Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

IzaBella Wertz

November 17, 2022

Ms. Elizabeth Stanford MSN, RN, CEN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Objective Data

Patient Identifier KW

Age 21

Sex Male

Date of admission October 20, 2022

Date of care October 27, 2022

Psychiatric Diagnosis Acute Psychosis

Other diagnosis Traumatic brain injury, anxiety, delusions

Behaviors on admission KW was brought in by their family due to them acting out of place and

continuous fights with family members. He was in the psychiatric ER hold for a couple of hours

and didn’t have any crazy behaviors. These behaviors by the patient have been happening for

months. KW denied any of these behaviors, saying that the family was lying and trying to kick

them out of the house. They were anxious, hostile, and manipulative during and after admission.

KW lied multiple times to staff during the initial interview and didn’t take it seriously, making

very light out of the situation. However, it is unclear if the patient was actually lying or if they

were delusions. They told staff that they were 27 and had seven children but the family informed

the staff that this was incorrect. The patient was slightly unwilling to cooperate, but eventually

completed the admission.

Behaviors on day of care KW was calm and trying to make jokes but didn’t really want to talk

to anyone. KW would talk to us, but nothing about his medical condition or how they were
MENTAL HEALTH COMPREHENSIVE CASE STUDY 3

feeling. Every time we would ask them about their condition they would walk away or redirect

the conversations. They did not participate in group therapy or do anything that involved a lot of

people. They just wanted to play cards and joke around with the other patients. At one point they

really wanted to play cards and thought they were in another patient's room, so they started to

bang on the door of that patient, possibly provoking them. Until they were redirected.

Safety and security measures KW had standard safety measures like others on the unit: 15-

minute checks, not allowed off the unit, and having no dangerous object near them. They were

allowed no visitors but did have monitored telephone time. However, KW was on cheeking

precautions meaning that they had to be watched after taking medications and they had to eat

dinner outside their room. This is just to assure the staff that the patient is not hiding or sneaking

anything and that they are receiving all the medications that they are supposed to. It is most

important to ensure the safety of the patient which includes from others and themselves.

Laboratory results

Lab Value Results

Glucose 104
TSH N/A
T4 N/A
RBC 4.92
Hbg/Hct 14.8/42.5
WBC 5.0
BUN/Creatine 12/1.0
QTc 70
Toxicology Positive cannabinoid

The only abnormal lab KW had was their positive tox screen of cannabinoids. The patient

was educated on the importance of sustaining from any type of substance out of their

recommended medications from their doctor.

MENTAL HEALTH COMPREHENSIVE CASE STUDY 4

Psychiatric medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

Risperidone Risperdal antipsychotics 2 mg/BID In acute
psychosis
Sodium Valproic anticonvulsant 750 mg/ BID Can be a mood
valproate stabilizer

KW is only on two medications at this time because they both have worked in the past.

With this type of diagnosis, it is better to try to limit the medications because of their compliance

and the possible side effects. KW was educated on some of the side effects of antipsychotics.

They were told to monitor themselves for EPS symptoms, dry mouth, blurred vision, and

orthostatic hypotension. To help treat the side effects, they were instructed to keep hard candy on

them, avoid other substances to avoid worsening the side effects, and to get up and move slowly

Also, it was included in the education that they were on an anticonvulsant because it can also be

used as a mood stabilizer, not just for seizures. Lastly, KW was informed by the doctor

prescribing them the importance of taking the medication as prescribed and to not abruptly

stopping or even to not stop taking it at all. KW voiced back that they understood what the

doctor was saying and that they will adhere to the medication regimen.

Summary of psychiatric diagnosis

Psychosis is a diagnosis which categorizes several symptoms together which includes the

disorganization of thoughts and behavior, delusions, and hallucinations. This diagnosis can be

contributed to another medical diagnosis, or it could be its own disorder. They typically have

different sets of symptoms depending on why it was diagnosed. When contributed to a medical

diagnosis, the patients usually experience changes in cognition like hallucinations and changes in

their normal vital signs. If they have a psychiatric diagnosis, they usually have more severe
MENTAL HEALTH COMPREHENSIVE CASE STUDY 5

hallucinations and delusions. (Griswold et al., 2015). Everyone has similar symptoms but they

aren’t all exactly alike.

