Running head: CASE STUDY 1

Mental Health Case Study

Megan E. Politano

Youngstown State University

CASE STUDY 2

Abstract

This case study is about a patient who was admitted to the psychiatric unit at Trumbull

Memorial Hospital. In this paper, many topics will be explored. It will begin with objective data,

specific psychiatric diagnoses related to the patient, and what brought them to the hospital. The

data that contributes to this study are laboratory results, observed behaviors, health history, and

prescribed medications. Next, the safety of a psychiatric unit and the importance of the safety for

all patient is explained. Then, stressors, family dynamics, and spiritual impacts will be discussed

and how it contributes to the patient and their condition. Lastly, the outcomes and plans for

discharge will be determined to improve the patient’s well-being and, to hopefully, improve their

mental illness status, and prevent rehospitalization.

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Mental Health Case Study

Mental illness occurs in everyone’s life, whether it is themselves, a loved one, or

someone they know. Mental illness is becoming more prevalent, therefore, it is important to

know about the illnesses that control a variety of patient’s lives. Many of these illness require

more than just medication. A disorder that is seen and spoken about in this case study is

schizophrenia, which can be defined as “spectrum disorders may have several causative

factors…there is not now and probably never will be a single treatment that cures the disorder…

Effective treatment requires a comprehensive, multidisciplinary effort, including

pharmacotherapy and various forms of psychosocial care.” (Morgan & Townsend, 2017, p.341)

This is important to mental illness because there are many illnesses that require more than

medication to live and cope with the disease – it involves a team of individuals to educate, treat,

and care for the patient.

Objective Data

This patient, KJ, is an African American 24-year-old female who was sent to the

Emergency Department by her counselor after a home visit due to being placed on a mental

health hold. KJ was transported in an ambulance to the hospital after threatening her counselor.

The patient was sent to the ED for further evaluation. KJ was involuntarily committed during her

home visit for medication noncompliance, anxiety, agitation, and paranoia. The patient was

admitted to the psychiatric floor on October 1st, 2019. The chief complaint for this admission was

psychiatric symptoms, such as agitation, paranoia, and being aggressive. On the date of care,

which was October 3rd, 2019, the patient had presented with signs of paranoia and agitation

during the interview. The patient had stated and described her visit as “frustrating” due to not
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knowing why she was there and the patient had stated multiple times that she disliked many of

the workers there, such as her physician and case worker.

During the interview, the patient had spoken language that was clear and speech was

understandable. The patient would speak at a regular pace and would sometimes fluctuate

volume, but the language was appropriate for her age. At times, she was slow to process, but

would answer the question that was being asked. KJ would keep minimum eye contact, have her

hands tightly squeezed, and kept her head low. She would look at me often, but return looking

down at her hands for most of the interview. The patient was confused on why she was there. She

had stated that she was compliant with her medication, but she was never prescribed the

medication from her last visit at Generations. Even though she was prescribed, she believed that

she was not and expressed that she could not take the medication because she did not have access

to it. She stated that she did not like being at any psychiatric unit and just wanted to return home.

During the interview, another patient had looked in her direction and KJ had yelled across

the room to ask why he was looking at her and to turn around and focus on what he is doing.

This was a very evident sign of paranoia. The patient did attend group on the date of care, but she

chose to sit off by herself near the window. She would make comments, but did not want to share

information when called upon during the activity. The patient had revealed to me in the interview

that she does not like talking to people, but would not consider herself antisocial. This is because

when she was younger, she would sit by a tree and sing alone when everyone was on the

playground. She thought everyone would think she was the ugliest duckling.

The reason for this psychiatric visit is because of her current diagnosis of schizophrenia.

The patient has a history of sexual abuse and current active problems include: schizophrenia;

bipolar disorder; nicotine dependence; obesity (BMI 30-39.9); schizophrenia, paranoid, chronic
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with acute exacerbation; and hyperglycemia. The patient’s past problem includes: cough,

depression, traumatic bursitis, and viral syndrome. Labs were drawn on the patient on October

1st, 2019, except TSH and T4 was drawn on the 2nd of October, 2019, and the results are

presented below in Table 1.

