Mental Health Comprehensive Case Study

NaKeisha Kelley

Youngstown State University

Mental Health Comprehensive Case Study

04/06/2024
Mental Health Comprehensive Case Study

Abstract

A.Z. is a 60-year-old female who was admitted to the psychiatric unit with a diagnosis of

Severe manic bipolar 1 disorder with psychotic behavior. She was paranoid, off her

medications, and her son called for a welfare check. When EMTs arrived, she was screaming

and combative. During her stay she was treated with medications, and she also attended group

therapy and individual therapy from nursing staff. With the medications adjustments and the

therapies the patient A.Z. was able to return to her normal routine.
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I was taking care of a patient initials A.Z. on February 15, 2024, who was admitted on

February 13, 2024, and which they gave a diagnosis of Severe manic bipolar 1 disorder with

psychotic behavior. Her labs are as followed potassium 3.8-normal, sodium 140, glucose A1C

5.5 which were all normal. Patient tested positive for benzo’s, cannabis and oxy. Her QTC level

was 477 patient is on Depakote which does not cause QTC prolongation. While in the

emergency room the patient was having delusions of grandeur saying that she was Donald

Trumps wife. On the day of admission to the psych unit the patient was combative with the

staff and didn’t want to admit that she was having a manic episode. On the day of care this

patient was displaying circumstantiality where she kept bouncing from the main idea or

question that was being asked. She also was showing signs of flight of ideas, she was bouncing

everywhere. If you would ask this patient a question, she would answer everything except what

was being asked. She would also interrupt others whenever they would be talking, and she

would start talking about things that didn’t have anything to do with the topic being asked. This

patient was very emotional throughout the day, she would start talking about something, then

she would bring up something from her past like her grandmother passing away and she would

start crying. A.Z. didn’t have any underlying medical conditions, but she has had the diagnosis

of bipolar 1 disorder for a while and she sometimes displays the psychosis that can go hand in

hand with this psychiatric disorder.

Some of the safety and security measures initiated during the patient’s hospitalization

include thoroughly searching patient’s belongings upon admission to remove items that could

potentially be used for harm such as: shoelaces, medications, or sharp objects. Another safety
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measure to be placed upon admission is the initiation of a constant observer. A constant

observer is most often a patient care technician who stays with the patient around the clock

and observes their behavior and activities. The constant observer, or C.O. for short, documents

behaviors and activity every 15 minutes frequently updating nursing regarding any unusual

findings/ concerns. Nursing staff can help keep the patient safe by frequently completing all

required screenings every shift, such as the delirium screening, to assess changes in cognition,

orientation, mood affect.

The patient, A.Z., is prescribed Depakote, or generically known as Divalproex, 500mg by

mouth every 12 hours. While classified as an antiepileptic, this medication is commonly used in

the treatment of bipolar disorder as a mood stabilizer. This medication helps reduce the

frequency/severity of acute manic episodes. Common side effects of this medication include

dizziness, diarrhea, constipation, and epistaxis. Depakote does require frequent monitoring via

blood work to assess Depakote blood level, prevent Depakote toxicity, and maintain adequate

liver function. The second medication this patient is prescribed is Haldol, or Haloperidol, 3mg

IM every six hours as needed for agitation. This medication is an antipsychotic agent used to

manage more extreme instances of agitation/aggression. This medication may cause dizziness,

dry mouth, drowsiness, and sleep disturbances. It is also important to monitor QTC while taking

this medication, as it can prolong QTC, it should be used with caution in patients with

prolonged QTC interval. The third medication this patient is prescribed is Vistaril/ Hydroxyzine

25mg by mouth 3x daily as needed for agitation. This medication is classified as an

antihistamine but is frequently utilized for treatment of agitation, as it has mild sedative

effects. Common side effects of Vistaril include sedation, headache, dry mouth, and
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tachycardia. This medication should be used with caution, especially in the elderly population,

as it may cause extreme dizziness, which could lead to falls/ falls with injury. The fourth and last

medication this patient is prescribed is Risperdal/Risperidone 3mg by mouth nightly. This

medication is classified as an atypical antipsychotic and is used in the treatment of Bipolar with

manic episodes. This medication is often taken nightly due to one of its side effects is

sleepiness. Other side effects of this medication include headache, weight gain, and difficulty

moving. A more worrisome side effect of this drug is EPS, or extrapyramidal symptoms. EPS can

be mild or severe and includes symptoms such as akathisia, akinesia, tardive dyskinesia,

parkinsonism, or the life-threatening condition neuroleptic malignant syndrome.

