Mental Health Nursing Case Study 1

Mental Health Nursing Case Study

Kyle Gulling
4842L: Mental Health Nursing Lab
Mrs. DeFiore-Golden
March 17, 2020
Mental Health Nursing Case Study 2

Abstract

This case study is for Mental Health Nursing clinical. “ZW” are the initials of the subject

for this case study. He was a patient at St. Elizabeth’s Mercy Psychiatric Unit on January 24,

2020. He is a 32-year-old Caucasian male presenting with depression and suicidal ideations. This

case study will go into an in-depth view of ZW’s mental illness, lab values, treatment, outcomes,

nursing diagnoses and nursing care for this patient, and discharge plan. The Psychiatric Mental

Health Nursing… textbook by Mary C. Townsend and Nursing Diagnosis Handbook... by Betty

J.. Ackley and Gail B. Ladwig., and other articles were utilized to assist in writing this case

study.
Mental Health Nursing Case Study 3

Mental Health Nursing Case Study

Objective Data

Patient, ZW, is a 32-year-old Caucasian male who was involuntarily admitted to St.

Elizabeth’s Mercy Hospital’s Psychiatric Unit after arriving to the emergency department on

January 22, 2020. The patient was noted to have been somewhat anxious and nervous to be there.

When questioned the patient revealed that he has been contemplating suicide. As the questioning

continued the patient admitted that he had a plan to overdose on pills and that he had access to

pills. At this time the patient was “pink slipped”, or put on an involuntary hold on them, because

the patient has a plan and the means to carry out that plan. The patient at first became upset when

finding this out and tried to leave but when explained the situation expressed an understanding.

The client was diagnosed with Major Depressive Disorder according to the DSM-V. For a

patient to be diagnosed with this they must have five or more symptoms of Major Depressive

Disorder. ZW’s symptoms were depressed mood most of the day, nearly every day, as indicated

by either subjective report, or observations made by others. Markedly diminished interest or

pleasure in all, or almost all, activities most of the day, nearly every day. Insomnia nearly every

day. Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive or

inappropriate guilt nearly every day. Recurrent thoughts of death with a specific plan for

committing suicide. (Townsend, 2015, p.462)

On the day of care, ZW’s behavior had improved since day of admission. He was more

upbeat and had an improved mood during care. The patient expressed hopefulness because he

had been going to group sessions and felt like they were helping. Facial expression still showed

some signs of sadness and depression. Patients posture was relaxed, neat and clean, and had on

appropriate clothes that were well kept. Motor activity was relaxed and smooth and had no
Mental Health Nursing Case Study 4

abnormal physical characteristics. He did not show any signs of akinesia, akathisia, tardive

dyskinesia, or acute dystonic reactions during care. ZW interacted well with the rest of the

patients on the unit and actively participated in group sessions. Overall ZW’s behavior on the

day of care was optimistic and pleasant.

Other Medical Conditions

ZW has a history of Irritable Bowel Syndrome, Crohn’s disease, opiate abuse, and

chronic backpain. Patient is currently taking Methadone to manage his opiate addiction. ZW is

not currently being treated for his Irritable Bowel Syndrome or Crohn’s disease. He does not

have any known allergies at this time.

Lab Results

Patient is having blood work done during the initial treatment to ensure that ZW is

getting the safe and appropriate dosing of medication. This blood work is also done in attempt to

determine if the patient’s depression is caused by a hormone imbalance. ZW’s Lab results:

Drug Screen Methadone, Negative for rest

EOS% 3.6% (normal)

BASO% 0.7% (normal)
WBC 7.9 (normal)
RBC 5.63 (normal)
Hemoglobin A1C 4.75 (Non-diabetic)
Glucose 115 (slightly elevated)
Thyroid Stimulating Hormone 1.050 (normal)
Free T4 0.97 (normal)
AST 31 (normal)
ALT 45 (normal)
BUN 11.5 (normal)
Mental Health Nursing Case Study 5

Patient’s lab results all came back as unremarkable. If the Thyroid Stimulating Hormone

levels were abnormal it could be a cause of depression. The staff on hand will continue to

monitor them for any changes.

