Mental Health Case Study 1

Mental Health Nursing Case Study

Sydney Schisler

Youngstown State University

Mental Health Case Study 2

Abstract

Objective data was important to the patient’s diagnosis and recognition of his

schizophrenic relapse and also know what medications the patient was supposed to be

taking is important in his treatment. Knowledge of each psychiatric diagnosis and how to

recognize it is vital in dealing with metal health patients. The patient had stopped taking

his medications, which was a major stressor that contributed to his current

hospitalization. The patient was unable to contribute family history but this is important

because mental illness can often be genetic. Patient safety is a top priority for psychiatric

nurses working on the floor. The patient’s religious background could be important and

contribute to his religious delusion. Nursing outcomes and diagnoses are important in

making sure the patient is treated and his needs are addressed and met.
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Objective Data

The patient was admitted to Trumbull Memorial Psychiatric unit on September

28th, 2017 and the date of care for this patient was October 4th, 2017. The patient was

admitted involuntarily on the date of admission and then agreed to sign a voluntary

admission form after discussing with his sister who thought it was a good idea he be

admitted for longer than the 72 hour hold. The patient was admitted with the following

psychiatric diagnoses schizophrenia (paranoid), chronic schizoaffective disorder,

psychosis, and depression. The patients other medical conditions include COPD, cigarette

smoker, diabetes, emphysema, and hyperlipidemia. The patient’s current labs were all

within normal range and his drug screen was negative upon admission.

During the day the patient exhibited several bizarre behaviors. His appearance

was careless with unkempt hair and clothes. The patient was very friendly towards others

and enjoyed talking. While talking the patient made very little eye contact and would

look off into the distance or into his lap when speaking. He also mumbled a lot and

exhibited a flight of ideas and he seemed to ramble a lot and forget words. The patient

showed circumstantiality and associative looseness and seemed to have a hard time

getting to the point he was trying to make. The patient exhibited several delusions, which

included delusions of grandeur and religious delusions.

While talking with the patient he stated to me that he was the little brother of

Jesus Christ and that the aliens consider him God. He told me he works for the United

States government against the aliens that visit earth and his current job is investigating

extraterrestrial life on Mars. He also stated he communicates telepathically with the

government but that’s all he could tell me about it because it was classified information.
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When asked about his current living situation he told me he lived in a very large

apartment is Warren which he “paid a mint for” and that he lived there alone. When

asked the patient told me he was taking all his medications and had not missed any doses

even though he has not been taking his medications. The patient had a journal that he

obsessively wrote in throughout the day and many papers in his pocket that he had

crumpled up and said were very important documents. In his journal he wrote about his

inventions and ideas and said that he did not just work for the government but was also

an inventor. He also wrote about the alien life he investigated and seemed very concerned

with going home because he claimed he had to get back to work.

This patient still on the psychiatric one week following the when I had him as a

patient. The patient at this time was taking his medications but his condition seemed to

have worsened. He was still experiencing many delusions and hallucinations and had

seemed to become more and more obsessed with his journaling and inventions. During

this day I observed him constantly erasing and rewriting things in his journal. He also

stated that it was his job to bless everyone he came across and the places he came across.

While sitting in group he did not participate as he was writing is his journal but I did

notice him grabbing at the air when nothing was there. This could be a sign that he was

hearing or seeing something that was not there.

The patient’s medications include fluoxetine (Prozac) 40mg orally daily,

lamotrigine (Lamictal) 100mg orally daily, paliperidone (Invega) 6mg orally daily,

haloperidol (Haldol) 5mg as needed for agitation intramuscular, and hydroxyzine

(Vistaril) 50mg as needed for agitaton intramuscular.

Mental Health Case Study 5

Fluoxetine (Prozac) is an antidepressant and SSRI used to treat depression.

Lamotrigine (Lamictal) is an anticonvulsant used as a mood stabilizer. Paliperidone

(Invega) is an atypical antipsychotic medication used to treat schizophrenia (Townsend,

2015). The patient was prescribed Invega orally but it is being discussed about changing

him to the long acting intramuscular injection of Invega due to medication compliance

issues.

Currently in psychiatric nursing long acting antipsychotic medications have been

shown to help increase the compliance in schizophrenic patients. This patient is currently

on oral Invega but during the court hearing for this patient they are going to discuss the

use of the Invega injection for this patient. Schizophrenics often think that nothings is

wrong with them so medication compliance is a huge issue and this is the case with this

patient. According to a journal article from The American Journal of Psychiatry,

“Compliance with a medication regimen has been found to improve when patients are

switched to depot agents and these agents enable physicians to rapidly detect

noncompliance” (Kane et al., 2003, p. 1125). Invega is an atypical antipsychotic which

has become more favorable than typical antipsychotics because it is safer with fewer side

effects and less extrapyramidal side effects (Townsend, 2015).

