Running Head: MENTAL HEALTH CASE STUDY 1

Elizabeth Hoelzel

Nursing, Youngstown State University

NURS 4842: Mental Health Nursing

Mrs. Peck

March 16th, 2020

ABSTRACT
Running Head: MENTAL HEALTH CASE STUDY 2

On February 20th, 2020, AW was a patient at Mercy Health St. Elizabeth’s

Psychiatric Unit. She is a 23 year old female who presented to the emergency room on

February 9th, 2020 with Suicidal Ideations, Auditory Hallucinations, depression and

borderline personality disorder. Her father brought her in because he was concerned for

her safety. In this case study I will discuss the events leading to her admission, the

psychiatric diagnosis, her stressors and behaviors, family history of mental health

disorders, ethinic, spiritual and cultural influences, patient outcomes, and nursing care.

OBJECTIVE DATA
Running Head: MENTAL HEALTH CASE STUDY 3

On February 9th, 2020, AW presented to the emergency room with her father.

She had expressed to her family that she was hearing voices that were telling her to kill

herself by either cutting her throat or shooting herself in the head. These voices and

command hallucinations were worsened by nothing. The auditory command

hallucinations were persistent for 7-10 days before her admission on February 9th.

Auditory Command Hallucinations are defined by “Command hallucinations are auditory

hallucinations that instruct a patient to act in specific ways; these commands can range

in seriousness from innocuous to life-threatening.” (Hersh, Borum, 1998). She has a

previous medical history of diagnosis of depression, suicidal ideations, and borderline

personality disorder.

On admission AW presented with her father. As I talked to her during my time on

the floor she perceived and described her family dynamics as supportive and says she

knows that she can always go to and confide in her parents and siblings when she is

struggling with her mental state. During my conversation with AW she talked alot about

her past in and out of psychiatric units. She stated she has had auditory command

hallucinations since she was 11 years old. She has been admitted to Belmont pines

greater than 10 times, multiple admissions to Belmont psychiatric unit, generations and

highland springs.

During our conversation, her affect was very flat. The rare occasion she would

smile, was when she was talking about her family, which consisted of her mom and dad,

and her twin siblings who are attending Youngstown State University. She hopes when

she can get her mental state more stable she can pursue an education at Youngstown

State university for exercise science. Hearing her say this left the impression she was in
Running Head: MENTAL HEALTH CASE STUDY 4

the right direction and wanting to move forward and make something of herself. She

was alert and oriented x4. During the short conversation we had we found that we knew

a lot of people in common, after this discovery she exhibited flight of ideas, when we

would ask about her history or her current stay at Belmont Psychiatric unit at St.

Elizabeth’s she would revert back to the people we had in common or to her siblings

lives.

In regards to her labs the tox screen they constructed on her was negative, to

rule out substance abuse prior to being admitted. She had trace amounts of WBC in her

urine with a diagnosis for a UTI and was being treated accordingly. Her HCG level was

negative, this is important because psychiatric medications are teratogens to a fetus

and can cause serious complications for the fetus. Another big lab they test and look for

upon admission to the psychiatric unit are TSH and T4, this is because hypothyroid

symptoms and also present as depressive symptoms. “The symptoms of

hypothyroidism are variable and sometimes hard to pin down. They may include fatigue,

sluggishness, cold intolerance, weight gain, constipation, muscle or joint pain, thin and

brittle hair or fingernails, reduced sexual drive, high blood pressure, high cholesterol,

and a slow heart rate. Patients may also have problems with concentration and

memory. Some of these symptoms also occur in depression or other psychiatric

disorders, and there may be links between hypothyroidism and depression.” (Harvard

Mental Health Letter, 2007). Her levels were normal, TSH was 2.070 and T4 was 9.8.

She does have a medical history of hypothyroidism and is on synthroid for this and

seems to be well controlled.

The medications AW is on for her psychiatric diagnosis include Olanzapine

(Zyprexa) 5mg nightly, it is an antipsychotic and is used for agitation for this patient. She

is on Citalopram (Celexa) 20mg daily, this is an SSRI used to treat depression. Next

she is on Hydroxyzine (Vistaril) 50 mg T.I.D. used for anxiety and is a histamine

antagonist. She is on Trazadone (Desyrell) 50 mg nightly which is an SSRI used to help

her sleep. And lastly for her psychiatric medications she is on Benztropine (Cogentin) 2

mg every 6 hours PRN for EPS. She also was being treated for genital herpes with

Acyclovir (Zovirax) 400mg daily, and Valacyclovir (Valtrex) 500 mg daily and these are

both antivirals.

