Running Head: PSYCHIATRIC MENTAL HEALTH CASE STUDY 1

Psychiatric Mental Health Case Study

Emily Schrecengost
Youngstown State University
PSYCHIATRIC NURSING CASE STUDY

Abstract

This case study focuses on a thirty-one-year-old African-American female who

was recently diagnosed with bipolar effective disorder, current episode manic with psychotic

symptoms. She was brought into St. Elizabeths emergency department in Youngstown, Ohio by

the police. Her mother found her at her house in a psychotic state. The police were promptly

called, and she was pink slipped to the behavioral health unit. In this paper, I will identify

objective data relating to my patients medical and nursing diagnoses, evaluation of the patients

psychiatric history, factors influencing the patients mental state, and plans for discharge.
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Psychiatric Mental Health Case Study

Objective Data

On November 9th, during my day of clinical on the behavioral health unit at St.

Elizabeths, I spoke with A.M., who had been a patient on the unit for five days. The police pink

slipped her on November 4th after the mother called regarding her dangerous hostility and

psychotic behavior. The mother claimed she was extremely agitated, aggressive, and

incoherently talking to herself. The mother said, its as if someone slipped her something. It was

like she was drugged. Information regarding this patient was obtained by the hospital patient

records and from a one-on-one interview with the patient. She is thirty-one-year-old and has a

five-year-old daughter. She is not with the father of her child, has never been married, and

recently went through a breakup with a man she has dated intermittently over the past twelve

years. The patient grew up in Youngstown, where she currently resides. Upon admission to the

hospital, she was mumbling, agitated, and unwilling to communicate. She was oriented to time,

place, and person. She was talking to self, possibly hallucinating. Grandiose delusions were

observed, in which she stated she has multiple degrees and can get a job overseas, get whatever

she wants, and can get her attorney out of the hospital. She was refusing all medication, being

loud and aggressive, and repeatedly stated she just wanted to leave.

The patient claimed she has no psychiatric history, and that there was no history of any

psychiatric illnesses in her family. The patient also denied any medical issues. The CBC on

admission revealed abnormal blood findings. Her Hemoglobin, Hematocrit, MCV, and MCH

were all lower than normal range. The blood cell was also positive for anisocytosis,

polychromasia, hypochromia, poikilocytosis, cystocytes, ovalocytes, and target cells positive.

A.M. denies any suicidal ideation, homicidal ideation, or hallucinations. Although suicidal and
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homicidal ideation may be denied, several standard measures are maintained to provide safety to

all patients on the unit. The patient has needed forced medications on multiple occasions while

on the unit, though, due to her unruly behavior. She was given Geodon, Benadryl, and Ativan IM

in the ER to control agitation. Later that day, she was given Zyprexa 10 mg IM after becoming

uncontrollably angry while on the phone with a family member. She was also medicated on 11/5

and 11/9 with IM Vistaril, Haldol, and Ativan due to loud and disruptive behavior. The patient

has shown an immense desire to leave the hospital on many occasions and has stated multiple

times that she doesnt know why she is there. Although she has gotten disruptive, agitated, loud,

and threatening, she has not physically acted out on staff or peers.

Using the DSM IV, the patients axes are: Axis I Bipolar Effective Disorder, current

episode manic with psychotic symptoms. Axis II None identified. Axis III acute cystitis. Axis

IV assumed pregnancy, financial issues, no job, eviction notice on house door, recent end of

relationship, verbal abuse from previous boyfriend, poor support system, assisting mother with

double hip replacement, father of child unable to help due to lack of employment and on dialysis

3 times per week while on waiting list for a kidney transplant. Axis V Not charted. The patient

is currently taking cephalexin (Keflex) 500 mg three times a day to treat her acute cystitis and

Nicoderm CQ 21 mg/24 hr patch for smoking cessation. She has PRN medication orders of

Haldol 5 mg (tablet and IM injection) for agitation and Vistaril 50 mg (tablet and IM injection)

for anxiety. Her future medications will include olanzapine zydis (Zyprexa) 20 mg, which is an

antipsychotic medication to treat bipolar disorder, and valproate (Depakene) 1000 mg, which is

an anticonvulsant that is used to treat bipolar disorder.

