Running Head: PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study- Bipolar 2 Disorder

Rachel Boano

Youngstown State University

NURSL 4842: Mental Health Nursing Lab

Mrs. Phyllis Jean Defiore-Golden

October 8, 2020
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Abstract

The following case study explicates the disease process of a patient with bipolar 2

disorder, along with the treatments and plan of care provided for this individual while inpatient

on a behavioral health unit. The subject of this case study is TB, a 50-year-old African American

female that presented to the behavioral health unit after a failed suicide attempt accompanying a

major depressive episode. TB is diagnosed with bipolar 2 disorder with a major depressive

episode. Bipolar 2 disorder is defined by a pattern of depressive episodes with at least one

experience of a hypomanic episode in one’s lifetime. Numerous academic and medical journals

will be reviewed and presented to supplement the information of this individual patient in the

following case study.

PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Objective Data

50-year-old African American female, TB, was admitted to the behavioral health unit on

September 16, 2020 after a failed suicide attempt. TB was admitted a week prior to the unit due

to suicidal thoughts and ideations. Once discharged, a few days after her admission, she

attempted her suicide. A suicidal attempt is defined as a self-injurious behavior with a nonfatal

outcome accompanied by evidence that the individual intended to die. TB was diagnosed with

bipolar 2 disorder with a major depressive episode. TB has a history of suicide attempts. She was

admitted to the behavioral unit twice in 2013 and once again this September 2020 prior to this

current admission. TB has a medical history of seizures in her childhood along with

osteoarthritis. TB was compliant upon admission and arrival to the emergency department and

displayed a blunted affect. TB had no will to live at that current moment. She described her

mood as “hopeless.”

During the day of care on September 24, 2020, TB was friendly, cooperative and willing

to share and speak openly. She was calm and relaxed. She participated in group sessions

throughout the day. TB was awaiting discharge to a crisis center, a mile away from the

behavioral health unit. TB had clear and intentional speech patterns and answered questions

appropriately when prompted. The safety measures put into place during TB’s plan of care

included suicide precautions. Safety checks were implemented around the clock every 15

minutes by staff members. All hazardous items such as razors, shoelaces, belts, scissors, and

pens were not permitted on the unit. The patient’s medications were administered by the nurse

with proper verification and adequate supervision to indicate that all medications were

swallowed in their entirety and not pocketed in TB’s mouth or discarded of.
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Laboratory Results

Lab Value Result

Glucose 122
Chloride 95
Neutrophil % 87
Lymphocyte % 9.2
Neutrophil Absolute 9.98
Lymphocyte Absolute 1.06
Lithium 0.36
Alkaline Phosphatase 191

TB had quite a few abnormal laboratory results. TB displayed a glucose level of 122.

This was concluded at 3:48 pm which most likely would not have been a fasted glucose,

resulting in an inadequate measurement. TB has no history of glucose irregularities. Her chloride

level was decreased at 95 which could be indicative of the beginning of hypertension and heart

disease. TB has a family history of heart disease and recently has dealt with hypertension issues

that she expressed was due to overwhelming stress that keeps her in a heightened state. The

increase in neutrophil and lymphocyte ratio is often seen in those with mental illness. Low- grade

systemic inflammation is found to be prevalent across a range of psychiatric diagnoses, including

psychotic, mood, neurotic and personality disorders (Brinn & Stone, 2020). TB’s lithium level

was 0.36. A therapeutic range for lithium is considered to be 0.6-1.2. Lithium is a newer

medication for TB therefore a therapeutic level may not have yet been achieved. TB had an

alkaline phosphatase (ALP) level of 191 which is elevated. Alkaline phosphatase is an enzyme

found in the bloodstream. It helps break down protein in the body and exists in different forms.

Elevated ALP in TB can be indicative of her osteoarthritis. Bone disease tends to cause large

amounts of ALP in the blood (Brinn & Stone, 2020).

