Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Madison Bova

November 16, 2023

Dr. Teresa Peck, DNP, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

This case study presents the clinical profile and treatment approach for a 33-year-old male

diagnosed with schizoaffective disorder, bipolar type. The patient's history revealed a suicide

attempt by overdosing on Risperdal and Buspar, and their psychiatric evaluation identified

prominent symptoms of both mood disorder and psychosis. The patient experienced recurrent

episodes of depression, accompanied by auditory hallucinations. Treatment comprised a

comprehensive approach, incorporating antipsychotics, mood stabilizers, anticonvulsants,

antidepressants, and antihypertensives, along with psychotherapeutic interventions, such as

cognitive-behavioral therapy and group therapy. The patient's response to treatment was assessed

through attendance to group therapy, compliance with medications, thorough evaluation with the

psychiatrist, demonstrating improvements in medication compliance and awareness, and

challenges managing depression. This case study underscores the complexity of managing

schizoaffective disorder, bipolar type, and the importance of individualized treatment plans. It

contributes to the growing body of knowledge regarding effective interventions for this

challenging mental health condition.

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Objective Data

Patient identifier RW

Age 33

Sex Male

Date of admission October 24, 2023

Date of care November 2, 2023

Psychiatric diagnosis Schizoaffective, bipolar type

Other diagnoses Drug abuse, drug overdose, self-harm attempt, borderline personality disorder,

polysubstance abuse

Behaviors on admission RW had taken handfuls of Buspar and Risperdal because he was

having auditory hallucinations of voices telling him to “keep counting.” He states he has no

recognition of what happened before or after his suicide attempt. The patient had a seizure in the

emergency department and his QTC was increased at 554 putting him at risk for Torsade’s de

pointe, so he was transferred to the ICU to monitor his EKG for QT prolongation. Later that day,

his QTC increased to 564, then went down to 404 on October 25th, which is back to normal

because it should be less than 440.

Behaviors on day of care RW attended the psychotherapy session and was very interactive

during the whole session. He wanted to talk more but there was a patient in there that had a

negative comment about everything, so it disrupted the group therapy from going smoother and

getting more interaction. When talking to RW one-on-one, he was able to express a lot of

feelings and tell us about his past, present, and future. RW expressed tears and feelings of suicide

by stating that he still feels that he’s better off not being here, which was reported back to his
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nurse. When this patient was asked why he was there, he said that he did not remember anything

before or after his admission only that he punched his TV and had scars on his knuckles.

Safety and security measures Throughout the inpatient admission there were safety checks

implemented around the clock every 15 minutes done by the behavioral health aide on the unit.

Eyes need to be laid on these patients every 15 minutes to ensure they’re not attempting suicide,

having a medical emergency, or fighting another patient. All hazardous items such as shoelaces,

razors, paperclips, pencils, and pens were not permitted on the unit, and only markers were used

for writing. If anyone has a pen or pencil on them, it must always stay on them. Medications

were administered to the patient by the nurse, and the nurse verified all medications were taken

at the time of administration and not pocketed or put in their cheek to potentially attempt suicide.

If a patient is believed to say something indirectly or directly that points to risk for suicide, it is

required to be reported to the nurse and documented to mark in their plan of care and prolong

their days on this floor.

Laboratory results

Lab Value Result

Glucose 103
Potassium 2.6
ALT 38
AST 53
QTC 554
Lactic Acid 19.5
Toxicology Positive for
amphetamine
and positive
for cannabis
Valproic 76
Acid
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Psychiatric medications

Trade Name Generic Name Class/Category Dose/Frequency Reasoning

Nicorette Nicotine Nicotine 2 mg oral PRN Tobacco
Lozenge replacement dependence
Zyprexa Olanzapine Atypical 10 mg oral QD Schizophrenia
Antipsychotic
Valproic Acid Depakote Anticonvulsant 500mg oral TID Seizures

