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Mental Health Clinical Case Study

Melissa Walko

Youngstown State University

NURS 4842: Mental Health Nursing

November 2018
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Abstract

This is a case study that was created on October 11th, 2018 on a 25-year old female Caucasian

American patient. The patient was admitted to St. Elizabeth’s Youngstown Mercy Health

Hospital on the psychiatric unit with presenting problems of hallucinations related to acute

psychosis and mixed bipolar 1 disorder. This case study consists of objective data of the patient,

a summarization of the patient’s mental illnesses, an identification of stressors and behaviors that

lead to the hospitalization, a discussion of previous mental illnesses with the patient and the

family, describing the nursing care and milieu activities the patient participated in, analyzing the

patient’s ethnic, spiritual and cultural influences, an evaluation of patient outcomes, a summary

of the plan for discharge, and a list of actual and potential nursing diagnoses.

Keywords: objective data, summarize, identify, discuss, describe, analyze, evaluate, nursing

diagnoses
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Mental Health Comprehensive Case Study

Objective Data:

This case study is created for a patient cared for on October 11th, 2018. The patient was

admitted on October 9th, 2018 at St. Joseph’s Mercy Hospital ER in Warren, Ohio and then

transferred to St. Elizabeth’s Youngstown Mercy Hospital on the Behavioral Health unit. The

25-year old female patient came to the ER via her aunt and uncle because she stated that she did

not know what was going on around her and was having auditory hallucinations. The admission

to the psychiatric unit was involuntary. Her psychiatric diagnosis were acute psychosis and

mixed bipolar 1 disorder. Her other medical conditions consisted of cerebral infarction, thyroid

disease, seizures, immune deficiency disorder, hypertension, diabetes mellitus, hyperlipidemia,

congestive heart failure, cancer, and arthritis.

The behaviors that were observed on the day of care was that she completely wrapped

herself in a blanket and was at first walking around with another patient. She had her own clothes

on and her hair was unwashed and not brushed through. She was pleasant to talk to albeit a few

mood swings when talked to about certain subjects. The patient made good eye contact and

spoke clearly.

The psychiatric medications that were prescribed to her was hydroxyzine (Vistaril) 50mg

every six hours when needed for anxiety, haloperidol (Haldol) 10mg every six hours when

needed for agitation, and divalproex (Depakote) 500mg daily for bipolar disorder.

Summarize:

The patient had psychiatric diagnoses of psychosis and mixed bipolar disorder. For

psychosis, an article made a statement that “the term psychosis refers to the presence of

delusions, hallucinations without insight, or both. These symptoms are clearly defined common
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features of psychosis in both psychiatric disorders and neurologic conditions. They are captured

by informal and structured clinical assessments and are reasonably amenable to treatment”

(Arciniegas, 2015). The patient presented with delusional thinking and hallucinations. Another

article relating to psychosis states, “In today's definition, the characteristic symptoms of

psychosis are related to the degree of severity (with psychosis being the severe form of mental

disorders), lack of insight, communication disorders, lack of comprehensibility of the symptoms,

and reduced social adaptation” (Gaebel & Zielasek, 2015). The patient definitely presented with

all of these defining characteristics.

The article going over mixed bipolar states, “In DSM-IV, bipolar mixed states were

recognized as a third major affective syndrome, simultaneously meeting diagnostic criteria for

both major depression and [hypo]mania nearly every day for at least a week (8). More recently,

DSM-5 recognized a ‘mixed features specifier’ defined as ≥3 hypomanic signs or symptoms in

nominally depressive episodes in major depressive disorder (MDD) or bipolar disorder (BD), or

≥3 depressive features in nominally [hypo]manic episodes in BD, except for ‘overlapping’

features that can be present during either depressive or [hypo]- manic phases, such as agitation,

distractibility, impulsivity, and sleep-loss (9)” (Tondo, Vazquez, Pinna, Vaccotto, Baldessarini,

2018). The patient’s behavior presented these aspects of mixed bipolar disorder.

Identify:

There were numerous occasions as to why this patient was hospitalized on the psychiatric

unit. She came into the ER due to hallucinations and not being aware of her surroundings. She is

originally from Buffalo, New York but states they came to Ohio because she “God is my dad and

he told me to beat the devil”. She also has a history of doing drugs and is currently a tobacco

smoker. When asked about her family, she stated her father died of an overdose, and her mother
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had a stroke and is in a nursing home as of right now. She mentioned she also had a sister, and

repeatedly mentioned that she would “die for her.” She and her sister apparently had an

extremely close relationship with their father, and the death severely affected her.

