Running head: COMPREHENSIVE CASE STUDY 1

Comprehensive Case Study

Makayla C. Sims

Youngstown State University

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Abstract

This paper will be a comprehensive case study of a patient dealing with acute psychosis, anxiety,

and polysubstance abuse. The purpose of this case study is to explore and document the analysis

and synthesis of patient care during the care of a selected patient on an adult inpatient psychiatric

unit. This case study will focus on objective data, psychiatric diagnosis, stressors and behaviors,

family history of mental illness, psychiatric evidence based on care, and analysis of ethical,

spiritual, and cultural influences. Finally this case study will close with the evaluation of patient

outcomes, plans for discharge, prioritization of actual diagnoses, potential nursing diagnoses, and

conclusions. These concepts will be key in the articulation of this case study and its components.
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Objective Data:

A.K was admitted on 9/14/2020, and presented to the ED with incoherent speech and

delusions. On admission the patient was observed talking to someone who was not present, and

answering questions in a manner that was not understandable or did not make sense. The only

thing the patient said clearly, was that they were out partying prior to this encounter. The patient

was found by the police wandering around a parking lot with little clothing on and no shoes,

yelling and unable to answer any direct questions. The patient was diagnosed with acute

psychosis as the primary psychiatric diagnosis, in addition to anxiety and polysubstance abuse.

The DSM-5 of Psychotic Disorders, notes the criteria of acute psychosis to be the presence of

one (or more) of the following symptoms, including delusions, hallucinations, disorganized

speech (e.g., frequent derailment or incoherence), or grossly disorganized or catatonic behavior.

It notes to not include a symptom if it is a culturally sanctioned response pattern. Medical

conditions include asthma, GERD, and hypertension. The patient's treatment of asthma includes

a prescribed rescue inhaler to treat symptoms. There is no medication, or formal treatments listed

in the chart for the patient's medical diagnosis of GERD. The patient is also taking Lisinopril for

hypertension, although it had been recently discontinued in the charts, and is listed as an allergy.

Laboratory results included an elevated BUN/Creatinine. Please note that the patient is not on

lithium and does not have any present kidney issues. Results also showed an elevated TSH level,

which can contribute to insomnia, jitteriness, and mania. A urine test was also positive for

Oxycodone and Amphetamines. These drugs can cause anxiety, kidney issues, difficulty

sleeping, paranoia, and psychosis. ”Psychosis is induced by use of amphetamine more than any

other illicit substance, perhaps resulting from its extended duration of action and because it tends

to be more readily available than psychedelic drugs such as PCP and LSD”(Tabernik, 2016, p.
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296). The date of care was 9/17/2020, and the behavior observed during the day of care was very

different from the behavior observed on admission. On the day of care, the patient was pleasant,

talkative, coherent, alert/oriented x4, with judgement well intact. The patient behaved

appropriately with a normal and pleasurable affect. A.K expressed some concerns about sobriety

after discharge, and was observed bouncing their knee and appearing anxious. The patient was

also observed taking part in hygiene activities, getting dressed, speaking to a family member on

the phone, and overall taking part in normal daily activities. No delusions or hallucinations

present, reality intact. Patient self harm precautions maintained. Safety measures included good

communication, thorough report, avoiding closed/secluded environments, avoiding clothing

/accessories that may be used to cause harm, surveying the environment, always having an

escape plan, close monitoring of the patient, and avoiding sitting against a wall or across from a

door. The patients psychiatric drugs included Librium for anxiety and alcohol withdrawal, Haldol

for anxiety and agitation, Vistaril for episodes of anxiety and nervousness, and Desyrel for

anxiety and anxiety related insomnia at night. In addition, the patient was on Cogentin for

involuntary movement that was not observed on the day of care.

