CASE STUDY 1

Case study

Maryna Farynets

Centofanti School of Nursing, Youngstown State University

4842L Mental Health Nursing Lab

Phyllis Defiore- Golden

September 20th
CASE STUDY 2

Case Study

Abstract

This case study is focused on bipolar disorder, cluster B personality disorder, and PTSD

as well as therapy and care provided to the patient. The subject of this case study is a 20-year-old

Caucasian female who was admitted to the Behavioral Health Unit on September 12th with

suicidal ideations and four previous attempts of suicide. Many academic journals and various

applicable references were reviewed to enhance the quality of information that is used in this

case study. Magg Library resources were accessed to find the relevant information. Additionally,

the search engines Academic Search Complete, EBSCO, and CINHAL were consulted during the

research.
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Objective Data

Patient identifier K.C.

Age 20

Sex Female

Date of admission September 13, 2023

Date of care September 15, 2023

Psychiatric diagnosis bipolar disorder

Other diagnoses Anxiety, depression, PTSD, Cluster B personality disorder, drug overdose, and

suicide attempts.

The patient K.C. is a 20-year-old Caucasian female brought to the emergency department

by her parents, hearing K.C.’s remarks concerning a suicide plan. The patient had four previous

attempts of suicide by overdose and a history of harming herself. Her parents stated that K.C.

was hitting herself and wanted to “end it all”. In the ER the patient presented calm while lying in

bed and answered in a soft, placid voice. She was well-groomed and behaved appropriately. The

chart states the patient was alert and oriented to person, place, and time upon admission to the

ER. Eyes were PERRLA. Upon the ER doctor’s assessment, the patient had no signs or

symptoms of infection. Her breathing was unlabored (16 breaths per minute) her chest moved

symmetrically and there were no adventitious sounds upon auscultation. Heart rate was regular,

S1, S2, no murmur, no signs and symptoms of bleeding, and carotid pulse +3. The patient’s skin

was warm to the touch, and the color was appropriate to ethnicity. There were multiple ear

piercings. The patient had four small tattoos on her arms and fingers and multiple scars on her

forearms and thighs. The patient’s temperature was 98.7, BP 114/68, O2 was 97%, and HR 92

bpm. The patient was tested for pregnancy and the result was negative. Additionally, the patient
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was positive for amphetamine and cocaine. Her abdomen was flat and soft, and bowel sounds

were present in all four quadrants. The patient was pink-slipped by her parents in the Behavioral

Health Unit due to suicidal ideation.

On the day of care, September 15, K.C. stated her suicidal thoughts had diminished and

was that she ready to go home. Her behavior was reasonable and she was well-groomed and

dressed appropriately. During the interview, K.C. was distant and sad in conversation. She stated

that she was “manic and could not sleep for three days and now she is tired and cold from

medications”. The patient stated that she “stopped her medications cold turkey” and this action

resulted in a manic episode which led her to use cocaine and drink alcohol with her friends. The

patient stated she does not remember what happened after she consumed alcohol but she does

recall why her parents brought her to the ER.

Since K.C was admitted during her acute manic episode with suicidal ideations, she was

prescribed Aripiprazole 5mg mood stabilizer, Oxcarbazepine 150 mg anticonvulsant, Haloperidol

5 mg for agitation, and Hydroxyzine 50 mg for anxiety. Additionally, K.C. was prescribed

aluminum and magnesium hydroxide-simethicone for indigestion and medroxyprogesterone as a

contraceptive. K.C. stated that she does not smoke, and only vapes daily. She was prescribed

NicoDerm to help with vaping cessation since vaping is not allowed on the unit.

Labs were assessed and some trends were noticed. The patient’s WBC count was 6.7,

which is at lower end of the spectrum. This result could be due to the side effects of Aripiprazole.

Aripiprazole is a mood stabilizer and was prescribed for the treatment and maintenance of K.C.’s

bipolar disorder. Her creatine, BUN, and glucose were in the normal range. The patient tested

positive for amphetamine and cocaine.

CASE STUDY 5

K.C. was closely monitored and was in a secure environment due to suicidal ideations.

The patient was on suicide precautions, so she was not allowed to use belts, shoelaces, sharp

objects, or mirrored items. The atmosphere in the unit was calm to promote recovery, and drug

and alcohol detoxification. The patient was educated to report an increase in suicidal ideations.

She was instructed to change position slowly to minimize orthostatic hypotension which can

result from several medications including Abilify. K.C. was advised to spend more time in

common areas and encouraged to attend group therapy session to further recovery and to keep

the patient socially active.

Summarize the Psychiatric Diagnoses and Expected/ Common Behaviors.

K.C. was diagnosed with several mental illnesses. The first, mental illness that was the

reason for the patient’s admission was bipolar disorder with periods of mania and depression.

According to the study of Koubaeva, D., Dimic, M., Timmis, V.H., Fiksenbaum, L. M., Mitchell,

R.H.B, Schaffer, A., Sinyor, M., Goldstein, B.I. (2023) patients with bipolar disorder have one of

the highest suicide attempt rates of all psychiatric disorders. Suicide is also the second leading

cause of death in patients with bipolar disorder. Depression is one of the leading indications of

bipolar disorder; these patients spend a large part of their lives suffering from depressive

symptoms (p.3).

