Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 1

Mental Health Comprehensive Case Study

Meghan Puster

Youngstown State University

NURS 4842L Mental Health Nursing Lab

and Teresa Peck

Spring 2021
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 2

Abstract

The purpose of this paper is to present a case study for a patient from Mental Health

Nursing Lab. This patient’s psychiatric diagnosis on admission was Severe Manic Bipolar I

Disorder with Psychotic Behavior. The patient’s objective data from the day of care will be

described. A summary of the patient’s psychiatric diagnoses and expected behaviors will be

provided. The events that precipitated the hospitalization will be presented. A summary of the

psychiatric nursing interventions and outcomes during the day of care will be outlined. The

influence of the patient’s ethnic, spiritual, and cultural influences regarding care will be

analyzed. Potential discharge plans and community care options will be explained. Actual and

potential nursing diagnoses for the patient will be provided along with a reflection of the care.
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Objective Data

E.H. was a 19-year-old male that presented to the Emergency Department at Mercy

Health St. Elizabeth Youngstown Hospital on March 11, 2021 for manic behavior and agitation.

E.H. arrived in a spit mask for spitting at police officers and was restrained for safety due to

belligerent spitting, swinging, kicking, lunging, and making threats toward the hospital staff.

E.H. was extremely angry, belligerent, sobbing, and crying on admission. His family stated this

was different than his baseline behavior.

The clinical date of care was March 25, 2021. E.H. had the psychiatric diagnosis of

Severe Manic Bipolar I Disorder with Psychotic Behavior. During the patient interview, E.H.

appeared to have flat facial expressions with tense and erect posture. He spoke with very rapid,

pressured speech, and flight of ideas after sitting down and taking a very long pause to begin

conversation at the start of the interview. He soiled his hospital gown during the interview as he

spilled his water down his initially clean gown. E.H. was very restless during the interview. He

stood up to walk around twice and demonstrated fine tremors in his hands. These tremors were

the contributing factor to him spilling his water down his gown and eventually dropping his cup

on the floor. E.H. stated he has been having a new onset of difficulty swallowing. This may be

related to his newly prescribed atypical antipsychotic aripiprazole.

E.H. demonstrated very labile emotions throughout the interview. His emotions ranged

from friendly and conversational to angry and agitated. E.H expressed a very frustrated mood

and prominent delusions of grandeur. He claimed to be a “made man” stating that his sisters do

everything for him to the extent that he does not even brush his own hair or sign his own papers.

He said that his grandpa works for the government and he was convinced he would never need to
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be accountable to the law. He claimed to be a “mega genius” without needing an IQ test to prove

his intelligence.

E.H. Exhibited poor judgement and made homicidal threats related to his delusions of

grandeur to the interviewer and to other nursing students participating in the interview. He stated

that the interviewer was an ant yet too insignificant to step on. He threatened to stab a male

nursing student stating that he had the ability to bring down bigger men. He made homicidal

threats to nurses on the unit. He was adamant that this was because the male nurse named Jason

had disrespected him. E.H. had persecutory delusions insisting that his diagnosis was ADHD. He

was convinced that he did not have Bipolar Disorder and the physician was forcing him to take

improper medications. E.H. may have had potential auditory hallucinations stating that he used

to hear voices in his head telling him to do right versus wrong but currently lost his conscience.

E.H was able to recall past events prior to his hospitalization yet appeared to have a complete

loss of reality during the interview.

E.H. communicated that his current coping strategies were smoking marijuana and

playing video games. His favorite games are always played on his Gameboy and he has a

specific interest in Pokémon. He said he can control his homicidal impulses though “Peace and

Love” and does not intend to harm anyone mostly because the people around him are too

insignificant.

During E.H.’s hospitalization lab values were drawn. On his admission date, his white

blood cell count was elevated to 18.8 x 10^9 / L. On the day of care his white blood cell count

had returned to 9.4 x 10 ^9 / L which was within normal limits. E.H.’s urine drug screen was

positive for cannabinoids on admission. This was consistent with his statements that he smokes

marijuana as a coping strategy to relax. He was not intoxicated on admission. On the day of care,
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his blood glucose level, TSH, T4, ALT, and AST were all within normal limits which ruled out

hypoglycemia, thyroid problems, and liver damage. E. H.’s red blood cell count, hemoglobin,

and hematocrit, and SPO2 were also all within normal limits which ruled out lack of oxygen. On

admission, E. H.’s QTC interval was prolonged at 509. On the day of care, the QTC interval was

measured at 412 which was within normal limits. This resolution could be due to his new

atypical antipsychotic aripiprazole.