Summarize the psychiatric diagnoses and expected/common behaviors:

Psychosis is a state of mind that has experienced some loss of contact with reality. “A

first episode of psychosis is the time when symptoms associated with psychotic illnesses first

emerge, and include both positive symptoms (e.g., hallucinations, delusions, etc.) and negative

symptoms (e.g., affective flattening, loss of motivation, etc.)” (Jordan, 2020, p. 1). Common

behaviors include delusions, hallucinations, anxiety, panic, aggression, hostility, and suicidal

behaviour. Generalized Anxiety Is characterized by excessive anxiety and worry. Some common
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behaviors include restlessness, feeling on edge, fatigue, difficulty concentrating, Irritability,

muscle tension, and sleep disturbances (Anxiety Disorders: Electric City Counseling 2019).

Identify the stressors and behaviors that precipitated current hospitalization:

The patient states that life in general is a stressor, and that being unemployed has played a

major role in the patient's stress level. The patient is stressed out because they do not have a job,

but also worries about fitting into the workforce after this hospitalization. “Psychotic symptoms,

even when optimally treated, may persist and be extremely disruptive and impair ability to work”

(Hampson, 2020, p. 1). All the stress and generalized anxiety of daily life, and not having

employment, led the patient to drug and alcohol use while out with friends. This essentially

contributed to hallucinations, confusion, irritation, incoherent speech, and disorderly conduct

presented when found by police. This behavior eventually precipitated hospitalization and further

evaluation.

Discuss patient and family history of mental illness:

Patient states they have no family history of mental illness, and no family history of

mental illness is recognized in the charts. Patient states they have never been diagnosed with a

mental illness prior to admission, and have no previous psychiatric hospitalizations. Patient does

however state a history of admissions into rehab facilities in the past.

Describe the psychiatric evidence based nursing care provided and milieu activities

attended:
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Evidence based nursing care provided, included assessment of the patient’s mental state,

which was established by using good communication and conversation with the patient. In

addition, a relationship was built with the patient through communication, consistency, and trust.

Caring language that showed consideration was used, and consultation with knowledgeable

mental health professionals was used when needed. This included social workers, practitioners,

and nursing staff. In addition, any hazardous object was removed from the patient’s self and

environment, and a structured schedule was in place. A milieu activity that I attended with the

patient was a group session. This session discussed self care, and provided a safe and ideal

setting for the patient to work toward their therapeutic goals. I also helped to create a milieu

environment by helping to provide physical safety and wellbeing, giving support by educating

the patient about their illness and treatment plan, providing structure by assisting in the

therapeutic and predictable activity schedule, providing social interaction, and acknowledging

the patient’s feelings.

Analyze ethnic, spiritual and cultural influences that impact the patient:

A.K is of German descent, and culturally values hard work, structure, privacy, and

punctuality. The patient values working and being able to say they work hard for everything they

have. Being unemployed has conflicted with the patient's personal values, and caused feelings of

stress, anxiety, and shame. These feelings have led the patient to alcohol and substance abuse.

Germany is one of the heaviest alcohol drinking nations in Europe. According to the World

Health Organization, the European region has the highest alcohol intake of all other regions in

the world, and consumption is twice as high as the world average. The patient expressed how

drinking was acceptable in their family from a young age. A.K states that this influenced the
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decision to use alcohol consumption as a coping technique early on in life. A.K is a christian, and

states that religion has been a motivator in the patient's life, and in their current situation. It has

given the patient faith and impacted the patient's judgement for what is right and wrong. The

patient plans to attend more church services after discharge, and commit more time to faith

practices and reflection.

Evaluate the patient outcomes related to care:

After building a therapeutic relationship with the patient, and using language that showed

consideration, the patient opened up about themselves and was comfortable enough to share

information about themselves and their past. This helped to comfort the patient and give them an

outlet to open up about some things that were on their mind. Through this process, we were able

to discuss alternative coping techniques to stress, and I was able to comfort the patient by

helping to show them more positive techniques when dealing with stress and anxiety. After

collaborating with mental health professionals, I was able to answer the patients questions in an

appropriate and accurate manner. This helped establish trust between myself and the patient,

which led A.K to feel cared for and more confident. This influenced the patient's decision to

engage in therapeutic activities like group and games during my day of care. A.K states since

being admitted she feels more aware of her situation and issues she has to work on. She has also

been sleeping more, and has a clearer thought process. Helping to provide physical safety and

wellbeing to myself and the patient by avoiding closed/secluded environments, avoiding clothing

/accessories that may be used to cause harm, surveying the environment, following the unit

safety measures and protocols, all contributed to no harm, injury, or accidents involving my

patient at the end of the day of care.

