MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Delaney Early

December 8, 2022

Dr. Teresa Peck, MSN, RN

Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY

Abstract

A.M. is a 46-year-old Caucasian male. He is currently in Erikson’s generativity versus

stagnation stage. He was admitted involuntarily with a paranoia delusion of his neighbor

poisoning his dog. A.M. has the diagnosis of Bipolar 1 and was in a state of mania. A.M. also

tested positive for HIV as well. He was prescribed a typical antipsychotic for aggression, an

atypical antipsychotic to manager his Bipolar 1, and an antiviral medication to help combat his

diagnosis of HIV positive. He also actively participated in group therapy. It seems that his

symptoms are improving, especially since he was not disclosing any delusions or hallucinations

or signs of aggression. A.M. displayed appropriate behavior while on the unit while I was

present.
MENTAL HEALTH COMPREHENSIVE CASE STUDY

Objective Data

Patient Identifier: A.M.

Age: 46 years old

Date of Admission: 11/15/2022

Date of Care: 11/17/2022

Psychiatric Diagnosis: Severe Manic Bipolar 1 with Psychotic Behavior

Other Diagnoses: HIV positive

A.M. presented in the emergency room with paranoia delusions thinking his neighbor

poisoned his dog. His speech was rapid, and he had a constant tremor of shaking his legs while

speaking with me. A.M. was appropriately dressed but had messy hair and a bad odor. AM was

oriented times four and was aware of his diagnosis of Bipolar 1. A.M. was cooperative and

friendly throughout the conversation. He had problems staying on track throughout the

conversation. He presented with perseveration and associative looseness with the topic of his

father. He often went on tangents regarding the sexual abuse he endured from his father growing

up. He shared that if he his faither was in front of him “he better be ready”. A.M. displayed a lot

of inappropriate laughing while discussing the trauma he endured from his father growing up.

The patient’s mood was labile, as he stated he was angry but was feeling good that day. A.M.

actively participated in group therapy that we held that day and did not display any inappropriate

behavior during the therapy.

A.M. tested positive for HIV but did not reference the diagnosis at all during our

conversation. He is being medicated with an antiviral called Biktarvy. The medication was given
MENTAL HEALTH COMPREHENSIVE CASE STUDY

by mouth once daily as 50-200-25 mg per tablet. The medication is made up of bictegravir (50

mg), emtricitabine (200 mg), and tenofovir alafenamide (25 mg). The medication is used to

lower the amount of HIV in the blood to an undetectable level. Some of the common side effects

of the medication include weight gain, sleep disorders, bloating, and depression. Some of the

things as nurses we need to implement are monitoring for lactic acidosis and hepatitis

exacerbations. For the diagnosis of Bipolar 1 disorder, A.M. was given Haldol (haloperidol) and

Zyprexa (olanzapine). Haldol is a typical antipsychotic and was given by mouth with a dose of 5

mg every 6 hours. Some of the side effects for this medication include extrapyramidal symptoms,

orthostatic hypotension, dry mouth, photophobia, and weight gain. The nursing interventions for

this medication include monitoring for therapeutic effectiveness and watching for neuroleptic

malignant syndrome, which can be obtained from taking antipsychotics. Zyprexa (olanzapine) is

an atypical antipsychotic that was given by mouth with a dose of 20 mg nightly. Some of the side

effects for this medication include drowsiness, dry mouth, nausea and vomiting, and weight gain.

Some of the nursing interventions for this medication include monitoring glucose and the ALT

levels.

The labs obtained were reviewed and most were within the normal range.

LAB and Reference Range AM’s Value

Potassium (3.5 – 5.0) 4.0

Sodium (132-146) 140

Glucose/A1C (74-99) 105

Blood Urea Nitrogen (6-20) 22

Creatinine (0.7-1.2) 0.9

RBC (3.8-5.8) 4.49

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Hemoglobin (12.5-16.5)/Hematocrit (37-54) HGB 14.8 HCT 42.1

WBC (4.5-11.5) 6.7

AST (0-39)/ALT (0-40) AST 20 ALT 19

Lithium/Depakote/Tegretol Level NA

TSH (.27-4.2)/T4 TSH 2.4 T4 not listed

Drug Toxicology Positive for cannabis

Alcohol Level Not listed

QTC/ECG QTC 382

The labs that specifically need looked at due to the medications the patient is on are

glucose, white blood cells, AST/ALT, and the QTC. All of these were within the reference range.