Table 1

Lab Value Normal Range Result

WBC 4.3 – 10.7 6.6
Hgb 12.0 – 15.0 10.8 L
Hct 36 – 46 33.7 L
MCV 80.0-100.0 79.9 L
MCH 27.0 – 33.0 25.6 L
RDW 11.7 – 13.7 25.6 L
Platelets 135 – 435 340
MPV 7.4 – 10.4 10.7 H
Creatinine 0.5 – 1.00 1.02 H
Glucose 0.50 – 1.00 126 H
TSH 0.36 – 3.74 1.57
Free T4 0.76 – 1.46 1.13
Valproic Acid 50.0 – 100.0 61.5

The patient has been diagnosed with hyperglycemia and the glucose level was high. This

could have been a contributing factor to the agitation after the patient had stopped taking her

medication. Besides the glucose being out of normal range, the labs drawn do not provide any

evidence that this could be an organic root cause for the psychiatric symptoms presented. The

patient denies use of any type of drugs or alcohol and all screening were negative. KJ had stated

to smokes cigarettes every day, but never drinks. The patient was on unit restrictions and patient

self-harm precautions.

The patient was knowledgeable about the medications she was taking. The patient is

prescribed Acetaminophen (Tylenol), Albuterol Sulfate (Ventolin Hfa), Aripiprazole (Abilify) for

schizophrenia, Divalproex Sodium (Depakote Dr.) as a mood stabilizer, Haloperidol (Haldol) for
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acute psychotic behavior, Haloperidol Lactate (Haldol Injection) for severe psychotic behavior,

Hydroxyzine HCl (Atarax) for anxiety and sleep agent, Hydroxyzine HCl (Vistaril) for severe

agitation, Ibuprofen (Motrin), Medroxyprogesterone Acetate (Provera) as a protocol for

Depakote Dr., and Trazodone HCl to aid with sleep. The patient states that she has trouble

sleeping and does not like to use Trazodone as a sleep agent because the KJ states, “It makes me

feel like roadkill.”

It is very significant that the patient takes Medroxyprogesterone Acetate (Provera), a birth

control pill, as a protocol medication for Divalproex Sodium (Depakote Dr.), an anticonvulsant.

This is because the patient is at child-bearing age and Depakote Dr. can cause major birth

defects. This medication would lead to fetal hydantoin syndrome, which “typically compromises

facial dysmorphism with wide-spaced eyes, deformed fingers and fingernails, and retarded

development, although more severe malformations such as hip dysplasias, facial clefts and

cardiac abnormalities are occasionally seen.” (Genton, Semah, & Eugen. 2006, p. 3) Because of

this syndrome and the birth defects it causes, Depakote Dr. is a pregnancy category D. (Pedersen,

2018, p.160) This is why the child-bearing age patient must be on a birth control as a protocol

while taking this medication to prevent future pregnancies and fetal deformities.

Summarize the psychiatric diagnoses and expected/common behaviors

The patient’s psychiatric diagnosed for this visit is schizophrenia. The National Institute

of Mental Health (2016) defines, “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.” After reading this definition and comparing it to KJ, the patient had

manifested paranoia which contributed to what the patient thought and felt about the other

patient looking in her direction and how the patient behaved in that situation. The patient did not
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seem to have a loss of reality, but she was not acting socially acceptable. Schizophrenia can also

be described as a complex disorder that has an onset in the late teens to early 20s. (Pedersen,

2018, p. 75) The expected/common behaviors include positive and negative symptoms. These

can be described as “positive symptoms are excesses in behavior (excessive function/distortions)

… Negative symptoms are described as, “deficits in behavior (reduced function; self-care

deficits).” (Pedersen, 2018, p. 79)

There are two types of symptoms with schizophrenic patients: positive and negative

symptoms. These symptoms contribute to eight areas of functioning: content of thought, form of

though, perception, affect, sense of self, volition, interpersonal functioning and relationship to

the external world, and psychomotor behavior. (Morgan & Townsend, 2017, p. 350-353)

Positive symptoms include content of thought (delusions, religiosity, paranoia, magical

thinking), form of thought (associative looseness, neologisms, concrete thinking, clang, word

salad, circumstantiality, tangentiality, mutism, preservation), perception (hallucinations,

illusions), and sense of self (echolalia, echopraxia, identification and imitation,

depersonalization). Negative symptoms contain affect (inappropriate affect, bland or flat,

apathy), volition (inability to initiate goal-directed activity, emotional ambivalence, deteriorated

appearance), interpersonal functioning and relationship to the external world (impaired social

interaction, social isolation, anosognosia), psychomotor behavior (anergia, waxy flexibility,

posturing, pacing and rocking), and associated features (anhedonia, regression). (Morgan &

Townsend, 2017, p. 351) Within positive symptoms, there is content of thought and this is

significant to the patient because this includes paranoia, which the patient had clearly presented

during the day of care.

