CASE STUDY 1

Case Study

Samuel Lofaro

Mental Health Clinical

Youngstown State University

CASE STUDY 2

Abstract

The involuntary hospitalized psychiatric patient whom is diagnosed with bipolar disorder and

post-traumatic stress disorder, presenting with suicidal and homicidal ideation is interviewed and

observed for the purpose of this case study. The observation and interview took place over the

course of a clinical on the 5th of October. Topics of discussion include; the objective data

regarding the patient, a summary of the psychiatric diagnoses, stressors and behaviors that

precipitated hospitalization, patient and family history of psychiatric illness, spiritual influences,

patient outcomes, possible plans for discharge, and lists of both actual and potential diagnoses.

The care of a mental health patient varies in many ways from that of a mentally healthy

individual and unique considerations and challenges must be taken in and accounted for in order

to maintain the safety and improve the health of the afflicted individual.
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Case Study

Objective Data

The client I am using as the subject of this case study was cared for on the date of

October 5th, 2016. The client was admitted to the hospital on the date of October 3rd, 2016. He

was diagnosed with Bipolar disorder and Post-traumatic stress disorder(PTSD) as his psychiatric

illnesses.

The following are his DSM IV-TR axes:

I: Bipolar Disorder, Post-traumatic stress disorder

II: None applicable

III: Gout, hypothyroidism, hepatitis C, polysubstance abuse, gun-shot and stab wound

IV: six family members dying within two years and illicit drug use.

V: Not available on chart.

When the client was admitted to the hospital, he was observed by other staff and

described as very hypermanic with flights of ideas and very pressured rapid speech, stating his

mood as very depressed and feeling suicidal every day, also expressed feeling homicidal with no

specific plan of who he wants to kill staff also noted that he was very tangential and at times

hard to direct in a conversation.

During my time on the unit, I was able to talk to and observe the client. Some of my

observations are similar to the aforementioned, though client appeared less manic. I noted that he

appeared animated, relaxed, friendly, and neat, with no inappropriate motor activity. He was

communicating his thoughts with a flight of ideas, rapidly transitioning through many subjects,

although still communicating in an organized and chronological fashion. He appeared to have a

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flat affect when discussing his homicidal ideation. He was experiencing disturbances in his

thought content while I was observing him, specifically delusions of persecution. He stated that

authority was always out to get him. He appeared insightful to precipitating events leading to

hospitalization. He was able to verbalize alternatives to suicide and coping mechanisms that may

assist him in the future.

As previously stated, my client was diagnosed with the following medical conditions;

gout, hepatitis C, and hypothyroidism. On the unit he was receiving treatment for his

hypothyroidism with a prescription for levothyroxine, 50mcg daily.

For the safety of all patients on the floor, the unit is locked and requires a staff badge to

be let in or out. The unit is equipped with state of the art devices to prevent clients from harming

themselves. There are sensors above the doors to prevent hanging, mirrors are made of metal

sheets rather than glass, belts and shoelaces are not permitted, sharp objects are not permitted,

clients are checked every fifteen minutes, confidentiality is maintained by strict contact lists,

door handles are designed to prevent hanging, doors are sloped, and chairs and tables are

weighted, to name a few of the implemented rules and devices used to promote safety of staff

and clients.

The psychiatric medications that my patient was prescribed are: Haldol(haloperidol),

Vistaril(hydroxyzine), Atarax(hydroxyzine), Flexeril(cyclobenzaprine), Seroquel(quetiapine),

and Minipress(prazosin). He was prescribed Haldol and Vistaril for treatment of anxiety and

agitation, Atarax for treatment of anxiety, Seroquel for treatment of Bipolar disorder, and

Minipress, which is typically used to treat high blood pressure, in this case used to treat night
CASE STUDY 5

terrors related to PTSD. According to research done by Kung, Espinel, and Lapid, Prazosin is a

well-tolerated generically available medication that has a small but positive evidence base for the

treatment of PTSD-associated nightmares. Given the difficulty of treating nightmares, combined

with the continued presence of patients with nightmares, prazosin can be an important

pharmacologic treatment option. (2012) This research supports the unorthodox use of Minipress

to treat night terrors like the ones reported by this client.

