Mental Health Case Study 1

Psychiatric Mental Health Comprehensive Case Study

Karina Seem
December 2, 2022
Dr. Teresa Peck
NURS 4842L
Youngstown State University
 Mental Health Case Study 2

Abstract

SP is a 39 year old female patient admitted to the inpatient psychiatric unit following

suicidal ideations and being pink slipped. Upon admission, she was diagnosed with Mixed

Bipolar II Disorder. She was experiencing visual and auditory hallucinations of shadows. Upon

medication treatment of a mood stabilizer, SP’s moods stabilized. She has a history of childhood

trauma and abuse with family hereditary. Nursing care provided on the unit was focused on

maintaining mood stabilization and symptom management through pharmacological

management. To go along with that, therapeutic groups and group psychotherapy.

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Objective Data

Patient identifier SP

Age 39

Sex female

Date of Admission November 14, 2022

Date of Care November 17, 2022

Psychiatric diagnosis Mixed Bipolar II Disorder and psychosis

Other diagnoses Suicide attempt, suicide ideations, postpartum depression, and gestational

diabetes mellitus

Behaviors on Admission SP had suicide ideations while being in a depressed state of her

Bipolar. She was having auditory and visual hallucinations of shadows. She states she can see

things before they happen. Flight of ideas and associative looseness were present. She was found

to be irritable, depressed, and anxious. Flat affect during communication with the health care

workers.

Behaviors on day of care SP was calm, friendly, cooperative, and willing to speak openly. She

participated in group sessions throughout the day. SP was getting ready to be discharged due to

her pink slip being over. Hallucinations were no longer present. SP’s mannerism was to give

minimal eye contact while speech. Eye contact was appropriate when being spoken to. Hand

movements were present when talking, also. Intonation was present with emotions and that
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would go along with rapid speech pattern. SP was in a hypomanic state but was able to sit for the

20 minute conversation.

Safety and security measures Throughout the inpatient admission there were 15-minute safety

checks implemented around the clock. The patient was also not permitted off of the unit, there

were staff present in the milieu at all times. All hazardous items were not permitted on the unit.

Those items include shoelaces, hoodie strings, razors, pencils, and pens. Items permitted on the

unit are shoes without shoelaces, crew neck sweatshirts, all types of shirts, and pants with much

more. Medications were administered by the med nurse to the patient. The med nurse will also

verify that all medication was taken at the time of administration.

Laboratory Results

Lab Value Result

Potassium (3.5 - 5.0) 3.7
Sodium (132 – 146) 139
Glucose (74 – 99) 107
A1C (4.0 – 5.6) 5.8
BUN (6 – 20) 5
Creatinine (0.5 – 1.0) 0.8
Red Blood Cells (3.5 – 5.5) 4.39
Hemoglobin (11.5 – 15.5) 13.0
Hematocrit (34.0 – 48.0) 40.6
White Blood Cells (4.5 – 6.8
11.5)
Platelet (130 – 450) 313
AST (0 – 31) 14
ALT (0 – 32) 10
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TSH / T4 Not drawn

Drug Toxicology (+) cannabis
UA. Alcohol Level Negative
QTc (<440) 496
HCG not drawn

Psychiatric medications
Generic Name Trade Name Class/Category Dose/Frequency Reasoning
Haloperidol Haldol Typical 5mg Q6hours Agitation
lactate antipsychotic PRN

Hydroxyzine Vistaril Antiemetic 50mg TID PRN Anxiety

pamoate

Oxcarbazepine Trileptal Antiseizure 150mg BID daily Bipolar

Summary of Diagnosis
Bipolar disorder is characterized by unusual shifts in mood, energy, activity levels,

concentration, and the ability to carry out day-to-day tasks. More specifically, Mixed Bipolar

Type II Disorder is characterized by exhibiting symptoms of both depression and mania, or

depression and hypomania simultaneously. Leading to symptoms that include irritability, high

energy, racing thoughts and speech, and overactivity or agitation. The younger the symptoms

start the more at risk for mixed episodes.

