MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Maren Abbattista

November 16, 2023

Teresa Peck, DNP, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

NW is a 22-year-old female patient admitted to the inpatient psychiatric unit being closely

monitored for psychosis and what is assumed to be her first psychotic/schizophrenic episode. She

has no history of mental illness, but a history of autism spectrum disorder. She is experiencing

extreme delusions and hallucinations. With inpatient monitoring and medication treatments, her

symptoms have become more manageable. She is still working on her level of communication but

has improved. The care provided on this unit is geared towards reorienting her to reality,

understanding her symptoms and diagnosis, medication compliance and education, and

management of symptoms. This is done through nursing care and communication, group therapy

sessions and individual therapy sessions.

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Objective Data

Patient identifier: NW

Age: 22

Sex: Female

Date of admission: October 25, 2023

Date of care: November 2, 2023

Psychiatric diagnosis: Acute psychosis

Other diagnoses: History of autism spectrum disorder

Behaviors on admission: NW presented to the emergency room after calling 911 from home

due to chest pain. She was calm and compliant during this visit and was diagnosed with a UTI.

She was then discharged and sent home on medication. After she arrived home, NW proceeded

to lock herself in the bathroom and call 911 again. Mother and sister who live with NW state

“she started trippin”. Paramedics arrived and evaluated her but didn’t see any signs of injury and

left. NW then called for a third time and EMS described that her family wanted her to be taken

back to the hospital and admitted. They stated dad was extremely overbearing and would not let

them near her or to be evaluated without him present. He tried to hand them $20 and stated he

“just wants her gone”. NW would not make eye contact and only shakes head yes or no when

asked questions. She was then brought to the hospital by paramedics. Her mother and sister

request she be taken to main campus for psychiatric evaluation but were told that was not an

option. After arrival and room placement in Boardman St. Elizabeth emergency department, NW

proceeded to jump over the rail of her bed and run through the department. She was caught by

multiple RNs and encouraged to return to her bed. De-escalation of the situation was

unsuccessful, so hospital police had to be called. NW was then placed with a 1:1 sitter. She then
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called in an x-ray technician from the hallway and stated she “needed to talk” and that she

“wasn’t okay”. She told the x-ray technician that her mother and sister were trying to poison and

kill her. She then stated that “it’s okay, my mother and sister are in jail. I have nothing to worry

about now”. The technician notified the RN and after, the RN notified the doctor. The doctor

came in to evaluate NW and pink slipped her due to her having significant delusions about her

mother and sister trying to poison her, stating they killed her baby (causing a miscarriage),

thinking they have been arrested, and now stating that she wants to poison her mother and sister

to “get back at them”. NW was then transferred to the Youngstown St. Elizabeth hospital and

admitted to the inpatient psychiatric unit. While being evaluated here, she would not get out of

her bed or make eye contact. When NW was asked, she denied any psychiatric illnesses or

symptoms. She also stated she didn’t know why she was admitted to the psychiatric unit. She

appeared very internally stimulated, disheveled, disorganized, and had poor grooming. After

evaluation, she was consistently yelling at the nurses that she was not crazy and inappropriately

laughing. She was then diagnosed with being acutely psychotic due to all of her behaviors and

delusions.

Behaviors on day of care: NW was calm and cooperative on the day of care and was willing to

speak to us. She attended but did not participate in group therapy this day. She appeared very

disheveled and had poor grooming. When speaking, NW had a very monotonous tone and a flat

affect, while occasionally laughing inappropriately. She did not make eye contact when

speaking. Her speech was slow, low, and mumbled with very short responses. She consistently

responded with “yes” or “no” and had the occasional short response. She was also very repetitive

with her phrases. During our conversation NW was still experiencing somatic, paranoid,

grandiose, and persecutory delusions. She was a poor historian and unable to tell us the true story
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of why she ended up here. NW stated she was feeling happy because she was being discharged

that day and got to go home to her family. When asked about their relationship, she stated it was

“good” and that they “got along well”. She also stated she was not sleeping well due to her new

medications and that she was very tired. After talking for a while, it was clear she was too tired

to keep going and after walking away, she had put her head down and fallen asleep at the table.

Safety and security measures: During her stay at the emergency department, NW was placed

with a 1:1 sitter until being transferred to the inpatient unit. Once being placed on the unit, all of

her belongings were removed, she was routinely searched, and placed in hospital safe clothing.

The staff did routine safety checks and nothing that could induce harm was allowed on the unit.

NW was also not permitted off of the unit, which has a very secure, double locked door system.

When given medications, they were administered by the RN who had to verify that all

medications were taken properly.