There are different types of hallucinations that these patients can have. First, a

hallucination is “sensory perception in the absence of outside stimuli. That means seeing,

hearing, feeling, or smelling something that isn’t present” (Carey, 2021). They truly believe that

they can see something when in reality nothing is there. Or, they can have an auditory one where

they think they can hear something, tactile where they think they can feel something, a gustory

where they think they can taste something, or olfactory where they think they can smell

something. These patients can also have delusions, which are “false belief or impression that is

firmly held even though it’s contradicted by reality and what is commonly considered true. There

are delusions of paranoia, grandiose, and somatic delusions” (Carey, 2021). Both symptoms are

severly detrimental to one’s daily life. They can lead to losing a job, losing custody, being unable

to care for self, and many more that will lead to a decrease in quality of life.

The way to help someone with this disorder changes with the type of symptoms they

experience. There could be a couple reasons why the disease is exacerbating, so they first try to

discover what those factors are and how to control it. Some of these factors are “stress, sleep,

poor nutrition and exercise habits, and having no support” (How, 2021). Unfortunately,

exacerbations still happen, but if we keep these factors at a minimum, it is possible to limit the

amount of them. When they are in a state of psychosis, they can be given medicine to lessen the

symptoms along with their regular medicine regimen. These patients will be prescribed

antipsychotics. This type of medicine is given to “treat voices and visions than changes in our

emotions, feelings, and facial expressions” (How, 2021). It is important for these patients to stay

consistent with taking their medicine to maintain a better quality of life.

MENTAL HEALTH COMPREHENSIVE CASE STUDY 6

Discuss patient and family history of mental illness

There is no family history of mental illness according to the patient or their chart.

However, KW has been struggling with mental illness since they were in a car accident where

their mother died. KW has been going to mental health clinic where they would receive medicine

and counseling, but they have missed the past couple appointments resulting in them running out

of medication. The family reported that KW had multiple fights and physical altercations with

family members including the grandma whom they lived with, destroying house objects like their

television, and putting their bowel movements in bags and leaving them around the house. KW

has been admitted to this psych ward before for the same diagnosis and was supposed to follow

up treatment at a psychiatric clinic. They did stay compliant with care for a couple sessions, but

eventually stopped attending.

Describe the psychiatric evidence-based nursing care provided and milieu activities

attended

Among other health issues today, mental health is one with the biggest stigma surrounding it.

Despite what we learn and see, nurses can also fall victim to it which is why it is important to

remember what evidence-based practice is. One of the evidence-based practices implemented

with this patient is “illness management and recovery” which is a “psychiatric treatment

framework designed to allow patients to participate proactively in their own recoveries” (7

mental, 2017). This is done by encouraging the patient to do certain things that will better their

treatment like attending group therapy or taking their medication but also giving them the choice

to do so. It helps them with independence and makes them feel like they are in charge of their

care, but still allows the treatment team to encourage certain things. A lot of patients struggle

with accepting their diagnosis, so giving them the choice of certain things increases their
MENTAL HEALTH COMPREHENSIVE CASE STUDY 7

confidence and trust. Another example is “Medication treatment, evaluation and management

involves the systematic, evidence-based application of prescription behavioral health

medications” (7 mental, 2017). One of the biggest aspects of mental health care is ensuring that

the patient is on medication, on the correct medication, and that they are taking their medications

consistently. It combines assessment, evaluation, and education all together to ensure that the

patient is receiving the correct care. This is the basis of nursing. It is crucial that nurses and other

healthcare members pay close attention to patients who are on psychiatric medications to see if

they are affective and if they are having any severe side effects. Some medications can have the

opposite effect or can make a patient too drowsy to participate in their care, so it is important for

the nurses to monitor the patients before and after the medication.

The milieu activities provided mostly consist of group therapy. Throughout their stay,

KW attended maybe one session. Group therapy is a good tool to help patients learn new things

about controlling their mental health, get out of their shell to talk about what is wrong, and to

show initiative in their care. KW showed little interest in group therapy and joked about it to us,

saying that it was stupid to attend. We tried to discuss with them how it would help and how it is

important in their care, however, they ignored us and just wanted to play cards. The treatment

team wants KW to attend more group sessions because it will show more initiative and progress

in their care, but they keep refusing.

Analyze ethnic, spiritual and cultural influences that impact the patient

KW didn’t state any ethnic or spiritual influences on their life. They don’t attend church or have

an interest in it or have any family traditions or practices that have a great impact on their life.

However, the patient did have a traumatic experience later in their childhood. In their early teens,

KW’s life shifted when they were in a car accident with their mother who died in that crash.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 8

They had no relationship with their father, so their main support system and usual routine of life

disappeared. This crash also resulted in the patient being diagnosed with a traumatic brain injury.