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Psychiatric Medications

TB is currently prescribed escitalopram (Lexapro) 5 mg by mouth daily. TB is prescribed

this selective serotonin reuptake inhibitor, antidepressant for the management of her major

depressive episodes. It works by helping to restore the balance of serotonin, a neurotransmitter in

the brain. This medication can help relieve the symptoms that accompany depression such as

feelings of sadness, emptiness, worthlessness, guilt, hopelessness, eating and sleeping less than

normal, low energy, suicidal thoughts and behaviors. The nurse providing care for TB instructed

her that she must not stop taking Lexapro even when she is feeling better and that missing doses

may increase the risk for the relapse of symptoms. The nurse also warned the client of a serious

side effect of this medication known as serotonin syndrome. This is a condition where the

medication can cause high levels of the chemical serotonin to accumulate in the body. Symptoms

range from mild such as shivering, dizziness, confusion, headache to severe such as muscle

rigidity, fever, irregular heartbeat and seizures. Severe serotonin syndrome can cause death if not

treated.

The second medication TB is prescribed is lithium. Lithium is categorized as a mood

stabilizer. It is used prevalently in those with bipolar disorder. TB is prescribed 450 mg by mouth

two times daily with meals. TB is prescribed this medication for the neurological/biochemical

changes related to mood instabilities of bipolar disorder. Lithium is also helpful when prescribed

as an “off-label” use for depression, often combined with an antidepressant medication. Bipolar

disorder and lithium treatment requires long term commitment. The nurse providing the care to

TB educated her to not stop taking lithium once she may feel better. Missing doses may increase

the risk for a relapse in mood symptoms. The nurse educated that for lithium to work properly, it

must be taken every day. The nurse also restated to TB to avoid drinking alcohol while taking
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

lithium. It is very important to ensure that TB does not encounter lithium toxicity. Lithium has a

therapeutic range of 0.6-1.2 mmol/L. Within this range, most clients will respond to the drug

without symptoms of toxicity. Lithium levels are tested weekly then monthly in those prescribed

lithium to ensure they do not have too much in their system. A diet low in sodium should be

avoided as well as ensuring adequate hydration. Dehydration can increase the risk of lithium

toxicity. It is also important to educate to avoid over the counter and prescription pain

medications that contain nonsteroidal anti-inflammatory medications because these can increase

risk for toxicity from lithium. Signs and symptoms of lithium toxicity may include tremor,

increased reflexes, difficulty walking, and an altered level of consciousness. Lithium toxicity

symptoms may last for a year after levels return to normal. It is imperative to achieve a

therapeutic level of lithium when prescribed (Videbeck, 2019).

Summarize the Psychiatric Diagnoses

Bipolar 2 disorder is a mental illness that is characterized with moods cycling between

high and low over periods of time. The “up” moods never reach full blown mania as they do in

bipolar 1 disorder. The less-intense elevated moods are called hypomanic episodes. Bipolar 2

disorder patients experience at least one hypomanic episode in their lifetime. Those with bipolar

2 disorder most often suffer more from depressive episodes. The symptoms that lead to

decreased social and occupational functioning result from the disturbance in mood due to

depression. In between episodes of hypomania and depression, a client can usually live a

typically normal life. Poor judgement control is noted in bipolar 2 disorder. Patients may act on

impulse or have problems coping and problem solving. Signs and symptoms may include mood

swings, deep sadness, hopelessness, impulsivity, self-harm, general discontent and loss of

interest in activities (Bobo, 2017).

PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

There are several environmental risk factors for bipolar disorder such as stressful life

events and childhood maltreatment. Biological risk factors also include a high intergeneration

transmission of bipolar disorder. Family history is one of the strongest risk factors for the

disorder. Researchers believe that depression is the most significant predictor of disabilities from

bipolar disorder (Marwaha & Rowland, 2017). Patients will usually take longer to recover from a

depressive episode rather than a manic one. Those that experience depressive episodes may have

greater impairment and residual symptoms from the episode. In bipolar disorder, the brain’s

normal ability to regulate emotion is compromised. Stress and conflict which often trigger

negative emotions may tend to worsen one’s symptoms. Those with bipolar disorder often

struggle with inadequate social support, hostility and criticism from their loved ones (Vieta,

2018).

