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MENTAL HEALTH COMPREHENSIVE CASE STUDY

Mental Health Comprehensive Case Study

Morgan Bosley

March 6, 2022

Mrs. Teresa Peck, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

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MENTAL HEALTH COMPREHENSIVE CASE STUDY

Abstract

JW is a 30-year-old male admitted to the inpatient psychiatric unit following being kicked out of

the halfway house for starting an argument and threatening that he had a knife on him while

living there. He was in jail before living at the halfway house. He has a mental health diagnosis

of severe manic bipolar one disorder with psychotic behavior and suicidal ideation. Along with

this, he also has borderline personality disorder, a history of severe cutting, depression, and

schizo-affective disorder. He is allergic to vancomycin and mushroom extract. He is being

treated with antipsychotics, mood stabilizers, individual and group therapy, and behavioral

therapy. He is on strict suicide precautions. He shows dominance on the psychiatric unit to others

and is capable of becoming very violent. He has frequent mood swings and is extremely loud and

attention seeking. Nursing care on the unit is focused on improving his mental health through the

use of pharmacologic therapy, behavioral therapy, group and individual therapy, and more.

Although he seems to be improving from his initial admission assessment, he still threatens

suicide as soon as he is discharged. He is currently homeless, after being kicked out of the

halfway house.
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Objective Data

Patient identifier JW

Age 30 years old

Date of admission 2/19/2022

Date of care 2/24/2022

Psychiatric Diagnosis Severe manic bipolar 1 disorder with psychotic behavior and suicidal

ideation

Other Diagnosis Borderline personality disorder, depression, schizo-affective disorder, history

of cutting

Behaviors on admission JW presented to the ED on 2/19/22 with a manic episode of bipolar 1

disorder and suicidal ideation. He arrived with parole officers and was handcuffed after

threatening having a knife in the halfway house. He was very frazzled and was

uncooperative with the ED staff. He refused to wear his gown and only wanted to wear

his clothes. He threatened the ED staff that if he cannot shower soon, he will hurt one of

the staff members. He got irritated when asked “triggering” questions in the ED and

refused to take off his sleeved shirt because his cutting scars and tattoos trigger him. He

wore fingerless gloves on his hands so that he could not see his hand tattoos.

Behaviors on day of care JW had several mood swings on the day of care but was more

cooperative than when he was first admitted. He was wearing a hospital gown and

hospital pants. He was hesitant to answer certain questions but discussed in detail about

his tattoo meanings and about his gang. He carried a blue bandana and stated that it was

to represent “his people” (meaning the Crips gang). He was an active participant in the
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group stretching activity. He was very loud-spoken and wanted the attention on him. He

made a friend on the unit and said that he was afraid to speak unless he had his friend

next to him. He discussed how he has led to many deaths with his gang and talked

proudly about his tattoos.

Safety and security measures JW is on suicide precautions on the psychiatric unit. He told the

nurse practitioner “Even though I’m laughing with the students I still am going to kill

myself as soon as I get out of this place”. He is closely watched by the staff to ensure that

he is safe and not able to kill himself. Several days into his stay on the unit after an

individual therapy session he stated “I can kill myself right now if I want to. I killed

myself at 14 and 17 and I became alive again. You can’t stop me with these suicide

precautions”. Because he recently got kicked out of the halfway house and has no other

place to go, the nurse practitioner is debating whether he is actually extremely suicidal or

if he is saying those things as a way to keep himself on the unit so that he will have

somewhere to stay. There is a rounding nurse that rounds every fifteen minutes to check

on the patients to ensure they are safe and to document what they are doing at that time.

No pens or pencils are allowed to be used by the patients. Only markers are used by the

patients. There are also no sleeves allowed on the patient’s clothing, as these could be

used to assist in suicide.

Laboratory Results

Lab Values Results

Glucose WNL
TSH WNL
T4 WNL
RBC WNL
Hbg/Hct WNL
WBC WNL
BUN/Creat WNL
QTc Normal sinus rhythm
Toxicology Positive for cannabis
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Psychiatric Medications

Generic Name Trade Name Class/Category Dose/Frequency

Magnesium hydroxide Maalox laxative 10-20 mg, 4x/day

lorazepam Ativan Sedative, anti-anxiety 2-6mg/day

Trazodone Desyrel Antidepressant, 150mg/day

sedative

Haloperidol Haldol antipsychotic 0.5-2.0 mg/day

Quetiapine Seroquel antipsychotic 50mg q 8 hours

Citalopram Celexa SSRI 20-40mg/day

Oxcarbazepine Trileptal anticonvulsant 300 mg/day

Summary of Psychiatric Diagnosis JW presented to the hospital with severe manic bipolar 1

disorder with psychotic behavior and suicidal ideation. Bipolar one disorder is more

severe than bipolar two disorder and is “characterized by manic episodes with at least one

depressive episode” (Videobeck 699). According to an article in the book Psychiatric

