Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Caitlyn Howe

November 22, 2023

Mrs. Teresa Peck, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

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Abstract

BR is a 39-year-old female patient admitted to the psychiatric unit after an outburst at her

outpatient therapist office. She has a diagnosis of Bipolar 1 with psychotic features and at the time

of her stay on the unit she is experiencing a manic episode. The nursing care is focused on

stabilization of her moods through pharmacologic means and education on coping mechanisms

through group and individual therapies. The goal is that by getting her back on to her medication

regiment, her symptoms will be better managed, and her moods will be stabilized so that she can

return home.
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Objective Data

Patient identifier BR

Age 39

Sex Female

Date of admission September 10, 2023

Date of care September 12, 2023

Psychiatric diagnosis Bipolar I with psychotic features

Other diagnoses Anxiety and depression

Behaviors on admission BR was brought in from her outpatient therapy office after having an

outburst of anger, which included her yelling and cursing at staff and throwing herself on the

floor. She was screaming that she felt as though “everyone was trying to control her”.

Behaviors on day of care BD was friendly and was very enthusiastic to talk to us. She

participated in the group that started while we were there and participated several times and

stayed to ask questions after group had concluded. BD was displaying signs of being in a manic

episode at the time of her hospitalization. Overall BD was in good spirits but did experience

some occasional lability when speaking to us. She got a bit upset when telling us that she

occasionally heard voices, and she also believed that the TV would talk to her. BD was also

afraid of one of the other patients on the units, as when he walked by, she got out of her chair

and hid behind me and began crying. After he had walked away, she returned to her seat and

began talking the same way she was previously. She also showed flight of ideas, as she would

switch from topics quite quickly. Her mannerisms were exaggerated and was having difficulties

staying still. She also displayed some occasional inappropriate behaviors, saying that she wished

she could “kiss and hug us” a couple of times during our conversation.
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Safety and security measures In the group area, there were multiple staff always present in

different areas of the room. The patient was not permitted off the unit. Items that could be

hazardous, such as pencils, pens, plastic garbage bags, and shoelaces were not permitted on the

unit. The entrance to the unit consists of two doors that could only be opened via keycard by a

staff member, and both doors could not be open at the same time.

Laboratory results

Lab Value Result

Toxicology Positive for

Cannabis

Psychiatric medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

Olanzapine Zyprexa Antipsychotic 5 mg BID Bipolar disorder
Sodium Depakote ER Mood Stabilizer 500 mg daily Mania
valproate
Paliperidone Invega Antipsychotic 6 mg daily Psychosis
Clonazepam Klonopin Benzodiazepine 0.5 mg BID Panic disorder
Mirtazapine Remeron Antidepressant 15 mg Depression

Summary of psychiatric diagnosis

Bipolar I is a disorder that involves mood swings that range from manic highs to

depressive lows. The mood swings are episodic and can last from days to weeks or months

depending on that patient’s diagnosis. It is the second ranked mental illness as a cause of

worldwide disability, with major depression being the first (Videbeck, pg 306). Those suffering

from bipolar disorder may be diagnosed with depression until a manic episode can be identified.

There are 3 main types of bipolar disorder, those being bipolar type I, bipolar type II, and bipolar
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mixed. In those with mixed bipolar disorder, there are recurrent cycles of mania, normal mood,

and depression. In bipolar II, there are recurrent depressive episodes with at least one episode of

hypomania, which is a less severe manic episode. In bipolar I, the patient maintains a lot of time

in a manic state, with episodes lasting at least a week (Nasim Mousavi, et al. 2021). These manic

episodes can be quite severe, even leading many to need hospitalization.

The diagnosis of bipolar disorder often comes after evidence of a manic episode, which is

most likely to occur in late adolescence to early adulthood. A manic episode is diagnosed with

the following criteria occurring over the course of at least 1 week: incessantly heightened or

agitated mood along with three or more of the following symptoms, “exaggerated self-esteem,

sleeplessness, pressured speech, flight of ideas, reduced ability to filter extraneous stimuli,

distractibility, increased activities, increased energy, and multiple grandiose, high-risk activities

involving poor judgement and severe consequences” (Videbeck, pg 307). These symptoms tend

to escalate quite quickly, then last for a significant amount of time.

When in a depressive episode of bipolar, the symptoms will mimic that of major

depressive disorder. These symptoms include fatigue, feelings of hopelessness, lack of interest in

activities, low self-esteem, difficulties with concentration, and sleep changes. Those with bipolar

are also at an increased risk of suicide, with young men early in the disease process being the

most at risk (Videbeck, 306).

Many individuals with bipolar disorder will experience psychotic symptoms during their

lifetime. These individuals do not quite meet the criteria to be diagnosed with psychosis but

share prevalent symptoms. with two-thirds of patients with bipolar I reporting these

manifestations (Chakrabarti and Singh, 2022). Someone experiencing psychosis has lost touch

with reality, and those with bipolar disorder have delusions and/or hallucinations that are
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congruent with their current mood. While these symptoms do not always impact their treatment,

it does create more difficulty with daily functioning.

Identification of stressors and behaviors precipitating current hospitalization

Before her admission, BD was non-compliant with her medications. She also told the ER

staff that she hasn’t been eating because she would forget. She lives at home, but it is unclear if

she lives with anyone else. In her file, it said she lives alone, but she spoke of a roommate that

lives with her. On the day of her admission, she went to her outpatient therapy office where she

became upset at the staff. After throwing herself to the ground and cursing and yelling “why

does everyone want to control me, you can’t control me!”, EMS was called, and she was pink

slipped to the psych unit due to her manic state and it being determined that she was unable to

care for herself.