Ativan Lorazepam Benzodiazepine 1 mg IM Q6H Status

PRN epilepticus in
ED
Haldol Haloperidol Antipsychotic 5 mg oral Q6H Psychosis
PRN
Desyrel Trazodone SSRI 50mg QHS PRN Major
hydrochloride antidepressant depression
Vistaril Hydroxyzine Antihistamine 50 mg oral TID Anxiety
hydrochloride PRN
Catapres Clonidine Antihypertensive 0.1 mg oral BID Decrease BP
hydrochloride
Coreg Carvedilol Beta-Blocker 12.5 mg oral Decrease HR
BID
Flexeril Cyclobenzaprine Muscle Relaxant 10 mg oral TID Fibromyalgia
hydrochloride PRN
Risperdal Risperidone Atypical OD on this Psychosis
Antipsychotic medication
Melatonin Pineal Hormone Acetamide 5 mg oral QHS Insomnia

Summary of psychiatric diagnosis

Schizoaffective disorder, bipolar type, is a mental health condition characterized by a

fusion of symptoms from both schizophrenia and bipolar disorder. Individuals with this disorder

experience episodes of mania or hypomania, depressive episodes, and concurrent psychotic

symptoms like hallucinations and delusions. The bipolar type specifically signifies the

coexistence of mood disturbances with psychotic features. (“Schizoaffective disorder,” n.d.)

Diagnosing schizoaffective disorder, bipolar type is a complex process that requires a

comprehensive psychiatric evaluation due to its symptom overlap with other mental health
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disorders. Treatment typically involves a combination of antipsychotic medications, mood

stabilizers, and psychotherapy tailored to address both mood and psychotic symptoms. Long-

term management and support are crucial components of the treatment plan (“Schizoaffective

disorder,” 2019.)

On admission, RW had hypertension and was on Coreg and Catapres for his blood

pressure and heart rate. He was also on antipsychotics for his Schizoaffective, bipolar disorder,

which made him highly at risk for Torsade’s de pointe. Torsade’s de pointe is a very rare

arrhythmia that is called ventricular tachycardia. It is measured by the QTc level, which is found

by performing an EKG. The QTc is the QT interval on a cardiac wave. The QTc gradually

prolongs as you get older and when you are on psychotropic drugs. RW’s QTc was 554 and a

normal QTc level is less than 440, so he was in a very critical state, and on top of that he had a

seizure in the emergency department (Funk & Beach, 2018.) RW’s potassium was also very low,

which is also critical because low potassium can cause cardiac arrhythmias.

Identification of stressors and behaviors

Before admission, RW was non-compliant with his medications. He lives at home with

his grandmother but did not comment on any stressors with their relationship. RW said his

thirteen-year-old daughter is one of his stressors because he wants to give her the best life and

doesn’t want to mess her up. He also doesn’t want her to struggle with depression and mental

disorders as he does. He said he didn’t push religion onto her because he wanted her to find it on

her own. He sees that she’s more scientific-based already and doesn’t have the same beliefs as

him.

Another stressor he has is the fear of the world ending. He said all the news and media of

war and terrorism and the evolving technology make him think the world is coming to an end.
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He said 9/11 scared him watching the people jump off the towers because they didn’t want to get

burned alive replays in his head to this day. RW has two coping mechanisms, smoking weed and

playing video games.

Patient and family history of mental illness

RW stated that he was diagnosed with depression at the age of twelve and was put on

Paxil, which is an SSRI. The only family history of mental illness is his biological father who

has a history of drug abuse. RW grew up living with his mother and stepfather and would go to

his biological father's house every other weekend. When asked about his relationship with his

mother he said he still has a good relationship with her but when asked about his relationship

with his stepfather he touched on abuse but didn’t go into detail sort of avoided it and blocked

the abuse out. But he did say that’s one of the reasons he was put on antidepressants so young.

