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Running head: Psychiatric Case Study

Psychiatric Case Study

Christopher Leymarie

Youngstown State University

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1. Objective Data

BB is a 19 year old female who was admitted to the psychiatric unit on 02/27/2021 for

self-harm. BB states that she was at home with her 1 year old daughter when she got into a

verbal argument with her mother. The patient became frustrated with the situation and used a

kitchen knife to cut her right wrist to harm herself. Her mother contacted the police

department who arrived shortly after the argument and found the patient covered in blood.

The patient was transported by EMS to the emergency room and was pink slipped by the police

department that responded to the scene. The patient was admitted to the psychiatric unit after

being medically cleared by the emergency room doctor.

I visited with BB on 03/02/2021. This was to be her last day on her psychiatric hold if

cleared by her treatment team. BB had no complaints when I met with her. Her demeanor was

pleasant and she denied any current or past suicidal or homicidal ideations. She denied hearing

or seeing things that weren’t actually there. She was relaxed and dressed appropriately for

being in the hospital. She did not appear agitated, restless, and had no visible akinesia,

akathisia, or tardive dyskinesia. BB was very open and friendly to caregivers and other clients

throughout the day and was more than willing to discuss her situation that brought her to the

hospital. BB mentioned to me that she feels many of her problems began when she was what

she believes “misdiagnosed” with bipolar disorder instead of personality disorder. She feels

better knowing that she feels she has been diagnosed correctly. Although pleasant today, BB

states that she has been feeling depressed more so for the past few months (specifically losing

interests in the things that she once enjoyed).

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Medically, BB had lab work completed upon admission to the hospital through the

emergency department. Her white blood cell count was 6.1, which is within the normal limits.

This was done to test for any possible infection. Her red blood cell count was 4.76, her

hemoglobin was 12.3, and her hematocrit was 41.8. Again, these are all within normal limits

and were tested to check for indications of blood loss and hypoxia, which can cause altered

mental status. Her blood glucose level was 82, which is normal and was monitored for

hypo/hyperglycemia, which can also cause altered mental status. Her urine screen was positive

for cannabinoids. BB admitted to me that she uses marijuana occasionally as a way to relax.

She also smokes cigarettes (around 0.5 packs a day). It is important to know what drugs are in

an individual’s system, as each can cause a wide variety of side effects that can mirror

psychological signs and symptoms. Finally, her thyroid stimulating hormone (TSH) was 0.46,

which is normal and was monitored for possible thyroid-related symptoms. She has allergies to

bee venom, lithium, and penicillin.

Beyond psychiatric diagnoses, BB has a past medical history of obesity, asthma, and

nicotine dependency. She reports to me that she has an albuterol inhaler at home that she

hasn’t used in years and was prescribed a nicotine patch following the birth of her son because

she wants to quit smoking cigarettes. She reports taking ibuprofen as needed for pain when

she fell a few weeks ago and scraped her knee. She did not seek medical treatment for this

incident. Her psychiatric diagnoses will be explained later in this case study. BB is on two main

psychiatric medications. BB takes oxcarbazepine (Trileptal) 300mg PO BID. Traditionally, it is

used as an anti-seizure medication, but is used is psychiatry as a mood stabilizer. BB takes it for

her personality disorder, depression, and bipolar II disorder. She also takes desyrel (Trazadone)
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50mg PO for depression. While on the unit, BB also has haloperidol (Haldol) 5mg IM and

hydroxyzine (Vistaril) 25mg IM prescribed PRN to be used as anti-anxiety and the in the event

the patient loses self-control and harm is threatened to herself or others. These are used only

as a last resort when other de-escalation measures fail.

To ensure BB’s safety and the safety of other clients on the unit, many safety measures

are put in place. Clients are checked on every fifteen minutes to ensure safety. Doors on their

individual bathrooms are Velcro attached to prevent injury. There are no sturdy hooks on the

unit to hang coats or other clothing from. Clients receive plastic silver wear for meals, which is

counted when the client returns their tray. If a client becomes combative or a danger to

him/herself or others, the least intrusive measures are used first to de-escalate the situation.

Beds are low to the ground and a screen protects windows to prevent any injury. Exposed

plumbing from sinks and toilets are covered. Soft tip markers are used in activities instead of

pens to prevent puncture wounds.

