1
MENTAL HEALTH CASE STUDY
Mental Health Nursing Case Study
Brian Nash
Youngstown State University
2
MENTAL HEALTH CASE STUDY
Abstract
The completion of a successful and legitimate case study requires the collection of
objective data from the subject to better understand the situation that lead them to an inpatient
psychiatric hospital stay. It is imperative to have a baseline understanding of the psychiatric
diagnosis to lend to the ability to gather important data effectively. The subject of the study in
this case suffered from bipolar disorder which led to periods of crippling depression and the
eventually led to the desire to take his own life. During the interview I was able to gather a
condensed family history which is important because many mental illnesses are genetic in nature.
A safe environment or milieu is imperative for all patients on a psychiatric unit and especially
when the client is in a state of potential suicidal behavior. The use of nursing diagnosis allow
nurses to assess and implement a plan of care for the patient for the length of stay.
3
MENTAL HEALTH CASE STUDY
Objective Data
The patient presented to Trumbull Memorial Hospital's emergency department on
November 11th, 2017. Upon arrival the patient told the staff that he had planned to commit
suicide earlier and that he was currently withdrawing from the use of heroin. Due to his claims of
suicidal ideation with a plan he was then admitted to the psychiatric unit for observation. Upon
claiming suicidal ideation, patients are admitted for a three day hold in which they are unable to
leave, however in this case the patient did not want to leave until he was feeling better. Upon
evaluation he was diagnosed with the following psychiatric diagnosis; Bipolar type 2 major
depressive, Cluster B personality disorder (borderline), and generalized anxiety disorder. The
only medical diagnosis was heroin dependence. All important labs were within normal ranges
including thyroid stimulating hormone which is drawn to rule out biologic causes of depression.
The only other lab value worth noting was Valproic Acid levels which were 28.8, which is low
and would normally indicate non-adherence to drug regiment; in this case the drug had just been
started and low levels were expected.
The gathering of data occurred on the day of care when we received our morning report
from the charge nurse, Debbie. The date of care was the morning of the fifth day of the patient's
admission. Report included the information that he was a 27 year old male with a history of
bipolar disorder and that he was very quiet and excessively sad. She suggested that he may have
a developmental delay as he was social maladjusted and spent most of his time completing
puzzles rather than socializing. She relayed that he had been attending groups, and stating a score
of 9/10 depression and 5/10 anxiety.
4
MENTAL HEALTH CASE STUDY
I approached my patient with a degree of trepidation, I was wanted to be careful not to
upset him any further and so after allowing him to eat his breakfast I asked if it would okay to sit
and speak to him while we both worked on a puzzle together since that is what I was told he
enjoyed doing. The fact that he was preferring to be alone and working on puzzles also indicated
moderate depression as it exhibits social isolation with focus on self (Townsend 2015). I sat
down and introduced myself and stated why I was there and asked him if he had any objections
to me asking him some fairly personal questions, to which he consented. One thing I noticed
straight away was that he made eye contact for only a very short period of time which is an
indicator of social maladjustment. He was dressed appropriately for someone of his age,
although he was careless in his actual appearance and his personal hygiene was adequate. He sat
to my left and was slouching throughout the entire encounter. When speaking he did so very
quietly and with little to no tone changes, and with little emotion. It was clear the patient was
exhibiting a flat affect a common and expected sign of bipolar type 2 (Townsend 2015).
I opened the conversation by asking how he was feeling that day to which he replied
"good", and I then probed into why he was there. He gave me an account of how he had been
driving to his mother's house to get a gun and shoot himself in the head. It was at that point that
he realized he need to be admitted to the hospital because he did not truly want to die. I listened
to him the entire time trying to remain objective and judgment free. I asked what events had led
him to feel as though he wanted to kill himself and he said that he was recently let go from his
job and as a result was kick out of his apartment where he had been living with some friends for
a few months. I recognized at this point that my patient may have had a personality disorder that
5
MENTAL HEALTH CASE STUDY
we discussed in class, borderline personality. Planning suicide and then seeking help before the
plan go into full effect is an indicator as is the manipulation of people around you to cause drama
and create unrest. I suspect that is what his chart was referring to when I found he was diagnosed
with cluster "B" personality disorder. He was clearly very upset by these developments in his life
and with good reasons these are life altering and jarring events with someone of sound mind and
adequate resources, unfortunately for this patient he did not have the luxury of these resources.
