Mental Health Case Study 1

Psychiatric Case Study

Steven Lukac

Youngstown State University

Teresa Peck, MSN, RN

Mental Health Case Study 2

Abstract

This case study was done to analyze a patient from Trumbull Memorial Hospital on the

psych unit. This patient is diagnosed with Depression, Bipolar II Disorder, and alcohol

dependency. Objective data, psychiatric diagnoses and common behaviors related to it, stressors

and behaviors prior to admission, patient and family history of mental illness, psychiatric

evidence-based nursing care provided and milieu activities attended, ethnic/spiritual/cultural

influences, patient outcomes, plans for the patient’s discharge, prioritizing a list of all actual

diagnoses, and listing potential nursing diagnoses are all sections discussed in this study.
Mental Health Case Study 3

Objective Data

B.T. is a 44-year-old Caucasian male who has psychiatric diagnoses of Depression,

Bipolar II Disorder, and Alcohol Dependency, and medical diagnosis of Myasthenia Gravis.

While on the unit, B.T. was friendly toward staff and peers, his facial expressions were animated,

with appropriate reactions to each discussion. He was relaxed in a slightly slouched posture. His

dress was neat, wearing clean scrubs, and had with well-kept hair. B.T. had fine motor tremors

in the hand, most likely from alcohol withdrawal, but no extrapyramidal symptoms such as

akinesia, akathisia, pseudoparkinsonism, or tardive dyskinesia. His thought process was direct

with no delusions, hallucinations, or flight of ideas. B.T.’s memory is appropriate and is able to

recall prior events (excluding this recent episode that brings him into the hospital due to extreme

intoxication) and appropriate judgment other than his urge to still drink. He communicates well,

clear and concise speech, doesn’t deviate from topic, holds eye contact through interaction, and

gestures as he talks. Overall it was a good interaction with no social impairment. B.T. states that

even with this recent episode that he does not want to stop drinking in whole, and either wants to

go about how he was before this admission or drink a bit less. When asked about his idea on

Alcoholics Anonymous, he said, “When me and my wife first had kids, she said I should go. I

told her ‘I don’t need them’ and just quit on my own. If I want to quit I’ll do it, but I don’t want

to quit now.” When asked what he likes about alcohol, B.T. said that he loved the taste and that a

certain amount makes him feel sharper and relaxed but admits he could pace himself a bit more.

Current safety and security protocols include standard unit restrictions and patient self-

harm precautions due to previous suicidal ideation. He is committed voluntarily now and is

waiting for discharge. B.T.’s labs were irregular from his alcohol dependency. His red blood

cells, hemoglobin, hematocrit, platelet levels, total protein, and AST liver enzymes were all low,
Mental Health Case Study 4

most likely due to chronic alcohol abuse causing malnourishment and damage to organs that help

maintain these levels. Along with this, his RBC morphology was abnormal, meaning there is a

great variation in the sizes of RBCs. Also, his urine protein was positive, due to kidney damage,

and he had ketones in his urine, most likely from poor nourishment. He was positive for

benzodiazepines which he stated he has at home and upon admission had a blood alcohol content

level of .578.

B.T. is currently prescribed acamprosate (Campral) 333 mg PO TID to decrease his urge

to drink, gabapentin (Neurontin) 600 mg PO TID for mood stabilization related to Bipolar II

Disorder, oxcarbazepine (Trileptal) 150 mg PO BID to decrease withdrawal symptoms,

pantoprazole (Protonix) 40 mg PO daily for gastric reflux related to chronic alcohol abuse,

duloxetine (Cymbalta) 20 mg PO daily for his diagnosis of depression, haloperidol (Haldol) 5

mg PO every six hours PRN as an injection and oral medication for acute agitation, hydroxyzine

(Atarax) 50 mg PO and (Vistaril) 50 mg injection every six hours PRN for anxiety and agitation,

trazodone (Trazadone) 50 mg PO every night PRN to assist in sleep, acetaminophen (Tylenol)

650 mg PO every six hours PRN as well as ibuprofen (Motrin) 400 and 600 mg every six hours

PRN for pain. The patient has multiple vitamins to help with his nutritional deficiency,

including folic acid (Folate) 1 mg PO daily, multivitamins PO daily, and thiamine (Vitamin B1)

100 mg PO daily. B.T. also was prescribed a transdermal patch of fentanyl 12 mcg/hr, one patch

every 72 hours for hip pain to allow him to be more mobile which after this visit will not be

prescribed again. B.T. is allergic to cefepime, a fourth generation cephalosporine, and kiwi.

