CASE STUDY 1

Mental Health Nursing Clinical Case Study

Cambrie Campbell

Youngstown State University

NURS. 4842 Mental Health Nursing

Mrs. Teresa Peck

November 19, 2021

CASE STUDY 2

Abstract

J.M. is a 35 year old admitted to the acute inpatient psychiatric unit at Generations following a

suicide attempt. He has a medical diagnosis of Major Depressive Disorder and Generalized

Anxiety Disorder. J.M. also has William-Beuren’s Syndrome. He experiences frequently suicidal

ideations and depression on a daily basis. Symptoms have been managed with medical treatment

(via cardiovascular agents, antidepressants, and anticonvulsants). Nursing interventions

implemented focus on cessation of suicidal thoughts and self-harm precautions.

CASE STUDY 3

Objective Data

Patient identifier J.M.

Age 35

Sex Male

Date of admission October 31, 2021

Date of care November 4, 2021

Psychiatric diagnosis Major Depressive Disorder

Other diagnoses Generalized Anxiety Disorder, William-Beuren’s Syndrome

Behaviors on admission J.M. had held a knife to his throat and threatened to slice it. J.M. had

also written and left a suicide note to his mother. The patient states “I’m just in so much pain”

and that he wanted it to end.

Behaviors on date of care J.M. was interacting with another patient prior to the conversation.

When approached, he was calm and willing to speak. It is noted his general appearance was poor.

He had poor hygiene, unkempt grooming, a slouched posture, and greasy/unwashed hair. His

speech patterns were slow and dysphoric. J.M.’s general attitude was cooperative, friendly,

attentive, and only slightly guarded. His mood was sad, depressed, anxious, fearful, and

despairing. J.M.'s affect was congruent with mood and appropriate for someone working through

the grieving process. His affect could be described as slightly blunted, flat, and dysphoric.

Evaluating his thought process, it was found he was able to think abstractly and concretely. He

was not experiencing delusions and/or hallucinations. It was the content of his thought where

issues were arising. He reported suicidal ideations, intent, and a plan, as well as some

obsessive/compulsive ideas and phobias. Treatment for J.M. includes suicidal floor safety
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measures, psychiatric medications for stabilization, group therapy, one on one therapy, social

work meetings, and grief groups.

Safety and security measures

Patients were not permitted off the unit, staff badges were required to enter and pass

various sections of the facility, staff was present within patient sight at all times (excluding

bedrooms), hazardous items were removed prior to admission, pencils and pens were accounted

for on the unit and taken when not in use, markers were used for coloring, suicidal fixations such

as flat doorknobs and box beds were in place, aggressive patients were moved to a different part

of the unit, the nurse’s station had clear plastic windows enclosing it from the common area,

medications were locked behind a metal garage door, a nurse verified all medications before

administration to the patient

Laboratory Results

Laboratory Value Normal Range Explanation of value

Measure

Potassium 4.6 3.5-5.0 Within Defined Limitations

Sodium 141 136-145 Within Defined Limitations

Glucose 109 70-100 Patient’s glucose is slightly

above normal range. Patient has
a BMI of 36 and a family history
of Diabetes Mellitus type 2.

Blood Urea 16 7-26 Within Defined Limitations

Nitrogen

Creatinine 0.95 0.5-1.4 Within Defined Limitations

Red Blood Cells 5.53 4.5-6.0 Within Defined Limitations

CASE STUDY 5

Hemoglobin/Hemat 16.7/47.9 13.5-17.5/41-5 Within Defined Limitations

ocrit 3

White Blood Cells 8.0 4.5-11.0 Within Defined Limitations

AST/ALT 20/29 13-61/8-34 Within Defined Limitations

Lithium/Depakote/ N/A Not recorded Unable to assess

Tegretol Level

TSH/T4 N/A Not recorded Unable to assess

Drug Toxicology Positive Negative Patient tests positive for

Benzodiazepines at Emergency
Room. Patient is prescribed
Xanax PRN for anxiety at home.

