Running head: MENTAL HEALTH CASE STUDY 1

Mental Health Case Study

Jasmine Crook

Youngstown State University

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Abstract

This case study will obtain both subjective and objective data observed and stated by the

patient during her interview. Also this study will discuss the patient’s psychiatric diagnosis and

expected behaviors for this diagnosis. Identification of the stressors and behaviors that

hospitalized the patient will also be discussed. Evaluation of the patient’s family history of

mental illness and analysis of the patient’s ethnic, spiritual, and cultural background will be

assessed during the conversation. Lastly, the plans for discharge will be summarized and a list of

nursing diagnoses and potential nursing diagnoses will be discussed for this specific patient.
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P.L is a 52 year old female who was involuntary admitted to the psychiatric unit at St.

Elizabeth’s Hospital in Youngstown on February 14th, 2018. The date of care for this patient was

February 15th, 2018. P.L was staying at the Serenity House in Youngstown for her addiction to

pain pills before being admitted to the hospital. While staying at the Serenity House the patient

called EMS and stated that she had fluid coming out of her ears and feet. EMS then brought the

patient to St. Elizabeth’s Hospital by ambulance to the emergency room. She stated in the

emergency room “I knew I couldn’t take another night at the house there is stuff coming out of

my ears”. She also presented with flight of ideas and racing thoughts while in the emergency

room. The patient kept talking about black/yellow fluid coming out of her ears and then

ruminating about parasites in her ear. The patient was then pink slipped and involuntary admitted

into the psychiatric unit.

P. L was admitted to the unit with the following psychiatric diagnosis: severe manic

bipolar 1 disorder with psychotic features. The psychiatric diagnosis for this patient according to

the DSM IV-TR are as follows: Axis I-mood disorders, Axis II-none, Axis III-PTSD, substance

abuse, depression, Axis IV-problems with a primary support group, housing problems, death of

husband, and patient is on disability, Axis V- not listed. According to the American Psychiatric

Association “Bipolar disorders are brain disorders that cause changes in a person’s mood, energy

and ability to function” the article goes on about the specifics on bipolar 1 disorder stating

“Bipolar I disorder can cause dramatic mood swings. During a manic episode, people with

bipolar I disorder may feel high and on top of the world, or uncomfortably irritable and “revved

up”. During a depressive episode they may feel sad and hopeless. There are often periods of
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normal moods in between these episodes. Bipolar I disorder is diagnosed when a person has a

manic episode”. Barekatain, Khodadadi, and Maracy’s (2011) study found the following:

“Although there are many options for effective treatment of mania and depressive

episodes of Bipolar I Disorder (BID), persistence of some symptoms, increased incidence

of serious medical diseases, elevated risk of suicide, and significant decrease in

psychosocial functioning has been reported during periods of remission in BID patients.

After remission of a depressive or manic episode, most of patients spend about 50% of

the following time with mood symptoms. Further to residual mood symptoms, they

frequently experience persistence of cognitive problems. This phenomenon results in

more decrease in quality of life despite remission of acute episodes. Multiple studies

showed that “one-year relapse rates have ranged from 28 to 44% and enduring

psychosocial impairment despite symptomatic recovery has been described in a

substantial number of patients. Because of this high level of psychosocial impairment,

BID is considered as the sixth leading cause of disability worldwide”

P.L presented to the emergency room with a manic episode. The patient has an extensive

psychiatric history with multiple involuntary stays starting in 2011 and numerous visits in

between and up until current admission.

On the day of care the patient’s facial expression was fixed or immobile and she had a

sad or depressed affect. The patient sat in the chair next to me slouched with a blanket wrapped

around her and she seemed a little tense to be speaking with me. Her appearance on the day of

care was unkempt and careless. P.L appeared to of not brushed her hair and her hair looked
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greasy. The patient also had multiple teeth missing. The patient also seemed very restless. She

showed no signs of akathisia, akinesia, tardive dyskinesia, or acute dystonic reaction.