My patient was only on several scheduled medications of my day of care, including;
valproic acid (Depakote) 250 mg/BID orally, sertraline (Zoloft) 200mg/daily orally and clonidine
(Catapres) 0.1mg/q4hrs orally, quetiapine (Seroquel) 200mg/daily orally, Trazodone 200mg/TID
orally. The list of PRN medications included; haloperidol (Haldol) 5mg/IM during acute
agitation episodes and hydroxyzine (Vistaril) 50mg/IM for agitation. Valproic acid is an anti-
seizure medicine that is used off label for mood stabilization for patients with bipolar disorder
and is especially usually in the mania phase. Sertraline is a SSRI which works in the brain to
help regulate the levels of serotonin and works to improve symptoms of depression. Clonidine is
a sedative and anti-hypertensive drug which in this case is being used to treat the physical and
mental symptoms associated with withdrawal. Quetiapine is an anti-psychotic medication that is
used to treat bipolar disorder (manic depression). Lastly Trazodone is an antidepressant that is
used primarily in major depressive disorder.
Summarize the Psychiatric Diagnoses and Expected/Common Behaviors
"Bipolar II disorder is characterized by recurrent bouts of major depression with episodic
occurrence of hypomania. The individual who is assigned the diagnosis may present with
symptoms (or history) of depression or hypomania. The client has never experienced a full manic
episode. The diagnosis may specify whether the current or most recent episode is hypomanic,
6
MENTAL HEALTH CASE STUDY
depressed, or with mixed features. If the current syndrome is a major depressive, psychotic or
catatonic features may also be noted" (Townsend, 2015. pg 501). Those afflicted with bipolar
disorder type 2 have mood swings that tend to remain on the depressive side with occasional flair
ups of a lesser form of manic episodes. Someone with this disease will exhibit signs of moderate
to severe depression with symptoms potentially including; feelings of utter despair,
worthlessness, slowed thinking processes, difficulty concentrating, anorexia or overeating,
insomnia, sleep disturbances, generally portraying pessimism and negativism, verbalizations and
behavior reflecting suicidal ideation (Townsend, 2015.)
Indentify the Stressors and Behaviors that Precipitated Current Hospitalization
There was a cacophony of events that led to the hospitalization of my patient. The most
obvious and blunt reason was his suicidal ideation with a plan, which is what led him into the
emergency department that day. He had several big stressors that lead to this hospitalization, the
loss of his job and his eviction from his apartment by his friends. The latter event served as a
devastating blow because not only did he lose a place to live, but he also says he lost those
friends with which he was living. The event that caused him to lose his job was when they asked
him to take on more routes at work and he agreed, but eventually the stress of taking on more
work caught up to him and he had what he described as a nervous breakdown and required him
to be admitted to the same facility earlier this year. These situations are a reason that many
people with bipolar disorder are unable to hold longer term jobs (O’Donnell et al., 2017). Due to
the loss of that job and thus the income it provided he was no longer able to afford rent and that
was a issue for his roommates. The actual reasons for his eviction at the hands of his friends is
actually unknown because he did not want to discuss it. The patient did mention that his
7
MENTAL HEALTH CASE STUDY
roommates were also doing heroin in large amounts and that he thought that perhaps it was for
the best since he believed them to be enabling him.
Discuss Patient and Family History of Mental Illness
I inquired into the patients family history to get a better understand of his illness.
Unsurprisingly, his mother had been diagnosed with generalized anxiety disorder which he said
she has been medication for. When I asked about his father he said his dad does not discuss his
emotions with him and he has never complained of anything being wrong with him. The family
history in the chart only mentioned peripheral vascular circulation as a medical problem. The
patients sister also suffers from depression which she is also medicated for. The patient told me
that growing up he and his sister got along well and used to discuss their issues with one another,
but since she is out of state now they don't talk as much which is something I find to be
significant.
Describe the Psychiatric Evidence Based Nursing Care & Milieu Activities Provided
For a patient whom is experiencing suicidal ideation with intent and a plan, there is no
better milieu than the psychiatric nursing unit. On admission the personal belongings of the
patient are screened to ensure nothing of harm can be brought into the patient population as to
protect other patients. They also conduct a cavity search in order to ensure no illicit drugs are
being brought into the unit. The unit itself is designed with no sharp edges, shatterproof glass,
rounded door frames, specially made light posts, and a variety of other safety precautions to
ensure that a patient that is having suicidal thoughts will have a very difficult time trying to take
their own life. It is positively essential for the patient to take an active role in their care and
participate in all therapeutic activities throughout their stay (Freeland et al., 2015). There is a
8
MENTAL HEALTH CASE STUDY
structured schedule posted on the unit and reminders when activities are going to commence
announced over the PA system. There is also several group therapy sessions to be utilized
throughout the day where staff attempt to teach various coping mechanisms, discuss medications,
and offer their assistance in any possible way to assist the patients toward feeling well again. The
overall goal of these interventions are to assist the patient to return to a higher level of daily
functioning in anticipation of discharge.
