Running Head: COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study

Kayla Smith

Youngstown State University

COMPREHENSIVE CASE STUDY 2

Abstract

This paper will explore a patient and their psychiatric diagnosis of schizoaffective disorder and

bipolar disorder and the events that lead to this diagnosis. This paper will go through what

schizoaffective disorder and bipolar disorder are and how the patient ended up needing

treatment. It will also analyze ethnic, spiritual and cultural influences that cause impact on the

patient. It will also go on to describe the nursing care and milieu activities involved in the care of

the patient. It will evaluate the patient outcomes related to the care provided and summarize the

plans for discharge. Lastly this paper will give actual and potential nursing diagnoses.
COMPREHENSIVE CASE STUDY 3

Objective Data

TI is a 57-year-old female and was admitted on the 21st of March in 2018 and was cared

for on 23rd of March in 2018. On the date of care, it was the patients third day of care. The

psychiatric diagnoses of schizoaffective disorder and bipolar disorder, with no psychotic

features. Was also medically diagnosed with hepatitis C, treated for tuberculosis, high

cholesterol and a history of a right hip replacement and hysterectomy According to a study there

is “a wide range of estimates for the prevalence of infectious diseases in homeless people have

been reported, particularly for tuberculosis, hepatitis C virus, and HIV” (Beijer, Wolf, & Fazel).

In addition to homelessness there was a study done on IV drug abuse in relation to hepatitis C.

This study was funded by National Institutes on Drug Abuse and there were one thousand eight

hundred participants. “The analysis revealed a thirty eight percent higher risk of catching Hep C

for women than their counterparts” (Gamboa, 2017). No global functioning level was found in

the chart on this patient.

Previously to the admission to the psych unit this patient came into the emergency

department because of numbness and tingling in the extremities on the right side of the body.

Was diagnosed with a TIA and discharged. Patient on admission to the psych unit said that she

has not been able to sleep at night because of the worry that the numbness and tingling in the

extremities will come back. On admission, the patient voluntarily committed self to the locked

down psych unit at Trumbull Memorial Hospital. The patient committed self because was at risk

for relapse of alcohol due to the stress about the diagnosis of the TIA and was also having

suicidal ideations. The patient did not have a plan for suicide but was having thoughts. Patient

has been clean from drugs and alcohol for about five years and did not want to relapse and stated

worry about own health. Toxic screen and urinalysis both came back negative for any
COMPREHENSIVE CASE STUDY 4

substances.

On the day of care the patient was relaxed and animated but appeared depressed. Was

dressed neat, hygiene was kept up and was friendly towards staff and other patients. Patient was

happy to talk and stated off by explaining the voluntary commitment to this unit happened.

Continued to talk about the previous visit to the emergency room when the diagnosis of a TIA

was given and explained and became very emotional when talking about own health. Patient

started crying, therapeutic touch was used and a moment of silence. The patient proceeded

talking on own after calming down from crying. When talking about family, they were stated to

not live around here. The mother was the only one that lives in the area but stays in a home and

does not have means of transportation to see her but has conversation on the telephone with the

mother on a weekly basis. Patient stated living alone in a small apartment building but having all

the necessities and a case manager would provide transportation when needed to assist with

grocery shopping and doctor appointments. Also, the neighbors in the apartment building would

also provide the patient with transportation in an emergency.

TI was on a locked down psych unit with many safety precautions in place. There are unit

restrictions and the patients stay on that unit for their entire stay unless they need additional

medical attention where they require an intravenous site, they would be transferred but will have

precautions. The nurses account for the patient every fifteen minutes to ensure that the patients

are safe and not doing anything that would be harmful to themselves or others.