The patient was friendly on the day of care but her emotion/feelings seemed to have an

unpleasant affect such as: depression and anxiety. The patient was open to discussing her

hospitalization and her past and also the reasons why she was hospitalized in the past. When

asked, “tell me what your mood has been like lately?” she stated “bad”. When asked “Are your

moods more or less emotional than usual?” the patient stated “I have been feeling more

depressed lately”. P.L on the day of care had flight of ideas and was rapidly speaking and would

change the subject from one to another. She presented with perseveration or the repetition of the

same word in reply to different comments or questions. P.L also had a disturbance in her thought

process. She had preoccupation or obsession with parasites and fluid in her ears. She also had

poorly organized thoughts but was oriented with her memory. On admission and on the day of

care the patient continued to deny that she was having any hallucinations. But after speaking

with the patient for a little awhile it was quite obvious that she was having visual and tactile

hallucinations. As I was wrapping up the conversation with the patient I noticed that she had

multiple scratch marks and her digging at her arms. When I asked the patient about her digging

she stated that she had multiple scabies infections and was paranoid about bugs crawling under

her skin. As far as her judgement the patient had poor insight and was illogical.

P.L has multiple medical diagnoses such as chronic lower back pain, vertigo, depression,

PTSD, scabies, and substance abuse. The patient stated that her lower back pain started in 2011

when someone “curb stomped her”. She then went on to say that since the incident she has

abused pain medication for her ongoing back pain. Before being admitted to the hospital the

patient stated she was using suboxone as treatment for her chronic lower back pain and her
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addiction to pain pills. Some of the other medications the patient is taking are as follows:

buprenophrine (Suboxone) 2 mg 1 tablet orally twice a day for opioid withdrawal, vortloxetine

(Trintellix) 5 mg orally once daily for depression, lorazepam (Ativan) 1 mg three times a day by

mouth for anxiety, lisdexamfetamine dimesylate (Vyvanse) 40 mg once a day by mouth for

manic bipolar episodes, and aripiprazole (Abilify) 5 mg twice a day by mouth for her bipolar

disorder. She also has a history of assault and physical abuse/verbal abuse. On admission the

patient denied any thoughts of suicidal ideation/homicidal ideation. When the patient was

admitted in the emergency room they did blood work for lab values and also a drug screen

because of the patients history. The patient was positive for cannabinoid and her lymphocyte

count was also elevated at 48.8, which could be indicative of an infection.

Some of the stressors that precipitated the patient’s hospitalization were her obsessions

with the fluid and the parasites in her ears. She stated in the emergency room that “scabies are

eating her bones and brains” and states that “fluid and sand are coming out of my right ear and

the top of my head” and she reports seeing things coming out of the wall and states “can’t do

anything because the discharge gets everywhere and contaminates everything”. The patient has

recurring thoughts about parasites being under her skin and fluid being in her ears. The patient

said that the parasites and fluid started when a storm hit a couple of months ago and water was

leaking through the roof and she claimed that black mold was throughout the home. She then

said shortly after she discovered black mold and she noticed that there were parasites in the

dishwasher, bathtub and throughout the walls in her home. P.L has since been obsessed with the

thought of parasites and infections in her ears. The patient also stated that she struggles with the

fact that her husband is deceased. P.L did not have a good relationship with her in-laws and feels

that her mother-in-law had something to do with death of her husband. She went on to tell me
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that her husband’s death was thought to be a suicide. She then proceeded telling me that her

husband’s uncle had raped him since he was a baby and he also raped her two children. P.L said

her two children do not speak to her and the patient lacks a support system. P.L was living with a

roommate in an apartment before being hospitalized and he fell ill unexpectedly and passed

away. The patient stated she is still mourning his death and since his passing the patient now has

no place to live. This is something that she struggles with deeply.

When discussing the patient and her family history of mental illness she stated that

mental illness did not run in her family. However, substance abuse runs in her family. The

patient’s deceased husband and herself both suffer/suffered from substance abuse issues. The

patient did not talk much about her parents other than to say that they were over protective and

sheltered her throughout her life. She stated that from her parents being over protective she

struggled once she was out on her own on how to make good choices for herself.

Another important issue when dealing with psychiatric patients is safety. Since patient

safety is top priority for the nurses and staff on the unit, many steps are taken to ensure patient

safety at all times. Psychiatric nursing care is a multidisciplinary team approach and everyone

works together to provide this safety and individualized care for each patient. Patients are cavity

searched and their belongings are taken and gone through when they are admitted onto the unit.

While this can be very intrusive to the patients, it is for their best interest and safety. Some of

these safety precautions include safety checks on each patient every fifteen minutes, anti-ligature

doors, giving patients prescribed medications, enclosing the nurse’s station, mirrors in patients

rooms that are made of steel to prevent breaking which could lead to self-harm, beds that are low

to the ground and don’t move, trash cans in the rooms that have brown paper bags in them

instead of plastic bags to prevent suffocation, windows that don’t open or break, and
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checking/removing anything off the patients that could cause potential harm to themselves or

others on the unit.