2. Summarize the psychiatric diagnoses and expected/common behaviors, with citations

This patient has received a formal diagnosis of severe manic Bipolar 1 disorder with

psychosis. “Bipolar type 1 disorder is defined by manic episodes that last for at least 7 days

(nearly every day for most of the day) or by manic symptoms that are so severe that the person

needs immediate medical care. Usually, depressive episodes occur as well, typically lasting at

least 2 weeks” (NIH 2024). Bipolar type 1 disorder is characterized by two different emotional

states, one being mania and the other depression. Mania is a state of emotional “euphoria”, so

to speak, in which the individual experiences abnormally elevated mood that could include

irritability, or excitement. “Manic symptoms often include hyperactivity, hyper-talkativeness,

decreased need for sleep, grandiosity, increased risk taking, and being easily distracted” (APA,

2000). Depressive episodes occur when the individual experiences the metaphoric “come

down” from a manic episode and the individual begins to feel extreme hopelessness and

sadness. “People with bipolar disorder experience periods of ‘highs,’ with mania and euphoria
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or irritability. These periods alternate with episodes of depression or ‘lows,’ with a loss of

interest, motivation, concentration, and energy,” said Matt Rudorfer, M.D., chief of the Adult

Psychopharmacology, Somatic, and Integrated Treatment Research Program at the National

Institute of Mental Health (NIMH). (Rudorfer & Santana, 2023)

3. Identify the stressors and behaviors that precipitated current hospitalization

The stressors and behaviors that precipitated this current hospitalization was the

patient stopped taking her medication. Once the patient stopped taking her medication it led to

signs and symptoms of psychosis. The patient started displaying symptoms such as talking

uncontrollably, going off topic, and saying she was someone that she wasn’t. The patient son

was concerned so he called 911 for a welfare check on the patient. Once the EMT’s arrived on

scene the patient became combative and locked herself in the restroom stating she was not

going to the hospital.

4. Discuss patient and family history of mental illness

Patient does not have a family history of mental illness, but the patient was

diagnosed early on in life with bipolar 1. Patient has a history of physical and verbal abuse from

an ex-husband. Patient stated her husband would get drunk and become violent, often times

shouting and striking her with his fist or anything in sight. Some of the things that helped the

patient cope with life is cooking and playing with her dog.

5. Describe the psychiatric evidence based nursing care provided and milieu activites

attended

Evidenced-based nursing care that was provided included the development of a

personalized plan of care that established goals based upon the patient’s unique
Mental Health Comprehensive Case Study

needs/diagnosis. The nurse also provided education regarding the utilization of healthy coping

mechanisms and encouraged the patient to practice them to prevent harm and aid in the

management of unwanted symptoms of their mental illness. Some of the duties to promote

safety on the psychiatric unit includes witnessing the patient take their prescribed medications,

setting and maintaining clear boundaries, establishing routines, regularly reassessing mood and

affect with appropriate documentation, performing routine safety checks according to facility

policy, know how to appropriately deescalate when it’s safe to do so and call for help “code

violent” when necessary.

6. Analyze ethnic, spiritual and cultural influences that impact the patient

The patient’s ethnicity is both Greek and Italian. Individuals of Greek descent have a rich,

interesting history in terms of the way they perceive mental health issues. During ancient times,

particularly the before Christ era, it was widely believed by the Greek population that those

suffering from mental illness were possessed by a demon and needed exorcism to expel those

entities. As time evolved, so did both religious ideals and thoughts regarding mental health.

