MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Madison M. Schrock

Centofanti School of Nursing, Youngstown State University

NURS 484L: Mental Health Nursing Lab

Mrs. Phyllis Jean Defiore-Golden

February 24, 2023

MENTAL HEALTH COMPREHENSIVE CASE STUDY

Abstract

She was an 18- year- old Hispanic female. M.G. is in the Intimacy vs. Isolation Erickson

stage. She was admitted involuntary with suicidal ideations. She has the diagnosis of Bipolar 1

disorder and was in a manic state when being admitted. She was prescribed Zyprexa and

Trileptal. She only started attending group therapy when I agreed to go with her. She says the

medications are helping but loud noises and the stress of school increase her psychological

symptoms. On the day of care, she said she felt depressed and anxious but did not have any

hallucinations or delusions. She had appropriate behavior when I was with her on the unit.
MENTAL HEALTH COMPREHENSIVE CASE STUDY

Objective Data

Patient Identifier: M.G

Age: 18 years old

Date of Admission: 2/7/23

Date of Care: 2/10/23

Psychiatric Diagnosis: Bipolar 1 disorder, Anxiety, Depression

Other Diagnoses: GERD, Iron deficiency anemia, Vitamin D deficiency, exercise induced

Asthma

M.G. came in on February seventh and presented with a panic attack and suicidal

ideations. She had previously been diagnosed with anxiety and depression. During this visit to

the emergency room, she was diagnosed with Bipolar 1 disorder. M.G. felt “cold and alone”

according to the emergency room note. She has had a previous suicide attempt five to six months

ago. M.G. admitted to having suicidal thoughts when she was admitted to the emergency room.

She was involuntarily admitted to the lock down psychiatric unit which would expire February

13th. The first thing I noticed when meeting her was the hygiene of her hair. It seemed to not

have been brushed or washed for a prolonged amount of time. She maintained eye contact well

throughout the duration of care. Her speech pattern was slower and softer than the normal

individual, but she had clear intonation. She was very friendly and cooperative during the time

that I spent with her. She had interest in certain things such as discussing her hobbies and her

family life, but was not interested in discussing what got her into the hospital. She appeared
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guarded when I would try to talk to her about her diagnosis and how she was feeling. She

seemed sad, depressed, anxious, and fearful during my time with her. This sadness and

depression gave her a flat affect when I was talking to her. She showed emotion at certain times,

but not very often. She also had some mood swings. When I would talk about her cooking she

got happy, but when I would ask her about school she seemed very upset. She did not present

with any hallucinations or delusions at any point during her stay. She was also oriented to time,

person, place, and circumstance. She had trouble making decisions. She could not decide what

exactly caused her to end up in the hospital. She also did not have very many coping skills.

When I asked her what type of coping skills she used, she could only list sitting in her room and

listening to music.

The labs obtained were reviewed and most of them were in the normal range.

Lab and Reference Range M.G’s values

Potassium (3.5-5) 3.9

Sodium (132-146) 139

Glucose (55-110) 94

BUN (5-20) 5 (low)

Creatinine (0.4-1.2) 0.6

Red Blood Cells (3.5- 5.0) 4.48

Hemoglobin (11.5- 15.5) 11.4 (low)

Hematocrit (34- 48) 36.5

White Blood Cells (4.5 - 11.5) 7.4

Drug toxicology (negative) Negative

U.A. Alcohol Level (negative) Negative

ECG (normal) Normal

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The two abnormal lab levels were M.G’s BUN and Hemoglobin. A low BUN can

indicate malnutrition or a low protein diet. M.G. is vegetarian which can explain why this lab

level would be low. The patient's Hemoglobin can also be explained for this reason. Due to her

dietary choice, she suffers from iron deficiency anemia which can cause low Hemoglobin or

Hematocrit levels. All of the other lab levels were within defined limits.

Safety and security measures were taken per unit guidelines. M.G. was monitored on the

unit and safety precautions were taken. M.G. was assigned to be on suicide precautions. Some of

these precautions were not having any items that could be used as a weapon or on the unit in

reach of any of the patients, and nothing that could be used to choke on hang yourself such as

shoelaces, belts, etc. I made sure I did not have anything on me that could be used as a weapon

such as a pen or a badge reel that had a string. There were two sets of locked doors on the unit so

the patients would not be able to get out. The staff was nearby at all times to monitor for an

escalation in patients symptoms. The floor was calm when I was there on the day of care.