The two abnormal levels were the blood urea nitrogen and the positive result for cannabis. The

blood urea nitrogen was minimally elevated but could be indicative of mild dehydration. The

patient disclosed that he smoked marijuana recreationally in our conversation.

The safety and security measures were done per unit. A.M. was monitored on the unit and

safety precautions were taken. A.M. was also on suicide precautions. Some of these precautions

were not having any sharp items, or anything that could be used as a weapon, on the unit in reach

of any of the patients, no shoelaces, no belts, etc. I made sure to have my pen either in my hand

or away in my pocket while on the unit. The doors of the unit were also locked so patients could

not leave the unit. The unit was very calm and there were always staff on the floor in case of an

incident.
MENTAL HEALTH COMPREHENSIVE CASE STUDY

Summary of the Psychiatric Diagnosis: Bipolar Type 1

There are two different types of bipolar disorder. Bipolar 1 occurs with those who are

more in a state of mania than depression. Bipolar 2 occurs with those who are more in a state of

depression than mania. According to the National Institute of Mental Health, bipolar 1 is defined

by “manic episodes that last at least 7 days (most of the day, nearly every day) or by manic

symptoms that are so severe that the person needs immediate hospital care. Usually, depressive

episodes occur as well, typically lasting at least 2 weeks”. These patients are seen are

hypomanic.

Mania occurs when there is a period of abnormally elevated and extreme changes in your

mood or emotions (Cleveland Clinic). There are also different stages of mania. The first stage is

hypomania. During the hypomania stage, the patient would be cheerful, have a rapid flow of

ideas, have increased motor activity, lack of sleep, increased libido, and inappropriate behaviors.

This stage may never be treated. Stage two is called acute mania. During this stage, the patient

may have elation and euphoria, flight of ideas, hallucinations and delusions, excessive motor

activity, social and sexual inhibition, and have a little need for sleep. They may have delusions of

grandiosity, which is when they think their abilities are greater than other peoples. We give these

patients finger food so they can eat on the go because they may forget to eat. Stage 3 of mania is

delirious mania. This stage is an intensification of the acute mania symptoms. This patient may

have a labile mood, panic anxiety, clouding of consciousness, frenzied motor activity, and

exhaustion. This stage can be fatal without intervention. At this point, the patient’s body and

brain would reach absolute exhaustion and we would need to medicate them for their safety.
MENTAL HEALTH COMPREHENSIVE CASE STUDY

Stressors and Behaviors that Precipitated Current Hospitalization

The chart stated that the reason A.M. was admitted was because he was paranoid that his

neighbor poisoned his dog. He did not disclose any of this information during the conversation,

even when I asked why he was there. He also did not say anything about hallucinating or

delusions. A.M. suffered from copious amounts of childhood trauma that he disclosed. He

informed me that his father sexually abused him growing up and this caused a lot of anger for

him. A.M. left home when he was 17 years old. He has not seen or spoken to his father in two

years. He also stated that he has a sister that confronted their father about the sexual abuse they

endured growing up. Most of the conversation always came back to his father, this is called

perseveration. A.M. showed a lot of anger towards his father by stating that if he saw him “he

better be ready”. The patient stated he has previously physically assaulted his father.

A.M.’s grandfather was his support system growing up and he helped raise him. When

speaking of his grandpa, he talked about him like he was still living. After my conversation with

A.M., I found out through his chart that his grandpa had passed away. A.M. also disclosed that

he did not graduate high school. I noticed that when A.M. would discuss his trauma, he would

laugh a lot. Therefore, I think laughing is one of his coping techniques. He also uses marijuana

and alcohol to cope. Some appropriate coping strategies he uses are playing pool and bowling

with his wife but has not done this since his wife and him separated. Since the patient’s

grandfather is deceased and his wife is out of the picture, A.M. has no support system.

