Running Head: MENTAL HEALTH CASE STUDY Wolanzyk 1

Mental Health Case Study

Ashley Wolanzyk

Youngstown State University

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Objective Data

E.B. is an 18-year-old male who was voluntarily admitted to the psychiatric floor at Saint

Elizabeth Hospital on February 25, 2019. The admitting doctor was Dr. Kassawat. The date of

care for this patient was February 28, 2019. The patient arrived on the evening of February 25

via private car, accompanied by parents, and with a chief complaint of chest pain, to Saint

Elizabeth Hospital ER and was placed in the BAC unit.

Initial vital signs revealed that the patient was tachycardic at 113 bpm. A CTA was

performed to rule out a pulmonary embolism. An EKG was also performed which again revealed

that the patient was tachycardic. Urinalysis revealed moderate bacteria in the urine. Urine drug

screen resulted positive for opiate and cannabinoid. Lab work determined the white blood cell

count was elevated at 20,100 (normal 4,500-11,500 per microliter of blood) and hemoglobin was

also elevated at 17.2 (normal 12.5-16.5 grams per deciliter).

It is important to develop a plan of care that is specific to the admitting psychiatric

diagnosis. Psychiatric diagnoses for this patient, unrelated to this hospital admission, included

anxiety and depression. The psychiatric diagnosis given for this hospital visit was listed as

psychosis (not otherwise specified).

There was a multitude of behaviors exhibited by the patient that the ER nurses observed

on the day of admission. The patient initially refused lab work and was not in his room multiple

times when the nurses completed patient rounding. When the nurse was rounding, the patient

was not found in his room and he later returned saying, “I just stepped outside.” When asked to
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provide a urine sample and instructed to urinate into a specimen cup, the patient reportedly

urinated into the toilet and returned back to his room with an empty specimen cup.

The patient was anxious and paranoid related to recent drug use. After being pink

slipped, the patient made 3 attempts to flee the ER. The patient then became violent during this

time and was sedated at 0018. He was given Haldol and Ativan. The patient was incontinent of

urine one time in the BAC. The ER nurse documented patient as having “flight of ideas, mood

swings, paranoia, and aggressiveness” during her re-assessment at that time.

On the day of care, patient was calm and cooperative. Patient was friendly towards both

staff and students. Patient exhibited appropriate, pleasurable affect. Patient was dressed

appropriately. Posture and gestures were relaxed, and speech was normal. He did not exhibit any

of the behaviors shown on the night of admission described by staff. Patient did not exhibit flight

of ideas, disturbance in thought content/delusions, or perceptual disturbances/hallucinations. No

restlessness, paranoia, or aggressiveness was observed during patient interview.

Patient has no medical conditions and/or treatments. Patient has no prior history of

psychiatric hospital stays. Psychiatric diagnoses for this stay included psychosis (not otherwise

specified). Patient has psychiatric diagnoses of anxiety and depression. Ho et al.’s (2018) study

found the following: “There is a high comorbidity between anxiety and depression disorders in

both adults and young people. Among adolescents, it has been reported that 10%–15% of youths

in the United States have concurrent anxiety and depressive disorder” (p. 1510).

With aggressive and potentially dangerous patients, it is important to maintain strict

safety regulations in order to protect the patient, staff, other patients, and visitors. There are two
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main safety risks when caring for psychiatric patients: harm to self and harm to others. This

particular patient did not express suicidal ideation or homicidal ideation, yet he was exhibiting

aggressive behavior. Even though the patient did not make any direct statements or allude to any

intentions of hurting himself or others, standard safety precautions were still implemented on the

unit. Safety and security measures in the emergency department were listed as assault

precautions during time in BAC due to patient exhibiting aggressive behavior. Assault

precautions serve to promptly recognize escalating aggressive or potentially dangerous behavior

and help the patient to regain behavioral control.

Patient denied suicidal ideation or homicidal ideation; however, suicidal precautions and

psychiatric safety measures were implemented on all patient rooms on the psychiatric unit as a

universal preventative measure. All unit doors, entries, and exits remained locked at all times.

Patients are not allowed to leave the unit. If the patient must be transported to another unit in the

hospital for diagnostic testing or any other reason, they must be accompanied by a staff member.

Patient unit deemed psychiatric safe as all unsafe objects or items that could be used to

cause harm were removed and kept locked away. Patients are not allowed access to any

potentially harmful objects such as objects that can be ligature risks. These include items that can

be tied, hooked, or knotted such as belts, strings, plastic bags, and certain types of sheets and thin

clothing. Patient rooms did not have hooks or handles that could be used to tie items that could

pose as ligature risks to. Patients are not allowed access to any sharp, or potentially sharp, items.

