Running head: PATIENT CASE STUDY 1

Patient Case Study

Makaela Giannini

Youngstown State University

NURS 4842L: Mental Health Nursing

Mackenzie Kriss

November 2021
PATIENT CASE STUDY 2

Abstract

This study explores the case of a patient diagnosed with major depressive disorder,

obsessive-compulsive disorder, and polysubstance dependence. Type 1 diabetes mellitus also

factors into the patient’s case as well. The patient is a 31-year-old Caucasian male admitted to

the behavioral health unit for a nonfatal suicide attempt caused by delusions, paranoia, and an

exacerbation of obsessive-compulsive disorder. The patient’s history, medical diagnoses,

stressors, nursing diagnoses, and medications are analyzed throughout this study to increase

overall understanding of the case. A variety of evidence-based care such as health-teaching,

medication adjustments, talk therapy, and goal setting was utilized based upon the patient’s

needs, and eventually assisted the patient in both stabilization and expression of feelings. The

care provided was then assessed based upon the patient outcome. After several days of inpatient

psychiatric care, this patient assisted providers in creating an appropriate discharge plan that will

facilitate recovery.
PATIENT CASE STUDY 3

Objective Data

The patient is a 31-year-old Caucasian male with a medical history of type 1 diabetes

mellitus with hyperglycemia, hypertension, irritable bowel syndrome, and tobacco abuse. As for

his psychiatric history, the patient’s primary diagnosis is major depressive disorder (MDD),

recurrent episode with mixed features. To be diagnosed with major depressive disorder, the

patient must have “a major depressive episode last[ing] at least 2 weeks, during which the person

experiences a depressed mood or loss of pleasure in nearly all activities” (Videbeck, 2020, pg.

656). Additionally, the patient struggles with obsessive-compulsive disorder (OCD) and

polysubstance dependence. According to the patient, his polysubstance dependence has been in

remission for two months.

The patient presented to the emergency department (ED) on October 23rd of 2021 with a

chief complaint of depression and attempted suicide by medication overdose. Upon arrival to the

ED, the patient disclosed that for over two months, he had been experiencing persecutory

delusions of police plotting to arrest him, despite any legal history. His obsessive-compulsive

disorder had also recently been exacerbated by his stress. The delusions and paranoia ultimately

led him to his suicide gesture. According to the patient, he had intentionally overdosed on five

bottles of prescription medication one to two hours prior to arrival to the ED, including

trazadone, aripiprazole, and pain medication. The patient estimated his ingestion to be about 100

pills. After ingesting the medication, the patient vomited but denies the presence of pills in his

vomit. From the ED, the patient was transferred to the intensive care unit (ICU) for stabilization.

On October 26th of 2021, the patient was involuntarily admitted to the psychiatric floor due to

being at substantial risk of physically harming himself.

PATIENT CASE STUDY 4

Upon arrival to the ED following the aborted suicide attempt, the patient’s complete

blood count (CBC) was within normal limits, but his complete metabolic panel (CMP) had some

abnormalities. Due to stress and type 1 diabetes mellitus, he had significant hyperglycemia with

his glucose at 468 mg/dL; this was treated with a 2-liter bolus of normal saline and 10 units of

regular insulin. The patient was also in uncompensated respiratory alkalosis with a blood pH of

7.46, PaCO2 of 30 mmHg, and HCO3 of 22 mEq/L. His electrocardiogram (EKG) showed sinus

tachycardia and a prolonged QTc of 520 ms. His drug and alcohol screen were negative, which

proves that the patient has, in fact, remained in remission from his polysubstance dependence as

stated. On October 26th of 2021, the patient’s labs were redrawn. His CBC showed a low

hemoglobin and hematocrit of 13.1 g/dL and 38.4%, which could be attributed to poor nutrition

caused by the patient’s critical state in the ICU. Because of his diabetes, his glucose was slightly

elevated at 124 mg/dL, and his A1c was very elevated at 9.0%. The patient’s high A1c showed

lack of adherence to his diabetic treatment regimen, which was addressed during the interview.

All other components of the patient’s CBC and CMP were within normal limits. His QTc also

decreased to 436 ms, but his EKG still showed sinus tachycardia.

