Sydney Ferguson

Mrs. Defiore-Golden

Mental Health Clinical

16 February 2024
Abstract

This case study follows S.S, a patient admitted to BHI following an incident with his son

due to an exacerbation of his psychiatric conditions. S. S’s son came down from his bedroom

requesting to speak with him, and in this conversation, he came out to his father as gay.

Immediately following that conversation, S. S’s wife had just finished making dinner and the

food was hot. They had no clean dishes, so the child’s mother asked him to wash some dishes

that were in the sink for them to eat dinner on so they can eat while the food was still hot. To

which the child replied, “Oh my God!” in an attitude which was perceived negatively by his

father. This lead S.S to slap his child across the face and knock him to the floor where he laid

and cried for ten minutes. This provoked an intense argument between S.S. and his wife. S.S had

some negative feelings towards his son being gay. Those negative feelings coupled with his son’s

attitude as well as an ineffective medication regimen led to this incident in the home. Amid this

argument, his wife called the local police department where S.S. was taken to St. Elizabeth

Youngstown Hospital, pink slipped, and admitted to BHI on a seventy-two-hour psychiatric hold.

Objective Data: Describe the patient using date of admission data, date of care data,

psychiatric diagnosis criteria, laboratory results. Include behaviors observed on admission

and the day(s) of care, medical conditions and treatments, safety and security measures

maintained, prescribed psychiatric medications and reason.

S.S was admitted on January 31st, 2024, for treatment of an exacerbation of Major

Depressive Disorder and for having suicidal ideations. In addition to having Major Depressive

Disorder and suicidal ideations, he also has a history of Post Traumatic Stress Disorder, Bipolar
Affective Disorder Type 1, and Cluster B Personality Disorder. On admission, his lab work

displayed low HDLs of 32, a low valproic acid of 34, a high LDL of 113, a high eosinophil

percentage of 9%, and a high eosinophil absolute of 0.59. All other lab work was within normal

limits. His drug and tox screen were all negative. His ECG was normal.

On admission, staff observed and documented S.S. as being in a hypomanic state

following an altercation with his twelve-year-old son and an argument with his wife. He was

pink slipped and brought to the unit following this incident. He was documented on admission to

be showing signs of remorse for causing his son emotional and physical distress. He was also

documted to be well groomed and cooperative despite still being a little agitated. On this day,

they also switched the Celexa he had been taking out for Depakote.

On the date of care, the patient expressed that the change in his medications is making a

positive difference and that he acknowledges that new medications take a while to kick in but

that he feels like this new regimen is really helping him to better manage his conditions. By this

time, he had been taking this new medication regimen for a couple days. During the treatment

team meeting on the date of care, S.S was taught by his team that the Celexa he was taking

elevated his mood, which led to feelings of impulsivity and euphoria, likely leaving him to live

chronically in a hypomanic state. Depakote, on the other hand, is a mood stabilizer, so it treats

the highs and lows, not just the lows, leaving him to live in a more comfortable balanced state.

He and the treatment team also discussed concerns of the Depakote losing efficacy by nighttime.

Due to this, they switched out the once-a-day Depakote for Depakote ER so that it works to

stabilize his mood all throughout the day, not just in the morning. In addition to the Depakote, he

also continued to take Abilify, Melatonin, and Prazosin which were prescribed to him prior to

admission. He takes Depakote and Abilify to treat his Bipolar Disorder, Major Depressive
Disorder, and Cluster B Personality Disorder and Melatonin and Prazosin to treat his Post

Traumatic Stress Disorder and associated night terrors. He also takes Haldol as needed for

agitation, and Vistaril as needed for anxiety.

On the date of care, S.S. displayed remorse for his actions, and an eagerness to follow his

new treatment plan so that he can get back home to his family and job that he loves. He feels that

he needs to rectify his relationship with his son after their altercation and explain to him how

deeply sorry he is. He and I also discussed his anxiety and biggest stressors. He expressed that

his biggest stressors were his rocky relationship with his wife and son, and his job that he now

feels is in jeopardy due to his hospitalization. I encouraged him to reach out to his employer

since it brought him so much anxiety and discuss the next steps and any documentation, he

should be prepared to bring with him on return to work, a discuss his approximate date of return.

He decided to call his employer and afterwards expressed some feelings relieved anxiety since he

was ensured by his manager that he still had a position at work post-discharge.

