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Mental Health Nursing: Case Study

Sophia R. Delatore

NURS 4842 Mental Health Nursing

Dr. Teresa Peck

March 22, 2023

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Abstract

AR is a 22-year-old male patient admitted to the inpatient psychiatric unit at Trumbull

Regional Medical Center for suicidal thoughts following a moderate manic episode. He has a

mental health diagnosis of Bipolar 1 with anxious distress without psychosis. He has been

without his needed medications for a couple months due to missing an appointment and in turn

no longer having a prescription for them. With medication treatments including antipsychotics,

antidepressants and mood stabilizers, the symptoms of his diagnosis have become more

manageable and AR has resumed a functioning level of daily hygiene, communication, and more

importantly, has worked with the nurses on completing a safety and stabilization plan. Nursing

care provided on the unit is focused on enforcing and encouraging the safety and stabilization

plan as well as symptom management through pharmacological methods in addition to

therapeutic groups and individual therapy sessions. Discharge planning is in progress.

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Mental Health Nursing: Case Study

Objective Data

Patient Identifier AR

Age 22

Sex Male

Date of Admission 03/18/2023 @0330

Date of Care 03/23/2023

Psychiatric Diagnosis Bipolar 1 (manic moderate episode) with anxious distress without

psychosis

Other Diagnosis None listed

Behaviors on Admission

AR was pink slipped. AR presented withdrawn but cooperative to the ED. Showed no

aggression, hostility, but did display depression and sadness. Alert and oriented to time, place,

person, and circumstance. Answered questions appropriately and respectfully, causing no issues.

Behaviors on Day of Care

AR currently calm, cooperative and appropriate with no signs of aggression, hostility. AR

willing to speak openly and states minimal level of anxiety and thankful that “meds are onboard

now.” Alert and oriented to time, place, person, and circumstance. Reports to sleeping and eating

better since being admitted. Answered questions appropriately and respectfully, causing no

issues. Agreed to speak with nursing students and partake in a student group therapy session.
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Safety and Security Measures

Suicide precautions: While in the ER, AR was continuously monitored by a sitter/safety

companion. During inpatient admission, safety checks were implemented every 15-minutes. The

patient was not permitted off the unit, and staff members were present at all times. All hazardous

items were not permitted on the unit, and only markers and crayons were used for writing.

Medications were administered to the patient by the nurse, and the nurse verified all medications

were taken at the time of administration.

Laboratory Results

Lab Values Results

Glucose 94
TSH -
T4 -
RBC 4.11 (L)
Hbg 12.9 (L)
Hct 38.5 (L)
WBC 6.5
BUN 18
Creat. 0.88
QTc 0.41
Toxicology (+) cannabis

Psychiatric Medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

divalproex Depakote Anticonvulsant 500mg PO BID Mood Stabilizer

haloperidol Haldol Antipsychotics 5mg PO Q6hr Bipolar Mania

hydroxyzine Atarax Antihistamine 400mg PO Q6hr PRN Sleep/Anxiety

risperidone Periseris Antipsychotics 120mg SQ Q30days Bipolar Mania

trazodone Desyrel Antidepressant 50mg PO QHS PRN Sleep/Anxiety

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Summary of Psychiatric Diagnosis

Bipolar disorder is a type of cyclic mood disorder characterized by mood swings from

profound depression to extreme mania, with intervening periods of normalcy in between. There

are a couple different subcategories under Bipolar including Bipolar I, II, and Cyclothymic

disorder.

“Bipolar I is the diagnosis given to an individual who is experiencing, or has experienced,

a full syndrome of manic or mixed symptoms; the client may also have experienced

periods of depression. Bipolar II disorder is characterized by recurrent bouts of major

depression with the episodic occurrence of hypomania; this individual has never

experienced a full syndrome of manic or mixed symptoms. Cyclothymic disorder is also a

chronic mood disturbance of at least 2 years’ duration, involving numerous periods of

depression and hypomania, but not of sufficient severity and duration to meet the criteria

for either bipolar I or bipolar II disorder,” (Belleza, 2021).

Since the definitions of these diagnoses are constantly being redefined, the DSM-IV needed to be

revised, and people still disagree. “Where DSM-IV required, as criterion A, the presence of one

of the two mood symptoms (elation/euphoric or irritable mood), in DSM-5, ‘the mood change

must be accompanied by persistently increased activity or energy levels’,” (Angst et al. 2013).

