Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Mary Deal

February 23, 2024

Mrs. Phyllis Jean DeFiore-Golden, MSN, RN, BC

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

MS is a 22-year-old female patient admitted to the inpatient psychiatric unit after chronic

suicidal thoughts progressed to a plan to use her father’s gun to commit suicide. She has a

diagnosis of Major Depressive Disorder and Post Traumatic Stress Disorder. She is currently

pink-slipped while her treatment progresses. The treatment plan consists of pharmacologic

management of symptoms along with therapy sessions in both group and individual settings, all

while providing a safe and therapeutic environment.

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Objective Data

Patient Identifier: MS

Age: 22

Sex: Female

Date of Admission: February 8, 2024

Date of Care: February 9, 2024

Psychiatric Diagnosis: MDD

Other Diagnoses: PTSD, chronic suicidal thoughts, anxiety, insomnia,

Behaviors on Admission: MS presented to the ER after chronic suicidal thoughts lead to a plan

to use her father’s gun to commit suicide. MS reported persistent thoughts occurring for months

that got worse within the past month. MS was accompanied by her father who reported that they

both were worried about her safety which ultimately lead to the decision to seek help.

Behaviors on Day of Care: MS participated in group therapy and conversed with other patients

in the common area throughout the day. During the assessment, MS was willing to talk about her

condition, stating she just wanted to get better. She was calm and cooperative, sitting

comfortably with a generally appropriate appearance, behavior, and attitude. Abnormal

assessment data includes slowed speech, flat affect, and impaired judgment related to current

ideations with a viable plan. She also reported difficulty sleeping throughout the night with

frequent recurring nightmares related to a traumatic event in her past that caused her PTSD. The

traumatic event occurred when her grandma died in a car accident. MS described what she

remembers from the event. She explained that her family drove around in the rain to look for her

grandma after she failed to arrive at their house for dinner. This was when they discovered the

accident. The nightmares involve her searching for other family members that are currently
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living. Although MS appeared clean during the assessment, she shared that she has difficulty

showering due to anxiety likely related to the rain during the traumatic event. MS shared this

information with a flat, inappropriate affect.

Safety and Security Measures: To ensure patient safety, the nurse had to see MS every 15

minutes. She was not allowed to leave the psychiatric unit until her pink slip expired. No patients

are permitted any items that can be used to inflict harm on themselves or others. All medications

had to be administered by the nurse to ensure that they were taken as documented.

Laboratory Results:

Lab Value Result

Glucose 102
TSH 1.45
T4 1.25
RBC 4.45
Hbg/Hct 13.4 / 39.2%
WBC 5.8
BUN/Crea. 5 / 0.6
QTc 404
Toxicology Negative

Psychiatric Medications:

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

olanzapine Zyprexa antipsychotic 5 mg daily Impulsivity and
insomnia
prazosin Minipress Alpha blocker 1 mg daily Nightmares
sertraline Zoloft SSRI 150 mg daily MDD
melatonin N/A Supplement/hormone 3 mg nightly Insomnia
PRN
hydroxyzine Vistaril Antihistamine 50 mg bid PRN Increasing
pamoate anxiety
MENTAL HEALTH COMPREHENSIVE CASE STUDY 5

Summary of Psychiatric Diagnosis

Major Depressive Disorder (MDD), also referred to as depression or clinical depression,

is a relatively common mood disorder that causes feelings of sadness and loss of interest in

previously enjoyed activities. Depression controls how a person feels, thinks, and behaves, which

can also lead to emotional and physical problems (Mayo 2022). There are a variety of symptoms

of depression which depend on the severity and the person affected. Some examples include

feelings of sadness, tearfulness, emptiness, or hopelessness, angry outbursts, loss of interest in

normal activities, sleep disturbances, tiredness or lack of energy, changes in appetite, difficulty

concentrating, and thoughts of death or suicide. Symptoms are usually severe enough to cause

problems with normal functioning (Mayo 2022).

The etiology of depression is not completely known, as it precipitates from a variety of

factors. Some causes include biological differences in the brain, chemical alterations specifically

with serotonin, hormonal imbalances, especially postpartum or in hypothyroidism, and it can be

inherited or familial (Mayo 2022). Additionally, there are many risk factors that can predispose a

person to develop MDD. Depression appears to be more prevalent in women than in men.

However, this may be due to differences in the likelihood of seeking treatment (Mayo, 2022).

Other risk factors include low self-esteem, dependence or lack of independence, exposure to

traumatic or stressful events, family history of depression or alcoholism, maladaptive coping

techniques, being lesbian, gay, bisexual, or transgender, alcohol and drug use, chronic illness,

and certain medications such as blood pressure or antianxiety medications (Mayo, 2022). Of all

risk factors, family history remains a key predictor of risk for MDD including long-term risk of

recurrence and poor outcomes (Weissman et al., 2016). Additionally worth noting, adolescence,
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specifically age 15-25, is a major period of onset which is exacerbated as the number of risk

factors increases (Weissman et al., 2016).

