Running Head: CASE STUDY

Mental Health Case Study

Emily Kelly

Youngstown State University

Abstract

The purpose of this paper is to take an in depth look at a psychiatric patient’s movement

through their hospitalization stay and understand the treatment plan that will be made for them to

help them get better. It will start with the factors or reasons that lead to the decision to come to

the hospital and get help. From there, the paper will discuss all medications, psychotherapy,

safety restrictions, nursing interventions, outcomes, and goals set for the patient and how they

progress though them. It will discuss the patient’s behavior and responses to new experiences

and if they have any new or potential diagnoses that may cause a change in their treatment plan.

Next it will discuss the patient’s diagnoses and signs and symptoms or behaviors commonly

seen. Next, it will take a look at the patient’s family history of mental illness, ethnicity,

spirituality, religion, and cultural influence that all contribute to the patient’s development

through life. Lastly the paper will evaluate patient outcomes to see if they were effective in

meeting goals and discuss the plans for discharge that would need to be set in place before the

patient leaves.
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Objective Data:

On October 7, 2019 a young male patient was brought to the Generations facility for an

evaluation to determine which type of treatment and care would be most beneficial. Prior to

arrival at Generations, the patient brought himself to the emergency room for help with ongoing

psychotic symptoms he had been experiencing. Upon admission to the unit, the patient stated that

at first he felt “nervous and anxious” about being in an unfamiliar place surrounded by so many

people. With time, he got comfortable with the staff and other patients which made his anxiety

level go down. The patient was diagnosed with Bipolar Disorder with psychotic features and also

Anxiety Disorder. In order to be diagnosed with Bipolar Disorder, you have to of had at least one

episode of mania and one episode of depression that disrupts the patient’s ability to function

during that time. For an anxiety diagnosis, you must be experiencing moderate to severe anxiety

symptoms that interfere with daily tasks and functioning. The patient has no other medical

conditions except seasonal allergies that he treats with over the counter allergy medication. On

the date of care, which was October 10, 2019, the patient appeared calm and relaxed. He sat

down for in interview and answered all questions asked with no hesitation or anxiety. The patient

talked about his progress made during their time there, how the medication treatment was

working, and all the support he received from staff and other patients that really made them

comfortable enough to open up.

The patient was put on several different psychiatric medications to help with the

symptoms he was experiencing. Divalproex sodium (Depakote) is an anticonvulsant that is

normally used to treat seizures. However, the same effect used to treat someone having a seizure

is same in someone experiencing mania which is part of Bipolar Disorder. The activity in the

brain is increased and the patient is restless and stimulated consistently. This medication reduces
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that activity in the brain making the patient calm and more relaxed. It is also considered a mood

stabilizer because it prevents the excitability of the nerve cells in the brain that would alter the

person’s mood and behaviors. The next medication is Gabapentin (Neuraptine), another

anticonvulsant, which reduces over stimulation of the nerve cells in the brain. It is helpful in

treating the symptoms of mania and anxiety. The last prescribed medication is an antipsychotic

class of medication called Paliperidone (Invega). This is a medication used to treat the psychotic

symptoms experienced when the patient loses touch with reality. They may include

hallucinations (visual, auditory, command, etc.) or delusions. These medications work by

altering neurotransmitters in the brain, especially dopamine.

Before arrival at Generations, the emergency room took blood to get lab values for the

patient. The results were sent over with the patient so the doctor and nurses could have more data

to use for their evaluation. Since the patient is on Depakote, it is important to especially monitor

the white blood cell count, platelet count, liver function tests, and valproic acid levels. Depakote

can cause neutropenia which puts the patient at risk to developing an infection because the levels

become so low. It also affects the platelet counts, which if to low, can lead to excessive bleeding

and longer clotting times. If enough blood is lost, it can alter oxygenation, red blood cells,

hematocrit, hemoglobin, and possibly lead to anemia. This medication is also hepatotoxic and

can damage the liver with long term usage. It is important to watch the liver function tests levels

to prevent the development of liver failure. Lastly Depakote, when chemically broken down, is

just valproic acid so it is important to make sure that level isn’t already increased. If it is too high

and we add more it will send that level sky high and become toxic to the patient. All of the

patient’s labs were within normal ranges, but their urine screening came back positive for THC.
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That is important to note because depending on what exactly the patient was smoking with the

THC it may cause hallucinations or other psychotic like symptoms.

