Mental Health Case Study

Mental Health Nursing Case Study

Anthony Scandy

Youngstown State University

Abstract
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When conducting a case study on a patient and their psychiatric diagnoses it is very important to

be knowledgable on the diagnoses, symptoms, and treatments associated with the patients

specific diagnoses. Knowing as much personal information as possible by interviewing through 1

on 1 conversation with the patient is crucial in planning the proper plan of care for the patient.

This specific patients depression and current state was brought on by the negative results of the

craniotomy procedure he had performed to try and reduce the seizures he was experiencing from

his epilepsy diagnosis. This led him to be extremely depressed, which then in turn led him to

polysubstance abuse and his current stay at Trumbull Memorial Hospital. A therapeutic milieu or

safe environment is essential on a psychiatric floor to promote healing. Nursing diagnoses allow

us to evaluate current problems along with those the patient is at risk for to set outcomes we

would like the patient to achieve.

Objective Data
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On October 18th, 2018 the patient was admitted to the psychiatric unit at Trumbull

Memorial Hospital. The patient was admitted involuntarily after having the cops called on him

by his neighbor. This patient was a 30 day readmit, which is always not a good thing because the

hospital eats the cost on the second stay. I was assigned this patient on two occasions. The first

occasion was on October 25th, 2018 and the second occasion was on November 8th, 2018. The

patient was 50 years old and had no known allergies. He had suicidal ideation and behavior and

was put on unit restrictions such as self harm precautions and other specific protocols.

The patients multiple psychiatric diagnoses were major depressive disorder, bipolar

disorder, anxiety, and a mood disorder. His multiple medical diagnoses were epilepsy, seizure

disorder, dysphagia, history of drug use, noncompliance, alcohol abuse, poly substance abuse,

hypokalemia, nicotine dependance, and cognitive dysfunction.

The patient appeared to have animated facial expressions that were leaning more towards

a sad, depressed, or angry state. He had a relaxed posture and communication gestures. He had a

pleasurable, normal affect, but did show signs of depression as well. He said his mood has been

the same for his whole hospital stay but he finally feels hopeful and optimistic for the future. He

was appropriately dressed and appeared to have sufficient hygiene. What stuck out to me were

his multiple tattoos going down both arms. He appeared to be restless with fine motor

retardation. This patient spoke clearly with good direction, although he does draw out his words

a little bit and it takes some time to get his point across. His memory was very accurate and he is

alert and oriented. I would say that his current judgement is fair, although it was recently very

poor when he decided to take Overall, this patient was friendly and did not give off any negative

or hostile vibes towards me as the student nurse communicating with him.

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When taking a look and comparing this patients labs from the first time I took care of him

versus the second time, I felt that some of the more important values for him were his BUN,

valproic acid level, carbamazepine level, AST, ALT, and vitamin B12 level. His BUN went from

a 6 on admission to a 14 on the second time I took care of him. His valproic acid level went from

46.7 to 32.6. His carbamazepine level went from 17.9 on admission, to 11.7, to 9.3. His AST was

11, his ALT was 20, and his Vitamin B12 level was 223. I felt that the BUN level was important

to look into his kidney and liver function by analyzing his urea nitrogen in the blood, since he

has been a chronic alcoholic all of his life. His valproic acid level is important because he is

currently prescribed Depakote, so he must be maintained within the therapeutic range of 50-125

to ensure the medication will be effective and no overdose will occur. His carbamazepine level is

very important because this is the drug he overdosed on and what led him to be brought into the

hospital. The therapeutic range of carbamazepine is 4-12. His AST, ALT, and vitamin B12 levels

are important to look at as well, again, since he is a chronic alcoholic.

This patient is currently prescribed the medications of Depakote (divalproex), an

anticonvulsant, ordered as 500mg PO BID to act as a mood stabilizer, Haldol (haloperidol), an

antipsychotic, ordered as 5mg PO Q6H PRN to treat agitation, Tegretol (carbamazepine), an

anticonvulsant, ordered as 200mg PO Q8H to treat his seizures, vitamin B12 (thiamine HCl), a

vitamin B12 complex, ordered as 100mg PO daily to treat his alcoholism, and Trazadone HCl, an

antidepressant, ordered as 50mg at bedtime to promote rest and treat this patients insomnia.

