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Josh DeSalvo
Abstract
A case study was performed on a 22 y.o. male who presented to the BAC with severe
anxiety as well as behaviors of crying loudly for his girlfriend, evidence of flight of ideas,
pressured speech, exaggerated facial and verbal expressions, inappropriate behavior through
wearing girlfriend’s jeans and refusing to remove them because he stated, “I feel closer to her,”
curled up in bed while punching the pillow, displayed word salad and rambling speech, and at
times was religiously preoccupied. This case study looks to identify precipitating events to
hospital admission, behaviors observed throughout care, treatments being provided and their
effectiveness, psychological diagnoses and the symptoms related, family history of mental
illness, psychiatric evidence based nursing care the patient participates in, any evidence of
ethnic, cultural, or spiritual influences impacting patient, priority nursing diagnoses to address
based on psychological diagnoses and patient situation, potential diagnoses, how patient is
progressing or regressing in treatment by identifying outcomes in care, and determining plans for
discharge.
COMPREHENSIVE CASE STUDY 3
Objective Data:
The patient, D.N., presented to the E.D. for a Psychiatric evaluator on 11/6/17. Per report,
D.N. was found outside his apartment with evidence of extreme anxiety due to relationship
issues between himself and his girlfriend. D.N. was received to the BAC and reported feeling
anxious with a complaint that has been persistent, moderate in severity, and worsened by
emotional upset. While in BAC, D.N. was observed as crying loudly for his girlfriend, evidence
of flight of ideas, pressured speech, exaggerated facial and verbal expressions, inappropriate
behavior through wearing girlfriend’s jeans and refusing to remove them because he stated, “I
feel closer to her,” curled up in bed while punching the pillow, displayed word salad and
rambling speech, and at times was religiously preoccupied and required medication to be
appropriately maintained in the BAC. D.N. required an involuntary admission to the unit on
11/7/17. After admission and orientation to unit, D.N. was observed as loudly crying to self.
D.N., however, was medication compliant and received PRN Ativan and Haldol given P.O.
Initial assessment findings related to D.N.’s psychological state included avoidance gaze,
exaggerated expressions, unstable affect, alert, excessive motor activity (restless), evasive
poor judgment and insight, and no SI or HI. According to the psychiatrist progress note, D.N.
would not respond to questions, just stared. D.N. was agitated when leaving room, PRN meds.
administered, refusal to sign involuntary permit, yelling and crying, and D.N. stated he hopes the
medication will help him out. On 11/7/17, D.N. attended community meeting and stated his goal
was, “To get better for my girl,” as well as, attempting to participate in 4:00 wellness group,
however, D.N. became quickly agitated and began yelling, requiring removal from the group. As
COMPREHENSIVE CASE STUDY 4
clinical picture progressed, at 6:44 a.m. of 11/8/17, D.N. was observed out of his room acting
bizarre, smelling the air and growling at staff, blurting out random words, and was easily
agitated. D.N. was administered Ativan 1 mg P.O. for anxiety and agitation. According to
reassessment data relating to D.N.’s psychological status, attentive concentration was observed,
recent and remote memory intact, speech remained fast and pressured, unkempt appearance,
cooperative with positive attitude, intermittent eye contact, euthymic mood, bizarre affect,
thought process and association is logical and tangential, paranoid delusions present, and
progress note concluding with D.N. not improving as expected. On 11/8/17 at 10:16 a.m., D.N.
attended group therapy. D.N. was in and out of room but was willing to sit and listen
appropriately, minimal participation but appropriate and normal speech, logical thought process,
flat affect, and euthymic mood. On 11/9/17, student nurse and patient interaction phase occurred.
