Running Head: Mental Health Case Study 1

Psychiatric Mental Health Comprehensive Case Study

Carlie Angelo

Department of Nursing, Youngstown State University

NURS 4842L Mental Health Nursing Lab

Mrs. Phyillis Jean Defiore-Golden

March 19, 2021

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Abstract

The purpose of this paper is to discuss the psychiatric care of a case study of a patient that was

observed on February 8, 2021. The patient has the psychiatric diagnosis of bipolar disorder with

suicidal ideation. This paper will summarize the data collected on the day of care, including the

important laboratory results, behaviors of the patient, treatments and medications, and safety and

security measures. This case study will summarize the psychiatric diagnosis, discuss the patient’s

previous history of mental illness, describe ethical, spiritual, and cultural influences, evaluate the

patient outcomes, and list nursing diagnosis for a patient with this psychiatric disorder. This

paper will include several nursing journals to further explain bipolar disorder and provide more

detailed information.
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Psychiatric Mental Health Comprehensive Case Study

Psychiatric mental health nursing involves working with individuals, families,

communities, and groups to assess and meet mental health needs of the individual. This branch

of medicine focuses on the treatment and prevention of mental disorders. The patient of this case

study is a 63-year-old male who was involuntarily committed to the behavioral health unit. The

patient’s initials are D.S. He is suffering from a manic phase of bipolar depression due to non-

compliance with medication.

Objective data

Date of admission: January 20, 2021

Date of care: February 5, 2021

Psychiatric diagnosis: bipolar disorder with suicidal ideation

Laboratory results:

Normal Value Patient value Reason for value

Creatinine (0.7-1.2) (0.6↓) Antipsychotics are nephrotoxic.

Glucose (74-99) (105↑) High levels cause manic

symptoms.

Lithium (0.6-1.2) (0.1↓) Monitor therapeutic range.

RBC (3.8-5.8) (4.78) Oxygenation

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WBC (4.5-11.5) (8.1) Infection

Hgb (12.5-16.5) (14.3) Oxygenation

Drug Screen negative Drugs exhibit psychiatric symptoms.

The behaviors observed of the patient on admission include aggressive and violent

behavior. When the patient was in the behavioral health center of the emergency room, the

patient had to be medicated because of the aggressive behavior the patient was displaying. The

patient was also frequently yelling and becoming verbally aggressive to the staff. The behaviors

observed on date of care included labile emotions and disorganized thinking. The patient was

swinging from one emotion to the next in every conversation. These emotions varied from

laughing and happy, angry, and hysterically crying and sad. The patient spoke very quickly and

was jumping from topic to topic. This is known as flight of ideas. The patient’s facial expression

was sad most of the time even during times where the emotion appeared happy. His mood and

affect did not match up with each other. The patient was unkept and was dressed sloppy with

dirty clothing. The patient was restless and presented with akathisia. The patient had a constant

urge to move. The patient also presented with tardive dyskinesia because of the long term use

and side effects of antipsychotic medication. These symptoms included excessive movement of

the mouth and a protruding tongue.

Other than the patient’s psychiatric diagnosis of bipolar disorder, the only medical

condition the patient had been diagnosed with was hypertension. In order to treat the

hypertension, the patient was taking metoprolol to control the blood pressure. However, the

patient had not been taking the medication for hypertension, as well as the medications for

bipolar disorder. The safety and security measures maintained for the patient included self-harm
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precautions. These precautions include taking away dangerous or potentially harmful personal

objects, and directly asking the patient about suicidal thoughts, means, behaviors, and intent.

The patient has several prescribed psychiatric medications. In the hospital, the patient has

been taking divalproex (Depakote) 1,000mg nightly. This medication is an anticonvulsant that is

used to treat bipolar disorder. The patient is also prescribed Lithium 300mg daily as a mood

stabilizer for mania. This medication has a therapeutic range of 0.6-1.2 so the patient must have

blood draws to ensure the patient is not reaching toxic levels. The last medication the patient is

prescribed is lorazepam (Ativan) 2mg as needed for anxiety and agitation.

