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Psychiatric Mental Health Comprehensive Case Study
Mackenzie Larch
James and Coralie Centofanti School of Nursing, Youngstown State University
NURS 4842L: Mental Health Nursing Lab
Mrs. Phyllis DeFiore-Golden
March 31, 2023
MENTAL HEALTH COMPREHENSIVE CASE STUDY 2
Abstract
ML is a 23-year-old male patient admitted to the inpatient psychiatric unit following a manic
episode where he was feeling homicidal towards the other patients in his rehab facility. ML
states he was tired of others “talking about him” and felt like he was on the verge of having a
mental breakdown. He has a mental health diagnosis of severe manic bipolar 1 disorder with
psychotic behavior and Amphetamine abuse. He also experiences command auditory
hallucinations and delusions. With medication treatments including antipsychotics and
anticonvulsants, and psychotherapy for anger management issues, the symptoms have become
more manageable, and ML is beginning to near a functioning level of daily living and
communication. Nursing care provided on the unit is focused on increasing socialization with
others and symptom management through pharmacologic methods, group therapy, and individual
therapy sessions.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 3
Bipolar Disorder
Objective Data
Patient Identifier: ML
Age: 23
Sex: Male
Date of Admission: March 15, 2023
Date of Care: March 17, 2023
Psychiatric Diagnosis: Severe manic bipolar 1 disorder w/ psychotic behavior
Other Diagnose: Amphetamine abuse, Anxiety, Depression, Drug overdose, Multiple suicide
attempts, Self-harming.
Behaviors on Admission: ML was expressing homicidal ideations towards the other patients at
his rehab facility. Patient manic and was having feelings of a potential mental breakdown upon
admission. He was having auditory command hallucinations telling him others were “talking
about him.” ML also expressed desire for new rehab placement upon discharge to one that can
“care for his psychiatric needs and addiction.”
Behaviors on Day of Care: ML was pleasant and cooperative and willing to speak openly.
Patient did participate in the group therapy my classmates and I led after asking him to attend.
Per the nurse, ML was having severe social anxiety since admission. However, after introducing
myself, he seemed very willing to sit in the common area and talk to me. ML was not actively
having any hallucinations or delusions. He expressed eagerness and readiness to be discharged
home with his “baby mom.” During our conversation, ML commonly showed flight of ideas,
associative looseness, and circumstantiality. He was very euphoric and jumped from thought to
thought. ML had a short attention span and would answer my questions with very short
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responses, then go off on tangents. He was able to answer appropriately and was oriented to
person, place, time, and situation. He was also very restless, constantly changing positions, and
shaking his leg vigorously. On occasion, he would show symptoms of inappropriate sexual
behavior towards me, and I had to redirect the topic of conversation to him and his life.
Safety and Security Measures: During inpatient admission, the patient was not permitted off
the unit. He was placed in a gown and pants with no strings. Any hazardous items including
shoelaces, razors, pencils/pens, and electronic cords were not permitted on the unit. Patients had
to use markers to write and draw with. Medications were administered to the patient by the med
nurse, who also was responsible for ensuring they swallowed their meds. Bathroom doors were
slanted, and bedroom doors had rounded edges to prevent suicide attempts.
Laboratory Results:
Lab Value Result
Glucose 128
AST 15
ALT 29
RBC 5.6
Hbg/Hct 15.9 / 48.0
WBC 12.2
BUN/Cr. 11 / 0.6
QTc 406
Toxicology Negative
Psychiatric Medications:
Generic Name Trade Name Class/Category Dose/Frequency Reasoning
divalproex Depakote DR Anticonvulsant 500 mg Q12 Mood
hours stabilization
insulin lispro Humalog SubQ Insulin 0-4 units AC & Diabetic control
HS
metformin Glucophage Antidiabetic 1,000mg daily Diabetic control
risperidone Risperdal Antipsychotic 1mg BID Mood
stabilization
MENTAL HEALTH COMPREHENSIVE CASE STUDY 5
Summary of Psychiatric Diagnosis
In an academic journal published by MD, George Guess, exploring an acute case of
mania in a bipolar patient, he explains the psychiatric diagnosis as follows:
Mania, or bipolar 1 disorder, is a psychiatric disorder characterized by an
elevated, expansive, or irritable mood of at least 4-7 days duration, plus at least three or
four of the following symptoms:1. Inflated self-esteem or grandiosity 2. Decreased need
for sleep 3. Loquacity or pressured speech 4. Flight of ideas or the feeling that one’s
thoughts are racing 5. Distractibility 6. Increase in goal-directed activity, whether social,
work-related, or sexual, or psychomotor agitation 7. Excessive involvement in
pleasurable activities that could have painful consequences (e.g., excessive spending,
sexual indiscretions, foolish investments).