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Paranoia is described as, “have extreme suspiciousness of others and their actions or

perceived intentions.” (Morgan & Townsend, 2017, p.351) The patient was paranoid on

admission and during the interview. The patient also has a psychiatric diagnosis of

schizophrenia, paranoid, chronic acute exacerbation. During the interview, the patient had made

a comment about my appearance and stated that she believed I did not want to talk to her and

knows I only do the interview to fill out paperwork. As the interviewer, I was using active

listening techniques, such as sitting squarely facing the patient, with an open posture, leaning

toward the client, using eye contact, and was relaxed. This was another sign of her paranoia.

Identify the stressor and behaviors that precipitated current hospitalization

The patient was born and raised in Florida, where she was raised by her mother. She had

stated in the interview that all she wants to do is hold her mother now that she lives away from

her. She also shared that she promised to God that she would get back to her mother before she

passes. The patient had denied that her mother was ill. Her father was never in the picture. She

has two brothers and two sisters, but she does not have contact with her siblings. The patient had

dropped out of high school and would work in customer service in the past, but currently she is

unemployed. The patient is currently not on any social security disability and lives alone in an

apartment. She moved to Ohio because of her boyfriend, which did not end well. The patient did

not want to talk much about it, except that she expressed that his family did not like her and she

did not know why because she treated him very well. The patient has a history of sexual abuse

and did not want to talk about it. During the interview she had shared this information and I had

replied, “I am sorry to hear that.” The patient responded, “No you are not.”

Before the patient was admitted, she said she was compliant with her medication and

states that she was feeling fine. According to her chart, she did not remember her last visit which
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the previous week at Generations. She had shared that she does not like any mental health

facilities she has been at. The patient said that she had not gone to any mental health facilities

while in Florida, but began going to them once she moved to Ohio. She has had previous visits at

Generations, North Coast at Heartland, and Coleman outpatient. Even though she had expressed

compliance with medication, her chart had revealed that during her follow up with her counselor,

she had refused to take her medication. Because she had refused to take her medication, she had

become very agitated, paranoid, and aggressive. Her chart had said she was threatening the

counselor when the decision was made to send her to the ED for further evaluation. She

explained to me that she was taken from her apartment for no reason in an ambulance to the

hospital.

Discuss patient and family history of mental illness

There is no family history listed in the patient’s chart. The patient denies family suicide

and family mental illness. The only family history stated from the patient and in the chart was

that her mother has hypertension. The nurse would check her blood pressure and it was higher

than the normal which made the patient believe she has hypertension as well. The patient’s

current psychiatric diagnoses include schizophrenia, bipolar disorder, and schizophrenia,

paranoid, chronic with acute exacerbation.

The patient has a history of sexual abuse, but would not discuss any details during the

admission process or during the day of care interview. Childhood sexual abuse can be described

as “a problem, frequently seen in behavior therapy patients and therefore also warranting special

attention in routine patient care.” (Linden & Zehner, 2007, p. 447) Even though we do not know

who the sexual abuse was from, research explains that “it is assumed that sexual abuse by

relatives is more pathogenic than sexual abuse by non-relatives as it is closely related to a

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dysfunctional family environment, which must be taken into account in the understanding of the

development and interpersonal problems and psychological symptoms.” (Linden & Zehner,

2007, p. 452) This is significant to the patient because if it was a family member, it could create

more problems relating to her mental illness and if we did know who the offender was, we could

treat the patient more effectively to her past.

The patient has a past diagnosis of depression and presented with symptoms of anxiety to

the ED, which could be correlated to her history childhood of sexual abuse. In another research

study performed by Dawn Peleikis, Arnstein Mykletun, and Alv Dahl (2004, p.71), it states

A main finding of this study is that among women treated for anxiety disorders and/or

depressions those with a history of CSA have a significant higher load of all childhood

adversities compared to those without CSA…Lack of parental protection against threats

posed by others and an environment described as non-protective and non-supportive, with

conflict, violence, and martial turbulence were the most commonly FBRF associated with

CSA.