Safe Milieu

Safety and security measures were maintained throughout the day. The patient was on

suicide precautions and the staff was checking and charting on him every 15 minutes. They also

removed any items that could be used by the patient to self-harm. The staff also ensured that the

environment was not overstimulating for the patients.

Medications

ZW was prescribed three medications to manage his depression during his stay in the

psychiatric unit. ZW’s list medications:

Trade/Generic Name Drug Class Dose Reason

Vistaril/ Hydroxyzine H1 Agonist 50mg PO x3 daily PRN Anxiety
Provigil/ Modafinil CNS stimulant 200mg PO BID Depression
Zoloft/ Sertraline SSRI 25mg once daily Depression

Summary of Psychiatric Diagnosis

ZW has been diagnosed with Major Depressive Disorder with suicidal ideations.

According to McConnell, Carter, and Patterson Major Depressive Disorder is defined as

“feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of

emotional and physical problems and can decrease a person’s ability to function at work and at

home”. (McConnell et al, 2019, p. 251) ZW reported that he has been dealing with these

depressive thoughts for several years now. He stated that there are a multitude of factors that
Mental Health Nursing Case Study 6

have been contributing to his depression. These factors made him feel as though he needed to be

institutionalized for a period of time to prevent hurting himself. The patient also presented to the

emergency department with suicidal ideations, which is not the same as suicidal intent. Suicidal

ideation is “thoughts of serving as the agent of one’s own death. Suicidal ideations may very in

seriousness depending on the specificity of suicide plans”. (Rayan, 2017, p. 63) While suicidal

intent is “subjective expectations and desire for a self-destructive act to end in death”. (Rayan,

2017, p. 63) Depression has a wide array signs and symptoms depending on the severity of the

depression. Upon admission ZW was experiencing feelings of sadness, difficulty experiencing

pleasure in activity, slumped posture, verbalization of his life failures and regrets, low energy

levels, sleep disturbances, and difficulty concentrating. These symptoms are consisted with

moderate depression. (Townsend, 2015, p. 474)

Stressors and Behaviors Precipitating Hospitalization

ZW stated that there were several different factors that contributed to the hospitalization.

The stressor that has caused the most problems in the patient’s life is that he estranged from his

daughter. He has tried several times to reestablish a connection, but it has been hard due to his

history of drug use. The drug use is another stressor that has caused a lot of problems in his life.

It caused a lot of his family members to become estranged from him due to him stealing items

from their houses to pay for his drug habit. These were long term factors that have been a

disruption in the patient’s life for several years. The factor that lead to the hospitalization is

breaking up with his current girlfriend. Not only was this a stressor in his life, he also lived with

her, so he did not have anywhere to go. These factors lead ZW to feel as though he had no hope

which lead to concern from friends who told him he should seek help.

Patient and Family History of Mental Illness

Mental Health Nursing Case Study 7

ZW has a small history of mental illness in his family, he has a great aunt that was also

diagnosed with depression. He has no other known psychiatric hospitalizations. Though he

admits that he has been trying to deal with this problem outpatient it has not been successful.

Evidence Based Nursing Care and Milieu Activities Experienced

During ZW’s stay in St. Elizabeth’s Mercy Hospital, he was treated with several

evidence-based practice nursing care. He was carefully monitored to ensure his safety and a

trusting nurse to patient was developed. The patient attended several group therapy sessions

every day. These group sessions were designed to educate the patient on coping strategies to help

him deal with the stressors of life. On the day of care the patient attended the two morning group

sessions, which he actively participated in and seemed to get a lot out of. The patient also attends

the group sessions in the afternoon along with cognitive therapy. “Cognitive behavioral therapy

(CBT) has consistently been shown to be effective for depression in a large database of clinical

trials, and patients often prefer psychological treatment to pharmacotherapy”. (Tanoue et al,

2018, p. 218) ZW felt as though the therapy was working and that he was starting to understand

that he is not the only one dealing with these problems. One technique that he is adopting is to

start journaling everyday to cope with the stressors in his life. He has made plans with his ex-

girlfriend to live there while they attempt to work out their relationship. ZW is working on

getting a solid support base together for when he gets out of the hospital. He is also working on

reestablishing a relationship with daughter, which is giving him a lot of hope.