B.T. has multiple medical issues. First, he has birth defects which affected his hands. He

can only use his right hand to do most tasks, which has four fingers, two work at full strength

and the other two do not work at all, and on his left hand there is only part of his fifth metacarpal
Mental Health Case Study 5

and his thumb, which do not have much strength. In 2007, B.T. was diagnosed with Myasthenia

Gravis (MG). Upon questioning whether this attributed to his alcohol dependency, he said no,

that he drank when he turned 20, stopped when he had kids, and didn’t start drinking regularly

until after his divorce. He does use a walker to help ambulate from this neuromuscular disease.

In 2009 due to high amounts of prednisone use from his diagnosis of MG, B.T. was found to

have avascular necrosis in his left hip and needed a hip replacement due to its extent of the

damage. The first surgery had an issue and months later his hip had to be redone, which led to

another problem, a MRSA infection. The infection spread into his abdomen, creating pockets of

bacteria that damaged his organs. He then went into a coma for a month where he was on a

ventilator by tracheostomy until he recovered, and a colostomy which he has still. After this

ordeal, he obtained bilateral foot contractures which also needed to be operated on.

Psychiatric Diagnoses Summaries

B.T. is diagnosed with Depression, Bipolar II Disorder, and alcohol dependency.

Depression is stated as “An alteration in mood that is expressed by feelings of sadness, despair,

and pessimism” (Townsend & Morgan p. 378). While feelings of sadness and melancholy are

short and common in everyday life, Depression happens when adaption is not effective and

symptoms impair normal life functioning. Depression is characterized by loss of interest in usual

activities, change in appetite, weight, sleep patterns, cognition, and possible somatic symptoms

(Townsend & Morgan p. 378). Depression is part of Bipolar II Disorder, which is a mood

disorder characterized by recurrent bouts of major depression with spontaneous occurrence of

hypomania (Townsend & Morgan p. 420). The main difference between Bipolar I Disorder and

this one is the occurrence of hypomania, which is a partial manic episode that does not interfere

with social or occupational functioning, lacks psychotic features, and does not warrant for
Mental Health Case Study 6

hospitalization in its own right (Townsend & Morgan p. 420). To get this diagnosis you must

have a history of one or more hypomanic episodes mixed in with depressive episodes. The

behaviors associated with this disorder involve Depression in its entirety and symptoms of

hypomania, which include inflated self esteem or grandiosity, decreased need for sleep, flight of

ideas, ability to be easily distracted, psychomotor agitation, and excessive involvement in

pleasurable activities that have a high potential for poor consequences (Townsend & Morgan p.

421).

Alcohol dependency is a substance use disorder that interferes with the ability to fulfill

role obligations due to the urge to consume alcohol (Townsend & Morgan p. 286). Drinking and

alcohol addiction is often seen with those who have depression to help forget or alleviate pain

from a certain incidence or stressful situations. According to Melisa Hall, alcohol dependency is

often seen with patients diagnosed with depression, with the comorbidities approaching as high

as 70% (Hall, 2012). Signs and symptoms of alcohol intoxication include disinhibition of sexual

or aggressive impulses, impaired judgment, mood liability, impairment of social or occupational

functioning, slurred speech, incoordination, unsteady gait, nystagmus, and flushed face

(Townsend & Morgan p. 291). These effects can make the user immediately prone to injury or

death of self and others, or over time could cause many dysfunctions of the body, such as

alcoholic cardiomyopathy, neuropathy, myopathy, esophagitis, gastritis, pancreatitis, hepatitis,

cirrhosis of the liver, leukopenia, thrombocytopenia, and sexual dysfunction.

The stressors and Behaviors Leading to the Admission

B.T. states he gets high social anxiety when interacting with people for too long, which

makes him want to drink to “feel relaxed and just enjoy myself more.” B.T. lives alone in an

apartment complex in the Warren area, which is located adjacent to a liquor store. He is
Mental Health Case Study 7

unemployed but currently enrolled in disability income. He first got a call from his landlord that

his rent was due and that he would be there in a few hours. This prompted B.T. to buy a 1.75-

liter bottle of vodka and drink a glass to keep him relaxed from this unanticipated visit. After he

paid his rent, his neighbor came over to talk to him. She said that your apartment needs cleaned

and then began to clean it for him (B.T. stated that this woman is a friend who helps take care of

his apartment regularly and he pays her some cash for the service). Due to this unexpected visit,

he poured another glass of vodka and consumed it as well. After this visit, his social worker

called and said that they were going to come for a visit today. At this point B.T. stated his

anxiety increased even more, which he then continued to drink the rest of the vodka before the

social worker arrived. When the social worker arrived, he was unconscious on the floor next to

the empty bottle and taken to the emergency department to be treated for his BAC of .578 and

dehydration. Then B.T. was taken to the ICU due to the risk of seizures upon alcohol withdrawal

during his hospital stay. During this stay he stated he wanted to die, did not care about his life,

and threatened to slit his throat. With these reoccurring threats, they sent him to the psych unit

once recovered.