These include scissors, knives, metal cutlery, glass containers, or dishes. Furthermore, any

chemicals, matches, lighters, and substances (such as cigarettes) are strictly prohibited.
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If at any time a patient’s behavior is escalating, the health care provider is to be notified

of the changes. Education is of utmost importance during this time. Patients, visitors, and patient

family members often do not understand the reasoning behind safety measures and policies.

Patients may think that a nurse is being mean or unfair for taking away any potentially harmful

and unsafe belongings. The nurse must thoroughly explain safety measures and precautions to

the patient, patient’s family, and/or visitors. Visiting hours are typically allowed on the unit, but

they are limited and strictly regulated. Patients are also typically allowed to make phone calls

during scheduled times of the day.

The patient was prescribed five psychiatric medications. First, he takes aripiprazole

(Abilify) 15 mg by mouth twice a day for agitation. The medication aripiprazole (Abilify) is a

second generation antipsychotic, as listed in the patient MAR. Second, he takes haloperidol

lactate (Haldol) 10 mg intramuscular every 6 hours. This was prescribed to the patient also for

agitation. The medication haloperidol lactate (Haldol) is a first generation antipsychotic, as listed

in the patient MAR. This was prescribed to the patient for episodes of agitation and delirium.

Third, he takes hydroxyzine (Vistaril) 50 mg by mouth every 6 hours for anxiety. The

medication hydroxyzine (Vistaril) is an H 1 antagonist, as listed in the patient MAR. Fourth, he

takes trazodone (Deserel) 50 mg a night for sleep. The medication trazodone (Deserel) is an

antidepressant serotonin reuptake inhibitor/antagonist used for insomnia, aggression, and major

depressive disorder, as listed in the patient MAR. Fifth, he takes benzotropine mesylate

(Cogentin) 2 mg intramuscular twice a day to prevent extra pyramidal symptom side effects due

to taking antipsychotics (Townsend & Morgan, 2016, p. 370).

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Summarize Diagnosis

As previously indicated, this patient had no former psychiatric hospitalizations and the

only diagnosis for this hospitalization was psychosis NOS. According to a study by Gronholm et

al. (2017) psychosis is “people experiencing first-episode psychosis; or experiencing attenuated

psychotic-like symptoms below the threshold of frank psychotic symptoms but indicative of an

increased risk of developing schizophrenia and other psychotic disorders; or people reporting an

early illness presentation characterized by the presence of subclinical psychotic-like experiences”

(p. 1870). A psychotic break is indicative of a deviation in normal patient baseline behavior.

Identify Stressors

Patient recently moved from South Carolina to Ohio. Patient wanted to attend Coastal

Carolina University for a degree in computer science. Patient left behind a brother, sister, his

mother, 5 dogs, and many friends. He had a job at a movie theater in South Carolina that he very

much enjoyed. Patient’s father and stepmother were present in the ER. History gathered from

patient’s parents reported that the patient was having “mood swings, paranoid, and aggressive”

behaviors in the days prior to patient’s arrival at ER. Patient’s father reported the patient was

“talking to himself and hearing voices.” The parents also reported “the girl he rides to school

with is a drug dealer” and the patient binged on and obsessed over a video game called Apex.

Patient reported being awake for three days playing Apex. Patient reported “feeling this way” for

“about 1 week”. Patient reported calling his mother to come to Ohio. His mother flew up to Ohio

to try to offer support to E. B. On February 24, 2019, the patient tried to run his mom off the

road two times while they were driving. When asked if the patient had ever felt this way before,
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the patient reported having “anxiety and panic attacks for a while but has never seen anybody

about it.” According to a research article by Mankiewicz, O’Leary, & Collier (2018):

“Many young people with mental health problems seem to delay seeking help from

professionals. One reason for this might be negative expectations of therapy, which may

act as a major barrier to achieving progress in recovery. Pre-existing negative attitudes

toward receiving mental health treatment were shown to be associated with lower help

seeking, poorer engagement, and lower rates of recovery; whereas positive expectations

were often linked with higher rates of improvement in psychosocial functioning and an

enhanced psychological wellbeing” (p. 5).

This article describes the negative stigma against mental illness and offers an explanation as to

why young people delay seeking medical help or treatment. When asked if the patient hears or

sees things that others do not, he reported “hearing sounds from the game.” When asked what he

does to cope with the feelings he has been having, the patient responded that he “finds strength in

praying.”

