Running head: CASE STUDY 1

Comprehensive Case Study: Mental Health

Kristy Eckman

Youngstown State University

NURS 4842L: Mental Health Nursing

Mrs. Phyllis Defiore-Golden

02 December 2021
CASE STUDY 2

Abstract

The patient chosen for this case study is a 31-year-old female diagnosed with Severe

Manic Bipolar 1, Polysubstance Abuse, and Opioid Dependence. The patient came into the

emergency room with delusions and psychosis. Her history consists of traumatic events that

could have led to her current diagnosis. This patient is homeless and has no support system. My

goal of care with this patient on this date is to develop a therapeutic relationship and provide

therapeutic communication.
CASE STUDY 3

1. Objective Data: Describe the patient using the date of admission data, date of care data,

psychiatric diagnosis criteria, and laboratory results. Include behaviors observed on

admission and the day(s) of care, medical conditions, and treatments, safety and security

measures maintained, prescribed psychiatric medications, and reason.

Client Initials: LH

Age: 31

Admission Date: 20 September 2021

Presentation of Admission: Psychotic Episode, Delusion of Being Pregnant, Combative,

Substance Abuse

Date of care: 23 September 2021

Diagnosis: Severe Manic Bipolar 1, Polysubstance Abuse Disorder, Opioid Dependency

Presentation of Date of Care: The patient has a diagnosis of Severe Manic Bipolar 1,

Polysubstance Abuse Disorder, and Opioid Dependency.. Some behaviors observed in this

patient during my date of care included extreme fatigue and social isolation. The patient stressed

the desire to go to a homeless shelter after discharge. The patient also discussed trauma

experienced while being homeless including being physically and sexually assaulted. Treatments

included medication, psychotherapy, and group therapy.

The patient’s appearance was well-groomed and clean, wore baggy clothing. She did not

make a lot of eye contact and tended to slouch or turn away during the conversation. Her speech

was appropriate however seemed irritable. Minimal shaking was observable in the patient’s

hands. When speaking to the patient about future plans she became very anxious about the “what

ifs”. The patient used ego defense coping mechanisms of rationalization and projection. She
CASE STUDY 4

blames her family being away as the reason why she was homeless. She also used

intellectualization when speaking of past trauma. The patient talked about her traumatic

experiences however did not show any signs of emotions towards them.

Medication Reason for Receiving

Cogentin (benztropine) Treat side effects of neuroleptic drugs such as EPS

2 mg PO q 2/day

Trileptal (oxcarbazepine) Treats hyperexcitability, seen in Mania

300 mg PO q 2/day

Vistaril (hydroxyzine) Sedative; suppresses hypothalamus

50 mg PO PRN q 3/day

Haldol (haloperidol) Decrease psychotic manifestations

5 mg PO PRN q 6h

Desyrel (trazodone) Increase sleep, treat depression

50 mg PO PRN nightly

Buspar (buspirone) Increase serotonin, treat anxiety

10 mg PO q 2hr

Risperdal (risperidone) Decrease psychotic manifestations

2mg PO q 2hr

Milk of Magnesia Treat side effects of medications (constipation)

30 mL PO PRN
CASE STUDY 5

The patient received a complete blood count, drug screen, and urinary analysis. Most

values were within defined limits however abnormals included red blood cell count, hemoglobin,

hematocrit, and drug screen which came back positive for the substance of cocaine indicating

drug use. Reasons for abnormals in the CBC could include improper hydration and nutritional

efficiency due to social factors and availability. They could also be side effects to medications.

Lab Normal Patients Value

Potassium 3.5 - 5.0 3.6

Sodium 135-145 139

Glucose < 140 109

BUN 6 - 24 11

Creatinine 0.7 - 1.35 0.7

Red Blood Cells 4.0 - 5.4 3.84

Hemoglobin 12 - 15.5 11.2

Hematocrit 36% - 44% 33.9%

White Blood Cells 4.5 - 11 9.1

AST/ALT 5 - 40 / 7 - 55 17 / 22

Drug Toxicology Negative Positive cocaine in urine

UA Alcohol Level Negative Negative

CASE STUDY 6

2. Summarize the psychiatric diagnoses and expected/common behaviors

Bipolar disorders are characterized by the alternative states of mania and depression. The

patient has a diagnosis of Severe Manic Bipolar 1 this is a form of bipolar in which the patient

stays primarily in the manic state and can reach severe mania however only reaches mild

depression when going into the depressive phase. Diagnosis criteria requires a manic episode of

an unusual or euphoric hyperexcited state that lasts for at least one week. Mania is characterized

by labile emotions between euphoria and hostility. The patient is also diagnosed with

Polysubstance Abuse Disorder and Opioid Dependence. Both of these diagnoses indicate the

patient has a history of drug abuse. Polysubstance abuse requires the abuse of at least three

different classes of substances. (Videbeck, pp. 305-315)

3. Identify the stressors and behaviors that precipitated current hospitalization

Behaviors and stressors contributing to current hospitalization include lack of housing, no

support system, drug abuse, and no employment. The patient stated she has been raped and

beaten in the past which could currently be affecting her mental state due to trauma response.

