Running Head: Mental Health Case Study 1

Madison Mistovich

Psychiatric Mental Health Case Study

Youngstown State University

October 2, 2018

Abstract
Running Head: Mental Health Case Study 2

This case study is focused on a patient in Trumbull Memorial Hospital that was admitted

with bipolar 1 disorder with psychiatric features. This paper will describe the experience the pa-

tient went through that brought her to the psychiatric unit. The paper will be based on the infor-

mation received from the patient herself and what was found on her chart. The psychiatric diag-

nosis will be explained along with other diagnoses related to the patient or diagnoses the patient

has been hospitalized with previously. These diagnoses will be described with expected out-

comes and compare it to the patients personal experience. Precipitating factors such as stressors,

patient and family history of mental illness, coping skills, and ethnic, spiritual and cultural influ-

ences will also be mentioned to help shape the emotional state the patient was in before admis-

sion. Treatment such as medications and milieu therapy will be discussed.

Objective Data
Running Head: Mental Health Case Study 3

F.S. is a 47 year old Caucasian female that was admitted to the psychiatric unit in Trum-

bull Memorial on September 11, 2018. The patient was at a softball game where she got irritated

and started yelling at the kids playing. A parent decided to confront her which resulted in the pa-

tient attacking the parent. The police took her away and brought her the the emergency room

where they pink slipped her. Patient was agitated, paranoid, and yelling when she was admitted

into the ER. The patient was repeatedly stating,“they are going to poison me!”. Once the patient

was transferred to the psychiatric unit she isolated herself, had a stoic expression, did not answer

questions, and remained paranoid about what the nurses would do to her. The week after admis-

sion on November 18, 2018 was the date of care with the patient. After a week the patient has

calmed down. She was attending and participating in groups. Although she still had a stoic ex-

pression, she answered questions and was comfortable discussing her life story and her current

illness. Sometimes it was difficult to understand her due to her mumbling and randomly switch-

ing topics. She made eye contact while talking but would get distracted with her surroundings

such as others on the unit.

The primary reason for seeking care is a diagnosis of bipolar disorder with psychotic fea-

tures. She has been diagnosed with bipolar 1 disorder, anxiety, and borderline intellectual func-

tioning in previous hospitalizations. She was taking Seroquel 200mg, an antipsychotic, for her

bipolar 1 disorder. For 2 months prior her hospitalization she stopped taking her Seroquel caus-

ing her to become manic and attack the parent. She is still on Seroquel on the psychiatric unit

along with Depakote 500mg, an anticonvulsant, for her mania. This medication lower the manic

phase in bipolar disorder so her “highs” will not be too high and the drop to her “lows” would

not be as dramatic. Haldol 5mg, an antipsychotic, is given as needed for agitation and Vistaril 50

mg, an anxiolytic or antihistamine, is given as needed for anxiety. Her chart stated that she
Running Head: Mental Health Case Study 4

abused benzodiazepines with no record of it being prescribed to her. The patient has trouble fall-

ing asleep so Trazodone HCL 50mg, an antidepressant, is given to help her sleep.

Expected and Common Behaviors with Patients with Bipolar Disorder

Bipolar Disorder is a chronic illness that can severely affect someone physically and

mentally. Someone with BD experiences episodes of manic or depressive symptoms (McCor-

mick, 2015). There are two different types of bipolar. The first one has the highs (mania) and the

lows (depression) whereas the second one is similar but the manic symptoms are less severe de-

scribed as hypomania. F.S. is a prime example on what is different between mania and hypoma-

nia, mania can cause the patient to receive psychotic features which gets the patient hospitalized

(McCormick, 2015).

According to McCormick (2015), the manic phase is when the patient gets a burst of en-

ergy and becomes agitated easily. This phase is individualized but can last at least for one week.

This patient has a fast thought process which include rapid speaking and having the need to do

risky things, this increase energy can cause lack of sleep. Their emotions are heightened so if

they are happy they are abnormally happy. In result, the mixture of increased thought process,

heightened emotions, and lack of sleep can impair the thought process creating delusions or even

hallucinations. F.S was going through this phase when admitted. Being off her medication for 2

months caused her to experience full mania causing to impair her judgement. Her manic phase

caused her to have delusions and paranoia.

