1 Psychiatric Mental Health Comprehensive Case Study

Kristy Farkas
Psychiatric Mental Health Case Study
Youngstown State University
November 21, 2017

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Abstract

This paper details the experiences of a 34 year old female admitted to Trumbull Memorial

Hospital diagnosed with Bipolar I disorder with psychotic features and suicidal ideations as well

as abuse and withdrawal due to opiates and cocaine. Throughout this paper, I will include

information pertinent to the patients background, subjective data as presented by the patient

themselves, objective data witnessed on the patients date of admission, medical conditions and

treatments, safety and security measures as well as psychiatric medications prescribed as it

appears in the patients chart at Trumbull Memorial Hospital. Next, I will define the patient’s

psychiatric diagnoses, identifying stressors and behaviors that precipitated their visit to the

psychiatric unit, discuss priority nursing diagnoses pertinent to the patient as well as discuss a

plan of care and goals upon discharge

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Objective Data
M.S. is a 34 year old African American Female admitted on November 17, 2017 with the

date of care being November 21, 2017, four days after admission to the unit. Axis I is the top

level of the DSM-IV-TR multiaxial system diagnosis representing clinical symptoms that need

treatment or the primary reason the patient is seeking care. My patients Axis I diagnosis is

Bipolar I disorder with psychotic features, cocaine, opiate, and marijuana abuse and suicidal

ideations. The Axis II is for assessing personality disorders and intellectual disabilities and has

been deferred. Axis III describes physical problems that may be relevant to diagnosing and

treating mental health disorders which is M.S.’s case would be opiate and cocaine withdrawal.

The patients also presents with impaired mobility related to a diagnosis of rhabdomyolysis from

a past heroin overdose in August of 2017. The patient’s unemployment, lack of permanent

residence, and a support system can be reported under the Axis IV. The Axis V quantifies the

patient’s ability to function in her everyday life using the Global Assessment of Functioning

Scale (GAF) which ranges from 0-100, with 0 being no ability to function and 100 being the

highest level of functioning. Although not available in the chart, I would presume M.S’s

functioning on admission to be 21-30 on the GAF scale due to auditory and visual hallucinations

with suicidal ideations on arrival to the unit. M.S. voluntarily admitted herself to the inpatient

unit after calling 911 and going to the ED stating, “I’ve had enough and I think I am really ready

to get clean this time and go to an inpatient chemical dependency program”. She was prescribed

Abilify 5 mg oral daily for Bipolar disorder and Clonidine 0.1 mg oral q4 for cocaine and opiate

withdrawal. In addition, she was prescribed Haldol 5 mg oral/injection PRN for agitation,

Vistaril 50 mg oral PRN for anxiety and Desyrel 50 mg oral PRN for insomnia.
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Expected behaviors of a client with Bipolar Disorder not otherwise specified

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As defined in the textbook, Bipolar Disorder is characterized by mood swings from

profound depression and extreme euphoria (mania), with intervening periods of normalcy.

Delusions or hallucinations may or may not be a part of the clinical picture (Townsend, pg 499).

During a manic episode, the mood is elevated, expanded, or irritable. The disturbance is

sufficiently severe to cause marked impairment in occupational functioning or in usual social

activities or relationships with others or to require hospitalization to prevent harm to self or

others. Motor activity is excessive and frenzied and psychotic features may also be present

(Townsend, pg 499). Bipolar I disorder is the diagnosis given to an individual who is

experiencing a manic episode or has a history of one or more manic episodes. The client may

also have experienced episodes of depression and psychotic or catatonic features may also be

noted (Townsend, pg 501). I also read an article the stated, “Bipolar disorder (BPD) is the Axis I

disorder with the highest risk for coexisting substance use disorder. One explanation for this

phenomenon is the ‘self-medication hypothesis’, which states that some patients experience

improvement in psychiatric symptoms as a result of substance use”.

On admission to the ED on 11/17/17, M.S. manic state was very evident upon arrival to

the unit, presenting with elevated mood and irritability. She presented with psychotic features

having anxiety, lack of sleep and decreased appetite, lack of awareness, rapid thoughts and

speech, excessive sexual indiscretions with people she barely knew as well as hallucinations that

were causing her to have suicidal ideations. She denied any paranoia and other delusions on

admission to the inpatient unit.

Expected Behavior of client with Substance- related disorders

The textbook describes substance- related disorders as composed of two groups: the
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substance- use disorders (addiction) and the substance-induced disorders (intoxication,

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withdrawal, delirium, neurocognitive disorder, psychosis, bipolar disorder, depressive disorder,

obsessive compulsive disorder, sexual dysfunction, and sleep disorders) (Townsend, pg 366).

