Keiser University

Associate Degree Nursing

Program
NUR 1035C Advanced Adult Health (Mental Health)
Mental Health Nursing Case Study

DIRECTIONS: This assignment will enable you to demonstrate the use of the Nursing Process in caring for
your client. Please complete all areas of this form. R e m e m b e r t o a t t a c h m e d i a t i o n
sheets, print and submit.
SECTION 1. ASSESSMENT
A. Data Collection: Admission

1. What bought the client into an in-patient setting?

Father was taking him to WMC, he didnt want to go so he exited the vehicle at a stop light and ran
away. He was reported as a missing person and was brought to COC after being found by the PD.

2. What is the Admission Diagnosis?

Psychotic D/O NOS, Aspergers D/O

3. Give a brief description of this primary condition.

Psychosis is a symptom or feature of mental illness typically characterized by radical changes in
personality, impaired functioning, and a distorted or nonexistent sense of objective reality.

Data from Present Problem (Chief Complaint,

Clinical Significance
S/S, Duration, Self-treatment and/or Prescribed
treatment)
Client was brought in on a 52 (baker) by
Client displayed signs of psychosis and catatonic
police, after he ran away from his fathers paranoid state. He needs continuous medication
vehicle. Psychosis Potential Harm to
therapy and frequent psychiatrist evaluations.
himself.

B. What data from the Past Medical History (PMH) are significant to the nurse, and may affect this present
MENTAL HEALTH complaint?
Client has a history of psychosis, one previous inpatient hospitalization in 2010. He has since controlled his
psychosis with the help of an outpatient psychiatrist (Dr. Gates). He has a history of ETOH use but has
reported no drinking within the last few years due to health reasons.

C. Current Medical History and Physical Results: Include rationale and implications for abnormal results
here. Are results better or worse since admission? Which results are clinically significant?) What other
MEDICAL or CHRONIC conditions may also affect their psychiatric care?

Current Vital Signs:

T,P,R,BP, O2 Sat,
Pain
Scale
General appearance:

Complete information Requested.

Indicate (CS) if clinically significant
Also indicate if (N) Normal or (AB)
and state Rationale for Abnormal
Abnormal Assessment (B)
Results
Better or
(W)
Worse
since
Admission
T- 97.5F, P- 60, R-18 BP- 106/74, WNL
O2 Sat- 100%, Pain- 0
Normal

Neurological

Normal

Respiratory

Asthma

Cardiac

Normal

GI

Normal

GU

Normal

Integumentary

Normal

Musculoskeletal

Normal

Psycho/Social/Pain

Aspergers Unmet intimate

need (10 years)

Not clinically significant for his

mental diagnosis.

The fact that he has not had a romantic

relationship in 10+ years causes him
severe depression that escalates to
anger. This causes outbursts and
threats directed toward his family,
friends and himself.

D. Mental Health Assessments

1. What are the MULTI-AXIAL ASSESSMENT SCORES? How do they correlate with the data
collected in A, B, and C above?
(Refer to Article and Handouts: GAF Scale).
Axis
Axis
Axis
Axis
Axis

IPsychotic D/O NOS, Aspergers D/O

II None
IIIAsthma
IVNone
V34

2. Mini Mental Health Assessment

Attach the Mini-Mental Health Assessment Form (may be different for each facility) for your client.
N/A

3. Mental Status Assessment

Directions: Refer to PowerPoint Slides in Mental Health Clinical Folder for assistance in completing the
following:
Primary Affect Noted: Appropriate Affect

Disorder of Motor Aspects of Behavior

Specific Examples

No psychomotor agitation or retardation.

Disorders of Perception

Specific Examples

Denies hallucinations, illusions, and other

perception disorders.

Disorders of Thought
Loose Associations

Disorder of Memory
None.

Describe in Detail any Pathology noted in:

Specific Examples
Hail storm. All hail the chief.

Specific Examples
He is able to recall even minor details of events
that happened several years ago. He is also able
to recall short term events.

Give Specific Examples

Judgment
Does not make rational decisions.

Insight

He ran away at a stop-light through traffic

because he didnt want to go to the hospital for
his evaluation.

Give Specific Examples

Does not understand own illness.

Defense Mechanisms
Intellectualization

Client was unable to explain or name his illness

but he did know he had some type of mental
illness.