2. Summarize the Psychiatric Diagnoses

BB is officially diagnosed with bipolar II disorder, major depressive order, and

personality disorder. There are many signs and symptoms that go into diagnosing these

conditions and often times many are similar for different medical problems. These conditions

are based on normal lab work and other normal bodily functions.

According to Videbeck, “personality disorders are diagnosed when there is impairment

of personality functioning and personality traits that are maladaptive” (2020). Personality

disorders are diagnosed when individuals have identity problems, such as egocentrism
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(Videbeck 2020). Other signs and symptoms of personality disorder include negative behaviors

towards others (lying, deceit, manipulative, etc.), irritable moods, general anger/frustration,

lack of guilt for negative actions, and mistrust (Videbeck 2020). Maladaptive behaviors can be

watched and monitored throughout childhood, although a formal diagnoses of personality

disorder cannot be made until a patient is 18, ensuring that individual’s true personality has

formed completely (Videbeck 2020). Personality disorders are longstanding, as an individual’s

personality does not often change, and does not change easily (Videbeck 2020). Personality

disorders are diagnosed according to “clusters”, which focus on a specific type of behavioral

pattern (Videbeck 2020).

There are many different treatment options available for those with personality

disorder. Pharmacologically, patients can be given selective serotonin reuptake inhibitors

(SSRIs), monoamine oxidase inhibitor (MAOIs), and other antipsychotic medications (Videbeck

2020). These are prescribed based on what “cluster” a patient falls into (Videbeck 2020).

Patients can also receive cognitive-behavioral therapy to address the certain maladaptive

personality that an individual has in an attempt to reverse or alter it (Videbeck 2020).

Major depressive disorder typically involves greater than two weeks of a sad mood or

general lack of interest in activities (Videbeck 2020). Also considered would be changes in

sleep, energy levels, concentration, self-esteem, decision making, goals, and weight (Videbeck

2020). Major depression is twice as common in females compared to males (Videbeck 2020).

BB is at risk for post-partum depression after the birth of her son one year ago. It is possible

that her depression symptoms could be related to post-partum depression. An article

published by Baczynski and Sharma report that often times bipolar disorder can be overlooked
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with post-partum depression, meaning that some women are not getting the correct

treatments that they need (2019). Very little research has been done correlating the two, and it

is interesting at how similar their symptoms are, with the birth of a child being the significant

stressor that brings the symptoms out.

Treatments for major depressive disorder include MAOIs, SSRIs, and typical/atypical

antidepressants (Videbeck 2020). Individual/group therapy options are also used (Videbeck

2020).

Finally, Videbeck describes bipolar disorder as extreme mood swings from episodes of

mania to episodes of extreme depression (2020). Bipolar disorder is often initially diagnosed as

only major depression disorder, and then when the mania is observed the diagnosis is switched

(Videbeck 2020). There are three types of bipolar disorder. Bipolar I is manic episodes with

one depressive episode (Videbeck 2020). Bipolar II is recurrent depressive episodes with at

least one hypomanic episode (Videbeck 2020). Bipolar mixed varies from extreme depression

to extreme mania (Videbeck 2020). Because of this, bipolar is often misdiagnosed, specifically

bipolar II. A study by Bayes, Paris, and Parker reports that it can be very difficult to distinguish

bipolar disorder and some personality disorders because the symptoms are so similar and

interwoven (2019).

Bipolar disorder has alternating treatment methods. It can be hard to pinpoint what

symptoms to treat if a patient is going back and forth between mania and depression.

Typically, the goal is mood stabilization to offer the patient a better quality of life. Lithium is a

common drug of choice for the treatment of bipolar (Videbeck 2020). Anticonvulsant drugs can
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also be used as mood stabilizers and are frequently used (Videbeck 2020). Cognitive-behavioral

therapy and other therapy options are also available (Videbeck 2020). An interesting point of

discussion is BB’s illegal drug use. Substance use of any kind can impact the effect of

medications and treatments. A study by Coles, George, and Sasiadek found that lamotrigine

(Lamictal) and valproic sodium are the best medications to use for those suffering from bipolar

disorder and have a substance dependency (2019).