Analysis of Ethnic, Spiritual, and Cultural Influences

ZW is a 32-year-old white male, who was never married, not religious, but does consider

himself to be spiritual. His age, race, and estrangement from his daughter have all put him at risk
Mental Health Nursing Case Study 8

for suicide. He is currently unemployed and does not have any skills in a trade job which adds to

the stress in his life. ZW does not know what he wishes to do for a job and has nothing lined up

at this time.

Evaluation of Patient Outcomes

ZW has not attempted to harm themselves or others during their stay. The patient is

sociable and interacts with other well on the unit, including the staff. He has followed the rules

of the unit and has attended and participated in almost all of the group sessions that have been

held on the unit. ZW has developed several coping strategies to deal with his depression during

his stay on the unit. During this time ZW’s hope has increased, he is sleeping for longer periods

at a time and states that it is a more restful sleep.

Summary of Discharge Plans

ZW will be discharged once the staff medical has set up his appointments for outpatient

therapy. He will be continuing his pharmacological treatment with an SSRI anti-depressant drug.

The patient plans on moving back in with his former girlfriend, who is also one of his support

people. He will use her, some friends, and the bus to get to all of his outpatient appointments.

Prioritized List of All Nursing Diagnoses

Using Betty J. Ackley and Gail B. Ladwig’s Nursing Diagnosis Handbook: An Evidence-

Based Guide to Planning Care; the following nursing diagnoses were made:

1. Risk for suicide related to the patient’s medical diagnosis of Major Depressive Disorder

as manifested by the patient’s suicidal ideations.

Mental Health Nursing Case Study 9

2. Safety risk related to the patient’s suicidal ideations as manifested by the patient having

a plan for suicide and a means to carry out that plan.

3. Insomnia related to diagnosis of Major Depressive Disorder as manifested by the patient

stating they only sleep about four hours a night.

4. Anxiety related to diagnosis of Major Depressive Disorder as manifested by patient

saying they struggle to make difficult decisions and is unable to set aside worry.

5. Chronic low self-esteem related to repeated unmet expectations as manifested by the

patient stating that this is not where he expected to be in his life.

6. Ineffective hygiene habits related to patient low energy level as manifested by the

patient stating they want to stay in bed most of the day and do not have the energy to do

much else.

7. Self-neglect related to depression as manifested by patient stating before arriving at the

hospital, he had trouble eating and maintaining body weight.

8. Ineffective coping mechanisms related to the patient’s suicidal ideations as manifested

by patient stating life stressors lead to the suicidal ideations.

9. Powerlessness related to pattern of hopelessness as manifested by patient saying that he

felt hopeless and powerless before hospitalization.

10. Readiness for enhanced hope related to chronic mental illness as manifested by the

client expressing a desire to enhance personal relationships with others.

Conclusion

In conclusion, ZW has made great strides getting his depression under control. He has a

better understanding of how the disease affects him and is developing coping strategies to better

control it. His lab results and general assessment all came back normal and indicates the patient
Mental Health Nursing Case Study 10

is in good health. ZW feels that the medication is working for him and stated he is satisfied with

his treatment. Overall, he is satisfied with his treatment and is hopeful that he will be able to

successfully manage his mental illness.

References

McConnell, V. L., Carter, S. L., & Patterson, K. (2019). Major Depressive Disorder: Treatment-

Resistant Depression and Augmentation of Other Medication Classes. CNE Series, 28(4),

251–256.
Mental Health Nursing Case Study 11

Rayan, A. (2017). Suicide Risk Assessment and Management for Adults with Major Depressive

Disorder. International Journal of Nursing and Health Science, 4(6), 63–70.

Tanoue, H., Yoshinaga, N., Kato, S., Naono-Nagatomo, K., Ishida, Y., & Shiraishi, Y. (2018).

Nurse-led group cognitive behavioral therapy for major depressive disorder amoung

adults in Japan: preliminary single-group study. International Journal of Nursing

Sciences, 218–222.

Townsend, M. C. (2015). Psychiatric mental health nursing: concepts of care in evidence-based

practice (8th ed.). Philadelphiaf, PA: F.A. Davis Company.