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Psychiatric Mental Health Comprehensive Case Study

Mackenzie Larch

James and Coralie Centofanti School of Nursing, Youngstown State University

NURS 4842L: Mental Health Nursing Lab

Mrs. Phyllis DeFiore-Golden

March 31, 2023

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

ML is a 23-year-old male patient admitted to the inpatient psychiatric unit following a manic

episode where he was feeling homicidal towards the other patients in his rehab facility. ML

states he was tired of others “talking about him” and felt like he was on the verge of having a

mental breakdown. He has a mental health diagnosis of severe manic bipolar 1 disorder with

psychotic behavior and Amphetamine abuse. He also experiences command auditory

hallucinations and delusions. With medication treatments including antipsychotics and

anticonvulsants, and psychotherapy for anger management issues, the symptoms have become

more manageable, and ML is beginning to near a functioning level of daily living and

communication. Nursing care provided on the unit is focused on increasing socialization with

others and symptom management through pharmacologic methods, group therapy, and individual

therapy sessions.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 3

Bipolar Disorder

Objective Data

Patient Identifier: ML

Age: 23

Sex: Male

Date of Admission: March 15, 2023

Date of Care: March 17, 2023

Psychiatric Diagnosis: Severe manic bipolar 1 disorder w/ psychotic behavior

Other Diagnose: Amphetamine abuse, Anxiety, Depression, Drug overdose, Multiple suicide

attempts, Self-harming.

Behaviors on Admission: ML was expressing homicidal ideations towards the other patients at

his rehab facility. Patient manic and was having feelings of a potential mental breakdown upon

admission. He was having auditory command hallucinations telling him others were “talking

about him.” ML also expressed desire for new rehab placement upon discharge to one that can

“care for his psychiatric needs and addiction.”

Behaviors on Day of Care: ML was pleasant and cooperative and willing to speak openly.

Patient did participate in the group therapy my classmates and I led after asking him to attend.

Per the nurse, ML was having severe social anxiety since admission. However, after introducing

myself, he seemed very willing to sit in the common area and talk to me. ML was not actively

having any hallucinations or delusions. He expressed eagerness and readiness to be discharged

home with his “baby mom.” During our conversation, ML commonly showed flight of ideas,

associative looseness, and circumstantiality. He was very euphoric and jumped from thought to

thought. ML had a short attention span and would answer my questions with very short
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responses, then go off on tangents. He was able to answer appropriately and was oriented to

person, place, time, and situation. He was also very restless, constantly changing positions, and

shaking his leg vigorously. On occasion, he would show symptoms of inappropriate sexual

behavior towards me, and I had to redirect the topic of conversation to him and his life.

Safety and Security Measures: During inpatient admission, the patient was not permitted off

the unit. He was placed in a gown and pants with no strings. Any hazardous items including

shoelaces, razors, pencils/pens, and electronic cords were not permitted on the unit. Patients had

to use markers to write and draw with. Medications were administered to the patient by the med

nurse, who also was responsible for ensuring they swallowed their meds. Bathroom doors were

slanted, and bedroom doors had rounded edges to prevent suicide attempts.

Laboratory Results:

Lab Value Result

Glucose 128
AST 15
ALT 29
RBC 5.6
Hbg/Hct 15.9 / 48.0
WBC 12.2
BUN/Cr. 11 / 0.6
QTc 406
Toxicology Negative

Psychiatric Medications:

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

divalproex Depakote DR Anticonvulsant 500 mg Q12 Mood
hours stabilization
insulin lispro Humalog SubQ Insulin 0-4 units AC & Diabetic control
HS
metformin Glucophage Antidiabetic 1,000mg daily Diabetic control
risperidone Risperdal Antipsychotic 1mg BID Mood
stabilization
MENTAL HEALTH COMPREHENSIVE CASE STUDY 5

Summary of Psychiatric Diagnosis

In an academic journal published by MD, George Guess, exploring an acute case of

mania in a bipolar patient, he explains the psychiatric diagnosis as follows:

Mania, or bipolar 1 disorder, is a psychiatric disorder characterized by an

elevated, expansive, or irritable mood of at least 4-7 days duration, plus at least three or

four of the following symptoms:1. Inflated self-esteem or grandiosity 2. Decreased need

for sleep 3. Loquacity or pressured speech 4. Flight of ideas or the feeling that one’s

thoughts are racing 5. Distractibility 6. Increase in goal-directed activity, whether social,

work-related, or sexual, or psychomotor agitation 7. Excessive involvement in

pleasurable activities that could have painful consequences (e.g., excessive spending,

sexual indiscretions, foolish investments).

Additionally, the symptoms do not qualify for consideration as a mixed episode;

the psychological disturbance is severe enough to substantially impair occupational

and/or social functioning, require hospitalization, or manifest psychotic features; and,

finally, the disorder is not caused by substance abuse, whether recreational or

prescription, nor by a medical condition (p. 22).