Bipolar is diagnosed over a period of time. The mean delay of the diagnosis is 5-10 years

after the onset of illness, only 20% of patients experiencing a depressive episode get diagnosed

within a year (Phillips & Kupfer, 2013). With the recurrent depressive episodes, there is no clear
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history of any mania or hypomania episodes causing the delay in diagnosis. Hereditary is an

immense risk factor for Bipolar. SP is a prime example of a mixed bipolar with hypomania that

has a genetic predisposition.

Stressors and Behaviors that Precipitated Current Hospitalization

SP lives at her single family home with her seven children and her uncle. She is a single

mom to all the children. Neither of the fathers of the children have any type of custody or is

mandated to pay child support. One is medical disabled and the other one has a substance use

disorder and currently addicted. The children range from 23 to 8 years of age. The eight year

olds are twins and one is autistic. SP stated “at least the belt gets that one in line” talking about

the autistic twin. The other twin was stated to be a terrible troublemaker that keeps her hands

full. SP is a full time caregiver for her uncle that has a diagnosis of cancer. To add to that, SP

recently took a pay cut with her LPN job. Also, there is no relationship with any other family

members or a support system outside of her children.

There was a Wal-Mart incident that happened on the day of admission. She went on her

monthly grocery shopping trip and when she went to checkout, there were only self-checkouts

open. SP claims that while she was checking out and scanning all of her groceries, someone was

watching her through a camera. This is all to due when she went to leave, she was questioned at

the door for shoplifting. She was then handcuffed in front of the children that she took with her.

They were then taken into a room was them to go through every single item while comparing it

to the receipt. Afterall, only 4 items out of the multiple carts were not scanned. SP was then let

go after some verbal exchanges. When she went home, her children refused to help put the

groceries into the house and completely away. That is when SP’s behavior changed.
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SP began to throw and break items throughout the whole house. She felt a release of

emotion through the physical actions. Following that behavior, she began to think very suicide.

That scared her, bring her into the emergency department.

Patient and Family History of Mental Illnesses

SP stated prior to this admission she had no mental health disorder diagnosis other than

postpartum depression. Did not state which child the postpartum depression came afterwards. SP

stated that her mother and maternal grandmother most likely had bipolar but was never

diagnosed to her knowledge. No other family or siblings have any other mental health diagnosis

to SP’s knowledge.

SP also stated trauma from her mother and maternal grandmother growing up. Lots of

physical, emotional, and physical abuse. Her maternal grandmother raised her for most of her

childhood and also along with her mother and uncle. An addition to the trauma, SP was molested

by her biological father and raped by a 25 year old male when she was young.

Evidenced Base Nursing Care

SP received nursing care from the mental health nurses during her impatient stay on the

unit. A nurse was assigned to SP each shift to build a relationship with and bring up any

concerns about her care to. The medication nurse would administer her medications. The nurse

checked for pocketing to make sure all of the medication was taken properly. She was placed on

an antiseizure medication for mood stabilization while inpatient. Care was provided for SP to

make her aware of the medication used for, typical side effects, and to not abruptly stop taking
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the medication at any time. During each shift, the nurse would use the nursing process to assess,

diagnose, plan, implement, and evaluate SP along with the medication administration.

During SP’s hallucinations, the staff used a newer technique. The staff asked about what

SP was visualizing and hearing. SP stated that she was seeing and hearing shadows. The staff

stated that they do not hear or see anything and then distracted from that conversation. It was not

practiced on the unit but down in the emergency department.

Included in SP’s treatment plan while inpatient is daily group sessions that she was

encouraged to attend and participate. Also, encouraged to participate in psychotherapy if

appropriate to SP. The unit provided a structured schedule daily along with structured mealtimes.

During the daily schedule, structure group run by social workers and nurses, time for personal

calls on the phones, and meeting times with the psychiatrists. SP attended as many of these

groups daily as she could.

Ethnic, Spiritual, and Cultural Influences

SP is an African American, single women. She is an LPN for a home health company that

provides for everyone in the home. SP states she is a spiritualist and can see what will happen

before it happens. SP does hallucinate of shadows. SP would not explore more on the topic.

Evaluation of Patient Outcomes

Some desired outcomes for a patient with bipolar disease include remaining free from

harming self or others, performing activities of daily living, and remaining free from aggression
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and inappropriate behaviors. On the day of care, SP was performing self-care that included doing

her hair, showering, and eating appropriately. SP was also taking her medications and remaining

free from further harm while on the unit.

