Running Head: STUDENT CASE STUDY 1

Mental Health Nursing:

Student Case Study

Chandace Regano

Youngstown State University

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Abstract

A comprehensive case study conducted at Trumbull Memorial Hospital was performed on

a client with the primary diagnosis of Bipolar I, Post Traumatic Stress Disorder, and Anxiety.

The above mentioned patient presented to the observation with animated expressions, relaxed

posture, a normal affect with a moderate degree of exaltation. Objective data, which includes

both physical and social aspects, subjective data obtained from the patient, and information

gathered from my examination of her are the details that will be referenced in the discussion of

this case. Accuracy and relevance in regards to time period are ensured to the best of not only

the patient’s knowledge but the conductor’s as well. Any component that could disclose the

identity of the client will not be included to ensure her privacy and protection.

The purpose of this case study is to aid in the understanding of psychological illnesses,

which includes the disease process, symptomatology, medications and individual afflictions, as

well as to refine the student’s capacity to interact with those affected by such conditions. It is the

responsibly of the student to use objective clarity to analyze a patient’s status and history and to

recognize patterns without personal views conflicting with observations and conclusions.

The following study will encompass objective data, a summarization of the psychiatric

diagnosis with expected behaviors, an identification of stressors and behaviors that led to the

current hospitalization, a patient and family history of mental illness discussion. In addition to

those aspects, this case will feature an evaluation of patient outcomes, plans for discharge,

potential nursing diagnosis, nursing diagnosis priorities, and several other categories. All of

these aspects will yield a complete and conclusive view of the patient’s case.
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Objective Data:

This study focused on a patient admitted on March 19th, 2018 to the psychiatric unit at

Trumbull Memorial Hospital with the date of care taking place on March 23rd, 2018, which

made the current length of stay at about four days. In accordance with the DSM-IV-TR and her

chart, she presents with Bipolar I, mixed with Depression, and Post Traumatic Stress Disorder.

The records also report a history of suicidal and homicidal thoughts, the latter directed at a select

order of people on the outside of the facility. According to one electronic note, the patient

exhibited guarded tendencies and confabulation. Leading up to the admission, the patient called

“211” feeling highly distraught and communicated that she did not want to live anymore. She

was brought to Northside Medical Center where she complained of feeling depressed and lacked

the desire to live. Afterwards, the client was pink slipped and transported via ambulance to

Trumbull. Her medical history consists of not only cardiovascular accidents and multiple

aneurysms but also brain surgeries, all of which have physically and emotionally affected the

client.

Upon observation during my visit to the unit, the client was open to communicating with

me about her personal life and history; she appeared to be cooperative and genuine throughout

the entire process. Although I did began the interview with an open ended question,

communication on her part required little prompting from me with the conversation lasting at

least two hours. It took place in the television room, during which she verbalized a minimal

amount of discomfort when other patients entered the room and sat near us. Despite this, she

continued to share her thoughts and memories, and she even confided that she enjoyed speaking
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with me and appreciated me listening to her due to my lack of judgement. While there were

times when she spoke that there a continuous jump from one topic to another, there seemed to be

a depth and intelligence that she was trying to convey with her verbalizations along with highly

animated facial features. For instance, she performed a type of poetry-like speaking that she

called “chanting,” in which she took a great deal of pride. It was a form of self expression and

way of connecting to her Native American heritage. According to the chart, the client stated that

she hears voices in her dreams and wakes up talking to the voices that she dreamed about but

will stop once fully awake and denies talking to or hearing voices at any time while awake. She

did admit to me that she has difficulty sleeping due to nightmares related to her post traumatic

stress disorder; the dreams involve abuse that she suffered at the hands of her brothers.

While the depression aspect of her condition has negatively impacted her will to live, she

states that she loves herself and does not want to die. However, the poor overall state of her

physical health in relation to her strokes, aneurysms, surgeries with subsequent infections, and

even a recent fall she had within the last few months appears to have dimmed the outlook she has

on her own quality of life. She does continue to attend to her hygiene and personal appearance.

In addition to the medication that she is prescribed, she self medicates with cannabis, for which

she tested positive upon admission. The scheduled medications she is taking include olanzapine

(Zyprexa) 2.5 mg PO BID for Bipolar Disorder, levetiracetam (Keppra) 500 mg BID for

seizures, various other physiological related medications. Her PRN medications are hydroxyzine

(Vistaril) 25 mg IM q6H for anxiety, trazodone (Desyrel) 25 mg PO daily for insomnia, and

olanzapine (Zyprexa) 5 mg PO q8H for anxiety. She is compliant with all medications and is
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hopeful that the Zyprexa will improve her condition, unlike Ability which she was prescribed

prior to the current antipsychotic. The client is under unit restrictions and self harm precautions

but has not exhibited any specific suicidal behavior.