TI has medications that are to be taken for the current psychiatric diagnoses. Patient

stated taking Abilify (aripiprazole) but when voluntary committing self to the unit asked the

physician to change medication. One of the medications TI was prescribed is called Risperdal

(risperidone). Risperdal is an atypical antipsychotic used to treat the diagnosis of schizoaffective

COMPREHENSIVE CASE STUDY 5

disorder. Risperdal has a side effect of weight gain. TI voiced concern about weight gain and

stated being on a diet before coming onto this unit. This side effect may have the possibly of

becoming a larger problem. TI was also prescribed Trileptal (oxcarbazepine) an anticonvulsant

and to use as a mood stabilizer for the diagnosis of bipolar disorder. TI was also prescribed

Cogentin (Beztropine) which is an antiparkinsonian drug in the classification of anticholinergic.

This medication was prescribed because of the side effects from Risperdal. These side effects are

those that mimic the symptoms of Parkinson’s Disease. “Cogentin improves muscle control and

decreases the stiffness and tremors and is therefore typically used in the treatment of Parkinson's

disease and to control movement side effects of medications” (Purse, 2017). There was also PRN

medications prescribed including Haldol (Haloperidol) for agitation, Desyrel (trazadone) used as

a sleep aid as needed, and

Summarize

TI is diagnosed with schizoaffective disorder and bipolar disorder. When a patient has

these diagnoses, it can make everyday life difficult for them. Making it hard to hold stable

relationships, hold a job and just function at a normal level.

Schizoaffective disorder is between a mood disorder and a thought disorder. Bipolar

disorder and schizoaffective disorder content overlap because they some similar share symptoms.

“Schizoaffective disorder is a chronic mental health condition characterized primarily by

symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood

disorder, such as mania and depression” (“Schizoaffective Disorder”, 2018).

TI did not show many symptoms of schizoaffective disorder on the day of care. There

were no delusions or hallucinations noted but the patient was constantly concerned about the

numbness and tingling in the extremities that was felt previously, coming back again. TI would
COMPREHENSIVE CASE STUDY 6

have moments where a pause in the discussion would occur because they thought they were

starting to feel the tingling in the right lower extremity. This could possibly lead to the diagnosis

of somatic symptom disorder.

Somatic symptoms “are perceived abnormalities of bodily structure or function that the

individual finds bothersome or concerning” (Sharpe, 2018). When a physician finds an organic

cause of the abnormality then they are treated appropriately. When the symptoms have no

organic cause, they are unexplained and still treat the symptoms. “if no disease is found in the

body, it is assumed that the disease is ‘all in the mind’ and that symptoms that are medically

unexplained are considered, by default, to be ‘psychiatrically explained’” (Sharpe, 2018).

TI other diagnosis was bipolar disorder which is defined as “a brain disorder that causes

unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks”

(‘Bipolar Disorder’, 2016). TI voluntarily committed self to the psych unit because of feeling

that they were unable to get through the day without a drink of alcohol and did not want to

relapse. TI was also showing symptoms of depression on the day of care. Explained how they

live alone and have no friends that they socialize with anymore because they are all doing drugs

and drinking alcohol. Also, that there is no family that lives close. TI is socially isolated because

of the lack of transportation and poor financial situation.

Identify

The behaviors and stressors that precipitated to the current hospitalization for TI was

feeling depressed due to the concern about current health state. TI was diagnosed with a TIA

cared for in the hospital and sent home a week prior. But came back a couple days after to the

emergency room because of a chocking episode that took place at home. Then a couple days

after that visit TI voluntarily committed self to the psych unit at Trumbull Memorial Hospital. TI
COMPREHENSIVE CASE STUDY 7

stated wanting to drink again and none of the coping mechanisms that were used prior to

admission were helping enough for TI to feel well on their own. TI has been clean of drugs and

alcohol for about five years and did not want to relapse. But stated being at home alone made it

very difficult to not drink again.

Discuss

When asking TI questions about family a lot of information was not given. Upon review

of the chart and discussion with the patient there is no report of mental illness in the family. TI

did not appear to be in close touch with anyone and was more focused on self rather than talking

about family. This made it difficult to get any information on family history of mental illness

without pushing TI to an emotional state because of already showing symptoms of depression. TI

when talking about family the only information really given was about a daughter that lives in

California wanting TI to move in with her. TI did not want to do that because of feeling like a

burden to the daughter. TI talked about being married twice and was a victim of domestic

violence because the men were both using drugs and drinking alcohol. TI also stated working for

two nursing homes. The first one they fired TI because of not doing all the job responsibilities

properly. The second nursing home job TI had to quit because of expecting a child and the job

required too much heavy lifting. TI did not talk about homelessness but did talk about not always

having somewhere to go but never directly stated being homeless.