Give Specific Examples

He spoke in detail about all of the medical
procedures his grandfather was having done,
rather than the fact that his grandfather is dying.

4. Suicide Evaluation Sheet

(Every Yes answer increases the possibility of suicide)
#

Assessment Areas

Evaluation Findings
Yes

NO

Has the client sustained a recent loss (of job, friend, family member,
home, status, or part of body)?

Is s/he isolated from others socially; without friends?

Has s/he ever attempted suicide?

Has a member of their family attempted suicide?

Has s/he ever been treated for mental illness?

Is s/he old, bereaved, or in physical pain?

Does s/he view suicide as a release?

Is s/he diagnosed as psychotic?

If so, does s/he hear voices telling him to kill himself?

10 Is s/he depressed?

X
X
X
X

11 Has s/he said he wished to die or has failed to perform life-saving acts?

12 Does s/he have a history of self-destructive behavior (consistently reckless,

accident prone, addicted to alcohol or other drugs)?

13 Does s/he lack a religious background that enjoins against suicide?

5. Suicidal Assessment - SAD PERSONS ASSESSMENT

(Utilization of this SCALE will help with decision making regarding hospitalization)
Category

Present

Absent

N
X

Sex

Assessment Details

Male

Men kill themselves 3x more than women, although women make attempts 3x more
than men.

Age
High-risk Groups:
19 years or
younger 45 years
and older.

Depression

32

Admits depression

35-79% of those who attempt suicide manifest a depressive syndrome.

Previous Attempts

No previous attempts

No longer drinks
alcohol

Of those who commit suicide, 65-70% have made previous attempts.

ETOH (Ethanol)
ETOH is associated with up to 65% of suicides. Heavy drug use is also considered in
this category.

Rational Thinking Loss

Psychotic

No job, religious
support or romantic
relationship.
Denies plan or
intention.

People with Psychoses (functional or organic) are more apt to commit suicide
than those in the general population.

Social Supports Lacking

A suicidal person often lacks significant others, meaningful employment, and
religious support. Access all three of these areas.

Organized Plan
The presence of a specific plan (date, place, and means) signifies a person at high risk.

No Spouse

Single

Those persons who are widowed, separated, divorced, or single are at greater risk than
those who are married.

Sickness
Chronic, debilitating and severe illness.

No sickness or injury.
Pt suffers from a mild
case of Asthma.

Total
Guidelines for Action
Total Points

Proposed Clinical Action

0-2

Send home with follow-up.

3-4

Close follow-up; Consider hospitalization.

5-6

Strongly consider hospitalization.

7-10

Hospitalize or commit.

Your Assessment

Client claimed and appeared to be

depressed due to not having a
romantic relationship. He admitted
loneliness that leads to anger.

Source/Citation: Patterson, W., Dohn, H., Bird, J., Patterson, G. Evaluation of suicidal patients: The SAD PERSONS scale.
Psychosomatics, April 1983, Vol. 24, No. 4.

E. Diagnostic and/or Laboratory Tests and Procedures:

1. What diagnostic tests would indicate, confirm, or preclude suspected diagnosis.
Test

Result

Rationale for Abnormal Results and

Implications

None

2. What laboratory tests would indicate, confirm, or preclude any suspected diagnosis?
List the lab test and findings, rationale for abnormal results and the implications. Especially note which tests
support current or past medical diagnosis. Are results better or worse since admission? Which results are
clinically significant?)
(In addition to the CBC and BMP, which tests are pertinent for this client)?
Adm.
results

High/low/
WNL

Sodium

141

WNL

Potassium

3.7

WNL

Glucose

77

WNL

BUN

23

HIGH

Creatinine

1.12

WNL

WBC

7.37

WNL

RBC

5.28

WNL

HGB

15.7

WNL

HCT

43.3

WNL

Addl lab work

(A1C, LFTs)
Platelets
MCV

Most
Recent

Rationale for Abnormal Results

and Implications

May indicate Impaired Kidney Function

or Dehydration

F. Medication Reconciliation
1. Correlate medication treatment with present, past, or current diagnoses. Clearly state which
medications treat which conditions? Are these medications continued in the hospital? If
medication reconciliation was not done at time of admission by facility, this section should still list
ALL psychotropic medications patient is taking. This section will NOT be left blank.
Diagnosis