Bipolar disorder is also characterized by extreme mood swings. Patients have periods of

mania followed by periods of depression. During manic periods, patients experience euphoria

and sleeplessness, they are energized and display grandiose behavior. This period is

characterized by poor judgment, rapid speech, actions, and thoughts. During depressed periods,

patients have the same symptoms as patients diagnosed with depression (Videbeck, S.L., 2017).
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The second mental illness is cluster B personality disorder. Cluster B includes Antisocial,

Borderline, Histrionic, and Narcissistic personality disorders. The most common behaviors of

cluster B include unstable interpersonal relationships, impulsivity, a pervasive pattern of

disregard for and violation of the rights of others, manipulations, excessive emotionality, and

attention seeking, need for admiration, and lack of empathy (Videbeck, S.L., 2017). According

to the studies of Van Veel et al., patients with cluster B personality disorders report poor quality

of sleep and poor impulse control (Van Veen et al., 2017, p. 224 ). K.C. reported not sleeping for

three days before hospitalization as well as poor impulse control which led to the consumption of

significant quantities of alcohol and cocaine, and suicidal ideations.

Thirdly, K.C. was diagnosed with PTSD. During the interview, she stated, “She feels like

all people around try to harm her”. She has flashbacks from childhood trauma and “can’t get over

it”. This appears to be a manifestation of PTSD from sexual abuse trauma. According to the

study by Walker, H. E., Wamser-Nanney, R., & Howell, K. H. (2021), sexual victimization is

associated with high levels of stress. Complex effects of multiple episodes of sexual trauma that

have significant short and long-term psychological effects. PTSD is an alarming model of actions

demonstrated by a person who was involved as a witness or experienced a traumatic event. Some

symptoms of PTSD include reexperiencing traumatic events through dreams, repetitive thoughts,

avoidance, negative cognition, and being on guard (Videbeck, S.L., 2017).

Lastly, K.C. was diagnosed with anxiety. Patients with this disorder can demonstrate

remarkable behaviors, such as panic without reason, and fear of various common conditions or

objects. This disorder has a significant impact on a patient’s life and can interfere with daily life

and normal functioning. Anxiety disorders are the most common mental illness in the United

States. Anxiety can have various negative effects on a patient’s performance. K.C. demonstrated
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many symptoms of anxiety disorder during the interview and stated, “It is very difficult to cope

with my anxiety”.

Identify the Stressors and Behaviors that Precipitated the Current Hospitalization.

K.C. stated that the main stressor in her life is “romantic relationships with her significant

other”. The patient stopped taking her prescribed medications before hospitalization. She stated

that” she did not like how they made her feel and stopped cold turkey”. This led to a manic

episode that lasted three days during which K.C. could not sleep and started using cocaine in an

attempt to fall asleep. The next day she went to a party and consumed a large amount of alcohol

and stated that she “does not remember what happened after that”. She was pink-slipped to the

unit by her parents after the patient hit herself and said that she wanted “to end it all” by drug

overdosing. K.C. reported access to the drugs through her significant other.

Discuss the Patient and Family History of Mental Illness.

The patient has a history of Bipolar disorder, PTSD, anxiety, and cluster B traits. She also

experienced four prior attempts of suicide. K.C. has a history of drug use, and during her current

hospitalization she tested positive for cocaine and amphetamines. The patient has visual and

auditory hallucinations when her “episodes get bad”. She has a history of eight previous

psychiatric hospitalizations.

K.C. reported a family history of mental illness, with depression and ADHD in her

mother, schizophrenia in her maternal aunt and paternal grandfather, and suicidal attempts in

maternal grandfather. K.C. was sexually assaulted by her older sister during childhood and was

twice sexually assaulted in high school.

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Describe the Psychiatric Evidence-based Nursing Care Provided and Milieu Activities

Attended.

After admission to the behavioral health unit K.C. was provided with different types of

evidence-based nursing care. For instance, the patient was provided with a secure environment,

and all belts, shoelaces, and hazardous objects were removed to ensure patient and staff safety.

Lights were lowered and the sound of the TV was down to promote a calm and healing

atmosphere for the patients. A structured schedule was in place to make the day of the patient

more predictable and minimize the stress of the hospital stay. The patient was provided with

warm blankets and access to the shower and toiletries. Both staff and the students practiced

therapeutic communication with the patient to help relieve any tension and reorient her to reality.

K.C. was provided with opportunities to access group therapies. The patient attended one group

session and stated her goal for each day is “to attend group therapy”. The patient was

administered pharmacotherapy in a timed and safe manner, and six rights of safe medication

administration were followed to ensure the patient’s safety and prompt recovery.

Analyze Ethnic, Spiritual, and Cultural Influences that Impact the Patient.

The patient stated that she “is not religious and does not believe in anything”. She was

fascinated with her genetic ancestry testing which indicated she has a German heritage. The

patient reported that she and her family practice only American culture. She does not have any

ethnic background that has a significant impact on her life. She was formerly a student at OSU as

a design major. This part of her life appears to have a meaningful impact on her personality. She

had to drop out, however, the school experience interfered with her health.