On the date of care, November 2nd of 2021, the patient encounter began at a table in the

milieu. He was well-groomed with good hygiene, wearing street clothes. The patient was

cooperative, polite, and friendly, and took interest to the conversation. His posture was rigid, and

he was restless, constantly adjusting his glasses and touching his head. His speech patterns were

rapid with a normal volume and no evidence of aphasia or impediments. The patient maintained

appropriate eye contact throughout the conversation. His affect was congruent with his mood and

remained appropriate throughout the conversation. The patient denied feelings of depression or

anxiety, but expressed guilt related to the stress caused to his parents by his suicide attempt. The
PATIENT CASE STUDY 5

patient’s form of thought was appropriate with no abnormalities. Patient was able to concentrate,

and his attention span was intact. The patient did, however, endorse persecutory delusions of

police plotting to arrest him, causing extreme paranoia and suspiciousness; he states that his

paranoia has decreased significantly since being admitted to the unit, and he is now able to

recognize that his thoughts regarding police were delusions. He was admitted for suicidal

ideations with an attempt to overdose but denies current suicidal or homicidal ideations due to

the decrease in paranoia. The patient denies hallucinations, illusions, or depersonalization.

The patient was oriented to time, place, person, and circumstances. His recent and remote

memory were intact with no evidence of confabulation, and his capacity for abstract thought was

intact. The patient endorsed impulsivity regarding substance use, stating that he is unable to

control himself when drugs are present, but denied issues regarding other areas of impulse

control. The patient has poor judgment and insight. His ability to problem-solve is poor due to

his use of substances to mask diabetic symptoms, rather than controlling his diabetes. His ability

to make decisions is also poor due to his need for encouragement to form decisions. The patient

has adaptive coping mechanisms of taking walks, listening to music, and spending time outdoors.

His maladaptive coping mechanisms include substance use and hoarding. This patient uses ego

defense mechanisms of avoidance, rationalization, and withdrawal.

Despite denying current suicidal ideations, due to his recent suicide attempt, the patient is

on suicide precautions. Because “the first 2 years after an attempt represents the highest risk

period [for suicide], especially the first 3 months,” the patient should remain on suicide

precautions throughout the entirety of his stay, with checks at least every 15 minutes (Videbeck,

2020, pg. 723). Suicide precautions taken on the unit include the removal of sharp objects and
PATIENT CASE STUDY 6

objects posing a ligature risk, ensuring that patients don’t cheek their medication, checks at the

minimum of every 15 minutes, and one-to-one supervision if necessary.

Psychiatric Diagnoses

The patient was admitted with an existing diagnosis of major depressive disorder.

Physical symptoms associated with MDD are changes in eating habits, weight changes, fatigue,

insomnia, and hypersomnia; inability to concentrate, impaired decision-making, inability to cope,

and poor problem-solving are also common with MDD. Patients with MDD often express

feelings of hopelessness, despair, guilt, worthlessness, and they may experience thoughts of

death and suicide. Upon discharge from his September of 2021 admission, the patient was

prescribed 150 milligrams of Effexor XR daily, with 5 milligrams of Abilify daily to augment

the antidepressant therapy. The patient, however, does not believe these medications were

effective so they were discontinued. To stabilize his mood without the use of an antidepressant,

the patient is now prescribed 50 milligrams of quetiapine once a day, and another 100 milligrams

of quetiapine at bedtime. He claims that quetiapine seems to be regulating his mood, and he

plans to remain compliant with this medication.

Regarding obsessive-compulsive disorder, the American Psychiatric Association (2013),

stated that:

OCD is characterized by the presence of obsessions and/or compulsions. Obsessions are

recurrent and persistent thoughts, urges, or images that are experienced as intrusive and

unwanted, whereas compulsions are repetitive behaviors or mental acts that an individual

feels driven to perform in response to an obsession or according to rules that must be

applied rigidly. (pg. 235)

PATIENT CASE STUDY 7

The patient struggles with compulsions related to germs and hoarding, which are two of the most

common obsessions associated with OCD. Other common behaviors associated with OCD are

repetitive and excessive checking, counting, arranging, washing, touching, and praying. To treat

this patient’s recent exacerbation of OCD, the provider ordered 150 milligrams of fluvoxamine;

fluvoxamine inhibits the reuptake of serotonin, which can decrease the presence of unwanted

thoughts and compulsions. According to the patient, his obsessions and compulsions have

decreased since being admitted to the unit, but he feels that it’s because his paranoia and

delusions have ceased. He was just recently started on fluvoxamine, so the maximum therapeutic

effect will be achieved in four to six weeks.