Identification of Stressors and Behaviors Precipitating Current Hospitalization

MS had a diagnosis of MDD and PTSD prior to admission. However, she stopped

continuing outpatient treatment due to frequent changes in staffing. She explained that she

became exhausted having to share her story with each new provider, and that she eventually

stopped taking her prescribed antidepressant because of unwanted side effects. Recently, MS has

lost 5 friends and family members with 2 of the deaths being sudden and unexpected. In

November, she broke up with her boyfriend of 8 years, who then attempted suicide as a result.

MS explained that all of her friends blamed her for his attempt and therefore cut her out of their

lives. In the week prior to admission, MS failed her pharmacy technician exam and subsequently

left her job and lost her insurance which covered her previous healthcare provider.

Patient and Family History of Mental Illness

MS lives with her father, who she reports as having situational depression. It is worth

noting that she describes her father as caring but occasionally emotionally abusive, and that he

resorts to alcohol as a coping mechanism. However, MS reports no alcohol, nicotine, or

substance use herself. MS states that her mother lives down south, and that she does not know

the full extent of her mother’s history but is aware that she has depression and anxiety. MS is

unaware of additional family history of mental illness.

Psychiatric Evidence-Based Nursing Care Provided

While inpatient, MS was monitored by her assigned nurse each day. The nurse ensured

basic physical and safety needs were met prior to continuing with additional care. As discussed

earlier, measures to ensure safety include a locked unit where only authorized persons can enter
MENTAL HEALTH COMPREHENSIVE CASE STUDY 7

and exit, the removal of any items that can be used as a weapon, 15-minute safety checks around

the clock, and appropriate milieu therapy where staff is always present.

Beyond ensuring patient safety and basic needs are met, nursing care included the

development of a therapeutic relationship using therapeutic communication. This allowed the

patient to share details openly and to rely on the nurse to assist her in improving her condition.

This is especially important because the nurse is responsible for assessing the patient and

reporting any changes in condition (Bains, 2023). The nurse additionally monitored for current

suicidal ideations, which is a priority assessment for this patient.

After the therapeutic relationship was developed and patient safety needs were met, the

nurse then administered psychiatric medications as listed earlier and encouraged the patient to

participate in group therapy and interact with other patients. Each patient on the psychiatric unit

is encouraged to follow the unit’s schedule, which is therapeutic for psychiatric patients in

general. However, the provision of structured activity has been shown to promote good outcomes

specifically for patients with depression (Bains, 2023). The nurse was also responsible for

teaching about antidepressants, including the effects of abruptly discontinuing, potential side

effects, and the fact that it will take 4-6 weeks to see an improvement in symptoms.

Psychoeducation is another intervention that is important in promoting good outcomes for

patients with depression (Bains, 2023).

Ethnic, Spiritual, and Cultural Influences

MS is a Caucasian female who lives at home with her father. When asked about ethnic,

spiritual, and cultural influences, MS shared that she is Pagan. She explained that she had not

been actively practicing her religious beliefs, and that she did not wish to discuss it further
MENTAL HEALTH COMPREHENSIVE CASE STUDY 8

because it is a subject that has been causing her some uncertainty lately. MS would likely benefit

from speaking to a chaplain.

Evaluation of Patient Outcomes

Short- and long-term outcomes identified for this patient included safety from self-harm,

decreased depression and anxiety, adequate sleep-wake cycle, improved self-care and hygiene,

improved social interaction, adequate support system, improved coping and health maintenance

behaviors, and resolved spiritual distress. Realistic expected outcomes on the day of care

included safety from self-harm, decreased depression and anxiety, and improved self-care,

hygiene, social interaction, and coping.

MS had already showered in the morning prior to the assessment and reported feeling “a

little bit better” after performing self-care. However, she rated her anxiety at a 7 out of 10 and

explained that showering causes her anxiety. She also reported feeling tired from a lack of sleep

the night before and rated her depression at an 8 out of 10.

MS participated in group after the initial assessment, which consisted of BINGO with

positive coping strategies. MS stated she was happy that she won a round because she picked out

a card game for her prize and was hoping to play with others on the unit. She also identified

some coping skills that she can utilize at home including drawing, petting her dogs, and playing

video games. MS rated her anxiety at a 5 out of 10 and her depression at a 6 out of 10 after

group. She also sat and talked with other patients in the common area until lunch arrived. She

remained free from self-harm and therefore progressed in each of the expected short-term

outcomes. Long-term outcomes that still need addressed include proper sleep-wake cycle,

adequate support system, improved health maintenance behaviors, and resolved spiritual distress.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 9

Plans for Discharge

Upon discharge after her pink slip has expired, MS will return home with a referral to

continue outpatient treatment. She requires referral to a provider that will accept her father’s

health insurance since leaving her job. She will be encouraged to continue her treatment plan

including seeing her referred provider and staying compliant with her prescribed medications.

