Mental Health Comprehensive Case Study

Psychiatric Mental Health Comprehensive Case Study

Paige Strobel

November 21, 2022

Ms. Mackenzie Kriss MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

https://jopm.jmir.org/2019/2/e11167/

https://www.ncbi.nlm.nih.gov/books/NBK559078/
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Abstract

MT is a 46 year old male who was admitted to the unit for Major Depressive Disorder,

recurrent episode, with mixed features and Cluster B personality disorder. He has been

struggling with depression for over a year and an event occurred where he attempted suicide.

Patient is on medication for his Multiple Sclerosis and anticonvulsants and antidepressant for

depression and mood stabilization. The patient is continuing to battle his disorders but the meds

are showing some improvement to his activities of daily living. The client seems more hopeful

and has plans on how to manage his stress and mood at home. Patient is hopeful things will

change at home and wants to be more active in his care by participating in more therapy sessions.
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Objective Data

Patient Identifier- MT

Age- 46

Date of Admission- November 5th 2022

Date of Care- November 11th 2022

Psychiatric Diagnosis- 1- Major Depressive Disorder, recurrent episode, with mixed features 2-

Cluster B Personality Disorder

Other Diagnoses- Depression, Multiple Sclerosis, Hyperglycemia, Tobacco Abuse, Suicide

attempt

Behaviors on Admission- Patient is currently going through a divorce with his wife and

reported taking 40-50 of his Zanaflex to “ end it all”. Patient reported he was tired of feeling this

way and the world would be better off without him. After the patient took pills he immediately

regretted it and told his father to call 911 so he could get help. Patient was also very angry

because his wife filed a restraining order against him so he is not allowed to contact her or their

son.

Behaviors on Day of Care- Patient was very eager to talk and tell his story. He had lots to talk

about and we talked for about an hour. He participated in all of the group therapy sessions on the
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unit today. He participated in puzzles and coloring. He also says he showers each morning.

Patient stated his depression was a 2 on a scale of 0-10 and his anxiety was a 0 on a 0-10 scale.

Patient thinks he learned alot from being admitted to the unit and he knows how to cope with

stress more sufficiently and is eager to go home and hopes to be able to work things out with his

wife and see his son.

Safety and Security Measures- Patient is to have visual checks every 15 minutes. The patient

does not have any special privileges and receives the same treatment as everyone else on the

unit. Patients are not permitted off the unit and the unit is locked at all times. Only nurses and

doctors have badges to unlock the lock. The nurses sit in the group rooms and maintain eyes on

all patients to ensure the safety of others. Patients are allowed to have privacy while they shower.

Their bathroom doors are big mats that are velcrowed to the wall for suicide precautions. There

are no razors or pens allowed on the unit for safety.The group room doors are to remain locked

when no one is in there. Patients are not allowed to have their cell phones. Patients are required

to stay on a strict schedule with their activities.

Laboratory Results

Potassium 3.2

Sodium 141

Glucose 162

BUN 7

Creatinine .67

RBC 5.04

HGB/HCT 15.5/42
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WBC 9.1

AST/ALT 22/25

TSH/T4 1.51/.9

Toxicology +amphetamines

QTC 362

Psychiatric Medications

Generic Trade Class Dose/ Reasoning

Frequency

Gabapentin Neurotin Anticonvulsant 400 mg TID MS

Tizanidine Zanaflex Muscle Relaxant 4 mg QHS MS

Nicotine Patch Nicoderm NRT 1 patch daily Tobacco

Dependent

Oxcarbazepine Trileptal Anticonvulsant 300 mg BID

Stabilize mood

Venlafaxine Effexor XR Antidepressant 75 mg daily Depression

Hydroxyzine Atarax Antihistamine 50 mg Q6H Anxiety

PRN
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Trazodone Trazodone Antidepressant 50 mg QHS Sleep

PRN

Summary of Psychiatric Diagnosis

Major Depressive disorder is diagnosed when an individual has a persistently low or

depressed mood, anhedonia or decreased interest in pleasurable activities, feelings of guilt or

worthlessness, lack of energy, poor concentration, appetite changes, psychomotor retardation or

agitation, sleep disturbances, or suicidal thoughts( Bains & Abdijadid, 2022). MT had changes in

his activity, eating patterns and social life. He reported feeling more withdrawn and wanting to

stay in bed a lot more. Also he has not been working since 2001 when he went on disability for

his MS. These feelings have to be persistent for two or more weeks and the person can not have a

history of mania. MT had no previous episodes of mania and has been feeling like this for over a

year. This disease is more common in adults and two times more likely in women( Bains &

Abdijadid, 2022).