Summarize the psychiatric diagnoses

The subject of this case study was diagnosed with two psychiatric illnesses, the first

being Bipolar disorder. This disorder is described by Townsend (2015) in our mental health

textbook as a disorder characterized by mood swings from profound depression to extreme

euphoria (mania), with intervening periods of normalcy. The behaviors one can expect to be

associated with this illness depend entirely on the stage the individual is presently in. If that

person is in the manic stage, which is separated into the hypomania, acute mania, and delirious

mania stages, based on intensity of symptoms and their effect on functioning; the individual may

be cheerful, but easily irritated. (Townsend, 2015) They will be easily distracted, with flighty

ideas, increased motor activity, and euphoria. (Townsend, 2015) With the more severe stages, the

bipolar patient can be emotionally labile, disoriented, delusional, extremely distractible, frenzied,

and may injure themselves or others. (Townsend, 2015) In the depressive stages of the illness,

which vary from mild, moderate, and severe; an individual may be expected to display sadness,

hopelessness, sluggish behavior, difficulty concentrating, anorexia, somatic symptoms, self-

destructive behavior, overeating, apathy, delusional thinking, and suicidal ideation to name a

few. (Townsend, 2015)

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The other psychiatric illness to be discussed that effected this patient is Post-Traumatic

stress disorder. As defined by Townsend, Post-Traumatic stress disorder is A syndrome of

symptoms that develop following a psychologically distressing event that is outside of the range

of usual human experience. (2015) A patient suffering from this illness would commonly

display the following symptoms; re-experiencing the traumatic event, a sustained high level of

anxiety, general numbing of responsiveness, intrusive recollections or nightmares, inability to

remember the event, symptoms of depression, substance abuse, anger, and aggression.

(Townsend, 2015) The subject reported night terrors related to abusive behavior that had

occurred in his past.

Identify the stressors and behaviors that precipitated

The client described his stressors that precipitated his behavior as six family members

dying over the time of two years. He stated that two of the individuals he lost, his mother and

grandfather, were very important to his support system, and that upon losing them, not only was

it very hard for him, but he no longer had what he would consider people to go to with his

problems. According to research conducted by Maulik, Eaton, and Bradshaw: for general

medical service use, increased social network or support was associated with increased service

use, but increased social support from relatives and friends or higher number of relatives was

associated with reduced use of more formal mental health or specialty psychiatric

services.(2009) Their research demonstrates that the lack (or loss) of a support system directly

contributes to increased rates of mental health and psychiatric services, such as admission to this

specific unit. Behaviors that precipitated his hospitalization include suicidal tendencies with past

suicide attempts, which include tying an ace bandage around his neck in the ED before
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presenting to the mental health unit. He also stated that he abuses prescription drugs, specifically

benzodiazepines at home.

Discuss patient and family history of mental illness

The subject described a lengthy personal history of mental illness. He has been admitted

to this unit in the past six other times. He also stated that he has been admitted to Trumbull

memorial hospital, Turning Point crisis center, and Riverbend. He stated that he has had

emotional problems his whole life, which he attributes to having started because of his father

who was abusive to him, his mother, and brother. He has a past history of suicide attempts

including overdosing and cutting his wrists, he has also tried to strangle himself with an ace

bandage. He also reported that he currently receives counseling at Valley Counseling. He reports

being taken to the county jail eighteen times, attributing at least a few of the arrests to his

mental illnesses.

He described his father as having unspecified mental illnesses, and he also stated that his

brother suffers from similar night terrors related to abuse from their father during their

childhood.

Describe the psychiatric evidence based nursing care

Evidence based nursing care provided to the client includes all of the safety features

mentioned before, especially relevant are the suicide and self-harm precautions instated such as

weight-triggered door monitors and safety checks by a nurse every fifteen minutes. These

measures are important for ensuring that patients dont have the means to harm themselves or
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commit suicide if they are suicidal. Medications are another responsibility of the nurse that are

important for maintaining and treating illnesses present on the unit.

Another important responsibility of the nurse is maintaining the milieu by ensuring that

the unit is maintained in a relaxed, quiet, peaceful state that fosters personal growth and

recovery. Milieu activities attended by the client include both group and individual therapy with

a nurse, social worker, or other mental health care specialist. These are especially important for

individuals such as the subject who has trouble maintaining relationships as it aids in the

development of communication skills. Many factors go into the maintenance of the milieu,

including establishment of the therapeutic nurse-client relationship, and communicating

therapeutically with the patient.

Analyze ethnic, spiritual, and cultural influences

The subject described a strong affiliation with the streets and illegal behavior throughout

his life. He verbalized that the streets raised him and described being exposed to many

negative coping mechanisms through this lifestyle and the associated activities. The impact of

this influence on his life is still apparent today, as the subject abuses non-prescribed drugs and

has a history of assaults and violent behavior, along with scars and wounds related to his past

behavior.