Discuss:

There is evidence of family history of mental illness. Her father overdosed on drugs due

to depression and that definitely took a toll on her own mental illness. Her mother does not have

a history of mental illnesses, but the mother did suffer from a stroke and is currently in a nursing

home. After that incident happened, she had to go in foster care for a while which she stated did

not go well with her. She now lives with her aunt and uncle but states she is “homeless” because

she was not sure how long the aunt and uncle were going to keep her for. These are all

incidences that lead to the patient’s history of mental illness.

Describe:

During her stay on the psychiatric unit, she complied with her medications and with

group therapy. However, when asked about group therapy, she stated “it helps a little but not

much”. She mentions she gets anxiety sometimes going to group therapy because she does not

like to speak up much, but she accepts group therapy because she knows it can be helpful in the

long run. On the day of care she was found to be talking amongst other patients, and when asked

questions she was very cooperative and was willing to give any information about herself.

When taking the Mini-Mental State Examination (MMSE), there were a couple problems

with taking it but overall was good in taking it. When asked to count backwards by 7 starting

with 100, she stated it was “near impossible to do that.” When asked to spell the word WORLD

backwards instead, she hesitated but then was able to do it. The patient was also unable to fully

copy the figure of pentagons provided on the MMSE.

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Analyze:

The patient is a 25 year old Caucasian American female. The Caucasian culture is very

broad, as every Caucasian American have a different aspect on life, and this patient definitely

had their own insight on how things should be handled. When asked if they were spiritual, they

said yes. They stated, “God is my dad and he gave me the mission to beat the Devil.” They also

believe that Catholics are very evil and that they have a lot of hate for people.

Evaluate:

The goals for this patient were to reduce anxiety, take control of their hallucinations, and

to be able to function normally with their bipolar disorder. Smoking cessation was also another

goal for this patient since they are a smoker. The patient mentioned while group therapy wasn’t

of major help to them, it did somewhat help to keep her anxiety at bay as she learned tactics from

group therapy on how to relax such as deep breathing techniques and not keeping everything in,

that it was okay to talk about anything that was on her mind.

For her hallucinations, she was educated by the nurses to differ what was real to the

patient and what is a hallucination, since she has auditory and visual hallucinations. The nurses

educated her on distracting techniques and the nurse’s role was to distract the patient when the

patient was experiencing hallucinations.

For her bipolar disorder, she was educated on taking her medications to keep her mood

swings at bay, and to never skip a dose or stop the medication immediately. Distraction

techniques were also taught for this disorder, to do what makes her happy and not frustrated.

Summarize:

The plans for discharge for this patient was to keep her anxiety and depression at bay, to

learn how to take care of herself and to use distraction techniques for her hallucinations, and to
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keep up with her medication regimen. She stated she is “tired of being hurt and hurting other

people,” so for her discharge teaching she is to find coping techniques that won’t make her feel

so defenseless.

Prioritized List of Actual Diagnoses:

1. Disturbed thought processes related to inability to trust as evidenced by inappropriate

thinking

2. Powerlessness related to complicated grieving process as evidenced by verbal

expressions of having no control

3. Complicated grieving related to absence of anticipatory grieving as evidenced by

prolonged difficulty coping following a loss.

List of Potential Nursing Diagnoses:

1. Ineffective coping related to situational crisis as evidenced by inadequate problem

solving

2. Risk for suicide related to depressed mood as evidenced by family history of suicide

Conclusion

Psychosis and mixed bipolar disorder can come from a combination of many aspects of a

person’s life, from family history of mental illnesses to how they handle certain things. The

patient clearly wants to get better and is willing to learn techniques to improve her moods as well

as take the medications needed for her mental illnesses. If the patient can follow up with her

illness with a psychiatrist and use the distraction techniques, her disorder may be able to improve

immensely.
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References

Tondo, L., Vasquez, G. H., Pinna, M., Vaccotto, P. A., & Baldessarini, R. J. (2018).

Characteristics of depressive and bipolar disorder patients with mixed features. Acta

Psychiatrica Scandinavica, 138(3), 243-252. https://doi.org/10.1111/acps.12911

Arciniegas, D. (2015). Psychosis. Continuum (Minneapolis, Minn.), 21(3 Behavioral Neurology

and Neuropsychiatry), 715-36.

Gaebel, W., & Zielasek, J. (2015). Focus on psychosis. Dialogues in clinical

neuroscience, 17(1), 9-18.