Evaluate Patient Outcomes Related to Care

CASE STUDY 9

K.C. had several positive outcomes while staying in the hospital. First, she started taking

her prescribed medications which helped to improve her manic symptoms. Second, the client’s

sleep improved from not being able to sleep for three days prior to hospitalization, to sleeping 6-

8 hours after starting her medication regimen. Third, the patient stayed free from harm and was

able to process the events that led to hospitalization. She attended group therapy and made

progress with articulating her goals for the day and learning new coping strategies. The patient

agreed to continue her medication regimen and participate in therapy as an outpatient after

leaving the hospital. She was informed about the side effects and red flags of medications and

was able to verbalize when she would need to seek medical help.

Summarize the Plans for Discharge.

Upon discharge, the patient will move in with her parents. She will continue taking her Abilify 5

mg to maintain her bipolar disorder. She will review her medication regimen with the nurse

before discharge. She will be educated about the side effects of the medications such as

orthostatic hypotension, suicidal ideation, nausea and vomiting, etc. The client will be instructed

to report any side effects to her doctor or a nurse. She will be informed about the importance of a

healthy diet and healthy lifestyle as contributing to a successful recovery. K.C. will be attending

individual and group therapy as an outpatient patient once a week.

Prioritize List of All Actual Diagnosis Using Individualized NANDA format

Suicidal behaviors related to ineffective impulse control evidenced by manic episodes, threats to

overdose, and consumption of cocaine and amphetamines.

Injury related to destructive behaviors related to suicidal ideations as evidenced by

overconsumption of alcohol, and consumption of cocaine and amphetamines.

CASE STUDY 10

Self-directed violence related to hallucinations is evidenced by the consumption of alcohol,

cocaine, and amphetamine.

Insomnia is related to constant anxious thoughts evidenced by altered mood, manic episodes, and

difficulty falling and staying asleep.

Disturbed thought process related to substance use as evidenced by hallucinations, consumption

of alcohol, cocaine, and amphetamines.

Disturbed sleep pattern related to manic episodes as evidenced by the absence of sleep for three

days.

Imbalanced Nutrition: Less than Body Requirements related to an inability to sit still long

enough to eat meals and depression as evidenced by electrolyte imbalances, pale mucous

membranes, and weight loss.

Disturbed Sensory Perception related to substance use and sleep deprivation evidenced by

auditory and visual hallucinations, exaggerated emotional responses, and inappropriate

responses.

List of Potential Nursing Diagnosis

 Risk of Self-care Deficit,

 Risk for Spiritual Distress,

 Risk for Imbalanced Fluid Volume,

 Ineffective Health self-management,

 Ineffective coping,

 Disturbed personal identity,

CASE STUDY 11

 Ineffective role performance,

 Social isolation

Conclusion

Bipolar disorder is a complex disease that affects not only the patient’s mental health but

also the physical health and well-being of the patient and the whole family. It is a complicated

disease that needs to be closely monitored with needs for constant pharmacological treatment.

This mental illness requires long-term psychotherapy. Clients with this disorder may benefit

from establishing a daily routine, sleep schedule, diet, and exercise. Multiple diagnoses in one

patient will require an even more intricate approach and close supervision.

Finally, it was very interesting to learn more about bipolar disorder, PTSD, anxiety, and

personality disorders. K.C.’s case was a striking example of how these disorders affect life and

the lives of people and their families. This case study also highlights the relationship between

mental illnesses and genetics and demonstrates that certain illnesses can be passed on to future

generations. The recommended goal for K.C. is to adhere to the prescribed medication regimen

and psychotherapy to prevent self-harm and to control exacerbation periods.

CASE STUDY 12

References

Khoubaeva, D., Dimick, M., Timmins, V. H., Fiksenbaum, L. M., Mitchell, R. H. B., Schaffer,

A., Sinyor, M., & Goldstein, B. I. (2023). Clinical correlates of suicidality and self-

injurious behaviour among Canadian adolescents with bipolar disorder. European Child

& Adolescent Psychiatry, 32(1), 41–51. https://doi-org.eps.cc.ysu.edu/10.1007/s00787-

021-01803-9

Van Veen, M. M., Karsten, J., & Lancel, M. (2017). Poor Sleep and Its Relation to Impulsivity in

Patients with Antisocial or Borderline Personality Disorders. Behavioral Medicine, 43(3),

218–226. https://doi-org.eps.cc.ysu.edu/10.1080/08964289.2017.1313719

Videbeck, S.L. (2017) Psychiatric-Mental Health Nursing. 8th Edition, Lippincott Williams &

Wilkins, Philadelphia.

Walker, H. E., Wamser-Nanney, R., & Howell, K. H. (2021). Child Sexual Abuse and Adult

Sexual Assault among Emerging Adults: Exploring the Roles of Posttraumatic Stress

Symptoms, Emotion Regulation, and Anger. Journal of Child Sexual Abuse, 30(4), 407–

426. https://doi-org.eps.cc.ysu.edu/10.1080/10538712.2021.1890295