Summarize the Psychiatric Diagnoses and Expected/Common Behaviors

The patient has a diagnosis of schizophrenia, which is a psychiatric disorder that

affects a persons thought process and perception and interferes with daily functioning.

Schizophrenia has four phases and is associated with delusions and hallucinations and

positive and negative symptoms. Each phase has different behaviors associated with it. In

the first phase, which is the premorbid phase patients can exhibit social isolation and poor
Mental Health Case Study 6

relationships. In the second phase, which is the prodromal phase patients exhibit social

impairments, which worsen as well as issues with functioning and sleep. In phase three

which is knows as schizophrenia the disease is active and the patient delusions,

hallucinations, and severe difficulty in functioning. In the fourth phase, which is the

residual phase symptoms go back to those exhibited in phase one and the patient is in

remission. Schizophrenics have chronic periods of exacerbation and remission

(Townsend, 2015). The patient is currently in the active schizophrenia stage and is

experiencing many delusions and hallucinations. According to Psychiatric Mental Health

Nursing: Concepts of Care in Evidence Based Practice,

Schizophrenia is probably the most devastating illness that psychiatrist treat. It

strikes people just when they are preparing to enter the phase of their lives in

which they can achieve their highest growth and productivity-typically in the

teens or early 20s-leaving most of them unable to return to normal young adult

lives (Townsend, 2015, p. 420).

The patient also has a diagnosis of schizoaffective disorder, which includes all the

behavioral issues of schizophrenia along with a mood disorder (Townsend, 2015).

Currently the patient is exhibiting psychosis, which is defined as, “a severe mental

condition in which there is disorganization of the personality, deterioration in social

functioning, and loss of contact with, or distortion of, reality. There may be evidence of

hallucinations and delusional thinking. Psychosis can occur with or without the presence

of organic impairment” (Townsend, 2015, p. 420).

Identify the Stressors and Behaviors that Precipitated Current Hospitalization

Mental Health Case Study 7

Patient was admitted to the psychiatric unit after his case manager and the case

managers office noticed an increase in abnormal behavior from the patient. According to

the patients chart the patient was seen outside the case managers office talking to

someone who was not there and the police were called and the patient was taken to the

emergency room where he was given a pink slip and involuntary admission. It was later

discovered that the patient had stopped taking his medications, which most likely lead to

the patient’s behavior and hospital admission.

According to the patient a woman named “Cindy” whom he did not even know

called him into her office at the case managers office and set him up to be taken into the

hospital by the police. The patient was very paranoid about this woman named Cindy and

claims he does not even know her and she told the police lies about him so he would be

forced to be admitted into the hospital. He claims the only reason the police took him in

was because he thought differently than they did and they did not agree with his thoughts

and his is allowed the right to say and think what he wants. He does not think anything is

wrong with him nor does he think he needs to be in the hospital but he later signed a

voluntary admission because his sister thought it was a good idea. The patient is waiting

for a court hearing for court mandated medications because he refuses to take any

medications.

Discuss Patient and Family History of Mental Illness

The patient was unable to contribute any family history. When asked about

history of mental illness patient does not believe himself to be mentally ill. Since he does

not believe himself to be mentally ill he states he does not have any history of mental

illness.
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Describe the Psychiatric Evidence Based Nursing Care & Milieu Activities Provided

The psychiatric floor provides many steps to ensure patient safety at all times.

These include safety checks every fifteen minutes, medications, group therapy, mirrors

that are made of steel to prevent breaking which could lead to self harm, one on one

physician meetings, meets with social workers and nurses, and plants which can provide

people with a sense of calming and welcoming. A study from a journal article titled

“What’s Therapeutic About the Therapeutic Milieu?” looked into not what types of

milieu therapies floors use but at what milieu therapies the patients thought benefited

them and helped them the most. Some milieu therapies they thought benefited the most

were relationships they formed with others on the floor, which they saw as a support

group. Some patients saw the locked unit as a form of milieu therapy that benefited them

because it made them feel safe and secure. Many patients greatly benefited from trusting

relationships they developed with the staff and the things they learned from different

therapy sessions (Thomas, Shattell, & Martin, 2002).

