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Comprehensive Case Study

Katie C. Demetrios

Centofanti School of Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

April 1, 2024

Professor Dr. Teresa Peck

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Objective Data

On February 21st, patient M.M, a 31-year-old male, was brought in by police officers and

pink slipped in the emergency department. Patient has a diagnosis of severe bipolar 1 disorder

with psychotic behavior. Past medical history includes substance abuse, and testicular cancer that

resulted in the loss of one of the patients’ testicles. Police were called by the patient’s mother

after seeing the patient had posted many videos and pictures on social media which concerned

the mother that the patient was off medications and would potentially hurt himself. The mother

reported he had been very unorganized, had not been sleeping, and she believes he has been off

his medications for the past 6 months. M.M. was found in his trailer home which was very messy

and unkept when police arrived. When arriving at emergency department, patient was mildly

aggressive towards staff. Patient was also experiencing disorganized thinking and hallucinations.

Patient kept seeing “bees” and stated they kept disappearing. He was also in a state of mania.

The patient was speaking quickly and exhibiting flight of ideas. He had very intense eye contact

but did seem to be well groomed. M.M. reported he stopped taking medications due to not

wanting to continue to gain weight and his “penis shrinking”. Urine was negative for drugs and

alcohol. Patient currently lives alone and works 60 hours a week at ATI. The patient had been

hospitalized in 2022 at Generations Behavioral Health. He currently sees Jennifer Joseph for

medical management.

On day of care, 02/29, patient is well groomed and cooperative. Patient still presents with

signs of mania, including fast speech and distractibility. During a game of uno, M.M. eventually

quit the game due to being unable to pay attention. Patient interested in conversations and does

not seem to be experiencing hallucinations at this point in time. M.M. shows flight of ideas and

circumstantiality when speaking with him but is very cooperative. Patient reports he used to have
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a problem with drinking and would drink around 30 beers in one evening. He states he now only

drinks a few every now and then. M.M. is very interested in talking with students and seems

excited to share his experiences. Patient interacts well with other patients during group therapy

and shows no signs of aggression to staff or patients.

M.M. diagnoses was severe manic bipolar 1 disorder with psychotic behaviors. As

learned in class, bipolar disorder can be characterized by extreme mood swings, including

periods of depression and mania, as well as some periods of normalcy. Bipolar 1 disorder, more

frequently than not, the patients experience mania. They do have periods of depression, but often

have many more periods of mania. Bipolar 1 disorder with psychotic features simply means this

patient was also experiencing some sort of delusions, hallucinations, or both (Videbeck, 2022).

In this patient’s case he was experiencing hallucinations upon arrival to ED. This patient was

clearly experiencing mania, as evidenced by his rapidly changing thoughts, distractibility, and

lack of sleep prior to hospitalization.

M.M. labs results show nothing significant on day of care. Patients’ glucose is

slightly elevated at 113, possibly due to medications. Some antipsychotics can cause increased

blood sugars, and even cause type 2 diabetes to develop if used for long periods of time

(Videbeck, 2022). Hemoglobin is slightly high at 16.7 and WBC are slightly high at 11.7. Both

of these increases are so minimal it is barely significant. M.M. could be near the end of an

infection, explaining his minimally elevated WBC count. As a nurse, we would be more

concerned if M.M. was experiencing low WBC counts because some antipsychotics can cause a

decrease in WBC count and an inability to fight infection (Videbeck, 2022).

Some medications M.M. was on include Depakote (Valproate) 1000mg, orally BID,

which is an anticonvulsant often used for patients experiencing mania. The anticonvulsants work
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by decreasing unwanted activity in the brain that contributes to mania (Videbeck, 2022).

Depakote (Valproate) is a medication that is important to measure levels in the body. Doctors

want the valproic acid level to be between 50 and 125 when patients are on Depakote

(Valproate). It is also important to teach patient’s not to abruptly stop this medication because

that will increase the patents’ chance of having a seizure (Videbeck, 2022). Another medication

this patient is on is Geodon (Ziprasidone) 60mg orally, BID, which is an antipsychotic. This

medication should help with the hallucinations the patient is experiencing upon arrival. It is also

very important to monitor patients EKG when they are on antipsychotics, especially Geodon

(Ziprasidone). This medication in particular can cause an elongated QTC which can be fatal,

especially in elderly patients. Zyprexa (Olanzapine) is another antipsychotic used for bipolar

disorder often. M.M. is on 5mg orally to be taken at night. These medications work well for

bipolar disorder, but non-compliance is often an issue due to severe side effects. In this patient’s

case, he was experiencing weight gain and erectile dysfunction which led to him stopping the

medication. These side effects are some of the most common side effects of antipsychotics and

are one of the many reasons medication compliance is an issue (Videbeck, 2022). M.M. is also

on nicotine patches for his history of smoking 2 packs a day and vaping. Patient education is

very important with these medications. Informing the patient that they may experience some of

these side effects will help them to understand these are to be expected. Educate the patient on

exercise and healthy eating to keep them from experiencing rapid weight gain. It is also

important to educate the patient on the importance of compliance. For some patients, doctors

recommend they receive IM injections of medication monthly, or every couple of months for

patients who will likely not take the pill daily.