Medication

Contd

Depression

Serogruel 100 mg

Yes

Anxiety

Paxil 20 mg

Yes

Panic Disorder

Klonapin 0.5 mg

Yes

Psychosis

Zyprexa 10 mg

Yes

Depression

Prozac

Yes

2. For each medication current being given, create a list including drug classification, dosage,
mechanism of action ,three (3) major side effects, nursing considerations, client teaching
information and rationale for why this client is currently receiving this medication. (Use ATI Med.
Template or a table may be made to include medication, classification, purpose,
dose/frequency/route, side effects, adverse effects, and nursing considerations).
SECTION 2. NURSING PROCESS
1. Nursing Diagnosis
Compile a list of Actual and Potential-At-Risk Nursing Diagnosis, appropriately written to include Nursing
Diagnoses with etiology statement and with As Evidenced By subjective and objective supporting data.
(Minimum of 5, Maximum of 10).List them in priority order by considering ALL pertinent diagnoses,
abnormal findings and potential complications.
1. Risk for suicide; r/t depressed mood and feelings of hopelessness
2. Knowledge deficit; r/t cognitive limitation; AEB Client admits he does not know what his illness is.
3. Anxiety; r/t interpersonal conflicts; AEB Insomnia, Feelings of helplessness
4. Ineffective Coping; r/t inadequate psychological resources; AEB Chronic Depression, Insomnia,
Irritability
5. Sleep Pattern Disturbance; r/t Anxiety/Fear; AEB Insomnia, Irritability

6. Sexuality Patterns, Altered; r/t Absence of Partner; AEB Expressed dissatisfaction with sexuality

2. Nursing Care Plan

Complete the following table for the two (2) priority actual diagnoses and one (1) highest priority potential
diagnosis. List highest priority first. Fill in Interventions, Rationale and Evaluation for each problem identified.
Nursing Diagnosis Expected
(List 3)
Outcome

Nursing
interventions

Rationale

Client has
Create a safe
Client safety is
Risk for selfviolence r/t
experienced no environment for
highest priority.
delusional thinking physical harm
the client.
and impulsivity
to self. Denies
suicidal
Maintain close Necessary to ensure
ideations.
observation of the client does not harm
client in frequent, self in anyway, and
irregular intervals.
makes staff
surveillance from
becoming
predictable.
Provide a quiet
This allows patient
Knowledge deficit, Pt verbalizes
r/t cognitive
understanding
atmosphere
to concentrate more
limitation, AEB
of illness.
without
completely.
Client admits he
interruption.
does not know what
This allows the
his illness is.
Focus teaching
learner to
sessions on a
concentrate more
single concept or
completely on
idea.
material being
discussed. Highly
anxious and elderly
patients have
reduced short-term
memory and benefit
from mastery of one
concept at a time.
Patient is able
Determine how
Anxiety; r/t
interpersonal
to recognize patient copes with
conflicts; AEB
signs of anxiety.
anxiety.
Insomnia, Feelings
of helplessness
Reassure patient
that he or she is
safe. Stay with
patient if this
appears
necessary.

Evaluation
Client denies
plans and desire
to harm himself.

Pt is interested in
learning and is
able to read and
write.

This assessment
Pt describes a
helps determine the reduction in level
effectiveness of
of anxiety.
coping strategies
currently used by
patient.
The presence of a
trusted person may
be helpful during an
anxiety attack.

3. Client Resources and Personal Strengths

Identify 5 Client Strengths. State how these can be used to help with treatment options.
1. Capable of ADLs. Client has some pre-established independence.
2. Client has access to mental health services. Client will be more likely to successfully continue therapy after
discharge.
3. Client has interpersonal relationships and support. Family will help facilitate support after discharge.
4. Client has a history of compliance while in structured environments. Client will adhere effectively to
treatment while in facility.
5. Client expresses motivation to get better and go home. Will help facilitate client adherence to therapy
programs.

4. Discharge Planning What is the clients discharge plan? (Discharge to home, Rehab Center,
Group home)

Client was discharged in the afternoon.

5. Client Education
1. Complete an Educational Assessment on your client:

Client is interested in learning, he can read and write.

2. Discharge Education Priorities:

What needs to be included in discharge teaching instructions?
Teaching Need

Teaching Instructions/Rationale

Methodology for Presenting

Relaxation Techniques

Relaxation techniques are a Verbal education and printed

great way to help with stress material.
management.