This puts the patient at risk for Post Traumatic Stress Disorder and increases the likelihood of

abusing substances.

4. Discuss patient and family history of mental illness

The patient did not state any family history of mental illness. She stated all of her family

lives in the Northern part of Ohio and does not have communication with them. This put’s the

patient with an inadequate social support system. The patient also believes this is the primary

cause of her current conditions.

CASE STUDY 7

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

attended

Care for this patient primarily included medication administration. This patient in

particular came into the E.R. showing aggression towards staff. The delusion she was

experiencing caused her to believe they were trying to steal her “baby”. Safety for the patient and

staff, calming the patient down, and reorienting her were the priority and goals at this time. Other

care for this patient included counseling due to high-risk behaviors and substance abuse. The

patient also attended group therapies.

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

The patient stated she is not religious, however, believes in a higher power. She does not

practice any religion. The patient discussed how being a female and homeless is difficult. She

believes these factors put her at a higher risk for abuse and rape.

7. Evaluate the patient outcomes related to care

After stabilizing the patient, her delusion of being pregnant went away and she was no

longer violent. This could have been a reaction to the substances she was taking. Goals for this

patient include collaborating with health professionals, the client will maintain compliance with

the medication regimen, the client will remain free from substances, and the client will seek

follow-up care and therapy.

CASE STUDY 8

8. Summarize the plans for discharge

This patient is planned to be discharged on today’s date of care, however, it appears the

discharge date is going to be pushed back further. The discharge plan includes referring this

patient to a homeless shelter and providing her with assistance from organizations such as those

with food and clothing. Other plans for discharge include follow-up therapy and attempting to

have the patient remain free from substance abuse. General healthcare is also a priority for this

patient due to risk behaviors. The patient stated hope to turn current life choices around after

discharge

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

1. Risk for injury related to Severe Manic Bipolar 1

2. Risk-prone health behaviors related to polysubstance abuse

3. Risk for self and other-directed violence related to opioid dependency and risk for

withdrawal

4. Ineffective Health Maintenance related to ineffective management of Severe Manic

Bipolar 1 and Polysubstance Abuse

10. List of potential nursing diagnoses (Ackley et al.)

● Ineffective coping related to personal vulnerability, situational crisis

● Risk for Injury related to high-risk behaviors

● Acute Confusion related to Substance Abuse

● Risk for other-directed violence related to delusional thinking

● Risk-prone health behavior related to addiction

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● Self-neglect related to substance abuse

● Interrupted Family Process related to situation transition

● Risk for Trauma related to homeless in high crime neighborhood

● Impaired Home Maintenance related to impaired cognitive functioning, inadequate

support system, and insufficient finances

● Ineffective Health Management related to insufficient finances, altered psychological

state, lack of home maintenance

● Sleep deprivation related to hyper-agitated state

● Ineffective Coping related to situational crisis

11. Conclusion paragraph

In conclusion, LH’s priority was safety upon admission related to delusional thinking

which was most likely proceeded by substance abuse. Severe Manic Bipolar 1 Disorder puts this

patient at risk to go into a severe manic state. This then could cause exhaustion and send the

patient into a hyper-agitated state. Polysubstance abuse is correlated to the diagnosis of Opioid

Dependency. This puts the patient at risk-prone behaviors. All of these diagnoses and risk factors

play an important role in planning out this patient’s care. Important goals for this patient include

medication regimen, follow-up care, and health maintenance.

CASE STUDY 10

References

Videbeck, S. L. (n.d.). Psychiatric-Mental Health Nursing Eighth Ed. Chapter 17 Mood

Disorders and Suicide (8th ed., pp 284-324) essay, Wolters Kluwer.

Ackley, Betty J., Ladwig, Gail B., Flynn Makic, Mary B. Nursing Diagnosis Handbook. (11th.
Ed., pp 18-120.). Elsevier.