D.N. was pleasant and cooperative however inappropriate social interaction behavior through
lack of respect for personal space, lack of social etiquette through passing gas and asking
interviewer about it, and lifting up shirt to show tattoos. D.N. displayed intermittent eye contact,
restlessness related to anxiety through shifting weight and constantly crossing and uncrossing
arms, flight of ideas, and rambling speech. D.N. identified stressor relating to breakup with
girlfriend but did not identify possible implementation of maladaptive coping mechanisms
resulting in hospitalization. D.N. exhibits high interest in cannabis substance and desired use for
medicinal purposes in his care. D.N. identified shadow boxing as a possible coping mechanism
but did not identify how it could be used appropriately in the event of a stressor. D.N. did not
identify strong family support system and denied religious affiliation. Care concluded with D.N.
on 11/9/17 at 8:30 p.m. in which D.N. refused his scheduled Zyprexa 10 mg P.O., and also
COMPREHENSIVE CASE STUDY 3
refused his scheduled Lamictal 50 mg P.O. D.N. informed the nurse that, “I only want my
Ativan, and I refuse these other ones.” D.N. was respectful, yet firm on his decision.
Based on the presenting data, clinicians have used the DSM IV-TR, Axes I-V in order to
diagnose D.N. with Schizoaffective disorder, bipolar type. Criteria necessary to meet this
diagnosis include, “This mental disorder is diagnosed when the symptom criteria for
Schizophrenia are met and during the same continuous period there is a Major Depressive,
Manic or Mixed Episode. During that same period hallucinations or delusions must be present
for at least 2 weeks while there are no mood symptoms” (“BehaveNet,” 2017). Due to this
diagnosis, D.N. has been prescribed Zyprexa, an atypical antipsychotic, in which the drug
neurotransmitter levels and treat both positive and negative symptoms of schizophrenia
(“Epocrates,” 2016). D.N. is also ordered maintenance doses of Lamictal, bipolar disorder/mood
stabilizer, in which the drug inhibits voltage-dependent sodium channels, decreasing presynaptic
glutamate and aspartate release. D.N. presented with subjective anxiety that has been persistent,
moderate in severity, and worsened by emotional upset. D.N. has Ativan, anti-anxiety and
benzodiazepine, ordered prn in which the drug binds to benzodiazepine receptors and enhancing
GABA effects forcing the body to slow down physiologically (“Epocrates,” 2016). D.N. also has
a severe dependence with cannabis, and anxiety related to lack of use or possible withdrawal
may also be treated by Ativan. D.N. is also participating in group therapy and individual therapy
sessions daily in order to foster coping techniques that promote adequate adaptation to stressors
accepting personal responsibility and personal control of situations, developing effective impulse
control, understanding effective social interaction, and identifying personal sense of drive
COMPREHENSIVE CASE STUDY 6
through developing goal related thinking. D.N. is seen daily by psychiatrist who observes
patient’s behaviors, responses to medication and treatment, and general psychological state. D.N.
from the patient and a structured schedule is provided in order to minimize anxiety and develop
patient to healthcare team trust. PRN medications are ordered in the event of illness exacerbation
and administered to prevent self-harm of patients and other directed violence. Individual group
therapy sessions are conducted to provide patients the opportunity to reflect on illness, past
behaviors, and past experiences in order to effectively develop coping strategies to deal with
future stressors, heal past emotional and psychological trauma, and promote healthy interaction
as a member of society.
Summarize:
and subjective complaints of anxiety. Each diagnoses has its own set of expected symptoms but
disorders (depression or mania). The client may appear depressed, with psychomotor retardations
and suicidal ideations. Or symptoms may include euphoria, grandiosity, and hyperactivity. The
decisive factor in the diagnosis of shizoaffactive disorder is the presence of hallucinations and/or
delusions that occur for at least 2 weeks in the absence of a major mood episode.” Specific
affective flattening, alogia, avolition-apathy, and anhedonia” (Robinson et al., 1999). Due to
prior hospitalization and current behaviors, D.N. also required a diagnosis of bipolar 1 disorder.