The patient has also been diagnosed with polysubstance dependence but has been in

remission for two months, as evidenced by his negative drug and alcohol urine screen. To

receive a diagnosis for substance abuse, a patient must “[use] a drug in a way that is inconsistent

with medical or social norms and despite negative consequences” (Videbeck, 2020, pg. 810).

According to Videbeck (2020), substance abuse can cause “problems in social, vocational, or

legal areas of the person’s life, while substance dependence also includes problems associated

with addiction such as tolerance, withdrawal, and unsuccessful attempts to stop using the

substance” (pg. 810). This patient claimed to experience many of these issues related to

substance abuse prior to remission and plans to remain in remission to prevent these issues from

arising again. According to the patient, his drugs of choice are marijuana, methamphetamines,

and cocaine. Following his hospitalization in September, the patient was discharged to an

inpatient addiction rehabilitation center in Columbus; he stayed for less than two weeks,

claiming that the facility was dirty and lacking resources. The current plan is to discharge the

patient to another inpatient addiction rehabilitation center. He will be transferring to this facility
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with goals of remaining compliant and completing the treatment process. Despite the patient’s

history of substance abuse, he is not prescribed any medications to suppress cravings. Vivitrol

could be an appropriate medication to suppress the patient’s drug cravings because it is a long-

acting injection, which would increase compliance to the treatment regimen.

Stressors and Behaviors

The patient stated that his diabetes is a significant stressor that exacerbates his psychiatric

disorders. When his blood sugar is fluctuating, he experiences feelings of confusion, agitation,

anxiety, and fatigue. Labile blood glucose can be a significant stressor for patients struggling

with both mental health and diabetes; studies have shown that patients with “diabetes described

experiencing fatigue from increasing blood sugar levels, which in turn had a negative impact on

their mental health (which affected motivation for self-management)” (Balogun-Katung et al.,

2021, pg. 13). Additionally, the treatment regimen for diabetes is complex and expensive,

causing the patient to have decreased compliance. Recent studies have proven that “participants

[that] were mentally unwell, were more likely to forget to take their medication or repeat doses,

or to check blood glucose levels and eat regularly” (Balogun-Katung et al., 2021, pg. 20). The

constant mood changes along with his exacerbation of MDD and OCD diagnoses caused severe

stress on the patient, leading him to enter a delusional state of mind where he believed that police

officers were plotting to arrest him. The two months of overwhelming paranoia caused by his

persecutory delusions ultimately led the patient to a suicide attempt.

Patient and Family History of Mental Illness

The patient denies a family history of mental illness or suicide, but states that his

grandmother does struggle with diabetes. According to the patient, his struggle with mental
PATIENT CASE STUDY 9

health began when he was diagnosed with diabetes at a young age. He felt “different” and was

constantly struggling with mood changes due to his fluctuating blood sugars. When he reached

his early 20s, he began to mask the symptoms of hyperglycemia and hypoglycemia with drug

use, which eventually lead to polysubstance dependence. Around the time he was diagnosed with

diabetes, he also began experiencing symptoms of OCD. The patient explained that his

compulsions with germs and cleanliness became so severe that it began to impact his

functionality. It even began to impact his social life; he claims that his online username was

“sanitizer1.”

Prior to the current admission, the patient had been hospitalized in inpatient psychiatry

multiple times for suicidal ideations. According to the patient, his first suicide attempt was in

2016 after a breakup with his significant other and the loss of a job. During the admission

following his 2016 suicide attempt, the patient was diagnosed with major depressive disorder.

