Professional Documents
Culture Documents
Valerie N Jeffery
Abstract
This study gives an in-depth analysis of a psychiatric mental health inpatient at Mercy
Health – St. Elizabeth’s Hospital in Youngstown, OH. Many facets of the patient’s care include,
but are not limited to, a DSM-IV-TR diagnosis, precipitating factors for hospitalization,
treatment orders, medication schedule and an evaluation of outcomes. The study dissects the
patient’s past medical and psychiatric history, analyzes spiritual influences pertaining to the
patient’s hospitalization, and provides a prioritized list of nursing diagnoses as well as a list of
Objective Data
Elizabeth’s Youngstown Hospital, Behavioral Health Institute on November 11, 2017. This
patient was diagnosed with the DSM-IV-TR Axis I #296.0–296.89 criteria of “Severe Bipolar
Affective Disorder with Psychotic Features” (Pini et al., 1999). Upon admission, the patient
stated she was “feeling overwhelmed and concerned that she hasn’t taken her medical test to
become a doctor, even though she already is one.” KM presented with a rapid flight of thoughts
with occasional points of clarity. Her physical manifestations included flushed skin, diaphoresis,
a rapid heart rate and enlarged pupils. The patient was irritable and not easily consoled. She was
put on self-harm precautions due to her combativeness when consolation was attempted. KM
also presented with acute kidney injury the day she was admitted to the ER, as evidenced by
elevated BUN and creatinine levels. Her past medical history consists of hypernatremia, acquired
endometriosis. The patient was put on q15minute safety checks, as well behavior counseling and
Summary
“Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes
unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks”
(NIMH, 2016). Bipolar disorders are placed in between depressive disorders and psychotic
disorders due to the “recognition of their place as a bridge between the two diagnostic classes in
terms of symptomatology, family history and genetics” (Parker, 2014). In the manic stage, a
patient is likely to experience “three or more of the following symptoms: low self-esteem,
decreased sleep, pressured speech, racing thoughts, activity at heightened levels, goal agitation,
risk-taking behaviors, and symptoms severe enough to cause marked impairment” (McCormick,
Murray, McNew, 2015). Upon admission, and throughout her stay at the BHI, KM presented
with decreased sleep, pressured speech, racing thoughts and activity at heightened levels. In the
major depressive stage, a patient is likely to experience “five or more of the following symptoms
over a 2-week period: depressed mood, loss of interest or pleasure, weight loss/gain,
stay, she has also presented with at least five of these symptoms, which include depressed mood,
Psychotic features “are also part of this disorder, which can severely impact a person’s
ability to function” (Ffrench, 2017). There can be two types of psychotic features: congruent or
incongruent. “Mood-congruent psychotic symptoms are delusions, which are false beliefs, or
hallucinations, which are false sensory perceptions, that are consistent with the person’s current
or most recent mood episode” (Ffrench, 2017). KM experienced these types of psychotic features
Identification
The patient presented in the emergency department with flank pain coupled with mental
confusion. After a comprehensive metabolic panel was completed, results pointed to acute
kidney injury as evidenced by elevated BUN and creatinine levels, 30mg/dL and 1.5mg/dL
respectively. It was unclear how KM arrived at St. Elizabeth’s, or where she came from. She was
involuntarily admitted, but I could not find who accompanied her to the ED. She stated in my
patient interview with her that she “lives in mansion with my cats,” and her “LPN takes care of
me.” When prompted to explain the events that led up to her arrival, the patient stated “I’ve been
here forever and my LPN made me come here because she wants me sick.” Again, it was unclear
if KM had been in a harmful environment to begin with, or if a stressful event took place that
triggered her manic episode. However, her flank pain was real and manifested in the lab results
thereafter. When asked about any problems with past medical diagnoses, KM stated “I’ve been a
diabetic all my life, but that hasn’t stopped me from being the best cadet in the Navy. I once did
500, one-armed push-ups for my drill sergeant and I never quit for a second to rest.” It’s unclear
if the patient had actually served time in the Navy, but if true, would explain possible PTSD
Discussion
Unfortunately, KM was unable to coherently describe her family or any past mental
illnesses they could have potentially had. However, KM has had two previous psychiatric
hospitalizations, both pertaining to her bipolar disorder with psychotic features. It appeared she
had been diagnosed with this mental illness approximately five years ago. It was unclear if she