Major depression can happen because of genetics, predisposing factors, decrease in

neurotransmitters, and decreased receptor sites. People with MDD have low levels of serotonin,

norepinephrine, and dopamine. MDD could also be caused by things like low socioeconomic

status, homelessness, losing a job, losing a loved one and other issues. There are many different

ways people can treat their MDD. Most people take medications for it called antidepressants.

These medications can cause more reuptake of the neurotransmitters the patient is deficient in or

bind with the recptors.It takes up to four to six weeks for the medications to work and patients
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start seeing success with their symptoms.Therapy is also another option too like support groups,

such as AA or other groups that meet regularly. MT stated that he liked participating in therapy

and it helped him learn new coping mechanisms and give him room to talk to other people about

what he is dealing with in his life.

Before diagnosing MDD it's important to rule out other natural causes in the body too.

Such as Hypothyroidism, because the symptoms of hypothyroidism commonly cause depression.

MT has had previous depressive episodes in the past but none as bad as this one. He was

previously seeing a psychiatrist at the Cleveland Clinic and was on Prozac but stated it never

really did anything for him.

Identification of Stressors and Behaviors Precipitating Current Hospitalization

MT has been struggling with depression for the past year following the divorce of him

and his wife. He has been seeing a doctor at the Cleveland Clinic for his depression and has been

on Lexapro for over a year. He said he doesn't feel like it's helping and he is still having

symptoms. He stated this is the only time he has ever though about suicide and even acted upon

it. He has been on disability because of his MS since the 2000’s. He states his wife is taking all

the money, the house, the cars and his son. Patient started crying when talking about this and

says this is why he wanted to end it all at that moment. He also states that he wants to go back to

school for some type of business job that he can do remotely so he will not have to give it up

when his MS progresses.

Patient has a domestic violence charge and a restraining order put in place November 4th

2022. His mother had passed away this year and they were very close. He reports his wife is

trying to frame him to make him look like the bad guy but she actually abuses him and things are
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the other way around. He lives with his father and says it has been very hard on both of them.

Patient states he normally does not act out like this and it was a one time thing and states he

knows what he can do better next time to deal with this situation. He thinks that he just had a

buildup of everything and it all exploded.

Patient and Family History of Mental Illness

MT was diagnosed with depression in 2021 when he got divorced. Patient states he

normally does feel sad a lot of the times and he never really got help for it until it was too bad.

Patient states that his mother suffered from depression all of her life and was in and out of the

hospital because of it once or twice a year. He states she was on a few meds but does not know

what they are.

Patient lives with his father in a trailer and they both do not work and are both on

disability. He doesn't like talking about his mothers death because when he was a child he was

not allowed to talk about his feelings. He feels like he did not get to fully grieve the loss of his

mother and says things have just kept piling up.

Psychiatric Evidence-Based Nursing Care Provided

During his stay on the unit MT was cared for by many nurses on the floor. He stated that

the nurses on the floor were mean and did not care about what he had to say. He said he did not

like talking to him and he felt very judged. The nurses administered his medications to him and

completed two sets of vitals daily.MT was receiving two news meds, Trileptal which is an

anticonvulsant for mood stabilization, and Effexor XR which is an antidepressant to treat his
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Major Depressive Disorder. The nurses carefully watched him to observe for any side effects of

the medications and to be sure he was taking them. The nurses provided him with education

about his new medications and the potential side effects. They also stated some antidepressants

take up to 6 weeks to reach full effect . For the Trileptal they taught him about side effects and

what to do if he notices changes. MT said it felt better talking to the other patients than the

nurses. But he was able to trust them more and more each day.

The nurses also talked with him about a new program online called Patientslikeme that

allows people with different diseases to talk to each other. More than 30,000 of these patients

have MDD and talk about their symptoms and what they are doing to deal with it and make their

lives better( Chiachuzzi et al, 2019). He seemed very interested in talking to other people going

through the same things such as having MS and MDD.

Another option at the hospital is group therapy sessions throughout the day. These group

sessions teach the patient everyday skills like how to manage their disease, coping mechanisms,

and many forms of other teachings. In today's group the nurses talked about how some mental

diseases affected you and what you can do for them. Like MDD, Schizophrenia, and personality

disorders. MT stated he learned alot from his group sessions and wants to attend some groups in

his community to keep him on the road to recovery. MT also did not miss one meeting and was

very talkative in them and answering questions. He also called his father everyday to let him

know how things were going and to see how he was doing.

Ethnic, Spiritual, and Cultural Influences

MT is a 46 year old caucasian man, single and in the lower socioeconomic class. Patients

live off of disability and says he gets roughly around two thousand dollars a month. He lives with
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his father in his trailer. MT believes in atheism and believes after this life there is nothing we just

cease to exist. When asked to elaborate on this topic MT says his parents “forced christianity

down his throat” when he was a kid so he wants nothing to do with it now. He believes in no

matter what you do, good or bad, there is no afterlife and there is no god. After you die there is

just nothing.

