Mental Health Case Study

Mental Health Nursing Case Study

Kayleigh Sciulli

Youngstown State University

Mental Health Case Study

Abstract

When conducting a case study on a patient and their diagnosis it’s necessary to gather objective

data regarding the disease process such as symptoms and medications along with factors that

contributed to relapse. Knowledge of the psychiatric diagnosis is extremely important in terms of

the plan of care and treatment. The patient’s relapse was brought on by his non compliance with

the medication regimen. Mental illness is often genetic in nature and I was unable to gather

information regarding family history from the patient. A therapeutic milieu or safe environment

is essential on a psychiatric floor to promote healing. Religion is valuable since in some cultures

and religions mental illness is not seen as an actual disease. Religious delusions were evident as

the patient believed he was a brother of Jesus. Nursing diagnoses allow us to evaluate current

problems along with those the patient is at risk for to set outcomes we would like the patient to

achieve.
Mental Health Case Study

Objective Data

On September 28th, 2017 the patient was admitted to the psychiatric unit at Trumbull

Memorial Hospital. Initially, the patient was admitted under involuntary conditions after meeting

with his case worker the same day. After the 72 hour hold was over the patient agreed to sign a

form consenting for voluntary admission. The patient’s psychiatric diagnoses included the

following: paranoid schizophrenia, chronic schizoaffective disorder, depression, and psychosis.

Medical conditions include diabetes mellitus, emphysema, COPD, and hyperlipidemia. Labs that

were collected on the day of admission were all in normal range (including TSH) and the

patient’s drug screen was also negative.

Gathering data on my patient began with getting report from Debbie on the morning of

clinical. My day of caring for the patient was his thirteenth day on the psychiatric unit. Debbie

stated that since being admitted he had taken a liking to journaling all of his thoughts and

“inventions” in a notebook which he carried around throughout the day. Debbie said that since

being admitted he had started off slowly improving but as the days began to pass he started to

decline in terms of cognitive functioning.

When I introduced myself to my patient I noticed his social inept behaviors rather

quickly, when in conversation he rarely maintained eye contact for more than several seconds.

His appearance was rather careless and sloppy with hair that was unkempt and clothes that did

not fit his small frame. When speaking he would mumble and experience a flight of ideas which

lead to speech that was jumbled with no direction. Associative looseness was a manifestation of

schizophrenia that I picked up on within five minutes of speaking to my patient. Speech had no

sequence or theme in terms of the subject matter being discussed. First I asked my patient what
Mental Health Case Study

had brought him into the hospital and he began by saying he had been framed by his case

manager. He stated that he had met with her for an evaluation and she was concerned that

something was off with his behavior and so she framed him which is why he was admitted to the

psychiatric unit. He said he was sick of living in the Warren area and that it was unsafe because

he felt as though his neighbor was also out to frame him. My patients level of paranoia was very

apparent since he seemed to be immersed in the idea that people were watching him or trying to

harm him. Next I asked my patient about his employment status and he said that he was currently

working on a mission with the United States government to investigate extraterrestrial life on

Mars. He wouldn’t go into great detail regarding what exactly he was investigating because it

was classified information. After my patient made this statement, he began touching his ear and

moving his hands. I asked him what he was hearing and he told me to give him a minute he was

communicating with the government. It was evident he was having auditory hallucinations and

believed that he was in fact communicating with the government telepathically.

I then asked about his living situation. He stated he lived alone in an apartment that was

huge and laid out. He said he loved his apartment since it was very large and it was located on

the second floor which was important for his safety. My patient stated that he collected glass jars

that were from the Dollar Tree that came in various colors and were antique and extraordinary. I

was curious to ask about his communication with family members, and when I did he stated he

had an older brother who was Jesus Christ. Next he went into how his family was very wealthy

and had been very successful even several generations ago. This type of behavior being exhibited

were delusions of two types. One being delusions of grandeur since he envisioned himself of

being wealthy and powerful, having access to items he believed were “antique” but were really
Mental Health Case Study

just junk to most people. The other were religious delusions since he believed he was the

younger brother of Jesus Christ and had a special connection with him that others did not. Both

of these delusions were trademarks signs of a patient with schizophrenia. When it came time for

9 o’clock group my patient did not participate. He remained in the common area and journaled

instead of going to group to participate with the other clients. When he was sitting alone at the

table journaling, I would notice periods where he would begin to grab at the air in an effort to

touch or grasp something that was not there. It was obvious he was grabbing for something he

thought was present but in fact was not.