Substance abuse is defined as the use of psychoactive drugs that pose significant hazards to

health and interferes with social, occupational, psychological or physical functioning and

substance addiction is defined as the inability to stop using a substance despite attempts to do so;

a continual use of the substance despite adverse consequences; a developing tolerance; and the

developing of withdrawal symptoms upon cessation or decreased intake (Townsend, pg 914).

M.S. has a long history of abuse and addiction to cocaine, heroin, and marijuana. She had

stated in her admission interview that she has been using marijuana since the age of 18, cocaine

and crack since the age of 20 and began snorting heroin in 2015. During our conversation she

told me, “I love to do speedballs”, which she explained to be a mix of cocaine and heroin that

causes her to have a more extreme high. She seemed almost proud of her drug use and while she

explained her patterns of use to me she had a smile on her face. She even stated “I have a very

high tolerance” which she bragging about. According to an article I found,

“There is evidence that cocaine is co-used with opioid drugs in different ways for

different reasons. Some users inject the two substances simultaneously in the form of a

speedball to experience the effects of both drugs at the same time. Some use the speedball

to achieve a greater level of euphoria, especially when they have insufficient quantities of

either drug. Other users mix cocaine with heroin with the goal of gradually reducing

heroin and, consequently, eliminating their physical reliance upon opioids. Heroin users

often report co-use of cocaine in a sequential manner either to enhance euphoria or to

reduce the withdrawal symptoms commonly experienced during their typical day (Kreek
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1997) or when they decide to detoxify from opioid drugs (Hunt et al.1984).”

(Understanding Poly-drug Use, pg11)

On review of M.S.’s chart I discovered that on a prior visit to the ED on August 1, 2017

she had been diagnosed with Rhabdomyolysis which was caused from muscle injury and death

related to prolonged immobility during a recent overdose on opiates. This in turn caused her

bilateral weakness and impaired mobility in her arms, hands, and legs as well as impaired kidney

function causing her to needed a catheter for over two months. She told me during our interview

that she developed Rhabdomyolysis after “snorting heroin and sitting indian style for over twelve

hours without moving.” An article I found futher clarified its cause,

“It is widely recognized that cocaine, heroin, other opiates, amphetamines, other club

drugs, like "ecstasy" and benzodiazepines cause rhabdomyolysis. Heroin is also

considered to have possible direct myotoxicity, while amphetamins are etiologically

connected to the serotonergic syndrome. However, the most common mechanism through

which all these drugs induce rhabdomyolysis is the muscle compression and ischemia,

due to prolonged immobilization on a rigid ground, after an acute intoxication and

subsequent unconsciousness or coma” (Efstratiadis, et al., 2007).

Precipitating Events to Current Hospitalization

Prior to her current hospitalization, M.S. had been in and out of local emergency rooms

and psychiatric units over the past year due to her escalating abuse of cocaine and heroin. She

admitted that her marijuana and cocaine use began around the age of 18 -20, after her brother

was murdered and that she used it to help her cope. She stated that her downhill spiral really
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began in 2015 when her mom became paralyzed from the waist down due to a botched back
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surgery which put her in a nursing home. This took a huge toll on M.S. emotionally, causing her

to fall into a depressed state where she used pot and cocaine more frequently to cope and marked

the beginning of her heroin use. Soon after this, she admitted to losing her job and becoming

homeless where she would bounce around from place to place trying to find somewhere to stay.

In August of 2017 she was admitted to the inpatient psych unit at St. Elizabeth’s for an overdose

and while there, she was diagnosed with Bipolar I disorder and Rhabdomyolysis. She admitted to

going right back to using drugs after this discharge and not being compliant with her Bipolar

meds. The precipitating event that lead to her current hospitalization occurred on November 17,

2017 when she called 911 and was taken to the ER at Trumbull Memorial because she said that

she has been drugged ( shot –up with heroin) by a man she was staying with and having sex with

for money. Upon chart review, I discovered that she had told the nurse on admission that she

never shoots up but only snorts her drugs and because of this she felt like she would overdose

and because of the man’s actions, felt unsafe. She also acknowledged having auditory

hallucination, voices telling her to kill herself, and visual hallucinations of dead people which

made her feel suicidal prior to calling 911. She has had a long history of eloping from the ED

and not following through with a treatment plan. M.S. is currently on the unit to seek help for her

addiction to cocaine, pot, and heroin and stated on admission that she wants to go to Neil

Kennedy to get clean.

Patient and Family History of Mental Illness

During M.S.’s chart review, it stated that she had no family history of mental illness that

she knew of. During my interview with M.S. she confirmed that she did not know of anyone in

her family with mental illness but that she did not talk to her father or his side of the family so
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she wasn’t 100% sure. She did state that her brother had issues with drugs and erratic behavior in

the years before he was murdered but had never been diagnosed.

