Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1
Psychiatric Mental Health Comprehensive Case Study
Caitlyn Howe
November 22, 2023
Mrs. Teresa Peck, MSN, RN
NURS 4842L Mental Health Nursing Laboratory
Youngstown State University
MENTAL HEALTH COMPREHENSIVE CASE STUDY 2
Abstract
BR is a 39-year-old female patient admitted to the psychiatric unit after an outburst at her
outpatient therapist office. She has a diagnosis of Bipolar 1 with psychotic features and at the time
of her stay on the unit she is experiencing a manic episode. The nursing care is focused on
stabilization of her moods through pharmacologic means and education on coping mechanisms
through group and individual therapies. The goal is that by getting her back on to her medication
regiment, her symptoms will be better managed, and her moods will be stabilized so that she can
return home.
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Objective Data
Patient identifier BR
Age 39
Sex Female
Date of admission September 10, 2023
Date of care September 12, 2023
Psychiatric diagnosis Bipolar I with psychotic features
Other diagnoses Anxiety and depression
Behaviors on admission BR was brought in from her outpatient therapy office after having an
outburst of anger, which included her yelling and cursing at staff and throwing herself on the
floor. She was screaming that she felt as though “everyone was trying to control her”.
Behaviors on day of care BD was friendly and was very enthusiastic to talk to us. She
participated in the group that started while we were there and participated several times and
stayed to ask questions after group had concluded. BD was displaying signs of being in a manic
episode at the time of her hospitalization. Overall BD was in good spirits but did experience
some occasional lability when speaking to us. She got a bit upset when telling us that she
occasionally heard voices, and she also believed that the TV would talk to her. BD was also
afraid of one of the other patients on the units, as when he walked by, she got out of her chair
and hid behind me and began crying. After he had walked away, she returned to her seat and
began talking the same way she was previously. She also showed flight of ideas, as she would
switch from topics quite quickly. Her mannerisms were exaggerated and was having difficulties
staying still. She also displayed some occasional inappropriate behaviors, saying that she wished
she could “kiss and hug us” a couple of times during our conversation.
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Safety and security measures In the group area, there were multiple staff always present in
different areas of the room. The patient was not permitted off the unit. Items that could be
hazardous, such as pencils, pens, plastic garbage bags, and shoelaces were not permitted on the
unit. The entrance to the unit consists of two doors that could only be opened via keycard by a
staff member, and both doors could not be open at the same time.
Laboratory results
Lab Value Result
Toxicology Positive for
Cannabis
Psychiatric medications
Generic Name Trade Name Class/Category Dose/Frequency Reasoning
Olanzapine Zyprexa Antipsychotic 5 mg BID Bipolar disorder
Sodium Depakote ER Mood Stabilizer 500 mg daily Mania
valproate
Paliperidone Invega Antipsychotic 6 mg daily Psychosis
Clonazepam Klonopin Benzodiazepine 0.5 mg BID Panic disorder
Mirtazapine Remeron Antidepressant 15 mg Depression
Summary of psychiatric diagnosis
Bipolar I is a disorder that involves mood swings that range from manic highs to
depressive lows. The mood swings are episodic and can last from days to weeks or months
depending on that patient’s diagnosis. It is the second ranked mental illness as a cause of
worldwide disability, with major depression being the first (Videbeck, pg 306). Those suffering
from bipolar disorder may be diagnosed with depression until a manic episode can be identified.
There are 3 main types of bipolar disorder, those being bipolar type I, bipolar type II, and bipolar
MENTAL HEALTH COMPREHENSIVE CASE STUDY 5
mixed. In those with mixed bipolar disorder, there are recurrent cycles of mania, normal mood,
and depression. In bipolar II, there are recurrent depressive episodes with at least one episode of
hypomania, which is a less severe manic episode. In bipolar I, the patient maintains a lot of time
in a manic state, with episodes lasting at least a week (Nasim Mousavi, et al. 2021). These manic
episodes can be quite severe, even leading many to need hospitalization.