Information on the
clients illness, he does
not know what specific
illness he suffers from.

When patients are provided Verbal education and printed

with a solid knowledge base material.
about their disease process
and treatment, the outcome is
more favorable.

3. Attach teaching materials or describe handouts given client (Ex. AA Step Booklet, Self Esteem
Packet as part of Psycho-education Teaching).
SECTION 3. EVIDENCED BASED PRACTICE
A. Attach an article from a nursing journal that is supportive of your clients care. (Use a peer
reviewed NURSING article related to the CARE you have given.) Remember to attach
Reference Sheet at back of Paper. Also remember to cite sources throughout paper.
B. State how content from this article was applicable to the care you provided?
The cognitive-behavioral therapy (CBT) approach for treating
Psychosis helps to minimize exacerbations and calm patients
Before their psychotic episode gets out of control.

SECTION 4. STUDENT/CLIENT INTERACTION

Directions: This must be a minimum of five (5) minutes/five recordings and be a record of the interaction
(or an excerpt of an interaction) Include both verbal and non-verbal observations/behaviors. Label your nursing
interventions (including specific names of communication techniques). Evaluate in detail specific
psychopathology, defense mechanisms, mood, etc. Evaluate the effectiveness of your intervention. Make
comments about interventions you neglected to use but would include if you could interact with client again.
Refer to textbook and ATI companion book.
Student

Client

Assessment/Evaluation
Client and Self

Ex. I said:
(My non-verbal, thoughts,
feelings) Technique used (Broad
opening, Reflection, Restatement
..)

Client said:
(Client non-verbal,
mood, behavior)

What I think was going on,

what techniques I could
have used differently. What
went well. What I would
change. I should have said
xxxxx

Student
I introduced myself to D.G.
NV: Smiling and making eye
contact.

Client

Appears excited,
smiling.

Yeah, lets go in here, this is where I

Hi. My name is Chrystal and I am
sleep.
a nursing student. I was wondering
if I could talk to you for a little
while.
(Broad Opening)
NV: Starts walking toward his
room.
NV: Made eye contact, smiled.

I directed the location of the

conversation to be outside of He seemed hesitant but
his room.
agreed.
Oh, well thats nice but how
about we sit right here and talk?
NV: Gestured toward a table
and sat down.

I inquired about his hobbies.

Assessment/Evaluation
Client and Self
Trying to establish rapport.
Client seems excited to have
someone to talk to.
Focusing on his comfort with my
presence.

Maintained a safe environment for

our conversation. Tried to ensure his
comfort as well.

Oh, well, ok.

NV: Sat down in the seat across
from me.

He answered my question.

Trying to build rapport by showing

interest in the client. Still keeping the
So what do you like to do for fun? You mean outside of here? I like to conversation focused on him.
go hiking, I used to surf when I
NV: Smiling, Leaning in, and
lived beach side but I live in Palm
maintaining eye contact.
Bay now so I dont surf as much
anymore.
NV: Rarely makes eye contact, but
is very talkative.
I continue to show interest in the
client.
So you like to do outdoors
activities?
NV: Smiling, maintain eye contact
and continue to lean in.

He is very excited.
Yeah, well I used to be a surfer, I
dressed like a surfer, talked like a
surfer, and I did all the things
surfers like to do.
NV: Uses a lot of hand gestures,
still only making eye contact after
he finishes speaking.

Tried to build the clients trust by

showing a genuine interest in him.

Shifted the conversation to more

personal topics.

He appears a little nervous but

answers my question.

Tell me about your family. I know

you live with your father, is there
anyone else at home?

Yeah, I live with my father, my

stepmother and my brother. Hes
older than me and I think I
embarrass him because, ya know,
little brothers.

NV: Facing client squarely,

maintaining eye contact, and
smiling.

NV: Shrugged his shoulders when

referring to his brother.

Establishing client comfort and

rapport, tried to go deeper in the
conversation to gain more knowledge
about the client.

