Running head: MENTAL HEALTH CASE STUDY 1

Mental Health Case Study: 17-Year-Old Male

Carly Greenwood

Youngstown State University

Author Note

[Include any grant/funding information and a complete correspondence address.]

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Abstract

This study is completed on a 17-year-old male patient at Belmont Pines acute care facility on

February 16, 2018. The Patient was previously admitted on February 13, 2018 for signs of

suicidal and homicidal ideation from Wooster Emergency Department. The patient was brought

to the Emergency Department from Village Network, where he is currently a resident, after he

cut his wrists with a sharp object he had found within the facility. He was previously diagnosed

with Bipolar disorder, Autistic Disorder, Attention Deficit Hyperactivity Disorder,

Unidentifiable Learning Disabilities. In order to maintain confidentiality, the patient will be

referred to as R.H. and his name will not be used.

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Mental Health Case Study: 17-Year-Old Male

Objective Data

This case study was started on February 16th, 2018 at Belmont Pines acute care facility.

R.H. is currently a resident at Village Network, which provides residential treatment for young

adults with behavioral and psychological issues requiring treatment. Employees of the facility

brought R.H. to the emergency department in Wooster, Ohio after he had made threats to harm

himself and people within Village Network and after he attempted cutting his wrists with a sharp

object he had found. While in the emergency department, he had told nurses that the employees

bully him and that he wants to kill them all; he mentioned that over the past few months he has

been hearing a male voice in his head telling him to hurt people. The patient stated to the ED

nurses, “I like to see people in pain. I want to taste the blood of my enemies. I am not a normal

human being.” After being identified as high risk for suicide due to his suicidal/homicidal

tendencies, he was admitted to Belmont Pines.

Prior to being admitted to Belmont Pines, the patient was being treated for mental illness

and has a history of admissions to multiple psychiatric hospitals. The following are his DSM IV-

TR axes:

I. Bipolar Disorder, Attention Deficit Hyperactivity Disorder

II. Autistic Disorder, Unidentifiable Intellectual Disorders

III. None

IV. Poor grades, loss of familial support, sexual abuse

V. None

The patient was admitted to the hospital on February 13th, 2018 and had treatment for

three days once I had the opportunity to speak with the patient. Prior to my visit, R.H. became
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violent towards staff members at Belmont Pines threatening harm and becoming physical which

led to a Dr.’s order for restraints until the patient calmed down. On the day of care, R.H. seemed

very calm while sitting in the group room and was openly initiating conversations with multiple

people within the room. Although calm, he still seems to be very hyperactive as he would

repeatedly change positions or fidget with the objects around him. He seemed to only be

interested in speaking to females and was less open to talking when placed in group therapy with

only males. He was wearing his own clothes from home consisting of jeans and a button-down

flannel and his hair was wet from a shower, so he has been keeping up with daily hygiene.

For safety reasons, all doors within the facility are locked and only staff members are

capable of opening the doors with the electronic keys. Any personal items that the patients want

to bring into the facility have to be looked over to make sure that could be considered unsafe.

This could include shoe laces, belts, hoodies and mirrors which are common belongings of

individuals. Mirrors within the facility are made of metal sheets rather then glass, there are no

sharp objects within the facility, only plastic silverware is used in the dining hall, pencils are only

permitted during group hour and are only around 2 inches in length. These are all special

precautions to keep the patients within Belmont Pines safe.

Since R.H. is a healthy young male without any medical diagnoses, he is not currently

taking any daily medications to treat medical issues. However, he is taking daily medications to

help treat his psychological and behavioral diagnoses: bipolar disorder and attention deficit

hyperactivity disorder. The patient is prescribed Depakote (divalproex Na) 250 mg, three times

daily and Zyprexa (olanzapine) 10 mg daily for treatment of manic episodes associated with the

diagnosis of bipolar disorder. He also takes Adderall (dextroamphetamine and amphetamine) to

treat his ADHD. He is also prescribed Haldol (haloperidol) and Trazodone (desyrel) to take as
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needed. While taking Depakote, valproic acid levels need to be checked routinely to be sure that

the patient is within therapeutic range. The normal therapeutic range is 50-125 mcg/mL and this

patient’s level on the day of care was 70.3 mcg/mL which would put him in therapeutic range.