To be broad, the medications listed above have the potential for side effects that many

patients would be uncomfortable with. Because of this, these patients are at a higher risk for

being noncompliant with their medications. Some of the general side effects of different

classes of psychiatric medications can include sexual dysfunction, weight gain, heat intolerance,

gynecomastia in males, and increased risk of suicidal and homicidal ideations (Videbeck 2020).

Should any of these symptoms occur, it is important that the patient reaches out to the health

care provider to see if doses can be adjusted or if alternative medications or treatment options

are available. When meeting with the client, the nurse should explain the possibly of these side

effects at the start of treatment and throughout medication therapy.

3. Identify the Current Stressors and Behaviors

As mentioned previously, BB was brought to the emergency department by ambulance

after a self-harm incident was observed by her mother. BB got into a verbal argument with her

regarding her schoolwork, which escalated to BB slicing her wrist multiple times. BB reports to

me that she has been depressed for much of her life (at least what she can remember), but

more so after the birth of her one-year-old son. Regarding other stressors, BB states that she is
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set to graduate high school at the end of May, and feels behind in her coursework. She reports

that she is having a difficult time raising her son while trying to pass all of her classes. The

child’s father is not in the picture to help with childcare. Typically, BB’s mother will watch her

son while she is in class. BB also states that she is feeling depressed because she cannot see

her friends as often as she would like due to the coronavirus pandemic. She finds her friends as

a good resource for when she is feeling depressed and sad. BB states that she uses friends and

her mother as her primary coping mechanisms. She mentioned repeatedly that she did not

think that caring for her son would be as difficult as it has been and the added stresses of the

pandemic is just too much to handle for her. As mentioned before, she denies any suicidal or

homicidal ideations.

4. Discuss the patient and family history of mental illness

BB reports that she believes both her mother and father had depression, but were never

formally diagnosed. She did not seek help for her mental health until after her son was born in

fear of embarrassment. That is when was “misdiagnosed” with bipolar disorder and not

personality disorder.

BB reports that her depression worsened following the birth of her son a year ago. She

suggests to me that she thought she may have been experiencing post-partum depression, but

feels her bipolar disorder is more important to treat first. BB reports she hasn’t spoken to her

family about these concerns.

5. Describe the psychiatric evidence based nursing care provided and milieu activities

attended
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BB was very willing to talk to me regarding her psychiatric problems and life in general.

She reports to me that she thinks talking about her problems with her friends and family is the

best way to seek guidance and opinions. On the day of care, a classmate and I created a group

therapy session regarding coping skills. During this session, patients were able to identify both

healthy and unhealthy coping skills and put them on a blank bingo card. The coping skills were

then placed in a bag and patients took turns drawing different coping skills and filling out their

cards until someone had a bingo. Everyone was eager to participate after they saw their

participation would earn them a piece of chocolate. BB did participate actively in this session.

She also participated in another session that was conducted by the social worker, which

incorporated coping mechanisms with a game of Jenga. BB mentions to me throughout the day

that she enjoys the therapy sessions and overall participating and getting help.

Along with the group therapy sessions, BB reminded me how to play one of my favorite

games from when I was younger-Uno. The other patients loved to play it. Uno is a simple game

that is easy to learn. The patients used it as a means of talking about why they are in the

hospital and life in general. The patients also have the option to color pictures and do

crossword puzzles. I noticed that some residents will color pictures for their new friends and

give it to them before they are discharged. BB showed me a few pictures that she had received

and one she was planning to give to one of her friends who was due to be discharged later that

afternoon.

6. Analyze ethnic, spiritual and cultural influences that impact the patient
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BB and I discussed a little about her beliefs and what she thinks of those around her. BB

stated to me that she believes in God, but to what extent she is not sure. She reports that she

does not consider herself to be a religious person at all. I brought up her family and she reports

that they are not religious at all. She became interested in religion after a friend took her to

church.

BB is Caucasian. She reports no ethnic influences. BB states that her friends come from

many different ethnic backgrounds and she feels that she has a good idea of their cultures. She

does state that she feels her obesity has prevented her from seeking help due to

embarrassment. She states to me that she believes she had an eating disorder in the past in

her younger teenage years, but did not go seek treatment and therefore was never formally

diagnosed with anything. She states that because her weight is more under control at this time,

she is more willing to seek help for her medical problems.