MS will receive education on prescribed medications and instructions to return to the ER if

suicidal ideations occur. She could also benefit from additional information on community

resources such as support groups in the area.

Prioritized Nursing Diagnoses

1. Sleep deprivation r/t recurring nightmares as evidenced by altered sleep-wake cycle

2. Fatigue r/t psychological demands and lack of sleep as evidenced by flat affect, slowed

speech, and inactivity

3. Anxiety r/t situational crisis as evidenced by helplessness and sleep deprivation

4. Death anxiety r/t psychological stress associated with traumatic event as evidenced by

recurring nightmares

5. Post-trauma syndrome r/t previous catastrophic event as evidenced by nightmares

6. Ineffective coping r/t personal vulnerability and anxiety as evidenced by suicidal

ideations and hopelessness

7. Ineffective health maintenance behaviors r/t impaired judgment as evidenced by suicidal

ideations and medication noncompliance

8. Impaired mood regulation r/t emotional instability as evidenced by suicidal ideations

9. Hopelessness r/t long-term stress and recent loss as evidenced by suicidal ideations and

flat affect
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10. Powerlessness r/t pattern of helplessness as evidenced by depressive symptoms and

suicidal ideation

11. Chronic low self-esteem r/t repeated unmet expectations and unresolved spiritual distress

as evidenced by depressive symptoms and suicidal ideation

12. Chronic sorrow r/t unresolved grief as evidenced by hopelessness and depressive

symptoms

13. Social isolation r/t inadequate support system as evidenced by ineffective coping

14. Disturbed personal identity r/t situational crisis as evidenced by low self esteem

15. Spiritual distress r/t altered spiritual practice as evidenced by expression of feelings of

uncertainty

Potential Nursing Diagnoses

1. Risk for suicidal behavior r/t suicidal ideations and ineffective coping

2. Risk for self-directed violence r/t suicidal ideations and ineffective coping

3. Risk for imbalanced nutrition: less than body requirements r/t depressive symptoms

4. Risk for maladaptive grieving r/t traumatic event and recent loss

5. Risk for impaired resilience r/t low self-esteem and ineffective coping

6. Risk for compromised human dignity r/t unmet expectations and low self-esteem

7. Risk for loneliness r/t inadequate support system

Conclusion

Major Depressive Disorder is a prevalent mood disorder that can range from mild

depressive symptoms to a debilitating level of sadness and hopelessness. Those with severe

depression often have impaired functioning and are at a high risk for suicidal ideations. MS

presented with severe depressive symptoms and suicidal ideations with a plan to use her father’s
MENTAL HEALTH COMPREHENSIVE CASE STUDY 11

gun to commit suicide. Risk factors for MDD that are seen in the case of MS include gender,

family history, age, multiple recent losses and stressors, and history of a traumatic event with a

subsequent diagnosis of PTSD. Depression is more prevalent in women than in men, those with a

family history of depression, and those aged 15-25, all of which are important facts that pertain

to this case study.

For those presenting with suicidal ideations, patient safety is the immediate concern. This

is possible through inpatient psychiatric admission with constant monitoring. In the meantime,

the interprofessional team works to stabilize the patient for discharge as well as equip them with

the necessary resources and education to prevent future suicide attempts. Inpatient treatment for

MS included pharmacologic therapy, a structured schedule with group and individual therapy,

and adequate discharge planning. Unfortunately, prescribed antidepressants take weeks to go into

effect, so it is important that patients with MDD are connected to any resources they might

require to continue immediate outpatient treatment. MS was referred to a provider that accepted

her father’s insurance and received additional information on community resources. General

goals for MS and others suffering from MDD include safety, decreased depressive symptoms,

and an overall improved quality of life.

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References

Bains, N. (2023, April 10). Major depressive disorder (nursing). StatPearls [Internet].

https://www.ncbi.nlm.nih.gov/books/NBK570554/

Mayo Foundation for Medical Education and Research. (2022, October 14). Depression (major

depressive disorder). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-

20356007#:~:text=Also%20called%20major%20depressive%20disorder,life%20isn’t

%20worth%20living.

Videbeck, S. L. (2022). Lippincott CoursePoint Enhanced for Videbeck's Psychiatric-Mental

Health Nursing (9th ed.). Wolters Kluwer Health.

https://coursepoint.vitalsource.com/books/9781975205867

Weissman, M. M., Wickramaratne, P., Gameroff, M. J., Warner, V., Pilowsky, D., Kohad, R. G.,

Verdeli, H., Skipper, J., & Talati, A. (2016). Offspring of depressed parents: 30 years later.

American Journal of Psychiatry, 173(10), 1024–1032.

https://doi.org/10.1176/appi.ajp.2016.15101327