Psychiatric Mental Health Comprehensive Case Study

Emily Morrison

Youngstown State University

Mental Health Case Study

Abstract:

A.D. a 19 year old female patient was admitted to the behavioral unit at St. Elizabeth’s

downtown on September 11, 2019. This patient was diagnosed with depression, major recurrent,

along with bipolar disorder with severe depression after attempting suidiced just three days

before admission. She attempted this suicide by asphyxiation via helium, along with taking

multiple unnamed over the counter drugs. At some point either before this attempt or after she

got into a large argument with her mother during which her mother kicked her out of the house

and leaving her to sleep under a bridge before admission. This patient has a history of suicidal

ideation, cutting, and she also reports and increase in depression, poor appetite, nausea, poor

sleeping schedule, and increased feelings of hopelessness. The hope upon discharge is to get her

to reach out to her mother and work things out so that she has somewhere to live. She plans to

work on her coping skills and be able to reach out for help before attempting to kill herself again.
Psychiatric Mental Health Comprehensive Case Study

Objective Data​:

The patient A.D. admitted to the mental health floor on September 11, 2019 by herself. Date of

care for this patient was September 12, 2019. Patient was diagnosed with a history of depression,

major recurrent. According to the DSM-5, criteria for major depressive disorder includes five or

more of the following symptoms: either a depressed mood or loss of interest or pleasure,

depressed most of the day almost every day subjectively (feeling sad, or hopeless) or objectively

(crying more often), diminished interest in all or almost all activities nearly everyday, significant

weight loss without trying, a decrease or increase in appetite, insomnia or hypersomnia, slowed

sluggish movement, fatigue or loss of energy, feelings of worthlessness or inappropriate guilt,

slower ability to think or concentrate, recurrent thoughts of death, or recurrent suicidal ideation.

Her laboratory results were all within normal limits apart from a cannabinoid serum urine test,

which she had a positive result for. Noted behaviors on the day of care was fidgeting, playing

with bracelets, walking around the floor to self sooth, while also avoiding others, playing with

hair while talking along with talking with her hands. Patient reported an increase in depression,

poor appetite, nausea, poor sleep, and increased feeling of hopelessness. A.D. also discussed

feeling anxious, an increase in sadness and suicidal ideations. Safety and security measures that

were maintained on this patient were normal suidice precautions including: removing any and all

objects that could potentially be used to harm herself, no curtains in her room, paper bags on the

floor instead of plastic on the floor, no one with shoelaces on the floor, etc. A.D.’s prescribed

psychiatric medications were: Cogentin (2mg injection intramuscular twice daily PRN),* in the

case of an episode of acute dystonia; Neurontin (100mg three times by mouth) is used as a way
Psychiatric Mental Health Comprehensive Case Study

of treating bipolar disorder; Vistaril (50 mg three times by mouth PRN) for anxiety; Zyprexa

(5mg by mouth every 4 hours PRN) for agitation; Paxil (10 mg by mouth daily) for treatment of

anxiety.

Summarize the psychiatric diagnoses​:

Depression, Major Recurrent: mood disorder that causes a persistent feeling of sadness and loss

of interest, affects how you feel, think, and behave, and can lead to a variety of emotional and

physical problems may have trouble with day to day activities (Mayo Clinic). Expected/

Common behaviors: feelings of sadness, tearfulness, emptiness, hopelessness, angry outbursts,

irritability or frustration, sleep disturbances, lack of energy, anxiety, and a loss of interest or

pleasure in all normal activites (sex, hobbies, or sports).

Bipolar Disorder with Severe Depression: formerly called manic depression, a condition that

causes extreme mood swings that include emotional highs (mania or hypomania), and lows

(depression) (Mayo Clinic). These mood swings may occur rarely or multiple times a year, can

be managed. Expected/ Common behaviors: euphoric mood, irritable mood, grandiosity,

decreased need for sleep, pressured speech, racing thoughts, distractibility, increased in goal-

directed activity/ psychomotor agitation, excessive involvement in pleasurable or risky activities,

psychosis, and suicidality.

Identify the Stressors and Behaviors​:

that precipitated the current hospitalization: Patient had a documented history of sexual abuse

with her step brother when she was younger (6-12 years of age). A.D. talked about having a bad

history with her mother and had a fight with her before being admitted. Her mom had kicked her

out of the house after she had attempted to kill herself. She attempted this suicide via
Psychiatric Mental Health Comprehensive Case Study

asphyxiation with helium, and by taking a large unidentified quantity of over- the- counter pills.

She had a positive screening for cannabinoid serum, and had spent the night under a bridge

before being admitted.

Discuss patient and family history of mental illness​:

A.D: has a history of cutting her arms, sexual abuse (ages 6-12) from a step brother, she has

social phobia, and she was admitted to belmont pines for having suicidal ideations historically.