Summarize the psychiatric diagnoses: Bipolar Type 1 Disorder

There are two different forms of Bipolar Disorder. Patients with Bipolar 1 Disorder have

more manic episodes than depressive episodes. Patients with Bipolar 2 Disorder have more

depressive episodes than manic episodes. According to Annals of General Psychiatry, “The

diagnosis of bipolar I requires the presence of at least one manic episode, with or without a

history of major depressive episodes, while bipolar II disorder requires at least one hypomanic

and one major depressive episode” (Datto et al., 2016). Bipolar 1 patients are usually diagnosed

based off of a manic state rather than a depressive state.

MENTAL HEALTH COMPREHENSIVE CASE STUDY

Mania is a period of 1 week or more in which a person experiences a change in behavior

that drastically affects their functioning (Dailey & Saadabad, 22). This functioning can include

basic care activities such as showering, eating, and sleeping. There also is a difference between

hypomania and mania. According to The National Library of Medicine, “Mania is different from

hypomania because hypomania does not cause a major deficit in social or occupational

functioning, and it is a period of at least 4 days rather than 1 week”(Dailey & Saadabad, 22).

Hypomania patients are in a manic state for a shorter period of time and also do not have the

high level functioning issues. Symptoms for mania include decreased sleep, rapid talking, racing

thoughts, becoming distracted easily, psychomotor irritation, and one- goal orientation (Dailey &

Saadabad, 22). Patients with mania need interventions by nurses to help them carry out normal

day activities. Schedules can be great for these patients so they do not get distracted. When it

comes to eating, small finger foods are great so it does not require as much thought such as

cutting the food. When patients become a danger to themselves or others in these manic states

they must be involuntarily admitted. This is to protect not only the people around them but

themselves.

Stressors and Behaviors that Precipitated Current Hospitalization

M.G came into the Boardamn Emergency Department on February seventh. She came

into the emergency department experiencing a panic attack. She stated to the staff that she had

suicidal ideations and had a plan to kill herself. She also stated that she felt “cold and alone”. She

was experiencing manic behavior upon arrival. Her father was the individual who brought her to

the emergency department. She was eventually involuntarily admitted to the acute psychiatric

facility at Mercy Health St. Elizabeth Hospital in Youngstown.

MENTAL HEALTH COMPREHENSIVE CASE STUDY

When I talked to her, she seemed to be much calmer than what the staff described her as

on admission. She seemed very guarded when I asked her about her admission but I was able to

get some information. She said that her mother left her family and moved back to Columbia in

South America when she was younger. This is some childhood trauma that could have

exacerbated her diagnosis of Bipolar 1 Disorder. She said that it really bothers her that she does

not have a better relationship with her mother. She also told me that she has a lot of stress when

it comes to school and graduating. It scares her to graduate and move on with her life. She said

another big trigger for her is loud noises. Whenever she is in a very populated or loud area, she

gets very anxious.

M.G talked about her relationship with her father. She said that she is very close to him.

When looking in her chart, I found that her father is the one that brought her into the emergency

department because he was worried about her. I also found out that her dad sent her books to the

floor for her to be able to read. She did not talk about another support system other than her

father. She did not talk about any friends or a boyfriend that is in her life. She talked about her

brother a little bit and explained that he “doesn’t understand her”. She also said that she takes

care of him a lot. I gathered from this that she considers her brother another stressor more than a

support system at times. I think that M.G. would benefit from socialization and creating some

more support systems.

I think that the trauma that M.G. has with her mother leaving along with the lack of

support system has caused the behaviors she has of Bipolar 1 Disorder. According to the

International Journal of Bipolar Disorder, “Additionally, among trauma subtypes (emotional,

physical, and sexual abuses), only emotional abuse has a suggestive dose-effect with BD” (Aas

et al., 2016). This applied emotional trauma applied to M.G. She had a major loved one
MENTAL HEALTH COMPREHENSIVE CASE STUDY

disappear out of her life and had to learn to adapt to a life without her mother. This emotional

trauma that she dealt with is a major risk factor to developing Bipolar 1 Disorder. When I would

talk to her about this trauma, she was guarded and did not want to talk about it. This indicated to

me that it hurts her more than she is letting on. Losing her mother also affected the support

systems that she has in her life. At one point she had both her mother and her father, but this was

lost once her mother left. M.G. now does not have the proper support systems in place to deal

with coping during her flare ups of Bipolar 1 Disorder.