Patient and family history of mental illness

BR was diagnosed with Bipolar 1 when she was 21 years old after a manic episode that

required hospitalization. Psychotic features were also diagnosed as she has auditory

hallucinations and delusions. She has been hospitalized two other times separate from her current

hospitalization.

BR has one brother who also struggles with depression. Her mother had a diagnosis of

both anxiety and depression, but BR is unsure if anyone else in her family has bipolar 1. She did

not discuss her father.

Psychiatric evidence-based nursing care provided

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While staying on the unit, BR was taken care of by the psychiatric nursing staff. She was

assigned a nurse each shift that she was able to build rapport with to ensure that she felt

comfortable voicing her concerns and asking questions. Each day the nurse would assess her

needs, implement nursing care based on those needs, and evaluate the outcome of the

interventions. The nurse would administer her daily medications, which included two

antipsychotics, an antidepressant, and a mood stabilizer. BR also had a PRN benzodiazepine

prescribed, so the nurse would assess if she needed it should she begin to have a panic attack.

The nurse is aware of all of the uses of her medications, their side effects, and their possible

interactions. The nurse is also aware of the signs and symptoms of neuroleptic malignant

syndrome, which is important because BR is on an antipsychotic medication.

BR was also involved in different group therapies that take place on the unit, which are

useful for her recovery. They helped with exploring emotions, coping skills, and connecting to

resources within her community. The psychiatric unit also keeps its patient on a schedule, which

is helpful to many patients, as making decisions can be stressful and can pull away from that

person’s recovery while admitted.

Ethnic, spiritual, and cultural influences

BR is white, single woman who is currently lives at a low socioeconomic status. She is

not employed and relies solely on government assistance. BR told us that she was a Christian but

was not very involved with church at the moment. She did ask us to pray with her at one point

during our conversation, and she said she felt better afterwards.

Evaluation of patient outcomes

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The outcomes that were planned for BR by the end of her stay were in increase in food

intake, performing self-care appropriately, and a stabilization of moods. On her day of care, BR

was taking care of herself appropriately, having taken a shower and groomed herself for the day.

She had also met her goal of increasing her food intake, as she had eaten over 75% of her meals

for that day and was eating a snack when we first began our conversation.

Her anxiety was improved from when she came in originally, despite the anxiety

surrounding another patient on the floor of the unit. Her anxiety when she was admitted was

related to her feeling of a loss of control in her life. While she is still stressed about her current

situation outside of the hospital, she felt as though she has more tools and resources to help her

when she is discharged. She also said that she understood the importance of taking her

medication regularly to keep her moods stable.

Plans for discharge

BR is to be discharged back to her home. She will be sent with a few days’ supply of her

medications, as well as educational information about her meds and the importance of taking

them as prescribed. This information will also be reviewed with her with a nurse before she is

discharged so that she may ask any questions if needed. She will have an appointment scheduled

at her outpatient psychology office for the following week. She will also be given resources for

groups and other support that she will be encouraged to attend.

Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for BR:

1. Impaired nutrition related to manic state as evidenced by forgetting to eat meals

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2. Disturbed thought process related to Bipolar 1 as evidenced by delusions

3. Anxiety related to other patients as evidenced by fear of other patients on floor

4. Complicated grieving related to mothers’ death as evidenced by verbalization of sadness

5. Risk for injury related to extreme hyperactivity as evidenced by pacing and restlessness

6. Hopelessness related to

Potential nursing diagnoses

1. Ineffective coping

2. Ineffective health maintenance

3. Impaired verbal communication

4. Disturbance of self-esteem

5. Sleep pattern disturbances

6. Alteration in nutrition

7. Fear

8. Impaired family processes

9. Impaired social interaction

10. Risk of Non-compliance

11. Social Isolation

12. Impaired cognition

13. Self-care deficit

Conclusion

Bipolar I is a complicated disease that involves dramatic mood swings from manic highs

to lows of depression. Patients with bipolar I that have long phases of mania often have difficulty

with compliance of treatments and medications. They often can be a danger to themselves, with
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that being through a lack of self-care or impulsive and risky behaviors. Many patients going

through an extreme manic phase need to be hospitalized in order stay safe.

BR experienced many of the key signs of mania, including flight of ideas, distractibility,

restlessness, and inappropriate behaviors. Along with this, the psychotic features of her diagnosis

are displayed with her hallucinations and delusions. The goal for her once she is discharged is

that she is able to take care of herself at home, as well as maintain compliance with her

medication and treatments. Another goal is that she attends group therapies and reach out to

resources that are available to her when she needs assistance. While medications will not cure the

disease even with compliance, the hope is that her moods are more controlled and that she is able

to identify when she is getting manic and to get help when that occurs.
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References

Chakrabarti, S., & Singh, N. (2022). Psychotic symptoms in bipolar disorder and their impact on

the illness: A systematic review. World journal of psychiatry, 12(9), 1204–1232.

https://doi.org/10.5498/wjp.v12.i9.1204

Mousavi, N., Norozpour, M., Taherifar, Z. et al. Bipolar I disorder: a qualitative study of the

viewpoints of the family members of patients on the nature of the disorder and

pharmacological treatment non-adherence. BMC Psychiatry 21, 83 (2021).

https://doi.org/10.1186/s12888-020-03008-x

Videbeck, S. L. (2022). Lippincott CoursePoint Enhanced for Videbeck's Psychiatric-Mental

Health Nursing (9th ed.). Wolters Kluwer Health.

https://coursepoint.vitalsource.com/books/9781975205867