Mental Health Nursing, “Bipolar disorder involves extreme mood swings from episodes

of mania to episodes of depression” (Videobeck 698). Some people show more signs of

mania than depression and vice versa, however it is always a combination of both over a

short period of time. According to an article titled Effect of Lithium Treatment on the

Content of Lithium, Copper, Calcium, Magnesium, Zinc, and Iron in the Hair of Patients

with Bipolar Disorder, it states, “Bipolar disorder is a lifelong mental illness that requires

psychopharmacotherapy. The frequency of subsequent episodes of mania and depression

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is strongly dependent on the systemic intake of appropriate mood stabilizers or

antidepressants” (Kabzińska-Milewska 792). Along with this, in a different article titled

Effectiveness of Mindfulness-Based Cognitive Therapy, it states, “Bipolar one disorder is

a debilitating mental health disorder characterized by mood lability, irritability,

depression, and mania, which increases the risk for psychosis, substance abuse, and

suicidality. Genetics appear to play a major role in the development of bipolar one

disorder” (Bruns, K 59).

Identification of Stressors and Behaviors Precipitating Current Hospitalization

JW was living in a halfway house following getting out of jail. While living in the halfway house

he became incompliant with his medications and was threatening carrying around a knife.

Because of this, police arrived at the house and brought him to the ED, where he was

then admitted to the psychiatric unit. JW has a history of manic episodes related to his

bipolar one disorder. He is at extreme risk for suicide upon discharge. He was manic in

the ED and was rude to staff. On the unit he had trouble sitting still, did not like

answering certain questions that triggered him, and did not like to talk about things that

irritated him.

Patient and Family History of Mental Illness JW’s family history is unknown. It can be

assumed that his family also suffers from bipolar disorder and borderline personality

disorder. He is diagnosed with severe manic bipolar one disorder with psychotic behavior

and suicidal ideation. He has been hospitalized multiple times over the years for his

diagnosis. According to an article by Brazilian Journal of Psychiatry, “Repeated episodes

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of bipolar disorder occur on average with increasingly shorter euthymic intervals and

increasing severity and treatment resistance” (Post, R. 552). Along with this, the journal

also states, “Greater numbers of prior episodes are also associated with increasing

cognitive dysfunction” (Post, R. 552). In 2018, JW had an episode where he cut off the

tips of his ears, tried to eat them but then choked, and then was intubated. He has scars

covering his arms from a history of cutting. It is noted in his chart that his tattoos and

scars are triggers for him, which is why he wears sleeves and gloves to cover them so he

cannot see them. He stated that he had several tattoos that he scraped off of his body with

his nails because he did not like them anymore. He stated that he had teardrops tattooed

under his eyelids but his daughter did not like them, so he took his nails and scraped off

the tattoos. In his chart, JW stated “I took a bite from my thigh because I don’t have meat

for my sandwich”. Along with this, while he was in jail, he swallowed razor blades. Upon

arrival to his previous hospital stay, the blades were found in his stool. While he was on

the unit, he kept referring to a jellybean as a sexual reference. He continuously was

asking some of the female students what their favorite flavor of jellybean is and then

would laugh.

Psychiatric Evidence-Based Nursing Care Provided JW has been admitted to the inpatient

psychiatric unit several times for manic episodes of bipolar one disorder. Because he is

sometimes uncompliant with his medications for his mental disorder, he has episodes of

his disorder, and then is admitted. During his stay on the unit this time, he has developed

a therapeutic relationship with several of his nurses. He actively participates in group

therapy and individual therapy. Group therapy allows JW and other patients to let go of
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some of their emotions and think of other things. During the group therapy that was

observed on the day that I had JW as my patient, I observed that he was a very active

participant. He wanted to be the center of attention for the therapy and was excited to be a

part of it. During the shifts, a rounding nurse is responsible for documenting where each

patient is every fifteen minutes. Because of this, JW was able to be kept track of for

safety. His nurse did a thorough head to toe assessment on him upon admission, took his

vitals, drew bloodwork, and offered him bath supplies to get cleaned up. Although

sleeves are not allowed to be worn on the unit for safety purposes, he was allowed to

wear fingerless gloves. JW stated that his tattoos and scars give him anxiety because they

remind him of the past, so he does not like to look at them, hence why he wears sleeves

all the time. During my shift with JW, he was cooperating with the no sleeve rule and

was compliant with wearing the fingerless gloves. Whenever JW had a question, the

nursing staff was compliant with helping him. He received all his medications via the

medication nurse on the psychiatric floor. He found social interest in some of the females

on the unit and formed a bond with another male patient on the unit who he referred to as

his “best friend”.