Although E.H. stated he did not take any psychiatric medications at home, during his

inpatient hospitalization he was taking a variety of medications. He was taking the atypical

antipsychotic aripiprazole 10 mg daily for bipolar mania. Two times daily he was taking the

anticonvulsant oxcarbazepine 450 mg and the benzodiazepine clonazepam 1 mg also for bipolar

mania. E.H. was prescribed a variety of stool softeners as needed for constipation. He also was

prescribed lorazepam 2 mg every 6 hours as needed for anxiety and agitation. E.H. was ordered

the analgesic acetaminophen 1000 mg every six hours as needed for pain and the proton pump

inhibitor pantoprazole every morning to prevent GI symptoms.

E.H. stated during the hospitalization he is eating well yet struggling to sleep. He said at

home, he normally sleeps about five hours per day during daylight hours due to caring for his

two young children at night. He has been struggling to adhere to the hospital sleep schedule and

this may also be related to his mania symptoms. When referencing E.H’s admission notes, he had

persecutory delusions toward staff regarding the food provided in the hospital. He had a strong

believe that the staff was out to get him. He stated, “I only eat the stuff at my house”. E.H. was

offered packaged food and refused it. He eventually agreed to eat the hospital food excluding

beef and pork.

While hospitalized, safety measured were implemented to protect E.H. He received the

standard unit restrictions and self-harm precautions of all the patients receiving care on the unit.

The focus of care on the day of care was talk therapy and milieu therapy. On admission E.H. was

put into four-point restraints for safety and received an intramuscular haloperidol injection due to

his agitated state and psychosis.

Psychiatric Diagnoses

E.H. was diagnosed with Bipolar I Disorder. Videbeck, S.L. (2020) depicted Bipolar

Disorder as extreme changes in mood from episodes of mania to episodes of depression. Bipolar

I Disorder consists of mostly manic episodes with at least one depressive episode. This may have

been E.H.’s first manic episode. He was 19 years old, and the first episode usually occurs in

one's early life during teenage years to age thirty. Manic episodes usually begin suddenly, and

symptoms escalate over the course of the next few days. Videbeck, S.L. (2020), identified for

one to be diagnosed with mania, the patient must have at least one week of unusual and

heightened grandiose or agitated mood. The patient must also have at least three of the following

symptoms: exaggerated self-esteem, sleeplessness, pressured speech, flight of ideas, reduced

ability to filter extraneous stimuli, distractibility, increased activities with increased energy,

multiple grandiose high-risk activities involving poor judgement and severe consequences.

Patients usually struggle to accept accountability for a bipolar diagnosis. Many patients do not

understand how their behaviors affect others and struggle due to the burden of their prescription

regimen and changes in moods.

Stressors and Behaviors

Prior to E.H.’s current hospitalization, E.H. claimed there was an altercation with his

mother that resulted in the police being called. He felt that this was an example of his mother

overstepping her boundaries. E.H. stated to the police “I have been doing shrooms and haven’t

slept, eaten, shit or pissed.” E.H. presented to the Emergency Room for manic behavior and

agitation. E.H.’s family claimed that this behavior was much different from his baseline after

returning from a party. He claimed he ingested an unknown drug and immediately vomited

afterward and has been vomiting in the days since party. In the article by Rougemont-Bücking,

A. et. al (2019), it was explained that the motive for psychedelic use is often self-medication,

self-exploration, or sensation seeking. The study represented in this article found that the use of

psychedelics is not associated with a significant deterioration in mental health. There was a

significant association with the cannabis group and mental health decline. Based on this

information, there is a possibility E.H.’s cannabis use could have impacted his illness state. On

admission, E.H. was restrained for safety due to belligerent spitting, swinging, kicking, lunging,

and making threats to hospital staff.

Patient and Family History

According to E.H.’s chart, he has a medical history of cannabis abuse, vomiting,

malingering, and he was a former smoker. He had no prior history of psychiatric hospitalizations

noted. He has no known allergies and no history of abuse or suicidal behavior. During the

hospitalization he made verbal assaults and was physically aggressive with hospital staff and

police officers. When asked about family history of mental illness, E.H. stated he has siblings

with Bipolar Disorder and ADHD. He stated his younger brother has anger management issues.

Many of his family members have “reality complex” issues. E.H. is a high school graduate of

Youngstown City Schools. He said he previously attended a school with a STEM focus. He is
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currently unemployed. He lives with his family in the home he was raised in. E.H. stated he is

close to his mother although she can overstep his boundaries. He stated he has two young

children. He made a remark that when his children are acting out and he is angry he is concerned

he could harm them.

Psychiatric Evidence Based Nursing Care and Milieu Activities

A large focus of E.H.’s care on the clinical day was talk therapy and milieu therapy.