His most recent hospitalization was in September of 2021 for suicidal ideations with a plan to

hang himself. The patient has also been admitted to inpatient addiction rehabilitation multiple

times for his polysubstance dependence diagnosis, with the most recent being in September.

Evidence-Based Nursing Care Provided

During the conversation, the patient mentioned difficulty communicating with his

parents. When asked how he could be assisted in improving communication with his parents, he

suggested that the feelings he expressed be documented. Rather than a complete documentation

of the conversation, it was agreed that creating a list of ten goals would show his parents his

desire to change. The goals the patient decided upon included remaining compliant with

treatment and medications, exercising more often, visiting an endocrinologist for his diabetes,
PATIENT CASE STUDY 10

visiting a nutritionist, downsizing his storage unit, refraining from drug use, securing a part-time

job, finishing filing for bankruptcy, visiting a physician and physical therapist for the muscular

atrophy in his left arm, and looking into getting a service dog. Creating a list of goals was

utilized because “goal-setting theory suggests that goal achievement leads to increased self-

efficacy” (Fredrix et al., 2018, pg. 971). This patient lacks self-efficacy, so encouragement to

become more self-reliant is essential. Furthermore, recent studies have suggested that “goal-

setting interventions could be a beneficial strategy for improving glycemic control” (Fredrix et

al., 2018, pg. 971). This patient needs a sufficient way to control his diabetes, and goal setting

may provide him with the motivation necessary to make a change.

Information regarding community-based support groups such as AA, Narcotics

Anonymous, and diabetic support groups were provided to the patient. Studies have shown that

“support groups often provide a safe place for group members to express their feelings of

frustration, boredom, or unhappiness and also to discuss common problems and potential

solutions” (Videbeck, 2020, pg. 146). The patient expressed difficulty communicating his

feelings with his parents; support groups may help the patient both identify and accept his

feelings. Because he has been living in a state of denial for many years, acceptance of his

situation and diagnoses can drastically improve the patient’s wellbeing. The patient was also

given the mental health crisis hotline, 211, and was instructed to call this number or 911 if he

was experiencing suicidal ideations.

During his stay on the unit, the patient has been attending group therapy sessions, as well

as participating in individual therapy sessions. According to the patient, he has attended therapy

sessions focused on MDD, loss of reality, substance abuse, coping mechanisms, and self-care.
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Due to the patient’s history of MDD and OCD, individual sessions of cognitive behavioral

therapy (CBT) would be most beneficial. CBT would allow the patient to reform his negative

thought processes related to MDD, and work on decreasing time spent on compulsions related to

his OCD diagnosis.

Ethnic, Spiritual, and Cultural Influences

The patient is 31-year-old, Caucasian male. His is unemployed and endorses struggling

with finances. He is Christian, and although he denies attending church regularly, he states that

Christianity used to be a significant aspect of his life. Religion could possibly play a key role in

the patient’s feelings of guilt. Regarding OCD, “highly religious individuals, both Christian and

Muslim, may have a heightened sense of personal guilt (about their symptoms) and beliefs that

they should be responsible for controlling unwanted, threatening thoughts” (Videbeck, 2020, pg.

566). Throughout the conversation, the patient repeatedly expressed guilt related to his poor

mental health and how it negatively affects his parents, leading the question of whether religion

is contributing to the patient’s fragile emotional state.

Patient Outcomes

Since admission to the behavioral health unit, the patient has been compliant with

medications and meeting expectations set by the providers. He has been attending group therapy

sessions and working towards improving his mental and physical health. After speaking with the

patient, he disclosed that he his paranoia and delusions have ceased since being admitted to the

unit. Additionally, although he was admitted for suicidal ideations, the patient denies current

suicidal or homicidal ideations. When discussing our conversation, he expressed that it made him

feel both heard and understood. He explained that the list of goals we had created would help
PATIENT CASE STUDY 12

him communicate with his parents. He also stated that he would be working on these goals when

he is released from drug addiction rehabilitation. Furthermore, he expressed interest in attending

the support groups suggested to him, such as Narcotics Anonymous or diabetic support groups.

He agreed to call either the mental health crisis hotline (211) or 911 if he experiences another

crisis or is having thoughts of harming himself.

