Running head: PSYCHIATRIC COMPREHENSIVE CASE STUDY

Psychiatric Comprehensive Case Study

Natalee Bommer
Youngstown State University

NURS 4842/L: Mental Health Nursing

Mrs. Teresa Peck
April 6th, 2016

PSYCHIATRIC COMPREHENSIVE CASE STUDY

Abstract
This case study outlines the objective and subjective history of a psychiatric patient
affected by severe major depressive disorder. Within this study is a discussion of police holds,
the link between thyroid dysfunction and depression symptoms, and how having multiple
precipitating stressors contributes to suicidal ideation. It outlines the objective data of this patient
with her psychiatric diagnosis, observed behaviors, medical conditions, and safety measures
maintained. Her diagnoses are summarized in this case study and appropriate nursing
interventions are described. The patient's precipitating stressors for current hospitalization and
family history are discussed. Any ethnic, spiritual, or cultural influences are discussed as well as
her plans for discharge. In addition, the patients actual and potential nursing diagnoses are listed
along with outcomes related to her care.

PSYCHIATRIC COMPREHENSIVE CASE STUDY

Objective Data:
During this clinical, I was assigned to communicate with and provide care for a forty year
old female who was admitted on March 18th, 2016. The date of care that I provided was March
23rd, 2016. Her psychiatric diagnosis, according to her psychiatric physician using the multi-axial
system of the Diagnostic and Statistical Manual of Mental Disorders IV: Text Revised (DSM-IVTR), was: Axis I - severe major depressive disorder with suicidal ideation and anxiety, Axis II
deferred, Axis III diabetes mellitus type II, hypertension, hypothyroidism, glaucoma, acute
renal failure, obesity, and polycystic ovarian syndrome, Axis IV the severity of stressors is
severe, Axis V patient's current global assessment of functioning is 21-30, which is poor.
On admission, the patient exhibited a calm but depressed demeanor and affect, stating the
many personal precipitating factors leading up to the day of her admission and her diagnosis. She
was admitted with a police hold because of her police referral for attempted self-harm. Police are
a major source of psychiatric referrals in Mahoning county and around the world. People referred
by police have been shown to have lower rates of serious mental illnesses while having higher
rates of behavioral problems. Suicidality, such as in this patient, remains the second most
common reason for police referrals (Maharaj, et. al., p. 205-212). In addition, on admission, the
patient's glucose, at 183 mg/dL, and level of thyroid-stimulating hormone, at 6.880 IU/mL, were
elevated while her T4 levels, at 8.0 mcg/dL, were within normal range. In multiple studies,
hypothyroidism has been linked to depressive symptoms, explaining a need to list thyroid
hormone levels for a psychiatric patient. It is thought that a dysfunction in the conversion of T4
to T3 can be a cause of major depression or depression symptoms (Kamble, et al., 2013, p. 1114). Her entire complete blood count panel was within normal limits and her toxicology panel

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was negative for all illicit substances.

On the day of care, the patient continued to speak and act in a calm manner, with a fixed
if not depressed affect, poor eye contact, slouching posture and slow, shuffling gait. Her nonpsychiatric diagnoses, as listed above, were: diabetes mellitus type II, hypertension,
hypothyroidism, glaucoma, acute renal failure, obesity, and polycystic ovarian syndrome. For her
diabetes mellitus she received blood sugar checks before meals and at bedtime, and as
prescribed, as needed, a sliding scale dose of insulin lispro before meals, and a low carbohydrate
meal. Her blood glucose level was 253 mg/dL before eating her dinner meal so lispro was
administered by the attending medication nurse. Her hypertension was managed with a low
carbohydrate, low sodium diet and metoprolol administered twice daily. Her hypothyroidism was
managed with a once daily dose of levothyroxine. Her glaucoma was managed with a dose of
timolol to be given twice daily with one drop into each eye. The patient's acute renal failure was
diagnosed upon admission and any treatments or medications to be given for that diagnosis were
to be announced by her family practice physician. Her diagnosis of obesity was addressed by her
physician with treatments including exercise and a low calorie diet as tolerated. Finally, her
diagnosis of polycystic ovarian syndrome was managed with a once daily dose of oral
contraceptive.
Safety was maintained by reducing the risk of self harm and harm against others on the
unit. These nursing safety interventions include: doing a visual check on all patients on the unit
every fifteen minutes, utilizing installed suicide-prevention alarms installed on the top of every
door of the unit, using polished metal mirrors instead of breakable glass, psychiatric beds that
resist breaking, locked doors to block off high risk areas such as the medication room, removing

