain, asthenia, dizziness, drowsiness, tremors, weight loss,

skin rash, anorexia, nausea

Zyprexa Side Effects: extrapyramidal symptoms (muscle weakness), dry mouth,

lightheadedness, amblyopia, upset stomach, drowsiness, dizziness

TE participated in daily group activities and took part in conversation with staff and

patients. He also built relationships with other patients and even exchanged numbers with some

of them. The patient stated that he felt group therapy was very beneficial and was something he

was going to miss after discharge. The mental health unit also provided the patients with a white

board that displayed the schedule for each day. This schedule included mealtimes, group

sessions, sleep times, etc. I feel like this schedule is extremely beneficial to the patients and

allows a sense of organization and avoids stress/paranoia.

Ethnic, Spiritual, and Cultural Influences

TE is a Caucasian male. He grew up in catholic faith and stated that he grew up going to

church with his family every week. I asked if he was still religious, and the patients demeanor

shifted. He became timid, tense, and slightly guarded. He looked off and simply said “September
MENTAL HEALTH COMPREHENSIVE CASE STUDY 9

16, 2017.” When asked what happened that day, TE refused to answer and changed the subject.

He said he did something awful that day. He did not have any current spiritual/religious

preference but did state that he plans to attend church more often and develop his faith after

rehabilitation.

Evaluation of the Patient’s Outcome

Before TE was admitted to the unit, he was not medicated and did not yet have a

diagnosis. With a diagnosis of Bipolar II Disorder and the implementation of treatment, the

patient remained free of suicidal attempts and ideations. TE had also shown that he understands

his illness, is aware of the consequences of drug abuse, and had developed a set of positive

coping skills/mechanisms for the future. He also displayed independence and the ability to

perform adequate self-care, grooming, and build relationships with others.

TE stated that he plans to begin counseling and therapy after discharge. He wanted to stay

sober and ‘start new.’ He was compliant to his prescribed medication and has also agreed to

speak to a social worker to stop smoking nicotine products.

Overall, I feel as though TE had a positive outcome during his stay on the unit. He had

plans for a better future, discussed his goals, and provided a set of steps to reach those goals. If

TE continues to approach his illness this way, he will continue to have a positive outlook on life

and improve in his mental health.

Plans for Discharge

Following my interview with TE, he was discharged after a total of 5 days on the unit.

His mother picked him up and he planned to return home and live with her. He wanted to avoid
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people that may negatively impact his road to sobriety, such as his old roommate and others who

participated in drug use. TE always mentioned his plan to get further rehabilitation care outside

of the hospital.

TE was discharged with a prescription for his medication and a list of referrals. Based on

his diagnosis, I assume he will beginning behavioral therapy and group therapy for his

addictions. He also wants to go back to school and focus on a career in cybersecurity.

Prioritized Nursing Diagnoses

List of NANDA Nursing Diagnoses for TE:

1. Risk for Suicide

 Related to history of suicidal ideations, childhood trauma, and stressors

2. Risk for Ineffective Coping

 Related to ineffective problem solving, cognitive changes, and neurological

abnormalities

3. Risk of Harm to Self or Others

 Related to manic symptoms (impulsivity, euphoria, and racing thoughts)

4. Risk for Disturbed Sleep Pattern

 Related to mania (prescription of 4mg Melatonin)

5. Risk for Impaired Attachment and Impaired Family Processes

 Related to past family roles, feelings of worthlessness, etc.

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Potential Nursing Diagnoses

Potential NANDA Nursing Diagnoses for TE:

1. Self-Care Deficit

 Related to depression and inability to concentrate

2. Impaired Religiosity

 Related to lack of current spiritual/religious beliefs

3. Acute Substance Withdrawal Syndrome

 Related to plan for sobriety following drug addiction

Conclusion

Bipolar II Disorder is an illness that affects many psychiatric patients in the hospital.

These patients may go through rapid periods of hypomania and depression. Though Bipolar II is

a disorder that is objectively difficult to overcome, patients can do so with the use of therapy,

medication, compliance, and education. complex disease process that requires both cognitive and

behavioral therapies. TE said he is ready to begin rehabilitation, therapy, and take his

medications accordingly. He also showed understanding of his illness and displayed coping skills

to deal with it in a nonpharmacological manner. He plans to remain sober and take steps to better

his life after discharge.

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References

Benazzi, F. (2012, August 29). Bipolar II disorder - CNS drugs. SpringerLink. Retrieved

December 1, 2022, from https://link.springer.com/article/10.2165/00023210-200721090-

00003

Mayo Foundation for Medical Education and Research. (2021, February 16). Bipolar disorder.

Mayo Clinic. Retrieved December 1, 2022, from https://www.mayoclinic.org/diseases-

conditions/bipolar-disorder/symptoms-causes/syc-20355955

The psychopathology and treatment of bipolar disorder. (n.d.). Retrieved December 1, 2022,

from https://www.annualreviews.org/doi/10.1146/annurev.clinpsy.2.022305.095332

U.S. Department of Health and Human Services. (n.d.). Bipolar disorder. National Institute of

Mental Health. Retrieved December 1, 2022, from

https://www.nimh.nih.gov/health/topics/bipolar-disorder

WebMD. (n.d.). Bipolar II disorder: Symptoms, treatments, causes, and more. WebMD.

Retrieved November 30, 2022, from

https://www.webmd.com/bipolar-disorder/guide/bipolar-2-disorder