Nursing Care and Milieu Activities

Trumbull Memorial Hospital’s psychiatric unit provides exceptional milieu to their

clients. The floor is very clean and organized and they limit distractions by keeping the stimuli

low and by banning harmful items on the floor to keep their clients safe. There is a schedule

posted on the wall for daily groups, meal times, and visiting hours. The patients also know when

they are allowed to use the phones and the staff all remain consistent with each client.

The floor is divided into a restricted area and a non- restricted area both being on

opposite sides of the nurses’ station. The group room is centrally located in front of the nurses’

station and can be viewed from the common room as well. During a typical day, the patients can

be found in the common area that has multiple tables and lounge chairs where they can watch

T.V., use the phone (during applicable hours), play games, write, and socialize with other

patients. The common area is open and in full view of the nurses’ station which allows the staff

to have eyes on all of the patients. For the patients who do not come to the common area, a

member of the staff must check on them in their room every 15 minutes. Nurses encourage

socialization among the patients especially in group. Going to group is a part of the patient’s

treatment as they must complete a certain amount of groups in order to be discharged.

M.S. was initially placed on suicide precautions based on her suicidal ideations on arrival

to the psych unit. She had also began going through the withdrawal process and stated that she

was having auditory and visual hallucinations before admission, in order to keep her and the
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other patients safe, she was being closely monitored.

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Ethical, Spiritual and Cultural Influence

M.S. did not discuss any cultural or spiritual influences that impacted her. There also

was not a religion group therapy session on the day of care.

Patient Outcomes Related to Care

On the day of care, M.S. stated that her symptoms of withdrawal were “under control for

the most part” due to the use of Clonidine while on the unit. She was still having some somatic

symptoms on the day of care like headache and aches and pains in her hands and legs which

could be related to withdrawal or side effects from her recent diagnosis of rhabdomyolysis. She

told me, “I feel a lot better than when I came in, I’ve been less emotional and have had fewer ups

and downs since I’ve been here. Now I feel like I can finally focus on getting help”. Although

M.S. stated that she was ready for help, she then told me “I want to go home for Thanksgiving

and to see my mom and few other people”, although not an option, this is still worrisome due to

her past history of elopement and non-compliance when it comes to getting clean and following

a treatment plan. I hope that she was genuine in wanting to get clean, but I wasn’t completely

convinced that she focusing on what was most important as she didn’t seem really interested in

talking about the recovery process and redirected the conversation to any other topic. I got a

sense that she knew she had nowhere else to go but back on the street and the option of a nice

warm bed seemed like a better plan.

Discharge Planning

M.S. will be going to Neil Kennedy Recovery Center’s inpatient program for help with

her addiction to cocaine, pot, and heroin upon discharge. On the day of care, there was no set
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day for discharge. The social worker told M.S. that she needed to continue to work on herself on
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the unit to show them she was ready for discharge by participating in group, working on her

coping skills, mentally preparing for recovery, and controlling her behaviors while on the unit.

Nursing Diagnosis

1. Ineffective coping related to inadequate support system and lack of coping skills as

evidence by being homeless, maladaptive behavior (drug use), and decreased ability to

handle stress.

2. Powerlessness related to episodic compulsive indulgence and multiple attempts at

recovery as evidence by excessive drug use and ineffective recovery attempts.

3. Knowledge deficit related to lack of information about addiction and the effects of drug

use and Bipolar Disorder as evidence by continuation of drug use despite complications,

lack of knowledge about community resources and non-compliance with bipolar meds.

Potential Nursing Diagnosis

1. Risk for suicide related to homelessness, lack of support system, and drug use as

evidence by depression with suicidal ideations and multiple overdoses.

2. Risk for injury related to drug use, impaired judgment, and erratic behaviors as evidence

by selling herself for drugs, staying with people she doesn’t know, and multiple

overdoses.

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References

DeepDiveAdmin, W. D. (n.d.). Axis I-V. Retrieved November 14, 2017, from

http://www.psyweb.com/DSM_IV/jsp/Axis_I-V.jsp

Efstratiadis, G., Voulgaridou, A., Nikiforou, D., Kyventidis, A., Kourkouni, E., & Vergoulas, G.
(2007). Rhabdomyolysis updated. Retrieved November 30, 2017, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658796/

Leri, F., Bruneau, J., & Stewart, J. (2003). Understanding polydrug use: review of heroin and
cocaine co-use. Addiction, 98(1), 7-22. doi:10.1046/j.1360-0443.2003.00236.x

Townsend, M. C., & Morgan, K. I. (2018). Psychiatric mental health nursing: concepts of care
in evidence-based practice. Philadelphia, PA: F.A. Davis Company.

Weiss, R. D., Kolodziej, M., Griffin, M. L., Najavits, L. M., Jacobson, L. M., & Greenfield, S. F.
(2004). Substance use and perceived symptom improvement among patients with bipolar
disorder and substance dependence. Journal of Affective Disorders, 79(1-3), 279-283.
doi:10.1016/s0165-0327(02)00454-8

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