Blood Alcohol <.003 <.08 Within Defined Limitations

Level

QTC/ECG 387/Abnormal <440/Normal Patient chart states Septal

Infarction, age undetermined.
Patient reports multiple heart
surgeries growing up in relation
to cardiac difficulties from
William-Beuren’s Syndrome.

Patient Medications

Drug Patient Dose Normal Freque Classification Reasoning

Range ncy

Furosemide 20 mg b.i.d. 20-80 mg in 0900 Loop Diuretic Edema/Fluid

(Lasix) divided 2100 Retention
doses (max
600 mg
daily)

Gabapentin 300 mg t.i.d. 900-1800 0900 CNS Agent; Pain

(Neurontin) mg/day 1700 Anticonvulsant
2100

Losartan 100 mg daily 25-50 mg/d 1200 Antihypertensive; Blood

(Cozaar) in 1-2 Cardiovascular Pressure
divided Agent
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doses (max
100 mg/d)

Atenolol 50 mg daily 25-50 mg/d 0900 Antihypertensive; Blood

(Tenormin) (max 100 Autonomic Pressure and
mg/d) Nervous System Anxiety
Agent

Buspirone 10 mg t.i.d. 7.5-15 mg/d 0900 CNS Agent; Anxiety

(Buspar) in divided 1700 Anxiolytic
doses (max 2100
60 mg/d)

Clonazepam 0.5 mg b.i.d. 0.5-1.0 mg 0900 CNS Agent; Anxiety

(Klonopin) q3d (max 20 2100 Anticonvulsant;
mg/d) Benzodiazepine

Clonidine 0.1 mg b.i.d. 0.1 mg b.i.d. 0900 Cardiovascular Blood

(Catapres) (max 2.4 2100 Agent; Analgesic; Pressure
mg/d) Antihypertensive

Duloxetine 30 mg at 40-60 mg in 2100 CNS Agent; Depression

(Cymbalta) bedtime 1-2 divided Antidepressant;
doses SNRI

Psychiatric Diagnoses

J.M. received two psychiatric diagnoses and one genetic diagnosis that are to be defined

and elaborated on to follow. The psychiatric diagnosis being Major Depressive Disorder and

Generalized Anxiety Disorder. William-Beuren’s Syndrome is the genetic diagnosis he received

at a younger age.

The Mayo Clinic states that “Depression is a mood disorder that causes a persistent

feeling of sadness and loss of interest. Also called major depressive disorder or clinical

depression, it affects how you feel, think and behave and can lead to a variety of emotional and

physical problems. You may have trouble doing normal day-to-day activities, and sometimes you

may feel as if life isn't worth living” (Mayo Clinic Staff, 2018). Major Depressive Disorder lasts
CASE STUDY 7

at least two weeks. The patient can experience symptoms such as unexplained weight loss or

gain, insomnia or hypersomnia, impaired concentration, impaired decision-making, suicidal

thoughts, and feelings of hopelessness, despair, and/or distress. These symptoms can affect the

individual’s occupation, socialization, and functioning (Videbeck, 2020, p.285).

Generalized Anxiety Disorder is characterized by an excessive feeling of worry

and anxiety felt by the individual at least 50% of the time within a 6 month frame or longer. Due

to a lack of control over the constant worrying the person may exhibit symptoms such as

“uneasiness, irritability, muscle tension, fatigue, difficulty thinking, and sleep alterations”

(Videbeck, 2020, p.237).

William–Beuren Syndrome is also known as Williams’ Syndrome. It is a multisystem

genetic disorder. This syndrome is caused by the deletion of the Williams–Beuren syndrome

chromosome region. This syndrome is rare, affecting approximately 1 in 10,000 persons.

Deletion of this gene shows increased risk for diabetes, hypertension, and anxiety in these

individuals. William’s Syndrome presents in various ways. One presentation, which J.M. seems

to present as, “is characterized by hypercalcemia plus persistent growth failure, characteristic

facial appearance, “mental retardation,” heart murmur, and hypertension, while the other was

characterized by supravalvular aortic stenosis” as well as a distinctive facial appearance

reflecting similarly to those with growth retardation and mental retardation (Pober, 2010).