Videbeck, S.L. (2020), describes talk therapy as one-on-one interactions between patients and

staff and milieu therapy as the environment’s effect on the patient’s treatment. Stable conditions

provide structure and support to assist the patient’s healing. Interactions are focused on

establishing trust and providing opportunities for self-disclosure. E.H. was encouraged to

participate in group therapy with the other patients on the floor. These groups served to provide

coping skills, resources, and education to meet the needs of the patients. On the day of care, E.H.

had the opportunity to attend a group that provided resources in the greater Youngstown area to

assist with addiction and substance abuse. There was also a spiritual group to assist to meet

E.H.’s spiritual needs while gaining acceptance and hope.

Ethnic, Spiritual, and Cultural Influences

E.H. was a young, African American male from Youngstown Ohio. He grew up with

western cultural influences and was high school educated. When discussing spirituality with E.H.

he identified that he believes in a higher power and that God is real. He does not attend any

formal services. E.H. mentioned his grandparents practiced a form of Christianity and attended

church services regularly. During the interview, E.H. expressed religious delusions. He said God

was reading people as he rolled two dice and each number on the dice had a particular meaning.
Running head: MENTAL HEALTH COMPREHENSIVE CASE STUDY 9

He stated that he figured out the Bible and now knows better than it. The article by Raab, K.A.

(2007), explains religious feelings during manic and hypomanic episodes are common. These

feelings can range from receiving messages from God, feeling as if they have become God, or

that they have been assigned a divine mission or are currently taking part in a mystical

experience. Religious practices have not been found to cause mental illness. Many patients that

are bipolar seek religious guidance from their spiritual leader of choice as a coping strategy.

Evaluation

On the day of care, E.H. remained safe and free from harm. He was well nourished and

willing to participate in the interview with nursing students. He was not actively engaged in group

therapy, although he was able to sit in the common area while the therapy was occurring. E.H. was

unable to accept his newly prescribed medication regimen and Bipolar I Diagnosis. He was

extremely agitated and unable to refrain from making homicidal assaults toward nursing students,

nurses on the unit, and his physician. E.H. was highly delusional and demonstrating a loss of

reality. E.H.’s care plan was ongoing. His coping strategies, medication compliance, orientation,

and behavior must improve before plans can be made to return to the community.

Plans for Discharge

E.H. demonstrated very acute mental health and medical needs on the day of care.

Discharge plans were not discussed in his chart on the day of care. For a safe discharge to occur,

E.H. must be able to meet his basic needs and no longer be a potential harm to himself or others.

He must be able to accept his diagnosis and adhere to his medication regimen.

If E.H.’s status does not improve, a legal guardian may be named to assist him with

decision making and to ensure safety and proper activities of daily living execution. He will
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likely need to make the transfer to outpatient treatment prior to returning to the community. He

may benefit from a residential living situation so he can work on social skills and make progress

toward becoming employable. Living with other residents with bipolar disorder under

supervision may help E.H. learn more appropriate behaviors.

The article by Finnerty, M.T. et al (2018), discusses the importance of ongoing mental

health treatment engagement. Patients should work with their providers to come up with a

realistic and evidenced based plan to manage their illness. The study discussed in this article

showed a modest but significant improvement in outpatient treatment engagement and

antipsychotic adherence when treatment regimens were mutually established between the patient

and provider. The nurses on the unit should advocate for E.H. to be part of the decision-making

process when the time for discharge planning occurs to encourage a better outcome for his

future. At 19 years old, E.H. is a very young patient and will need to learn to manage his

condition achieve his full potential.

Actual Nursing Diagnoses Prioritized

When a patient is experiencing acute bipolar mania symptoms, it is essential to meet their

needs for safety and physiological needs prior to addressing their psychosocial symptoms. The

following are actual nursing diagnoses from Ackley, B.J. et al (2015), and are listed in order of

priority for E.H.:

1. Imbalanced nutrition less than body requirements related to refusal or inability to sit still

long enough to eat meals as evidenced by extreme restlessness.

2. Fatigue related to psychological demands of mania as evidenced by five hours or less of

sleep per night.

3. Self–care deficit related to perceptual impairments as evidenced by delusions and

inability to independently meet basic needs.

4. Ineffective coping related to ineffective problem-solving strategies and skills as

evidenced by destructive behaviors towards self and delusions of grandeur.

5. Social isolation related to ineffective coping strategies and hospitalization as evidenced

by refusal to answer phone calls from family.

A variety of nursing interventions can be implemented to address these nursing

diagnoses. To address imbalanced nutrition, E.H. can be provided easily transportable foods and

snacks so he can eat small amounts without sitting for a structured meal. The nurses can create a

restful environment for sleep by dimming lights and eliminating unnecessary noise on the unit.

E.H. should be encouraged to attend group therapy sessions on the unit to develop coping skills

for a smoother transition back into the community. E.H. should be encouraged to start answering

phone calls from his family to reestablish his support system.

