MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Aubrianna McClellan

November 2nd, 2023

Dr. Teresa Peck, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

RW is a 33-year-old male patient who was admitted to the inpatient psychiatric unit

following an overdose suicide attempt. He has a mental health diagnosis of schizoaffective

disorder, bipolar type. He experiences command auditory hallucinations and delusions of

grandeur, paranoia, and religion. Medication treatments including mood stabilizers and

antipsychotics have helped the patient maintain daily functioning and activity of ADLs. Nursing

management for this patient includes assessing positive and negative symptoms, developing

coping strategies, maximizing the level of functioning, and group and individual therapy

sessions.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 3

Objective Data

Patient Identifier RW

Age 33

Sex Male

Date of Admission October 24, 2023

Date of Care November 2, 2023

Psychiatric Diagnosis Schizoaffective, bipolar type

Other Diagnoses Drug abuse, drug overdose, self-harm attempt, borderline personality

disorder, polysubstance abuse

Behaviors on Admission RW had ingested handfuls of Buspar and Risperdal with the

intention of overdosing. The patient also had cuts all up his arm from punching the

television. The patient was having auditory command hallucinations that stated “keep

counting” when he was taking the pills to overdose.

Behaviors on Day of Care RW was very cooperative and willing to speak openly on the

day of care. He was one of the few people who participated in group therapy and

psychotherapy. RW was still experiencing suicidal ideation. He shared that he believed it

would be “easier if he was gone.” He had very clear and responsive speech and was very

emotionally labile. On the day of care, RW was experiencing grandiose and paranoid

delusions but was still able to answer orientation questions appropriately.

Safety and Security Measures With the inpatient admission, there were many safety

checks implemented. They have an aide walking around the unit doing checks on the

patients every 15 minutes. The patient was also not allowed off the unit, and the doors
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were locked. Hazardous items are not permitted on the unit like razors, pens, and pencils.

All medications were taken at the time of administration. The unit also has weighted

chairs at every table so patients cannot throw them at each other or out the windows.

Laboratory Results

Lab Value Result

Potassium 2.6
Glucose 103
AST / ALT 53 / 38
Drug (+) for
Toxicology marijuana and
amphetamine
Valproic Acid 76
Lactic Acid 19.5
QTC 554

Psychiatric Medications

Generic Name Trade Name Class / Dose / Reasoning

Category Frequency
Olanzapine Zyprexa Atypical 10mg daily Schizophrenia
antipsychotic
Pineal Hormone Melatonin Acetamide 5mg nightly Insomnia
Trazadone Trazadone SSRI 50mg nightly Depression
antidepressant and anxiety
Desyrel Depakote Anticonvulsant 500mg TID Manic phase
of bipolar
disorder
Lorazepam Ativan Benzodiazepine 1mg Q6 hours Anxiety
s PRN
Carvedilol Coreg Beta-blocker 12.5mg BID Lower HR
Clonidine Catapres Anti- 0.1 mg BID Decreases BP
Hydrochloride hypertensive
Cyclobenzaprin Flexeril Muscle relaxant 10mg TID PRN Fibromyalgia
e Hydrochloride
Risperidone Risperdal Atypical Overdosed on Schizophrenia
antipsychotic this medication
Haloperidol Haldol Conventional 5mg Q6 hours Schizophrenia
antipsychotic PRN
Hydroxyzine Vistaril Antihistamine 50mg TID PRN Anxiety
Nicotine Nicorette Nicotine 2mg PRN Tobacco
MENTAL HEALTH COMPREHENSIVE CASE STUDY 5

Lozenge replacement dependence

Summary of Psychiatric Diagnosis

Schizoaffective bipolar type is a mental health disorder that includes episodes of

schizophrenia and mood disorders. The person can have symptoms of both schizophrenia

(delusions, hallucinations, and disorganized speech) and bipolar disorder (extreme mood swings,

mania, and depression). It can affect a person’s behavior, thoughts, and mood. There are two

types of schizoaffective disorder, bipolar type which has symptoms of mania and major

depression, and depressive type which is only major depressive episodes (Schizoaffective

disorder 2019). RW had the diagnosis of schizoaffective disorder, bipolar type.

At first, schizoaffective disorder bipolar type is often misdiagnosed as either just bipolar

disorder or schizophrenia (Schizoaffective disorder 2022). Since schizoaffective is a combination

of both bipolar disorder and schizophrenia, the treatment options are borrowed from their

treatment regimens. To get the official diagnosis of schizoaffective disorder a patient must meet

the following criteria: uninterrupted duration of illness that must contain a major depressive

mood episode, two or more presentations that last a month including delusions, hallucinations,

disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms,

hallucinations and delusions for two or more weeks in the absence of mood episodes, symptoms

to meet the criteria for a mood episode must be present during the active and residual portions of

the illness, and disturbance must not be a result of the effects of a substance or underlying

medical condition (Schizoaffective disorder 2022).