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Summarize the plans for discharge:

The plans for discharge involve discharging the patient home with a complete list of

medications with dosages and usage information, written in clear simple language. The nurse

will educate and give instructions on medications and usage verbally as well. They will be

instructed that they may need to take their medicine for several weeks before they begin to feel

better, and to tell their healthcare provider about any side effects or problems with any

medications. The type or amount of medication may need to be changed. They will need to

sustain from any alcohol or drug use, and the nurse will discuss support group options with the

patient, including A.A, N.A, and support groups for anxiety and other mental illnesses.

Discharge planning will also involve plans for self care, including activities to manage stress and

anxiety levels. In addition, discharge planning will include follow up care, and referrals to other

providers.

Prioritized list of all actual diagnoses using individualized NANDA format:

● Anxiety R/T fear of relapse of substance abuse, finding a job

Evidenced by: verbalization of worry and fear, fidgeting, history of past relapses,

statement “ i'm worried I will end up using again”

● Ineffective Health Maintenance R/T ineffective coping strategies

Evidenced by: drug and alcohol use as coping techniques, poor diet, positive drug screen

for oxycodone/amphetamine, poor sleep habits

● Ineffective coping R/T loss of job, feelings of generalized worry

Evidenced by: Verbalization of inability to cope, substance use, alcohol use, destructive

behavior towards self, fatigue

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List of potential nursing Diagnoses:

● Risk for infection R/T impaired immune system from malnutrition associated with

chronic excessive alcohol intake, functional impairment, drug use

● Risk for injury R/T impaired judgement, mental status changes, risk taking behaviors

● Risk for constipation R/T opioid use, stress, poor diet

● Risk for disruption of gas exchange R/T smoking, asthma, opiod use and respiratory

depression

Conclusion paragraph:

This was the patients first encounter with issues of mental health. The patient was

diagnosed with anxiety, acute psychosis, and polysubstance abuse. The patient understands the

negative effect that substance abuse and alcoholism can have on a person's mental health. The

patient uses substance abuse, alcohol, and smoking to deal with feelings of anxiety, stress, and

worry. While talking to the patient, we discussed the need for alternative coping habits that are

effective for the patient. One positive coping technique the patient uses to cope with stress, is

interacting with their dog. We discussed more animal and comfort based alternatives to coping

that did not harm the patients mental or physical health. One major stressor in the patient's life

has been her lack of employment. Overall I feel with the proper medication regimen, effective

coping strategies, support groups, lifestyle changes, and routine follow ups, the outlook for A.K

is very bright.
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References

Anxiety Disorders: Electric City Counseling. (n.d.). Retrieved September 18, 2020, from

https://www.electriccitycounseling.org/anxiety-disorders?gclid=Cj0KCQjwtZH7BRDzARI

sAGjbK2baU7sIbP11VHm1Hu91ykPB_n357M9jgSgZIycaOzPAzm6IGp4iPUoaApGME

ALw_wcB

Hampson, M. E., Watt, B. D., & Hicks, R. E. (2020). Impacts of stigma and discrimination

in the workplace on people living with psychosis. BMC Psychiatry, 20(1), 1–11.

https://doi-org.eps.cc.ysu.edu/10.1186/s12888-020-02614-z

Jordan, G., Malla, A., & Iyer, S. N. (2020). Perceived facilitators and predictors of positive

change and posttraumatic growth following a first episode of psychosis: a mixed methods

study using a convergent design. BMC Psychiatry, 20(1), 1–16.

https://doi-org.eps.cc.ysu.edu/10.1186/s12888-020-02693-y

Tabernik, H. E., & Vitacco, M. J. (2016). Psychosis and Substance Use: Implications for

Conditional Release Readiness Evaluations. Behavioral Sciences & the Law, 34(2/3),

295–307. https://doi-org.eps.cc.ysu.edu/10.1002/bsl.2229

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

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