Discuss patient and family history of mental illness

M.G was given the diagnosis of Bipolar 1 Disorder when she was admitted to the

Boardman Emergency Room. She had been previously diagnosed with anxiety and depression.

There is no known history of mental illness in her family. Her mother did leave her family and

move back to Columbia when she was younger. This is considered a traumatic event and could

have triggered this mental illness.

Psychiatric evidence based nursing care provided:

The main implementation for M.G was patient safety. M.G. was on suicide precautions

which increased the amount of patient safety that was provided for this patient. This patient was

not allowed anything in her room or around her that could be used as a weapon. This meant that

the patent could not have anything sharp such as soda cans, pens, or pencils. She also could not

have anything that could be used to choke or hang herself such as shoe laces or belts. M.G. also

had to be constantly monitored throughout her stay to make sure she was not injuring herself.

Bipolar 1 Disorder patients have more manic states than depressive states which differentiates
MENTAL HEALTH COMPREHENSIVE CASE STUDY

Bipolar 1 from Bipolar 2 disorder. This meant that I had to pay attention to my patients safety

due to the risk of her going into a manic state. I made sure that I did not have a pen or pencil on

me for the safety of my patient. I also made sure that I did not have a badge reel that would pull

on a string. When sitting with my patient, I also made sure that I had my chair turned out in case

M.G. became aggressive at any point during our conversation.

Due to the manic state that can be seen with Bipolar 1 patients, a calm environment is

needed. The floor made sure that the TV was on a low volume. The nurses also made sure to

monitor the patients very closely. If patients become aggressive, they would be able to notice it

right away and get the other patients to their rooms. Patients also were able to have phone calls

in a quiet environment. They were also allowed to go in and out of their rooms and decide if they

wanted to sit at tables and talk to other patients or have some alone time.

Group therapy time was also another form of care that was provided to the patients. I was

able to have M.G. attend because I promised I would go with her. During group therapy, some

students from my clinical that day were talking to the group about meditation. These patients

were able to participate in a 5 minute meditation with the guidance of the nursing students. This

also helped provide a calm environment for my patient to avoid a manic state. M.G. stated after

the group therapy session that she found it very relaxing and enjoyed the peace and quiet

involved with the meditation.

M.G. also used pharmacological therapy for her Bipolar 1 Disorder. She was prescribed

Zyprexa, and Trileptal. Zyprexa is an antimanic drug that helps to decrease the amount of manic

states M.G. had. She was also prescribed Trileptal which is a mood stabilizer to help keep her

calm. The medication nurse made sure that M.G. got her medications on time to prevent manic

states from occurring. The medication nurse made sure that M.G. took the medication and did
MENTAL HEALTH COMPREHENSIVE CASE STUDY

not leave it in the side of her mouth or hide it somewhere in her room. My patient indicated to

me that the medications are helping. The only thing that bothered her about the medications she

was on is the sleepiness that comes along with them.

Ethnic, spiritual, and cultural influences

M.G is a 18- year- old female that is of Hispanic descent. Her family is originally from

Columbia in South America. She did not mention that she had any religious preferences and

none were listed in her chart. She did seem to be passionate about her heritage. She said she

loved to cook food that was popular in her culture. She also works at a Mexican restaurant and

loves to experiment with different recipes there. Her mother did leave her family when she was

little to go back to Columbia which seemed to have deeply affected her and her family. She

seems to come from a middle socioeconomic household. M.G’s father has a job and she never

commented on there being economic trouble within the household. M.G commented on having a

very strong relationship with her father, but a very weak relationship with her mother.