PSYCHIATRIC COMPREHENSIVE CASE STUDY

all potentially dangerous items from all patients and their rooms, not entering patient rooms
unless absolutely necessary, putting oneself between a patient and an exit, and other precautions.
A major safety intervention utilized that is characteristic of any psychiatric lock-down unit is
blocking off all entrances to the unit with locked doors that only open after a call and verification
is made from the nurses' station. This prevents escape of a potentially dangerous patient to other
parts of the hospital or outside of the hospital into town, which would put many people in
jeopardy.
Prescribed psychiatric medications for this patient include alprazolam 0.5 mg, a
benzodiazepine, to be administered by mouth, as needed, every six hours for anxiety, and
citalopram 40 mg, an antidepressant, to be administered by mouth every day for depression.
Summary of Psychiatric Diagnoses:
The patient's main psychiatric diagnosis was severe major depressive disorder. According
to Townsend (2006), a depressed mood and loss of interest in both everyday and pleasurable
activities encompasses what it means to have major depressive disorder. It is diagnosed after a
patient displays at least a two week period lack of social and occupational functioning without a
history of manic behavior. This diagnosis cannot be associated with a diagnosed medical
condition or use of substances. In addition, major depressive disorder can be either characterized
by a single episode or as a recurrent condition. As the patient has not been hospitalized before
and this is her first documented incident of major depressive disorder, her condition would be
described as a single episode. If classifying the patient's major depressive disorder as mild,
moderate, or severe, her degree of severity would be severe. As one must meet the diagnostic
criteria for their diagnosis, in which a patient must meet five criteria among a list in the DSM-IV-

PSYCHIATRIC COMPREHENSIVE CASE STUDY

TR, the patient's symptoms that allowed her to be diagnosed with major depressive disorder
include: depressed mood most of the day, nearly every day; markedly diminished interest or
pleasure in most activities of the day; fatigue nearly every day; feelings of worthlessness or
excessive guilt; and diminished ability to think or concentrate (a subjective account or as
observed by others). (Townsend, 2006, p. 461-462) Expected behaviors by the patient in order to
observe an improvement in her condition include: that the patient will maintain her safety and
the safety of others both on the unit and upon returning home, see her psychiatric physician on
regular visits, attend group therapy while on the unit and as prescribed upon returning home, and
taking her psychiatric medications as prescribed.
Identification of Precipitating Stressors:
This particular patient had a plethora of precipitating stressors leading up to her eventual
admission to the unit. The patient stated that she has had three major family deaths in the last five
months, her father dying five months prior, her aunt dying four months prior, and another family
family that was important to her dying about two months prior to her admission. Before
admission she was trying to provide care to her ailing grandmother, her husband, and her son, all
within her own home. Her maternal grandmother was bedridden and affected by an unspecified
mental illness of her own, her husband is in the final stages of congestive heart failure, and her
son was living at home at the same time. She stayed at home and provided meals and care with
activities of daily living for all three of her dependent house mates.
Over the last several weeks, a neighbor of the patient complained to a local health
inspector over an abundance of trash lying around the exterior of the patient's home. Upon
inspection, the patient's home was found to be in deplorable condition, therefore, child protective

