Running head: COMPREHENSIVE CASE STUDY 1

Ashley Kane

Mental Health Case Study

Youngstown State University

Abstract

This paper will be informative of R.K’s care at St. Elizabeth’s Hospital. It will

discuss how the patient was admitted, how she acted and what she was doing on the

day of care along with behaviors that were observed throughout this process.

Stressors that lead to hospitalization will be discussed as well as a summarization of

her psychiatric diagnosis. Discussion will be given on family history of the illness,

and analyzation will be given to her cultural, spiritual and ethical beliefs. Evaluation

of her outcomes related to care would be discussed. Lastly, a summarization of

discharge and nursing diagnosis will be given related to R.K.

Objective Data

R.K., a 54 year old female presented into the Emergency room at St.

Elizabeth’s Hospital on November 3, 2017, accompanied by family. The patient was

in a manic state and she was expressing that she heard voices, but was unable to tell

staff what they were saying to her. Her family expressed that they told her they

were bringing her in for her cold, but in reality, just used it as a way to get R.K. to the

hospital for the psychiatric help she needed. While in the Emergency Room she was

manic and urinated on the floor, and gave reason that she was “afraid to walk all the

way to the bathroom because she would fall.” The patient became agitated and

began acting out so PRN emergency medications were administered to relax her and

bring her back to an appropriate state.

R.K. has had multiple psychiatric hospitalizations in the past beginning in

2007. She was admitted to the Behavioral Health unit with the standing diagnosis of

Schizophrenia, and Bipolar Disorder. According to the DSM IV-TR, the multi-axial

system, for R.K, Axis I refers broadly to the principal disorder that needs immediate

attention, for R.K. Schizophrenia in manic exacerbation would be appropriate. Axis

II lists any personality disorders that may be shaping the current response to Axis I.

for R.K. she had previously been diagnosed with Bipolar Disorder. In order to fall

into Axis III, any medical or neurological problems that may be relevant to the

individual’s health. R.K. does have Hypertension, which is typically controlled with

medication, when compliant. Compliance is an issue with this specific patient. Axis

IV codes the major psychological stressors the individual has faced, whereas she

believes she is engaged to a man that does not exist, and is upset that he isn’t
COMPREHENSIVE CASE STUDY 4

visiting. Lastly, Axis V codes the level of function, where I would personally rank

R.K. at a code 21-30.

When transferred up to the floor, there are standard safety and security

precautions the hospital follows. It is a locked unit, so any visitors must lock up their

belongings out side and have a password to be able to attain access to the unit. All

sharp objects are locked up and all harmful objects are removed from the area. Beds

are kept low to the ground, and doors are now pressurized so if there were to be any

abnormal amount of weight hanging from the top of the door, alarms would sound.

Doorknobs are also cone shaped, making it much more difficult to be able to tie

anything around. The chairs and furniture in the common room and all private

rooms are also rather heavy and bulky, making it difficult to pick up, so they are not

used if a patient becomes agitated.

R.K. is prescribed a handful of medications, which she is supposed to be

taking at home as well as in the hospital. Compliance is an issue for her, and she

does not have much of a support system in order to get this remedied. She is

currently prescribed a handful of medications including: Ariprazole (Abilify) –

5mg/daily and Clozapine (Clozaril)- 25mg/twice daily as antipsychotics to try to

remedy the schizophrenic manic behaviors. She is also currently taking Divaloproex

(Depakote) – 250mg/ twice daily and Topiramax (Topamax) 25mg/ twice daily as

anticonvulsants to also assist with the mania. Along with those she is on

Hydroxyzine (Vistaril)- 50mg/ three times daily and Lorazepam (Ativan) – 2mg/

q6hrs PRN for her anxiety related to her bipolar and schizophrenic states. To
COMPREHENSIVE CASE STUDY 5

prevent extraparameter symptoms she is prescribed benztropine(Cogentin)-

2mg/twice daily.

Summarize

According to the National Institute of Mental Health, Schizophrenia is a

chronic and severe mental disorder that affects how a person thinks, feels and

behaves. People with Schizophrenia may seem like they have lost touch with reality

(National Institute Schizophrenia, 2016). When dealing with schizophrenia, there

are both positive and negative symptoms. Positive symptoms are behaviors that are

not typically seen in generally healthy people, whereas, negative symptoms are the

absence of healthy behaviors. Some examples of positive symptoms include:

hallucinations, delusions, thought disorders or unusual ways of thinking, and

movement disorders. Some examples of negative symptoms are the following: a flat

affect, reduced feelings of pleasure in everyday life, difficulty beginning and

sustaining activities and reduced speaking (National Institute Schizophrenia, 2016).

When R.K. was admitted, she was in a manic state, so her symptoms were

appealing more toward the positive side rather than negative. She was having

auditory hallucinations and delusions as she was claiming she heard voices, but also

admitted to being engaged to a man that is known not to exist. She has exhibited

poor functioning and poor relationships in the unit as she begins to “stir the pot”

and agitate others with her behavior, due to the exacerbation of schizophrenia in

mania.

Along with those symptoms there are also cognitive issues, and those with

schizophrenia commonly struggle to organize their thoughts or complete tasks.

(NAMI, 2017). Those who are diagnosed typically have anosognosia or lack of

insight; meaning that the person is unaware of the illness. This relates to R.K.’s

situation due to her lack of knowledge about what is going on with her current

mental health status. She had great difficulty organizing thoughts and completing

tasks in a timely manner.