Analyze Ethnic, Spiritual, and Cultural Influences that Impact the Patient
The client denied and religious and or ethnic affiliation. Culturally it is clear that the
patients struggles to fit in. His use of heroin seems to be a result of hanging out with his friends
and he used that as a negative coping technique. The patient also claimed to struggle where the
other sex is concerned and his attempts to communicate always seem to fail which leads to
anger. Due to the heavy emphasis our society puts on relationships and sex it is clear he is
frustrated and that only further contributes to his depression. I also believe that his coping
mechanism of cutting is another way of seeking attention from others. When I asked him why it
was that he cut he said because people respond to him doing it. This is an example of a learned
behavior that receives attention from others something he clearly desires.
Evaluate the Patient Outcomes Related to Care
To me there are several nursing outcome that must be met before this patient should leave
the facility. Obviously his depression needs better control and that is why they started him on
valproic acid, a therapeutic level should be met and then evaluate the patients mood before going
any further. Additionally this young man would benefit from someone to talk to, and it was a
role I felt very comfortable fulfilling. It appears to me as thought he is wrapped up in his own
9
MENTAL HEALTH CASE STUDY
head and he needs a medium for him to express himself. Positive reinforcement and sense of
purpose should also be established; perhaps a token economy where he is rewarded for
participating in group, or simply a compliment when he takes a shower and dresses appropriately
(“Bipolar Disorder,” 2017). Lastly teaching the usage of coping techniques and positive in nature
is crucial as he was implementing a vast array of negative coping techniques; and he would
certainly benefit from this kind of instruction.
Summarize the Plans for Discharge
Once a therapeutic level of valproic acid has been reached and he is able to maintain it
(indicating medication program adherence) discharge should be considered. An important aspect
of discharge for this patient would be a living situation that is free of the type of enablers that
lead to unacceptable exacerbations of depression. Ensuring that the gun that the patient was
going to use be locked away where it would be difficult for him to access should also be
established. Should all of these criteria be met the discharge of this patient should go smoothly
and he should be able to return and be a functional member of society once again.
Nursing Diagnoses
Nursing diagnoses are an important part of patient care as they help to identify and care
for problems the patient is likely to encounter. The following are nursing diagnoses which could
apply to the patient that I interviewed. Impaired social interaction related disturbed thought
processes as evidenced by inability to develop satisfying relationships. Ineffective individual
coping related to ineffective problem solving skills as evidenced by destructive behavior toward
self. Risk for injury related to self harm behaviors as evidenced by impaired judgment.
Interrupted family processes related to situational crisis or transition as evidenced by inability to
10
MENTAL HEALTH CASE STUDY
deal with traumatic or crisis experiences constructively. Self-care deficit related to severe anxiety
evidenced by observation or valid report of inability to eat, bathe, toilet, dress, and/or groom self
independently.
11
MENTAL HEALTH CASE STUDY
Works Cited
Ackley, Betty J., and Gail B. Ladwig. Nursing Diagnosis Handbook: an Evidenced-Based Guide
to Planning Care. Elsevier, 2014.
Bipolar Disorder: Implications for Nursing Practice. (2017). ISNA Bulletin, 43(4), 12–15.
Freeland, K. N., Cogdill, B. R., Ross, C. A., Sullivan, C. O., Drayton, S. J., Vandenberg T., A.
M., … Garrison, K. L. (2015). Adherence to evidence-based treatment guidelines for
bipolar depression in an inpatient setting. American Journal of Health-System Pharmacy,
72, S156–S161. https://doi.org/10.2146/sp150023
O’Donnell, L. A., Deldin, P. J., Grogan-Kaylor, A., McInnis, M. G., Weintraub, J., Ryan, K. A.,
… O’Donnell, L. A. (2017). Depression and executive functioning deficits predict poor
occupational functioning in a large longitudinal sample with bipolar disorder. Journal of
Affective Disorders, 215, 135–142. https://doi.org/10.1016/j.jad.2017.03.015
Townsend, M. C. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based
Practice. Philadelphia, PA: F.A. Davis Company, 2015.
