Mental Health Case Study

Tori McCormick
Youngstown State University Nursing
February 16, 2018
 Abstract
The purpose of this paper is to evaluate, identify proper nursing diagnoses,
outcomes and goals that will better prepare the patient for success. Through
research articles that identify coping strategies like mindfulness meditation and
correlation to correctable behavior such as smoking, marijuana and cigarettes I have
identified proper outcomes that will if incorporated lead to great outcomes for this
patient. This case study evaluates the patient’s culture, family history and past
experiences, which all directly relate to the patients manic psychosis and
depression. Identifying the problem is the only way to find a solution this analysis
gives the first steps to implementing a solution.
Objective Data / Identify: Pt JK presented to hospital on 1/30/18 with neighbor

and was involuntarily admitted. The patient lives at parents home and this is where

the event happened that led up to her being admitted. The parents were away on

vacation when patient went into a state of mania. According to the chart the patient

complained of insomnia for two to three days, states she has been napping but not

sleeping throughout the night. Patient was on Ambien but it wasn’t working. She

complained of her fibro myalgia pain that could have led to this. Her neighbor

reports she was hallucinating. The police were at her house twice the day of

admittance and the second time she was found running round the home with a

knife. Patient states she was chasing a man in all black who she saw riding up and

down her street on a dirt bike. Then him and his gang were riding dirt bikes on her

roof and that is when she went outside with a knife. There was no mention of this in

the IPA interview. She has been diagnosed with anxiety, acute psychosis, depression,

and lumbago that she says is fibro myalgia, and tobacco use disorder. Patient was

previously in an outpatient program at turning point.

Throughout the interview on the date of care February 6 2018 the patient

was extremely positive, and made it known that she was cured and ready to go

home. The patient had a pleasurable affect and was in a good mood to talk to us.

However patient did have some disturbance in thought process such as

perseveration, this means she repeated the same word in reply to different

comments or questions. Her word was happy, she always led the questions back to

her being happy. She had a disturbance in thought process which were delusions. A

delusion that her parents were in danger and a delusion that she was happy and
cured. A registered nurse made a note in the chart earlier this day explaining the

patient responded “ All of my problems were taken care of in the form of

medication” when asked about the events leading to her admission. On February 5

2018, just the day before my interview with the patient the psychiatrist notes that

patient is not improving as suspected. The family also states on February 5 that the

patient is still not herself and that she thinks the hospital workers are hacking into

her cell phone for information. With evidence from others it is clear that the patient

still obstacles to overcome. Some of the history of the patient includes sexual abuse,

fibromyalgia, post traumatic stress disorder and major depressive disorder.

During the interview one of the leading questions was could you explain

what events brought you in here. The patient used defensive coping throughout the

interview. By this mechanism the patient was so positive with every thing she told

us and did not want anything brought up that would challenge her being cured so it

was natural for her to leave out the fact she had called the police twice and that she

was running around her home with a knife. However the patient was coherent and

understood the situation enough to get the basics of the story correct. She identified

her neighbor to bring her in and that she had a terrible gut feeling that something

was wrong with her parents, which made her act the way she did.

During the interview the patient was pleasant enough, when asked if she

would talk to us she replied that she would only for a little bit though because of the

pain. This pain was brought up numerous times over the length of the interview.

You can tell that this pain is something that impacts her life on a daily basis. Upon

talking about how the patient was doing today she explains that she was rather
emotional today at group. She did not want to talk about that particular experience

however she brought up something that I thought was unrelated at first. She said

she had a teacher he would put all of the kids desks in a circle and let them sit on the

top of them. She said he did this so he could look up girls skirts but he never looked

up hers, that she wasn’t sexually abused at school. She let us know that this man

sexually assaulted children and that he was never caught. Later we find out that she

wrote down an instance of an abuse in her past (her grandfather raping her) on a

piece of paper during group which she explains freed her. The patient is currently

single, and she got a tattoo of her exes initials covered up with a star on her ring

finger. Patient feels like she is a burden on her family for living with them but she

lets us know that she indeed helps out around the house to the best of her abilities.

She wants to go back to school to be able to help out more. She also has plans to go

to church with her father and cook with her mom because she knows that will make

them happy. She explains that she has a better relationship with her father than

mother. To control the patient’s psychosis, depression and anxiety disorders the

patient is on medication. This medication she’s stated has taken care of all of her

problems.