Potential Nursing Diagnoses

E.H.’s current symptoms of bipolar mania and loss of reality make him vulnerable to a

variety of risk factors. The following are important potential risk nursing diagnoses from Ackley,

B.J. et al (2015), for E.H.:

1. Risk for suicide related to impulsiveness and male gender as evidenced by inability to

maintain self-control.

2. Risk for injury to oneself or others related to extreme hyperactivity and mania as

evidenced by impaired judgment and homicidal ideation.

3. Risk for violence related to mania as evidenced by verbal threats to others.

4. Risk for loneliness related to stress and separation from friends and family as evidenced

by conflicts with hospital staff.

5. Risk for spiritual distress related to new medication treatment regimen as evidenced by

inability to accept diagnosis and health status.

Nursing interventions can be made to address these potential risk nursing diagnoses. To

address the risk of suicide and injury to the patient and others, the nurse should continue to

control E.H’s environment through milieu therapy. The nurse should provide frequent

supervision by making safety checks every fifteen minutes. The patient should receive extra

supervision during group activities and redirection and de-escalation techniques should be

implemented during the first sign of agitation or aggression toward others. The milieu therapy

interventions should assist E.H. to control violent impulses. Weighted furniture and removal of

all harmful objects will prevent E.H. from easily being able to cause injury to self or others. The

hospital staff should strive to establish trust and therapeutic relationships with E.H. to prevent

loneliness. They should encourage E.H. to contact his family to receive updates on the

occurrences in his home during his hospitalization to ease his eventual transition back into the

community. E.H. should attend the group therapy session with a spiritual focus to create more

formal spiritual practices and rituals as a coping strategy. This may also promote reorientation to

reality and correct his religious delusions.

Conclusion

E.H. was a very interesting and challenging patient. He was the first patient I have

interviewed experiencing mania and loss of reality. It was fascinating to observe his behaviors

and realize the severity and impact on functioning of a patient with Bipolar I Disorder during an
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exacerbation of symptoms. I always thought symptoms displayed in the videos from class were

exaggerated, but E.H.’s presentation of symptoms was very similar.

I felt very empathetic toward E.H. At 19 years old , he may have a difficult life ahead if

he is unable to establish an adequate treatment regimen. He may struggle to receive the care he

needs due to such a prominent family history of mental illness.

E.H. had been in the hospital for nearly two weeks on the day of care. He expressed

sincere frustration toward hospitalization. Discharge plans had yet to be discussed on the day of

care due to his lack of progress in the acute setting. The danger to himself and others and

inability to meet basic needs was evident. I can understand why E.H.’s would be dissatisfied with

a long hospitalization when he believes he has done all he can to improve and follow directions.

Healthcare providers are responsible for making safe decisions. I’m sure it is difficult to see a

patient so frustrated although they are acting in his best interest.

I struggle to process how someone as sick as E.H. will need to work to the same basic

needs as myself. Without the barriers of mental illness, it can be difficult to function in the

community to meet basic needs. Mental illness would make meeting basic needs much more

challenging. Planning for a future would be nearly impossible when meeting d aily demands are

so taxing.

I hope to work in behavioral health as a nurse someday. Patients like E.H. are the exact

population I feel compelled to help. Society should strive to see the capability and value of all

citizens while encouraging their success. All challenges can be overcome though perseverance.
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References

Ackley, B.J., Ladwig, G.B., Makic, M.F. (2015), Nursing Diagnosis Handbook An Evidenced-

Based Guide to Planning Care. St. Louis, Missouri: Elsevier.

Finnerty, M.T., Layman, D.M., Chen, Q., Leckman, E., Bermeo, N., Ng-Mak, D.S., Rajagopalan,

K., & Hoagwood, K. (2018). Use of a Web-Based Shared Decision-Making Program:

Impact on Ongoing Treatment Engagement and Antipsychotic Adherence. Psychiatric

Services, 69 (12), 1215-1221. doi:10.1176/appi.ps.201800130

Raab, K.A. (2007). Manic depression and religious experience: the use of religion in therapy.

Mental Health, Religion & Culture, 10(5), 473–487. doi:10.1080/13674670600941361

Rougemont-Bücking, A., Jungaberle, H., Scheidegger, M., Merlo, M. C. G., Grazioli, V. S.,

Daeppen, J.-B., Gmel, G., & Studer, J. (2019). Comparing Mental Health across Distinct

Groups of Users of Psychedelics, MDMA, Psychostimulants, and Cannabis. Journal of

Psychoactive Drugs, 51(3), 236–246. doi:10.1080/02791072.2019.1571258

Videbeck, S.L. (2020). Psychiatric-Mental Health Nursing. Philadelphia, PA: Wolters Kluwer.