Analyze Ethnic, Spiritual, and Cultural Influences that Impact the Patient

The patient states he is a very religious person and claims he is the little brother of

Jesus Christ and is experiencing religious delusions. He claims he went to church

frequently while growing up and prays a lot and talked about how it is his job to bless

people and cities around him. The patient was unable to contribute anything about any

cultural or ethnic influences he may have. According to a journal article titled “Are

religious delusions related to religiosity in schizophrenia?”, “The term ‘religious

delusions’ comprehends such different phenomena like acute apocalyptic ideas as well as

chronic ideas of being damned by God or being God” (Rudalevičienė et al., 2008). This
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same journal also discusses the idea that the different types of delusions can be

influenced by the patients background, culture, gender, age, length of illness, education,

and religious importance. They stated the fact that it was proven that men were likely to

have the delusion that they were God than women and that those who reported a frequent

religious practice where more likely to have religious delusions (Rudalevičienė et al.,

2008).

Evaluate the Patient Outcomes Related to Care

There are many outcomes put into place for the patient when it comes to the care

of the patient. The following are several outcomes the nursing staff would want the

patient to meet before discharge. The patient will show the ability to relate with others.

The patient will recognize the distortion of reality and will see self realistically. The

patient will see his environment around him correctly. The patient will keep anxiety at a

reasonable level. The patient will not show a need for delusions or hallucinations. The

patient has not harmed himself or others. The patient performs activities of daily living

on his own. The patient will show appropriate communication towards others. (Towsend,

2015).

Summarize the Plans for Discharge

For discharge the plan is have the patient follow up with his case manager in

hopes the case manager will help him with anything he needs. This includes medication

compliance, follow up appointments, hygiene, making sure activities of daily living are

taken care of, housing, foods, and any other essentials the patient may need. The patient

stated that before the case manager would take him to the grocery store or any

appointments he had so the plan is to continue with that. Also pending the court hearing
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mandated medication will most likely be enforced and the patient will need to make sure

to attend any follow ups related to that. The patient currently lives alone in an apartment

so we will want to make sure that is where he is returning and that he has the support he

needs to continue to live there.

Nursing Diagnosis

Nursing diagnoses are important to patient care because they identify patient

problems and potential problems that need to be addressed. Impaired verbal

communication related to psychosis, disorientation, inaccurate perception, hallucinations,

and delusions as evidence by loose association of ideas, poor eye contact, difficulty

expressing thoughts, and circumstantiality. Ineffective coping related to unrealistic

perceptions, inadequate coping skills, disturbed thought processes, and impaired

communication as evidence by inability to concentrate, difficulty expressing thoughts,

delusions, and hallucinations. Social isolation related to lack of trust, regression, and

delusional thinking as evidence by withdrawal and preoccupation with own thoughts.

Impaired social interaction related to impaired communication patterns, self-concept

disturbance and disturbed thought processes as evidence by withdrawal, preoccupation

with own thoughts, and suspiciousness of others. Self-care deficit related to loss of

contact with reality and impairment of perception as evidence by difficulty completing

tasks such as bathing and dressing. (Ackley & Ladwig, 2014).

Risk for suicide related to psychiatric illness and loss of reality. Risk for self and

other directed violence related to lack of trust, hallucinations, and delusional thinking.

Risk for compromised human dignity related to stigmatizing label. (Ackley & Ladwig,

2014).
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Work Cited

Ackley, B.J., & Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An Evidence-Based

Guide to Planning Care. Maryland Heights, Missouri: Mosby Elsevier.

Kane, J.M., Eerdekens, M., Lindenmayer, J., Keith, S.J., Lesem, M., Karcher, K. (2003).

Long-Acting Injectable Risperidone:Efficacy and Safery of the First Long-Acting

Atypical Antipsychotic. AM J Psychiatry, 160(6), 1125-1132.

http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.160.6.1125

Rudalevičienė , P., Stompe, T., Narbekovas, A., Raškauskienė , N., Bunevičius, R.

(2008). Are religious delusions related to religiosity in schizophrenia?.

Medicina (Kaunas), 44(7), 529-535.

http://europepmc.org/abstract/med/18695349

Thomas, S.P., Shattel, M., Martin, T. (2002). What’s Therapeutic About the Therapeutic

Milieu?. Archives of Psychiatric Nursing, 16(3), 99-107.

http://www.psychiatricnursing.org/article/S0883-9417(02)03996-1/pdf

Townsend, M.C. (2015). Psychiatric Mental Health Nursing: Concepts of Care in

Evidence-Based Practice. Philadelphia, PA: F.A. Davis Company.