Plans for discharge

Upon discharge, the patient will be released to an inpatient addiction rehabilitation center

where he will continue with his mental health treatment and recovery from addiction. The patient

plans to remain compliant with his medications, as well as participate in outpatient therapy

sessions. He will be prioritizing his mental health by working towards completing the list of

goals he created. Additionally, he plans to collaborate with an endocrinologist to generate a

diabetic treatment regimen that is less complex and easier to remain compliant with.

Nursing Diagnoses Prioritized

1. Risk of Suicide r/t major depressive disorder, persecutory delusions, paranoia, and history

of multiple suicide attempts as evidenced by suicidal ideations with attempt to overdose

on medication

2. Risk for Self-Directed Violence r/t history of multiple suicide attempts, major depressive

disorder, paranoia, persecutory delusions as evidenced by suicidal ideations with attempt

to overdose on medication

3. Risk for Unstable Blood Glucose Level r/t type 1 diabetes mellitus, lack of adherence to

diabetes management, stress, poor mental health status, and inadequate blood glucose

monitoring as evidenced by fluctuations in blood glucose, A1C of 9.0, and repeated

hyperglycemic episodes
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4. Ineffective Self-Health Management r/t type 1 diabetes mellitus, complexity of

therapeutic regimen, and economic difficulties as evidenced by reports of difficulty with

prescribed regimens, fluctuating blood glucose, and A1C of 9.0

5. Chronic Low Self-Esteem r/t major depressive disorder, obsessive-compulsive disorder,

and repeated failures as evidenced by self-negating verbalizations and repeated

expression of worthlessness

Listed Potential Nursing Diagnoses

1. Powerlessness r/t illness-related regimen

2. Risk for Impaired Liver Function r/t hepatotoxic medication (quetiapine/Seroquel)

3. Insomnia r/t fear, anxiety

4. Anxiety r/t threat to health status

5. Ineffective coping r/t inadequate level of perception of control

6. Readiness for enhanced knowledge r/t patient expressing desire to expand knowledge on

diagnoses

Conclusion

The patient was admitted involuntarily following a nonfatal suicide attempt. Once

admitted to the behavioral health unit, the patient was started on a new medication regimen.

After multiple days on the new medications, the patient began to stabilize. With the help of the

medication regimen, individual and group therapy, and the patient’s own participation in care,

his paranoia, delusions, and suicidal ideations have ceased. The patient will be discharged to an

inpatient addiction rehabilitation center where he will continue treatment for his psychiatric
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disorders and polysubstance abuse. Overall, I am proud of myself for thoroughly educating the

patient on his diagnoses, as well as including him in creating a list of goals to work towards.
PATIENT CASE STUDY 15

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Balogun-Katung, A., Carswell, C., Brown, J. V. E., Coventry, P., Ajjan, R., Alderson, S.,

Bellass, S., Boehnke, J. R., Holt, R., Jacobs, R., Kellar, I., Kitchen, C., Lister, J.,

Peckham, E., Shiers, D., Siddiqi, N., Wright, J., Young, B., & Taylor, J. (2021).

Exploring the facilitators, barriers, and strategies for self-management in adults living

with severe mental illness, with and without long-term conditions: A qualitative evidence

synthesis. PLoS ONE, 16(10), 1–28.

https://doiorg.eps.cc.ysu.edu/10.1371/journal.pone.0258937

Fredrix, M., McSharry, J., Flannery, C., Dinneen, S., & Byrne, M. (2018). Goal-setting in

diabetes self-management: A systematic review and meta-analysis examining content and

effectiveness of goal-setting interventions. Psychology & Health, 33(8), 955–977.

https://doi-org.eps.cc.ysu.edu/10.1080/08870446.2018.1432760

Videbeck, S. (2020). Psychiatric-Mental Health Nursing (8th ed.). Philadelphia, PA: Wolters

Kluwer.
PATIENT CASE STUDY 16

Case Study Comment Sheet 4842 (Turn in with Case Study)

Student Name: Makaela Giannini

Pt Identifier: J.P.
Date(s) of Care: 11/2/2021

__________ 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