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services were called and the patient's son was relocated to the home of the patient's mother, who
she is in a good relationship with, upon exploring the issue with the patient. Visitation
restrictions were placed upon the patient from visiting her son for a small period of time. The
patient's home is in risk of becoming condemned unless the patient cleans up the area within a
specific time frame. In addition, upon admission to the emergency room, and subsequently, the
floor, the patient was diagnosed with acute renal failure. The patient expressed marked concern
over this, as she is now worried of not being able to care for her family if she becomes more ill
or dies because of her renal failure. These precipitating factors, stated by the patient during our
conversation, were verified by comparing her testament with the charting of previous healthcare
providers.
Finally, on the day of admission, while fighting with her husband, she held a knife to her
wrist in front of him, prompting him to call 911. The patient stated to me that I had enough and
that was the only thing I could think to do. I don't think I would have actually hurt myself but I'm
still not sure. He called for an ambulance but a police officer was sent instead because the
dispatcher thought I [the patient] was trying to attack others with the knife.
Suicide is the fourth leading cause of death among women between the ages of 15 and 44
in the United States. Women have lower mortality rates from suicide attempts than men, but
fatality rates have only increased in recent years. Although suicide is often linked to depression
overall, it is caused by many precipitating factors. The most frequently cited causes of suicide or
attempt of suicide, from greatest to least cited, are: having a current mental health problem,
having ever been treated for a mental health issue, and current depressed mood. Of women
between ages 15-44 who have committed suicide among a given population, 80 percent were

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currently receiving mental health treatment and 37 percent had a history of suicide. Other
precipitating factors, from greatest to least common, include: physical health problems, problems
with a family member, friend, or associate, financial problems, death of a friend or family
member, recent criminal legal problem, and other legal problems. (Ortega & Karch, 2010, p. 5-7)
The patient that which this case study is referring to had many of the listed precipitating
factors linked to suicidal attempt, completion, or ideation.
Discussion of Patient and Family History:
The patient stated that her grandmother and a few of her cousins have been affected by
mental illness in the past, mostly depression. She would not elaborate to me about the nature of
her grandmother's psychiatric issues. She stated that her mother was not affected by the same
illness. The patient verbalized that she has been overweight for most her life, and her comorbidities are quite familiar to her at this point in her life. She repeatedly said things about how
she knows that she's fat and that you can't get like this from eating healthy. She also stated
multiple times that I don't care what people think of my appearance. She did not express
concern on the date of care over starting a physical fitness plan, however, she did avoid parts of
her meal that might raise her glycemic index.
During our conversation, the patient did state that she has experienced abuse from her
father long ago during her childhood. She refused to elaborate about the abuse to me specifically
but stated that she has been trying to work through those issues while staying here [on the
unit].
Evidence-Based Care Provided:

PSYCHIATRIC COMPREHENSIVE CASE STUDY

On my evening spent on the unit, the patient seemed very involved in attending group
sessions and watching television with the other patients. She frequently shuffled back and forth
from her room and took a shower during the time that I was looking at her computer-based chart.
She seemed to have developed a good rapport with some of the other patients, sitting with them
in group and talking with them often. She is involved in her care, asked questions to the nurses
during medication administration times, and attends all groups possible. On the date of care,
according to the patient, she was started on a new medication and said that she just woke up
at about 3'o'clock p.m. She said she slept 12 hours last night and went back to bed at 10 a.m. The
patient said that this is why she did not attend earlier groups.
Evidence-based nursing care provided included: assessing her objective data and
behaviors, using therapeutic communication with all interactions, and creating a safe
environment for the patient. All potentially harmful items were removed from the patient's
access, the patient was visually observed at least every 15 minutes, and the patient was
monitored after administration of her medications to make sure they were taken correctly. During
our interactions I frequently encouraged the patient to express her feelings concerns about her
stressors, condition and care. I encouraged the patient to participate in her activities of daily
living and therapy groups. Although, as a student, my nursing care is limited on the unit, I
provided as much care as possible through the use of therapeutic communication with the
patient.
Analyzation of Ethnic, Spiritual and Cultural Influences:
According to the patient, her family was not focused much on ethnic traditions or
practices other than going to church when she was growing up. The patient stated that she is