Discuss History

The patient does not have an extensive history of mental illness. This is his first

psychiatric admission. The patient did express that he had these feelings for a while but never

sought help for his feelings. He has previously been diagnosed with anxiety and depression. The

patient revealed that he had been seen at Conway Medical Center in South Carolina in the past

few years, but was never admitted. It was noted that there is a family history of bipolar disease.

The patient noted that his mother is diagnosed with bipolar and that she seems to manage it quite

well.
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Patient reports no suicidal ideation or homicidal ideation. Patient has never had thoughts

of hurting himself previously or presently. During the day of care and patient interview, the

patient did not exhibit any signs, symptoms, or behaviors such as those that were described

during time in BAC upon arrival at Saint Elizabeth’s. These behaviors were indicated as being

possibly related to the patient’s recent drug use at that time. The patient did not admit to using

drugs or indicate that he was struggling with substance abuse. However, there were positive

results on his urine drug screen for opiates and cannabinoids. His father and step mother that

were present with him in BAC did speculate that the girl E. B. rides to school with is suspected

to be a drug dealer.

Describe Care

Research by Mankiewicz, O’Leary, & Collier (2018) described evidenced based

psychiatric nursing care:

“In the recent years there has been an increased acknowledgement of the importance of

addressing all aspects of recovery in psychosis, both clinical, personal and social, through

provision of evidence-based psychological input. The growing popularity of qualitative

methods has allowed for greater consideration of service users’ priorities and

subsequently increased clinicians’ understanding of recovery from the perspective of

suffering individuals. Likewise, a strengths-based [therapy] intervention model indicates

that, at times, the prioritization of service users’ subjectively rewarding goals, over the

alleviation of clinical symptomatology, might produce a considerable and sustainable

long-term outcome in their overall psychosocial recovery and create a buffer against

future episodes of acute emotional distress” (p. 5).

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Like all nursing, psychiatric nursing involves a multidisciplinary team approach.

Collaborating with multiple disciplines is important to ensure consistent care and treatment

modalities. Unit Milieu therapy is a large component of psychiatric care. The nurses on the unit

work very hard to keep a consistent, safe, and healing environment for patients. All staff work

together to ensure patient safety and provide individualized care to each unique patient. Safety is

top priority with psychiatric patients. Unit safety checks and patient rounding is conducted every

15 minutes. Beds and furniture are low to the ground. The patient beds do not move and the

chairs/furniture are purposefully heavier than standard furniture to discourage moving, throwing,

or using furniture with intent to cause harm.

Medication management is another factor in nursing care. Nurses on the unit ensure

medication regimens are strictly followed. They also observe for pocketing medication. This is

when a patient hides pills in their mouth instead of swallowing them. Different therapy sessions

are conducted multiple times each day. Group therapy and one on one therapy are both

important. Group therapy provides social interaction and patients are able to discuss and share

similar experiences, issues, and topics of interest. Groups provide an outlet for patients to

express their thoughts and ideas while commenting and responding to other group members.

A main treatment modality for psychosis is cognitive therapy. Cognitive therapy is used

as “an evidence-based psychological intervention for individuals experiencing psychosis”

(Mankiewicz, O’Leary, & Collier, 2018, p. 4). In research done by Mankiewicz, O’Leary, &

Collier (2018) “cognitive and behavioral interventions [are] utilized collaboratively with
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individuals to restructure their appraisals of anomalous experiences and support their coping with

distressing symptoms” (p. 5). Cognitive therapy helps patients put their thoughts and behaviors

into perspective.

Analyze Cultural Influences

E. B. did not discuss cultural influences during the day of care. It was noted that the

environment in Ohio is drastically different than E. B.’s typical home environment of South

Carolina, as environment does have some influence on psychiatric behavior and symptoms. He

did not discuss spirituality in detail with staff, although he did state that he “finds strength in

praying.”

Evaluate Outcomes

There are many patient outcomes related to care received while admitted in the inpatient

psychiatric clinic. It is important to note that outcomes must be realistic for the individual,

attainable, and have measurable goals.

Outcomes and evaluations related to anxiety are as follows. One outcome is the patient

will “verbalize ways to intervene in escalating anxiety by end of hospitalization” (Townsend &

Morgan, 2016, p. 461). The patient verbalized learning during a group therapy to focus on three

senses. He stated that he could listen to something that he hears or feel the touch of the surface of

the table. Another outcome is: by the time of discharge from treatment, the patient will be able to

recognize symptoms of the onset of anxiety and intervene before symptoms worsen (Townsend

& Morgan, 2016, p. 461). The patient verbalized understanding signs and symptoms of
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worsening anxiety such as him being unable to focus or having chest pain. He did state that chest

pain was the initial complaint at time of arrival to the emergency department.