The article describes depressive episode as a period an individual experiences that in-

clude a lost of interest in anything and refuses to participate for over a two week period. This

phase is individualized so it might be a little more difficult to spot. Some people experience

sleeping too much (hypersomnia) or difficulty sleeping (insomnia) and weight loss or weight
Running Head: Mental Health Case Study 5

gain. These symptoms can cause other symptoms such as fatigue, lost of interest, lack of focus or

can even cause more severe symptoms such as feeling worthless and suicidal ideation. This

phase can also impair the thought process.

Misdiagnosing, late diagnosis, and under-treatment are common with this mental illness

due to the complexity with diagnosing someone with a bipolar disorder. It is complicated to di-

agnose because these patients have similar characteristics as other personality and psychiatric

disorders such as depression and schizophrenia. Comorbidity is often seen with these patients re-

sulting in a mixture of medications such as antipsychotics so every symptom can be managed

(Hilty, 2006). Medication incoherence is one of the main causes of relapsing.

On the day of care the patient did not show either of these phases. She was more relaxed

and back to reality. She no longer believed the nurses were going to poison her. F.S. was aware

why she was there and that she needed help. She had no suicidal ideation or showing any signs

of feeling defeated or worthless.

Stressors and Behaviors that Precipitated Current Hospitalization

Prior to hospitalization F.S. was unemployed and living with her boyfriend of nine years.

Hilty, 2006 states that there is a higher rate of bipolar disorder in individuals that are unmarried.

She had many jobs throughout the years but none of them were able to stick. She got sick of the

place. When she gets out the hospital she wants to look for jobs so it can keep her busy. Two

months prior to hospitalization she stopped taking her antipsychotic medications. Her boyfriend

reported that she started to get paranoid and accuse him of cheating multiple times. She experi-

enced jealousy paranoia and took it out on her boyfriend. She was irritable but it never processed

in her mind that she needs to take her medications. On the hospital chart it stated that she abused

benzodiazepines to try to self-medicate herself with her anxiety and agitation she was feeling.
Running Head: Mental Health Case Study 6

Patient and Family History of Mental Illness

Many studies show the significance a parent with mental illness has on the child. F.S.

falls into this category due to her mother being diagnosed with bipolar disorder. The patient also

reports the other family members in her family experience something similar. F.S mentions she

was diagnosed with bipolar disorder a long a she remembers. Hilty, 2006 describes the correla-

tion between bipolar disorder and genetics as unknown. He also mentioned that 2.9 to 14.5 per-

cent of people with family history of bipolar disorder are at morbid risk.

Nursing Care and Milieu Activities

Due to her attacking a parent at the game precautions were put in place so she did not

harm others while being there. The nurses gave an injection of Haldol when she was agitated and

consistency with the other medications started working after 48 hours. The nurses checked on

her every 15 minutes to make sure she does not harm self or others.

There are several ways that milieu is present. There are plants in several places to supply

more oxygen and the presence reminds them of outside. F.S. gave me a tour of the floor and

showed me all of the plants. The environment was quiet and free from anything that can be

turned into a weapon. There are multiple therapy groups that occur throughout the day with spe-

cific topics. The topics challenge the patient’s to think about alternative ways to deal with certain

stressors instead of going back to old habits. They also provide activities to distract the patients

such as drawing or coloring. The nurses also give the patients privacy in their own room and do

not demand participation but encourages it.

In the article “Resilience concepts in psychiatry demonstrated with bipolar disorder”, fo-

cuses on resilience or the positive adaptation to stressors. This is also called “engineering resi-

dence” when trying to teach people with bipolar disorder ways to cope with stressors and bounce
Running Head: Mental Health Case Study 7

back from events that shift one’s life. Medication and a form of therapy are commonly used to

help people with this disorder. Examples of therapy are cognitive therapy, psychosocial therapy

and exercise (Angeler, 2018).

On the day of care, there were two psychosocial groups that I was able to attend to with

the patient. The focus in the first group was effective coping skills and the second one was spirit-

uality spirituality. Effective coping skills taught the patients that maybe how they handled certain

situations and relationships might of not been the best way and that can be why they are in the

hospital. We allow the patients to voice their opinions if they are willing. Sometimes listening to

what others go through can help an individual to open up also. The second one was spirituality

and it was not about one spiritual beliefs but that in any spiritual belief that they may have, if

they get more involved it can help them through their dark times. We offered different groups

outside of the hospital so when they return home they can continue getting support so they have

a less chance of relapsing. During group we sit in a circle with everyone side by side to provide a

more open environment. The nurses and social workers talked with calm voices and did not show

any judgement.

F.S. attended to both of these groups and participated. She was a little shy and it was dif-

ficult to hear her voice but she voiced her experience without anyone telling her to do so. She

even recalled something from an earlier group and connected it with what she was hearing in that

group.

Ethnic, Spiritual, and Cultural Differences

F.S. does not categorize herself with any specific ethnic or cultural groups. She does not

follow any traditions and doesn’t know entirely what she is when it comes to her ethnicity. She

just says she is several things but doesn’t describe herself as one ethnic group other than being
Running Head: Mental Health Case Study 8

caucasian. She characterizes herself as being a christian and found it hard before to attend church

but would like to start going . Her reasoning of not attending before was that she did not want to

wake up really early on Sundays to go.

Patient Outcomes Related To Care

Patient is no longer agitated or irritated. Boyfriend notes that “she is getting back to her

normal self”. Her jealousy issues and paranoia have diminished. She does not seem too low (de-

pressive episode), experiencing worthlessness, or suicidal ideation. But, she was constantly

pointing out the deaths that were happening around her and this includes people that she did not

know. She did not have too much energy or making risky decisions (manic episode). She was co-

operative, aware of her surroundings, talking to her boyfriend on the phone so she had a comfort

of knowing she had support, and she stated that she was “relaxed”. She did mention some stories

that were not true or sugar coated the truth showing me that she was embarrassed on how she got

to that point. She mentioned her having a panic attack while watching a soccer game because she

was off her medication. She did not explain the whole story even though I did ask open-ended

questions to find out what else happened. She also said that she did not abuse drugs and then I

noticed on her chart that she had.

Discharge Plans

Patient will be leaving with her boyfriend. Before discharge teach patient and boyfriend

to watch for symptoms such as difficulty sleeping, eating more than usual, feeling dizzy, having

trouble managing bipolar disorder, or if the patient has suicidal ideation. Call health care pro-

vider or psychiatrist. Stress to patient how important it is to keep up with their medication and to

try to stay out of stressful situations. Educate patient about the support groups in the area that can

help her manage her disorder so she can have less of a chance of relapse.
Running Head: Mental Health Case Study 9

Nursing Diagnoses

Risk for suicide related to mood alteration as evidenced by frequently agitated, risk for

violence related to impulsivity as evidenced by delusional thinking, risk for injury related to ex-

treme hyperactivity/physical agitation as evidenced by impaired judgement, ineffective individ-

ual coping related to ineffective problem-solving skills as evidenced by extremely poor judge-

ment, and disturbed sleep pattern related to hyperactivity as evidenced by restlessness, chronic

low self-esteem related to anxiety as evidenced by social withdrawal.

Potential Nursing Diagnoses

Self-care deficit related to perceptual or cognitive impairment as evidenced by inability to

meet basic needs and impaired social interaction related to disturbed thought process as evi-

denced by increase manic behaviors in a highly stimulated environment

Work Cited

Angeler, D. G., Allen, C. R., & Persson, M. (2018). Resilience concepts in psychiatry

demonstrated with bipolar disorder. International Journal of Bipolar Disorders,

6(1). doi: 10.1186/s40345-017-0112-6

Hilty, D. M., Leamon, M. H., Lim, R. F., Kelly, R. H., & Hales, R. E. (2006). A Review of

Bipolar Disorder in Adults. Psychiatry (Edgmont), 3(9), 43–55.

Mccormick, U., Murray, B., & Mcnew, B. (2015). Diagnosis and treatment of patients with

bipolar disorder: A review for advanced practice nurses. Journal of the American

Association of Nurse Practitioners, 27(9), 530-542.

Running Head: Mental Health Case Study 10