Having to live with their grandmother after completely shifted the family dynamicfor them. A

grieving family had to learn how to take care of a brain-injured child who was also mourning the

loss of their mother. There wasn’t any information on the mother and her childhood, but there is

a chance that her childhood was toxic and now KW had to grow up with the same people. KW

had to adapt to this change pretty quickly along with dealing with physical health changes.

Evaluate the patient outcomes related to care

KW is slowly progressing. Despite the education the staff has provided about the importance of

following the doctors' recommendations and medication regimen, they are still hesitant to

commit to their treatment plan. Ever since admission, they have been hostile, attempting to

manipulate the nurses, lying about things, and having to be put on cheeking precautions because

they were throwing away the medication after they were given it. KW has started to willingly

take medications and has started talking more to the treatment team about his feelings and his

thoughts. There are still times when the patient will put up a fight or just refuse the medication,

but not as much as when they were first brought in and admitted. If the staff keeps the same

routine for them and maintains a solid relationship with them, their progress should start to

improve.

Summarize the plans for discharge

KW has quite a few more days left in the psych ward before they can be discharged elsewhere.

There’s no current plan if they have to stay at another facility after this one or if they have to

carry on outpatient. It is hard for them to assess the patient and discover what they would like to
MENTAL HEALTH COMPREHENSIVE CASE STUDY 9

do because of their delusions and eagerness to manipulate the staff. They haven’t made any real

progress while in the psych ward, so the treatment team has to evaluate how much progress they

think KW will make. The staff has discussed with them multiple times that their willingness to

work with them will only help them more and quicker. Originally, KW lived with their grandma,

however, after the fights and being physical with their grandma she no longer wants them there.

So, one of their aunts is supposed to take them in as long as they continue with their care. This is

still up for discussion by the family and the patient because of KW being hard to live with and

how easy it is for them to be hostile with family members. It is also hard for the family to

provide for the patient financially due to their health issues and just because of the economy

today. Also, the patient is unemployed, and it would be difficult for them to get a good job and

stick with it due to the uncertainty of their mental illness.

Prioritized list of all actual diagnoses using individualized NANDA format

1. Risk for violence related to maladaptive behaviors as evidenced by patient's paranoid

delusions.

2. Defensive coping related to trouble checking reality perceptions as evidenced by patient’s

disorganized thinking and behaviors.

3. Disturbed thought processes related to incorrect interpretation of environment as

evidenced by known psychosis and hallucinations.

4. Impaired social interaction related to difficulties with communication and concentration

as evidenced by withdrawal from others and negative symptoms.

List of potential nursing diagnoses

1. Ineffective coping skills.

MENTAL HEALTH COMPREHENSIVE CASE STUDY 10

2. Increased anxiety.

3. Disturbed sensory perception.

4. Interrupted family processes.

Conclusion

Those who are diagnosed with acute psychosis are experiencing delusions, hallucinations, and

disorganized thinking that affects their daily life and functions. Patients like KW often

experience such convincing delusions and hallucinations that they do not believe anyone when

they say it’s not true. They can be treated with medication and therapy, but it is most crucial that

they remain consistent with their medication regimen. Unfortunately, it is hard to care for these

patients because their reality is so different than the truth. They don’t trust others and will do

things to make that known. Hopefully, KW will be able to stick to their treatment and get better.

References

Carey, E. (2021, December 16). Psychosis: Symptoms, causes, and risk factors. Healthline.

Retrieved November 15, 2022, from https://www.healthline.com/health/psychosis#causes

Griswold, K. S., Regno, P. A. D., & Berger, R. C. (2015, June 15). Recognition and differential

diagnosis of psychosis in primary care. American Family Physician. Retrieved November

15, 2022, from

https://www.aafp.org/pubs/afp/issues/2015/0615/p856.html#:~:text=Acute%20psychosis%

20is%20primary%20if%20it%20is%20symptomatic,auditory%20hallucinations%2C%20p

rominent%20cognitive%20disorders%2C%20and%20complicated%20delusions.

How do you treat psychosis? MHA Screening. (2021, May 13). Retrieved November 15, 2022,

from https://screening.mhanational.org/content/how-do-you-treat-psychosis/
MENTAL HEALTH COMPREHENSIVE CASE STUDY 11

7 mental health evidence-based practices in nursing. 7 Mental Health Evidence-Based Practices

in Nursing. (n.d.). Retrieved November 15, 2022, from

https://onlinenursing.regiscollege.edu/resources/dnp/articles/7-mental-health-evidence-

based-practices-in-nursing/rc-msndnp-mental-health-thumb/