The medications that the patient is taking are as follows: benztropine 2mg

injection everyday, diazepam 5mg by mouth every eight hours as needed,

haloperidol 5 mg inj every day, hydroxyzine 50 mg by mouth every day as needed,

levetricatam 750 mg by mouth every night at bedtime, quetiapine 300mg every

night at bedtime, topiramate 100 mg twice a day, trazodone 50 mg every night at

bedtime as needed and vortioxetine 5 mg every day. The benztropine and

haloperidol are for agitation, the diazepam, topiramate and hydroxyzine are for

anxiety, quetiapine, trazodone, and vortioxetine are for mood and sleep. As stated

before the patient stated that these medications have taken all of her problems

away.

Summarize: To summarize this patient she was brought in for acute mania

psychosis. Psychosis is characterized by an impaired relationship with reality, and is

a symptom of a serious mental disorder. People who are psychotic may have either

hallucinations or delusions. Hallucinations are sensory experiences that occur

within the absence of an actual stimulus. Symptoms of psychosis include difficulty

concentrating, depressed mood, sleeping too much or not sleeping enough and

suspiciousness. All of witch the patient exhibits in some degree.

This patient was noted to smoke marijuana in earlier years which she quite

but along with marijuana she chained smoked cigarettes from an early age.

According to Hannah Jones PhD from Center for Academic Mental Health people

who smoke either cannabis or nicotine have a two to three times increase risk of a

psychotic outcome. She explained that this would help her cope with her problems

when she was younger. Also in this article Teenage Cannabis, Cigarette Use may

Heighten Risk for Later Psychosis she explains that there are confounding patterns

related to childhood psychotics experience being linked to teenage cigarette and

cannabis use. Another article that supports this study is Major Depression and

Stages of Smoking A Longitudinal Investigation. This study conducted by Naomi

Brestau correlates smoking correlates with major depressive disorder. In this study

it is explained how smoking is a coping mechanism that helps with stress. It is an

ineffective way of coping with stress. When a patient cannot cope with stress they

are more likely to have depressions which leads into major depression if not

handled properly. In my patient’s case the horror of her sexual abuse from her

grandfather may have triggered this smoking to deal with stress. Trying to cope at

such a young age is hard because you don’t have the necessary tools or thought

processes to only use effective coping strategies. Many turn to alcohol, drugs and

even nicotine to help cope. In this case it could definetly be called a contributing

factor.

Discuss: The patient has a history of mental illness however it is not hereditary.

There are no others reported in her immediate family with history of mental illness.

Allegedly her grandfather sexually abused her as a child but the client never

confirmed or denied or brought up any sexual abuse history in her life. Obviously if

this were true the grandfather would be mentally ill for sexually abusing a child but

what this patients depression is stemmed from is her past experience of abuse. She

also have chronic back pain which she contributes her depression to as well. This

back pain causes her insomnia which she treated with Ambien. No other people in

her family have fibromyalgia or insomnia.

Describe: Upon interview a mini- mental state examination (MMSE) was conducted.

The client was happy to cooperate and scored very well on all categories. The only

category she had slight difficulty with was counting backwards by seven, but given

time she too got that answer correct. This patient received an score of thirty out of

thirty meaning her cognitive ability has not been affected. The psychiatric based

nursing care provided is mostly geared toward making her more comfortable with
her flares of pain from her fibromyalgia. She said cold, light, noise, and people all

affect her pain. Some nursing practice that is applied is to follow the settings that

contribute to relieve the patients pain. The patient lists a slightly cooler

temperature, few to no people, dim lights and quiet are when she feels most

comfortable and the pain can go away. These are all things that can easily be done

by the nurse that can alleviate pain and therefore relieve depression in the patient.

Analyze: The ethical, spiritual and cultural influences are clearly all related to her

family. She attended a catholic school while she was younger, to which she

contributed a story of a teach looking up other girls skirts and abusing them but was

never caught. Personally I believe this is symbolic of what her grandfather did to

her. She did not feel comfortable talking about her experience but putting it into a

different perspective could have been therapeutic to her. Her father is a major

influence to her and he is very religious. Patient said she has the best relationship

with her father in her family. There are future plans to go to church with him

because patient knows it would make him happy. Patient lives in a small town and

worked at the Avon Target. This small town life contributes to her family values. She

plans to go back to school however because there isn’t one close to her she is

debating online classes for business.