Three basic trends in psychiatric thought can be traced back to earliest times: (a) organic

approach, the attempt to explain diseases of the mind in physical terms; (b) psychological

approach, the attempt to find a psychological explanation for mental disturbances; and (c)

sacred or magical approach, which can be further divided into the animistic, mythological and

demonological models. (Tzeferakos & Douzenis, 2014). It was also widely believed within

in the magical approach that sacrifice would appease the Gods who would then grant

benevolence and cure the ailment.

7. Evaluate the patient outcomes related to care

Mental Health Comprehensive Case Study

During inpatient hospitalization, the patient actively participated in evidenced-based

therapies such as Cognitive Behavioral Therapy (CBT), as well as group activities. CBT is a type of

therapy that involves working closely with a licensed therapist to work through complex

emotions and develop a plan to healthily process them to promote healing. During group

therapy the students presented an activity using a game called “Jenga” to assist the patients to

openly express their emotions and encourage them to relate to each other to prevent feelings

of isolation and loneliness. On each puzzle piece there were also affirmations such as “You are

stronger than you seem.” Patients were encouraged to read the affirmations aloud, so that

everyone could reinforce concepts learned in CBT.

Other than the CBT therapy and group therapy sessions the patient outcomes for her

inpatient treatment included getting the patient back on a medication regimen and adding an

additional pill to help with the agitation breakthrough, because she resumed her pills and

added another one, she was able to decrease her manic state. Now that she went to these

therapies, she was able to establish healthy coping mechanisms, decrease feeling of isolation,

and develop relationships with others who shared similar struggles thus preventing feelings of

isolation.

8. Summarize plans for discharge

Plan of discharge is determined by a collaborative, or team effort. Both the Psychiatric

Attending, therapists, nurses, case manager, social workers, family/friends, and the patient

work together to establish the common goal of getting the patient stabilized to go home safely.

Discharge planning begins the day the patient is admitted to the inpatient setting. As previously

discussed in this case study, the patient is actively encouraged to set small attainable goals for
Mental Health Comprehensive Case Study

themself during their stay and the rest of the direct support staff build their treatment plan

based of those goals and are then able to identify barriers to discharge as well as progress.

These assessments can help determine an estimated length of stay unique to the patient. The

plan is to discharge this patient home with appropriate support systems in place to prevent re-

admission. Social work and case managers utilize nursing screenings to determine

socioeconomic barriers to discharge and work closely with insurance companies and local

organizations to provide shelter, ride assistance, meals on wheels, prescription assistance,

medica l equipment, home care, and so much more! Staff will also assist the patient in finding a

psychiatrist and therapist to establish a care with, so the patient has continuity of care in the

outpatient setting. Staff will schedule follow-up appointments within the week of discharge to

keep a close eye on the patient. The patient will be discharged home alone with support from

their son, follow-up appointment information provided, medication delivered to pharmacy and

son was able to pick it up at a discounted price with a prescription voucher provided by case

management.

9. Prioritized list of all actual diagnoses using individualized NANDA format.

1. Patient is diagnosed with bipolar 1 related to drastic fluctuation of mood as evidenced

by recent manic episode.

2. Patient is diagnosed with acute psychosis related to abrupt discontinuation of

medications as evidenced by aggressive and irrational behavior.

3. Impaired communication related to delusions of grandeur thinking as evidenced by

stating she is Donald Trump’s wife.

4. Impaired nutrition related to hyperexcitability as evidenced by pacing around the floor.

Mental Health Comprehensive Case Study

5. Self-care deficit related to poor hygiene as evidenced by unkept appearance

10. List of potential nursing diagnoses

One nursing diagnosis that is appropriate for this patient is: risk for injury. This patient is at risk

for injury during both acutely manic and depressive episodes. During manic episodes, the

patient may engage in risky behaviors such as, gambling, unprotected sex, drug abuse, and

more. While conversely, the patient is equally at risk during the depressive stage due to

potential for self-harm with, or without serious injury, and suicidal ideation. The expected, or

desired outcome of this nursing diagnosis would be that the patient remains free from injury. A

second nursing diagnosis that is appropriate for this patient is impaired thought processes.