Summarize the Psychiatric Diagnoses

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In order to get a diagnosis of bipolar 1 disorder, according to the DSM-5 desk reference

(p.65), the patient must experience episodes of mania lasting at least 1 week, presenting most of

the day nearly every day. During this period, the patient must have an increase in energy and

experience at least 3 symptoms of mania. A few of the mania symptoms the patient may

experience include, inflated self-esteem, decreased need for sleep, excessive talking, flight of

ideas, and distractibility. The patient must also have periods of depression to be classified as

bipolar (American Psychiatric Association, 2020). Manic patients often present with high

amounts of energy. They may need to be walking or constantly moving. They may talk very fast,

non-stop, and jump from idea to idea rather quickly. Often times they get distracted and have

great difficulty focusing. Patients often do not sleep for days at a time or require very little sleep.

With bipolar 1 specifically, patients usually experience the mania a lot more often than

depression (Videbeck, 2022). Bipolar 1 disorder with psychotic behavior is classified as all of the

criteria to be diagnosed with bipolar 1 disorder, but the patient also presents with either delusions

or hallucinations. Psychotic behavior is more often seen with bipolar 1 disorder than with bipolar

2. It is also noted in this study that though more patients have psychotic behavior with bipolar 1,

they do not necessarily have poorer outcomes as far as treatment goes. In fact, patient’s often

have better outcomes if diagnosed with multiple psychiatric disorders. (Chakrabarti & Singh,

2022). In this patient’s case, he exhibited many symptoms of mania upon admission and

currently as well. He also experienced hallucinations and was seeing “bees disappearing”, which

is why he was given a diagnosis of bipolar 1 with psychotic behaviors. Some of the symptoms of

mania M.M. experienced were flight of ideas, decreased need for sleep, excessive talking, and

distractibility. The patient was unable to play a simple game of uno due to being so easily

distracted.
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Identify Stressors and Behaviors

In this patient’s case, many stressors and behaviors were present that may contribute to

this manic episode leading to hospitalization. First and foremost, M.M. had stopped taking

medications. Medication compliance becomes a huge issue with mental health patients due to the

many side effects of the medications often used. Many patients experiencing mental health issues

also do not believe they have anything wrong with them. Patients’ symptoms and hallucinations

are very real to them, so they may stop medication due to seeing no issue (Videbeck, 2022). He

also experienced the loss of his father in 2023, which though it was a year prior, he may have

never properly coped with this loss. He also had attended graduate school and never passed his

boards, which may have contributed to feelings of failure. M.M. admits to drinking 2-3 beers

nightly, but claims it used to be 30 a night. Alcohol use may contribute to manic episodes and

poor mental health. M.M. also works 60 hours a week at ATI, which is well over full-time. This

could lead to being overworked and exhausted, possibly worsening symptoms. His past medical

history of testicular cancer resulted in loss of one of his testicles, which could also be very

difficult for him. He may be insecure about his body image due to this loss, or he may have

never coped with the loss. On day of care, the patient also verbalized a poor relationship with his

family. His stepfather in particular and his father that passed seem to cause a lot of emotional

abuse to the patient, according to him. This could be a huge stressor on him and being raised in

an environment of abuse may have led to mental health issues. Trauma and abuse during

childhood years is a factor that contributes to mental health issues later in life (Videbeck, 2022).

Overall, this patient had many different stressors that likely combined to create issues for this

patient, thus leading to his hospitalization.

Describe the Patient and Family History of Mental Illness

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According to the patient’s chart, M.M. has no immediate family history of mental illness.

He does admit to having a cousin who is also bipolar and has a history of alcohol abuse as well.

M.M. states his cousin attempted suicide in the past. Though this is in the family, a cousin with

mental illness is not extremely significant due to the fact that it is not immediate family. Mental

illness often has many genetic factors so this finding is surprising, though he could potentially

have family members that are not diagnosed.

Describe the Evidence Based Nursing Care Provided

Nursing care for a patient with bipolar disorder typically depends on whether the patient

is manic at the time of care. For a patient who is manic and has not slept in days, making sure the

patient gets sleep would be the nurses priority. A patient can only go so many days without sleep

before death, so before any other teaching or health promotion, the patient must sleep.

Decreasing stimuli and providing a relaxing environment is very important to promote sleep.