Describe

The nursing care of this is patient is based upon safety. The nurses are to do every fifteen-

minute checks for all the patient on the floor and make sure that everyone is accounted for. All

the patients on this unit must be medically stable because the patients are not allowed to have IV

sites in or IV tubing. There is also a room behind the nurses station that is used when someone
COMPREHENSIVE CASE STUDY 8

needs close observation. There are no gloves in the patients room they have to be obtained from

the nurses station as needed by the staff. The nurses prepare all the patient medications behind

the nurse’s station and make sure that the patients are taking their medications and know what

medications they are on and why they were prescribed those medications. The nurses taking the

time to teach the medications and what they are for to the patient every day that they are on the

unit helps with discharge. The patients may be more likely to understand why they need to be

sure to take their medications properly when they return home. The nurses also really encourage

the patients to go and participate in group therapy sessions that are scheduled for that day. They

keep these patients on a schedule diligently and this is important to keep the patient involved and

working to make themselves healthy. Whenever the schedule changes the staff needs to be sure

to tell the patients and apologize for this change to keep a good rapport with them.

Milieu therapy is also a therapy that is used to keep the patients from themselves. They

have several ways of doing this on the psych unit. The patients on the floor are not allowed shoes

with laces, most are in nonskid socks some have slippers others still wear their shoes with the

laces removed. During the meals they are sure to count all the utensils that were given and be

sure that none of the patients were taking and hiding them to harm themselves or someone else.

The call lights in the room are short that way they cannot be used for strangulation, the sides of

the bed rails are solid, so the patients cannot put their head in them. The mirrors in the rooms are

made so they cannot be broken and used as a weapon or for self-harm. The sink water in the

rooms do not get very hot to avoid from burns only lukewarm water. Also, the sinks are very

small, so they cannot fill them up and cause self-harm by drowning self. The trash cans have

brown paper bags instead of plastic. Canes are not permitted, instead walkers are given if the

patient has a need for an assistive device. All the doors on the unit are locked and need a key to
COMPREHENSIVE CASE STUDY 9

be opened and none of the windows open or can be broken.

Analyze

TI verbalized multiple times reading the Bible every day. Read it for enjoyment but also as a

coping mechanism when having a difficult day or wanting to relapse. TI also talking about

journaling about the Bible. There was nothing in specific other than that the New Testament was

preferred over the Old Testament. TI stated not being able to get to church because of

transportation difficulties but would like to go whenever possible. When having a discussion

with TI multiple times it was stated about the feeling of being blessed because of crossing the

paths of the people while being on the psych unit. Was very thankful and blessed for the help

from others and stated that God had a plan, and this was part of it.

Evaluate

Outcomes for this patient would include medication compliance. Although the patient

will not have a perfect positive day everyday the medications can minimize the negative

symptoms and allow the patient to be stable and be able to care for self on a daily basis. Because

with the diagnosis of both schizoaffective and bipolar disorder it is difficult for TI to find the

energy to take part in day to day activities. Also taking the Cogentin would help to keep the side

effects of the tremors away while taking the other medications to help with mood.

Another outcome would include maintaining anxiety at a manageable level when the

patient worries about own health. To do this patient would need to continue healthy coping

mechanisms and maintain compliance with medications. Other outcomes would be appropriate

communication and interaction with staff and other patients. However, the outcomes have a lot to

do with medication compliance to stabilize the moods that the patient is experiencing that are

negative.
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Summarize

The discharge plans for this patient are to return home and to remain compliant with

prescribed medications. TI will need to be sure that the case manager helping with needs is

providing transportation for TI to refill and pick up medications when needed. Also, TI will need

transported to doctor appointments for follow ups and to scheduled therapy sessions with a

psychiatrist. TI was referred to Salvation Army where there are social events that take place

weekly, allowing for TI to stop isolating self alone for days at a time and to get involved in the

community. TI was also referred to AA meetings because of the thoughts of wanting to relapse.