Again, According to NIMH, Bipolar Disorder is also known as a manic-

depressive disorder, with different types, all including changes in mood, energy and

activity level. R.K. was diagnosed with Bipolar I Disorder which is defined as a manic

episode that lasts at least 7 days, or by manic symptoms that are so severe that the

person needs immediate hospital care (NIMH, 2016). Symptoms that could be

expected with someone experiencing Bipolar I Disorder in mania would be the

following: having a lot of energy, increased activity, having trouble sleeping, talking

really fast and about a lot of different things, think they can do multiple things at

once, being irritable or “touchy” (NIMH,2016). All of the previous symptoms stated

were apparent in R.K’s specific case. She would cause arguments with other patients

and wouldn’t be able to focus long enough to finish putting sugar in her cup of coffee

without changing subjects and focusing on something new.

Identify

R.K. could have multiple stressors, but I was unable to identify one specific as

the main cause. She has no family support, due to her continuously burning bridges

with everyone. Her family brought her in for the last time and claimed that it was

the last time, and she is on her own now. She doesn’t have a job and hasn’t been

employed for the last 20 years when she worked at a convenient store. She currently
COMPREHENSIVE CASE STUDY 7

resides in a small apartment with a friend. She is dependent upon others for a

majority of life responsibilities and activities, but she has minimal people to depend

on, resulting in her constant hospitalizations.

Discuss

Due to the lack of family involvement and support, there was not much

information that was available on the family history. There is a connection of her

mother having bipolar disorder, but other than that, there was no information

available. Her personal history includes a mile long list of different hospitalizations

and facilities that she has been in in order to receive help, but in turn is turning into

a revolving door. She has multiple doctors, some of which are now refusing to see

her.

Describe

R.K. has been a patient on this floor previously, so she is aware of the

surroundings and is almost very comfortable being there as she knows the staff and

ins and outs of how everything runs. The environment is calm and she is always out

in the common area and typically participates in conversation, and sets her daily

goal, which she sometimes achieves. As for group therapy sessions, R.K. always

makes an attempt to come to them, but often is distracted and leaves the room

multiple times or distracts others while trying to work on the selected topic of the

day. She seems to never have a focus on anything for more than 3 minutes.

Analyze

Upon looking through the chart and multiple attempts to discus with R.K.

there was very minimal evidence as to a spiritual or cultural aspect had any
COMPREHENSIVE CASE STUDY 8

relevance to her current schizophrenic state. This patient was very difficult to talk to

and could not hold attention.

Evaluate

In comparison to the admission date, with mania, R.K. had made

improvements, and has been compliant with her medications without giving staff

any difficulty. She still remains sporadic in activity and still agitates others and

speaks freely. There was only one incident of urination on the floor as it used to be a

recurrent thing. She still fears of falling when getting up at night, but refuses to wear

her non-slip socks. As she continues to have a long road ahead of her, she has

improved since her most recent admission.

Summarize

There is currently no tentative discharge date for R.K. Due to the lack of

family support and stability in a home; they are looking into a residential

rehabilitation type center for her to stay. This would increase her medication

compliance and overall improve her current state. She will be discharged on the

following Medications:

NANDA Nursing Diagnosis - Prioritized

1. Disturbed thought process r/t inadequate support system AEB delusions and

inaccurate interpretation of thinking.

a. Goal: Patient will build a support system through relationships

beginning in the hospital prior to discharge.

b. Intervention: Nurse will advocate for patient and assist and encourage

whenever needed.
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2. Impaired Verbal Communication r/t altered perceptions AEB inappropriate

verbalization

a. Goal: Patient will appropriately verbalize communication before

discharge.

b. Interventions: Nurse will administer medications at scheduled times

to relax and calm the patient in order for them to appropriately

communicate.

3. Risk for injury r/t manic behavior AEB dangerous and risk y behavior

a. Goal: Keep patient free from injury during hospital stay.

b. Intervention: Abide by standard safety and security precautions

through the duration of the stay.

NANDA Nursing Diagnosis - Potential

1. Interrupted Family Processes r/t nonadherence to antimanic and other

medications AEB effectiveness in completing assigned tasks

a. Goal: Patient will continuously be compliant with medications

b. Intervention: set up a schedule for client in order to adhere to routine

and complete assigned tasks.

2. Risk for Violence r/t manic excitement AEB hallucinations and delusional

activity

a. Goal: Reduce manic episodes while on unit in hospital

b. Intervention: Nurse will redirect and orient patient whenever there is

a hallucination or delusion taking place.

3. Self Care deficit r/t inability to concentrate on one thing at a time AEB

inability to groom self independently.

a. Goal: Patient will independently take on self care and groom

independently.

b. Intervention: Nurse will assist at first with set up and then wean off

until ADL’s become independent.

References

6 Schizophrenia Nursing Care Plans. (2017, October 05). Retrieved November 30,

2017, from [Link]

Bipolar Disorder. (2016, April). Retrieved November 30, 2017, from

[Link]

NAMI. (n.d.). Retrieved November 30, 2017, from [Link]

More/Mental-Health-Conditions/Schizophrenia

Schizophrenia. (2016, February). Retrieved November 30, 2017, from

[Link]