Drugs may be used to help promote sleep as well and are used often (Videbeck, 2022). As

discussed in class, encouraging a nighttime routine can be helpful for promoting sleep. In this

patient’s case, group therapy was encouraged because the patient was not severely manic at this

point. It is sometimes hard for the patient to focus on the activity at hand, however, group

therapy can be good for this patient to learn about what is socially acceptable. It also helps

patients relate to each other. Cognitive therapy could also be used to help the patient perceive the

world in a more positive manor and feel less threatened. Individual psychotherapy can be used

but is best used when the patient is not in a manic state. (Videbeck, 2022). It can be very useful

to teach these patients coping skills because many of them were never properly taught healthy

skills to cope. The patient may also need to assist patients with ADL’s. Providing snacks, the

patient can take with them while walking could be helpful for the manic patient who can’t sit still
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long enough to eat. In this patient’s case, snacks were very useful at the start of his stay to

promote nutrition. Patients in a depressive state or even severely manic patients may need

encouraged to perform basic hygiene, such as showering or brushing teeth. Providing all hygiene

materials can be helpful so the patient is less overwhelmed by the task. For patients severely

impaired, the nurse may need to perform ADLs for the patient until the patient is well enough to

contribute. Overall, in this patient’s case, it is important to provide a relaxing environment to

promote calmness.

Analyze Ethical, Spiritual, and Cultural Influences

Spiritual care and cultural influences can be useful in providing appropriate nursing care.

In this patient’s case, he is a 31-year-old, Caucasian male. It is unclear what his religion is,

though he does speak briefly about the existence of a God. After the death of his father, he stated

he became more religious and often prayed. Learning more about his spiritual beliefs may be

helpful in aiding in his care. It may also be helpful for him to explore his spiritual beliefs more to

provide a healthy coping mechanism for the patient. It is also important to note his social class

and health literacy. Given that M.M. attended college and law school, he likely understands

topics as they are explained to him. This is important to note when providing patient teaching for

him. Patients with a lower level of knowledge will need patient teaching to be provided at a level

they will understand.

Evaluate the Patient Outcomes

M.M. is currently doing much better meeting outcomes. He is no longer hallucinating and

is not aggressive. He has been compliant with staff and medications. He is very cooperative and

open to talking about his diagnosis and getting better. He seems especially passionate talking to

students and feels he is aiding in the learning of students. Though he still seems to be in a state of
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mania, he is able to sit for a meal and sleep 5-6 hours a night. He communicates wanting to leave

the facility as soon as he can, however, verbalizes an understanding of needing to get better

before he can do this. As of now, the patient has no discharge date planned. He wants to return to

working at ATI and living on his own in the trailer. It is important to educate the patient prior to

discharge on medication compliance. It is also important to explain the side effects he may

experience prior to discharge. His mother does voice concerns of allowing him to live on his own

again. Medication compliance is an issue she is concerned about. Overall, the doctor is going to

have to use his judgement to decide if this patient is well-enough to continue to live on his own,

or if he will potentially go to a different facility.

Prioritized List of All Actual Nursing Diagnoses

1. Disturbed sensory perception related to physiological stress as evidenced by visual

hallucinations

2. Insomnia related to manic episode as evidenced excessive hyperactivity and lack of

sleep

3. Inadequate nutrition related to inability to sit still as evidenced by extreme weight loss

4. Disturbed family processes related to mental illness as evidenced by patient statements

of a poor relationships

5. Ineffective health maintenance related to stopping medications as evidenced by inability

to perform basic self-care tasks upon arrival

6. Risk for injury related to extreme hyperactivity as evidenced by constant movement and

lack of sleep

List of Potential Nursing Diagnoses

1. Ineffective coping
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2. Risk for harm to self

3. Risk for harm to others

4. Ineffective impulse control

5. Risk for spiritual distress

6. Risk for complicated grieving

7. Impaired social interaction

8. Risk for substance abuse

9. Disturbed personal identity

10. Risk for suicide

Conclusion

Bipolar 1 disorder is a complex disease that can be difficult to treat and manage. Patients

experience many highs and lows, as well as mood swings and irritability. Often patients with

bipolar 1 disorder also experience delusions or hallucinations. There are many medications used

to treat bipolar disorder, but some also have extreme side effects, making non-compliance an

issue as well. Bipolar disorder can be a difficult disorder for patients, as well as family and

friends of the patient because of the variability that goes along with the disease. It is important

for nurses and staff to meet the patient where they are at and provide care on an individualized

level.

Patient M.M. is improving day by day. M.M. no longer is experiencing hallucinations and

is now able to sleep at least a little each night. He is able to eat and perform activities of self-care

such as grooming and hygiene. Though M.M. still is having difficulty focusing and is still manic,

improvement is noted. This patient has been compliant on medication regimen while hospitalized

but must continue working on self before ensuring it is safe to return to living on his own and
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maintaining compliance to his medication regimen. It is important staff continue to work with

him and his family to find what is safest for him.

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References

Chakrabarti, S., & Singh, N. (2022). Psychotic symptoms in bipolar disorder and their impact on

the illness: A systematic review. World Journal of Psychiatry, 12(9), 1204–1232.

https://doi.org/10.5498/wjp.v12.i9.1204

Desk reference to the diagnostic criteria from DSM-5. (2020). . American Psychiatric

Association.

Videbeck, S. (2022). Psychiatric - Mental Health Nursing (Ninth). Lippincott Williams &

Wilkins.