There were many safety and security measures that were maintained to keep the patient

safe. The primary safety measure that was performed was pink slipping him and thus keeping

him on the unit for a seventy-two-hour psychiatric hold due an exacerbation of his mental health

disorders and suicidal ideations. This kept him safe from himself and his family. Stress was high

at home, and he could have further hurt his son, wife, or himself staying in that location. By

admitting him to the unit, the staff was able to take other safety and security measures such as

15-minute visual checks, even in the middle of the night, ensuring there are no sharp or

dangerous objects on the unit that can be used for self-harm, and the option to attend groups to

learn positive coping strategies to use post-discharge in everyday life.

Summarize the psychiatric diagnoses and expected/common behaviors, with citations.

S.S has been diagnosed with Major Depressive Disorder, suicidal ideations, Post

Traumatic Stress Disorder, Bipolar Affective Disorder Type 1, and Cluster B Personality

Disorder.

Major Depressive Disorder is a mental health disorder that leads to a chronically low and

depressed mood and a lack of interest in activities that previously brought them happiness.

Depressive episodes with such lows can even have an impact on appetite, sleep patterns, and the

ability to think. Patients must display these symptoms for two weeks before being able to achieve

a diagnosis. Major Depressive usually presents in “waves” or “episodes”. Each episode can

persist for multiple weeks or even months (Cleveland Clinic). According to the National Institute

of Health, people who suffer from Major Depressive Disorder may also feel feelings of

worthlessness, guilt, a lack of energy and concentration, suicidal thoughts, or agitation. Suicidal

ideations are thoughts, desires, or plans to take your own life. Suicidal ideations are a common

side effect of many mental health disorders, including Major Depressive Disorder (National

Institute of Mental Health).

Post-Traumatic Stress Disorder is a disorder that develops in someone after someone has

endured an experience that was extremely shocking, terrifying, or dangerous. Symptoms of

PTSD include but are not limited to, vivid flashbacks, intrusive thoughts, nightmares, intense

distress following a trigger, pain, sweating, nausea, and trembling (National Institute of Mental

Health).

Bipolar Affective Disorder Type 1 is classified by manic episodes. Some people with

Bipolar 1 Affective Disorder may get an intense increase in energy and may have feelings of
euphoria and irritability. However, they may also have episodes of the opposite, where they have

feelings of depression, fatigue, and feelings of worthlessness. To be considered in a manic state

the feelings of being on top of the world must persist for longer than a week. To be considered in

a depressive episode, symptoms of depression only need to be present for four days. With proper

medication and treatments, patients with Bipolar Affective Disorder can live in a comfortable

neutral state (National Institute of Mental Health).

People who have Cluster B Personality Disorder usually have dysfunctional, dramatic,

and unpredictable behaviors. Some of these behaviors include a strong fear of being alone or

abandoned, feelings of emptiness, threats of self-harm, impulsive and angry outbursts, and

paranoia. People who have Cluster B Personality Disorder may also engage in risky behavior

such as having unsafe sex, binge eating, or gambling (Mayo Clinic).

Identify the stressors and behaviors that precipitated current hospitalization.

S. S’s teenage son had an intimate conversation with him about being gay. S.S had

negative feelings about his son being gay. Immediately following this conversation, the teenager

gave his mom an attitude about doing the dishes, which led to more negative feelings for S.S.

With all these negative feelings towards his son, S.S slapped him and knocked him to the ground.

This led to an intense argument between him and his wife, who is also his main support system.

Prior to this altercation at home, S.S had already been dealing with increased levels of stress at

work. He has been having some trouble getting along with his coworkers, but he loves the job

itself and doesn’t want to leave because he feels as though he is unqualified to do anything else

since his highest level of education is a high school diploma. It was also found out by the
treatment team that he was feeling increased levels of chronic hypomania and impulsivity which

made it hard for him to handle day to day life. All of these stressors piled up on him and led to

the exacerbation of his mental health disorders which led him to be hospitalized.

Discuss patient and family history of mental illness.

S.S does not have a family history of mental illness; however, his son has been diagnosed

with ADHD, depression, and anxiety and he carries many feelings of guilt because of it. He feels

as though he is to blame for passing psychiatric illnesses on to his son. Overcoming these

feelings and helping himself while also helping his son is something he is currently working on.

Describe the psychiatric evidence-based nursing care provided and milieu activities

attended.

