CASE STUDY 1

Case Study

Ava M. LaGamba

Department of Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

Mrs. Elizabeth Sanford

November 2, 2023
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Abstract

Bipolar disorder is a condition that affects the emotional regulation within the brain, causing

varying periods of mania and depression. These disruptions in their behavioral and emotional

control can cause distress for the individual in their personal, social, and work lives. The client

that I have interviewed specifically has been diagnosed with bipolar 2 disorder. Manifestations of

this type of bipolar disorder include all characteristics of bipolar 1, but tend to have more periods

of depression and hypoactivity. In this case study, bipolar disorder will be examined in a young

woman who will be referred to as “MK”.

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Bipolar Disorder: Case Study

Objective Data:

My patient on October 19th, 2023 was a biological female however, she referred to

herself as a male for the duration of my visit. The patient’s initials are MK, but she also went by

a fake name which was “Fawn”. She presented as an young adult woman who preferred to be

separated from the rest of the patients on the floor. Her behaviors and appearance were normal

aside from her having multiple tattoos over her body and an unnatural hair color. She looked as

though she took care of her physical appearance aside from being slightly underweight. During

my time on the floor, we talked about various topics including interests, relationships, and our

personal lives. I felt as though I was bonding well with her as she was very open to talking about

her health history and diagnoses. In order to be diagnosed with bipolar disorder, the individual

must have a depressive cycle of at least two weeks in addition to a hypomania episode not

related to any other mental illness (Mitchell and Malhi, 531). MK was admitted after a suicide

attempt at her home which involved cutting one of her wrists and attempting to overdose on one

of her antidepressants. She was admitted voluntarily and has been on the floor for a little under a

week at the time of our meeting. Looking at her most recent lab results, everything that was

tested was within their normal ranges. No drugs were found in her system on time of admission

into the ED.

As I was talking with her, I noticed during our entire conversation that she was very

anxious. I came to this conclusion by her behaviors which included bouncing her legs off of the

ground, stuttering, a lack of lengthy eye contact, and laughing nervously after sharing her

opinions. I tried to accommodate this by actively listening to her and focusing on her when she

wanted to speak. MK was in a group with a couple of other patients at one point of the interview,
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so she was getting talked over a lot during that time. Some of the comorbidities she had were

major depressive disorder, cluster B personality disorder, and generalized anxiety. Her

treatments were to establish a specific routine, monitor for sudden changes in mood and

behaviors, and watch for worsening signs of depression, such as seeking isolation and a sudden

lack of energy. In order to keep her and the other patients safe, all patients were monitored out in

the milieu room and rounds were done frequently to check on each individual patient. If a

situation arose, the nurses are to separate the patients and urge them to their rooms for safety and

as a de-escalation method.

Psychiatric Diagnoses:

MK had multiple psychiatric diagnoses such as major depressive disorder, cluster B

personality disorder, generalized anxiety, and bipolar disorder type 2. In cases of major

depressive disorder, the diagnosed person will experience a continuous loss of interest, energy,

and motivation. They struggle with day-to-day activities and tend to separate themselves from

their friends and families due to their symptoms. Common behaviors would be to not attend

functions, gain or lose weight, lack in their personal hygiene, and may become suicidal. Cluster

B personality disorders are described as unpredictable, inappropriate, and dramatic responses to

situations. Borderline, histrionic, antisocial, and narcissistic personalities are what make up

cluster B personality disorder. In order to get diagnosed with cluster B, one must exhibit

symptoms of at least two of the disorders within it. Behaviors one might see with this condition

include angry outbursts, impulsive, or dramatically over exaggerated responses.