In this article, CSA stands for “child sexual abuse” and FBRF stands for “family background risk

factors.” Despite there was not any family history of mental illness, the family could have

contributed to the patient’s mental illness. It is unknown who the sex offender was, but if it was

someone in the family, it could create detrimental family dynamics and could contribute to the

overall health of the patient.

Describe the psychiatric evidence based on nursing care provided and milieu

activities attended

Psychiatric evidence based on nursing care provided and milieu activities are portrayed

on the psychiatric unit at Trumbull Memorial hospital. This unit provides a safe and therapeutic
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environment for all patients to heal, which is extremely important. The number one priority for

all these patients is safety. There are many measures taken for the safety of the patients, workers,

and visitors. First, the unit is a locked down unit. This means there are two doors that are locked

before getting in or out of the unit. The nursing station must buzz the visitor in or they must have

a key. Not only is the unit locked, the nurses station and other rooms on the floor are locked.

They have a secluded PICU area for the severe patients for the protection of them, the other

patients, and the workers.

The patients’ rooms are also modified for their safety. Their bathroom mirrors are not

made of glass, they are made of polished steel in case of damage or breaking, the pieces could

not be used for harm. There are no paper bags on the unit, instead they use brown paper bags to

reduce the risk of suffocation. The curtains are tear away and perforated so if the patient put

pressure, such as body weight, the curtains could not hold and would rip if attempted to hang

themselves. The nurses must check on each patient and document every fifteen minutes. Upon

admission, the patient’s belongings are searched and all dangerous or potentially dangerous

objects are taken, such as shoe laces. The patient and their belongings will be searched for

weapons and drugs. Some patients, such as suicidal patients, are unable to shower unattended,

therefore a nurse must supervise.

The floor provides many opportunities to learn about their diagnoses, reduce stress, and

learn effective coping mechanisms. All patients have the option to go to and participate in group.

If the patient attends group, it increases their chances of being discharged compared to not

participating and staying in their room being isolated. The floor provides group therapy and

therapeutic groups for the patients to learn about medication therapy, daily goals, coping skills,

and much more. Other activities that the floor provides are coloring pages with crayons, puzzles,
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board games, and the Nintendo Wii. To help the patients on this floor, the unit provides a daily

scheduled that is strictly followed. These schedules provide structure for these patients and helps

making decisions less stressful. The goal of these strategies is for the patient to use them outside

of these walls. By using a daily schedule and effective coping mechanisms, it can contribute to

less decompensation and positive outcomes for the patient.

Analyze ethnic, spiritual, and cultural influence that impact the patient

In the patient’s chart, there was no religion documented, but the patient had referred to

God, church, and the bible multiple times during the interview. When discussing her family

dynamics, she stated about her mother, “I promised God that I would go back to Florida before

she dies.” The patient denied that her mother was sick. The patient had expressed missing her

mother and wanting to hold her. I had asked her about this statement relating to God later on the

in the conversation and about her religion, but she reverted the statement and said to me, “I know

you are not religious.” This shows another sign of paranoia because I had never mentioned if I

was religious or not nor did I make comments or actions for the patient to believe that. After this

statement, she continued to say that the only book she would read on the floor was the bible. She

had mentioned that this was one of her coping skills. I had asked if she goes to church and she

responded that she tries to go every Sunday, but it is a hassle. It is most likely a hassle due to

lack of transportation and the patient had expressed that she does not have many friends or talk

to her neighbors.

Evaluate patient outcomes related to care

Patient outcomes for a schizophrenia patient may include an ability to relate satisfactorily

with others, recognizes distortions of reality, has not harmed self or others, perceives self

realistically, demonstrates the ability to perceive the environment correctly, maintains anxiety at
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a manageable level, relinquishes the need for delusions and hallucinations, demonstrates the

ability to trust others, use appropriate verbal communication in interaction with others, and

perform self-care activities independently. (Morgan & Townsend, 2017, p.354) For this patient,

some of these outcomes apply, but most importantly, the priority outcome should be that the

patient is compliant with medication. This can be met with proper education and comparing the

feelings of being compliant with medication versus feelings of noncompliance with medication.