Identifying stressors and behaviors precipitation current hospitalization

J.M. presents to the emergency room on October 31st, 2021 with anxiety, agitation, and

suicidal ideations. When asked if he has a suicidal plan, he answers by stating “I was going to
CASE STUDY 8

slice my throat” to the nurse. He also expresses “I’m just in so much pain” to the staff. His

admitting diagnosis is Major Depressive Disorder.

After investigating further, his mother informs staff of important information pertinent to

J.M.’s psychiatric exacerbations. His mother reveals that the father had recently passed away in

August and J.M. had not had these psychiatric experiences prior to the incident. She reports that

she has been in the process of obtaining guardianship of J.M. since the father’s death, and has

been watching for J.M. and administering his medications. Additionally, she hands staff the

suicide note J.M. had written. She also informs the nurse that the patient’s father had diabetic

neuropathy, which J.M. now believes is what causes his own pain and this pain causes him to

have increased anxiety consistently. J.M. made the suicide attempt in front of her.

While talking with J.M., he shares some factors that uncover potential contributing

factors precipitating his hospitalization. Prior to admission, it is unclear whether he was

compliant with his medications or not. He expressed a dependency on someone to organize and

remind him of his medications. He also shares he is unaware of important information pertaining

to his medications. When asked, he did not know what medications he was on, how many he

should have been taking, when he should have been taking them, why he was taking them, or the

side effects of his medications. Moreover, he fails to express any information relating to the

recent passing of his father. He also fails to mention that this is his third psychiatric admission

within the past two months. When asked about any potential triggers to his anxiety/sadness he

blames neuropathic pain. The way he describes the onset of anxiety in relation to the nerve pain

seems to resemble that of an anxiety attack. He does express a fear of the recurrence of this pain.

He claims things go “blank” when he feels an onset occurring.

CASE STUDY 9

Patient and family history of mental illness

The patient is partially aware of all his diagnosis. Pertaining to his psychiatric diagnosis,

he is aware that he should not be feeling this way, that he knows something is wrong. He was

only recently diagnosed with them (within the past two months). The passing of his father seems

to have triggered these onsets. He is more aware of his genetic diagnosis of William-Beuren’s

Syndrome. He was able to explain how it caused developmental/intellectual issues, as well as

cardiac and facial formation problems. There is no family history of mental illness listed in his

chart. The only time the patient shares information pertaining to his family is during the group

session. Even here he only briefly mentions his mother and brother, listing them as his support

system.

Psychiatric evidence based nursing care provided

Nursing interventions implemented for J.M. are maintaining safety, self-harm

precautions, assisting through the grief process, encouraging self-control over life situations, and

ensuring that his needs related to nutrition, elimination, activity, rest, and personal hygiene are

met. Additional nursing intervention, related to J.M.’s medications, would be reminding him

when to go to the medication station to receive his prescriptions, and educating him on their

purpose, side effects, and intended results.

Ethnic, Spiritual and Cultural influences

J.M. is a white/caucasian single male. He had lived with his father up until his death. He

now lives with his mother. Their economic class is unknown. J.M. does not mention a
CASE STUDY 10

job/employment. His source of income is unknown. He does not express any religious

beliefs/practices.

Evaluation of patient outcomes

1. Has self-harm been avoided? Yes.

2. Have suicidal ideations subsided? No.

3. Does J.M. know where to seek assistance outside of the hospital if suicidal thoughts

reoccur? Not sure.

4. Has the client discussed the recent loss with the staff and/or family members? No.

5. Is J.M. able to verbalize feelings and behaviors associated with each stage of the grieving

process and recognize one's own position in the process? No.

6. Is the client able to verbalize positive aspects about self, past accomplishments, and

future prospects? Yes.