Laboratory results:

Lab Value Result

Glucose 114
Potassium 3.7
Sodium 137
AST/ALT N/A
TSH/T4 N/A
Platelets 236
RBC 4.4
Hbg/Hct 13.5 / 38.8
WBC 6.6
BUN/Crea. 9 / 0.8
Valproic Acid 49
QTC 423
hCG Negative
Drug Toxicology Negative
UA. Alcohol Level Negative
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Psychiatric medications:

Generic Name Trade Name Classification Dose/Route/Frequency Reasoning

Risperidone Risperdal Antipsychotic 2mg, orally, BID Schizophrenia and autism
symptoms
Valproic Acid Depakene Anticonvulsant 250mg, orally, BID To decrease psych symptoms

Haloperidol Haldol Antipsychotic 5mg, orally or IM, PRN As needed for agitation

Melatonin N/A Sleep aid 3mg, orally, PRN nightly Sleep disturbances

Summary of Psychiatric Diagnosis

Acute psychosis is a brief psychotic disorder characterized by a loss of contact with

reality. To be diagnosed with this, there must be one or more of these features seen: perception

changes due to hallucinations, an inappropriate or blunted affect, and/or a decreased level of

social functioning. This diagnosis is generally given to those who are experiencing their first

psychotic break and have not had any specific mental health issues in the past. They have not had

enough history to make a specific diagnosis but still know something is going wrong. For NW,

this is assumed to be her first psychotic break and what seems to be leading to schizophrenia.

According to the textbook, “If the client exhibits acute, reactive psychosis symptoms for over 6

months, the diagnosis is changed to schizophrenia” (Videbeck, 2022). So, if her symptoms

persist and are not controlled by medication, or she is not compliant, she may end up back with a

more serious diagnosis.

The other diagnosis given to NW is a history of autism spectrum disorder, which many of

these symptoms also mimic psychiatric symptoms, specifically the negative symptoms of

schizophrenia. So, the symptoms NW is manifesting such as flat affect, lack of eye contact,

reduced social interaction, alogia, and anergia, all may be a combination of her autism spectrum

disorder and her psychiatric diagnosis. With autism spectrum disorder, these symptoms will
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likely never go away, and with schizophrenia the negative symptoms are the hardest to treat. So,

her symptoms may not improve, but that would not be at fault of her treatment plan, it could be

the role of her autism disorder. Those with autism spectrum disorder are at a higher risk of

developing mental health issues and have a harder time seeking support and coping with them

(Coleman-Fountain, Buckley & Beresford, 2020). Due to many of these symptoms being so

similar, it can be difficult to differentiate between the two and allows mental health disorders to

get ignored.

Identification of stressors and behaviors precipitating current hospitalization

NW lives at home with her mother, father and sister and when speaking with her on the

day of care stated they had a good relationship and got along well. According to her admission

notes and behaviors on admission, her family seems to be a large stressor in her life. NW denies

any hallucinations or delusions but family states they have witnessed them, and her care team has

as well. These hallucinations and delusions would cause extreme stress and abnormal behaviors.

Her somatic delusions specifically, are also making her health a stressor for her, enough to call 9-

1-1 three times. Upon admission she claimed she was having a heart attack and during her

second admission she claimed she also had recently suffered a miscarriage. Due to all of these

behaviors, she was pink slipped and admitted into the inpatient psychiatric unit.

Patient and family history of mental illness

NW has no know history of any psychiatric illnesses but does have a history of autism

spectrum disorder. This is assumed to be the start of a schizophrenic development but is her first

known psychotic break. Patient’s mother states she believes NW has some sort of psychiatric

illness. Her mother states she has delusions the world is going to end, hallucinations where she
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talks to herself and others that are not there and has an unhealthy obsession with social media.

NW denies any presence of mental illness or psychiatric symptoms.

When NW was asked, she said she doesn’t know of any family history of mental illness.

When her mother was asked, she stated that she has an older daughter who is a ward of the state

and had a similar psychotic break. She is unknown of the daughter’s current state or exact

diagnosis but says she is afraid the same thing is happening.

Psychiatric evidence-based nursing care provided

During her stay at the inpatient psychiatric unit, NW was provided care from her mental

health care team. This team consisted of providers, nurses, therapists, social workers, student

nurses, and more. Each shift she was assigned a nurse and it was their responsibility to build

rapport with NW and obtain a trusting relationship. This nurse would perform the unit’s routine

safety checks and assessments. They also communicated with the rest of the care team to discuss

problems, future living situations and plans, and other ways to improve her quality of life. She

also had a medication nurse that was assigned to give prescribed medications to the entire unit. It

was this nurse’s responsibility to administer the correct prescription medication to the correct

patient, and assure they took this medication properly. For the medication nurse and the nurse

assigned to NW, it was important for them to know the possible side effects and adverse effects

these medications could have. Due to it being her first time on any psychiatric medication, it is

important to see how her mind and body react.

During this stay, she also got the opportunity to attend group therapy sessions. These

sessions were held at 10:30 every morning and went along with their daily schedule. The unit

had a specific schedule for things such as group times, mealtimes, phone calls, and much more.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 9

This allowed them to keep their mind at ease and have a schedule to follow. During these group

sessions, NW said she enjoyed them a lot but didn’t participate much. She stated she learned a

lot of new life skills from them, especially about better handling her emotions, and believed they

were beneficial. The unit also offered psychotherapy, but NW did not attend any of those

sessions.

