Running head: MENTAL HEALTH CASE STUDY

Mental Health Case Study

Alyssa Blosser

Youngstown State University

Patricia Flamino
MENTAL HEALTH CASE STUDY

Abstract

This case study is an analysis of a psychiatric patient on an inpatient unit at Mercy St.

Elizabeth’s Hospital in downtown Youngstown, Ohio. The patient is a 21-year-old male

diagnosed with Bipolar 1 and Major Depression admitted after thoughts of suicide and self harm.

Throughout the study there will be discussion on past mental history, stressors leading to the

event, summarization of date of care, nursing diagnoses, and interventions for the nursing

diagnoses.
MENTAL HEALTH CASE STUDY

Objective Data

DC is a 21-year-old male patient was admitted voluntarily to Mercy’s St. Elizabeth

Behavioral Health Unit on March 4th, 2019. The patient presented to the ED on March 3rd, 2019

stating he ‘needed help and didn’t know where else to turn to.’ The reported precipitating event

was a breakup with his girlfriend of over a year who lived with him and now he has no one

because he has no friends. Patient refers to himself as a loner. DC has a history of suicidal

ideations and reported a prior hospitalization in high school after placing a pocket knife to his

neck during an argument with his mother. He stated he was ‘too weak to kill himself then and is

too weak to go through with it now.’ Family has a history of mental illness amongst four

members. His biological father was abusive towards his wife and children, his mother is bipolar,

his sister struggles with substance abuse, and his brother has anger management issues. The

patient was not irritable upon admission and had no physical manifestations, just reported hope

for the future. There was no prior medical history provided. A diagnosis of Major Depression

and Bipolar 1 Disorder without psychotic features was provided by Dr. Kassawat MD. Both

diagnoses fall under Axis I which is the top-level of the DSM-5 system (“Axis I”, 2015). His

current prescribed medications that are scheduled include:

 Apripiprazole (2 mg, PO BID for maintenance of Bipolar 1)

 Gabapentin (100 mg, PO TID used off label for Bipolar treatment)

His current as needed medications include:

 Benzotropine Mesylate (2 mg, IM BID PRN for acute dystonia)

 Haloperidol Lactate (10 mg, IM Q6H PRN for agitation)

 Hydroxyzine (50 mg, PO Q6H PRN for anxiety)

 Trazadone (50 mg PO, PRN for sleep)

Upon date of care on March 5th, 2019, he was dressed neatly in a hospital gown and pants

with unkempt hair and facial hair. He remained calm, relaxed, and friendly throughout the

conversation but had to be asked to repeat things multiple times due to talking too quietly. Upon

reading notes in his chart I found that this was a common occurrence. He slouched in his chair

when talking but maintained eye contact and a smile on his face which was fixed and immobile.

There was no diverting in the conversation and he seemed to tell the truth about everything

without avoidance. He laughed appropriately throughout the conversation and remained serious

when talking about topics regarding his mental health and precipitating factors. Feelings of

optimism and goal setting were reoccurring topics of conversation.

Summarize

Bipolar Disorder can be characterized by episodes of mania, hypomania, or moods that

alternate between mania and major depression, as does DC. Another name that this disorder is

references by is manic-depressive disorder due to the fluctuation of moods (Lane, 2015). Bipolar

I Disorder is defined by episodes of mania that last for seven days and can also include episodes

of depression which may last at least two weeks. These two moods can also mix and have

symptoms of mania and depression at the same time, called mixed symptoms (“Bipolar

Disorder”, n.d). According to Psycom (Shelton, 2019), there are eight symptoms that fall within

the criteria for Major Depression. A person must experience five or more during a two-week

period and must include either a depressed mood or loss of interest or pleasure. These symptoms

include:

 Depressed mood most of the day, nearly every day

 Markedly diminished interest or pleasure in all, or almost all, activities most of

the day, nearly every day.

 Significant weight loss when not dieting or weight gain, or decrease or increase in

appetite nearly every day.

 A slowing down of thought and a reduction of physical movement (observable by

others, not merely subjective feelings of restlessness or being slowed down).

 Fatigue or loss of energy nearly every day.

 Diminished ability to think or concentrate, or indecisiveness nearly every day.

 Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or

a suicide attempt or a specific plan for committing suicide.

According to an article written on Epocrates, Bipolar I can be characterized by the occurrence of

at least one manic or mixed episode. This episode must be a period of ‘abnormally and

persistently elevated, expansive, or irritable mood, and increased goal-directed activity or

energy.’ The episode must be present most of the day or nearly every day and during it, 3 or

greater of these symptoms must occur:

 Inflated self-esteem or grandiosity

Decreased need for sleep

 Pressured speech

 Racing thoughts or flight of ideas

 Distractibility

 Increased activity

 Excess pleasurable or risky activity

Most people that are diagnosed with Bipolar I experience both mania and depression. In order to

be diagnosed with Bipolar I, the patient’s episodes of mania need to last one week or be so

intense that the patient must be hospitalized (“Bipolar Disorder”, 2017).

Identify

DC described to me what his childhood was like and what led to his past suicidal

ideations. When he was in high school he was moved from New York to Puerto Rico because his

parents wanted to start over. He soon became depressed because he was moved from his friends

and life as he knew it. When he brought it up to his mother, they began fighting. That is when he

took a pocket knife and placed it to his neck but stated he was ‘too weak’. DC then compared

that situation to his current situation where his girlfriend broke up with him after being together

for over a year and living together. He doesn’t have many friends and considers himself a loner

besides his online gaming friends. One of his main triggers is that she left her stuff remaining in

the apartment and refuses to take it. He stated, “It’s hard to have to look at her stuff every day. I

tried to move it to the other room and that’s how I ended up here.” DC reports that he has only

ever wanted to hurt himself but never others.