I think a lot of the behavior exhibited and the diagnosis of Bipolar 1 comes from the

trauma and lack of support A.M. has endured. According to mind.org, experiencing a lot of

emotional distress as a child can lead to bipolar disorder. Some of the factors that play into

Bipolar 1 are neglect, sexual, physical, or emotional abuse, traumatic events, and losing someone
MENTAL HEALTH COMPREHENSIVE CASE STUDY

very close to you. All these factors have applied in some way to A.M. The neglect came from not

having a proper father figure growing up and he also did not mention his mother at all. The only

person he seemed to have in his life was his grandpa growing up. He experienced sexual abuse

from his father, which was obviously traumatizing for him. He also lost his grandpa but talked

about him like he was still alive. Therefore, the diagnosis of bipolar one seems to stem from the

childhood trauma that A.M. endured. His poor coping skills, like marijuana use and laughing at

his trauma, also may have come from the trauma he endured as well, as he did not learn to

properly cope with the hardships he faced.

Patient and Family History of Mental Illness

AM has the diagnosis of Bipolar 1. He also has a history of alcohol and drug abuse. The

only family history listed was his father’s. His father has a history of bipolar disorder,

schizophrenia, and obsessive-compulsive disorder. The chances of having bipolar disorder are

increased if a parent or sibling has bipolar disorder (NAMI, 2019). Although, the genetic role in

having bipolar disorder is not certain (NAMI; 2017). Therefore, there could be a genetic link

between his father and the patient, resulting in bipolar disorder.

Psychiatric Evidence-Based Nursing Care Provided

The number one nursing implementation that was focused on was patient safety,

especially since A.M. was on suicide precautions. Interventions that were implemented were no

objects that could be used for harm present on the unit, no shoelaces, and constant monitoring on

the floor as well. There was always a nurse out on the floor. Since A.M. has Bipolar 1, he lives

more in the manic phase than the depressive phase. Therefore, safety would be the main concern

for him specifically. During my conversation, I made sure not to leave my pen out when
MENTAL HEALTH COMPREHENSIVE CASE STUDY

conversing with the patient and I also had my chair turned out in case I needed to get up for my

own safety in case A.M. became violent.

The unit was kept calm and quiet to decrease stimulation. There was television at a low

volume, phone time available, and tables for patients to sit at to talk with other patients. A.M.

actively participated in group therapy, which was done by my group that day. The group

consisted of listening to motivational songs and going around discussing how the songs made us

feel. One of the songs played is called “Rise Up”. A.M. disclosed that he would “rise up” and do

better for himself. He also seemed to enjoy being around other patients during group therapy and

getting to listen to music.

A.M. also used pharmacological therapy. He was prescribed Haldol (haloperidol),

Biktarvy, and Zyprexa (olanzapine). Haldol (haloperidol) is a typical antipsychotic, that was

used PRN, used to decrease his agitation. Biktarvy was used to decrease the HIV levels in the

patient’s blood to an undetectable level. This medication was specifically important for his

physical health to the consequences of not treating HIV properly, which can be fatal. Zyprexa

(olanzapine) is an atypical antipsychotic used to treat his diagnosis of Bipolar 1. The nurse made

sure that the medications were given on time and used when needed, like Haldol (haloperidol).

The nurse also made sure that A.M. took his meds and did not try to pocket them by physically

watching him swallow his oral medications.

Ethical, Spiritual, and Cultural Influences

A.M. is a 46-year-old Caucasian male. He did not disclose any type of religious practices

and there also nothing in his chart for religion. A.M. is unemployed and disclosed that he has not

had a job for years. Therefore, I believe that he would have a lower socioeconomic status. He
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also disclosed that his wife left him, and he is now single. He did not mention any cultural

influences and there was none listed in his chart.

Evaluation of Patient Outcomes

A.M. met most of his outcomes during my time on the floor with him. One of the

outcomes I developed was for A.M. to state he will attend support groups at the end of the shift.