Ethnic, spiritual, and cultural influences

NW is an African American, single female who comes from a lower-class family. She is

unemployed and her highest form of education is a high school diploma. She resides with her

mother, father and sister, and depends on her family for financial assistance. “The mental health

of individuals is shaped by the social, environmental and economic conditions in which they are

born, grow, work and age…Poverty and deprivation are key determinants of a person’s social

and behavioral development…Individuals living in the most deprived areas report higher levels

of mental illness and lower levels of well-being than those living in the most affluent areas”

(Knifton & Inglis, 2020). According to the data in this article, it is true for my patient. NW

comes from a lower-class family with less opportunities and is experiencing poor mental health.

NW practices Christianity as a religion and prays often. She states she has not been to

church since the Covid-19 outbreak but regularly practices to herself. She believes in God as her

higher power and states she knows she can get through anything because of him. She states

without her religion and the practice of prayer, she would be lost.

Evaluation of patient outcomes

For a patient to be admitted to the inpatient psychiatric unit they must meet one or more

of these criteria, a danger to themselves, a danger to others, or unable to care for their own basic
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needs. During her admission NW met all three of these criteria. She was jumping over her bed

rails with risk of harming herself, threatening to poison her family, and not in any state of mind

to be properly caring for herself. But, on the day of care, some of these symptoms have

improved. Throughout her stay she had no suicidal ideations or attempts and remained free of

any harm to herself. She gained a better understanding of reality where she no longer wanted to

hurt her family and also believed they no longer wanted to harm her. She denied wanting to

poison them and stated they had a good relationship. She was still slightly disheveled and

disorganized but had improved from her admission appearance. NW was able to perform self-

care activities on her own. On the day of care, she was also still experiencing delusions, but had

only just begun her medication regimen. Enough time was not given on these medications to

make a proper judgment on whether or not they were showing improvement. NW did believe her

stay here was beneficial and that she learned a lot from her peers, care team, and the group

therapy sessions that she will take with her in life.

Plans for discharge

Our day of care was the day of discharge for NW, so her spike in psychiatric symptoms

and delusions was expected to be seen. When NW is discharged, she will return to her home

where she resides with her mother, father and sister. Due to this being her first psychotic break

and her improvement/absence of symptoms, she was deemed a low suicide and homicide risk,

and her care team decided she did not need any type of long-term or facility care. NW also

denied any thoughts of hurting herself or anyone else. She stated she no longer believed her

mother and sister were trying to poison her and denied wanting to harm them. NW no longer

meets the criteria for an inpatient facility.

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She is being sent home with new prescriptions of Risperidone (Risperdal) and valproic

acid (Depakene) to continue treating her symptoms. The RN discharging her reviewed these

medications and informed her of the risks, benefits, side effects, drug-to-drug interactions, and

alternate forms of treatment. Education was also given on the importance of medication and

treatment compliance. NW was encouraged to call the outpatient clinic and set up an

appointment with the provider to follow up. She was also informed to visit her nearest ED or call

911 if her symptoms become unmanageable. Her family members were called and notified of her

discharge.

Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for NW:

1. Risk for self-harm related to first psychotic break and delusions

2. Disturbed thought processes related to mental illness as evidenced by delusions and

bizarre thoughts

3. Risk for violence related to delusions as evidenced by patient stating she wants to harm

family members

4. Disturbed family processes related to mental illness as evidenced by delusional thinking

related to family

Potential nursing diagnoses

1. Acute confusion

2. Impaired memory

3. Ineffective coping
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4. Impaired verbal communication

5. Fear

6. Disturbed sleep pattern

7. Knowledge deficit

8. Self-care deficit

9. Impaired social interaction

10. Social isolation

Conclusion

In conclusion, NW was a very educational patient to complete this case study on. With it

being her first psychotic break, care was in depth and prioritized by her team. During her time

here she was very cooperative and improved well during her treatment. I believe with medication

compliance, outpatient psychiatric therapy, and support from her family at home, she can remain

free of or with very minimal symptoms. Moving forward, it will take a collaborative effort to

keep her symptoms to a minimum but with compliance she should be able to function at an

optimal level.
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References

Coleman-Fountain, E., Buckley, C., & Beresford, B. (2020). Improving mental health in autistic

young adults: a qualitative study exploring help-seeking barriers in UK primary care.

The British journal of general practice: the journal of the Royal College of General

Practitioners, 70(694), e356–e363.

https://doi.org/10.3399/bjgp20X709421

Knifton, L., & Inglis, G. (2020). Poverty and mental health: policy,

practice and research implications. BJPsych bulletin, 44(5), 193–196.

https://doi.org/10.1192/bjb.2020.78

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