Other treatment offered to the patient is the facility’s group therapy sessions that occurred

multiple times throughout the day. Each session is different but targets issues that the patient

might be experiencing or can relate to in some way. They offer advice, ways of dealing with

stressful situations, and a place where the patient can open up and talk without being judged. The

patient mentioned that they enjoy going to group because it gives them insight on how to handle

situations and gives them a sense of belonging.

It is important that during the patient’s time at the facility they and the other patients

remain safe at all times. The patient was put on certain restrictions and precautions to keep them

safe at all times. Unit restrictions and self-harm precautions for this patient must be maintained at

all times. For that reason the patient must be visualized every 15 minutes, he cannot have any

type of laces, belts, plastic, sheets, sharp objects or anything that could be used to harm himself.

At each medication pass it is important to make sure the patient swallows the pill so they do not

pocket them to use all at once later. The unit is locked, structured, and rules must be followed

without any variation. This is all in the patient’s best interest to keep them safe and other the

other patients and staff.

Summarize the Psychiatric Diagnosis:

The first disorder the patient was diagnosed with was Bipolar Disorder with psychotic

features. According to Townsend and Morgan, this disorder is characterized by “mood swings

from profound depression to extreme euphoria (mania), with intervening periods of normalcy.

Delusions or hallucinations may or may not be a part of the clinical picture” (2017). In this
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particular patient’s case, they do experience psychotic features which are the hallucinations and

delusions. Since this disorder has two different mood swings that affect the person, the behaviors

and common symptoms are different for both. In the depression phase the patient may have

feelings of guilt, worthlessness, helplessness. They may have trouble concentrating, loss of

interest in things once pleasurable, and thoughts of suicide. Their behavior changes to become

more fatigued, sleeping all day or insomnia, over/under eating, and irritability toward others.

They also have aches, pains, headaches, cramps, or digestive problems that will not get better

with treatment.

On the other end with mania it is very different. The mood is elevated, expansive, or

irritable causing impairment in normal functioning. The patient may experience a boost in energy

level, racing thoughts, talking fast, restlessness, distractibility, needing less sleep to feel rested,

risky behavior, and intense senses of smell and touch. Occupational functioning, social activities,

and relationships with others will be severely affected. Hospitalization might be required to

prevent the individual from harming themselves or others. Lastly, the psychotic features tend to

manifest during this stage.

The next disorder the patient was diagnosed with was Anxiety Disorder. Townsend and

Morgan define anxiety as “a feeling of discomfort, apprehension, or dread related to anticipation

of danger, the source of which is often unspecific or unknown. Anxiety is considered a disorder

when fears are excessive and there are associated behavioral disturbances such as interference

with social and occupational functioning” (2017). Although we all experience anxiety on a daily

basis, in this case, it is severe enough to impair normal function in all aspects. Some people may

experience lack of concentration, racing thoughts, excessive worry, feelings of impending doom,
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insomnia, nausea, diarrhea, palpitations, sweating, restlessness, agitation, or trembling.

Hospitalization may be required if coping techniques fail.

Identify the Stressors and Behaviors:

The patient stated he has always suffered from depression since he was 13 years old. As

time went on, the patient developed anxiety that was so bad he would not leave the house for

days at a time and quite going to school. If the patient did leave, he always felt paranoid that

other people were talking about him. Next the patient described the hallucinations he experiences

on a daily basis. The patient has auditory and command hallucinations that tell him to hurt

himself or do other “bad things”. The patient also has visual hallucinations, especially at night, of

people and shadow figures standing in the corners of rooms or at the end of the bed. With all of

these manifestations the patient was on multiple medications to try and stop these symptoms, but

none of them were working. At that point the patient started to develop suicidal ideation because

he couldn’t take it anymore. Instead of acting on any thoughts, the patient went to the emergency

room to get help because he still has hope that he can get better. At the hospital, the medications

were changed up and the patient said they feel a lot better and that they believe the medications

are working.

Discuss Patient and Family History of Mental Illness:

The patient has history of mental illness that runs in his family. His maternal aunt and

paternal grandfather both suffered from Bipolar Disorder. Also, the patient believes his

biological father suffers from Bipolar Disorder and Major Depressive Disorder but this has not

been confirmed by physicians. There has been much research in mental illness being passed on

through genetics of families. One such study states that “Findings from such studies have shown
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that the majority of the rare variants identified are private to a family indicating the underlying

heterogeneity in the genetic architecture of severe mental illness. Multiplex families may provide

valuable insights into the genetic correlates of these syndromes when tested using high through-

put sequencing” (Ganesh et al., 2019). Since the patient has a family history of mental illness,

this put him at a greater risk for developing the disorders he already presents with now. If the

patient were to have any children, they would have a predisposition to developing a mental

disorder throughout their life.