The subject also described a spiritual influence as being important in his life. He stated

that he is Catholic and describes his religious affiliation as helpful when it comes to coping

strategies and dealing with his stressors. He was upset that the unit wouldnt allow him to carry

his rosary beads due to safety precautions, but allegedly let someone else have one. Religious
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affiliation affects mental health outcomes in many ways. Not only is an individual with a

religious affiliation less likely to commit suicide than their non-religious peers (Townsend,

2015), but according to research; most religions prescribe or prohibit behavior that may inhibit

health, religion can provide social cohesion and a sense of belonging to a group, fellowship in

times of stress, religion can enhance acceptance, endurance, and resilience, and religious

practices can maintain mental health and prevent mental diseases. (Behere, Bas, Yadav, and

Behere, 2013)

Evaluate the patient outcomes related to care

There are many applicable goals for a client who suffering from bipolar disorder and

experiencing both suicidal and homicidal ideations. Some goals that apply to this particular

subject and can apply to other similar clients are; client is able to express anger through

appropriate verbalization and healthy outlets this goal leads to better management of stress and

negative feelings in a way that does not put the client in danger, client will have an absence of

self-harm this goal involves protection of client safety and maintaining a safe environment that

fosters recovery, absence of suicidal ideations, this goal is enacted to prevent the client from

having any thoughts of harming them self, able to display appropriate communication and

problem solving, this goal aspires to push the client to a level of functioning where they will be

able to integrate into society and be capable of making rational decisions that better their health

and make them capable of forming healthy relationships.

Summarize the plans for discharge

Although discharge plans were not established at the time of care for this client, many

suicidal clients require similar planning that can be generalized but may be tailored to fit specific

needs. Individual barriers to care should always be considered with discharge planning. Some
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expected plans a nurse can expect for client discharge include scheduling an early follow up,

providing crisis cards for patients to contact medical professionals, developing a personalized

safety plan which may include safety contracts, and personally reviewing discharge planning

with the patient to ensure competency and understanding. According to research conducted by

the Suicide Prevention Resource Center; The risk of suicide attempts and death is highest within

the first 30 days after a person is discharged from an ED or inpatient psychiatric unit, yet as

many as 70 percent of suicide attempt patients of all ages never attend their first outpatient

appointment. (Suicide Prevention Resource Center, 2013) This research helps to stress the

importance of making and ensuring that patients follow up with some sort of psychiatric care

because patients who have been freshly discharged are at a greatly increased risk of suicide.

Prioritized list of all actual diagnoses

As mentioned earlier in this paper, the subject of my case study is diagnoses with the

following psychiatric illnesses: Bipolar Depressive Disorder, Post-Traumatic Stress Disorder,

and Night terrors. He is also diagnosed with the following medical illnesses: gout,

hypothyroidism, hepatitis C, and polysubstance abuse. The following actual nursing diagnoses,

listed in order of priority, may be applicable to this patient:

1. Risk-prone health behavior as evidenced by history of stab wound and gunshot wound

related to aggressive and threatening behavior.

2. Disturbed thought process as evidenced by delusions of persecution by related to

homicidal ideations of doctors, cops all the way on up to the president.

3. Insomnia as evidenced by difficulty falling asleep related to verbalizing recurring

nightmares and lack of sleep.

4. Post-trauma syndrome as evidenced nightmares by related to childhood abuse by father.
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5. Impaired social interaction as evidenced by inability to develop satisfying relationships

related to stating I dont have any friends because I talk too loud and fast.

Risk-prone health behavior is the priority here because the patient not only has a past history

of violence, but is experiencing suicidal and homicidal ideations which may be acted upon

and directly affect his safety. Disturbed thought process is another priority diagnosis here

because this diagnosis endangers not only the patients safety but the safety of others because

of verbalized threats. Insomnia comes next because sleep deprivation can be dangerous and

is a high risk factor for suicide. Post-trauma syndrome follows because this is what leads to

the insomnia and sleep problems. Impaired social interaction comes last according to

Maslows hierarchy because it falls under the category of love and belonging. The

aforementioned either fall under the safety, or physiological categories.

List of potential nursing diagnoses

Listed below are potential diagnoses that may occur in the client and are deemed

appropriate for the subject of the case study, based on his psychiatric and medical illnesses.

1. Risk for Suicide as evidenced by past suicide attempts and verbalization of suicidal

ideations.
2. Risk of loneliness as evidenced by verbalization of no support system or friends.
3. Risk for complicated grieving as evidenced by loss of six relatives over two years.
4. Risk for other-directed violence as evidenced by verbalized homicidal ideations.
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References

Behere, P. B., Das, A., Yadav, R., & Behere, A. P. (2013, January). Religion and Mental

Health. Indian Journal of Psychiatry.

Kung, S., Espinel, Z., & Lapid, M. I. (2012, September). Treatment of Nightmares with

Prazosin: A Systematic Review. Mayo Clin Proc.

Maulik, P. K., M.D., Eaton, W. W., Ph. D, & Bradshaw, C. P., Ph. D. (2009, September). The

Role of Social Network and Support in Mental Health Service Use: Findings from the

Baltimore ECA Study. Psychiatric Services.

Suicide Prevention Resource Center. (2013, November). Continuity of Care for Suicide

Prevention: The Role of Emergency Departments. Retrieved October 14, 2016.

Townsend, M. C., & Townsend, M. C. (2015). Psychiatric nursing: Assessment, care plans, and

medications, 9th edition; Psychiatric mental health nursing: Concepts of care in evidence-

based practice, 8th edition. Philadelphia: F.A. Davis.