Townsend also states, “Bipolar 1 disorder is the diagnosis given to an individual who is
experiencing a manic episode or who has a history of one or more manic episodes. The client
may also experience episodes of depression” (book ch. 26). As far as common behaviors
associated with bipolar disorder type 1, Skjelstad, Malt, and Holte (2010, pp. 1-13) identified,
hyperactivity, anxiety, and mood swings,” to be clinically significant in diagnostic criteria. Upon
admission to hospital, per EMS and Pt. report, D.N. was experiencing severe anxiety. Townsend
(2017, p. 531) determines abnormal anxiety as, “…out of proportion to the situation that is
creating it and a level of anxiety that interferes with social, occupational, or other important areas
of functioning.” Anxiety can often be difficult to identify due to its subjective nature, however,
common feelings are experienced across this patient population as well as some identifiable
physical signs such as, “excessive worry, motor tension, hyperarousal, insomnia, chest pain,
Identify:
Stressors often determine our ability to effectively function in society. Due to mental
illness, it is difficult to develop effective coping mechanisms to promote adequate cognitive view
points and establish optimal behavior responses to situations. Often times, medication regimens
are required to alter our brain chemistry in order to maintain normal neurotransmitter levels and
have contributed to a schizoaffective, bipolar type 1 disorder, and anxiety exacerbation. D.N.’s
prior hospital admission was 10/27/17-11/3/17, where he was admitted for mania and psychosis.
COMPREHENSIVE CASE STUDY 8
Pt. was treated in the inpatient psychiatric setting with Zyprexa and PRN medications. Pt.
responded well to treatment and was discharged to home. However, in the opinion of his
psychiatrist, pt. continued to present as hypomanic and disorganized, but court didn’t support
continued stay. Pt. verbalized that he was not compliant with medication since discharge and
used cannabis. So, lack of medication compliance and substance use may have contributed to
brain chemistry imbalance and exacerbation of disease state. Pt. also identified social interaction
issues due to recent break-up with girlfriend that contributed to anxiety state in which pt. was
crying loudly for his girlfriend with evidence of flight of ideas, pressured speech, inappropriate
social behavior in which D.N. was wearing his girlfriend’s jeans and refused to take them off,
exaggerated facial and verbal expressions, insomnia, word salad, religiously preoccupied, and in
active acute psychosis. Pt. also identified other precipitating stressors including financial stress
Discuss:
As identified in the previous section, D.N. has a history of illness exacerbation pertaining
to mania and psychosis. Patient’s chart also identified previous history of psych. med. use, as
well as, a previous history of suicide attempt. No information was provided on suicide attempt
specifics such as method, support provided, or reason for attempt. Chart also identified a family
Cardno and Owen (2014), “Schizoaffective disorder has been less investigated but shows
substantial familial overlap with both schizophrenia and bipolar disorder. A twin analysis is
consistent with genetic influences on schizoaffective episodes being entirely shared with genetic
influences on schizophrenic and manic episodes, while association studies suggest the possibility
COMPREHENSIVE CASE STUDY 3
bipolar subtype.”
Describe:
to develop patient trust, improve cognitive distortions, promote social interaction, improve
equilibrium within the body. Certain psychiatric evidence based nursing care is necessary in
order to foster the most beneficial outcomes for the patient. As far as individual psychotherapy
goes from a nursing stand-point, nurses, identified by Townsend (2017, p. 439), need to focus
on, “Reality-oriented individual therapy is (as) the most suitable approach to individual
psychotherapy,” and later states, “The primary focus in all cases must reflect efforts to decrease
anxiety and increase trust.” Particular steps taken to reach this goal are done by being honest,
direct, and providing respect for the patient’s dignity. Education should be provided to help the
client identify evidence of stressors and their emotional feelings to those stressors as well as
(Townsend, 2017, p.440). D.N. is scheduled to meet with his psychiatrist daily to determine
psychological status and progression in treatment. Patient is also scheduled to attend daily group
therapy and be an active participant in the activities provided. However, according to psychiatric
evidence based nursing care, “Group therapy in inpatient settings is less productive. Inpatient
treatment usually occurs when symptomatology and social disorganization are at their most
intense. At this time, the least amount of stimuli possible is most beneficial for the client”
(Townsend, 2017, p. 440). With D.N., pt. attempted to attend the 4:00 p.m. wellness group on
11/7/17, however, he became quickly agitated, started yelling, and left the room. Pt. on 11/8/17
COMPREHENSIVE CASE STUDY 10
attempted to attend group therapy at 10:16 a.m. however, he was in and out of room with
minimal participation but improvement was noted in concentration, speech, logical processing,
and treatment of others. According to Townsend (2017, p. 441), the benefits of group therapy
fundamental aspect of care for schizoaffective patients. Townsend identifies that, “In the
treatment setting, the healthcare provider can use praise and other positive reinforcements to help
the client reduce the frequency of maladaptive or deviant behavior.” D.N. is provided behavior
therapy with each healthcare interaction and care provided in order to promote behavior change.