Summarize:

Bipolar disorder, previously labeled as manic depression, is a mental illness known for its

unusual shifts in mood, energy, behavior, and interference with the ability to function normally

on a daily basis; the condition is further divided into four subcategories of Bipolar I, Bipolar II,

Cyclothymic Disorder, and other specified and unspecified and other related Bipolar disorders

(NIMH). While Bipolar II is marked by a pattern of depressive episodes and hypomanic

episodes, Bipolar I is defined by manic episodes that last at least one week or severe enough

symptoms that warrant hospitalization along with depressive episodes that last about two weeks;

it is even possible for the two types of episodes occur simultaneously (NIMH). A manic episode

can consist of having increased energy and activity levels, having difficulty sleeping, feeling

more agitated, or doing risky things. The opposite, on the depression side, includes having

decreased energy and activity levels, sleeping too much or too little, feeling tired or slowed

down, feeling worried and empty, or thinking about death or suicide. Although bipolar

symptoms can mirror those of other mental illnesses, it is necessary to diagnose it and treat with

the appropriate medications and therapies. Mood stabilizers, antipsychotics, and antidepressants

must be taken continuously without any abrupt cessation to the intake of the medication for

proper functioning.

While there is no single cause of Bipolar disorder, there are several risk factors that
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contribute to the condition, such as brain structure and functioning, genetics, and family history

(NIMH). In addition to those commonly known factors, there has been research done which

looks into other associating elements.

For example,

“In bipolar disorder, there are indications that childhood trauma is associated with

clinical characteristics [5], including earlier onset of the illness [6], a rapid cycling

course [6], more psychotic features [7-9], higher number of lifetime mood

episodes [10-12], as well as suicide ideation and attempts [13]”. (Larsson et al., 2013 )

Various forms of trauma have often been connected to disturbances in the human mind, and it

appears that there is a positive correlation between the two, especially in the case of this

particular disease. In terms of trauma, one type that is frequently discussed is abuse. According

to Huh, H. J et al.:

“Childhood emotional trauma has more influence on interpersonal problems in adult

patients with depression and anxiety disorders than childhood physical trauma. A history

of childhood physical abuse is related to dominant interpersonal patterns rather than

submissive interpersonal patterns in adulthood. These findings provide preliminary

evidence that childhood trauma might substantially contribute to interpersonal problems

in adulthood” (2014).

Depression and anxiety are heavily intertwined with Bipolar disorder, therefore, emotional abuse

can strongly impact the thoughts, feelings, actions, etc. of the patient in regards to other people in

a negative way.
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Identify:

According to the patient’s chart, the main reason why she was admitted was because she

called 211 and told them that she did not want to live anymore. She further explained to me that

she is tired of dealing with her poor health. There was a particular instance some years ago after

one of her brain surgeries that she was seeking employment, during which, the interviewer

denied her request with the reason being the client could not perform the necessary work because

she was “retarded.” The PTSD that she deals with is a result of a great deal of emotional abuse

from her family as a child as well as sexual abuse from almost all of her five brothers. She is

currently separated from her husband, the reason behind it she did not disclose, and her two

children live in Philadelphia. Although she states she loves her children, she is ultimately

without a strong and readily available support system. At no time did she mention seeing a

therapist of any kind, but she is hopeful that the antipsychotic the doctor put her on after

admission will help her.

Discuss:

The patient did not disclose when she was diagnosed with her illnesses, but she did

verbalized that the majority of the abuse she suffered at the hands of her mother’s and brothers

occurred mainly during childhood and adolescence. She was often reminded by her mother,

once it became known to the client, that she was the unwanted product of an affair; her mother

even stated on several occasions that she should have aborted the pregnancy and it was her

daughter’s fault that her mother’s marriage ended with her husband leaving her. In addition to

the emotional abuse her mother inflicted onto her, she also ignored her pleas for help in regards
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to stopping her brothers from mentally, physically, and sexually abusing her. Despite not loving

her mother, the patient said she did respect her for her ability to provide for her family. In

addition to that, she also pitied her mother for the neglect and abuse she suffered as a child as

well at the hands of her foster family. While the client was unaware if she had a family history

of mental illness, and known was reported in her chart, there is a possibility. Either way, the

mother’s actions, and lack thereof, had a strongly negative impact on her daughter. According to

Wittkowski et al.:

“When parenting is compromised, children’s development might be affected. Although some

children might not experience any difficulties [22], children with a parent with SMI are at

greater risk for developing a range of problems including relationship difficulties, mental

illness, developmental delay and lower academic attainment [23]” (2014).

There is a likelihood that the abuse and absence of appropriate parenting during the patient’s life

had an affect on the development and current condition of her mental illness.