This new rule is more restrictive and excludes all individuals who report only one of the three

entry symptoms and those with both elated and irritable mood. These changes to the true

definition alter how and who are diagnosed.

The pathophysiology of bipolar disorder has not been determined, and no objective

biologic markers correspond definitively with it. However, there is a concerning relationship

between patients with bipolar disorder and suicidal thoughts, ideation, and suicidal behavior.
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Data exists that suggests that “...at least 12% of deaths among manicdepressive patients were the

result of suicide. In 9 studies, 12% to 19% of deaths were due to suicide, and in 8 studies, the

suicide rate ranged from 35% to 60%,” (Jamison & Simpson, 1999). The researchers concluded

that by the time all the patients in the studies they had examined had died, about 15% would

have committed suicide, which would make the rate in manic-depressive illness at least 30 times

higher than that in the general population. Later the research identifies the group of bipolar

patients at highest risk of suicide are young men who are early in the course of the illness,

especially those who have made a previous suicide attempt, those abusing alcohol, and those

recently discharged from hospital as well as conclude that the risk of suicide in bipolar patients

remains substantial even today.

Identification of Stressors and Behaviors Precipitating Current Hospitalization

Prior to admission, AR was unable to access much needed medications due to missing an

appointment for and being unable to pick up the prescriptions to get refills due stated “lack of

transportation. He is currently homeless and unemployed but recently rekindled a relationship

with his mother. He did not comment on any stressors with their relationship, however he did

mention that he has never talked to his father since his parents divorced. He states he has extreme

difficulty keeping a job. He states his choices are slim since he wants a job that offers housing.

Prior to admission, AR was feeling very hopeless after being fired from a job where he was fired

on the spot which in turn forced him to leave where he was staying. He then went to a shelter and

that is where he began to feel more depressed and anxious. This led to a major shift where he

became manic and began to have suicidal thoughts. AR was then pink slipped and admitted to

inpatient psych early in the morning on the 18th.

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Evidence Based Nursing Care

During his stay in the inpatient unit, AR received nursing care from the mental health

nursing staff. He was assigned a nurse each shift who established rapport, built a trusting

relationship with and brought any concerns about his care to their attention. Each nurse used the

nursing process to assess, diagnose, plan, implement and evaluate their care individualized to

AR. The nurse would also administer daily medications and ensure that AR was keeping to the

medication regimen. AR was placed on a mood stabilizing medication while inpatient as well as

antipsychotics and sleep aides. The nurses that provide care for AR were aware of what the

medications are used for, typical side effects and signs and symptoms of concerning adverse

effects and how to monitor them. For example, certain medications AR takes such as Haldol

cause EKG changes such as QT prolongation, which can put someone at risk for arrhythmias like

Torsades. Another aspect of the treatment his stay was group sessions. The unit provided a

structured schedule that included meal times, times for personal care or phone calls, and

structured therapeutic groups run by nurses, social workers and the psychiatrist. AR regularly

attended group sessions and stated that they were helpful to his recovery. AR stated that he

learned new coping skills, and about new resources that were available to him in the community.

Ethical, Spiritual, Family and Cultural Influences

AR is a Caucasian, single man from a lower middle-class broken family in Pittsburgh.

His mother and father divorced when he turned three and he has never spoken or seen his father

since then. After he graduated high school, his mother got engaged to a man and they never got

along, so he was kicked out of the house. He deems his mother his main support person and

states that they talk on the phone every day. He also has an older sister that he is potentially

looking to contact about living situations. He is currently unemployed, going in and out of jobs.
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He states all the places he has worked for in construction have treated him poorly. He is currently

homeless and has been since getting kicked out of his home in Pittsburgh but has been taking

jobs that offer housing. AR practices Christianity as a religion and states he prays occasionally.