It’s important to remember that to diagnose a patient with bipolar disorder, they must

have mood swings, or a “cycle,” between profound depression to extreme euphoria (mania) with

intervening periods of normalcy. Patients diagnosed will also commonly have delusions or

hallucinations (Videbeck, 2017, p. 698).

There are officially five types of bipolar disorders. A bipolar 1 patient lives day to day in

the manic phase, and when their mood swifts to the opposite spectrum it is considered a “mild”

form of depression. Most of the patients’ problems will arise during their manic phase. Mania
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can be categorized by its degree of severity into three different stages. Stage two is considered

“acute mania” which is most fitting for my patient. It is marked by impairment in functioning,

typically requiring hospitalization. Symptoms of acute mania include elation and euphoric

emotions, flight of ideas, accelerated or pressured speech, hallucination and delusions, excessive

psychomotor activity, social and sexual inhibition, little need for sleep, constantly moving, can

forget to eat, lack of impulse control, and commonly are the monopolizes in group therapy

settings. (Videbeck, 2017, p. 715-716).

Once diagnosed with bipolar disorder, there are a couple options for treatment plans. We

can use different forms of therapy including individual psychotherapy, group therapy, family

therapy, or cognitive therapy. Medications used to manage bipolar disorder include mood

stabilizers such as Lithium carbonate, which is considered the “gold standard treatment,”

anticonvulsants such as Depakote, and antipsychotics such as Risperidone, Seroquel, or Geodon.

If patients do not tolerate or respond to medications, our last option would be electroconvulsive

therapy, which helps treat mania by triggering a grand mal seizure (Videbeck, 2017, p. 674-676).

Identification of Stressors and Behaviors Precipitating Current Hospitalization

Prior to admission, ML was in rehab for noncompliance with his medications beginning

in January of this year. He was working as a carpenter at the time, however, that stopped shortly

after stopping his meds. ML went to rehab about a week prior to being hospitalized, where he

also became one week clean of Amphetamines. He stated he stopped taking his meds because he

did not like the way they made him feel. Since the age of eighteen, he has had numerous

occurrences of noncompliance with his treatment plan. Within the last three years, ML has lost

his dad, his grandfather, and a newborn prior to the birth. Upon admission, ML was suffering
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from auditory hallucinations. He also stated he was from the Cleveland area and now was relying

on his “baby mom” for a place to stay during his initial recovery phase.

Patient and Family History of Mental Illness

ML stated that he was diagnosed with bipolar at the age of six due to his constant

euphoric and manic behavior mixed with his hyperactivity. When asked what he did specially

that made him different from other kids, the only explanation he could provide me with was

“hitting people in the back of the knees with a baseball bat.” He then proceeded to laugh about it.

ML also disclosed he first tried meth when he was eight years old after stealing it from his sister.

Along with bipolar 1, ML also suffers from anxiety, depression, drug and alcohol abuse, suicidal

ideations and attempts, and self-harming. When reviewing his chart, it stated that ML has shot

himself six different times and hung himself ten different times.

Both his mother and father suffered from bipolar disorder, schizophrenia, and depression.

ML stated he has six other siblings; however, he was unsure if any of them suffered from a

mental illness.

Psychiatric Evidence-Based Nursing Care Provided

During his stay on the behavioral health inpatient unit, ML received care from the mental

health staff, consisting of a designated RN and LPN med nurse for each shift, a social worker, a

therapist who led group therapy and one-on-one therapy, a psychiatrist, and their Nurse

Practitioner. It was important for all members of ML’s care team to develop a good, strong

repour with him, but specifically his nurse. Any questions or concerns that ML had, were to be

directed to the nurse first. From there, his nurse would use the nursing process to assess,
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diagnose, plan, implement, and evaluate ML daily. The med nurse was responsible solely for the

administration and explanation of any prescribed or as needed medications.

ML was started on an anticonvulsant, Depakote, and an antipsychotic, Risperdal, both

acting as mood stabilizers to help manage his manic behavior. Upon administering the first dose,

it was important for the med nurse to review what the med’s action was and potential side effects

they may have from it. Depakote has a therapeutic range of 50-125 ug/mL, but toxicity does not

fully take effect until 150ug/mL. It is important to teach the patients potential side effects of

toxicity, including confusion, weakness, headache, and dizziness. It is also important for the med

nurse to teach the patient that Depakote is very hepatoxic so they will need to keep up with their

scheduled lab draws upon discharge. The two big side effects to teach the patient regarding

Risperdal is weight gain and a prolonged QTc. It is important for the med nurse to teach the

patient to call his doctor if he starts having heart palpitations, a seizure, or suddenly faints for no

apparent reason.