Summarize the Psychiatric Diagnoses

R.H. was diagnosed with bipolar disorder and ADHD prior to hospitalization but was

being treated for recent suicidal and homicidal ideation. According to Scrandis, “The Diagnostic

and Statistical Manual of Mental Disorders (DSM-5) lists two types of BPD: bipolar I and

bipolar II. Symptoms include inflated self-esteem, decreased need for sleep and feeling rested,

racing thoughts, more talkative or rapid speech and more interest in sex or risk-taking behavior”

(Scrandis, 2014, P. 31). When diagnosing BPD, it is important to review the symptoms and to

rule out any other possible causes which could commonly include, hypothyroidism, anemia,

tumors or syphilis (Scrandis, 2014, P. 31). The patient had lab values drawn while in the hospital

and had normal T4 and TSH levels which would rule out hypothyroidism and he also received a

full head to toe examination. The Doctor’s found that he had no medical conditions that could be

mimicking the signs and symptoms of bipolar disorder. He also had a full drug screen completed,

which came back negative, to rule out any pharmacological causes of his symptoms. Some of the

substances that could induce a manic episode are: stimulants, corticosteroids, decongestants,

caffeine, alcohol, CNS depressants and benzodiazepines (Scrandis, 2014, P.31).

When admitted into the emergency department at Wooster, the patient was determined to

currently be suicidal. In order to come to this conclusion, the nurses asked him if he wanted to

harm himself. When the patient answered yes, they asked if he wanted to kill himself and if he

had a plan. The patient said that he hears a voice that is telling him to kill himself and others but

did not have an active plan. The National Institute of Mental Health (NIMH) has put in place a
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screening tool to see what patients are at risk to commit suicide by using a standard

questionnaire. The questions identify whether the patient has thought about killing or harming

themselves, attempted to commit suicide in the past or if they wish they were dead (NIMH). It

was important to complete a suicide screening on R.H. because of his attempts to harm himself

and because patients with bipolar disorder are at a high risk for committing suicide, as states by

Scrandis (Scrandis, 2014, P. 32).

R.H. was also diagnosed with attention deficit hyperactivity disorder which affects

approximately 6.4 million school aged children within the United States, according to Wesemann

(Wesemann, 2018, P.8). “ADHD is a clinical diagnosis characterized by three symptom clusters

of inattention, hyperactivity and impulsivity. Individuals who have ADHD are identified as

having a predominate presentation in either inattention, hyperactivity and impulsivity, or both”

(Wesemann, 2018, P.10). He presents with all three; hyperactivity, impulsivity and inattention

which had made it difficult for him to focus in school and he feels that’s why his grades are so

poor. Interestingly, studies are beginning to show a link between ADHD and autism spectrum

disorder, which is another diagnosis of R.H. According to Weill, “At least one-third of children

with ASD are estimated to have ADHD as a comorbid condtion” (Weill 2018, P.26).

Identify the Stressors. The patient has a long history of hospitalization due to

exacerbations of behavioral problems. His mother was an avid drug user while pregnant and

admitted to taking multiple illegal substances during all nine months of pregnancy. As a young

child he was sexually abused by his mother and did not have much familial support or anyone to

confide in. He also witnessed his mother attempt to kill his infant sister by placing her in the

freezer because ‘she wouldn’t stop crying.’ These topics were the main focus during his active

therapy sessions since he states he feels like he has no one to turn to.
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A week before being admitted into Belmont Pines, his step mother went to visit him at

Village Network, where he is currently a resident. Village Network works with adolescents with

behavioral issues in order to help them cope better within the environment using therapies and

familial encouragement. R.H. says that when his step mother came to visit, she had told him that

no one wants him and they don’t want to deal with him any longer. After her visit, staff began to

notice that he was very agitated and more verbally aggressive. He became angry and started to

threaten staff which escalated to him stating he was going to kill himself and everyone around

him. The employees are unsure about how he obtained a sharp object, but noticed that he was

trying to slit his wrists with it and that was when he was brought to the Wooster emergency

department.

Discuss Patient and Family History. The patient has a history of mental illness within

the family including both parents, grandparents and an uncle. His father was diagnosed with

anxiety, as well as his grandfather who also committed suicide. His uncle has bipolar disorder

and suicidal tendencies. Lastly, his mother has depression and struggles with drug and alcohol

abuse.

Describe the Psychiatric Evidenced-based Nursing Care. Using evidenced based

practice, the facility is kept as safe as possible by keeping the doors locked within the facility and

there are precautions in place. All of the patient’s belongings are gone through to be sure that

there is nothing harmful, the mirrors are sheet metal rather than glass, pencils are not allowed,

and all eating utensils are plastic. While at Belmont Pines, the patient’s attend multiple group

therapy sessions throughout the day as part of their treatment plan. They must attend these

sessions in order for the doctor to release them from the facility as evidence that their condition

is improving. The adolescent boys had their own group sessions separate from the adolescent
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girls and younger children. The session only had six boys compared to the 19 girls, which made

the group easier to control and also made it easier for each patient to participate. The purpose of

the first two sessions were to help the patients identify coping mechanisms and how to use them

when they become angry, anxious or upset. Whenever the group became side tracked or

unfocused the therapist, or individual running the group, would redirect them and keep the

session on track. Most of the day is spent in group sessions, they even share rooms, so they are

not alone within their bedrooms, however they also have meetings with the social worker and

family members to work on helping the patient adapt at home.