Patient and Family History of Mental Illness

There is little known about family history for this patient, but he stated that on his dads’

side there is a long history of alcohol addiction. B.T. stated that he saw his dad drinking a lot

and that it was almost encouraged. Many families have a long history of multiple chronic

alcoholics. According to Dr. Jeremy Quickfall and Dr. Nady el-Guebaly:

Although it is unlikely that there is a single alcoholism gene, multiple genes (which may

exist in various allelic distributions in individuals) each exert a small effect to reach a threshold

of liability when combined with environmental factors. Genes are associated both with risk and
Mental Health Case Study 8

protection and are linked to the heritability of comorbid medical and psychiatric illness—specific

traits seen in people with alcoholism and their offspring—and patterns or symptoms of alcohol

abuse or dependence. (Quickfall & el-Guebaly, 2006, pp. 463)

This is saying that the more often alcohol dependency occurs in a family, the higher the chance

that offspring will have a shared affected gene that puts them at risk. The patient has no

recorded episodes of admission to the psychiatric unit but has appeared in the hospital for a few

other incidences, such as the MRSA infection and other alcoholic incidences. There was one

occurrence when he was in his 30s where he unintentionally overdosed on Xanax due to a high-

stress period in his life, but he woke up and was decided he was okay. It is not stated when his

diagnosis of Depression can about, but with B.T. having multiple medical diagnoses might have

played a role in it.

Psychiatric Evidence-Based Nursing Care Provided and Milieu Activities Attended

B.T. had stated in the intensive care unit that he wanted to harm himself multiple times,

leading to him being placed on self-harm precautions. This means that the patient is to be

watched even more closely than other patients, especially during times when using objects that

could be used as weapons (ex; pencil, shaving razors). Some general features that are

preventative measures for self-harm are patient checks every 15 minutes, immovable beds, steel

mirrors instead of glass, paper trash bags instead of plastic, breakaway shower curtains, locked

windows, no long cords of any sort (phone cords, call lights), and prohibition of clothing that

could be used in a harmful manner, such as hoodies, items with strings (sweatpants, shoes with

laces). Every patient that is admitted to Trumbull Memorial has the option to join in on group

therapy. It is held the same time every day and announced so that patients know when to come.
Mental Health Case Study 9

Attending multiple groups during an admission is a discharge criterion, the reason being that

these groups are beneficial to patients and can help their situation. B.T. attended groups for the

majority of his stay, and today he attended both that I witnessed. The first group was goals,

where the patients select a daily goal, like controlling anger through the day. The next group

was based on time management. In this group B.T. participated frequently and shared answers,

stating that he needed to manage his time better. The patient stated he liked to attend groups

because it gave him something to do and that it showed him differences in people’s minds.

A great tool to help patients is by building a rapport with them and creating an

environment of nonjudgment and free-thinking. B.T. was open to talking about his problems,

and even acknowledged he has a problem with alcohol, suggesting that I should not drink

because it can cause more damage than help. Having a strong rapport with a patient allows

deeper discussion to find out where problems stemmed from and gives insight on how to help

them through it. Some interventions included supporting him through the initial withdrawal,

teaching different positive coping mechanisms, and monitoring behavior.

Ethnic, Spiritual, and Cultural Influences

When asked about what his religious views were, B.T. said that he was strictly agnostic.

He stated, “I don’t believe it is in my place to assume or guess what power controls life, some

believe God, some nothing, and some just believe in stars and crap. There may be something

and there may be nothing.” He also stated that this reasoning was shared through his family.

This viewpoint on religion could affect his ability to quit if he ever wanted to, as one of the main

resources, Alcoholics Anonymous, is deeply based is religion or a higher power. While it is

possible to use others as your higher power rather than the religion itself, it becomes much

harder.
Mental Health Case Study 10

Patient Outcomes

For B.T. there are a few desired outcomes. The first and foremost is that patient safety

will be maintained throughout his stay. Due to his suicidal ideations, he is at risk for self-harm.

