MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study- Acute Psychosis

Emerson Fletcher

November 17, 2022

Mrs. Teresa Peck, MSN, RN

Youngstown State University

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Abstract

MS is a 40 year old male patient admitted to the inpatient psychiatric unit for overdosing on

Heroin and Cocaine. His sister said she wasn’t allowing him to live with her anymore and

brought him to the emergency department. He has a medical diagnosis of acute psychosis and

experiences auditory hallucinations. With medication treatments including antipsychotics and

mood stabilizers, MS has been able to begin functioning at a stable level and is sustaining a more

concrete form of communication. Nursing care provided throughout his day- to-day routines on

the unit include reorientation and symptom management through pharmacological methods, and

group therapy.
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Objective Data

Patient Identifier: MS

Age: 40

Sex: Male

Date of admission: October 22, 2022

Date of care: October 26, 2022 & November 3, 2022

Psychiatric diagnosis: Acute psychosis

Medical Diagnosis: Anxiety

Behaviors on admission: MS has an addiction to Heroin and Cocaine and was brought to the

emergency department by his sister for his odd behavior. Patient was found defecating in his own

backyard and was also found holding knives in his kitchen breathing heavily. Patient was having

auditory hallucinations where he stated voices were telling him “he needs to do better for

himself.”

Behaviors on day of care: MS was very friendly, cooperative, and open when talking to him.

He was aware to person, and place, but was not completely aware to time and what brought him

to the unit. MS was experiencing flight of ideas and rambling speech, while still experiencing

auditory hallucinations. He did not have good recent memory and also had low abstract thought.

He had poor eye contact and poor hygiene and was also very fatigued when talking to him. At

times he would also laugh inappropriately which made it hard to stay on track with him.

Safety and Security measures: MS remained safe and free of injuries while on the psychiatric

unit. He was constantly being observed by nurses and doctors and liked to spend his free time in

the common area where he watched TV and interacted with others. He remained free of weapons
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and drugs during his time and followed nursing commands when told. The only complaint the

nurses had that they documented in his chart is that at night he would become very irritable and

angry and they would have to calm him down with therapeutic techniques or medication.

Laboratory results: yellow= abnormal, * = important because of medications patient is on

LAB VALUE RESULT

Potassium (3.5-5) 3.6

Sodium (132-146) 142

Glucose (74-99) * 82

Blood Urea Nitrogen (6-20) 11

Creatinine (0.7-1.2) 1.1

RBC (3.8-5.8) 5.12

Hemoglobin/ Hematocrit 15.4 / 47

WBC (4.5-11.5) * 14

AST (0-39) / ALT (0-40) * 18 / 15

Depakote level * Not taken at time

TSH / T4 * Not taken at time

Drug toxicity (+) Fentanyl

U.A Alcohol level Negative

QTC * (<440) / ECG 455 / normal ECG

CK * 261

Total Protein (6.4-13) 8.8

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Psychiatric medications:

Generic Name Trade Name Class/ Category Dose/ Frequency Reasoning

Divalproex Depakote Anticonvulsant/ 500mg Mood stabilizer/

Sodium Mood Stabilizer control BP

Risperidone Risperdal Antipsychotic 2mg Psychosis/

Mania diagnosis

Summary of psychiatric diagnosis

Acute psychosis is a mental illness that is described as a condition in which you lose

contact with reality. It has some special characteristics that accompany it for example, these

patients normally have a reduced level of social functioning, blunted or inappropriate affect, and

changes in perception due to hallucinations they may experience. Some causes of psychosis are

genetics, trauma, and drug use with drug use psychosis being the main type of psychosis that we

see with this patient.

Acute psychosis is defined by one or more of the following domains which are: trouble

thinking clearly, difficulty concentrating, feeling paranoid or suspicious of others, a disinterest in

personal hygiene, difficulty separating reality from unreality, trouble communicating,

hallucinations, delusions, disorganized behavior, negative symptoms and catatonia (Calabrese &

Khalili, 2022). MS exhibits hallucinations, delusions, negative symptoms, and when he is

experiencing periods of exacerbations he exhibits a lot of disorganized thoughts, behaviors, and

speech.

In MS's case, disorganized thought and behavior were the most common characteristics

he displayed. Disorganized thought is normally noticeable in patients' speech pattern and

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communication ability. It is associated with unrelated loose events where the person is not able

to directly answer questions without excessive or unnecessary details. MS exhibited rambling

speech and flight of ideas when talking to him.