Identify the Stressors and Behaviors that Precipitated Current Hospitalization

TB expressed during the day of care that she feels as though the reason for all her

problems and emotional highs and lows are due to the over expectancy her boss has for her at

work. TB holds a master’s degree in accounting and currently works as an accountant. She

expressed that her boss “expects too much” and had placed her under “job review” for a few

mistakes she had made. She expressed that that action by her boss made her feel “worthless” and

made her feel as though no matter how hard she tried; it was “never enough.”

TB has felt as though her depression has worsened as of recently, so much so that she felt

as though there is “no reason to live.” TB had a suicide plan on her first admission this month,

was able to gain stability, however, when she was discharged, she proceeded with her suicide

plan. TB had a specific plan and carried out that exact plan during her suicide attempt. TB

illegally bought a firearm, even though she had never used one prior. She then proceeded to the
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

cemetery where her mother is buried and along the way made phone calls to loved ones to say

goodbye. Her loved ones became concerned and called law enforcement to inform them that she

was in danger. TB attempted to fire the firearm and failed. Law enforcement arrived at that

moment and were able to gain control of the situation after TB surrendered the firearm. TB

stated to the police officer’s that she felt “great remorse” for putting others in danger due to her

lack of knowledge of firearms and quickly handed over the weapon to prevent a mishap that

would “hurt any of the officers.” TB was then readmitted to the behavioral unit for more

psychiatric care. TB expressed during admission that she does have a 16-year-old son at home

but that “he would be okay” without her.

Patient and Family History of Mental Illness

TB stated that she was diagnosed with bipolar 2 disorder approximately 10-15 years ago.

The only family history of mental illness is her late mother who was diagnosed with bipolar

depression. No other relatives share her disorder or any other mental illness that she is aware of.

TB has a sister and few other close family members in her life. She also has a 16-year-old son

whom lives with her. The mother of TB is deceased. There was no mention of a father figure in

her life.

Psychiatric Evidence Based Nursing Care Provided

During her admission to the behavioral health unit, TB received nursing care from the

mental health staff. Staff was present in the milieu at all times. TB was assigned a nurse each

shift that enabled her to build a new relationship and rapport with as well as being able to present

any concerns to her care. The nurse provides safe medication administration by watching the

patient to ensure she is not pocketing or discarding the medication. TB is compliant with her

medication and expresses that she does feel as though it controls her symptoms. The nurse that
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

provides care for TB is aware of which medications are used for which purpose and common

side effects of the medications. With the use of lithium, the nurse educates the need for a

therapeutic range and blood level testing. The nurse also implemented psychotherapy which can

be an effective treatment plan for those with bipolar disorder. It is also called “talk therapy” and

consists of a variety of treatment techniques aimed to allow the individual to identify and change

troubling emotions, thoughts and behaviors. This type of therapy can provide support for the

patient (Vieta, 2020).

TB stated that she feels as though being able to have a “support system” and have people

who “care for her well-being” is a rather important aspect she needs in her life. She expressed

that being able to attend therapies where she is able to talk about her emotions and gain insight

and support is where she flourishes and is most helpful to her and her individual growth.

Ethnic, Spiritual and Cultural Influences that Impact the Patient

TB is an African American, single woman from a middle-class family. She is currently

employed as an accountant but intends to apply for disability due to the stresses of her workplace

and inability to cope. TB stated she does have a belief in a higher power but that she does not

specifically identify with a religion.

Evaluate the Patient Outcomes Related to Care

Desired outcomes for a patient with bipolar 2 disorder include lifelong, ongoing

treatment that can help control symptoms and enable these individuals to live a healthy lifestyle.

Outcomes include remaining free from harming selves or others, performing self-care activities

appropriately, and gaining insight of proper judgement. On the day of care, TB was performing

her self- care activities for herself by showering, combing her hair, changing into newly washed
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

clothes, eating meals and sleeping appropriately. TB had remained free from harm while on the

behavioral health unit and had been compliant with all medications. Her sleep improved to 6-7

hours a night. TB felt as though her depression was more managed and stable than on admission.