In the realm of behavior involves social skills training. According to Townsend (2017, p. 441),
“Social dysfunction is a hallmark of the disorder,” and later states, “The educational procedure in
social skills training focuses on role-play. A series of brief scenarios are selected. These should
be typical situations clients experience in their daily lives and be graduated in terms of level of
difficulty. The health care provider may serve as a role model for some behaviors.” Social skills
training, like behavior therapy, is an opportunity for the health care provider to role model
appropriate behavior in every social interaction and help the patient identify areas of weakness in
order to facilitate optimal social interactions in the future. Although therapy can be intentional
and direct in patient care, subtle therapy can be provided to the patient through the environment
they occupy. Milieu therapy helps to establish a structured environment through hospital rules
and policy in the hope that through, “ group and social interaction; rules and expectations are
mediated by peer pressure for normalization of adaptation. When patients are viewed as
responsible human beings, the patient role becomes blurred. Milieu therapy stresses a patient’s
COMPREHENSIVE CASE STUDY 3
rights to goals and to have freedom of movement and informal relationships with staff”
(Townsend, 2017, p. 441). D.N. identified the benefits of connecting with other patients during
the interview process, and stated how it helps to reduce anxiety and promote a feeling of
connection. D.N. is also encouraged to establish a daily goal in order to promote pt. autonomy
and self-confidence that can be transitioned to the non-hospital setting. Mental illness often
results from biological and biochemical imbalances effecting the presentation of disease states.
For schizoaffective disorder, medication is required for effective health maintenance and optimal
quality of life. Anitpsychotic medications, “…are effective in the treatment of acute and chronic
experienced a psychotic episode relapse within a year. This relapse rate can be reduced to about
medication regimen of olanzapine, 2nd generation antipsychotic, 10 mg/2 times a day for
schizoaffective disorder and evidence of psychosis. Pt. also receives Ativan 1 mg for acute
anxiety and agitation exacerbations. However, D.N. has a history of medication incompliance
and on 11/9/17 D.N. refused his scheduled Zyprexa 10 mg by mouth and also refused his
scheduled Lamictal 50 mg by mouth. As long as the patient is not a harm to himself or others, he
has the right to refuse this level of treatment. Patient education is crucial in order to develop
rapport as well as to help the patient gain a better understanding of their disease state in order to
Analyze:
In continuation, ethnic, spiritual, and cultural influences can play a major role in
influencing patient’s behaviors and cognitive outlooks on life. D.N. is a caucasian male who was
COMPREHENSIVE CASE STUDY 12
raised in the United States the entirety of his life. He lived in a suburban to urban environment
and was considered middle to low socioeconomic status when he lived with his parents. D.N. is
now unemployed and would be considered under the federal established poverty line. D.N.