On the day of my care, I observed this patient discussing her issues during a group

session. She expressed her anger to the leader, stating she has been there for five days and she
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doesnt need to be there. She kept repeating, I dont know why Im here. The doctor wont even

talk to me. She was frustrated with the doctor, claiming he walked right by her and refused to

discharge her for no reason. Although her frustration was being expressed, she continued to show

respect to the group leader. She became defensive and started arguing when another patient

brought up that she did not like all the fighting on the floor. After the group session ended, A.M.

went to the nurses desk to speak with her nurse. I approached her, introduced myself, and asked

if she would be willing to speak to me. She was very pleasant with me. She agreed to sit down

with me once she was done talking to her nurse. While we talked, the patient was very open to

communication. She was smiling and showed no aggressive behavior towards me. Her stressors

and problems were addressed, as well as general conversation about life. The problems that she

brought up in the group session were elaborated on, and she explained other problems in her life.

The patient told me that she was pregnant by a man she has been dating on and off for 12 years.

He verbally, emotionally, and financially abused her, then broke up with her when she told him

she was pregnant. She denied any instances of physical or sexual abuse. She did not want to have

a baby, but could not afford an abortion, so she resorted to starving herself and depriving herself

of sleep for 10 days to cause a miscarriage. She claimed when her mom came over, she was just

mad because she wanted to sleep and be left alone but the mother wouldnt leave. Several times

throughout our conversation, she stated if she had some cigarettes, a coke, and sleep, she would

be fine. A.M. does not believe she has any psychiatric issues. Despite her belief that she was

pregnant, her hCG levels (hormone produced during pregnancy) upon admission were less than

0.1 mIU/ml. The average levels of hCG in a non-pregnant woman are less than 0.5 mIU/ml.

Anything above 25 mIU/ml is considered positive for pregnancy. If she would have had a

miscarriage prior to hospitalization, her hCG levels would have been higher than 0.1 mIU/ml.
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Summary of Psychiatric Diagnoses

This patient was diagnosed with Bipolar Disorder Type 1. Her most recent episode

involved severely manic with psychotic features. Per the National Institute of Mental Health,

bipolar disorder is a disorder of that brain that initiates shift in energy, mood, activity levels, and

daily activity abilities. Bipolar I disorder is defined by manic episodes lasting at least seven days,

or by manic symptoms severe enough to cause immediate hospitalization. Depressive episodes

usually occur as well, lasting at least two weeks (National Institute of Mental Health, 2016).

People suffering from bipolar disorder usually experience stages of intense emotion, unusual

actions and manners, and changes in sleep patterns. This patient was currently in a manic

episode. Intense amounts of energy, high levels of agitation and irritability, risky behaviors, and

trouble sleeping are common in this phase. They may also have trouble sleeping, feel jumpy,

and talk faster than normal. All of these symptoms were apparent in this specific patient. She was

irritated with her doctor and her hospitalization. She required medication to calm her down on

multiple occasions. She also spoke at a very fast pace, jumping from one topic to another. I

noticed this patient walking around a lot, rather than sitting still and relaxing. In some cases,

psychotic symptoms, such as delusions or hallucinations, may occur with bipolar disorder. In this

patients case, she showed delusions of pregnancy. She kept stating she had a miscarriage, but

her bloodwork did not show any sign of a recent pregnancy.