Describe the Psychiatric Evidence Based Nursing Care provided:

Alongside the medication therapy, the patient will also have group therapies to attend to

help teach them skills to use and incorporate throughout life. This education is important because

in some cases, the people may not have been taught these skills and therefore they cannot cope

well during stressful times. Group therapies may teach patients healthy ways to cope with stress,

how to form and maintain healthy relationships, long term consequences of substance usage,

socialization, and offer outside resources available to them if they need a place to turn to for

help. Generations offers several types of these groups that the patient can attend as part of their

treatment plan. The patient stated that at first the group therapies gave him anxiety, but now he

enjoys going because it gives him a feeling of belonging and hope that he will get better.

Milieu therapy is another type of therapy used and it controls or manipulates the patient’s

environment with a view to preventing self-destructive behavior. For this reason, each patient is

put on individual precautions based on their diagnosis and symptoms. In this patient’s cases, he

was put on self-harm precautions because of the suicidal ideation and general unit precautions
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that every other patient is also on the facility. No shoe laces, bed sheets, plastic bags, or sharp

objects on the floor are just a few examples of precautions taken. Instead they unit is locked,

furniture is weighted down, only markers or crayons are available, medication passes are closely

observed, and activity is structured and monitored constantly. This is necessary in order to keep

the patient, others, and faculty safe at all times.

Analyze Ethnic, Spiritual, and Cultural Influences:

The patient is a young, white, Caucasian male who lives with his mother, step father, and

younger siblings. He claims that he used to stay in touch with his biological father, but his father

started taking “hardcore drugs” again, has been in and out of jail, and was either high or drunk

every time he would go over to visit. His father has a history of violence toward others and it

stressed him out every time he went to see him. At that point the patient decided it would in his

best interest to stay away from his father because his symptoms would increase due to the stress.

He states that he would like to have a relationship with his father but it is just not healthy for him

to do so at this point. The patient has a good relationship with his mother and siblings but not

with his stepfather. His stepfather doesn’t believe he actually is suffering from mental illness, but

instead thinks he is just “lazy” and uses it as an excuse for attention. For that reason, the patient

has a lot of resentment built up towards him and it forms a lot of stress in the family. The patient

also did not graduate high school and doesn’t have a job because of his mental disorders.

Due to all the stress and dysfunction experienced by the patient during his adolescence

years, that may have caused the symptoms to start showing. Sakurai and Gamo state that

“adolescence to early adulthood is also the time period in which many neuropsychiatric disorders

emerge. In particular, psychosis, a typical manifestation of schizophrenia, appears during this

period, representing a loss of mental connection with the real world” (2019). The patient is in the
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common age range and already experiencing psychotic manifestations that could indicate a

possible early onset of schizophrenia. It is important to identify these early symptoms and

provide treatment that targets the prevention of progression of the disorder.

The patient doesn’t have any formal religion or set of beliefs he follows, but instead talks

about how he has hope. When he started to develop suicidal ideation, that was when he knew he

needed to get help or he would end up attempting suicide. He expressed that he still had hope

that things would get better and decided to go to the emergency room that night. People do not

have to have a set formal religion they follow, but just need something they believe in that gives

them a sense of purpose in life and something to keep them going. A lot of people with mental

illness tend to have the manifestation of helplessness and hopelessness that things will not get

better. In a recent study about the relationship between mental illness and

religiousness/spirituality, Braam and Koenig stated that “based on identification of 152

prospective studies, the current review found that about half of these reported a significant

association between measures of religiousness/spirituality and a better course of depressive

symptoms/depression over time” (2019). Since there is a positive relationship between

depressive symptoms and spirituality/religiousness, it is important to educate patients with

mental illness about these topics and install hope into them.

Evaluate the Patient Outcomes:

It is important to monitor the patient’s progress during their time there to see if they are

meeting the set outcomes to achieve goals. They may need to be changed at times if the patient

cannot meet a certain standard to one they can meet. This is done through evaluation when you

look back and see if the interventions are working or if they need to be altered. In our patient’s

case, he was doing very well with his treatment and nursing interventions. He went to group
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often, socialized with other patients, and expressed how he had a decrease in anxiety and

psychotic symptoms since being on the medication. At this point the patient knew they would be

getting discharged soon and started to develop a plan for the future when he would be out in the

world again.