7. Evaluate the patient’s outcome related to care

After speaking with both the patient and the care team, BB has in my opinion a good

prognosis for both discharge and following discharge. While on the unit, she has attended all

available therapy sessions and has been extremely eager to speak with anyone that is willing to

listen and possibly help with her medical care. She has had no incidents of lashing out at

caregivers or other patients and has been pleasant the entire hospital stay. She is goal-oriented

and has a plan that she wants to follow following discharge. She told me during a game of Uno

following therapy that she has a folder that she keeps the paperwork and handouts from group

in.
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When she leaves the hospital, BB wants to focus on her son and finishing high school.

Although she is thankful for the care received at the hospital, she states she does not want to

be in this situation again. She says being on the unit was an eye-opening experience and that

she knows she can’t ignore her mental health problems anymore.

8. Summarize the Plans for Discharge

The tentative discharge date for BB is 03/03/2021. BB lives a few miles away from the

hospital and has transportation from her mother available to pick her up when she is

discharged. BB states that she enjoyed the different group therapies that were on the unit and

was going to speak to her doctor about getting involved with some following discharge in an

outpatient setting. BB also wants to continue trying to quit smoking cigarettes and eventually

marijuana. Her top priority is taking care of her son and ensuring that she is healthy to do so.

BB after graduating high school wants to take a few years to get her life together and hopefully

attend a local beautician school and become a hair stylist. She also states that she wants to find

another psychiatrist or counselor that she feels will better understand her mental health needs

once she is discharged.

9. Prioritized list of all actual diagnoses using individualized NANDA format.

The following are nursing diagnoses that are relevant and noted in BB’s care. These are

either observed or more than likely present:

 Ineffective coping related to maladaptive coping techniques

 Chronic low self-esteem related to feelings of sadness

 Self-care deficit related to anergia

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 Interrupted family processes related to family member role shift

 Disturbed sleep pattern related to life changes

In relation to the first nursing diagnosis, the most important nursing diagnosis with

any patient is to ensure safety for both the patient and healthcare providers.

10. List of potential nursing diagnoses

The following are possible nursing diagnoses for BB and her care (related to her

Risk for Impaired Social interaction

 Risk for spiritual distress

 Risk for low self-esteem

 Risk for suicidal ideations

 Risk for impaired body image

 Risk for caregiver role strain

Nursing diagnoses in sections 9 and 10 are from Videbeck’s textbook and Martin’s website.

11. Conclusion Paragraph

Overall, this was a really interesting experience for me. I never realized how closely

mental health ties in to other diagnoses. Mental health is often overlooked, even in the

medical world. After talking with BB and having other clinical experiences thus far this

semester, it is easier for me to understand what factors can influence mental health and how

mental health as a whole can impact general wellbeing. Completing this case study helped me
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piece everything together and better understand all that goes into caring for patients with

psychiatric problems.
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References

Bayes, A., Parker, G., & Paris, J. (2019). Differential Diagnosis of Bipolar II Disorder and

Borderline Personality Disorder. Current Psychiatry Reports, 21(12).

https://doi.org/10.1007/s11920-019-1120-2 

Coles, A. S., Sasiadek, J., & George, T. P. (2019). Pharmacotherapies for co‐occurring substance

use and bipolar disorders: A systematic review. Bipolar Disorders, 21(7), 595–610.

https://doi.org/10.1111/bdi.12794 

Martin, P(2019, April 11). 6 Bipolar Disorders Nursing Care Plans. Nurseslabs.

https://nurseslabs.com/bipolar-disorders-nursing-care-plans/. 

Sharma, V., & Baczynski, C. (2019). Is bipolar post-partum depression overlooked? The Lancet

Psychiatry, 6(11), 891–892. https://doi.org/10.1016/s2215-0366(19)30386-4 

Videbeck, S. L. (2020). Psychiatric-mental health nursing. Wolters Kluwer. 

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Case Study Comment Sheet 4842

Student Name: Chris Leymarie

Pt Identifier: BB

Date(s) of Care: 03/02/2021

__________ 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