Patient Outcomes

Some of the outcomes that are desired for a patient suffering from suicidal thoughts

include recognition and upholding a safety and stabilization plan, remaining free from harming

themselves or others, perceiving themselves in a realistic manner and performing self-care

activities appropriately. On the day of care for AR and the majority of his stay, he was

performing self-care activities for himself and showering, combing his hair and eating

appropriately. He also had remained free from any harm or thoughts of harm while he was in the

inpatient unit, and was taking his medications appropriately on schedule. Some other outcomes

were only partially met on the day of care, such as his ability to recognize and report anxiety and

fear around discharge. AR was still experiencing mild anxiety when discussing plans after being

discharged. However, he did recognize the importance of reorienting himself to his safety and

stabilization plan and listing his short term and long term goals. He also is still progressing

towards building a stronger support system of individuals or groups he can count on to prevent

another crisis. He stated that he talks to his mother every day and is beginning to build a

relationship with his new step-father. He has not been able to reach his older sister. AR also had

his anxiety and depression better managed on the day of care compared to when he was

admitted. When asked to rank his anxiety and depression on a scale of one to ten,with one being

the lowest and ten the highest, he ranked his anxiety a four and he denied any depression at the

moment. AR credited the medications, sleep, eating, a routine schedule, and the tools learned in

group sessions with helping him to manage both the anxiety and depression symptoms.
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Discharge Plan

The plan of discharge is tomorrow (03/24/2024). When AR is discharged, he has to “go

to court after'' and then he will be getting a bus ticket back to Pittsburgh where he is from in

Cranberry. Staff felt that AR did not need transitional or long-term placement after discharge

from the inpatient unit. LL is encouraged to regularly attend sessions with a psychiatrist, and to

stay compliant with his medications as well as appointments to get them prescribed. Education

material will be provided on his medications, possible side-effects, and adverse reactions that can

occur.

Prioritized List of Actual Diagnoses

The following are prioritized nursing diagnoses for AR:

● Risk for Self-Harm/Injury related to suicidal thoughts, manic episode and

hopelessness. (Patients with bipolar disorder are at risk for injury due to a

combination of affective, cognitive, and psychomotor factors that can affect their

judgment, impulsivity, and coordination. Exhaustion, dehydration, and rage may

also contribute to the risk of injury in patients with bipolar disorder.)

● Risk for Suicide related to suicidal thoughts, manic episode and hopelessness.

● Disturbed Thought Processes related to mental illness as evidenced by non-

realistic thinking, ineffective coping, and poor judgment.

● Anxiety/Fear related to discharge as evidenced by patient verbalizing worry over

discharge, unemployment and homelessness.

● Risk for Violence related to suicidal thoughts, manic episode and hopelessness.

● Impaired Social Interactions related to maturational crisis, homelessness and

unemployment
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Potential Nursing Diagnoses

● Risk for Injury

● Risk for Suicide

● Risk for Violence: Self Directed or Towards Others

● Impaired Social Interaction

● Ineffective Individual Coping

● Interrupted Family Process

● Others such as: Total Self Care Deficit, Hopelessness, Anxiety/Fear, Disturbed

Thought Process, Deficient Knowledge

Conclusion

All in all, AR is a young man in a crisis without an adequate support system to reach out

to and feeling hopelessness. Bipolar 1 Disorder is a complex, cyclic disease process that has

remissions and exacerbations of symptoms, often complicated by patient non-compliance to

medications. During a manic or hypomanic episode, especially when suicidal/homicadal

thoughts or ideations are involved, the patient can become a danger to themselves and others.

The patients also have communication and self-care deficits during mania that may make

hospitalization and are able to care for themselves. AR experienced a mania related to a

situational crisis exacerbated the fact that his family kicked him out and he became homeless and

current unemployment. AR is at an increased risk for suicide due to the fact that he had suicidal

thoughts and feeling of fear and hopelessness. However, with education and therapy from the

start of admission to discharge, it is the goal for AR to remain compliant with medications and

therapy schedules to avoid another manic episode. With regular and consistent treatment, the

exacerbation should be able to be controlled before it comes to the point of a manic episode.
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References

Angst, J. (2013, August 23). Bipolar disorders in DSM-5: Strengths, problems and Perspectives -

International Journal of Bipolar Disorders. SpringerLink. Retrieved April 1, 2023, from

https://link.springer.com/article/10.1186/2194-7511-1-12

Belleza, M. (2021, February 11). Bipolar disorder: Nursing care management study guide.

Nurseslabs. Retrieved April 3, 2023, from https://nurseslabs.com/bipolar-disorder/

Simpson, Sylvia G, and Redfield Jamison. “The Risk of Suicide in Patients With Bipolar

Disorders.” Psychiatry.org - Suicide Prevention, 23 Sept. 1999,

https://www.psychiatry.org/patients-families/suicide-prevention