For his safety, he was checked on visually every fifteen minutes, including in the middle

of the night. All his medications were administered to him and ensured that they were taken by

the nursing staff. He was placed on the unit on a seventy-two-hour psychiatric hold since he

admitted to having suicidal ideations. That way, the staff could protect him from being a danger

to himself. On the unit there are no objects that can be used to hurt himself, there are support

measures in place such as groups, social workers, and recreational therapists. He also saw a

treatment team regularly to balance his medications and to discuss discharge planning.

He attended a group in the milieu regarding fair fighting rules. This group discussed ways

to handle and deescalate altercations, how to turn them around into a conversation rather than an
altercation, and how to cope with the stress that arises from a disagreement or argument. I think

this was very helpful for S.S following the altercation he had with his wife and son, and the

stress it brought him in his day-to-day life. He was very attentive during this group, and he

seemed to appreciate being taught these new skills.

Analyze ethnic, spiritual, and cultural influences that impact the patient.

In our conversation, S.S did not portray that he had any ethnic or spiritual influences that

impact his life. However, he did discuss with me how culturally he feels that as a man he needs

to be the provider for his family, and he should be able to handle all the stress that his family

endures so his wife and son do not have to. In a respectful conversation between he and I, we

discussed how he does not have to bear the weight of the world on his shoulders, how it is not

solely his responsibility, and how that can take a toll on his mental health over time. We also

discussed ways he can work towards having a healthier relationship with his wife and son, how

he can learn to delegate and share responsibilities with his family and talk about stressors with

his support system and therapist.

Evaluate the patient outcomes related to care.

S.S was able to remain calm since admission. He also attended, and participated in

groups and was very attentive the whole time. He also adhered to the new medication regimen

and displayed no qualms regarding it. He even acknowledged that he knows psychiatric

medications take a few weeks to take full effect but that he was already feeling much better and
more like himself on the new medication regimen. He kept himself well-groomed and was

properly dressed on the day of care. He ate both his breakfast and lunch on the day of care as

well and socialized with the other patients throughout the day as well. Overall, the patient is

meeting all expected outcomes and appears ready for discharge soon.

Summarize the plans for discharge.

I saw S.S on Friday and the treatment team discussed releasing him on the following

Monday, as long as he participated in groups, felt stable, and remained calm over the weekend.

Upon discharge he is going to return home to his wife and son and work towards mending his

relationship with them. He is going to continue going to talk therapy, and continue his

medication regimen of Depakote ER, Abilify, Melatonin, Prazosin, and Melatonin routinely and

Haldol and Vistaril as needed at home. He is going to follow up with his family doctor after

discharge as well.

Prioritized list of all actual diagnoses using individualized NANDA format.

1. Suicidal Ideations – Hopelessness and Impaired Coping, related to Suicidal Ideations, as

evidenced by impulses and urges to harm himself and a overwhelming feeling of

inadequacy.

2. Major Depressive Disorder – Self-Care Deficit, related to Major Depressive Disorder, as

evidenced by the inability to maintain an effective medication regimen at home, and a

lack of interest in doing things that previously made him happy.

 3. Post-Traumatic Stress Disorder – Disturbed Sleep Pattern related to Post-Traumatic

Stress Disorder as evidenced by recurring night terrors and excessive daytime sleepiness.

4. Bipolar Affective Disorder – Impaired Self-Concept, related to Bipolar Affective

Disorder, as evidenced by feelings of worthlessness and euphoria.

5. Cluster B Personality Disorder – Altered Mental Status related to Cluster B Personality

Disorder, as evidenced by manic and depressive episodes, and struggling to get along

with his coworkers.

List of potential nursing diagnoses.

 Altered Mental Status

 Hopelessness and Impaired Coping

 Impaired Self-Concept

 Altered Communication Pattern

 Self-Care Deficit

Conclusion paragraph.

S.S is meeting all expectations, participating in groups, keeping himself well groomed,

eating his meals, socializing appropriately, maintaining his medication regimen, and is eager to

get home. He is compliant with his new medications and plans to continue them as well as talk

therapy at home. He appears very remorseful about the altercation with his son and is eager to

get home to mend his relationship with his son and wife, especially since they are his main
support system. He seems to be relieved to know that he won’t always feel the way he did in that

moment, and that exacerbation could have been due to an improper medication regimen that

made him impulsive and hypomanic. He is on the right track and is taking the appropriate steps

to integrate back into his life at home. He contacted his employer so that he can ensure his

position will still be waiting for him, and to make sure he returns with all necessary

documentation from his leave.

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