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mostly African American and partly Caucasian. She stated that she is a Christian and used to
attend church, but she does not any longer. She said she believes in God but not in going to
church. She stated that she has no interest in talking to a chaplain or religious counselor during
her hospital stay and she had no spiritual considerations that she wanted met during her stay.
Evaluation of Patient Outcomes:
The patient's main two main problems listed in her chart were depressive behavior with
or without suicide precautions and altered mood, depressive disorder. These two problems
had the same goals listed for each. Some of the goals for these problems and outcomes listed
include the short terms goals of: patient able to verbalize suicidal ideations during my shift,
which was an ongoing goal; absence of self harm during my shift, which was met during my
shift; and patient able to verbalize support system,which was met during my shift as the patient
reported minimal supports as her husband requires assist and she usually has a minor son at
home. Long term goals include that the patient will be able to verbalize acceptance of life and
situations over which she has no control, which was an ongoing goal and patient will be able to
verbalize and/or display a decrease on depressive symptoms, which was also ongoing.
Summary of Discharge Plans:
The patient verbalized that her main discharge plan is to return home, take her
medications as prescribed, and go to regular visits with her physicians. She also stated the
importance of going home to continue cleaning her house so that her son can resume living with
the family. Upon discharge she was to follow up with and attend visits to her psychiatric
physician with Turning Point Outpatient Rehabilitation Center. She was also expected to take her
medications as prescribed. She has an upcoming court hearing in order to get her son back into

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her custody. During my evening on the floor, the patient told me that her physician advised her to
stay on the unit for one more entire day then could be discharged the next day.
Prioritized List NANDA Diagnoses:
1. Caregiver role strain r/t difficulty completing required tasks a.e.b. son taken away by
child protective services and health inspector called for patient home condition.
2. Anxiety r/t situational crises a.e.b. son taken by child protective services and
verbalization of concerns.
3. Ineffective coping r/t inadequate social support created by characteristics of relationships
a.e.b. patient providing care for ailing husband, son living at home as a minor and
decreased use of social support.
4. Anxiety r/t change in health status a.e.b. new diagnosis of acute kidney failure and
verbalization of concerns.
5. Risk for suicide r/t impulsiveness and threats of killing oneself a.e.b. threat with knife to
cut wrists at home.
Potential Nursing Diagnoses:

Disturbed body image r/t overweight physical condition a.e.b. behaviors of

acknowledgement of one's body and patient reports perceptions that reflect an altered
view of one's body in appearance.

Ineffective coping r/t inadequate level of perception of control a.e.b. inability to meet role
expectations, inadequate problem solving, and destructive behavior toward self.

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Dysfunctional family processes r/t inadequate coping skills a.e.b. escalating conflict,
inappropriate expression of anger, and inconsistent parenting.

Impaired home maintenance r/t inadequate support systems a.e.b. taking care of three
dependent individuals in own home and unclean surroundings in the home.

Hopelessness r/t long-term stress a.e.b. caring for three dependent individuals in own
home with inadequate support systems, recent family deaths, health deterioration,
decreased affect, decreased appetite, sleep pattern disturbance.

Impaired parenting r/t lack of resources and social support networks a.e.b. inadequate
child health maintenance and unsafe home environment.

Ineffective role performance r/t lack of resources and stress a.e.b. depression, inadequate
external support for role enactment, ineffective coping, and role strain.

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References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to
planning care (10th ed.). Maryland Heights, MO: Elsevier.
Kamble, M. T., Nandedkar, P. D., Dharme, P. V., L., L. S., & Bhosale, P. G. (2013). Thyroid
function and mental disorders: An insight into the complex interaction. Journal Of
Clinical And Diagnostic Research, 7(1), 11-14.
Maharaj, R., Gillies, D., Andrew, S., & O'brien, L. (2011). Characteristics of patients referred by
police to a psychiatric hospital. Journal of Psychiatric and Mental Health Nursing, 18(3),
205-212.
Ortega, L. A., & Karch, D. (2010). Precipitating Circumstances of Suicide among Women of
Reproductive Age in 16 U.S. States, 20032007. Journal of Women's Health, 19(1), 5-7.
Townsend, M. C. (2006). Psychiatric mental health nursing: Concepts of care in evidence-based
practice (8th ed.). Philadelphia: F.A. Davis.