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

The patients psychiatric diagnoses are major depressive disorder, bipolar disorder,

anxiety, and a mood disorder. Depression, or major depressive disorder, is a common but serious
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mood disorder. It causes sever symptoms that affect how you feel, think, and handle daily

activities, such as sleeping, eating, or working. To be diagnosed with depression, the symptoms

must be present for at least 2 weeks (National Institute of Mental Health). Bipolar disorder is

included on the list of different forms of depression. People suffering from bipolar disorder have

extreme highs of euphoria or irritability which would be considered the manic stage, and extreme

lows of depression. Both depression and bipolar disorder would be considered mood disorders,

since they both are diagnosed because the patients mood is ultimately changed from their stable

state of mental health. Some signs and symptoms of these diagnoses would be persistent sadness,

feeling of hopelessness, being pessimistic, irritability, feeling guilty, worthless, or helpless,

losing interest in normal hobbies and activities, decreased energy and fatigue, moving or talking

slowly, restlessness, difficulty concentrating, remembering, or making decisions, sleeping issues,

appetite changes, weight changes, and suicidal ideation. These symptoms will not be experienced

by every patient diagnosed with these issues, but they can be seen in various people.

Depression and anxiety refers to an array of abnormal variations in the mood of a person.

These conditions originate as a result of chemical reactions in the brain (omicsonline.org).

Anxiety disorders are present in up to 13.3% of individuals in the United States. When anxiety,

which is worry, fear, apprehension, or unease, happens over a 6 month span without control, this

is considered generalized anxiety disorder (Torpy, 2011). Panic disorder, social phobia, specific

phobias, PTSD, acute stress disorder, OCD, and generalized anxiety are all various influences on

anxiety. Anxiety disorders can be effectively treated with psychopharmacological and cognitive

behavioral interventions. (Bystrisky, 2013)

Identify the stressors and behaviors that precipitated current hospitalization

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This patient has been dealing with the symptoms of epilepsy since he has been a child.

He has been experiencing seizures ranging from petit to grand mal since he was 7 years old. He

has been medicated for them his whole life and tolerated living like this, but as of recent he

decided to have a craniotomy performed to the parts on his brain that doctors thought could be

causing these seizures. Before the procedure was performed, the doctors and surgeons warned

him that because the surgery would be near his optic nerve, he could potentially lose some

peripheral vision. The patient decided that the risk would be worth the reward if the procedure

went smoothly. After the procedure was performed, his seizures did slow down, but the risk of

losing peripheral vision did in fact happen. The patient now has a lot of peripheral vision from

his left eye completely gone and has issues with his fine motor skills. The big problem this

patient ran into was that his occupation was being a head chef of local restaurants around this

area and due to his vision loss and fine motor skills being impaired he can now no longer cook,

which means he can no longer be employed the way he was his whole life. This patient made a

good living doing what he did and is having an extremely hard time facing reality and this is

leading him to be majorly depressed. Due to his depression and previous chronic alcoholism, he

decided to try and drink himself to death. He went 11 days with no food and only drinking

alcohol and smoking cigarettes until he ran out entirely. He then grabbed his bottle of

carbamazepine and swallowed a whole handful which led him to overdose. He crawled over to

his neighbors house pleading for him to take him to get more cigarettes. He told me that his

neighbor said he would take him but he would have to call the cops on him and he wanted him to

get the help he really needed. This led him to Trumbull Memorial Hospital and to his current

state.
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Discuss patient and family history of mental illness

This patient has a history of bipolar disease, anxiety, and a mood disorder. Based on the

conversations we had and looking through the computer chart, there is no family history of

mental illness. Both his mother and father have passed away but during their time living they had

no documented psychiatric diagnoses or mental illnesses. His sister is living with children and

again, based on our conversations and the computer charting she also has no documented history

of mental illness.