My patient also showed delusions of grandeur by stating she had a Masters degree, a

Bachelors degrees both in nursing and psychology. She even mentioned being able to get a job

overseas and doing whatever she wants. The fact that this patient is African American could have

an influence on her symptoms of delusions. Some studies suggest there are racial differences in

psychotic symptoms. In a study titled, Symptoms of Psychosis in Schizophrenia,

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Schizoaffective Disorder, and Bipolar Disorder: A Comparison of African Americans and

Caucasians in the Genomic Psychiatry Cohort, more African Americans have symptoms of

hallucinations and delusions. This was significantly true for cases diagnosed with bipolar

disorder and schizoaffective-bipolar disorder (Perlman, et al., 2016). It is interesting to see the

differences among African American and Caucasians when it comes to symptoms of mental

illness.

A.M. denied any history of medical problems, but her CBC levels on admission were

abnormal. Her hemoglobin was 10.5 (normal 12-16), hematocrit 32.7 (normal 34.9-44.5), MCV

78.5 (normal 80-96), MCH 25.3 (normal 27-33), and RDW 16.1 (normal 11.5-14.5). The blood

cell was positive for anisocytosis, polychromasia, hypochromia, poikilocytosis, cystocytes,

ovalocytes, and target cells positive. These results suggest she suffers from a hematological

problem, such as anemia. Seeing these results prompted me to look at the relationship between

blood disorders and psychiatric illnesses. In a Frequency of anemia in chronic psychiatry

patients, Korkmaz et al. (2015) performed a study looking at the frequency of anemia in chronic

psychiatric patients. When anemia is left untreated, it can cause multiple complications,

including fatigue, exhaustion, heart palpitation, and psychiatric symptoms, such as depression

and cognitive function disorders. This study states that there is may be a correlation with anemia

and an increase in the severity of preexisting diseases. It was determined that 25.4% of the

psychiatric patients had anemia as well. Anemia was noted in 25% of the bipolar disorder

patients. Results of this study showed that anemia was more prevalent in chromic psychiatric

patients as compared to the general population.

PSYCHIATRIC NURSING CASE STUDY

Identification of Precipitating Factors

As mentioned earlier, the patient spoke with me about multiple stressors occurring in her

life that have led her to be in the mental state she is now. First, she stated she has a five-year-old

daughter that she raises herself. The father of her child is facing his own health issues, doesnt

work, and doesnt take any part in caring for their daughter. The patient also claimed she was in

school. She mentioned to me that she was majoring in psychology and minoring in business

management. She says she must work hard to keep 4.0 GPA. She is currently unemployed, so

financial issues are a problem in her life. There is an eviction notice on her door and she doesnt

know where she will be living. Her recent off-an-on relationship is toxic and unstable. The

patient said he stresses her out, takes her money, and causes too much drama.

A.M.s support system is very limited. She has a mother, sister, and brother that she does

not get along with because they are in her business too much. The patient said her mother is too

nosy and around too much. Her siblings and cousins always ask her for help, but never return the

help when she needs it. She claims she still helps them when they need it. Her mother recently

had a double hip replacement and needs help around her house. She also takes care of her other

family members. The patient said a few times, I feel like Im doing 30 things a day and never

get a chance to rest. A.M. declared she doesnt get along with a lot of people because they are

always testing her, using her, and always on some type of bull****. She mentioned a few

friends that she said she liked to party with, but she doesnt trust any of them. In an article titled,

The role of social relationships in bipolar disorder: A review, it stated that individuals with

bipolar disorder have a more difficult time forming social relationships and attachment to other

individuals as compared to people with other mood disorders and normal controls (Greenberg,

Rosenblum, McInnis, Muzik, 2014). The authors also mentioned that individuals with bipolar
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disorder have a higher likeliness to be living alone, more poor, less educated, or unemployed

compared to others with major depression or no affective disorder. Several studies performed

determined that a relationship is shown with lower levels of perceived social support and

unfavorable outcomes in bipolar disorder. The findings by Greenberg et al. proved to be

extremely true with this patient. Her ability to form relationships with friends and family is

inadequate, causing her to feel alone. She also lives alone, has no job, and is very poor.