Additionally, the symptoms do not qualify for consideration as a mixed episode;
the psychological disturbance is severe enough to substantially impair occupational
and/or social functioning, require hospitalization, or manifest psychotic features; and,
finally, the disorder is not caused by substance abuse, whether recreational or
prescription, nor by a medical condition (p. 22).
It’s important to remember that to diagnose a patient with bipolar disorder, they must
have mood swings, or a “cycle,” between profound depression to extreme euphoria (mania) with
intervening periods of normalcy. Patients diagnosed will also commonly have delusions or
hallucinations (Videbeck, 2017, p. 698).
There are officially five types of bipolar disorders. A bipolar 1 patient lives day to day in
the manic phase, and when their mood swifts to the opposite spectrum it is considered a “mild”
form of depression. Most of the patients’ problems will arise during their manic phase. Mania
MENTAL HEALTH COMPREHENSIVE CASE STUDY 6
can be categorized by its degree of severity into three different stages. Stage two is considered
“acute mania” which is most fitting for my patient. It is marked by impairment in functioning,
typically requiring hospitalization. Symptoms of acute mania include elation and euphoric
emotions, flight of ideas, accelerated or pressured speech, hallucination and delusions, excessive
psychomotor activity, social and sexual inhibition, little need for sleep, constantly moving, can
forget to eat, lack of impulse control, and commonly are the monopolizes in group therapy
settings. (Videbeck, 2017, p. 715-716).
Once diagnosed with bipolar disorder, there are a couple options for treatment plans. We
can use different forms of therapy including individual psychotherapy, group therapy, family
therapy, or cognitive therapy. Medications used to manage bipolar disorder include mood
stabilizers such as Lithium carbonate, which is considered the “gold standard treatment,”
anticonvulsants such as Depakote, and antipsychotics such as Risperidone, Seroquel, or Geodon.
If patients do not tolerate or respond to medications, our last option would be electroconvulsive
therapy, which helps treat mania by triggering a grand mal seizure (Videbeck, 2017, p. 674-676).
Identification of Stressors and Behaviors Precipitating Current Hospitalization
Prior to admission, ML was in rehab for noncompliance with his medications beginning
in January of this year. He was working as a carpenter at the time, however, that stopped shortly
after stopping his meds. ML went to rehab about a week prior to being hospitalized, where he
also became one week clean of Amphetamines. He stated he stopped taking his meds because he
did not like the way they made him feel. Since the age of eighteen, he has had numerous
occurrences of noncompliance with his treatment plan. Within the last three years, ML has lost
his dad, his grandfather, and a newborn prior to the birth. Upon admission, ML was suffering
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from auditory hallucinations. He also stated he was from the Cleveland area and now was relying
on his “baby mom” for a place to stay during his initial recovery phase.
Patient and Family History of Mental Illness
ML stated that he was diagnosed with bipolar at the age of six due to his constant
euphoric and manic behavior mixed with his hyperactivity. When asked what he did specially
that made him different from other kids, the only explanation he could provide me with was
“hitting people in the back of the knees with a baseball bat.” He then proceeded to laugh about it.
ML also disclosed he first tried meth when he was eight years old after stealing it from his sister.
Along with bipolar 1, ML also suffers from anxiety, depression, drug and alcohol abuse, suicidal
ideations and attempts, and self-harming. When reviewing his chart, it stated that ML has shot
himself six different times and hung himself ten different times.
Both his mother and father suffered from bipolar disorder, schizophrenia, and depression.
ML stated he has six other siblings; however, he was unsure if any of them suffered from a
mental illness.
Psychiatric Evidence-Based Nursing Care Provided
During his stay on the behavioral health inpatient unit, ML received care from the mental
health staff, consisting of a designated RN and LPN med nurse for each shift, a social worker, a
therapist who led group therapy and one-on-one therapy, a psychiatrist, and their Nurse
Practitioner. It was important for all members of ML’s care team to develop a good, strong
repour with him, but specifically his nurse. Any questions or concerns that ML had, were to be
directed to the nurse first. From there, his nurse would use the nursing process to assess,
MENTAL HEALTH COMPREHENSIVE CASE STUDY 8
diagnose, plan, implement, and evaluate ML daily. The med nurse was responsible solely for the
administration and explanation of any prescribed or as needed medications.
ML was started on an anticonvulsant, Depakote, and an antipsychotic, Risperdal, both
acting as mood stabilizers to help manage his manic behavior. Upon administering the first dose,
it was important for the med nurse to review what the med’s action was and potential side effects
they may have from it. Depakote has a therapeutic range of 50-125 ug/mL, but toxicity does not
fully take effect until 150ug/mL. It is important to teach the patients potential side effects of
toxicity, including confusion, weakness, headache, and dizziness. It is also important for the med
nurse to teach the patient that Depakote is very hepatoxic so they will need to keep up with their
scheduled lab draws upon discharge. The two big side effects to teach the patient regarding
Risperdal is weight gain and a prolonged QTc. It is important for the med nurse to teach the
patient to call his doctor if he starts having heart palpitations, a seizure, or suddenly faints for no
apparent reason.