SECTION 5. JOURNALING
DIRECTIONS: This assignment will enable you to focus on YOUR THOUGHTs, FEELINGs and BEHAVIORS
experienced during each clinical experience to identify changes in your attitudes, as well as identify your
growing edges in understanding mental health.
1.
Answer the following questions regarding your MENTAL-HEALTH CLINICAL EXPERIENCE.
2.
The following weblinks may be used to cultivate this section.
https://www.youtube.com/watch?v=cRMogDrHnMQ Zig Ziglar
https://www.youtube.com/watch?v=pfWGoLj1JCM Will Smith

1. In what sense does the quote, Its not your aptitude that determines your altitude but your attitude
that determines your altitude (Zig Ziglar), apply to your (a) personal, (b) academic and, (c) professional
growth?
Response: I think this quote is very true. The smartest person in the world wouldnt achieve
anything if they had the wrong attitude. Aptitude does play an important role but it is not the
deciding factor on how far you will go in life.

2. Did you find that you were able to use your voice during the mental-health rotation? Describe?
Response: Yes I do, I think I was a bright spot in my clients day. The fact that someone took the
time to focus on him made him very happy.

3. Did you have any Significant Learning Opportunities (SLO) moments where you either learned a new
life lesson or learned something about yourself?
Response: I learned a lot about the psychotic client. In some cases, if properly medicated, a
psychotic client can seem like any other person. There were a few instances in my conversation
with D.G. that I almost forgot we were at COC, I felt like I was talking to a person who had no
mental illness. Of course, there were several instances in the conversation that was not true as
well.

4) In what sense were you Challenged?

Response: I was more challenged at first, I felt a little scared when we first arrived at COC. I didnt
know what the environment was going to be like and how ill the patients were going to be. After a
few minutes of being there and talking to a few clients I quickly gained a certain comfort level.
Although, I was never fully comfortable the entire time I was there.

5) a. What did you identify/uncover as your personal strengths?

b. How can you apply them in the academic setting and also with your future patients?
Response: I identified I am able to not react when a client acts in a way that might be funny to
another person. I can apply that with almost every patient. People are the most vulnerable when
they are in a health care setting so there will almost always be an instance when it would be easy
to laugh or smile in response to a patient, I now know I can keep a straight face and give the client
a great level of care even in their worst situations.

6) a. What did you identify/uncover as your limitations?

b. What strategies, utilizing the personal strengths you have identified in the prior question, can you
use to overcome these limitations in the academic setting and also with your future patients?
Response: My biggest limitation is shyness. I can use my strength to overcome my limitation
by seeing them as people and not patients.

2.

Answer the following questions regarding your Daily Clinical Experience

Clinical Day/Date

Thoughts
(Cognitive
Learning

Feelings
(Affective Learning)

Actions
(Behavioral
Understandi
ng)

Ex. What I
learned today
was .
I was able to apply
.

EX. I saw a change in my

feelings

EX. I noticed a
change in my
posture and in my
approach toward
clients.

Orientation

Clinical Day #1

Clinical Day #2

What I learned today is

that people with
psychosis can appear
perfectly normal. I was
able to apply active
listening while speaking
with my patient.

I was unable to attend

my second clinical day
due to an emergency
outpatient surgery
that had to be
performed on my
daughter.

I saw a change in my
I noticed a change in
feelings after speaking to my my posture and in
first patient. At first I was
my approach toward
nervous and a little scared. clients. I was more
After speaking to him I felt open and less
understanding and empathy. guarded.

3. Complete the following: (If attaching support group reflection this box may be omitted.
Directions: You are to attend one (1) support group, outside of your scheduled clinical
experiences. After attending the meeting, record the following information:

Date, Time and Address of Meeting

Brief Evaluation of the Meeting

Support Group #1
Already turned in.

SECTION 6. DOCUMENTATION METHODOLOGY

Effective communication is essential for optimal client centered care and continuity of care for your
client. Summarize your shift report in the SBAR format.
Situation: Client is a 32 yr old white male, who was brought in on a 52 (baker) by police after
running away from his fathers vehicle at a stop light.

Background: He has a history of depression and psychosis.

Assessment: He seems very pleasant and cooperative. He understands why hes here. He has
good speech and medicine compliance. He is socially active and talkative.

Recommendations: I recommend this client is properly educated regarding medication. I also

recommend education regarding seeking help early in a crisis and not waiting as long as he did.
He will need to learn the signs and symptoms of exacerbation.

SECTION 7. RESOURCES - Attach APA references to case study.