TI was very interested in all these community resources but just was not sure of how to get to

them.

Prioritized

Anxiety related to unconscious conflict with reality (Ackley, 2014). As evidenced by

patient being unable to have a discussion without interruption of what was thought to be the

numbness and tingling that was previously felt in extremities.

Interrupted family process related to inability to express feelings (Ackley, 2014). As

evidenced by the patient not wanting to tell the daughter in California how they are really

feeling. And the patient stating about not wanting to be a burden to anyone with the problems

that the patient is currently facing.

Social isolation related to lack of trust (Ackley, 2014). As evidence by the patient

receiving help from their case manager but does not ask for a ride to be left somewhere. The

patient has help for errands and appointments not for social events that the patient wants to

attend but is unable to without transportation. Patient also stated that in an emergency the

neighbors in the apartment would provide the patient with transportation if needed.
COMPREHENSIVE CASE STUDY 11

Insomnia related to sensory alterations contributing to fear and anxiety (Ackley, 2014).

This is evidenced by patient only sleeping about five hours the night before the date of care with

the assistance of a sleep aid. Was nervous about the numbness and tingling coming back after

awaking from the sleep in the morning like it did when it first happened and could not fall

asleep.

Impaired memory related to psychosocial condition (Ackley, 2014). This is evidenced by

the patient not be able to recall where all the children are living and gave multiple stories about

the same situation.

List

Potential nursing diagnoses for this patient include: risk for sleep deprivation related to

intrusive thoughts, risk for imbalanced nutrition related to disinterest toward food, impaired

social interaction related to disturbed thought process, risk for self-care deficit related to loss of

contact with reality, ineffective coping related to inadequate coping skills (Ackley, 2014).

Conclusion paragraph

In conclusion TI was diagnosed with schizoaffective disorder and bipolar disorder and

was compliant with medications at home. But the deterioration of the patients health triggered

the patient to want to relapse and changed the mood and energy level of the patient which

resulted in the patient coming to the psych unit at Trumbull Memorial Hospital. The patient did

have good judgement to voluntarily commit self to the unit to avoid the relapse after being clean

for about five years. Along with other good judgement that was made to remove self from

friends and family that were poor role models for the patient after getting clean from drugs and

alcohol. Overall this patient has good judgement but needs additional help with mental and

physical well being as normal aging continues.

COMPREHENSIVE CASE STUDY 12

References

Beijer, U., Wolf, A., & Fazel, S. (2012, August 20). Prevalence of tuberculosis, hepatitis C

virus, and HIV in homeless people: A systematic review and meta-analysis [PDF].

Bipolar Disorder. (2016, April). Retrieved April 03, 2018, from

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Gamboa, C. (2017, October 14). Injecting drugs increases Hep C risk for more women than men

• Addiction Now | Substance Abuse, Drug Addiction and Recovery News Source.

Retrieved April 02, 2018, from

https://www.drugaddictionnow.com/2017/10/14/injecting-drugs-increases-hep-c-risk-for-

more-women-than-men/

Purse, M. (2017, July 26). Treating Tremors Caused by Antipsychotic Medications With

Congentin. Retrieved April 01, 2018, from https://www.verywellmind.com/cogentin-

benztropine-side-effects-380552

Schizoaffective Disorder. (2018). Retrieved April 02, 2018, from https://www.nami.org/Learn-

More/Mental-Health-Conditions/Schizoaffective-Disorder

Sharpe, M. (2018, January 03). Somatic symptoms: Beyond 'medically unexplained' | The British

Journal of Psychiatry. Retrieved April 01, 2018, from

https://www.cambridge.org/core/journals/the-british-journal-of-

psychiatry/article/somatic-symptoms-beyond-medically-

unexplained/B3D386D6DEF41184DCB44640CB4F1043