Bipolar type 1 disorder criteria for a manic episode include: a period of abnormal and

persistent elevated, expansive or irritable mood and increased activity or energy, lasting one

week and present most of the day that cause marked impairment in social or occupational
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functioning; and the episode is not attributable to the physiological effects of a substance or other

medical condition (Videbeck, 2016). In the article “Bipolar II Compared with Bipolar I Disorder:

Baseline Characteristics and Treatment Response to Quetiapine in a Pooled Analysis of Five

Placebo-controlled Clinical Trials of Acute Bipolar Depression”, in cases of bipolar two

disorder, the individual will still express the same symptoms and behaviors as someone with

bipolar type one, but “requires at least one hypomanic and one major depressive episode” in

order for the diagnosis of BD-II (Datto et. al, 2). Although both extremes may happen in both

types of bipolar, those with BD-II will be more likely to commit suicide as a result of their

lengthy depressions. Bipolar disorder “is associated with substantial disability, comorbidity,

mortality, and impact on quality of life” (Datto et. al, 1). According to MK, having manic

episodes are considerably less likely for her than having a depressive period, which aligns with

the criteria for being diagnosed with bipolar type II. She does still claim to have outbursts,

elevated mood and energy on occasion, and emotional lability, but she rarely has them in public

or in the company of others. Her periods of depression can last from about a week to a month,

she stated. The medications she is prescribed to help treat her disorders include: Haldol, Vistaril,

Remeron, and Abilify.

Stressors and Behaviors that Precipitated Current Hospitalization:

Reported stressors and behaviors that led to MK being hospitalized changed when asked

about it more than once. After getting comfortable with her, I then started to ask about her

medical history and personal life. As we continued our conversation, MK added more

information to her story and I noticed there were some inconsistencies in it. At first, I was told

that the reason she was hospitalized was because she got into an argument with her long distance

boyfriend, which caused her to go into a panic and that made her want to harm herself. Then as
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we continued to talk, the reason she was admitted to the hospital was that she was having a

depressive episode for about a month and had been talking to her boyfriend about moving in with

him to his home in Cleveland. This caused her to get overwhelmed and thus in a panic, she

started cutting herself to try and relieve the stress. When asked if the argument with him

contributed to her panic, she denied that she ever argued with him and that they got along very

well.

She claims that the reason she cut herself was because she was tired of waiting to move

in with him, so she started to doubt if it was ever going to happen. Her behaviors leading up to

her admission were “normal” to her. She said that she hadn’t been acting in a way that she

normally doesn't, including her most recent depression episode which lasted for about two weeks

before her admission. I then questioned her about previous suicide attempts and what triggered

those as well. MK claims she can’t fully recall, but most likely they were caused by stress from

her relationships with her parents and boyfriend. She said she doesn’t have a very good

connection to her parents, and that attributes to a lot of the stress she has. When looking in her

chart, she voluntarily admitted herself after attempting to overdose on her antidepressants. MK

stated that she “was worried about not being able to move in with her boyfriend”. Due to this

anxiety and stress in combination with her depression she had been experiencing for a while, it

caused another one of her suicide attempts.

Patient and Family Medical History:

When asked about her medical history, MK stated that “everything started around

thirteen”. When she was about thirteen, supposedly her parents noticed a change in behavior, but

didn’t act on it due to them passing it off as normal adolescent behavior. As time went on, MK

recalled that she started to isolate herself from her friends and family and chose to start building
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personal relationships online with people “all over the world”. On the internet, she would share

her drawings on platforms such as Tumblr and Instagram and eventually, she gained the attention

of her current boyfriend. While she considered many of these people on the internet her friends,

she said that “nothing made her feel real”, which I interpreted as that she still felt alone despite

having such an internet presence. She claims that even though she felt loved by many people on

the internet including her boyfriend, it was never enough to make her happy. From thirteen to

eighteen, she noticed that her moods would fluctuate very easily and abnormally, so she started

to seek out professional help.

At the age of seventeen she was diagnosed with major depressive and bipolar disorder.

When asked about her feelings during that time, she stated that “I expected to get something

from my mom”. MK’s current medical diagnoses can both be related back to her mother and

father. She claims that both of her parents have a history of mental illness, much like she does.