Evaluation of Patient Outcomes

For patients with MDD it's important for them to be able to gain their motivation back to

do activities in life and get out of their depressive mood. It is important for patients to be

compliant with their medications because abruptly stopping antidepressants can be

fatal(Videbeck, 2020).It's also important to teach the patients the side effects of the new

medications they are taking. For example, Antidepressants and Anticonvulsants cause dry mouth,

insomnia, and Nausea. It's important to warn patients about these effects so they know what to

expect and can help prevent them from abruptly stopping treatment. During the patient's time at

the hospital he learned many different ways to cope with his stress like drawing, coloring,

exercises, cooking and playing with his animals. Before the patient said when he was stressed he

did not know how to handle it and would smoke cigarettes and punch things.

On the day of discharge MT was still feeling sad about his divorce with his wife and

desperately wanting to fix it but he had a plan now of what he could do to reverse the situation

and try and make things better . During his stay he promised and signed a contract to not have

any behaviors of self harm and he completed this. MT no longer had feelings of wanting to die

and stated he had a lot to live for in his life and was eager to get out and back into his daily

routine with some minor adjustments.

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Upon admission MT rated his depression a 10/10 and anxiety 8/10. On discharge he

stated he had a 2/10 on the depression scale and 0/10 for anxiety. He stated that he no longer has

ideas of harming himself and plans to be compliant with his medications unlike before. MT was

also taught proper medication safety and the importance of staying on his regimen and the

importance of taking his medications as they are prescribed. Before his admission to the hospital

MT stated whenever he was feeling really depressed he would take more pills than he was

prescribed to take. Now he understands that medications sometimes take a little longer to work

correctly and the importance of taking the correct dose.

Plans for Discharge

For discharge MT plans to go back and live with his father while the divorce with his

wife is playing out. He plans on going to meetings in his community with other people who have

depression. He thinks that joining some groups and being more social will make him feel better.

MT is on two new medications, Effexor XR and Trileptal. He is going to get them filled at the

pharmacy and verbalizes his knowledge of how to take the meds and what to do about side

effects. He has an appointment with his doctor at the Cleveland Clinic next week to update his

doctor on things and check in.He plans on having his dad control all of his medications with a

med box so he does not have access to them again to prevent another possible suicide attempt.

Prioritized Nursing Diagnosis

1. Ineffective coping related to insufficient control of emotions manifested by recent

divorce, no job, and a suicide attempt.

2. Risk for self inflicted violence related to suicide attempt manifested by overdosing on

zanaflex, feeling hopeless, and history of depression.

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3. Impaired social interaction related to lack of support system manifested by having no job,

having a restraining order from wife and son, and death of his mother.

4. Dysfunctional grieving related to loss of mother manifested by Suicide attempt, social

isolation, and feeling hopeless.

5. Self care deficit related to Multiple Sclerosis manifested by tremors, ataxia, and inability

to do things without help.

Potential Nursing Diagnoses

1. Social isolation

2. Fear

3. Deficient knowledge

4. Low self esteem

5. Risk for caregiver role strain

6. Risk for injury

7. Interrupted family processes

8. Ineffective health maintenance

9. Risk for injury

10. Risk for suicide

Conclusion

Even though MDD is a complicated disorder with many lows it can be managed through

meds and therapy. Patients can be a danger to themselves and others and have periods of really
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low phases. Depression is very common in adults and many of them are scared to seek treatment

for it due to the stigma. MT has been adjusted to his meds and is going to start regular therapy

sessions to help him manage this disorder. Although this disease is tough, MT is encouraged to

make the best of it and do what needs to be done for him to get better and get back to being

himself and having hope to never reach another low point like this again.
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References

Bains, N., & Abdijadid, S. (2022, June 1). Major depressive disorder - statpearls - NCBI

bookshelf. Major Depressive Disorder. Retrieved November 21, 2022, from

https://www.ncbi.nlm.nih.gov/books/NBK559078/

Chiauzzi1, E., Drahos1, J., Sarkey3, S., Curran1, C., Wang1, V., Tomori3, D., 1PatientsLikeMe,

& Chiauzzi, C. A. E. (2019, November 2). Patient perspective of cognitive symptoms in major

depressive disorder: Retrospective database and prospective survey analyses. Journal of

Participatory Medicine. 11(2), https://jopm.jmir.org/2019/2/e11167/

Videbeck, Sheila L. (2020). Psychiatric-mental health nursing (8th ed). Philadelphia, PA:

Wolters Kluwer. 87