This can be achieved by making sure B.T. is observed more frequently, keeping the unit

restrictions in place, administering medications, and instructing the patient to seek out help when

these thoughts are there. Another would be the return of lab values to normal. This can be done

by ensuring that the patient is getting his daily vitamins and supplements that he is ordered and

making sure he eats most of his meals (having a high iron diet). Since B.T. stated that he drinks

to decrease anxiety, another outcome is verbalizing and demonstrating adaptive coping strategies

as alternatives to alcohol use. This could be using distraction to take the mind away from the

source of anxiety, meditation/guided imagery to decrease the stressor, exercise, managing time

more appropriately, and making pro-con lists to decide options. Setting realistic goals for self

can help decrease incidences of increased depression, as the patient will not feel that he failed.

This can be achieved by having small daily goals that can be completed, such as taking a shower

or taking a walk. Some goals for B.T.’s Bipolar II Disorder would be sleeping 6-8 hours a night,

interacts appropriately with other peers, and no longer show signs of agitation. A few long-term

goals for this patient are decreasing or stopping alcohol consumption (through withdrawal

therapy and abstinence program) and increased feelings of self-worth (through medication

compliance and positive thinking techniques).

Plans for Discharge

At the moment there are no listed plans for discharge. When it does come time, B.T.

stated that he wants to return to his home and doesn’t want to stop drinking. He dismissed the

idea of going to an alcohol rehab center or attending AA meetings to help quit, and there are no
Mental Health Case Study 11

court orders issued to make him do so. However, he has stated that he wanted to try to decrease

his drinking and would continue to take his Campral to decrease the urge, saying he doesn’t

know what will happen once he is back home, “I may go out there and just drink because I

haven’t in a bit, I may just drink here and there, or end up not wanting to, I won’t know until I’m

in that situation.” Even if B.T. decides to only consume minor amounts of alcohol, it can cause

him to return to previous habits. According to Howard C. Becker, “Events that potently trigger

relapse drinking fall into three general categories: exposure to small amounts of alcohol (i.e.,

alcohol-induced priming), exposure to alcohol-related (i.e., conditioned) cues or environmental

contexts, and stress” (Becker, 2008). What this is saying is that with any alcohol consumption

there is always a chance to have a relapse. B.T. wants to continue to take his Cymbalta for

Depression and his Neurontin for Bipolar II Disorder to help combat negative thoughts and

feelings. Ultimately, he has a chance of not necessarily quitting alcohol, but lowering the risk of

severe intoxication leading up to another hospital admission.

Prioritized List of All Actual Diagnoses

Iron and electrolyte imbalance related to chronic alcohol consumption as evidenced by

lab values out of normal range (low hemoglobin and protein)

Imbalanced nutrition: less than bodily requirements related to inappropriate diet with

increased carbohydrates as evidenced by stating he eats fast food often, drinking alcohol, lab

values out of normal range (urine ketones suggesting improper dietary intake)

Insomnia related to irritability and tremors as evidenced by patient stating only getting

about four hours of sleep at night

Risk for suicide related to multiple psychiatric illnesses as evidenced by patient stating he

wanted to die and didn’t care to live

Mental Health Case Study 12

Risk for falls related to multiple diagnoses as evidenced by the use of walker from hip

pain and diagnosis of Myasthenia Gravis

Anxiety related to social situations as evidenced by patient stating perceived stress when

unexpected interactions happen

Social isolation related to ineffective coping mechanisms and decreased mobility as

evidenced by stated decreased contact with family and friends, as well as diagnosis of

Myasthenia Gravis

Risk for cardiac arrhythmias related to electrolyte imbalance and chronic drinking as

evidenced by lab values out of normal range

List of Potential Nursing Diagnoses

Ineffective immune protection related to sleep deprivation and malnutrition

Ineffective coping related to use of alcohol to cope with life events

Risk prone health behaviors related to lack of motivation to change behaviors,

addiction

Risk of infection related to chronic alcohol addiction

Risk of ineffective renal perfusion related to chronic alcohol dependency

Impaired home maintenance related to Myasthenia Gravis and hip pain

Fatigue related to malnutrition

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References

Becker, H. C. (2008). Alcohol Dependence, Withdrawal, and Relapse. Alcoholic Research &

Health, 348-361

Hall, M. (2012). Alcohol and Depression. Home Healthcare Nurse, 543-550

Quickfall, J., & el-Guebaly, N. (2006, June). Genetics and Alcoholism: How Close Are We to

Potential Clinical Applications? The Canadian Journal of Psychiatry, pp. 461-467.

Townsend, M. & Morgan, K. (2017). Essentials of psychiatric mental health nursing.

Philadelphia, PA: F. A. Davis Company.