Furthermore, MK believes that the source of her diagnoses were from her mother, which she

claims to be exactly like hers. She blames her mental illnesses on her mother more than her

father. When examining her chart, the only family history she had listed was her father who had

a history of bipolar disorder. According to the article “The Emerging Neurobiology of Bipolar

Disorder”, studies have found that “a child of an affected parent has about a tenfold increased

risk of developing BD” (Harrison et al., 18). This statement applies to MK because her father has

also been diagnosed with bipolar disorder, therefore explains where she got it from. MK also has

a history of anxiety and depression, but it is unknown if her parents did as well. There are no

other reported family histories of mental illness. The only diagnosis she couldn’t explain was the

cluster B personality disorder. MK didn’t know if her parents were also diagnosed with it.

Nursing Care:
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The nursing care provided on October 19th was more so for every patient as opposed to

individualized care. The nurses on the floor did not interact with the patients on the day during

my interview with MK. The only interaction she had was with another patient and myself during

the last hour of my interview. The general nursing care provided for the patients was maintaining

a safe environment and encouraging independence. If the nurses were to interact with MK, some

of the nursing care they could have done would be to help her improve her self-esteem, teach her

better coping skills for when she is stressed, anxious, or depressed, educate her on how to control

her moods better and help to recognize triggers, and encourage medication adherence. The way I

offered support to her was that I was engaged in our conversation, actively listened, and made

her feelings and opinions feel validated.

The milieu activities I attended were social interaction with the other patients and myself.

Together we talked, colored, and found common interests in one another. There was another

patient in the group MK and I had made and she also socialized with us. By interacting with MK,

myself and the other patient were having a positive impact on her by allowing her to feel

welcome and safe in her environment. Another milieu activity she engaged in during my visit

was that she followed a structured schedule. By having a schedule, this allowed her to have some

sort of sense of responsibility and it also allowed her not to stress about what to do with all of her

free time. Lacking structure in one’s life can impact their mental health by causing complications

such as panic or depression. So by having a schedule, MK was able to feel confident in herself

and relax during her time in the psych unit.

Ethnic, Spiritual, and Cultural Influences:

MK is a young, caucasian woman with a Christian background. As also being a young

Christian white woman, I attempted to find common ground with her on this aspect. This
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however proved to be difficult as she had recently denounced her faith. According to her, she

was raised in a Catholic household where she had to participate in church regularly. In her

childhood, she stated that her faith in God and mother Mary had a strong impact on her life and

values. MK claimed that she attended her local church every weekend until she reached

adolescence, about the same time when her parents noticed her emotional lability. The reason she

abandoned her faith was because she felt as though she had no choice in the matter and that now

that she’s an adult, she wants to be free from her religion. She said she felt “limited” on what she

was able to do if she wanted to continue a life of Catholicism. Both of MK’s parents are

caucasian and were brought up Catholic as well in their households.

MK stated that she had no spiritual or ethnic influences on her life. She stated that she

doesn’t believe in anything supernatural or “otherworldly”. She claims that her relationship with

her boyfriend is the only thing that has an impact on her life and values. Her cultural background

is Irish and German, with her father being of Irish descent and her mother German. Growing up,

this did not have a big impact on her life. The only thing that she says she can recall is that

during holidays, such as Christmas, she and her family would celebrate with traditional foods of

German culture. Other than on Christmas, MK remarked that her family would not celebrate

either any recognized German or Irish holidays. It is a part of both Irish and German tradition to

believe in one God and both nationalities are mostly Catholic Christian. She claims that she

dropped her religious beliefs because she didn’t want that to be her biggest “defining feature”.

From my understanding, this implies that she didn’t want to identify with Christianity if she

didn’t have to anymore.

Evaluation of Patient Outcomes:

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The outcomes that I identified what MK should be able to achieve on the day of care

were created and based off of if they were realistic and measurable. The first goal I identified for

MK is that she will be free from any excessive physical agitation and purposeless motor activity

within the day of care. I chose this goal specifically for her because of her diagnoses of both

bipolar and cluster B personality disorder. While bipolar alone can cause the affected person to

become easily agitated or aggressive, in situations where there is a comorbidity of cluster B

personality disorder, her impulsivity and lack of emotional control may be amplified. This goal

was achieved. The second goal I set for her is that she will refrain from making verbal threats,

and using inappropriate language towards others. In addition to her dual diagnoses of bipolar and

cluster B personality, aggression is common in those with these diagnoses. Based on these two

conditions, establishing positive or normal relationships with others may be a problem for her

too, as she has a difficult time regulating her moods and controlling her outbursts. People with

cluster B personality disorders also tend to be over dramatic and socially awkward. This goal

was achieved.