This disorder may manifest differently in every patient. Some general symptoms of this

disorder may include hallucinations, delusions, disorganized speech, catatonic behavior, feelings
MENTAL HEALTH COMPREHENSIVE CASE STUDY 6

of emptiness, sadness, or worthlessness, and negative symptoms (Schizoaffective disorder 2022).

These negative symptoms may include things like showing little emotion, poor attention span or

concentration, and asociality.

Treatment options for schizoaffective bipolar type may include pharmacologic therapy,

individual therapy, family or group therapy, electroconvulsive therapy, and psychotherapy. Some

medications a patient might receive are antipsychotics, mood stabilizers, or antidepressants

(Schizoaffective disorder 2022). RW was taking Risperdal (Risperidone) which is an atypical

antipsychotic to help manage symptoms of schizoaffective disorder.

Antipsychotic drugs tend to lengthen the QTC interval, which can lead to Torsade de

Pointes, a cardiac arrhythmia that can lead to sudden cardiac death (Glassman, 2001). RW has a

history of high blood pressure, which he had already been taking medication for. Since he

attempted to overdose on Risperdal, and has a cardiac history, he was at an extremely high risk

of developing Torsade de Pointes, and possibly dying. A normal QTC interval is 440, and when

RW was admitted, his was 554.

Identification of Stressors and Behaviors Precipitating Current Hospitalization

Prior to this admission, RW was not compliant with his medications. He lives in a one-

story house with his grandmother. He does have partial custody of his daughter, so when he has

her, she lives there too. RW said that he has a good relationship with his grandmother, daughter,

and mother (although she does not live with them). RW said that he had been very anxious

before his admission. He talked about some of his stressors which included his daughter,

news/media, and the world in general. Normally, he copes by playing video games, but he shared

that in the past couple of weeks, he has not wanted to play his games. He said that he had been
MENTAL HEALTH COMPREHENSIVE CASE STUDY 7

lying in bed feeling very depressed. He shared with us that he was playing video games and then

his mind went blank, and when he was able to remember again, he was standing in front of a

broken television with glass in his hand and a police officer and his mother standing in front of

him. Further investigation of his chart showed that he had tried to take his own life by taking

handfuls of Buspar and Risperdal because the voices had told him to “keep counting.” An

ambulance had brought him to the hospital where they put him on an involuntary hold due to

being a danger to himself.

Patient and Family History of Mental Illness

RW stated that he started taking medications for his mental health at a very young age.

He was diagnosed with depression around age 11 or 12. He started taking Paxil at that time to

help him deal with his symptoms. The patient also has a history of fibromyalgia. He stated that

he had a gene test done, and it showed that the medications he was taking for this were not good

for his health, so he stopped taking them. Since the patient stopped taking his prescribed

medications, he has a history of medication non-compliance. When asked about a history of

sexual, physical, or emotional abuse, RW got quiet. He explained that there is history of abuse,

but he did not specify what kind, and he also did not want to go into detail. His parents got

divorced when he was young, and he lived with his mom and stepdad. His biological dad had a

history of drug abuse. RW also has a history of drug abuse. He started using heroin at age 22 but

was clean during the time of admission, and he also explained that he has a medical marijuana

card to use at the dispensary.

RW had also shared that this was not his first time at a psychiatric facility. He told us that

in April earlier this year, he had admitted himself to a psych unit because he felt like he was
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going to harm himself. He was transferred to a facility in Canton where he stayed for a month

working on his mental health. After being released from this facility, he started going to two AA

meetings a week, which helped him cope with a lot of his stress. RW also shared that his ex-wife

(the mother of his daughter) also struggles with mental health issues, and she is very

understanding of him going to get help.

Psychiatric Evidence-Based Nursing Care and Milieu Therapy

Throughout RW’s stay at the inpatient psychiatric unit, he received evidence-based

nursing care and milieu therapy. When RW was admitted to the unit, any hazardous objects were

removed from him. This was to prevent any injuries including the patient harming themselves or

any other patients. The nurses on the floor removed personal belongings that may have the

potential of causing harm including things like shoelaces, anything glass, keys, or belts. The

floor keeps a very stress-reduced environment by keeping noises to a minimum and the lights

down low. The nurses also ensure medication safety when they pass out patient’s medications.

They give the patient their medications and must stay with them and make sure they are not

pocketing pills in their mouths. This is to ensure that the patients can’t save them to help prevent

any type of overdose on the unit.

Some other nursing-based care that was implemented on the psychiatric unit was with the

nurse's aides. Since people on the psych unit are at higher risk of harming themselves and others,

the floor has aides that go around every 15 minutes. The aides must physically see each patient in

their room, in the day room, or in group therapy. They must account for every patient to ensure

that they are still alive and breathing, so they walk around the unit and check on every patient,

then chart that they physically saw them.