Ethnic, Spiritual and Cultural Influences JW is a 30-year-old African American male who has

a history of street violence, drug use, alcohol abuse, and e-cigarette use. He states that he

is a part of the Crips gang and killed multiple people. JW stated “I have the birth dates

and expiration dates of everyone I’ve killed tattooed around my waist”. He then stated, “I
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have convinced so many people to commit suicide and got them to actually do it”. He

stated that he grew up with violence all through his childhood and has a history of

childhood kidnapping, as well as gang violence. He is not religious and does not practice

a religion. He does not associate with his family. He stated that he “wants his parents

dead”. He talks about having a partner, but it is unknown as to if he is married or not. He

bases much of his actions around his gang. All of his tattoos are related to his gang. He

was incarcerated and then was living in a halfway house. He was kicked out of the

halfway house because he was telling others that he had a knife on him and was

threatening them with it. He is now homeless, upon discharge.

Evaluation of Patient Outcomes Some of the desired outcomes for someone who is admitted to

the inpatient psychiatric unit for a diagnosis of bipolar one disorder is better compliance

with medications, having self-control when they feel that they are starting to become

angry or irritated, agreeing to therapy for diagnosis, and finding new hobbies that better

themselves and do not cause harm. On the day that I evaluated JW, he was actively

participating in the group activities. He was only able to talk about certain topics and did

not like to talk about topics that reminded him of bad things. He was manic, so it was

hard for him to sit still. When I asked him questions that he did not like, he got very

angry. He did not make eye contact and consistently looked down and all around. He

appears to be social and actively engaging in activities, however he seems very paranoid

and suspicious because he constantly is looking around with his eyes. He was admitted

with suicidal ideation and though he appears to be doing better, he pulled the nurse

practitioner to the side and said, “Even though I seem happy, as soon as I leave here, I’m
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going to kill myself”. Upon his discharge, the parole officers will oversee him. He will

need to attend outpatient therapy. He appears to be much better than when he arrived at

the unit upon admission, however he is still in a crisis state.

Plans for Discharge

JW currently is homeless. He was living in a halfway house, after recently getting out of jail. He

was kicked out of the halfway house because he was threatening other people who live in

the house that he was carrying a knife with him. The social workers are being advised to

coordinate with JW’s parole officers for where he will go upon discharge. Since he was

released from the halfway house, it is unsure of where exactly he will go. When

discharged, he is required to be picked up by his parole officers. It is possible that he will

go back to jail for causing problems at the halfway house.

Prioritized Nursing Diagnosis

1. Risk for suicide related to previous suicide attempts and constant threatening of suicide
upon discharge.
2. Self-destruction related to thick scarring across arms from cutting and tips of ears cut off
from self-harm.
3. Risk for violence on the psychiatric unit related to manic behavior and a history of
violence.
4. Disturbed thought processes related to an episode of manic bipolar one disorder and
auditory hallucinations.
5. Biochemical/neurological imbalances related to incompliance with psychiatric
medications while in halfway house.
6. Physical agitation related to manic episode, paranoia, and mood swings

Potential Nursing Diagnoses

1. Self-care deficit
2. Interrupted family Processes
3. Incompetent medication compliance
4. Risk for violent acts against others
5. Social isolation
6. Paranoia
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7. Ineffective understanding of self
8. Poor decision-making skills
9. Hyperactivity
10. Self-harm
11. Manipulation of others
12. Verbally abusive of others
13. Ineffective life management

Conclusion JW will continue to be closely monitored and on strict suicide precautions on the

psychiatric unit. He will be evaluated before discharge for risk of suicide and likely

placed in a mental health facility. He is still a danger to himself and to others. He will

need to learn about compliance with his medications because if he is not compliant, he

will likely end up back in the psychiatric unit again. He is showing signs of improvement

from when he first was admitted to the unit, however he has much more to improve

before being discharged.

References

Bruns, K., Guardia, A. L., Brubaker, M., Farrow, J., Cotton, S., & DeIBello, M. (2021).
Effectiveness of Mindfulness-Based Cognitive Therapy-Child With Youth Who Have a
Parent Diagnosed With Bipolar I Disorder. Journal of Mental Health Counseling, 43(1),
59–74. https://doi-org.eps.cc.ysu.edu/10.17744/mehc.43.1.04

Kabzińska-Milewska, K., Czajeczny, D., & Wójciak, R. W. (2021). Effect of Lithium Treatment
on the Content of Lithium, Copper, Calcium, Magnesium, Zinc and Iron in the Hair of
Patients with Bipolar Disorder. Journal of Elementology, 26(4), 791–805. https://doi-
org.eps.cc.ysu.edu/10.5601/jelem.2021.26.3.2172

Post, R. M. (2020). How to prevent the malignant progression of bipolar disorder. Revista

Brasileira de Psiquiatria, 42(5), 552–557. https://doi-org.eps.cc.ysu.edu/10.1590/1516-
4446-2020-0874
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Videbeck, Sheila L., Miller, C. J. (Cathy J.). (2020). Psychiatric-mental health
nursing (8th). Jakarta: Wolters Kluwer.