Some other outcomes were only partially met on the day of care. SP’s coping skills were

not implemented at this point. SP was able to verbalize certain positive and negative coping

skills that she has done in the past and new ones. None of these coping skills were in use while

she was inpatient on the unit. SP stated the use of marijuana, working, and painting areas of her

home.

When the patient was admitted onto the unit, SP was in a depressed state for weeks and

having a flat affect. On the date of care, she was presented in a hypomanic state. Fast speech and

no pressure speech was present. Facial expression was appropriate to topic at time. Hands were

in use while talking. Eye contact would only be made if someone was talking to her.

Summarized Plans for discharge

Upon discharge, SP will return to the single family home where herself, seven of her

children, and uncle reside. It was felt by staff that SP didn’t need transitional or long-term

placement after discharge from the inpatient unit. She will be sent home with a week worth of

medication and will have an appointment with an outpatient within a week. SP will be

encouraged to regularly attend sessions with a psychologist, and to stay compliant with her

medication. Education will be provided on her medications, possible side effects, and adverse

reactions that can occur and materials will be provided.

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Prioritized Nursing Diagnosis (related to, evidenced by)

1. Risk for suicide related to previous suicidal ideation and attempt, childhood abuse, and

hallucinations evidenced by suicide behavior.

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

visual hallucinations.

3. Risk for violence related to impulsivity is evidenced by hallucinations and previous

trauma.

4. Risk for injury related to affective, cognitive, and psychomotor factors evidenced by lack

of control over purposeless and potentially injurious movements.

5. Interrupted family process related to shift in the health status of family member

evidenced by family in crisis.

6. Ineffective individual coping related to ineffective problem-solving strategies/skills

evidenced by destructive behavior toward self or others.

7. Disturbed thought processes related to disturbed thought process as evidenced by

dysfunctional interaction with family, peers, and/or others.

8. Altered family processes related to inadequate coping skills evidenced by altered role

function.

9. Deficient knowledge related to unfamiliarity with medication used and potential adverse

effects evidenced by expresses an accurate perception of health status.

10. Impaired social interaction related disruptive or abusive early family background

evidenced by destructive behavior toward self or others.

Potential Nursing Diagnosis

1. Impaired individual resilience

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2. Hopelessness

3. Rape-Trauma Syndrome

4. Total Self-Care Deficit

5. Low Self-Esteem

6. Deficient Knowledge

7. Imbalanced Nutrition: Less Than Body Requirement

8. Powerlessness

9. Social Isolation

10. Anxiety

11. Fear

12. Risk for Self-Mutilation

Conclusion

Bipolar is a complex disease that a person will go into moods of depression and mania or

hypomania. Medications compliance is an issue with patients due to them feeling better. In

severe states of either, the patient can become dangerous to self and/or others. Communication

and activities of daily living will have deficits. During those times, hospitalization is necessary

for safety.

SP exhibited both depression and hypomania in rotation to each other. But along with

that, there are mania symptoms present in her depressed state and vice versa. SP experienced

suicidal ideation and hallucinations with current hospital admission. She is at a risk for suicide

related to a pervious attempt. With education, the goal for SP is to maintain compliance on
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medication and visits as psychiatrist regularly. With regular and consistent treatment, SPs mood

lability can stay stable and almost no existent in her daily life.
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Reference Page

Jackson, D. C., McLawhorn, D. E., Slutzky, A. R., Glatt, S. J., & Daly, R. W. (2022). Bipolar

Disorder, Religion, and Spirituality: A Scoping Review. Journal of Religion & Health, 61(5),

3589–3614. https://doi-org.eps.cc.ysu.edu/10.1007/s10943-022-01502-y

Nunes, A., Scott, K., & Alda, M. (2022). Lessons from ecology for understanding the

heterogeneity of bipolar disorder. Journal of Psychiatry & Neuroscience : JPN, 47(5), E359–

E365. https://doi-org.eps.cc.ysu.edu/10.1503/jpn.220172

Phillips, M. L., & Kupfer, D. J. (2013). Bipolar disorder diagnosis: challenges and future

directions. Lancet (London, England), 381(9878), 1663–1671. https://doi.org/10.1016/S0140-

6736(13)60989-7