Outcomes and evaluations related to depression are as follows. One outcome is that the

patient will not harm self during hospitalization (Townsend & Morgan, 2016, p. 396). This

outcome was met as the patient remained free of harm. Another outcome is that the patient will

verbalize a measure of hope for the future by identifying reachable goals and ways to achieve

them by time of discharge (Townsend & Morgan, 2016, p. 400). This outcome was met when the

patient verbalized that he is making arrangements to move back to South Carolina because that is

his home and where he feels most comfortable. The patient stated that he was already making

arrangements with his mom to secure airline tickets for the day after his discharge.

Outcomes and evaluations related to psychosis are as follows. Patient will be free of self

harm during hospitalization. This outcome was met as the patient remained free of harm.

Another outcome is the patient will participate in therapeutic regimen during hospital stay. This

outcome was met as well. The patient expressed interest in and participating in group therapy,

one on one therapy, and daily goal making and attaining.

Summarize Discharge

The planned day of discharge was the day after the date of care, March 1, 2019. This

patient will be instructed on the importance of medication compliance and will be educated on

the new psychiatric medication prescriptions and the medication regimen started during his

hospital admission. Outpatient psychiatric services are being arranged in South Carolina since

the patient plans to move after discharge. The patient will be living with mother and siblings
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when he moves. He will have a greater support system when being united with many friends that

he lost touch with while in Ohio. The patient will also be assisted in setting up a follow up

appointment with his primary care provider.

Prioritized List

A list of actual nursing diagnoses in order of importance helps identify and address

problems that affect the patient. One nursing diagnosis is anxiety related to chest pain as

evidenced by patient stating his chief complaint during emergency room triaging was “chest

pain.” Another nursing diagnosis is ineffective coping related to inability to meet basic needs as

evidenced by not sleeping for 3 days. Similarly, adult failure to thrive related to depression as

evidenced by demonstrated difficulty in reasoning, decision making, judgment, memory, and

cognition during psychosis.

List Nursing Diagnoses

Potential nursing diagnoses for this patient include risk for suicide related to depressed

mood, social isolation related to staying at home playing video games, hopelessness related to

absence of support systems, and disturbed family coping related to highly ambivalent family

relationships.

Conclusion

Patient data, date of admission, psychiatric diagnosis, safety measures, and psychiatric

medications have been reviewed and analyzed. Current nursing research helps to summarize and

explained psychiatric diagnoses and behaviors exhibited by this patient. Patient stressors such as

moving from South Carolina to Ohio were identified and the patient and family medical history

was reviewed. Psychiatric nursing care has been noted to focus heavily on safety measures such
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as suicide precautions and therapeutic regimen compliance by patients. Although this patient did

not identify ethnic, cultural, or spiritual influences, it is noteworthy to be mindful of how factors

such as these may impact the patient. Actual and potential nursing diagnoses on E. B. have been

identified throughout this case study. Likewise, outcomes have been evaluated in reviewing the

patient’s therapy and willingness to participate in treatments during hospitalization.

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Resources

Gronholm, P. C., Thornicroft, G., Laurens, K. R., & Evans-Lacko, S. (2017). Mental health-

related stigma and pathways to care for people at risk of psychotic disorders or

experiencing first-episode psychosis: a systematic review. Psychological Medicine,

47(11), 1867-1879. doi:10.1017/S0033291717000344

Ho, S. M., Cheng, J., Dai, D. W. T., Tam, T., & Hui, O. (2018). The effect of positive and

negative memory bias on anxiety and depression symptoms among adolescents. Journal

of Clinical Psychology, 74(9), 1509-1525. doi:10.1002/JCLP.22597

Mankiewicz, P. D., O’Leary, J., & Collier, O. (2018). “That hour served me better than any hour

I have ever had before”: Service users’ experiences of CBTp in first episode psychosis.

Counselling Psychology Review, 33(2), 4–16. Retrieved from

https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,uid&db=pbh&AN=1

33130633&site=ehost-live&scope=site

Townsend, M. C., & Morgan, K. I. (2016). Essentials of psychiatric mental health nursing:

Concepts of care in evidenced-based practice (7th ed.). Philadelphia, PA: F. A. Davis

Company.