When interviewing RW he said he took himself off Paxil, SSRI, because he did genetic testing

and found that it wasn’t compatible with his genes. RW lives with his grandmother in a one-story

home and has split custody of his thirteen-year-old daughter and says he now has a great

relationship with her mother.

Psychiatric evidence-based nursing care provided

During his stay on the inpatient unit, RW received nursing care from the mental health

nursing staff. Each shift, RW was assigned a nurse and this nurse served as the point of contact

for any care-related concerns. Using the nursing process, the nurse conducted daily assessments,

diagnosed issues, devised care plans, implemented interventions, and evaluated RW's progress.

Among the nurse's responsibilities was the administration of RW's daily medications, including

his antihypertensives, beta-blockers, SSRI antidepressants, antihistamines, muscle relaxants, and

MENTAL HEALTH COMPREHENSIVE CASE STUDY 8

atypical antipsychotics. To ensure proper medication adherence, the nurse monitored RW to

prevent any attempts to retain pills for later use.

The nursing staff overseeing RW's care possessed comprehensive knowledge about the

medications, including their intended purposes, common side effects, and, particularly with

antipsychotic medications, awareness of signs and symptoms associated with neuroleptic

malignant syndrome—a rare but serious condition that may occur. As well as the seriousness of

taking handfuls of Risperdal, an antipsychotic, while on blood pressure medications, and the risk

for Torsade’s de pointe. RW’s seizure in the emergency department was an NMS resulting from

his overdose on Risperdal.

Additionally, during RW's inpatient treatment, a key component was the incorporation of

daily group sessions and psychotherapy sessions. The unit maintained a structured schedule that

was written on the whiteboard every day encompassing mealtimes, personal care, phone calls,

and organized groups facilitated by nurses, student nurses, social workers, and the psychiatrist.

RW actively participated in as many of these group sessions as possible and found them

beneficial to his recovery. RW’s time in this unit provided him with new positive coping skills

and information about available community resources. He stated that having people to talk with

made him feel like he wasn’t the only one struggling and gave him many people to talk to and

express his emotions (Wy & Saadabadi, 2023.)

Ethnic, spiritual, and cultural influences

RW is a Caucasian, single male from a lower-class family. He has a thirteen-year-old

daughter with split custody and has a great relationship with the girl's mom. He is not employed,

has his GED, and went to college for a few years majoring in IT but didn’t finish because he

believes he’s “too smart.” He currently lives with his grandma. RW practices Christianity as a
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religion and states that he “tries to get on my knees every day and pray but most days I don’t end

up doing it.” The patient loved listening to a band named Behemoth but figured out that it was a

Satanistic band by listening to the words they sang and by watching the music videos. He said if

he had known that before, he wouldn’t have started listening to them. RW did have religious

delusions because he was disagreeing with his ex-girlfriend’s boyfriend and the new boyfriend

had him pinned against the wall with a knife. RW said he was praying to God that the guy would

drop the knife and leave. He said God sent an angel down to save him.

Evaluation of patient outcomes

Outcomes that are desired for a patient with schizoaffective, bipolar-type disorder include

recognition of distortions in their reality, remaining free from harming themselves or others,

realistically perceiving themselves, and performing self-care activities appropriately. On the day

of care for RW, he was performing self-care activities for himself such as showering, attending

group therapy, and psychotherapy, and eating appropriately. He also had remained free from any

further harm while he was on the inpatient unit, and was taking his medications appropriately,

but he was still actively depressed and suicidal noted by stating that he feels like he would be

better off not here and emotional labile.