Another part of the treatment plan is attending group. ML had no interest in attending the
first two groups. However, after him and I had our conversation, he was more open and
understanding to the idea that attending group benefits him tremendously in his recovery process.
He was able to sit down, listen, and complete the worksheet as asked, however, he started
mimicking actions of a monopolizer, always wanting to talk and voice his opinions or ideas.
Ethnic, Spiritual, and Cultural influences
ML is a Caucasian, single man from a lower-class family. He was self-employed through
carpentry at the beginning of the year but now solely relies on state assistance. When asked
about his spiritual beliefs, he stated he believes in God but did not say if he identified with a
MENTAL HEALTH COMPREHENSIVE CASE STUDY 9
specific religion. He does not attend church or practice any religious practices or beliefs. ML
also disclosed his desire to be with his dad, his grandpa, and his unborn baby boy in heaven one
day.
Evaluation of Patient Outcomes
Some of the outcomes desired for a patient with bipolar disorder include reduction in
suicidal thoughts or self-harming behaviors, improved social and occupational functioning,
improved hygiene care, and remission of co-occurring substance use disorder (Gitlin, 2018, p. 5).
On the day of care, ML admitted to no current suicidal thoughts or ideation. He stated he was
having a good day with no feelings or sadness or depression. He attended one of the three
groups, which was something he had not done the first two days on the unit. ML’s hygiene,
however, was still lacking. His hair was greasy, his gown was inside out and had food spilled all
over the front of it, his teeth were not brushed, and he had an uneven, unkept beard. I asked the
nurse for supplies to set him up for a shower but because of his homicidal ideations, she said she
would take them into his bathroom. To more knowledge, he never showered on the day of care.
Lastly, ML denies any desire to use Amphetamines upon discharge, however, did disclose the
urgency for a drink of alcohol.
Plans for Discharge
ML’s pink slip expires on 3/21. Upon discharged, he will return to Stubbonville where he will
reside with his “baby mom.” He no longer wished to return to the rehab he initially came from.
Instead, he expressed his want to find a rehab that treats both his psychiatric diagnosis and his
addiction. After leaving the inpatient unit, he will be encouraged to admit himself into the
MENTAL HEALTH COMPREHENSIVE CASE STUDY 10
suggested rehab facility located closer to his home, stay compliant with his new medications and
needed lab draws, and refrain from Amphetamine use. Education materials will be provided
upon discharge regarding his medications, possible side effects, and adverse reactions that can
occur from toxicity.
Prioritized Nursing Diagnoses
The following are prioritized nursing diagnoses for ML:
1. Risk for injury related to extreme hyperactivity, increased agitation, or lack of control
over purposeless and potentially injurious movements.
2. Risk for self-directed or other-directed violence related to manic excitement, delusional
thinking, hallucinations, or impulsivity.
3. Imbalanced nutrition less than body requirements related to refusal or inability to sit still
long enough to eat, evidenced by loss of body weight.
4. Disturbed thought process related to biochemical alteration in the brain, evidenced by
delusions of grandeur or persecution, or inaccurate interpretation of the environment.
5. Disturbed sensory perception related to biochemical alterations in the brain or sleep
deprivation, evidenced by auditory or visual hallucinations.
6. Impaired social interactions related to egocentric and narcissistic behavior,
hypersexuality, or impulsivity.
7. Insomnia related to excessive hyperactivity and agitation.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 11
Potential Nursing Diagnoses
1. Ineffective individual coping
2. Ineffective activity planning
3. Impaired verbal communication
4. Ineffective health maintenance
5. Impaired memory
6. Impaired individual resilience
7. Self-care deficit
8. Impaired social interaction
9. Social isolation
10. Interrupted family processes
Conclusion
Bipolar disorder is a complex and diverse diagnosis. The disorder consists of five types
and three stages of mania. It can range from severe depression to severe mania and is
complicated by patients’ noncompliance with medications. ML’s hospitalization was a direct
result of his noncompliance with his medications, along with his Amphetamine and alcohol
abuse. Since being admitted and started on two new medications, ML’s auditory hallucinations
have subsided, and his social anxiety has improved. The goal upon discharge is to find ML a new
rehab facility, expressing the importance of continued medication compliance, and remain drug
and alcohol free to better manage his mania.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 12
References
Gitlin, M. J. (2018). Semantics and expanding the treatment goals in bipolar disorder. Australian
& New Zealand Journal of Psychiatry, 52(1), 89–90.
https://doi-org.eps.cc.ysu.edu/10.1177/0004867417717801.
Guess, G. (2018). An Acute Case of Mania in a Bipolar Patient. American Journal of
Homeopathic Medicine, 111, 22–24.
Videbeck, S. L. (2017). Psychiatric - Mental Health Nursing Eighth Edition. Wolters Kluwer.
