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MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Madison Kimes

October 10, 2022

Mrs. Phyllis Fiore-Golden, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

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Abstract

PM is an 82-year-old female patient admitted to the inpatient psychiatric unit for suicidal

ideations and depressive thoughts. In addition to her recent mental health diagnosis of

bipolar disorder, she has maintained a long-term diagnosis of major depression as

well. Over that last three weeks, PM’s symptoms have become increasingly

unmanageable with her current treatment regimen, thus resulting in admission for

inpatient care. The nursing care provided on the unit is focused on stabilizing mood

and providing a medication regimen to lessen depressive thoughts and behaviors.

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Objective Data

Patient Identifier PM

Age 82

Sex Female

Date of admission September 23, 2022

Date of care September 30, 2022

Psychiatric diagnosis Bipolar Disorder

Other diagnosis Depression, Hypertension

Behaviors on admission Upon admission PM was seriously depressed, exemplified by her

inability to get out of bed that day. She expressed that had feelings of guilt over past

indiscretions that happened in her life including an extramarital affair resulting in a subsequent

abortion. Although she stayed married to her husband until his death, she expressed feelings of

regret, shame and guilt in not being forthcoming to her husband prior to his death. These

thoughts possibly prompted her recent conversation with her son in which she stated that she

wished to “fall asleep and not wake up” or “I would be better off dead”. Her son drove her the

emergency department and PM willing was admitted to hospital care. PM also expressed that her

symptoms had worsened over the past week due to an argument she had with her sister, Judy.

PM also reported that she was feelings of anxiety and loneliness. She stated that she had no “self-

worth” initially in the ED.

Behaviors on day of care PM was pleasant, cooperative, and open to discussing her issues.

Although she was anxious about participating in group therapy, PM admitted that therapy was

helping her work through her current diagnosis. PM had previously gone to several months of

outpatient treatment for her depression which she felt had been beneficial and was therefore
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upset to be readmitted to an inpatient program. While she was discouraged about readmission,

PM had a positive outlook towards recovery and felt comfortable with her treatment team. PM

was A/Ox4, and speech was clear and concise. Her overall appearance could be classified as

poor, exemplified by her unkempt hair and dirty eyeglasses.

Safety and security measures The patient was not permitted to leave the unit’s floor but could

go back and forth between common area and her room. A variety of staff were present at all

times to monitor the actions and behaviors of the clients. All items considered hazardous,

including razors, shoes laces or strings, metal on notebooks or scissors, were not permitted on the

floor. Sharp items such as pencils and pens were only permitted in the common area and were to

be counted by staff after use. During medication administration, the medications were given by

the nurse following verification of name and DOB.

Laboratory results

Lab Value Result

Glucose 115
TSH 2.66
T4 1.2
RBC 4.4
Hbg/Hct 40.5
WBC 9.5
BUN/Crea. 14
QTc 455
Toxicology negative

Psychiatric medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

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paroxetine Paxil SSRI, Antidepressant 12.5 mg HS Depression

venlafaxine Effexor SNRI, Antidepressant 50 mg TID Depression, GAD

amlodipine Norvasc Antihypertensive 5 mg daily Moderate

agent
hypertension

hydroxyzine Atarax Antihistamine 50 mg PRN Anti-anxiety/sleep

Summary of psychiatric diagnosis

People suffering from bipolar disorder experience dramatic changes in their mood and

energy, as well as their ability to think clearly. Bipolar patients experience highs and lows in

mood, known as mania and depression, which are different from the typical ups and downs

experienced by mentally healthy individuals. Typically bipolar disorder begins in the late

twenties or childhood, but it can occur at any age. It affects both men and women equally, with

2.8% of U.S. citizens diagnosed with bipolar disorder with nearly 83% of that group being

classified as severe. In the absence of treatment, bipolar disorder usually worsens, often resulting

in suicidal tendencies or inability to perform normal daily functions. (Bhandari MD, 2022).

The condition can, however, be managed well with a good treatment plan, including

psychotherapy, medications, a healthy lifestyle and a regular schedule. Early identification of

symptoms and appropriate diagnosis are also vital in appropriate management of these patients.

(Bhandari MD, 2022). Bipolar disorder can feel like riding a never-ending roller coaster of

emotions, but with the right treatment plan and support system it can be managed well.
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Symptoms and their severity may vary from person to person. It is possible for a person

with bipolar disorder to experience distinct manic or depressive states, but they may

also experience extended periods—sometimes years—without having any symptoms (Bhandari

MD, 2022). Both extremes can also be experienced at the same time or in rapid succession.