While the patient was experiencing acute mania, they displayed signs of grandeur, flight of

ideas, and a general state of hyperexcitability. The desired outcome for this nursing diagnosis

would be the patient gaining insight into their diagnosis and developing the ability to

distinguish signs and symptoms of mania and seek proper help for symptom management. A

third nursing diagnosis for the patient is impaired sleep pattern. Patients experiencing mania

with psychosis often find themselves needing less sleep due to the hyperexcitability properties

of the disorder. Patients with type 1 bipolar disorder, experiencing a depressive episode, may

also be at risk for impaired sleep pattern. Many individuals who are cycling into depression will

sleep too much, or too little for a variety of different reasons. For example, a depressed person

may sleep most of the time due to lethargy, and lack of interest in life. An expected outcome

would be establishing a sleep goal with the patient and developing a routine to promote a

healthy sleep cycle and regulate circadian rhythm. A fourth nursing diagnosis for this patient is

risk of suicide. When the patient cycles into depression, the risk of suicide vastly increases. The
Mental Health Comprehensive Case Study

patient may exhibit suicidal ideation for which they have thoughts of not wanting to be alive, or

the patient may be actively suicidal with a concrete plan of how they are going to do it. The

desired outcome is that the patient will utilize appropriate resources such as a safety plan and

knowing when to seek professional help. The fifth nursing diagnosis is impaired coping. The

patient may utilize risky behavior to “help” them live with unmanaged symptoms of their

mental illness. The patient is at risk for drug abuse, self-harm, risky sex practices, isolation from

support systems, etc. A desired outcome would be for the patient to develop healthy coping

patters. This patient identified spending time with her pet dog as a comfort measure to her, an

example of an effective coping mechanism unique to this individual’s plan of care.

11. Conclusion paragraph

Throughout this case study objective data was collected and analyzed from a patient, A.Z. in

dept exploration of the diagnosis provided insight on the patient unique behaviors during an

acute episode of mania with psychotic features. Patient was examined during an in-patient

hospitalization where the author was able to gain first-hand knowledge of the signs and

symptoms experienced by the individual being studied. Special factors influencing the case

study included familiar history of mental illness, patient’s ethnicity, and psychiatric history. An

individualized care plan was collaborated on by members of the psychiatric care team utilizing

both subjective and objective data collected by nursing through varies assessments and direct

conversation with the patient. Based off raw data collected, the appropriate plan was devised

which included CBT, group therapy, and medication regimen adjustment. Evidenced-based

nursing practices were implemented to aid patient in achieving recovery goals established in

plan of care to thus facilitate safe discharge home. The patient benefitted immensely from in-
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patient stay and was able to utilize effective coping mechanisms, safety plan, and proper

medication management upon discharge which led to remission of symptoms and gave the

patient a better quality of life. The case study examined brought insight into the deficits of

bipolar 1 with psychosis but was able to show how utilizing evidenced-based practice in a team

approach can help to minimize adverse side effects associated with the disorder and prevent

future relapses requiring hospitalization.

Mental Health Comprehensive Case Study

Reference:

Open Resources for Nursing (Open RN). (1970b, January 1). Table 8.4B, [common nursing
diagnoses related to bipolar disorder [],[]]. - nursing: Mental health and community
concepts - NCBI bookshelf. Nursing: Mental Health and Community Concepts [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK590048/table/ch8applying.T.common_nursing_d
iagnoses_r/

Rudorfer, M., & Santana, J. (2023, December 12). The Ups and Downs of Bipolar Disorder.
National Institute of Mental Health. https://www.nimh.nih.gov/news/science-
news/2023/the-ups-and-downs-of-bipolar-disorder

Tzeferakos, G., & Douzenis, A. (2014, April 12). Sacred psychiatry in ancient Greece. Annals of
general psychiatry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991897/

U.S. Department of Health and Human Services. (2024, February). Bipolar Disorder. National
Institute of Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-
disorder#:~:text=Bipolar%20I%20disorder%20is%20defined,lasting%20at%20least%202
%20weeks.