Although he did not specifically state that he would do this, he did attend and actively participate

in group therapy. Another outcome A.M. met was verbalizing control of his feelings. He stated

that was in a better mood and was positive throughout the conversation and group therapy. From

what I witnessed, A.M. had no angry outbursts or aggressive behaviors. He also did not disclose

experiencing any type od delusions as well. Since he was on suicide precautions, A.M. met the

outcome of not attempting any self-harm to himself or harm to others as well. His behavior

overall was appropriate on the floor.

Plans for Discharge

Upon discharge, A.M. was not being sent to any type of psychiatric facility. His expected

discharge was November 18, 2022. A.M. lives alone and will return to his apartment, being

supplied with multiple resources as well. He will be required to participate in outpatient therapy

sessions upon discharge. He will also be instructed to continue to take his Biktarvy by mouth

daily, as well as Zyprexa (olanzapine) nightly to help control the diagnosis for Bipolar 1. Along

with these medications, his doctor will inform him of when to report specific symptoms from his

medications that could result in a medical emergency or the need to change a medication

promptly. Due to A.M. being on suicide precautions, confirmation of no weapons inside of his
MENTAL HEALTH COMPREHENSIVE CASE STUDY

home that may cause self-harm or harm to others will be done as well. He stated that when he

was discharged, he was hoping to find a good job and do better for himself.

Prioritized Nursing Diagnoses

The following are prioritized nursing diagnoses for A.M.:

1. Risk for other-directed violence related to manic excitement, physical

violence ideation, paranoid ideation

2. Disturbed thought processes related to psychotic process and use of alcohol

and drugs

3. Ineffective individual coping due to childhood trauma and lack of support

4. Risk for injury due to hyperactivity and use of cannabis and alcohol

5. Impaired nutrition due to hyperactivity

6. Disturbed sleep pattern due to hyperactivity and paranoia delusions

7. Interrupted family processes due to sexual abuse by father and death of

grandpa and separation from wife

8. Impaired social interaction due to thought processes and paranoia delusions

Potential Nursing Diagnoses

The following are potential nursing diagnoses for A.M.:

1. Low socioeconomic status related to no job

2. Extreme hyperactivity

3. Fluid deficit

4. Overstimulation

5. Risk for low self-esteem

MENTAL HEALTH COMPREHENSIVE CASE STUDY

6. Risk for suicide

7. Self-care deficit

8. 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. A.M. presented with a lot of the behaviors listed during a

manic phase. To control this disorder, a variety of treatments may be used. A.M. will continue to

use the treatment of pharmacology, Zyprexa (olanzapine), as an anti-manic medication. He also

will participate in outpatient therapy. A resource that could greatly benefit A.M. is a support

group, so he knows that he is not alone and that others struggle with the same things he

experiences with his disorder. This also may grant a support system for him, which he does not

have at all. With this use of these therapies, I believe that the flareups experienced in those with

Bipolar 1 will be decreased as well. Overall, A.M. was a very interesting patient, and I learned a

lot about his diagnosis and what it physically and mentally looks like.
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References

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

Mental Health. Retrieved December 7, 2022, from

https://www.nimh.nih.gov/health/topics/bipolar-disorder#:~:text=Bipolar%20I%20disorder

%20is%20defined,lasting%20at%20least%202%20weeks.

Mania: What is it, causes, triggers, symptoms & treatment. Cleveland Clinic. (n.d.). Retrieved

December 7, 2022, from https://my.clevelandclinic.org/health/diseases/21603-mania

Bipolar disorder. NAMI. (n.d.). Retrieved December 7, 2022, from

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

Case Study Comment Sheet 4842

MENTAL HEALTH COMPREHENSIVE CASE STUDY

Student Name: Delaney Early

Pt Identifier: A.M

Date(s) of Care: 11/17/2022

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual, and cultural influences that impact care of the patient

___________ Patient education required (based on symptoms, diagnosis, medications, labs,

safety, etc.)

___________ Priority patient needs (day of care and discharge)

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format