Non pharmacological treatments include group therapy. She stated that she was

not always wanting to go to group therapy and she didn’t feel it was very helpful for her.

During our conversation we asked her to come to a group with us and she did and she

really seemed to enjoy it. During my conversation with AW she stated that she was very

upset earlier that day with the NP on the unit because she was putting her on a

behavioral plan because she was not attending group therapy and was sleeping most of

the day and this made her very upset when she was informed. She then proceeded to

threaten the NP and began to bang her head on the floor. After this incident she was

restrained and medicated with 5mg of haldol. After she calmed down, she stated she

was still suicidal but was now in control and signed a contract to not harm herself while

on the unit and said “I didn’t realize how out of control I was” and continued to eat lunch

and now understands appropriate behavior.

SUMMARY OF PSYCHIATRIC DIAGNOSIS

On the day of care with AW we discussed many of her psychiatric diagnosis, she

struggles with depression and borderline personality disorder, one study stated

“Especially in clinical practice, the belief is widespread that depressed patients with PD

respond less favorably to treatment of depression than depressed patients without such

a diagnosis” (Unger, Hoffmann, Kohler, Mackert, Fydrich, 2013). They saw the reason

for this as “A possible reason might be the ego-syntonicity of PD pathology, which can

lead to a poorer ability and willingness to comply with treatment and, consequently,

poorer treatment outcome.” (Unger, Hoffmann, Kohler, Mackert, Fydrich, 2013).

Another psychiatric diagnosis she had was auditory command hallucinations, for

AW these command hallucinations were telling her to kill herself and in multiple ways of

doing it. She stated that the voices were more a man's voice but she would sometimes

hear a woman's voice. Barrowcliff and Haddock (2010) state “As compliance with

commanding voices continues to be implicated in clinical reports of engagement in

dangerous behaviours.” The patient that I talked to stated that when she hears her

voices, they are usually telling her to hurt herself in one way or another.

The last psychiatric diagnosis she has is suicidal ideations. Suicidal Ideations

become more evident the more stressors the person has on their life. Her other

diagnosis has a big impact on the fact that she is suicidal. “Risk factors for suicidal

ideation among adolescents are well known through many previous studies and can be

divided into personal and environmental factors. Typical personal risk factors for suicidal

ideation in adolescents include mental disorders, such as a mood disorder, particularly

depression, anxiety disorder, or post-traumatic stress disorder [5–8], and psychological

impairments, such as hopelessness, low self-esteem, and impulsivity, are other well-

known risk factors.” (Lee, Jung, Park, Hong, 2018).

STRESSORS AND BEHAVIORS

While talking with AW, she didn’t give much information about things that stress

her out in her day to day life because she would typically revert things back to me or the

student i was working with that day. These things have been going on for so long with

her, since she was 11 years old and now she is 23, so with that alone going on for so

long with little progress is extremely stressful to her. She desires to get better and work

through things but hasn't been able to make much progress. She spoke fondly of her

family, her parents are very supportive of her condition and care very much about her.

Her younger siblings are also very helpful and seem to be stable and attending

Youngstown State University. Her behaviors while talking to her, she seemed very flat,

she would revert things back to me and my life and was somewhat restless in her

movements.

PATIENT AND FAMILY HISTORY OF MENTAL ILLNESS

The patient has a history of auditory command hallucinations since she was 11

years old, leading to her state of depression and her suicidal ideations. She was also

diagnosed with a personality disorder which is contributing to her want and desire to do

what it takes to get to a healthy mental state. She does not have a family history of any

mental illnesses that she was aware of, and i think that could also put a stigma up about

her that she is the only one around her in her close family life going through what she is

going through.

PSYCHIATRIC EVIDENCE BASED NURSING CARE AND MILIEU ACTIVITIES

Nursing care provided for AW includes intense group therapy. Having her go to a

group and making that part of her behavioral plan. The NP has put her on a behavioral

plan because AW was not putting in the effort she needed to, to make progress. Next is

her medication administration, the medications she is on will help stabilize her mood

and the command hallucinations she experiences. And lastly it's important to put her on

a plan that she will be able to carry out when she leaves the hospital and has to be a

part of everyday life. Implementing a plan for her to find a job, and go back to school

and insert herself into social situations and to not seclude herself from those around

her.

AW was initially placed on an involuntary hold and after the hold expired after 3

days, she admitted herself voluntary and was complying with the plan of care for the

most part aside from a couple of incidents. Her staying voluntary is a good indicator that

she is intentional about getting better and that's something that is very important to her.