Mother: Has a history of depression

Father: Has a history of depression

Paternal Grandma: history of depression

Paternal Grandpa: history of depression

Maternal Aunt: has a history of depression

Paternal Uncle: has a history of depression

It was also documented in her files that there was a family history of thyroid disease, but where

in the family tree wasn't listed.

Describe the psychiatric evidence based nursing care provided and milieu activities attended​:

Patient on the floor has her own room and safe environment, She meets regularly for group

therapy, and follows along with the structured program as scheduled on the floor. Group therapy

gives each individual a chance to be realized and encouraged to grow. Other techniques used on

the floor to help the patients are providing space for the patient so that they have their own

privacy, but providing furniture that mimic a homelike atmosphere. On the floor clients help with

the decision making and problem solving that can and do affect the way the treatment settings

go. This being said, patients are to take an active role in their treatment teams. Patients are also
Psychiatric Mental Health Comprehensive Case Study

expected to be assigned a responsibility that they are capable to accomplish, that way it can help

build their self esteem, and encourage them to try the next task even if it is slightly harder. While

on the floor, patients are expected to follow the floors scheduled program, this is done so the

patients’ have some structured background and it gives them something to follow and keep track

of. This structure helps with self healing, due to being easy to follow, and it gives them

something to look forward to instead of worrying about what they have to do next. Structure also

gives patients a social and work related activity to help encourage their growth of interpersonal

skills, and for some like A.D. to work on their social anxiety and phobias. Group therapies also

helps some patients learn basic human mannerisms by subjecting them to the criticisms of peer

pressure. For example if you have a patient who talks over everyone because they don’t

understand about not being the center of attention, someone in the group will usually tell them to

stop. This helps them learn social cues involving others.

Analyze ethnic, spiritual, and cultural influences that impact the patient​:

Ethnicity: According to the textbook ​Essentials of Psychiatric Mental Health Nursing​,

“ethnically speaking caucasians are at a higher risk” for mental illnesses like depression and

suicidal ideations, and this impacts A.D. because she is a caucasian and is at a higher risk. She

stated that she really didn’t associate with any ethnical background that could impact her, but

even knowing her ethnic “identity or national origin does not reliably predict [their] beliefs and

attitudes.” (Egede). Ethnicity can play a role in how a patient gets treatment, or even whether or

not they feel comfortable searching for treatments at all. It can also play a part into what types of

treatments they will subject themselves to. All in all ethnicity can play a huge role in patients that
Psychiatric Mental Health Comprehensive Case Study

carry on the traditions of their ancestors, but for those who don’t like A.D. it may have no affect

on them.

Spirituality: The patient claimed to be of wiccian faith, which can be often play a part in her life.

Socialization, faith, family, and just overall her life can be impacted by her faith and it can lead

to her being more socially excluded. She plans to be more involved in a coven, but stated that

mostly she just plays with things like tarot cards. A.D. also stated that telling people that she is of

wiccian faith usually leads to them to place prejudices on her or stigmatize her and her beliefs.

The academic journal ​Spiritual Needs of Wiccan, Pagan, and Nature Spiritualists at End of Life

talked about how “many practitioners are hesitant to reveal any part of their spiritual beliefs

because of common misconceptions and prejudices regarding Paganism as a whole”.

Cultural: A.D. is of a Northern European American culture. Typically seen in this culture is less

emphasis being placed on the family, and how it works and more attention being focused on

technology. This type of culture is also seen with a decreasing number of adherence to any and

all religions. Efficiency and punctuality are traits most often valued amongst this culture.

Common characteristics that are noted in the culture of the United States can also be noted in

A.D’s behaviors, and have an impact whether it be large or small on her. These characteristics

being: individuality, perfectionism, direct communication, consumerism, and social challenges.

She like most Americans’ have a problem with individuality because she strives to be

independent and in control of her life, but with her history of sexual abuse she feels her life is

increasingly out of control, all the way to the point where she literally didn’t know where she
Psychiatric Mental Health Comprehensive Case Study

was going to live when she left the floor. She struggles with social challenging because of her

religion and how others view her for practicing it. Culturally she’s impacted by perfectionism

because she doesn’t fit society's view on how a girl of her age should act, look, think, or even

just be, and because of this it can lead to a whole lot of self doubt and consciousness. This can be

a very important part of where a lot of her social anxiety, and social phobia comes into.

Evaluate the patient outcomes related to care​:

1. Patient should be able to therapeutically talk about her past, and developing

healthy coping mechanisms by discharge.

2. Patient will not self harm, but rather have better ways to express her feelings such

as writing in journals and talking to reliable people.

3. Patient will be able to list and access three resources that she can reach out to for

help if she starts to feel, think, or act suicidally.