Another part of the treatment plan is attending group. ML had no interest in attending the

first two groups. However, after him and I had our conversation, he was more open and

understanding to the idea that attending group benefits him tremendously in his recovery process.

He was able to sit down, listen, and complete the worksheet as asked, however, he started

mimicking actions of a monopolizer, always wanting to talk and voice his opinions or ideas.

Ethnic, Spiritual, and Cultural influences

ML is a Caucasian, single man from a lower-class family. He was self-employed through

carpentry at the beginning of the year but now solely relies on state assistance. When asked

about his spiritual beliefs, he stated he believes in God but did not say if he identified with a
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specific religion. He does not attend church or practice any religious practices or beliefs. ML

also disclosed his desire to be with his dad, his grandpa, and his unborn baby boy in heaven one

day.

Evaluation of Patient Outcomes

Some of the outcomes desired for a patient with bipolar disorder include reduction in

suicidal thoughts or self-harming behaviors, improved social and occupational functioning,

improved hygiene care, and remission of co-occurring substance use disorder (Gitlin, 2018, p. 5).

On the day of care, ML admitted to no current suicidal thoughts or ideation. He stated he was

having a good day with no feelings or sadness or depression. He attended one of the three

groups, which was something he had not done the first two days on the unit. ML’s hygiene,

however, was still lacking. His hair was greasy, his gown was inside out and had food spilled all

over the front of it, his teeth were not brushed, and he had an uneven, unkept beard. I asked the

nurse for supplies to set him up for a shower but because of his homicidal ideations, she said she

would take them into his bathroom. To more knowledge, he never showered on the day of care.

Lastly, ML denies any desire to use Amphetamines upon discharge, however, did disclose the

urgency for a drink of alcohol.

Plans for Discharge

ML’s pink slip expires on 3/21. Upon discharged, he will return to Stubbonville where he will

reside with his “baby mom.” He no longer wished to return to the rehab he initially came from.

Instead, he expressed his want to find a rehab that treats both his psychiatric diagnosis and his

addiction. After leaving the inpatient unit, he will be encouraged to admit himself into the
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suggested rehab facility located closer to his home, stay compliant with his new medications and

needed lab draws, and refrain from Amphetamine use. Education materials will be provided

upon discharge regarding his medications, possible side effects, and adverse reactions that can

occur from toxicity.

Prioritized Nursing Diagnoses

The following are prioritized nursing diagnoses for ML:

1. Risk for injury related to extreme hyperactivity, increased agitation, or lack of control

over purposeless and potentially injurious movements.

2. Risk for self-directed or other-directed violence related to manic excitement, delusional

thinking, hallucinations, or impulsivity.

3. Imbalanced nutrition less than body requirements related to refusal or inability to sit still

long enough to eat, evidenced by loss of body weight.

4. Disturbed thought process related to biochemical alteration in the brain, evidenced by

delusions of grandeur or persecution, or inaccurate interpretation of the environment.

5. Disturbed sensory perception related to biochemical alterations in the brain or sleep

deprivation, evidenced by auditory or visual hallucinations.

6. Impaired social interactions related to egocentric and narcissistic behavior,

hypersexuality, or impulsivity.

7. Insomnia related to excessive hyperactivity and agitation.

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Potential Nursing Diagnoses

1. Ineffective individual coping

2. Ineffective activity planning

3. Impaired verbal communication

4. Ineffective health maintenance

5. Impaired memory

6. Impaired individual resilience

7. Self-care deficit

8. Impaired social interaction

9. Social isolation

10. Interrupted family processes

Conclusion

Bipolar disorder is a complex and diverse diagnosis. The disorder consists of five types

and three stages of mania. It can range from severe depression to severe mania and is

complicated by patients’ noncompliance with medications. ML’s hospitalization was a direct

result of his noncompliance with his medications, along with his Amphetamine and alcohol

abuse. Since being admitted and started on two new medications, ML’s auditory hallucinations

have subsided, and his social anxiety has improved. The goal upon discharge is to find ML a new

rehab facility, expressing the importance of continued medication compliance, and remain drug

and alcohol free to better manage his mania.

MENTAL HEALTH COMPREHENSIVE CASE STUDY 12

References

Gitlin, M. J. (2018). Semantics and expanding the treatment goals in bipolar disorder. Australian

& New Zealand Journal of Psychiatry, 52(1), 89–90.

https://doi-org.eps.cc.ysu.edu/10.1177/0004867417717801.

Guess, G. (2018). An Acute Case of Mania in a Bipolar Patient. American Journal of

Homeopathic Medicine, 111, 22–24.

Videbeck, S. L. (2017). Psychiatric - Mental Health Nursing Eighth Edition. Wolters Kluwer.