The biggest stressor in in A.M.s life was her belief that she was pregnant. She was

definite on not wanting a baby, but could not afford an abortion. When desperate times call for

desperate measures, she resorted to not eating and not sleeping for multiple days to cause a

miscarriage. Her mother came over to check on her after the patient made a Facebook status and

the mother thought the daughter was going to commit suicide. She said she just wanted to be left

alone for a few days, but her mother wouldnt respect her wishes. The patient was apparently

rambling nonsensical sentences, yelling at everyone, and unreceptive. This led to the mother

calling the cops, in which they came and pink slipped her for psychotic behavior.

Discussion of Patient and Family History

When discussing the patient about her mental history, she denied any past issues. She

even said she has been going to the same doctor her whole life and he would never believe she

was diagnosed with Bipolar Disorder. She boldly stated she doesnt fit in with the koo-koos

that are in the behavioral health unit and that she isnt crazy. This patient did not comprehend

why she was in the hospital. When I asked the patient about her familys history of mental

illness, she did not recall any information. There was no family history of mental illness noted in

the patients medical record, either.

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Description of Nursing Care

Numerous methods of psychiatric evidence-based nursing care are provided to patients

on the behavioral health unit. The most important technique is to provide a safe environment for

everyone. This is accomplished by having staff make rounds every fifteen minutes, or safety

checks, checking off each patient that is on the floor. It is important to ensure no patient is doing

something inappropriate, trying to harm themselves, or causing problems. The furniture on the

floor are also weighted to make it more difficult to be picked up and thrown. The doors are

angled and have sensors on them to prevent any hanging. The rooms and bathrooms are

strategically constructed so the patients cant make sharp objects out of any item. The mirrors are

made of aluminum instead of glass, toilet paper rolls holders are eliminated, the toilet flusher is a

button rather than a handle, and furniture drawers are not allowed. The behavioral health unit is

locked down so patients cant get out. This also prevents unauthorized visitors from coming onto

the floor. All personal belongings are taken and searched upon arrival on the floor. Most clothing

items are allowed, but certain items, such as shoe laces, pocketknives, jewelry, and anything

deemed to be potentially dangerous, are prohibited. Meals are served on plastic with plastic

utensils and counted after the patient has finished the meal. Medication administration is also

important in maintaining safety.

It is vital to guarantee a patient is taking their medication rather than pocketing it in their

cheek or spitting it out. Along with guaranteeing medication is being taken, monitoring the

patients for adverse effects is a critical part in nursing care. Side effects to some of the drugs

used on the floor could potentially be life threatening. For instance, Clozaril, an antipsychotic,

can cause agranulocytosis. This medication requires regular blood test monitoring. Geodon,

another antipsychotic, can cause neuroleptic malignant syndrome. Lamictal use may cause a life-
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threatening rash. These medications may lead to EPS, or extrapyramidal symptoms. Examples

include, akathisia, dystonia, drug-induced Parkinsons, and tardive dyskinesia. Tardive

dyskinesia happens later in drug therapy and is irreversible. Any signs of this side effect prompts

immediate discontinuation of medication. The nurses on this floor must be well educated on

common side effects of the medications they are administering.

Nursing care on the behavioral health unit involves a positive milieu. The goal of milieu

therapy is to provide an environment that is considered therapeutic. A patient will recover best in

a nonjudgmental, hostile-free, relaxing environment. Patients feel safe and independent. The staff

should also make sure the patient feels respected and supported. Increasing their self-esteem and

confidence while avoiding any belittling of the patient is important in nursing care. Certain

events, such as group discussions, allow the patients to voice their opinions and concerns. The

individuals are also allowed to engage in activities such as playing card games, watching

television, and exercising during their free time. Nurses must provide a safe and therapeutic

environment to every patient.

Analysis of Ethnic, Spiritual, and Cultural Influences

During my interview with my patient, A.M. told me she has no religious beliefs. She said

she used to believe in God, but hasnt gone to church since she was a teenager. There were no

ethnic or cultural influences noted by the patient, either.