There are examples of outcomes from the above paragraph that contribute to this specific

patient. Interventions must be put in place to reach these outcomes. To achieve an ability to relate

satisfactorily with others can be met by going to group and participating or going to therapy to

talk about situations. The patient can achieve not harming self or others by learning coping

strategies when she has these feelings of aggression or agitation. She can learn relaxation

techniques or can use journaling to express feelings. Another important outcome for the patient

would include perceives self realistically. I believe this is important because the patient lacks

self-confidence, especially from her childhood, which could contribute to psychiatric symptoms.

Two important outcome for the patient that contributes to one another are demonstrating the

ability to trust others and use appropriate verbal communication in interaction with others. This

is extremely important to the patient because of the experienced paranoia. The patient had

verbally yelled at another patient on the floor because she had felt feelings of judgement from

that patient and had a verbal outburst. Interventions to help achieve this outcome would be to

teach the patient proper conversation strategies and what she can do when feeling an outburst of

aggression.
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Summarize the plans for discharge

The patient currently lives in an apartment by herself and is unemployed. The patient had

expressed that she does not want to look for a job when leaving the psychiatric unit. She had also

expressed wanted to go to Florida to visit her mother. When ready for discharge, the

multidisciplinary team could discuss attempting home visits again and medication compliance.

These would be beneficial to the patient because the patient’s counselor had noticed symptoms

during a follow up visit and if the patient is in her own environment, it could be more relaxing

and comfortable for the patient. Medication compliance should be the main priority for the

patient upon discharge because this was the reason her symptoms were present and the reason for

this admission. If the patient had learned any coping skills or information regarding her illness or

medication, she should utilize those practices when she returns to her everyday life.

Prioritize list of actual diagnoses using individualized NADA format

1. Social Isolation related to repressed fears as evidenced by history of sexual abuse

2. Impaired Home Maintenance related to inadequate support system as evidenced by lack

of communication with family

3. Anxiety related to suspicious thoughts as evidenced by patient yelling at another patient

for looking in her direction

4. Impaired Social Interaction related to altered thought process as evidenced by

dysfunctional interaction with family and peers

5. Fear related to real or imagined threat to own well-being as evidenced by aggression

List of potential nursing diagnoses

1. Risk for chronic low self-esteem related to inability to trust others

2. Risk for Loneliness related to social isolation

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3. Risk for other-directed violence related to being suspicious of others and their actions

4. Risk for trauma related to cognitive or emotional difficulties

5. Risk for suicide related to psychiatric disorder and poor support system

Conclusion

Mental illness is a huge factor that contributes to the patient’s and the family’s life. To be

able to survive with mental illness, the patient must be compliant with the medication and

learning to cope with everyday struggles that occur. It is important for the patient to understand

the benefits of medication compliance, group therapy, and psychiatric agencies and units.

Dealing with mental illness is a constant battle and must be dealt with every single day, which

makes compliance to the treatment plan so important.

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References

Geonten, P., Semah, F., & Trinka, E. (2006). Valproic Acid in Epilepsy Pregnancy-Related

Issues. Drug Safety, Vol. 29 Issue 1, p.1-21.

Linden, M., & Zhener A. (2007). The Role of Childhood Sexual Abuse (CSA) in Adult Cognitive

Behaviour Therapy. Behavioural and Cognitive Psychotherapy, Vol. 35 Issue 4. P.447-455

Morgan, K.I., & Townsend, M.C. (2017). Essentials of Psychiatric Mental health Nursing:

Concepts of Care in Evidence-Based Practice. Philadelphia: F.A. Davis Company.

Peleikis, D., Mykletun, A., & Dahl, A. (2004). The realive influence of childhood sexual abuse

and other family background risk factors on adult adversities in female outpatients treated

for anxiety disorders and depression. Child Abuse & Neglect, Volume 28 Issue 1, p.61-76.

Pedersen, D.D. (2018). Psych Notes: Clinical Pocket Guide. Philadelphia: F.A. Davis Company.

(2016). Schizophrenia. U.S. Department of Health and Human Services: National Institute of

Mental Health. Retrieved from

[Link]
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