The diagnosis of bipolar disorder often comes after evidence of a manic episode, which is
most likely to occur in late adolescence to early adulthood. A manic episode is diagnosed with
the following criteria occurring over the course of at least 1 week: incessantly heightened or
agitated mood along with three or more of the following symptoms, “exaggerated self-esteem,
sleeplessness, pressured speech, flight of ideas, reduced ability to filter extraneous stimuli,
distractibility, increased activities, increased energy, and multiple grandiose, high-risk activities
involving poor judgement and severe consequences” (Videbeck, pg 307). These symptoms tend
to escalate quite quickly, then last for a significant amount of time.
When in a depressive episode of bipolar, the symptoms will mimic that of major
depressive disorder. These symptoms include fatigue, feelings of hopelessness, lack of interest in
activities, low self-esteem, difficulties with concentration, and sleep changes. Those with bipolar
are also at an increased risk of suicide, with young men early in the disease process being the
most at risk (Videbeck, 306).
Many individuals with bipolar disorder will experience psychotic symptoms during their
lifetime. These individuals do not quite meet the criteria to be diagnosed with psychosis but
share prevalent symptoms. with two-thirds of patients with bipolar I reporting these
manifestations (Chakrabarti and Singh, 2022). Someone experiencing psychosis has lost touch
with reality, and those with bipolar disorder have delusions and/or hallucinations that are
MENTAL HEALTH COMPREHENSIVE CASE STUDY 6
congruent with their current mood. While these symptoms do not always impact their treatment,
it does create more difficulty with daily functioning.
Identification of stressors and behaviors precipitating current hospitalization
Before her admission, BD was non-compliant with her medications. She also told the ER
staff that she hasn’t been eating because she would forget. She lives at home, but it is unclear if
she lives with anyone else. In her file, it said she lives alone, but she spoke of a roommate that
lives with her. On the day of her admission, she went to her outpatient therapy office where she
became upset at the staff. After throwing herself to the ground and cursing and yelling “why
does everyone want to control me, you can’t control me!”, EMS was called, and she was pink
slipped to the psych unit due to her manic state and it being determined that she was unable to
care for herself.
Patient and family history of mental illness
BR was diagnosed with Bipolar 1 when she was 21 years old after a manic episode that
required hospitalization. Psychotic features were also diagnosed as she has auditory
hallucinations and delusions. She has been hospitalized two other times separate from her current
hospitalization.
BR has one brother who also struggles with depression. Her mother had a diagnosis of
both anxiety and depression, but BR is unsure if anyone else in her family has bipolar 1. She did
not discuss her father.
Psychiatric evidence-based nursing care provided
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While staying on the unit, BR was taken care of by the psychiatric nursing staff. She was
assigned a nurse each shift that she was able to build rapport with to ensure that she felt
comfortable voicing her concerns and asking questions. Each day the nurse would assess her
needs, implement nursing care based on those needs, and evaluate the outcome of the
interventions. The nurse would administer her daily medications, which included two
antipsychotics, an antidepressant, and a mood stabilizer. BR also had a PRN benzodiazepine
prescribed, so the nurse would assess if she needed it should she begin to have a panic attack.
The nurse is aware of all of the uses of her medications, their side effects, and their possible
interactions. The nurse is also aware of the signs and symptoms of neuroleptic malignant
syndrome, which is important because BR is on an antipsychotic medication.
BR was also involved in different group therapies that take place on the unit, which are
useful for her recovery. They helped with exploring emotions, coping skills, and connecting to
resources within her community. The psychiatric unit also keeps its patient on a schedule, which
is helpful to many patients, as making decisions can be stressful and can pull away from that
person’s recovery while admitted.
Ethnic, spiritual, and cultural influences
BR is white, single woman who is currently lives at a low socioeconomic status. She is
not employed and relies solely on government assistance. BR told us that she was a Christian but
was not very involved with church at the moment. She did ask us to pray with her at one point
during our conversation, and she said she felt better afterwards.