7. Can the client identify areas of the life situation over which he has control over? No.

8. Is anxiety at a manageable level? Yes.

9. Can the patient function with exposure to the stimuli? No.

J.M. actively seems to have responded to some of the interventions and therapy however,

there are many areas where J.M. could improve with the continuation of care. For instance, J.M.

has refrained from self-harm while under acute care but he states he is still experiencing suicidal

ideations “around 10-15 times a day”. Also, J.M. is unsure of where to seek assistance aside from

a hospital and his mother if suicidal ideations were to recur upon discharge. Additionally, J.M.

has not discussed the recent loss with the staff and has not verbalized feelings/behaviors
CASE STUDY 11

associated with the stages of the grieving process. It is not known if J.M. is even aware of the

stages of the grieving process. J.M. recognizing his own position in the process appears

unachievable at this current time due to the lack of previous knowledge and difficulty with

denial. Moreover, it is evaluated that J.M. is unable to gain control over his anxiety exhibited by

restlessness, fidgeting, and stuttering during the group when exposed to stimuli (stimuli being

discussing death, family, and pain).

Discharge

When J.M. is discharged, he will be returning home where he resides with his mother.

J.M. may be probated to stay longer at Generations due to the lack of cessation of suicidal

ideations. J.M. would benefit from medication education, establishing an everyday home

routine/schedule, reaching out to family/friends for emotional support, encouragement in

self-care, having an activity or hobby to instill responsibility, motivation, and purpose (such as

having a support animal, joining a club, starting a career, extending schooling). Support services

that he may benefit from include support groups, group therapy sessions, and/or one-on-one

therapy sessions.

Nursing Diagnosis

Prioritized Nursing Diagnosis for J.M. (NANDA format):

1. Risk for suicide related to depressed mood as evidence by recent statements of suicidal

ideations and attempt prior to admission

2. Ineffective coping related to recent death of father as evidence by recent suicide attempt

3. Self-neglect as evidence by poor hygiene and lack of grooming

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4. Complicated grieving related to death of father as evidence by denial

5. Stress Overload related to death of father as evidence by three psychiatric emergency

admissions within the past two months

Potential Nursing Diagnoses:

1. Panic anxiety

2. Powerlessness

3. Disturbed thought process

4. Self-care deficit

5. Caregiver role strain

(Peck, Depression Disorders Chapter 17, 2021)

(Health-Conditions: For All Your Healthcare Needs, 2018-2020)

Conclusion

Major Depressive Disorder is an alteration in mood expressed by sadness, despair, and

pessimism. These individuals experience a decrease in dopamine, serotonin, and norepinephrine.

These neurotransmitters are responsible for feelings of pleasure, happiness, movement, and

motivation. These all may become diminished or absent with Major Depressive Disorder. The

mood disorder can be life-long, meaning the client may never stop experiencing fluctuating

stages of depression (Peck, Depression Disorders Chapter 17, 2021).

J.M. is currently still working through the grieving process, and trying to do so with his

recent diagnosis of Major Depressive Disorder. J.M. is at risk for suicide ideations and another

suicidal attempt. Goals for J.M. are cessation of suicidal ideations and plans, practicing positive

coping strategies, medication compliance, and compliance at outpatient follow-up appointments.

CASE STUDY 13

With encouragement, compliance, supportive services, and consistent treatment, J.M. may

hopefully prevent further suicidal ideations/self-harm and obtain his optimal quality of life.
CASE STUDY 14

References

Mayo Clinic Staff. (2018, February 3). Depression (major depressive disorder). Mayo Clinic.
Retrieved from
[Link]
007

NANDA Staff. (2018-2020). Health-Conditions: For All Your Healthcare Needs

[Link]

[Link]

Peck,T. (2021, November 10). Depression Disorders Chapter 17 [Lecture notes/PowerPoint

Slides]. Blackboard. [Link]

Pober, B.R. (2010). Medical Progress - Williams-Beuren Syndrome. Williams Syndrome

Association. Retrieved from

[Link]

Videbeck, S.L. (2020). Psychiatric - Mental Health NURSING. Wolters Kluwer.