AW has practiced personal hygiene and is showing signs that she is interested in taking

care of herself. The environment around her is made so that if she did try to hurt herself

it would be more difficult than if she were in her own environment at home. The week

after care that I had her another one of my classmates informed me that she had tried to

hang herself 2 days prior to their date of care with her. She tried to hang herself with a

pair of pants. So after this was discovered the nursing staff took her belongings and

gave her only a paper gown to wear that is made very thin and any weight would cause

it to rip. She eventually got her things back after they determined if she was still a harm

to herself.
Running Head: MENTAL HEALTH CASE STUDY 9

The group I witnessed AW attend was one on the day of care that I had her

which was a spiritual group. She seemed very intune with her desire and own

relationship with a higher power which for her was God. She was very interactive in the

group. The second class I saw her attend was the following week when two of my

classmates performed a music therapy group and she was extremely involved in this.

There was one song that was played that she stated was played at her church and she

liked very much.

AW has coping skills that usually work for her, these coping skills included music,

exercise, showering and attending church. She uses these things to help her calm down

in times of distress but she did say that this time around they weren't as effective as

they normally are for her. Which has contributed to her being admitted to the psychiatric

unit.

ETHNIC, SPIRITUAL, AND CULTURAL INFLUENCES

As stated in the previous section, AW does have some spiritual background. She

states that she attends church on a regular basis. She stated that going to church and

worshiping was something that really helped her cope with some things she has going

on in their life. She listens to music centered around god to help her in times of distress

when she feels out of control. She didn’t really have any ethnic or cultural influences

that helped or harmed her process of healing.

EVALUATION OF PATIENT OUTCOMES

Medication management for AW’s depression and suicidal ideations, in relation

to this an outcome would be that the patient's mood is improving since starting the new

medications. This goal was not met this shift because AW disclosed to me that since
Running Head: MENTAL HEALTH CASE STUDY 10

being in the hospital and on her new medications she has felt worse than how she did

when she came in. Another outcome would be that AW does not hurt herself this shift.

This was not met this shift because right before my clinical arrived she was banging her

head on the ground after threatening the nurse practitioner on the floor. When I got

there for the remainder of the shift she was doing much better and realized she did not

want to hurt herself.

PLANS FOR DISCHARGE

As I spent my time on the floor with AW they did not have any plans of discharge

for her yet. They had put her on a behavioral plan and were going to see how that would

benefit her and then they would discuss further what discharge would look like. She is

there voluntarily so they don’t need to go through any courts to keep her there longer

than the 3 day psychiatric hold.

PRIORITIZED LIST OF ALL ACTUAL NANDA DIAGNOSES

1. Risk of self harm related to voices telling her to kill herself as evidenced by

banging her head on the ground

2. Risk of impaired social interaction related to altered mental process as

evidenced by command hallucinations

3. Disturbed thought process related to hallucinations as evidenced by

statements such as “they tell me to kill myself”

LIST OF POTENTIAL NURSING DIAGNOSES

1. Risk for self harm related to suicidal ideations

2. Risk for hopelessness related to depression

3. Risk for self care deficits related to depression

Conclusion

In conclusions AW is a 23 year old female who is diagnosed with suicidal

ideations, auditory command hallucinations, depression, and borderline personality

disorder. She has tried to commit self harm acts twice while on the psychiatric unit. She

plans to attend college and get her degree at Youngstown State University once she is

able to get her mental illnesses under control and is able to control her emotions. She

has a very good support system at home that will stand by her side when she goes

through times of crisis. She is on new medications and hopefully with continued

monitoring by the nursing staff, counselors and the doctors they can help her. Overall,

her mental health state has improved since being in but she has a road ahead of her,

but with the right treatment they can get her on the right track.

REFERENCES

Thyroid Deficiency and Mental Health. (2007, May). Retrieved from

https://eps.cc.ysu.edu:3253/ehost/pdfviewer/pdfviewer?vid=4&sid=01993975-78a6-4589-b4f7-

6d894313bdbd@pdc-v-sessmgr05
Running Head: MENTAL HEALTH CASE STUDY 12

Unger , T., Hoffmann, S., Kohler , S., Mackert , A., & Fydrich , T. (2013, October). Personality

Disorders and Outcome of Inpatient Treatment for Depression: A 1-Year Prospective Follow-Up

Study. Retrieved from https://eps.cc.ysu.edu:2255/docview/1433078534?accountid=29141

Hersh , K., & Borum , R. (1998). Command hallucinations, compliance, and risk assessment.

Retrieved from https://eps.cc.ysu.edu:3248/ehost/detail/detail?vid=4&sid=05f15e6c-c647-414a-

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WxpdmUmc2NvcGU9c2l0ZQ==#AN=9785279&db=mnh