had any previous psychiatric hospitalizations other than at St. Elizabeth’s. KM frequently
COMPREHENSIVE CASE STUDY 6
presents to the emergency department at St. Elizabeth’s roughly three to four times a month
Description
Throughout her stay, KM was provided with extensive patient education and support of
her thoughts and feelings. During medication passes, the staff LPN consoled her when she felt
too anxious to take them, which increased compliance and was a step toward better management
of her diagnosis. KM was encouraged to attend group therapy sessions, which allowed her to
witness good behavior modeling. She was also exposed to different viewpoints during group
discussions, which could have promoted better listening skills. Being out in the milieu
environment could have potentially escalated her manic behaviors, since most episodes occurred
in the common area. However, the space also allowed her to interact with new people, possibly
Analysis
KM stated she was “Polish and a little bit of German, but I know I have some African in
me because my great grandfather was 100% black.” Due to her diagnosis, it was unclear how
valid that statement was. KM talked extensively how much she loved God, but how “sometimes
the Devil tells my cats that I need to get up at 1:30 in the morning to check out my mansion
because burglars are sneaking around trying to steal my stuff.” She appeared to have many
delusions of religion, saying how she went to Catholic school when she was younger, but joined
the Navy later in life, and “it was God who got me through basic training.” It seemed that her
COMPREHENSIVE CASE STUDY 7
religion must have been an important part of her life, considering the amount of praise she gave
God and the expression of hatred she had toward the Devil.
Evaluation
In regards to KM’s outcomes, the patient remains hospitalized due to ongoing events and
interactions with the staff and other patients. Dr. Jason Rock states “patient has ongoing
symptoms of mania and psychotic features. Patient has not been improving as expected.”
Throughout the patient’s progress notes regarding nursing diagnoses and outcomes met, there are
a few ongoing outcomes and a few outcomes that are consistently met every day of care. For
example, “Risk of Self-Harm” with the intervention of “absence of self-harm” has been met
every day of her care. An ongoing outcome example would be “Altered Mood; Manic Behavior”
with the intervention of “ability to sleep.” This outcome has yet to be met.
As of November 28, 2017, KM’s guardian (Steve) contacted the Behavioral Health
Institute and asked that KM would be transferred to the state hospital and be put on Lithium.
However, Dr. Rock had consulted with the treatment team and they concluded that the patient
was “not sick enough to be transferred to a state hospital” and that he “would like to see her go
on a step-down unit for medical treatment.” Dr. Rock believes that a state hospital “is not an
option at this moment in time.” He also stated, again, “patient has not been improving as
expected.” It appears plans for a prolonged stay is taking precedence over discharging KM as of
today.
COMPREHENSIVE CASE STUDY 8
1. Risk for self- or other-directed violence related to delusions and manic/psychotic state.
a. Goal: Patient will identify 2 factors contributing to aggressive behavior by the end
of the shift.
b. Intervention: Assess the patient for risk factors of violence, including those in the
2. Sleep deprivation related to hyper-agitated state as evidenced by pacing around the floor
a. Goal: Patient will verbalize 2 actions that can be taken to improved quality of
sleep.
b. Intervention: Keep the sleep environment quiet by avoiding use of the intercoms,
turn off the television, and speak in a low-toned voice on the unit.
evidenced by pacing around the floor and complaining about being “too skinny because
b. Intervention: Monitor food intake; record percentages of served food eaten, and
References
https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
DeepDiveAdmin, W. D. (2015, December 2). DSM IV. Retrieved November 30, 2017, from
http://www.psyweb.com/DSM_IV/jsp/dsm_iv.jsp
Ffrench, D. K. (2017, August 14). Bipolar 1 Disorder With Psychotic Features. Retrieved November
McCormick, U., Murray, B., & McNew, B. (2015, July 14). Diagnosis and treatment of patients
with bipolar disorder: A review for advanced practice nurses. Retrieved December 07, 2017,
from http://onlinelibrary.wiley.com/doi/10.1002/2327-6924.12275/full
Parker, G. F. (2014, June 01). DSM-5 and Psychotic and Mood Disorders. Retrieved November 30,
Pini, S., Dell'Osso, L., Mastrocinque, C., Marcacci, G., Papasogli, A., Vignoli, S., . . . Cassano, G.
(1999, November 01). Axis I comorbidity in bipolar disorder with psychotic features. Retrieved
Student Name_____________________________________
Pt Identifier______________
Date(s) of Care_____________
___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient