MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Zeina Abdul-Aal

September 29, 2023

Dr. Teresa Peck & Mrs. Phyllis Jean Defiore-Golden

NURS: 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Mental Health Comprehensive Case Study

ABSTRACT

The following case study describes the disease process of a patient with severe manic Bipolar I

disorder as well as the treatments and care provided for the patient. The subject of the case study

is CD, a 39-year-old African-American male who presented to the emergency room during a

manic episode. He has also recently been diagnosed with schizophrenia and is dealing with

nicotine withdrawal. Several academic journal articles were used and researched to contribute to

o this case study as well as information provided by the patient and his chart. Nursing care

provided focused on pharmacological therapy, as well as group and individual therapy sessions.

With the proper medications CD’s symptoms are improving and he was taking care of his daily

hygiene and dietary needs.

MENTAL HEALTH COMPREHENSIVE CASE STUDY 3

OBJECTIVE DATA

Patient Identifier: CD

Age: 39

Sex: Male

Date of Admission: September 26, 2023

Date of Care: September 29, 2023

Psychiatric Diagnosis: Severe Manic Bipolar I disorder with psychotic behavior

Other Diagnoses: ADHD, Amphetamine Abuse, Acute Alcoholic Intoxication without

complication, Bipolar Disorder with Psychotic Features, Polysubstance Abuse.

Behaviors on Admission: CD was exhibiting signs of mania and had refused to eat and barely

drank anything for four days. He had stopped taking his medications for an unknown period of

time. He was experiencing paranoia and thought his mother wanted to hurt him. While in the

emergency room, he exhibited more signs of paranoia by thinking the nurses were trying to stab

[Link] was experiencing delusions and paranoia that made him think everyone was attempting

to harm him. He was avoiding everyone’s gaze and was highly distractible. He had poor insight

and poor judgment which was evident by the lack of medication compliance and the self-

medication with Adderall, alcohol, and cannabis. While in the emergency room, he was

exhibiting signs of word salad, pressured speech, and extreme agitation.

Behaviors on Day of Care: On the day of care CD was calm and personable. He was interested

in walking around the floor to clear his head. He was talkative and spoke openly about his life

and why he stopped taking his medicationt. He was still experiencing some paranoia about his

relatives, mainly his mother, and the situation that led him to be hospitalized. Heshared this with

me as well as the Nurse Practioner who was overseeing his care. He was experiencing some
MENTAL HEALTH COMPREHENSIVE CASE STUDY 4

anxiety about talking with his mother and going back to the house where he lives with her after

discharge. He was overall very optimistic and hopeful about the new medication that he was

prescribed and because it is an injection hopeful that it didn’t provide the same side effects as the

medication he was previously on.

Safety and Security Measures: The patient was considered an elopement risk and was not

allowed off the unit. There was safety signage provided, visitor check-ins, and environmental

safety checks that were performed around the clock. All materials that were considered

hazardous were not allowed on the unit, these included things such as shoelaces, sharp objects,

scissors, mirrors, lighters, cell phones, electronics, pens, pencils, and metal utensils. Medication

was administered by a nurse and all of his medications were verified with another nurse to make

sure that the patient was getting the proper medications and dosages.

Laboratory Results:

Lab Value Result

Potassium 3.9

Sodium 136

Glucose 109

TSH 2.470

T4 9.8

Creatinine 1.1

RBC 5.06

WBC 9.3

BUN 9

Toxicology Positive for

amphetamine and
cannabinoid
MENTAL HEALTH COMPREHENSIVE CASE STUDY 5

Alcohol 153 mg/dl on intake

Psychiatric Medication:

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

acetaminophen Tylenol analgesics 650 mg Q6 Mild Pain

hours PRN

benztropine Cogentin Anticholinergic 0.5 mg twice Tremors

antiparkinson daily
agent

Aluminum and Maalox antacids 30 mL PRN Indigestion

magnesium
hydroxide
simethicone

divalproex Depakote Fatty acid 500 mg twice Manic episode

derivative daily
anticonvulsants

haloperidol Haldol Antipsychotic 5 mg Q6 hours agitation

agent PRN

hydroxyzine Vistaril antihistamine 50 mg 3 times anxiety

pamoate daily PRN

risperidone ER Perseris Atypical 120 mg sq every Bipolar disorder

antipsychotic 30 days

thiamine Vitamin B1 vitamin 100 mg daily Anxiety

Nicotine patch Nicoderm Smoking 14 mg patch Smoking

cessation agent daily cessation

melatonin melatonin Minerals and 3 mg nightly sleep

electrolytes PRN

Magnesium Milk of Antacids, 30 mL daily constipation

hydroxide Magnesia laxatives PRN

SUMMARIZE THE PSYCHIATRIC DIAGNOSIS

MENTAL HEALTH COMPREHENSIVE CASE STUDY 6

Bipolar I is a disorder that “involves extreme mood swings from episodes of mania to

episodes of depression.” (Videbeck, 2022, p. 306). During the low, depressed, stages of the

disease, the person may not eat, bathe, or take care of any hygiene needs. The low stage often

imitates a major depressive episode. If a person has not had a manic state yet this low stage will

probably be diagnosed as a Major Depressive Episode. During manic phases, patients are

euphoric, grandiose, energetic, and sleepless. They may exhibit pressured or forced speech, they

also may exhibit poor judgment, poor actions, and rapid thoughts.

“Bipolar disorder ranks second only to major depression as a cause of worldwide

disability. The lifetime risk for bipolar disorder is about 2% in both adults and children.”

(Videbeck, 2022, p. 306). A big risk with Bipolar disorder are thoughts of suicide, men that are

in their late teens and early 20’s are at the highest risk for suicide. This is compounded with

those that already have a history of suicide attempts, alcohol abuse, and drug abuse.

Those with bipolar I disorder go in between major depressive and manic episodes with

some periods of normal behavior. There are different cycles for each mood and a depressive or

manic stage can last for weeks or months before alternating to another stage.

IDENTIFY THE STRESSORS AND BEHAVIORS

Before admission CD was noncompliant with his medications for an unknown period of

time. He is a very educated man with several law degrees and according to the textbook,

“Bipolar disorder occurs almost equally among men and women. It is more common in highly

educated people. Because some people with bipolar illness deny their mania, prevalence rates

may actually be higher than reported.” (Videbeck, 2022, p. 306). He was self-medicating with

Adderall, cannabis, and alcohol because he thought the mixture of cannabis and Adderall
MENTAL HEALTH COMPREHENSIVE CASE STUDY 7

stabilized him, he initially denied drinking but did end up saying that sometimes durin his manic

stages he doesn’t remember what he does. There have been several studies done to see if there is

any correlation between cannabis and improvement with symptoms; “The first patient showed

symptoms of improvement while on olanzapine plus CBD but showed no additional

improvement during CBD monotherapy. The second patient (a 36-year-old woman) had no

symptoms of improvement with any dose of CBD during the trial. Both patients tolerated CBD

very well and no side-effects were reported. These preliminary data suggest that CBD may not

be effective for the manic episode of BAD.” (Zuardi, 2008, 135).

Another stressor that added to his hospitalization was that he moved back home with his

mother and stepfather during the pandemic but wants to move out. He added that the the stress of

being back home might have contributed to his problem since he didn’t want to listen to his

mother and felt like she was micromanaging him. According to the patient’s mother, he had

refused to eat for the previous four days and was exhibiting manic behavior. CD’s mother was

worried about his safety and the safety of others so the police ended up being called to help

subdue the situation. After that he was taken to the hospital for evaluation where they decided to

involuntarily hold him for three days. After the three days hold came to an end he was given the

opportunity to stay voluntarily which he decided to do.

DISCUSS PATIENT AND FAMILY HISTORY OF MENTAL ILLNESS

The patient has no family history from his mother’s side of mental illness. His biological

father has never been in the picture and his family history is unknown. CD has three younger

siblings with no current signs of mental illness, they are all in their late teens and early twenties.

They are all younger than he was when he was initially diagnosed. He was diagnosed with
MENTAL HEALTH COMPREHENSIVE CASE STUDY 8

ADHD as a teen and prescribed Adderall for it. In 2011, at 27, the patient was diagnosed with

Bipolar I disorder due to several reported cases of manic and depressive states spanning a year.

He and his family attributed his earlier symptoms to the stress of work. Most recently at 39, he

was diagnosed as having schizophrenia with several hospitilizations within 2023.

DESCRIBE THE PSYCHIATRIC EVIDENCE-BASED NURSING CARE PROVIDED

Upon admittance to the psychiatric floor, several psychiatric evidence-based nursing care

interventions were provided. When he got there safety precautions were put into place, those

included the removal of watches, shoelaces, anything with a drawstring, smoking paraphernalia,

belts, and other things that could potentially be hazardous. CD was involved with group therapy

that was available on the floor, he was an active listener and was engaged with what everyone

else had to say but didn’t partake in any of the talking unless directly prompted. CD was

involved with private therapy where he was more engaged with his providor. He was encouraged

to walk around the floor to help release some extra energy.

Medical therapy was initiated again when he was admitted. His medications were

changed to risperidone ER due to the fact that it comes in a longer-lasting dose than what he was

previously taking. This was done with the hope that compliance would be adhered to if he had to

take it less often.

ANALYZE ETHNIC, SPIRITUAL, AND CULTURAL INFLUENCES

CD is an African-American, single male from a lower-class family. His mother had him

when she was a teenager and his biological father is not involved. He is a lawyer but is not

currently practicing due to a moving back to Ohio 3 years ago and not taking the Bar exam in
MENTAL HEALTH COMPREHENSIVE CASE STUDY 9

this state yet. He is living with his mother and stepfather and depends financially on them, he

also is using what savings he has left.

When asked about his spiritual beliefs he stated that he believes in God and considers

himself a Christian. He spoke openly about his spirituality and how he wants to start a non-profit

to help those that are underprivileged with housing and food. He also stated that his goal was to

reach out to local churches to see what needs were not being met for those parishners.

EVALUATE THE PATIENT OUTCOMES

Some of the outcomes that are assessed with patients that have Bipolar I disorder are

quality of life, functioning, manic/psychotic symptoms, boxed warnings of medications, and

medical morbidities. One of the outcomes that was partially met during care was control of his

manic/psychotic symptoms. He was no longer exhibiting signs of mania but he was still

exhibiting some signs of paranoia. According to some of the research, “The persistence of

depressive morbidity, despite pharmacological treatment, indicates that achieving an adequate

response for these mood states remains a challenge in BD.” (Fellendorf, 2023, 182.) Quality of

life was also partially met, he was talking about going back to work and wants to start the

process of looking for housing outside of his parent's house when his symptoms became

stabilized. Functionality was met and he was able to meet his basic needs such as showering,

grooming, and feeding himself. Pharmacologically his medication was adjusted and he was

showing a partial outcome of compliance, he was still talking about using Adderall and cannabis

even though the Nurse practitioner warned about how all of these substances might interact with

the medications that he been prescribed.

MENTAL HEALTH COMPREHENSIVE CASE STUDY 10

SUMMARIZE THE PLANS FOR DISCHARGE

The patient will potentially be discharged into his mother's care on Monday, October 2nd.

The plan is that he will be getting assistance at home for the foreseeable future because his

mother is worried about him being by himself while she is at work. This plan will continue until

he is able to take his medication correctly without skipping any doses. Medication compliance

should become easier now since they switched his medication to a monthly injection, risperidone

ER, versus what he was taking previously.

PRIORITIZED LIST OF ALL ACTUAL DIAGNOSES

The following are prioritized diagnoses for CD:

1. Risk for elopement evidenced by patient trying to leave.

2. Disturbed thought processes evidenced by paranoia and manic episode.

3. Anxiety risk as evidenced by patient stating he was nervous about discharge into

mother’s house.

4. Coping risk evidenced by previous noncompliance.

5. Confusion risk evidenced by manic and depressive stages.

6. Dehydration risk as evidenced by not drinking for four days prior to admission.

7. Feeding self care deficit as evidenced by not eating for four days prior to admission.

8. Injury risk as evidenced by mixing different medications.

9. Sleep deprivation as evidenced by manic state.

LIST OF POTENTIAL NURSING DIAGNOSES

The following are potential nursing diagnoses for CD:

MENTAL HEALTH COMPREHENSIVE CASE STUDY 11

1. Risk for suicide

2. Risk of violent behavior

3. Risk for distubed personal identity

4. Impaired verbal communicaction

5. Ineffective health maintenance

6. Self-care deficit

7. Impaired social interaction

8. Risk for injury

9. Risk for physical trauma

10. Risk for wandering

CONCLUSION PARAGRAPH

In conclusion, CD is a very educated man who is suffering from different mental

disorders that were exacerbated by his medication non-compliance. This ended up with the

police being called for assistance because he was manic and paranoid. He ended up being taken

to the ER and then an involuntary hold was placed on him at the Psych facility in St. Elizabeth

Youngstown Hospital. Once he is compliant with his medication a lot of his agitation and

paranoia should subside and he will be able to get back to his day-to-day life.
MENTAL HEALTH COMPREHENSIVE CASE STUDY 12

References

Fellendorf, F., Canoni, E., Paribello, P., Pinna, M., D’Aloja, E., Carucci, S., Pinna, F.,

Reininghaus, E.Z., Carpiniello, B., & Manchia, M. (2023). Treatment of Bipolar Depression A

Review of Observational Studies. Pharmaceuticals, 16, 182. [Link]

8247/16/2/182

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V.,

Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A.

H., & Mansur, R. B. (2020). Bipolar disorders. Lancet (London, England), 396(10265), 1841–

1856. [Link]

Videbeck, S. L. (2022). Lippincott CoursePoint Enhanced for Videbeck's Psychiatric-Mental

Health Nursing (9th ed.). Wolters Kluwer Health.

[Link]

Zuardi, A., Crippa, J., Dursun, S., Morais, S., Vilela, J., Sanches, R., & Hallak, J. (2008).

Cannabidiol was ineffective for manic episode of bipolar affective disorder. Journal of

Psychopharmacology, 24(1), 135–137. [Link]