Another common occurrence in psychosis patients are hallucinations. Hallucinations are

thought to be “voice hearing” and are very common in patients with this diagnosis. MS

experiences auditory hallucinations where the voices he hears are telling him “to do better” and

“be a better person so you can get out of this situation.” Auditory hallucinations can be very

stressful for a patient and can cause them to be in distress if it goes on for a long time (Calabrese

& Khalili, 2022).

Identification of stressors and behaviors precipitating current hospitalization

MS recognizes his drug abuse and that this abuse is what brought him to the psychiatric

unit. He has admitted to using Heroin and Cocaine, and also admits to having an addiction to

these drugs. When asked why he started to use drugs he stated, “I grew up in this environment

and since I was going to be around drugs all the time I thought to myself I mine as well start to

sell them.” MS stated growing up in a poor home environment and only having contact with his

sister and brother. MS stated multiple times that he doesn't feel like he can get out of this cycle

but wants better for himself and knows he is capable of it. Before bringing him to the emergency

department, his sister stated that MS was caught defecating in the backyard and was also found

in the kitchen holding knives in his hand while breathing heavily.

In a research article titled, The Connection Between Substance Use Disorders and

Mental Illness, the author talks about how when you start abusing drugs early in life it has a

direct correlation to developing a mental illness later on in life. The article states, “The brain
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continues to develop through adolescence. Circuits that control executive functions such as

decision making and impulse control are among the last to mature, which enhances vulnerability

to drug use and the development of a substance use disorder. Early drug use is a strong risk

factor for later development of substance use disorders, and it may also be a risk factor for the

later occurrence of other mental illnesses.” This article directly describes MS life and what he

went through as an adolescent to now. Being stuck in a bad environment and being introduced to

things which overtime has led him to develop other illnesses.

Patient and family history of mental illness

MS does not directly say that any of his family members were officially diagnosed with

a mental illness however, he stated that he was “born into this drug environment” and has been

around drugs since he was little. MS stated that he lives with his sister who takes care of him and

she was the one who brought him into the emergency department to try to get him help. He also

stated that he has one other brother that he is close with, and that his family are his biggest

supporters. MS is single with no close friends or children.

Psychiatric evidence-based nursing care provided

During MS’s time in the psychiatric unit he was observed by multiple nurses and doctors

who cared for him and did their best to help him reach his daily goals. His nurses would assess

and observe him on a day to day basis while the medication nurse would make sure he was

receiving his medications in a timely manner and was compliant with them. MS was very good

about taking his medications and did everything the medication nurse would ask of him. The

main medications he was on were Depakote for mood stabilization and Risperidone for his
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mania/ psychosis diagnosis. When on Depakote you have to check MS’s valproic acid level to

make sure the medication was in a therapeutic range, and also his AST/ALT because Depakote is

hepatotoxic. With Risperidone you want to watch side effects. Because of the certain side effects

this medication can have, we want to monitor MS’s blood sugar because Risperidone can

increase blood sugar, WBC count because Risperidone can decrease WBC counts, and the QTC

interval because Risperidone can prolong a patient's QTC interval. Along with his medication

compliance, MS attended multiple group therapy sessions, also known as Milieu therapy

activities, where he actively participated and engaged in conversation. Milieu therapy helps meet

the treatment needs of people who are recovering from past trauma by allowing patients to

develop more concrete thoughts and behaviors to manage their vulnerability (Vatne & Home

2008). Group therapy is a good way for patients to interact with other patients on the floor and to

come to terms with why they were admitted to this unit, and what they can do to better

themselves.

Ethic, spiritual, and cultural influences

MS is a African American male who is from a lower-class family. He is not employed

but stated he used to work at a restaurant with his brother before he was admitted inpatient. MS

stated that he graduated from Wilson high school in Youngstown but did not attend college.

When asked about spiritual beliefs he stated that he believes in “Jesus and God.”

Evaluation of patient outcomes

During MS’s stay in the psychiatric unit he grew as a person and had a lot of growth

since when he first got admitted. MS remained safe while on the floor and free from injury. MS
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came to the realization that his medications were working and that if he is compliant with them it

will reduce the risk of having periods of exacerbations. MS stated he did not have many

withdrawal symptoms and is going to continue to keep up with his medications. He was very

friendly where he started to interact more with patients on the floor and started to attend group

therapy sessions where he actively participated in.

Plans for discharge

Upon discharge, MS will be transferring to Midwest, a rehab facility in Austintown Ohio.

He was very excited for this new transition and hopes that it will treat him well. He spent

approximately two weeks in the psychiatric unit and feels that he is ready for the new transition.