Evaluation of Patient Outcomes

M.G met all of the outcomes that I made for her on the day of care. One of the outcomes

that I made for her is she would attend a group therapy session. It took a little bit of a push, but

she decided to attend with me. She said after the therapy that she was glad she went and learned

a lot. Another outcome that M.G met was not experiencing any self injury during my time on the

floor. During my time, she did not try to self harm. She was very calm and decided to read a

book that her dad brought her. She remained very calm during my time with her. She was a little
MENTAL HEALTH COMPREHENSIVE CASE STUDY

unmotivated, but she pushed through and ended up attending group therapy. Her behavior was

appropriate during my time on the floor.

Plans for discharge

Upon discharge, M.G. was not to be sent to any type of psychiatric facility. Her expected

discharge was February 13th 2023. M.G. will be transported from the hospital to home by her

father who she lived with along with her younger brother. She has agreed to participate in

therapy upon discharge at the Columbiana Counseling Center. She will be instructed to continue

her medication therapy that she was put on in the hospital. These medications include: Zyprexa 5

mg at night, and Trileptal 150 mg two times a day. These medications can cause constipation.

She has a prescription for Glycolax which can be given if she experiences constipation. The

doctor will also review other side effects of the medication before discharge and when she should

seek medical attention. Due to M.G. having suicidal ideations, the doctors want to confirm that

she does not have any access to weapons in her fathers house. I personally think that more

socialization would help M.G. develop some more support systems. As of right now, she only

considers her father a support system. I think her condition could improve more with further

support systems. She talked to me about her goals once she left. She wants to become a licensed

interpreter through an online school program after she graduates from high school. She is fluent

in both Spanish and English which she is really proud of. She also has the goal of finishing her

GED on time so she can accomplish her goal of becoming an interpreter.

Prioritized Nursing Diagnoses

The following are prioritized nursing diagnosis for M.G.

MENTAL HEALTH COMPREHENSIVE CASE STUDY

1. Risk for injury related to extreme hyperactivity, destructive behaviors.

2. Imbalanced nutrition: less than body requirements related to refusal or inability to

sit still long enough to eat meals.

3. Disturbed thought processes related to psychotic processes.

4. Disturbed sensory perception related to sleep deprivation, psychotic process.

List of Potential Nursing Diagnoses

The following are potential nursing diagnoses for M.G.

1. Extreme hyperactivity

2. Overstimulation

3. Risk for low self-esteem

4. Risk for suicide

5. Self-care deficit

6. Stress overload

Conclusion

Bipolar 1 is a disorder where the patient has more periods of mania than states of

depression. These periods of mania may include euphoria, delusions, hallucinations, tremors,

rapid speech, aggressive behaviors, etc. M.G. presented to the emergency room with mania and

suicidal ideations. She did not present with any delusions, hallucinations, or aggressive behavior.

To control the symptoms of Bipolar 1 Disorder, a variety of different medications can be used.

M.G will continue her Zyprexa (antimanic medication), and will also continue Trileptal (mood

stabilizer medication). The combination of medications should help some of her symptoms
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subside when she is discharged. M.G. will also begin therapy at the Columbiana Counseling

Center. With the medication therapy and psychotherapy, I think M.G. will have a decrease in the

number of flare ups she has with Bipolar 1 Disorder. M.G. was a great patient to do this case

study on. This project taught me a lot about what Bipolar 1 disorder is and how it affects patients

both mentally and physically.

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References

Aas, M., Henry, C., Andreassen, O. A., Bellivier, F., Melle, I., & Etain, B. (2016). The role of

childhood trauma in bipolar disorders. International Journal of Bipolar Disorders, 4(1).

https://doi.org/10.1186/s40345-015-0042-0

Dailey, M. W., & Saadabad, A. (22AD, July 19). Mania - StatPearls - NCBI Bookshelf. National

Library of Medicine . Retrieved February 20, 2023, from

https://www.ncbi.nlm.nih.gov/books/NBK493168/

Datto, C., Pottorf, W. J., Feeley, L., LaPorte, S., & Liss, C. (2016). Bipolar II compared with

bipolar I disorder: Baseline characteristics and treatment response to quetiapine in a

pooled analysis of five placebo-controlled clinical trials of acute bipolar depression.

Annals of General Psychiatry, 15(1). https://doi.org/10.1186/s12991-016-0096-0