The third goal I created for MK is that she will initiate and maintain goal-directed and

mutually satisfying activities or verbal exchanges with others. The reason for this goal is because

with milieu therapy, which is a therapeutic technique for treating mental disorders, one core

principle of milieu is encouraging positive socialization with others. By doing this, she might be

able to develop healthy and uplifting relationships with those who may be going through

something very similar to herself. With bipolar disorder, having stable connections with others

can be difficult for them due to their impulsivity and social awkwardness. This goal was also

achieved on the day of care. The final goal I established for her is that she will identify positive

coping mechanisms to improve feelings of hopelessness. In relation to her history of bipolar type
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II disorder, long lasting depressive episodes are extremely common. When MK goes into a

depression, she will then begin to use coping mechanisms she’s established many years prior

which include self-harm and planning for another suicide attempt. I made developing better

coping mechanisms the primary goal for her as suicidal idealation is the most threatening

complication to her life. We established two positive coping techniques which are reaching out

to suicide hotlines when contemplating it, and distraction techniques when stressed or

overwhelmed which can be going to events, talking with her significant other, drawing, and

video games.

Summarized Plans for Discharge:

MK plans to go back home to her apartment that she lives in with a friend. Not much

detail was given on her roommate other than that according to MK, she’s a girl. I then asked

about what the environment is like at the apartment, to which she replied that it’s “alright”. MK

did not specify whether or not her current living situation is helpful or harmful to her, she simply

stated that she wanted to move in with her boyfriend as soon as possible. She was being

discharged with the same medications that she was admitted with which include Remeron,

Haldol, Vistaril, and Abilify. She said she wasn’t fully informed on what she should be doing

when she returns back home. I used this opportunity to educate her on some important

information she should have if she’s going to be returning back home. I tried to assess what her

home life was like, but it was to no avail.

The education that I gave her was reinforcement of the coping skills we developed

together whenever she feels like cutting or ending it all when she gets depressed. Her labs were

not abnormal and she did not use drugs, alcohol, or nicotine, so no teaching was done in regards

to that. I also educated her on some of the medications she was on, specifically Remeron which
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is an antidepressant. One thing that I mentioned in regards to this is that antidepressants take four

to six weeks for the effects to start being noticeable to the user. Although she had been on the

drug for longer than six weeks, it is still important to reinforce this knowledge for potential

changes in medications. One recommendation I made with her consent is that whenever she feels

overwhelmed or about to have an outburst, she should try to excuse herself from the situation

and find comfort somewhere that she can be alone but still feel safe.

Diagnoses Using Individualized NANDA Format:

When creating nursing diagnoses for MK, I focused mostly on the factor that seems to

have the greatest impact on her life, which are the complications that arise from her mental

illnesses. Specifically, her suicidal idealation and tendencies for self harm pose the biggest

threats to her as of currently. Risk for injury related to self harm as evidenced by suicidal

idealation can be tied back to both her major depressive disorder and bipolar type II disorder. As

a result of these disorders, a person has excessively long periods of depression and

accompanying hopelessness. When a person is in such a state for so long, they start looking for

escape methods, which include self harm and ultimately suicide. As MK has stated in her

interview with me, she’s attempted to end her life in most of the depressive episodes that she's

experienced thus far.

A second diagnosis that I identified for her is social isolation related to inappropriate

social behaviors as evidenced by diagnosis of cluster B personality disorder. As stated by MK,

she recalls in her past having difficulty forming relationships that started around her adolescent

years. Symptoms of cluster B personality disorders include having abusive relationships as well

as having difficulty forming proper or normal ones. With cluster B personality disorders, it also

is a problem for the person to make connections and to have sympathy for others. They see
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forming relationships as means to get something they want, so if they don’t benefit from a

relationship, they won’t care for it. Therefore, an effort needs to be made in order for her to be

able to socialize better. For both of these diagnoses, I utilized the Nursing Diagnosis Handbook:

An Evidence-based Guide to Planning Care by Ackley et. al.