stated on admission that part of the contributing factors or precipitating events leading to his
illness exacerbation included financial stress. D.N. stated he has read the Bible, Koran, and
Torah. D.N. stated that he believes in God but enjoys doing what he wants to do. He stated his
mantra is peace, love, and happiness and everything else will fall into place. Part of D.N.’s
psychiatric disorders includes a history of severe cannabis use disorder or dependence. Use of
particular substances may relate to the type of culture D.N. surrounds himself with and
Prioritized:
Nursing diagnoses help to identify a problem and the contributing factors, in order, to
help establish goals and implement interventions to help the patient reach the desired, realistic
goals in their care. For D.N., several nursing diagnoses are appropriate for his present
inadequate coping skills, disturbed thought processes, and impaired communication as evidence
by recent breakup with girlfriend and no known familial support, lack of understanding of
disease process and necessity for medication management, history of severe cannabis
communication evident through flight of ideas and poor concentration; Social isolation related to
COMPREHENSIVE CASE STUDY 3
lack of trust and delusional thinking as evidence by poor group meeting attendance and focus,
communication patterns and disturbed thought processes as evidence by poor social boundaries,
thought pattern consisting of flight of ideas, poor concentration in interactions, and delusions of
grandeur and persecution present. Interventions need to target the source of the problem and
frame in order to deliver the most optimal care for this patient as possible. Although, these are
prioritized nursing diagnoses for this particular patient, there is a potential for many other
List:
Based on the patient’s medical diagnoses, the patient may present with anyone of the
following potential diagnoses if their symptoms so shall indicate, such as: Ineffective activity
feelings, impaired communication; Fear related to altered contact with reality; Hopelessness
related to long-term stress from chronic mental illness; Insomnia related to sensory alterations
contributing to fear and anxiety; Risk for compromised human dignity: risk factor: stigmatizing
label; Risk for loneliness: risk factor: inability to interact socially; Risk for self- and other-
directed Violence: risk factors: lack of trust, panic, hallucinations, delusional thinking; and
readiness for enhanced hope: express desire to enhance interconnectedness with others and
COMPREHENSIVE CASE STUDY 14
problem-solve to meet goals. Although the patient is not diagnosed with these nursing diagnoses,
a flexible approach must be taken in order to deal with the priority problem at any given time.
Evaluate:
In order to determine that nursing interventions are effective, goals must be evaluated to
determine if the establish goal was met or not met and what revisions need to made. For D.N.,
based on the nursing care plan, his goals maintain a sense of continuity in the sense that even
though the goal was met this shift; we also want to see the patient continue to meet the goal
throughout the entire stay. These types of goals, based on the chart, are often written as short
term goals and relate to self-harm behaviors. For example, the goal for 11/7/17 included the
client’s ability to verbalize suicidal ideations and 11/8/17 included the exact same goal as well as
absence from self-harm and maintaining adequate nutrition. D.N.’s long term goals relate more
so to behavior and cognitive changes pertaining to his chronic illness rather than the short-term
goals relating to illness exacerbation. Examples of long-term goals may include appropriate
social interaction. For the goal, appropriate social interaction on 11/7/17, patient did not meet the
goal due to being withdrawn to room much of shift, disheveled appearance, poor concentration,
and would walk away during any interaction. As D.N.’s stay continued, goals such as patient’s
ability to verbalize a decrease in frequency and intensity of racing thoughts were considered to
be continually evaluated or looked at on an ongoing basis. D.N.’s behavior and cognition on days
of 11/8/17 and 11/9/17 included descriptions as pt. presently denies SI, HI, and hallucinations
,however, pt. was seclusive to self even while up and out on unit. Pt. did attend evening group
and was compliant with medications. Observations of 11/9/17 stated pt. was up and about on the
milieu and attended probate this morning. Pt. is cooperative, thoughts have slowed, and no unit
or behavioral cautions are implemented at this time. D.N. is recommended to see his psychiatrist
COMPREHENSIVE CASE STUDY 3
daily in order for a psychological assessment to take place and determine the effectiveness of
treatment and if goals are effectively being met. On 11/8/17, according to the psychiatrist
progress note, D.N. was not improving as expected. Thus, goals need to be modified and original
Summarize:
Plans for discharge begin with admission. Care is tailored to promote patient autonomy in
which the patient plays an active member in his/her care in order to promote better and more
sustainable outcomes. However, goals cannot always be effectively reached due to complications
relating to illness, financial barriers, lack of access to resources, patient motivation level, or any
number of unforeseen events. In order to promote patient safety and improve health outcomes,
discharge plans may need to be revised for the individual’s situation. Due to D.N.’s improvement
trajectory, his discharge and outpatient care required to be bumped back in order put D.N. in the
most optimal position to be as healthy as possible upon discharge. Upon admission, D.N. had an
appointment in Struthers with Psycare on 11/13/17 at 11:45 a.m. and he was also scheduled to
see Dr. Norvak on 11/10/17 at 1:00 p.m. However, based on psychiatric assessment relating to
patient’s social interactions, intensity and severity of racing thoughts, presence of bizarre
behavior, and lack of medication compliance, required the outpatient appointments to be moved
to 11/17/17 in which D.N. will attend appointments at Struthers Psycare at 10:45 a.m. and see
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