Analyze Ethnic, Spiritual, and Cultural Influences. R.H. was raised by his mother for

most of his childhood who struggles with drug and alcohol addiction. His mother continued

using drugs throughout both of her pregnancies and made it a large part of her life which greatly

impacted the patient. He was exposed to drug dealers and the effects of the drugs on his mother.

This was the only life R.H. knew which made it hard for him to adjust behaviorally in school and

outside of the home.

The patient had no spiritual beliefs that he followed but he does believe that he is strictly

in control of his own life. He believes that there is “no higher power out there” and that “we are

in control of our own lives and can do what we want.”

Evaluate the Patient Outcomes. Patient outcomes are considered obtainable goals that

we can create for patients in order for them to achieve optimal health. There are specific goals

for each patient and at the end of the day or shift it is identified whether the patient met the

criteria or not. Some of the patient’s outcomes are as follows:

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- Patient will remain free of any angry outbursts including becoming verbally or

physically aggressive during group sessions.  Goal met. Patient was calm and

cooperative throughout all group sessions.

- Patient will actively participate in group sessions.  Goal met. Patient willingly

answered questions and shared ideas during group therapy.

- Patient will identify one coping mechanism he can use at home when he becomes

angry.  Goal Met. Patient identified listening to music as a way of coping when he

becomes angry.

Summarize the Plans for Discharge. The patient was on a 10 day hold at Belmont Pines

and during that time the staff will be working towards developing a discharge plan. Social

workers, doctors and nurses evaluate him daily to see when it is appropriate to discharge him

from the facility. He must actively participate in group sessions, be within therapeutic ranges for

all medications and show signs of improvement. After being in the acute facility, he may then be

a part of the outpatient clinic and return on the weekdays from 9-3 for treatment. The patient as

of now will not be discharged home or back to Village Network but rather a different facility

similar to Village Network that meets the patient’s needs.

Prioritized List of Actual Nursing Diagnoses

- Risk for injury related to extreme hyperactivity as evidenced by stating he wants to

kill himself and others.

- Disturbed thought process related to overwhelming stressful life events as evidenced

by inappropriate non-reality-based thinking.

- Impaired social interaction related to excessive agitation as evidenced by

dysfunctional interaction with family, peers and others.

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- Ineffective individual coping related to inadequate level of perception of control as

evidenced by destructive behavior towards self and others.

- Interrupted family process related to mental disorder as evidenced by changes in

familial participation.

List of Potential Nursing Diagnoses:

- Chronic low self-esteem related to depressive state as evidenced by family stating,

“no one wants him.”

- Powerlessness related to consistent negative feedback as evidenced by lack of

familial support.

- Anxiety related to situational crisis as evidenced by poor impulse control,

hyperactivity and pacing.

Conclusion. R.H. has a childhood history that could be linked to his behavioral problems

and mental health diagnoses. His recent hospitalization is due to suicidal and homicidal

ideations, but he also is diagnosed with bipolar disorder, ADHD, and autism. He is currently on

medications to treat these diagnoses and is receiving treatment at Belmont Pines Acute Care

facility. The hospital is working with him in order to manage his behavioral issues and work

through some of his past in order to keep him safe.

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References

National Institute of Mental Health. Ask Suicide-Screening Questions. Retrieved from The

National Institute of Mental Health website: https://www.nimh.nih.gov/labs-at-nimh/asq-

toolkit-materials/asq-tool/screening-tool_155867.pdf

Schmid, A.M., Troug, A.W. & Damian, F.J.(2011) Care of the Suicidal Pediatric Patient in the

ED. American Journal of Nursing, 111(9), 34-43.

Scrandis, D.A. (2014) Identification and Management of Bipolar Disorder. The Nurse

Practitioner, 31-37.

Weill, V.A., Zavodny, S. & Souders, M.C. (2018) Autism Spectrum Disorder in Primary Care.

The Nurse Practitioner, 43(2), 21-27.

Wesemann, D., Van Cleve, S.N. (2018) ADHD from Childhood to Young Adulthood. The Nurse

Practitioner, 43(3), 8-14.

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