Discussion

DC was very open to conversing about his mental health history as well as his treatment

plans and plans for the future. He is actively involved in group sessions and stated, “I know there

is hope for the future and I just want to get better. This place is really helping.” He discussed his

personal favorite group session that consisted of musical therapy and how each member had to

pick a song that was positive for them. His choice was Happier by Marshmello. One of the plans
MENTAL HEALTH CASE STUDY

he came up with alongside the social worker was to rescue a pet from the shelter. He feels as

though this will help with his loneliness. His support system consists of his mother and step-

father that reside in close proximity to him as well as his sister in Buffalo, NY that he is also in

close contact with. With the help of his sister, that is how he found the strength to admit himself

voluntarily to the inpatient Behavioral Health Unit. DC is currently employed as a general

manager at a convenience store and is attending classes online in the study of business.

Describe

Safety and prevention of self harm takes priority when providing care to a patient with

suicidal ideations. This begins upon admission to the unit when the belongings of the patient are

locked away to prevent using anything to harm themselves such as shoe laces, belts, etc.

Maintaining close observation of the suicidal patient is important and the Joint Commission has

instilled patient head counts every 15 minutes to ensure all patients are accounted for and safe.

Rapport between the caregiver and the patient is also necessary to ensure that the patient will be

honest and open to get the help that is necessary. This must be provided without judgment and be

in the best interest of the patient to promote an entirely therapeutic environment. DC commended

the care of the nurses at Mercy’s St. Elizabeth hospital and how the environment promotes

positivity and getting better for him. Care on the Behavioral Health Unit promotes getting the

patients back to a place mentally where they can perform their basic ADL’s such as bathing,

making their beds, eating, etc. This is especially important in patients with depression, such as

DC, to prevent feelings of hopelessness and like they no longer have any control or power.
MENTAL HEALTH CASE STUDY

Analyze

The patient is Puerto Rican and for Latinos, there can be a stigma attached to being

diagnosed with a mental illness or going to see a counselor. There are a few cultural differences

associated with Latinos but these did not pose a barrier with DC. According to an article by Lisa

Fortuna, Latinos tend to use indirect communication such as using metaphors, jokes, or stories to

transmit information. Also, religion can play a factor in reducing suicide attempts but DC reports

to not be strong in his faith of Catholicism. Another important factor regarding mental health is

that visions of spirits does not necessarily mean the patient is experiencing psychosis but rather

relate to their spiritual beliefs. Latinos tend to fall into a category of minorities with barriers to

accessing care that is necessary due to lower rates of insurance, immigration status, as well as

language and cultural barriers (Fortuna, n.d).

Evaluate

DC remains hospitalized due to only being held for 24 hours and will remain in the

hospital for his required 72 hours. The outcomes for DC should be focused around what to do at

home when he feels that he wants to self harm or has thoughts of killing himself. He is

progressing as expected and does not currently have any thoughts of harming himself. With an

example diagnosis of ‘Risk for suicide’, a nurse could intervene by providing accessible

resources to the patient for once he is discharged. This could help with his feelings of loneliness

and also help to cope with feelings of self harm by engaging in social activities. Another

intervention would be determining particular stressors and how to avoid them as he voiced his

ex’s things remaining in his apartment as a stressor. The most important focus is maintaining his

safety.
MENTAL HEALTH CASE STUDY

Summarize

Before discharge DC must verbalize an understanding of the situation and identify the

stressors that led to his feelings of suicide. Patient must be free of thoughts of self harm and be

able to identify healthy ways of coping with stress and loss of relationships. He has a strong

support system of family members and they should be contacted prior to discharge to discuss

what resources to utilize once he is home. Medication education is also important to be reviewed

prior to discharge. The importance of compliance should be stressed even if he feels better since

the patient has not previously been prescribed medication for Bipolar or depression.
MENTAL HEALTH CASE STUDY

Prioritized List of Nursing Diagnoses

1. Risk for Suicide related to feelings of loneliness and helplessness as evidenced by

2. Impaired Social Interaction related to fear of rejection by peers as evidenced by

3. Spiritual Distress related to life changes as evidenced by expression of lack of hope,

Potential Nursing Diagnoses

 Risk for suicide r/t history of suicide attempt.

 Low self-esteem r/t not having friends to help cope.

 Powerlessness r/t inability to cope with break up.

 Disturbed thought process r/t thoughts of self harm and suicide.

 Ineffective coping r/t break up with girlfriend.

 Risk for injury r/t thoughts of self harm.

 Complicated grieving r/t break up with girlfriend.

 Stress overload r/t life changes beyond his control.

 Impaired mood regulation r/t diagnosis of Bipolar Disorder.

 Decisional conflict r/t removing stressors.

References

Axis I. (2015, December 2). Retrieved March 21, 2019, from

http://www.psyweb.com/DSM_IV/jsp/Axis_I.jsp

Bipolar Disorder. (n.d.). Retrieved March 21, 2019, from

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Bipolar Disorder. (2017, August). Retrieved March 21, 2019, from https://www.nami.org/learn-

more/mental-health-conditions/bipolar-disorder

Bipolar Disorder in Adults. (n.d.). Retrieved March 21, 2019, from

https://online.epocrates.com/diseases/48836/Bipolar-disorder-in-adults/Diagnostic-Criteria

Fortuna, L. (n.d.). Working with Latino/a and Hispanic Patients. Retrieved March 21, 2019, from

https://www.psychiatry.org/psychiatrists/cultural-competency/treating-diverse-patient-

populations/working-with-latino-patients

Lane, C. (2015, December 2). Bipolar Disorder. Retrieved March 21, 2019, from

http://psyweb.com/Mdisord/MoodDis/bipolar1.jsp