Describe the psychiatric evidence based nursing care provided and milieu activities attended

Many different forms of psychiatric evidence based nursing care were provided to this

patient and the milieu environment was kept extremely safe and comfortable for not only this

patient, but all of the patients on the floor. One example of a milieu activity, and I personally

think the most effective example is group activities. This patient was very cooperative and

participated in every group we offered to him. He even worked through his vision and

handwriting issues to participate, so this tells us he is willing to adapt and mold to his current

state with time and effort.

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

Ethnic, spiritual, and cultural influences play a big part on impacting patients on the

psych floor. Ethnic influences brought to the floor for the patient can make them more

comfortable and easier to work and deal with as the nurse. Respecting and considering a patients

ethnicity is mandatory at all times. Spiritual influences are also very important. If a patient is

very religious they may want time to themselves to pray or practice their religion of choice. As
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the nurse, you must grant these wishes and accommodate the patient that way they feel better

about everything during their hospital stay. Cultural influences are just as important and should

be treated the same way as the other aspects previously addressed. Unfortunately, during my

time with this patient we didn’t address this topic and it was also not addressed in the computer

charting.

Evaluate the patient outcomes related to care

This patient is coming along fairly well. On admission, he was extremely depressed, felt

hopeless for the future, and wasn’t eager to participate in anything or make any progress. Slowly,

with time and persistence, he is starting to change his outlook on things. He is now hopeful for

the future and eager to find out what the next move is from here, participating in all group

therapy sessions possible, and pleasant to talk to and work with with all of the staff. He is

progressing fairly well.

Summarize the plans for discharge

This patient is running into some roadblocks when it comes to being discharged. The

staff was trying to get him placed in a nursing home so they could take care of him there and

address all of his needs, but because he owns his own home they won’t accept him as a patient at

any nursing homes. Then, he decided he wanted to sell his home, but if he sells his home he will

then have too much money to be considered for social security. He also cannot get disability

because his issues aren’t bad enough to consider him disabled. I feel bad for him because he was

looking forward to all of these things happening and he keeps running into issues in the system.
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Prioritized list of actual nursing diagnoses using individualized NANDA format

1 Risk for self directed violence AEB suicidal behavior

2 Disturbed thought processes r/t severe anxiety/depressed mood

3 Ineffective coping AEB feelings of despair, hopelessness, and worthlessness

4 Chronic low self esteem AEB negative view of self and abilities

5 Powerlessness r/t pattern of helplessness

6 Denial r/t overwhelming thoughts of hopelessness

7 Anxiety r/t situational crises

8 Impaired social interaction AEB dysfunctional family interactions

List of potential nursing diagnoses

Constipation r/t inactivity

Disturbed energy field r/t disharmony

Failure to thrive r/t depression

Ineffective health maintenance r/t lack of ability to make good judgements

Chronic sorrow r/t unresolved grief

Conclusion

In conclusion, I enjoyed my time talking with and getting to know this patient. He

seemed like a good man that has just had medical problems with his epilepsy his whole life and

continuously is getting worse and worse news. I hope for the best for him in his future and that

he can one day face reality and recover and become fully self sufficient with no depression. Life

is tough, but it is possible to be tougher than what you are facing and I think he simply needs to
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change his outlook on things and it will make everything around him easier and more enjoyable.

I learned a lot about his diagnoses, medications, labs, and personal information. I will use this

information to help any similar patients I take care of in the future.

References

Bystritsky, A., MD, PhD, Khalsa, S. S., MD, PhD, Cameron, M. E., PhD, & Schiffman,

J., MD, MA, MBA. (2013). Current Diagnosis and Treatment of Anxiety Disorders. Retrieved

from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173/.

Journal of Depression and Anxiety. (2018). 7(3). Retrieved from

https://www.omicsonline.org/depression-and-anxiety.php.
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Torpy, J. M., MD. (2011). Generalized Anxiety Disorder (R. M. Golub MD, Ed.).

Retrieved from https://jamanetwork.com/journals/jama/fullarticle/645425.

Depression. (n.d.). Retrieved from

https://www.nimh.nih.gov/health/topics/depression/index.shtml