Evaluation of patient outcomes
MENTAL HEALTH COMPREHENSIVE CASE STUDY 8
The outcomes that were planned for BR by the end of her stay were in increase in food
intake, performing self-care appropriately, and a stabilization of moods. On her day of care, BR
was taking care of herself appropriately, having taken a shower and groomed herself for the day.
She had also met her goal of increasing her food intake, as she had eaten over 75% of her meals
for that day and was eating a snack when we first began our conversation.
Her anxiety was improved from when she came in originally, despite the anxiety
surrounding another patient on the floor of the unit. Her anxiety when she was admitted was
related to her feeling of a loss of control in her life. While she is still stressed about her current
situation outside of the hospital, she felt as though she has more tools and resources to help her
when she is discharged. She also said that she understood the importance of taking her
medication regularly to keep her moods stable.
Plans for discharge
BR is to be discharged back to her home. She will be sent with a few days’ supply of her
medications, as well as educational information about her meds and the importance of taking
them as prescribed. This information will also be reviewed with her with a nurse before she is
discharged so that she may ask any questions if needed. She will have an appointment scheduled
at her outpatient psychology office for the following week. She will also be given resources for
groups and other support that she will be encouraged to attend.
Prioritized nursing diagnoses
The following are prioritized nursing diagnoses for BR:
1. Impaired nutrition related to manic state as evidenced by forgetting to eat meals
MENTAL HEALTH COMPREHENSIVE CASE STUDY 9
2. Disturbed thought process related to Bipolar 1 as evidenced by delusions
3. Anxiety related to other patients as evidenced by fear of other patients on floor
4. Complicated grieving related to mothers’ death as evidenced by verbalization of sadness
5. Risk for injury related to extreme hyperactivity as evidenced by pacing and restlessness
6. Hopelessness related to
Potential nursing diagnoses
1. Ineffective coping
2. Ineffective health maintenance
3. Impaired verbal communication
4. Disturbance of self-esteem
5. Sleep pattern disturbances
6. Alteration in nutrition
7. Fear
8. Impaired family processes
9. Impaired social interaction
10. Risk of Non-compliance
11. Social Isolation
12. Impaired cognition
13. Self-care deficit
Conclusion
Bipolar I is a complicated disease that involves dramatic mood swings from manic highs
to lows of depression. Patients with bipolar I that have long phases of mania often have difficulty
with compliance of treatments and medications. They often can be a danger to themselves, with
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that being through a lack of self-care or impulsive and risky behaviors. Many patients going
through an extreme manic phase need to be hospitalized in order stay safe.
BR experienced many of the key signs of mania, including flight of ideas, distractibility,
restlessness, and inappropriate behaviors. Along with this, the psychotic features of her diagnosis
are displayed with her hallucinations and delusions. The goal for her once she is discharged is
that she is able to take care of herself at home, as well as maintain compliance with her
medication and treatments. Another goal is that she attends group therapies and reach out to
resources that are available to her when she needs assistance. While medications will not cure the
disease even with compliance, the hope is that her moods are more controlled and that she is able
to identify when she is getting manic and to get help when that occurs.
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References
Chakrabarti, S., & Singh, N. (2022). Psychotic symptoms in bipolar disorder and their impact on
the illness: A systematic review. World journal of psychiatry, 12(9), 1204–1232.
https://doi.org/10.5498/wjp.v12.i9.1204
Mousavi, N., Norozpour, M., Taherifar, Z. et al. Bipolar I disorder: a qualitative study of the
viewpoints of the family members of patients on the nature of the disorder and
pharmacological treatment non-adherence. BMC Psychiatry 21, 83 (2021).
https://doi.org/10.1186/s12888-020-03008-x
Videbeck, S. L. (2022). Lippincott CoursePoint Enhanced for Videbeck's Psychiatric-Mental
Health Nursing (9th ed.). Wolters Kluwer Health.
https://coursepoint.vitalsource.com/books/9781975205867