Summarize the psychiatric diagnosis

Bipolar disorder is a psychiatric illness that causes extreme mood swings of highs, called

mania, and lows, which is depression. These mood swings can affect an individual’s energy,

judgement, behavior, sleep, and cognitive function. There are different categories of bipolar

disorder. Bipolar I disorder indicates the client has had at least one manic episode, followed by

hypomanic or major depressive episodes. Bipolar II disorder indicates the client has had at least

one major depressive episode and at least one hypomanic episode, but never a manic episode.

Some signs and symptoms of mania in bipolar disorder include, high self-esteem, flight of ideas,

rapid speech pattern, easily distracted, risk taking behaviors, and enthusiastic mood. During

depressive episodes of bipolar disorder, the signs and symptoms are the same as those for major

depression (Videbeck, 2020). A study was conducted to examine mixed features of bipolar

disorder. According to Bartoli et al. (2018), a mixed state occurs when an individual

simultaneously exhibits symptoms of depression and manic features during the same episode.

Bartoli et al. (2018) states, “individuals who suffer from bipolar disorders may show more severe
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clinical characteristics when mixed features occur” (p. 234). This study found that mixed

features of bipolar disorder are characterized by depressive symptoms, as well as anxiety, rapid

cycling, and suicidality.

To further evaluate bipolar depression and its pathophysiology, a study was used to find

out if chronobiology represents a major element in bipolar disorder (Hochman et al., 2016). This

chronobiology is expressed as seasonal patterns in moods. The data collected for this study was

from the electronic medical record (EMR). The data collected from the EMR included age at first

admission, gender, number of admissions each year, type of mood episode for each admission,

psychotic features, history of suicidal ideation or attempt, substance use, anxiety, and personality

disorders as well. According to Hochman et al. (2016), the study concluded, “seasonal patterns

of manic admissions is associated with male gender and the presence of psychotic features, thus

might be associated with more severe form of the disorder” (p. 123).

To examine bipolar disorder with suicidal ideation, a study aimed to assess alterations of

execution function and biochemical metabolism in bipolar disorder with and without suicidal

ideation. According to Zhong et al. (2018), “Suicidal ideation (SI) is a major predictor of

subsequent suicide attempt or completed suicide, indicating increased suicide risk” (p. 282). The

results of this study state, bipolar disorder with or without suicidal ideation may have abnormal

N-acetyl aspartate (NAA) metabolism that may distinguish suicidal ideation from the bipolar

disorder patients. Bipolar disorder with suicidal ideation may have executive function

impairment, that is associated with the abnormal NAA metabolism in the left thalamus. (Zhong

et al., 2018).

Identify the stressors and behaviors

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The stressors and behaviors that precipitated the current hospitalization included non-

compliance with medication. The patient had not been taking the prescribed medication to treat

bipolar disorder in weeks. Due to this, the patient was in a manic state of bipolar disorder. The

patient was attending a counseling session with his therapist when the patient stated he was

going to kill himself and his ex-wife. He was going to do this by overdosing on cyanide pills.

The therapist called the police, and the patient was pink slipped on arrival to the hospital. The

patient also has a history of drug use. The patient stated he likes to use drugs, including acid to

help him “let loose” at least once a week.

Discuss patient and family history of mental illness

Besides bipolar disorder, the patient does not have any further history of mental illness.

The patient has had bipolar disorder for the majority of his life and has been on and off the

medication since symptoms first started. The patient has had several other psychiatric

hospitalizations in the past two years for the mania and major depression. The patient does not

have a family history of psychiatric illness.

Psychiatric evidence-based nursing care provided and milieu activities attended

The patient attended two group therapies on this day of care. One group therapy utilized a

social worker to communicate the goals the patients have made for themselves to recover. The

social worker also talked about coping mechanisms and appropriate measures to take to start

using those skills. Another group therapy the patient attended was with a recreational therapist so

the patients could be more interactive and participate in the care provided. The patient socialized

with others on the floor in card games and conversation. The patients participate in treatment

teams to meet with the doctors, nurses, and social workers to discuss the progress they have
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made, the treatment they are providing, as well as any changes to the treatment, and concerns

made by the patient’s family members, and the plans for discharge. To maintain a safe

environment for the patients, the behavioral health unit is a locked floor so patients cannot

wander off the unit. The recreational area has locked cabinets as well, and when games or items

are requesting to be used, staff will come and open it for them. The patient has suicidal ideation,

so the patient will have more self-harm precautions, and dangerous personal belongings will be

taken away. To keep track of the patients on the floor, there is an employee who walks around

the unit every fifteen minutes to keep track on a device the whereabouts of each patient.