Evaluation of Patient Outcomes

Although the patient does not feel she needs to be hospitalized anymore, it is evident she

still needs help. The patient had made progress since her admission five days before my day of

care in certain aspects. For example, she is no longer having delusions or talking to herself. She
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was more approachable, talkative, and understanding. She still has not achieved the goal of being

able to express her anger through appropriate verbalization and healthy physical outlets, though.

A few hours before my shift, she required IM administration of Vistaril, Haldol, and Ativan

because of an angry outburst. She was able to achieve the goal of acknowledging positive coping

patterns, but she did not practice them. She also achieved the goal of successfully competing

activities of ADLs. She was well groomed, recently showered, and dressed appropriately on my

day of care. A.M. achieved adequate nutritional intake as well as adequate sleep during her stay

on the unit. She is progressing well, but still requires additional days in the unit.

Summary of Plans for Discharge

A.M. has been on the floor for five days. Right now, there is not a specific discharge date.

Discharge planning begins on admission to the hospital. This helps in goal planning and an easier

discharge. Depending on the patients progress, additional days may be necessary. Because of the

most recent episode of needing medicated, my patient will probably require a longer stay.

Turning Point Counseling in Youngstown was notified of the patients situation. She will have an

assessment here upon discharge.

Prioritization of Actual Nursing Diagnoses

Ineffective individual coping related to changes in motor and sensory function as

evidenced by angry outbursts that cannot be controlled without medication intervention

Defensive coping related to situational crisis as evidenced by inability to control

aggressive behavior
Disturbed thought processes related to as evidenced by tangentiality of ideas and speech
Deficient knowledge related to lack of interest in learning as evidenced by denial of

psychiatric illness
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Risk for other-directed violence related to hostile behavior as evidenced by threatening

aggression toward staff

Potential Nursing Diagnoses

Risk of self harm related to feelings of loneliness and helplessness as evidenced by lack

of support
Risk for imbalanced nutrition related to failure to eat as evidenced by patient verbalized

she does not eat for multiple days in a row

Risk for self-care deficit related to distraction as evidenced by forgetting to attend to

Activities of Daily Living until reminded by staff member

Risk of loneliness related to limited support as evidenced by patient verbalized having

poor relationships with family and friends

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Conclusion

My patient is a 31-year-old African-American female recently diagnosed with Bipolar Disorder.

Upon admission, she was in a manic episode with psychotic symptoms. She has no known

medical disorders, and this is her first hospitalization regarding psychiatric issues. She has a

multitude of stressors in her life that have been altering her mental health. This patient has a poor

support system, financial issues, and a denial of her illness as well. It is important for her to

remain hospitalized in order to have a better understanding of her illness and learn methods to

control her angry outbursts. Although her explosions have not led to self-harm or harm to others,

there is a chance it could occur in the future. Medication compliance and outpatient counseling

will be necessary for this patient to maintain her illness.

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References

Greenberg, S., Rosenblum, K. L., McInnis, M. G., & Muzik, M. (2014). The role of

social relationships in bipolar disorder: a review. Psychiatry Research, 219(2), 248-254.

doi:10.1016/j.psychres.2014.05.047

Korkmaz, S., Yildiz, S., Korucu, T., Gundogan, B., Sumbul, Z. E., Korkmaz, H., & Atmaca, M.

(2015). Frequency of anemia in chronic psychiatry patients. Neuropsychiatric Disease

and Treatment, 2737-2741. doi:10.2147/ndt.s91581

National Institute of Mental Health. Bipolar Disorder. (2016, April). Retrieved November 16,

2016, from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Perlman, G., Kotov, R., Fu, J., Bromet, E. J., Fochtmann, L. J., Medeiros, H., . . . Pato, C. N.

(2016). Symptoms of psychosis in schizophrenia, schizoaffective disorder, and bipolar

disorder: A comparison of African Americans and Caucasians in the Genomic Psychiatry

Cohort. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics,

171(4), 546-555. doi:10.1002/AJMG.B.32409