Summarize the plans for discharge​:

The discharge notes reported upon were that they had to contact her mother but the patient was

not ready for that contact yet. They addressed her having to eventually talk with her mother but

gave her time to delve into it. Apart than that discharge plans should include patient having

follow up care with a psychiatrist. The patient will need to have a stable place to live in, whether

it be with her mother or if we have to find her a place to go until she gets better. Other important

topics for this patient to be talked about is the National Suicide Prevention Hotline, along with

other places or people can reach out to. This would be given to her to hopefully give her

something to reach out to for help incase she starts to get more suicidal ideations and plans to kill

herself again. The biggest thing about this patient’s discharge is helping her to feel less
Psychiatric Mental Health Comprehensive Case Study

depressed, she should be placed on some antidepressant medications. When given these

medications they should warn her that she will get an increase in energy before getting feeling

better, and that puts her at an increased suicide risk.

Prioritized list of all actual diagnoses using individualized NANDA format​:

Due to this patient’s history of trauma, both self inflicted and acted upon her, along with her

mental state and behavior before being admitted to the floor, the treatment team assigned to her

case diagnosed with: depression, major recurrent, along with bipolar disorder with severe

depression. These diagnoses were given to this patient due to her history of past suicidal thoughts

and ideations along with history of suicidal attempts. It was also taken into consideration her

latest thoughts and feelings which were: an increase in depression, poor appetite, nausea, poor

sleep, and an increased feeling of hopelessness. Other considerations to these diagnoses were her

usage of cannabinoids, because a large majority of psychiatric patients self medicate with things

like cannabis and alcohol.

List of all potential nursing diagnoses​:

1. Risk for suicide related to depressed mood and feelings of hopelessness as evidenced by

patients claims of being depressed and history of attempted suicide.

2. Risk for self harm related to a history of previous self harm, as evidenced by cuts on

forearms.

3. Low self-esteem related to feelings of abandonment by mother as evidenced by being

kicked out of her house.

4. Hopelessness related to absence of support systems evidenced by decreased affect and

suicidal attempts.
Psychiatric Mental Health Comprehensive Case Study

5. Imbalanced nutrition: less than body requirements related to decreased appetite and

nausea, evidenced by not eating, and weight loss.

6. Impaired social interaction related to social phobia as evidenced by lack of eye contact,

and avoiding others.

7. Substance abuse related to ineffective coping mechanisms, as evidenced by positive drug

screen for cannabinoids.

Conclusion Paragraph​:

In conclusion, A.D. is a 19 year old female patient that was admitted to the unit on

September 11, 2019. She has been diagnosed and was being treated for depression, and bipolar

disorder. She had attempted suicide three days before admission. She attempted this suicide by

asphyxiation via helium, along with taking multiple unnamed over the counter drugs. This

attempt at suicide was precented by large fight with her mother where she was kicked out of the

house and had to sleep under a bridge. She believes at the time of care that she is homeless, but

after being released she hopes to reconcile with her mother and establish a better relationship

with her mother. This patient has a history of suicidal ideation, cutting, and she also reports and

increase in depression, poor appetite, nausea, poor sleeping, and increased feelings of

hopelessness. Before discharge we hope to establish a good sleeping schedule, return her

appetite, decrease her nausea, and decrease her feelings of depression and hopelessness. It is also

our hope that after being discharged she will have a more willingness to be involved in and

participate in social activities, so as to not isolate herself from society. After being discharged

from the floor, the hope is that she will have the capability and knowledge to reach out to

someone if her suicidal thoughts and ideations continue. A.D. has been started on a therapeutic
Psychiatric Mental Health Comprehensive Case Study

regimen on the floor that will provide some structure to her day to help her maintain control of

her days and it is her hope to be able to keep a similar structure once leaving the floor.
Psychiatric Mental Health Comprehensive Case Study

References:

1. Bipolar disorder. (2018, January 31). Retrieved from

https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-0

355955

2. Depression (major depressive disorder). (2018, February 3). Retrieved from

https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

3. Egede, L. E. (2006, June). Race, ethnicity, culture, and disparities in health care.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924616/

4. Smith-Stoner, M., & Cedarwind Young, R. N. (n.d.). Spiritual Needs of Wiccan, Pagan,

and Nature Spiritualists... : Journal of Hospice & Palliative Nursing. Retrieved from

https://journals.lww.com/jhpn/Abstract/2007/09000/Spiritual_Needs_of_Wiccan,_Pagan,

_and_Nature.15.aspx

5. Townsend, M. C., & Morgan, K. I. (2020). Essentials of psychiatric mental health

nursing: concepts of care in evidence-based practice (6th ed.). Philadelphia: F.A. Davis

Company.