My patient’s daily medications include fluoxetine (Prozac) 40 mg/day orally,

paliperidone (Invega) 6mg/day orally, lamotrigine (Lamictal) 100mg/day orally. In addition to

daily meds, PRN medications included haloperidol (Haldol) 5mg/ IM during periods of agitation

and hydroxyzine (Vistaril) 50mg/IM for agitation. Prozac is an SSRI antidepressant used to treat

depression (in schizoaffective disorder) by increasing serotonin by inhibiting the re-uptake or

disposal of serotonin. Lamictal is an anticonvulsant that is being used in this case as a mood

stabilizer to level out the patient’s mood. Invega is an atypical antipsychotic that is used to treat

schizophrenia by decreasing symptoms. Invega comes in both oral forms as well as a long acting

intramuscular injection which the patient was being switched to while admitted on the

psychiatric unit in order to increase medication compliance. “Nonadherence with medication

occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the

illness’s association with social isolation, stigma, and comorbid substance misuse, plus the effect

of symptom domains on adherence, including positive and negative symptoms, lack of insight,

depression, and cognitive impairment” (Haddad et al., 2014).

Mental Health Case Study

Summarize the Psychiatric Diagnoses and Expected/Common Behaviors

Schizoaffective disorder is a mental health condition that includes both schizophrenia and

a mood disorder, in this patients case depression. Schizophrenia is characterized by a distortion

in thoughts, perceptions, emotions, and reality perception. Associated with the delusions and

hallucinations of schizophrenia there are both negative and positive symptoms. The disease is

separated into four phases, each characterized by different behaviors. In the initial stage or the

premorbid phase, patients experience social isolation and poor interpersonal relationships. Next

in the prodromal phase social impairments are worsened and issues with sleep and functioning

are more apparent. In the third phase which is considered the active phase, functioning is

severely difficult due to hallucinations and delusions the patient can experience. The last phase

known as the residual phase is where the patient is in remission and symptoms typically return to

the state they were in the first phase (Townsend, 2015). Like other chronic diseases,

schizophrenia is a mental disease characterized by periods of remission and exacerbation.

Patients are likely to be seen in the psych ward during periods of exacerbation since they often

have ineffective coping skills and lack the ability to function in day to day life. Depression is

marked by feelings of worthlessness and hopelessness that often cause concentration issues

(Goldberg, 2017). “Schizophrenia is a chronic and debilitating disorder, which affects general

health, functioning, autonomy, subjective well being, and life satisfaction of those who suffer

from it. Despite 50 years of pharmacological and psychosocial intervention, schizophrenia

remains one of the top causes of disability in the world” (Solanki et al., 2008).

Identify the Stressors and Behaviors that Precipitated Current Hospitalization

Mental Health Case Study

The event that led to the patient’s current hospitalization on the psychiatric unit was an

appointment with the patient’s case manager. The patient was seen outside the case manager’s

office having an auditory hallucination accompanied by abnormal behavior that was increased

from the last appointment. The notes in the patient’s chart indicated he was brought to the

emergency department where he was pink slipped and given an involuntary admission to the

unit. This event was precipitated by the patient being noncompliant with his medication which

lead to an increase in psychiatric behaviors.

When I spoke with the patient regarding his admission to the unit it was very clear he felt

as though there was nothing wrong with his thoughts or behavior. He stated on several occasions

that “Cindy” framed him to be taken to the hospital by the police after she was the way he was

behaving at the case manager’s office. After his involuntary admission had concluded, the patient

spoke with his sister who influenced the patient to then sign a voluntary admission for the

psychiatric unit. My patient’s major downfall regarding his illness is that he believes there is

nothing wrong with him which is the reason he is noncompliant with his medications. A court

hearing was scheduled for mandated medications due to the patient’s refusal of compliance.

“Nonadherence with antipsychotic medication can lead to relapse for patients in remission and

persistent symptoms for those with existing symptoms, and both scenarios can cause multiple

patient and service costs” (Haddad et al., 2014).

Discuss Patient and Family History of Mental Illness

When I asked the patient about history of family illness he was unable to give me any

information. He was able to give me physical diseases that his family members had suffered

from such as diabetes and heart disease but said nothing regarding mental illness. The impression
Mental Health Case Study

that was left upon me was that since he believed that he did not suffer from any mental illness he

thought the same of his family members.