Analyze Ethnic, spiritual, and cultural influences

The patient is a Caucasian, 63-year-old, male. The patient’s highest level of education is

a high school diploma. He is retired from working in the steel mill for thirty-seven years. He is

chronically ill and is currently unemployed because he is unable to maintain a job due to the

instability of the illness and lack of medication compliance. The patient did not recognize having

any spiritual beliefs. He is divorced from his wife but remains in communication with her daily.

Evaluate the patient outcomes

The patient was compliant with medications on the day of care. He took all medications

without question and is starting to use more of his coping mechanisms when redirected. The

patient had labile emotions and continued to have flight of ideas. Near the end of the day, the

patient was verbally aggressive with the staff. He was angry that we would not allow him to have

a cigarette and made it known to the staff that he was unhappy through abusive language and

pounding on the desk of the nurse’s station. The Nurses handled the situation well and had him

walk away and perform deep breathing techniques. One nurse even said to him he could be
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angry, but he cannot use the aggressive behavior. The patient is using drawing as a coping

technique to channel relaxation and redirect the disorganized thinking pattern. The patient

participated in the group therapy sessions and was very open to talking with me about his life.

However, the patient did not want to share any information on why he was in the hospital and

quickly changed the topic when I asked about it.

Plans for discharge

The patient was involuntarily admitted on January 20th. The plans for discharge for the

patient were not fully put into place on the day of care. The patient still had several days left on

the court ordered pink slip to stay on the behavioral health unit. The patient had an ankle bracelet

on to track him in the hospital and will continue to wear it for the time being and when he is

discharged. He will have mandatory outpatient appointments, including therapy sessions. Based

on the conversations we had, the patient will not be choosing to stay longer on the unit

voluntarily.

Prioritized list of nursing diagnosis

1. Ineffective individual coping related to ineffective problem-solving strategies as

manifested by use of drugs to cope and aggressive behaviors.

2. Impaired social interaction related to excessive hyperactivity and agitation as manifested

by poor attention span and difficulty focusing on one thing at a time.

3. Interrupted family process related to nonadherence to antimanic and other medications as

manifested by changes in communication patterns and an inability to deal with traumatic

or crisis experiences constructively.

List of potential nursing diagnosis

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1. Risk for suicide related to bipolar disorder.

2. Risk for self-directed violence/others directed violence r/t verbal threats against self and

ex-wife.

3. Risk for injury related to extreme hyperactivity and physical agitation.

Conclusion

Taking care of this patient allowed me to understand the severity of mental illness and the

true effects it has on individuals. Having the opportunity to obtain insight on what it is like to

care for patients with severe and unstable mental illnesses allows me to understand the

challenges of this category of nursing. Seeing the long-term effects antipsychotic medications

have on patients was a great experience. Psychiatric nursing is used on every type of nursing, not

to the same extent of the psychiatric floor, but nurses still need to learn how to take care of these

patients and develop skills in forming therapeutic relationships.

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References

Bartoli, F., Crocamo, C., & Carrà, G. (2020). Clinical correlates of DSM-5 mixed features in

bipolar disorder: A meta-analysis. Journal of Affective Disorders, 276, 234–240.

https://doi-org.eps.cc.ysu.edu/10.1016/j.jad.2020.07.035

Hochman, E., Valevski, A., Onn, R., Weizman, A., & Krivoy, A. (2016). Seasonal pattern of

manic episode admissions among bipolar I disorder patients is associated with male

gender and presence of psychotic features. Journal of Affective Disorders, 190, 123–127.

https://doi-org.eps.cc.ysu.edu/10.1016/j.jad.2015.10.002

Videbeck, Sheila L. (2020). Psychiatric-mental health nursing (8th ed). Philadelphia, PA:

Wolters Kluwer.

Zhong, S., Wang, Y., Lai, S., Liu, T., Liao, X., Chen, G., & Jia, Y. (2018). Associations between

executive function impairment and biochemical abnormalities in bipolar disorder with

suicidal ideation. Journal of Affective Disorders, 241, 282–290.

https://doi-org.eps.cc.ysu.edu/10.1016/j.jad.2018.08.
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