TB denied any suicidal ideations or plans to kill herself on day of care. TB had credited group

therapy, talking with others and compliance with medication for the progress she has made on

the unit.

Summarize the Plans for Discharge

When TB is discharged she will be going to a crisis center. She will go there to continue

treatment in a therapeutic environment so she can achieve the highest level of independence,

stability and life satisfaction. Clients are admitted to a crisis center when they are stepping down

from inpatient psychiatric units. The crisis center is focused on providing client-driven services,

focusing on the individual’s strengths and building upon them, providing a realistic and

supportive therapeutic environment and empowering the clients to personally be responsible for

their lives. Treatment interventions at the crisis center are focused on stabilizing the current crisis

the client is dealing with and doing so in a less restrictive environment than that of a hospital

admission on a behavioral unit. TB will continue medication compliance and was instructed to

increase salt intake along with at least 2000 ml of fluids daily while taking lithium. TB stated

that she will apply for disability while searching for a new job that can provide her with more

satisfaction than her current position.

Prioritized Nursing Diagnoses

1. Risk for Self-Violence related to self- destructive behaviors

2. Ineffective Individual Coping related to ineffective problem solving as evidenced by self-

destructive behavior
PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

3. Risk for Situational Low Self-Esteem related to change in job expectation

4. Interrupted Family Process related to mental illness of family member as evidenced by

detachment to son

5. Disturbed Sleep Pattern related to reduced mood as evidenced by three- four hours of

sleep each night

6. Impaired Social Interaction related to disturbed thought processes as evidenced by

inability to develop satisfying relationships and poor attention span

7. Imbalanced Nutrition: Less Than Body Requirements related to inability to focus on

healthy eating habits as evidenced by lack of appetite and desire to eat

List of Potential Nursing Diagnoses

- Self-Care Deficit - Ineffective Health Maintenance

- Risk for Situational Low Self- - Ineffective Impulse Control

Esteem - Risk for Spiritual Distress

- Risk for Loneliness

Conclusion

In conclusion, TB was a patient that allowed me to gain a deeper knowledge of mental

illness as a nursing student. TB is an individual that if not questioned, one would most likely

never know she was battling with a mental illness. It opened my eyes as a nursing student to see

the different ways individuals cope with their mental illness and the outward projection of what

differing mental illness can look like to the outside world. With adequate support from her

family and continued medication compliance, I believe TB can thrive and have a high quality of

life. I believe a collaborative effort will need to be made between TB, her family and outside
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resources and services to allow her to function at her optimal level socially, individually and

occupationally. TB will need the additional support as she works through these current

depressive stages. As TB is discharged from the inpatient behavioral health unit, I believe

proceeding to the crisis center is the most efficient additional services that she needs to regain

her stability and gain that extra support she is needing.

PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

References

Bobo, W.V., (2017). The diagnosis and management of bipolar I and II disorders: clinical

practice update. Mayo Clinic, 92 (10), 1532-1551. Doi:10.1016/j.mayocp.2017.06.022

Brinn, A., & Stone, J. (2020). Neutrophil-lymphocyte ratio across psychiatric diagnoses: a cross-

sectional study using electronic health records. BMJ open, 10(7), e036859.

https://doi.org/10.1136/bmjopen-2020-036859

Marwaha, S. & Rowland, T. A., (2018). Epidemiology and risk factors for bipolar

disorder. Therapeutic Advances in Psychopharmacology, 8(9), 251-269.

doi:10.1177/2045125318769235

Videbeck, S. L. (2019). Mood disorders and suicide. Psychiatric-mental health nursing (8th ed.,

pp.284-324). Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins.

Vieta, E., Salagre, E., Grande, I., Carvalho, A. F., Fernandes, B. S., Berk, M., . . . Suppes, T.

(2018). Early Intervention in Bipolar Disorder. American Journal of Psychiatry, 175(5),

411-426. doi:10.1176/appi.ajp.2017.17090972
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Case Study Comment Sheet 4842

Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format