Certain outcomes for RW were only partially achieved during the day of care. RW still

experienced persistent auditory hallucinations. This was noted by him stating he feels like he

hears everyone so clearly even when they’re at a distance and that he still hears people jumping

off buildings from the 9/11 videos. Furthermore, RW continued to harbor delusions of grandeur,

saying that he was too intelligent to finish college and for a therapist he had in the past, so he has

a hard time finding one he likes. Additionally, he maintained a religious delusion about God

listening to him and bringing an angel down to save him. RW also previously experienced
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paranoia symptoms such as not wanting to leave his house because he felt as if everyone was

looking at him and his ex-girlfriend cheating on him. There was better management of

depression on the day of care compared to admission. However, it was noted that he was still

depressed and suicidal because he stated he felt that he would be better off not here. RW has

been attending group therapy and taking his medications without any problems as required for

discharge.

Plans for discharge

When RW is discharged, he will return to his home where he lives with his grandmother

in a one-story home. The staff felt that RW did not need transitional or long-term placement after

discharge from the inpatient unit because he had a safe environment at home. However, the staff

felt that it was important for him to develop a routine and schedule while he was inpatient to

carry with him when he gets discharged to help him keep up with his medications. He will also

be prescribed a shorter supply of medications at a time because he overdosed on his medications

previously and this is to prevent that from happening again. There is also a risk for him not

taking his medications because of having to pick them up so frequently but the benefit outweighs

the risk.

Weekly therapy groups will also be implemented in his plan of care to help with his

depression and social isolation. He will have a doctor’s visit with his psychiatrist within the first

week of his discharge then every two weeks then once a month to make sure he's staying

compliant with medications and to make sure he’s not a threat to himself, or others and able to

care for himself. Education will also be provided on the importance of taking his medications

regularly, the possible side effects, and adverse effects that can occur and to alert the doctor
MENTAL HEALTH COMPREHENSIVE CASE STUDY 11

about them if they do occur. Positive coping skills will also be available to RW to try before

using his negative coping skills.

Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for RW:

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

hallucinations.

2. Disturbed thought processes related to mental illness as evidenced by non-realistic

thinking and delusions.

3. Risk for suicide related to previous suicidal ideation and attempt, hallucinations, and

patient stating he would be better off not in this world while crying.

4. Impaired memory related to the patient not having any memory of what happened before

or after the suicide attempt.

5. Risk for self-harm related to delusions and hallucinations and severe depression.

Potential nursing diagnoses

1. Loneliness

2. Ineffective coping

3. Ineffective health maintenance

4. Impaired social interaction

5. Fear

6. Hopelessness

7. Impaired individual resilience

8. Self-care deficit
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9. Social isolation

10. Ineffective impulse control

Conclusion

In conclusion, the case of RW, a patient diagnosed with schizoaffective disorder, bipolar

type, highlights the complex interplay of psychiatric, medical, and psychosocial factors in the

context of mental health care. RW's condition presented unique challenges, including the delicate

balance required in managing both mood and psychotic symptoms, as well as addressing the

physical health implications of psychotropic medications.

The discharge plan prioritizes medication adherence, routine development, and ongoing

psychiatric care. RW's journey underscores the need for a personalized, multidimensional

approach to navigating the complexities of schizoaffective disorders. The collaboration between

psychiatric professionals, nursing staff, and the patient's support network is crucial in fostering

long-term stability and promoting the highest possible quality of life for individuals navigating

such complex mental health conditions.

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References

Funk, M. C., & Beach, S. R. (2018, June). Resource Document on QTc Prolongation and

Psychotropic Medications. Apa Resource Document - psychiatry.org.

https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-

Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-

Psychotropic-Med.pdf

Mayo Foundation for Medical Education and Research. (2019, November 9). Schizoaffective

disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/schizoaffective-

disorder/diagnosis-treatment/drc-20354509

U.S. National Library of Medicine. (n.d.). Schizoaffective disorder: Medlineplus genetics.

MedlinePlus. https://medlineplus.gov/genetics/condition/schizoaffective-disorder/

Wy, T., & Saadabadi, A. (2023, May 27). Schizoaffective disorder - statpearls - NCBI bookshelf.

Schizoaffective disorder. https://www.ncbi.nlm.nih.gov/books/NBK541012/