On the psychiatric inpatient unit, there is a milieu environment being promoted.

The goal is for the milieu to be therapeutic. Patients on the floor are encouraged to learn adaptive

coping techniques, socialize with others, and communicate with staff in a positive manner. The

therapeutic milieu environment is achieved through group therapy, one-on-one physician

meetings, and counseling/therapy sessions with social workers and nurses. The colors on the

walls and floors are of light colors making a bright environment for patients. To keep the patients

oriented to the time and day there is also a whiteboard that lists daily activities and the date and

day of the week. Patients also have access to exercise equipment to burn off some steam and

frustrations.

When speaking to the patient she unfortunately did not discuss into detail any ethnic,

spiritual or cultural influences. The patient is a Caucasian female who belongs to a lower

socioeconomic class. The patient is on disability due to chronic lower back pain and is currently

faced with being homeless. She did state she practices Christianity but does not attend church on

a regular basis.

Each patient on the unit has individualized care plans and patient outcomes. These

outcomes are set to not only protect the patient but to also help set goal oriented outcomes.

According to Culpepper (2014) “Early, accurate diagnosis can substantially reduce the burden of

bipolar disorder and improve the long-term outcome for patients”. The following outcomes were

set for a patient specifically diagnosed with severe manic bipolar 1 disorder with psychotic

features. The patient will be free of self-inflicted injury. The patient will participate in impulse

control training. Patient will practice alternative coping skill mechanisms. Patient will express
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feelings related to stress and tension instead of acting-out behaviors. Patient will participate in

therapeutic regimen. The patient will remain safe during hospitalization. Patient will demonstrate

decreased manipulative, attention-seeking behaviors. The patient will not act out anger or cause

injury toward other patients or staff on the unit.

The patient was unsure when she would be discharged from the unit. She said her typical

psychiatric visits were almost 2 weeks. Her plans after discharge were for her to continue her

drug regimen and she had plans to go to a women’s center after discharge until she can get back

on her feet. When going over discharge instructions it’s important to make sure that the patient

understands the dosage of medication, how the patient will pick up her prescriptions, and the

understanding of compliance with the medication. It is also important that the patient goes to

follow up appointments and understands the importance of going to narcotics anonymous

meetings. The patient is currently homeless so it is important to make sure that the patient has

transportation and resources to get to the pharmacy to get her prescriptions and so she also has

transportation to follow up appointments and meetings.

Nursing diagnoses are set and individualized for each patient. These diagnoses are used

to provide safer and effective care to the patient. The patient’s nursing diagnoses are prioritized

as follows: Risk for injury related to affective, cognitive, and psychomotor factors,

biochemical/neurologic imbalances, exhaustion and dehydration, extreme hyperactivity/physical

agitation, rage reaction as manifested by abrasions, and impaired judgement. Risk for violence:

self-directed related to biochemical/neurologic imbalances, impulsivity, manic excitement,

psychotic symptomatology, rage reaction, restlessness as manifested by delusional thinking,

hallucinations, and poor impulse control. Ineffective individual coping related to

biochemical/neurologic changes in the brain, inadequate level of perception of control,

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ineffective problem-solving strategies/skills as manifested by changes in usual communication

patterns, inability to problem-solve, inability to meet basic needs, and presence of delusions.

A list of potential nursing diagnoses are as follows: disturbed thought processes,

disturbed sensory deprivation, impaired social interaction, interrupted family processes, total

self-care deficit, anxiety, and risk of violence to others.

In conclusion, P.L was enjoyable to speak to and was open to talking to me about her

diagnosis and past history of being hospitalized. Since her husband passed away, the patient has

been pink slipped multiple times for the obsessions and delusions about parasites in her ears. She

also struggled with abusing pain medication in the past for her chronic lower back pain after an

accident in 2011. The patient has a lack of support system and is currently homeless once she

leaves the psychiatric unit. Her plans after discharge are to go to a women’s center until she can

get back on her feet.

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References

Barekatain, M., Khodadadi, R., & Maracy, M. R. (2011, January). Outcome of single manic

episode in bipolar I disorder: A six-month follow-up after hospitalization. Retrieved

February 26, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3063423/

Culpepper, L. (2014, June 19). The Diagnosis and Treatment of Bipolar Disorder: Decision-

Making in Primary Care. Retrieved February 26, 2018, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195640/

(n.d.). Retrieved February 26, 2018, from https://www.psychiatry.org/patients-families/bipolar-

disorders/what-are-bipolar-disorders