Describe:

Following the patient’s admission, she has attended several groups and voices an

enjoyment from the discussion of various topics. She admits to doing more listening than talking

because she does not being judged by other patients or especially the staff. When she does

speak, she feels as though no one will really listen to her. According to the staff, her cooperation

and mood have steadily improved compared to admission but find she is physically frustrated

occasionally. In one instance, she argued with a case worker because the patient wanted help

finding a new place to live but the worker attempted to explain to her she was not there for
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discussing housing.

Analyze:

The patient considers herself to be highly spiritual person. At one point during her

hospitalization, she verbalized a need for spiritual guidance, so the staff had religious services

come speak with her, which she found enlightening and helpful. She voices a close relationship

and connection with God and nature since she was younger and finds her spirituality to be a

source of comfort during difficult times of her illness.

Evaluate:

The primary goal for this patient is to improve her outlook on life, whether it is through

cognitive therapy, continuing an effective medication, or both. In addition to that, another prime

focus is for her to experience fewer nightmares with an improved quality of sleep. It is vital for

the overall condition of the patient’s mental health and subsequent physical health that she would

be well rested without being limited by harmfully invasive thoughts and have a positive view on

her own life.

Summarize:

In accordance with the patient’s wishes, one of the plans for discharge is for her to find a

new place to live; she does not have any stressors in relation to financial status as her pension

from teaching and disability cover all her expenses. Furthermore, she will continue with the 2.5

mg olanzapine BID and report if the medication is working for her. In order to improve her

cognitive thought process, she will see a counselor to help manage her Bipolar disorder, PTSD,

and anxiety. The client has no plans to discontinue the use of cannabis.
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Prioritized:

-Risk for Violence: Other Directed related to restlessness as evident by verbal threats against

others (verbalized homicidal tendencies on certain people on the outside)

-Impaired Social Interaction related to disturbed thought processes as evident by dysfunctional

interaction with family, peers, and/or others (wanting to live somewhere else because of conflict

with landlord, arguing with case worker, dislike of communicating with others because fear of

judgement)

-Ineffective Individual Coping related to disturbance in tension release as evident by presence of

delusions (thinking landlord is stealing her belongings)

-Ineffective Coping related to stress as evident by negative outlook on life and lack of desire to

live

-Rape-Trauma Syndrome related to sexual assault as evident by anxiety, nightmare and sleep

disturbances, and feelings of revenge (verbalized high level of anxiety, nightmares about

brothers, and homicidal feelings towards certain people of outside)

-Anxiety related to unconscious conflict about essential values and goals of life as evident by

feelings of discomfort and disorganized thought process (discomfort around other patients and

jumping from one topic to another)

List:

-Risk for suicide related to bipolar disorder I, depressive episode

-Risk for injury related to hyperactivity

-Risk for impaired social interaction related to excessive hyperactivity and agitation
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-Risk for interrupted family processes related to situational crisis or transition

-Risk for social isolation related to panic level of anxiety

In conclusion, the above discussed case study that focused on a patient diagnosed with

Bipolar I disorder, PTSD, and Anxiety was completed on a geriatric mental health floor at

Trumbull Memorial Hospital. The study featured the detailed aspects of objective data,

specifically the psychiatric diagnosis using the DSM-IV-TR, behaviors, medical conditions, and

prescribed psychiatric medications, and several other categories including but not limited to,

expected behaviors, patient and family history of mental illness, psychiatric based nursing care,

and plans for discharge. The information necessary to complete these sections were acquired

through, observation, interview, and patient charts. Cooperation was given fully by both parties,

and the patient verbalized appreciation for the session.

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References

Huh, H. J., Kim, S.-Y., Yu, J. J., & Chae, J.-H. (2014). Childhood trauma and adult interpersonal

relationship problems in patients with depression and anxiety disorders. Annals of

General Psychiatry, 13, 26. Retrieved from http://link.galegroup.com/apps/doc/

A383782062/PPNU?u=ohlink104&sid=PPNU&xid=5c85b562

Larsson, S., Aas, M., Klungsoyr, O., Agartz, I., Mork, E., Steen, N. E., ...Lorentzen, S. (2013).

Patterns of childhood adverse events are associated with clinical characteristics of bipolar

disorder. BMC Psychiatry, 13, 97. Retrieved from http://link.galegroup.com/apps/doc/

A327764116/PPNU?u=ohlink104&sid=PPNU&xid=15651033

Mental Health, T. I. (2016, April). Bipolar Disorder. Retrieved April 1, 2018 from https://

www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Wittkowski, A., McGrath, L. K., & Peters, S. (2014). Exploring psychosis and bipolar disorder in

women: a critical review of the qualitative literature. BMC Psychiatry, 14, 281. Retrieved

from http://link.galegroup.com/apps/doc/A390887874/PPNU?

u=ohlink104&sid=PPNU&xid=83c0c646