There at Midwest, they are going to work with him in a drug rehab program which will hopefully

keep him off drugs and keep his withdrawal symptoms to a minimum. MS was newly put on

Cogentin due to side effects he was experiencing from his antipsychotic medications. These side

effects will need to be continuously monitored as he transitions to a new facility. A big objective

the nurses wanted to figure out for MS before he was discharged was his medication compliance.

They gave him a bunch of outside resources to call if he had questions and also made sure he had

a primary pharmacy that was close and that he had transportation to it. Another thing his nurses

did was make sure he could afford all of his medications so that he could have a successful

transition from facility to facility.

Prioritized nursing diagnosis

● Impaired thought process related to psychiatric diagnosis as evidenced by hallucinations

and flight of ideas.

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● Interrupted family process related to patient having little family relations besides his one

brother and sister.

● Altered sensory perception related to substance abuse, hallucinations, and inappropriate

responses.

● Impaired verbal Communication related to disorganized thinking and flight of ideas.

● Impaired social interaction related to inappropriate affect and exaggerated mannerisms

such as eyes rolling in the back of his head, no eye contact, etc.

● Anxiety related to discharge plans and future living situations.

● Disturbed sleep pattern related to manic episodes where the patient was loud and irritated

and got three to four hours of sleep.

Potential nursing diagnoses

● Acute confusion

● Impaired memory

● Ineffective health maintenance

● Risk for loneliness

● Fatigue r/t physiologic demands

Comparison/ Conclusion

I got to observe and assess MS two weeks in a row while on the psychiatric unit. On the

first day of observing MS he was very monotone, lethargic, his eyes would roll in the back of his

head and he would not make eye contact when talking to us. He exhibited rambling speech with

flight of ideas and also had some auditory hallucinations. He had poor recement memory and
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was not oriented to time at all and just seemed out of it. The medications MS are on are:

Depakote (500 mg PO Q12) and Risperidone (2 mg PO Q12). His WBC count, QTC, and CK

enzymes were elevated and they did not draw a valproic acid or TSH/T4 level at that time.

After a week went by I got to observe and assess MS again where he still had rambling

speech and flight of ideas. He also exhibited grandiose delusions and still had auditory

hallucinations. His recent memory was still poor and he still was not aware of the time or year.

MS was more alert this time around where he was laughing and making eye contact while talking

with us. The medications he is now on are: Cogentin (1mg PO Q12), Depakote (750mg → which

is an increase from week one), Risperidone (3mg → which is an increase from week one), and

Olanzapine (5 mg PO Q12). His WBC count is now in a normal range as well as his AST/ALT,

valproic acid levels, and QTC level. His QT levels also decreased from last week showing

improvement.

As stated in the paragraph above, MS was put on Cogentin the second week due to the

side effects he was having with Risperidone, an antipsychotic medication.. EPS symptoms are

common when using antipsychotic medications and need to be controlled to help avoid distress

to the patient. In a research article titled, The Use of Antiparkinsonian Agents in the Management

of Drug-Induced Extrapyramidal Symptoms, the author states, “ Extrapyramidal symptoms

produce unnecessary suffering and add to the health burden; therefore, prompt recognition of

these symptoms is necessary. If EPS does occur, it is of paramount importance to start an

antiparkinsonian agent immediately to provide relief to the patient.” The paragraph above is of

great importance because MS was started on Cogentin right as the nurses saw he was starting to

have some antipsychotic side effects which will now hopefully leave MS in less distress because

they caught his EPS symptoms early.

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Overall Acute psychosis is a complex disease that has remissions and exacerbations of

symptoms when not treated properly. MS was a very interesting patient to do this case study on

and I believe if he follows his medication regimen and has a stable support system he will have a

decreased rate of his exacerbations.

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References

Acknowledging communication: A milieu‐therapeutic approach in ... - wiley. (n.d.). Retrieved

November 14, 2022, from

https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2007.04565.x

Burgyone, K., Aduri, K., Ananth, J., & Parameswaran, S. (2004, July 1). The use of

Antiparkinsonian agents in the management of drug-induced extrapyramidal

symptoms. Latest TOC RSS. Retrieved November 10, 2022, from

https://www.ingentaconnect.com/content/ben/cpd/2004/00000010/00000018/art00013

Psychosis - statpearls - NCBI bookshelf. (n.d.). Retrieved November 8, 2022, from

https://www.ncbi.nlm.nih.gov/books/NBK546579/

U.S. Department of Health and Human Services. (2022, September 27). Part 1: The

connection between Substance Use Disorders and mental illness. National Institutes

of Health. Retrieved November 8, 2022, from

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https://nida.nih.gov/publications/research-reports/common-comorbidities-substance

-use-disorders/part-1-connection-between-substance-use-disorders-mental-illness