Evaluate: Because the patient is using defensive coping it is hard to track her

progress. Doctors, nurses and family all state that progress is not moving in the right

direction. Patient is telling everyone exactly what they want to hear but people just

aren’t buying it. The patient still has not noted all of the events that lead up to her

being admitted in the hospital. She fears her court hearing and I believe she is saying
what she thinks is socially acceptable instead of letting her guard down and working

on herself. Whenever she is discharged the patient needs to follow up with

outpatient and continue her medication regimen.

Summarize: According to the patient she has post traumatic stress disorder,

normally when I think of PTSD I think of military vets who have been discharged but

there are so many other people with this disorder. Although many journal articles

focus on the military it is easily comparable to an event such as being sexually

abused by a grandfather. One article that is comparable is; Self-Care Mindfulness

Approaches for Refractory Posttraumatic Stress Disorder. In this article it gives

ways to cope with post traumatic stress disorder. One being mindfulness

meditation. Mindfullness meditation is used to increase awareness of where the

patient is now and focusing on the patients breath. Many people would shrug off a

breathing technique that could help them deal with such a traumatic event but

giving statistics will open their thoughts. In this article Marina Khusid explains “Two

random controlled trials (RCTs) of an 8-week mindfulness-based stress reduction

(MBSR) training course offered to cancer patients, illustrated significantly decreased

perceived stress and posttraumatic avoidance symptoms and increased positive

states of mind. ” Looking at the facts would open anyone’s mind and at least try this

coping strategy. It is essential to give all of the necessary and available tools upon

discharge. This could be the very thing that helps patient throughout manic states.

Other plans for discharge would be setting up appointment with outpatient

services. The patient is in a depressive state and needs therapy and an outlet. Also

better management of her fibromyalgia could be beneficial. Giving the patient non
pharmacologic ways to manage the pain would also be tools to help in the

management of depression. The medication will be continued taking care of her

insomnia, depression, anxiety and psychosis. The patient stated that all of her

problems went away with the medication given to her so she will be highly likely to

comply with medication regimen.

Prioritized: Defensive coping repeated projection of falsely positive self evaluation

based on a self protective pattern that defends against the underlying perceived

threats to positive regard. Risk for self directed violence related to psychosis as

evidence by previous attempts of violence (running with a knife around home).

Disturbed thought process: a state in which individual experiences a disruption I

cognitive operations and activities related to persistent feelings of anxiety.

List: According to the Nurseslabs website there are many nursing diagnoses that are

associated with the patient’s condition which are listed as follows. Potential nursing

diagnosis for anxiety include fear, ineffective coping, powerlessness, social isolation,

self care deficit, and deficient knowledge. For depression potential nursing

diagnosis include; risk for self directed violence, impaired social interaction,

spiritual distress and chronic low self-esteem. Acute psychosis also have related

nursing diagnosis that include; impaired verbal communication, disturbed sensory

perception, and interrupted family process.

Conclusion: The interaction with this patient was overall effective. Although the

patient knew what we wanted to hear, our questions at least got her thinking of her

progress and future. The main focus of this client would be cessation of smoking

because as evidence by articles it is a major contributing factor. Knowing the

triggers will help the patient avoid strain on her mental state. Non pharmacologic

measures such as mindful meditation, music, drawing, coloring, movies could also

help relieve fibromyalgia pain that contributes to her depression. Patient teaching is

key, as long as the care plans and medication regimen is followed this patient has

high goals that could be accomplished.

 Works Cited

Breslau, N., Peterson, E. L., Schultz, L. R., Chilcoat, H. D., & Andreski, P. (1998). Major
Depression and Stages of Smoking. Archives of General Psychiatry, 55(2), 161.
doi:10.1001/archpsyc.55.2.161

Jones, H. (2018). Teenage Cannabis, Cigarette Use May Heighten Risk for Later
Psychosis. Jampa Psychiatry,10(1001). Retrieved February 16, 18, from
https://www.healio.com/psychiatry/schizophrenia/news/online/%7b25d39e85-fc2b-4d08-
bbbd-4576dde01c44%7d/teenage-cannabis-cigarette-use-may-heighten-risk-for-later-
psychosis.

Khusid, M. (2013). Self-Care Mindfulness Approaches for Refractory Posttraumatic

Stress Disorder. Psychiatric Annals,43(7), 340-344. doi:10.3928/00485713-20130703-11