Potential Nursing Diagnoses:

When formulating other suitable nursing diagnoses for MK, I attempted to focus less on

her mental disorders and more on what I’ve learned from her history and current presentation.

Self-care deficit related to a lack of motivation as evidenced by weight loss from eating

inconsistently could be a diagnosis to give her. The reason for this is because when conversing

with her, she mentioned that as of recently she has had a more noticeable loss of appetite and

weight. MK also is noticeably underweight. She stated that she doesn’t know if it’s an effect of

her meds, but rather that it might have something to do with her more lengthy depressive

episodes. MK said that when she gets depressed, she refuses to eat or eat very little every so

often. This poses a threat to her health because she needs to maintain a healthy diet and adequate

intake if she plans to live a prosperous life free from developing more illnesses.

Another diagnosis she could potentially have is hopelessness related to long-term stress

as evidenced by suicidal idealation. As stated by MK, when she has those depressive periods, she

begins to harm herself again and contemplates suicide. She has had multiple suicide attempts and

they all can be tied back to those long states of depression and feelings of hopelessness. This is

something to really prioritize because if those feelings of hopelessness and despair were focused

on and treated, potentially she would have less incidences of being admitted to the ED and psych

ward.

Conclusion:
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Through a multidisciplinary approach, it is highly likely for MK to live out a prosperous

life without being limited due to her mental illnesses. As someone who has only known her for a

couple of hours, it’s clear to understand her character and what improvements she could make in

her life. Even though she has multiple mental illnesses, that doesn’t deter her from seeking a

better life for herself. Although bipolar disorder and major depressive disorder can be

debilitating for most, she still seeks to improve her quality of life. From my perspective, changes

could still be made in order to maximize her chances at a safer and more normal life with the

right professional help. I hope that the time I spent talking with her may have been something

she could have benefited from in the end as I did

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References

Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martinez-Kratz, M. R., & Zanotti, M.

(2020). Nursing diagnosis handbook: an evidence-based guide to planning care. Twelfth

edition. St. Louis, Missouri, Elsevier.

Datto, C., Pottorf, W. J., Feeley, L., LaPorte, S., & Liss, C. (2016). Bipolar II compared with

bipolar I disorder: baseline characteristics and treatment response to quetiapine in a

pooled analysis of five placebo-controlled clinical trials of acute bipolar depression.

Annals of General Psychiatry, 15, 1–12. https://doi.org/10.1186/s12991-016-0096-0

Harrison, P. J., Geddes, J. R., & Tunbridge, E. M. (2018). The Emerging Neurobiology of

Bipolar Disorder. Trends in neurosciences, 41(1), 18–30.

https://doi.org/10.1016/j.tins.2017.10.006

Mitchell, P. B., & Malhi, G. S. (2004). Bipolar depression: phenomenological overview and

clinical characteristics. Bipolar Disorders, 6(6), 530–539. https://doi.org/10.1111/j.1399-

5618.2004.00137.x

Videbeck, S. (2022). Chapter 17: Bipolar Disorder. In Psychiatric-Mental Health Nursing (pp.

306-315). Lippincott Williams & Wilkins.

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Case Study Comment Sheet 4842 (Turn in with Case Study)

Student Name: Ava LaGamba

Pt Identifier: MK

Date(s) of Care: 10/19

_________ Objective Data presentation the patient, treatments, medications

_________ Discuss patient / family history of mental illness

_________ Identify stressors and behaviors that precipitated current hospitalization

_________ Summarize the psychiatric nursing interventions with rationales

_________ Evaluate patient outcomes for nursing care provided

_________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

_________ Patient education required (based on symptoms, diagnosis, medications, labs, safety,

etc.)

_________ Priority patient needs (day of care and discharge)

_________ Summarize discharge plans and community care

_________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

_________ List of potential nursing diagnoses

_________ Conclusion paragraph

_________ Style, spelling, grammar, clarity, organization, APA format