Symptoms of psychosis may occur as a result of serious episodes of bipolar mania or

depression. This kind of psychotic behavior is usually a manifestation of someone's extreme

mood. Those with psychotic symptoms of bipolar disorder can be misdiagnosed as schizophrenia

sufferers (Videbeck pHD, 2020).

Bipolar disorder is diagnosed when a person has had at least one episode of mania or

hypomania. Hypomania is a milder form of mania without psychotic episodes (Videbeck pHD,

2020). It is often possible for people with hypomania to function well at work and in social

settings. A person with bipolar disorder may experience mania or hypomania many times

throughout their life, while others may only experience them occasionally.

Though someone with bipolar may find an elevated mood of mania appealing, especially

if it occurs after depression the "high" is not comfortable or controllable (Videbeck pHD, 2020).

As a result, moods can become more irritable, behaviors can become unpredictable, and

judgment can become impaired more quickly. It is common for people during periods of mania

to act impulsively, make reckless decisions, and take unusual risks.

Many people with bipolar depression experience such debilitating lows that they are

unable to get up in the morning. When suffering from a depression episode, people often find it

difficult to fall asleep and stay asleep, while others sleep for extreme periods of time (Videbeck
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pHD, 2020). In times of depression, it can be difficult to make even the smallest decisions, such

as what to eat for dinner. It is possible for them to become obsessed with thoughts of suicide

because they may become consumed with feelings of loss, failure, guilt, or helplessness.

A person must experience depressive symptoms, that obstruct their daily habits, nearly

every day for at least two weeks before being diagnosed with depression. An individualized

treatment plan may be required when treating depression with bipolar disorder (Bhandari MD,

2022).

PM was experiencing a period of extreme depression while staying on the psychiatric

floor. She was consumed with guilt over her past life choices. When discussing past decisions,

PM explained that her longtime affair and abortion “plagued her mind” in recent weeks. PM was

unable to forgive herself and exhibited signs of depression in recent weeks which included no

longer eating and not getting out of her bed. Many people who suffer with depression also deal

with a mix emotion of punishment. Throughout their lives, especially during the depressive

phase, they often feel they should be “punished” for past actions, even including the ones they

could not control (Bhandari MD, 2022).

Identification of stressors and behaviors precipitating current hospitalization

Prior to admission, PM was experiencing a hyper-depressive state of mind. She was no

longer eating, performing hygiene care, or leaving her bed for most days. Her son Brian, who she

lives with, decided to take her to the Youngstown Mercy ED. PM stated that her depressive

thoughts began after her fight with her sister. Although their argument had nothing to do with her

past actions, PM began feeling extremely guilty over her past affair and abortion. She was
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married to her former husband for over 25 years, and for a period of their marriage they were

unhappy. During that time she had an affair with a friend and kept it a secret during the time they

were together. At one point PM found out she was expecting a baby with her friend, panicked

and had an abortion quickly. While she was able to forgive herself once before over these

choices, she was no longer able to in recent months. PM believes that her guilt from her fight

with her sister grew so much that it caused her to relieve her past trauma and “re-blame” herself

once more.

Patient and family history of mental illness

PM explained that she was diagnosed with depression in 1987 and had been taking Paxil

to treat symptoms up until 2018. She ceased the medication because she did not like the side

effects Paxil gave her. After her evaluation by the treatment team, it was decided that she should

once again continue to take Paxil and treat any adverse effects. No other family members suffer

from bipolar disorder, but she did explain that her dad had major depression. Her father went

undiagnosed for year, which ultimately lead to a substance use disorder of alcohol. Pm also

stated that her son also suffers with alcoholism but refuses any form of medical treatment for the

disease.

Psychiatric evidence-based nursing care provided

PM received care from a variety of mental health professionals while she was an

inpatient. Every working shift, PM had a nurse, social worker, therapist, and spiritual advisor

assigned to her. In addition to building a therapeutic relationship with PM, the nurses addressed

any concerns she had. Throughout the day, PM's assigned nurse checked on her periodically.
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Every day while on the unit, the nurse completed the nursing process of assessing, diagnosing,

planning, implementing, and evaluating PM. Additionally, the nurse administered the morning

medications, noting if any pills were pocketed. An ant-anxiety medication is included in the PM

medication regimen, along with two SSRIs. As PM received her medication, the nurse asked

how she described her mood that day and offered assistance in finding resources if needed. She

needed a spiritual advisor, and her nurse was able to schedule an appointment for her that day.