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My patient participated in several Milieu therapies while on the psychiatric unit. Another

student and I ran group therapy, and he was an active participant. I was then able to watch their

psychotherapy with the social worker. The patients talked about what was currently a stressor for

them and then discussed ways they would be able to cope with that specific stressor.

Ethnic, Spiritual, and Cultural Influences

RW talked about several topics that were ethnic, spiritual, and cultural influences for him.

For example, during our group therapy, he talked about how he tries to “get on his knees and

pray” at least once a day. RW shared that he is not always consistent in praying, but he tries his

best because it is able to help him cope with his stressors.

RW also shared that he really enjoys listening to music when he is stressed. He likes to

listen to heavy metal bands, one of his favorites being Behemoth. He went on to explain that

when he listens to music, he tends to get down a “rabbit hole.” This led him to listen to some

Satanist songs, which he didn’t particularly enjoy since he believed in God.

Evaluate the Patient Outcomes Related to Care

RW exhibited many positive outcomes during his stay on the psychiatric unit. Although

violent at home during his time of crisis, he was able to keep his composure on the unit. He

shared with us that he had felt a lot calmer being here and felt that he was starting to feel better

physically. He told us that he would also like to start going to a therapist again because he felt

like it would help him control his anger and stress. RW shared that he was taking his medications

on the unit with no problems and that he felt like they were helping him. Another positive

outcome of his stay was that he felt as though he was sleeping better. Before being admitted, he
MENTAL HEALTH COMPREHENSIVE CASE STUDY 10

said that he would “lay in bed feeling depressed but would not sleep.” RW also felt that

participating in group therapy and psychotherapy was helping him verbalize his emotions and

helping him realize he was not alone. He found several other patients whom he had common

interests with.

Summarize the Plans for Discharge

When RW is discharged, he plans on returning home with his grandma. He shared that he

also plans on seeing his daughter when he returns home. RW would like to work with the social

worker to find a new therapist that he is able to better connect with, and he feels like that will

help his recovery. He also shared that he would like to start going to AA meetings again because

he found that it really helped him get through his week. We shared some positive coping

techniques with him like going on walks and grounding techniques, and he said that he feels like

those would help him in times of crisis. RW also shared that he would like to work on having a

better routine/schedule when he gets home, especially when it comes to taking medications

because he feels like it will help him keep his mind busy.
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Prioritized Nursing Diagnoses

The following are prioritized nursing diagnoses for RW:

1. Impaired social interaction related to isolation as evidenced by being fearful and

anxious around others.

2. Disturbed sensory perception related to severe stress as evidenced by hallucinations.

3. Insomnia related to hyperactivity as evidenced by sleeping for only short periods of

time.

4. Risk for self-violence related to a history of self-harm and command hallucinations.

5. Risk for suicide related to previous and current suicidal ideation and attempt, and

hallucinations.

6. Risk for self-harm related to previous self-harm and delusions and hallucinations.

Potential Nursing Diagnoses

1. Self- Neglect

2. Hopelessness

3. Loneliness

4. Self-care deficit

5. Ineffective impulse control

6. Risk for injury related to lack of control

7. Disturbed thought process

8. Ineffective health maintenance

9. Fear

10. Impaired memory

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Conclusion

In conclusion, schizoaffective bipolar type can be an extremely debilitating disorder if not

properly treated. A patient with this disorder can experience psychotic symptoms, like

hallucinations or delusions, and bipolar symptoms including things like lacking energy, feeling

hopeless, and self-doubt. With the combination of these symptoms, plus a history of suicide

attempts and self-harm, RW may be at a very high risk of suicide or harming others. If RW stays

compliant with his medications, develops a structured daily schedule, attends therapy sessions,

and goes to AA meetings regularly, I believe that he can control his exacerbations and manage

his symptoms. This will help prevent RW from future self-harm or harming others.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 13

References

Glassman, A. H. (2001, November 1). Antipsychotic drugs: Prolonged QTC interval, Torsade de

Pointes, and sudden death. American Journal of Psychiatry.

https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.158.11.1774#:~:text=Risperidone

%20does%20lengthen%20the%20QTc,due%20to%20torsade%20de%20pointes.

Mayo Foundation for Medical Education and Research. (2019, November 9). Schizoaffective

disorder. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/schizoaffective-

disorder/symptoms-causes/syc-20354504

Schizoaffective disorder - statpearls - NCBI bookshelf. (2022).

https://www.ncbi.nlm.nih.gov/books/NBK541012/

Schizoaffective disorder. NAMI. (2022). https://www.nami.org/About-Mental-Illness/Mental-

Health-Conditions/Schizoaffective-Disorder