Describe the Psychiatric Evidence Based Nursing Care & Milieu Activities Provided

For a patient who is suffering an exacerbation from a mental illness the psychiatric ward

is a therapeutic environment that ensures a patient’s safety. When a patient is admitted onto the

unit their personal items are searched to ensure that no harmful weapons or objects are brought

onto the unit in order to protect the patient and others. A structured schedule is posted in the

common area of the floor in order to ensure a sense of structure and safety. Safety checks are

conducted every fifteen minutes on the unit (Townsend, 2015). The therapeutic milieu of the

common area is that of an open space characterized by large windows which allow patients to

look outside and not feel constricted all while being in a central location to the nurse’s station for

safety. Plants are placed on the windows which are seen as calming. Patient rooms have steel

mirrors so they can not be broken by a patient who is angry or looking to self harm. The doors

are also angled at the top to prevent patients from hanging themselves in an attempt to commit

suicide. Support groups are implemented daily and patients are to attend in order to gain

knowledge regarding medications, coping skills, and anger management (Townsend, 2015).

Trumbull Memorial Hospital uses both family intervention and an interdisciplinary approach to

treat patients who are placed onto the unit. The ultimate goal of the Milieu and activities

provided during the patient’s stay are to improve daily functioning by giving patient’s coping

mechanisms and knowledge on how to handle life situations once discharged and into the

everyday world.

Analyze Ethic, Spiritual, and Cultural Influences that Impact the Patient
Mental Health Case Study

When asked about religion, the patient stated that he went to church while growing up

and that he considers himself to be religious. The patient believes he is the younger brother of

Jesus Christ and is experiencing religious delusions. I observed my patient blessing the city of

Warren on the day of care which he sees as his duty.

Evaluate the Patient Outcomes Related to Care

After caring for this patient I was able to identify several outcomes the nursing staff

would want to be met before discharge. A major concern of this patient is his unwillingness to

adhere to his medication regimen, upon his discharge it would be important to see the patient

identify his behavior as a problem and why it is necessary to have pharmacologic intervention

(Townsend, 2015). The patient be able to recognize the distortion of reality and will see self

realistically. The patient will show appropriate communication with others. The patient will be

able to perform activities of daily living on his own such as hygiene practices, medication

administration, and financial matters.

Summarize the Plans for Discharge

The plans for discharge for this patient include being able to identify with his case

manager and build a trusting relationship. Since the patient felt “framed” upon discharge it is

important to establish a trust with his case manager and ensure that the patient understands his

case manager is a tool and is to be used to help him and not hurt him. Continued communication

among a health care professional and the patient is crucial in terms of medication compliance,

future doctor’s appointments, and activities of daily living. Since the patient lives alone it is

important that has regular intervention and education to enforce the prescribed treatment for the
Mental Health Case Study

patient. It is also crucial that the patient has an understanding of the consequences now involved

if he doesn’t adhere to the plan of care since his medication is now court ordered.

Nursing Diagnoses

Nursing diagnoses are an important part of patient care since they address the problems

the patient is having or that he is at risk for. Ineffective self-health management related to

noncompliance with prescribed healthcare regimen as evidenced by cessation of psychiatric

medication against medical advice. Impaired social interaction r/t psychiatric illness as

evidenced by disturbed thought processes (auditory hallucinations). Ineffective coping related to

unrealistic perceptions and social withdrawal as evidenced by disturbed thought processes and

impaired communication. Impaired individual resilience r/t psychological disorder as evidenced

by delusions and hallucinations. Social isolation r/t self concept disturbance and disturbed

thought processes as evidenced by inability to concentrate and social withdrawal (Ackley &

Ladwig, 2014).

Risk for powerlessness related to distorted thinking. Risk for self and other directed

violence related to lack of trust and delusional thinking. Risk for loneliness related to inability to

engage in social interactions (Ackley & Ladwig, 2014).

Mental Health Case Study

Work Cited

Ackley, Betty J., and Gail B. Ladwig. Nursing Diagnosis Handbook: an Evidence-Based Guide

to Planning Care. Elsevier, 2014.

Haddad, Peter M, et al. “Nonadherence with Antipsychotic Medication in Schizophrenia:

Challenge | PROM.” Patient Related Outcome Measures, Dove Press, 23 June 2014.

Solanki, Ram Kumar, et al. “Schizophrenia: Impact on Quality of Life.” Indian Journal of

Psychiatry, Medknow Publications, 2008.

Townsend, Mary C. Psychiatric Mental Health Nursing: Concepts of Care in Evidence-Based

Practice. F.A. Davis Company, 2015.

“What Is Schizoaffective Disorder?” WebMD, WebMD, www.webmd.com/schizophrenia/

guide/ mental-health-schizoaffective-disorder.