Ethnic, spiritual and cultural influences

PM is a Caucasian, widowed woman from a middle-class family. She retired 5 years ago

from a management job but continues to lease her land to boarders. PM practices Christianity as

her religion and wears a cross necklace outside the hospital. PM also ties in religion with her past

choices claiming that she cannot wash away her “sins”. Interestingly enough PM believes God

forgives all who have “sinned” but believes she is the exception and God is unable to specifically

forgive her.

Evaluation of patient outcomes

Outcomes that are important for a patient with bipolar disease to achieve include, staying

well hydrated, maintaining adequate sleep and rest, performing basic hygiene, demonstrating

thought control with the aid of staff and medication and avoiding attempts of self-harm. On the

day of care, PM was adequately groomed and was able to perform self-care which included

showering and brushing teeth. She also willingly took all of her medications and remained free

of self-harm.

Other outcomes were met during the day of care, which included PM participation and

attendance of group therapy. Although PM did not believe group therapy was helping her in any
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way, she still attended and actively participated in the group. On the other hand, one outcome

that PM has yet to achieve is the acceptance of her new diagnosis. While she has stated that she

needs help and future therapy for her illness, she has yet to fully accept that she has bipolar

disorder.

Plans for discharge

When PM is discharged, she will return to her home to live with her son again. Multiple

members of PM treatment team believe outpatient therapy is the best way to deal with her new

diagnosis. PM attended outpatient therapy for several months before recent inpatient admission.

She and her health care providers both believe that is the best way for stabilization and recovery.

She will also continue her medication regimen and call her physician before altering medication

dosages. PM will be encouraged to reach out to her personal therapist at any point she becomes

overwhelmed and upset with her thoughts. Education will be provided on medications, possible

adverse effects that can occur, and tools to help her cope with negative feelings and emotional.

PM will also be given a list of resources on local education and support groups specifically

focusing on bipolar disorder.

Prioritized nursing diagnoses

The following are prioritized nursing diagnosis for PM:

1.) Risk for suicide either self-directed or other-directed.

2.) Disturbed thought process related to mental illness as evidenced by extreme episodes

or mania or depression.

3.) Total self-care deficit related to patient’s poor concentration and impaired perception.

4.) Impaired verbal communication.

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5.) Altered thought processes evidenced by depressive statement and/or actions.

6.) Risk for nutritional deficits.

Potential nursing diagnoses

1.) Hopelessness

2.) Impaired memory

3.) Anxiety

4.) Interrupted family processes

5.) Impaired social interaction

6.) Ineffective individual coping

7.) Risk for injury

8.) Social isolation

9.) Flight of ideas

10.)Sleeplessness

Conclusion

Bipolar disorder is a lifelong disease, affecting a person’s daily care, thoughts, actions

and relationships with others. There is no known cause of bipolar disorder, but genetics,

environment, and altered brain chemistry may contribute to the condition. It is common for

patients experiencing manic episodes to experience symptoms such as high energy, reduced

sleep needs, and loss of touch with reality. In addition to feeling tired and unmotivated,
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depression may also cause a loss of interest in daily activities. In these cases, mood episodes are

associated with suicidal thoughts and can last for weeks or months.

It was clear that PM was experiencing the depressive phase of bipolar disorder. Although

weeks before she was active in her community and traveling with family, she was no longer able

to get of bed let alone experience any form of enjoyment in life once arriving on the unit. With

proper education and resources given to PM, her new goal will consist of complying with

medication treatment plan and actively engaging in outpatient therapy. By following new

outcomes and following up on upcoming appointments with her psychiatrist, PM should be able

to regulate her symptoms and regain the ability perform her activities of daily living.
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References

National Alliance on Mental Illness. (2017, August). Bipolar Disorder.

https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Bipolar-Disorder

Cleveland Clinic. (2022, April 12). Bipolar Disorder.

https://my.clevelandclinic.org/health/diseases/9294-bipolar-disorder

Wagner, M. (2022, April 6). Bipolar Disorder Nursing Diagnosis & Care Plan. NurseTogether.

https://www.nursetogether.com/bipolar-disorder-nursing-diagnosis-care-plan/

Videbeck, S. L. (2017). Psychiatric - Mental Health Nursing Eighth Edition. Wolters Kluwer.
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