Summarize the Plans for Discharge:

Before the patient is actually discharged and leaves the facility, there is a lot of planning

and education that needs to be provided for the patient and family so they can continue their

treatment plan. Since the patient will not be surrounded by nurses, doctors, and counselors at all

times, it is important that they get set up with a team of healthcare providers in their area so the

therapy and evaluation of progress can continue. Also the patient will need to be set up with a

local pharmacy to get their prescription medication refilled. By having a local doctor and going

to each checkup, the patient can express any concerns or worries to the doctor regarding their

symptoms, medication side effects, or any other issue in their ongoing therapy. The doctor can

then change or modify the plan of care as needed to keep the patient compliant. Education about

side effects of medication, importance of compliance to regimen, effects of abruptly stopping the

medications, and when to call the doctor are all very important for the patient and family to

understand before they leave. The patient can also be referred to group therapies taking place

close to where they live so they can continue learning psychotherapy techniques to help with any

impairment in function or times of stress when they are feeling low. This is all important because

if the patient continues on this plan of care they will live and maintain a level of normalcy in

their lives. If they choose to not comply with the plan of care or medication therapy, they will

end up back where they started in the hospital.

Prioritized List of all Actual Diagnoses:

1. Anxiety related to situational and maturational crisis as evidenced by restlessness,

feelings of discomfort, apprehension, helplessness, delusions, hyperactivity, and

pacing.

2. Ineffective Individual Coping related to ineffective problem solving strategies/skills

as evidenced by destructive behaviors toward self, inability to problem solve, and

change in normal communication pattern.

3. Social Isolation related to panic level anxiety as evidenced by withdrawn, no eye

contact, insecurity in public, and expression of feelings of rejection.

4. Interrupted Family Processes related to erratic and out of control behavior by family

member with potential for dangerous behavior affecting all family members as

evidenced by inability to deal with traumatic or crisis experienced constructively.

5. Powerlessness related to fear of disapproval of others as evidenced by verbal

expression of having no control and dependence on others that may result in

irritability, resentment, anger, and/or guilt.

List of Potential Nursing Diagnoses:

1. Risk for Suicidal Ideation related to psychotic illness (Bipolar Disorder).

2. Risk for Violence: self-directed or other directed related to psychotic

symptomatology.

3. Risk for Injury related to extreme hyperactivity/physical agitation.

4. Risk for Imbalanced Nutrition related to insufficient dietary intake to meet

metabolic needs for psychiatric illness.

5. Risk for Insomnia related to anxiety and psychotic manifestations.

Conclusion:

There is an extensive amount of care and information to gather and consider when a

patient is first admitted to the hospital. Psychiatric diagnoses and symptoms are trickier to treat

than a physiologic one because some patients often do not think they have any problems and it’s

the world around them who has the issue. Getting them to see and understand their disorders is

the first step so they will be compliant to get help. Also, with mental disorders, the treatment

regimen is often a lifelong commitment with medication and psychotherapy to keep them stable.

Most will not comply with this and will end up back in the hospital for the same reasons they

entered beforehand. In our patient’s case, he understood that what he was feeling and

experiencing was not normal and knew it would not go away with time, but instead get worse.

He made the decision to get help and understands the importance of compliance to maintain a

happy and healthy life.

References

Braam, A. W., & Koenig, H. G. (2019). Religion, spirituality and depression in prospective

studies: A systematic review. Journal of Affective Disorders, 257, 428–438. doi:

10.1016/j.jad.2019.06.063

Ganesh, S., Ahmed P, H., Nadella, R. K., More, R. P., Seshadri, M., Viswanath, B., …

Mukherjee, O. (2019). Exome sequencing in families with severe mental illness identifies

novel and rare variants in genes implicated in Mendelian neuropsychiatric syndromes.

Psychiatry And Clinical Neurosciences, 73(1), 11–19. https://doi.org/10.1111/pcn.12788

Sakurai, T., & Gamo, N. J. (2019). Cognitive functions associated with developing prefrontal

cortex during adolescence and developmental neuropsychiatric disorders. Neurobiology

of Disease, 131, 104322. doi: 10.1016/j.nbd.2018.11.007

Townsend, M. C., & Morgan, K. I. (2017). Essentials of psychiatric mental health nursing:

concepts of care in evidence-based practice (7th ed.). Philadelphia, PA: F.A. Davis

Company.
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