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Running head: PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Shauna Letcher

Mental Health Nursing 4842

Teresa Peck MSN, RN

November 6th, 2018


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PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Abstract

In this psychiatric mental health comprehensive case study, we get a first-hand look into

the long-term effects of lifelong alcohol abuse and various mental illness like major depressive

disorder, anxiety, and bipolar met with noncompliance and lifelong health issues. With

medications, outpatient therapy and compliance, mental illnesses are very manageable, and

individuals can lead very productive lives if they choose to do so. In this case study, multiple

mental health diagnoses, medications and nursing diagnoses will be discussed and explained.

MM’s detailed history of past and current hospitalizations, personal life, family, medications,

and discharge plans will be provided.


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PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Objective Data

On October 23rd, 2018, Patient MM was interviewed for this psychiatric mental health

comprehensive case study. Patient MM was admitted to the psychiatric unit on floor 3 South at

Trumbull Memorial Hospital on October 17th, 2018 through the emergency department after a

failed suicide attempt. MM is diagnosed with multiple mental illnesses which include major

depressive disorder, alcohol dependence, bipolar 2, anxiety, and polysubstance induced mood

disorder. The DSM IV outlines the following criterion to make a diagnosis of depression; The

individual must be experiencing five or more symptoms during the same 2-week period and at

least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day. 2. Markedly diminished interest or

pleasure in all, or almost all, activities most of the day, nearly every day. 3. Significant weight

loss when not dieting or weight gain or decrease or increase in appetite nearly every day. 4. A

slowing down of thought and a reduction of physical movement (observable by others, not

merely subjective feelings of restlessness or being slowed down). 5. Fatigue or loss of energy

nearly every day. 6. Feelings of worthlessness or excessive or inappropriate guilt nearly every

day. 7. Diminished ability to think or concentrate, or indecisiveness, nearly every day. 8.

Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide

attempt or a specific plan for committing suicide. (“Depression Definition and DSM-5

Diagnostic Criteria”)

On admission MM was very upset with his present circumstances that precipitated his

suicide attempt, voicing his suicidal ideations along with the plans he intended to use to carry out

the suicide attempts. MM rated his depression and anxiety very high upon admission. On the
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PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

date of care, MM’s mood had improved greatly. MM was no longer voicing suicidal ideations

and stated that his depression and anxiety had decreased some since admission. MM was very

open and willing to talk about his mental illness and what lead him to the attempt at taking his

life. MM had preoccupations of thoughts, his thoughts included his financial hardships, loss of

vision, loss of independence and loss of familial support. MM was cheerful on the unit and with

other patients and nurses and attended all groups with eager participation.

3 South at Trumbull Memorial Hospital is a locked unit as a safety measure to the

patients, meaning patients are not able to leave the floor until they are discharged from the

hospital and no one can enter the floor unless they are allowed on by the nursing staff. A

psychiatric unit differs from a medical-surgical floor in that are unit restrictions with an emphasis

on patient safety from self-harm and harming other patients and staff members. Treatments of a

psychiatric patient and all visitations are to take place in the activity room and/or the common

area. Nurses are observing the activity and common areas at all times with a visualization on

patients at least every fifteen minutes. There are ligature safety precautions taken with all

patients to reduce the risk of an attempted suicide by hanging, and showers are locked until

opened by nursing staff. After medications are handed out to the patient, the nurse checks the

mouth of the patient to ensure that the patient swallowed their medication. If there was not this

safety measure, patients could pocket their medication in their mouth and save the medication

until they had enough medication to attempt a suicide by overdosing.

At the time of the interview, MM was currently on seven different medications for his

mental illnesses. Tegretol (Carbamazepine) is an anticonvulsant that MM utilized for his seizure

disorder and mood stabilization. Tegretol (Carbamazepine) stops the rapid firing of neurons in
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PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

the brain, this calms the overactive brain to stop and prevent seizures and to stabilize the mood.

MM’s Tegretol (Carbamazepine) blood level was 11.7 mg/L, which is in the therapeutic range of

4-12 mg/L. Librium (Chlordiazepoxide) is a benzodiazepine taken to ease the symptoms of

alcohol withdrawal. MM was on Librium (Chlordiazepoxide) because he has been an alcoholic

since his teenage years, although MM had been admitted with a negative alcohol screen, stating

he had not drunk alcohol for three weeks, the physician wanted to take precautions as alcohol

withdrawal can cause seizures. Depakote (Valproic Acid) is another anticonvulsant used for

epilepsy and mood stabilization through the cessation of rapid firing of neurons in the brain,

calming the overactive brain to stop and prevent seizures and to stabilize the mood. MM’s

Depakote (Valproic Acid) blood level was 46.7 µg/mL, which is close to the therapeutic range of

50-125 µg/mL. Within a couple more doses of Depakote (Valproic Acid), MM would be within

the therapeutic range. Every patient on a psychiatric unit has a standing order of Haldol

(Haloperidol). Haldol (Haloperidol) is an antipsychotic that is prescribed to all psychiatric

patients to treat agitation as needed. Hydroxyzine (Hydroxyzine HCl) is an antihistamine that

was prescribed to MM to treat anxiety as needed while on the floor. Every patient on a

psychiatric unit has a standing order of Trazodone (Oleptro). Trazadone (Oleptro) is an

antidepressant that is prescribed to all psychiatric patients to treat insomnia as needed. The last

medication prescribed was Thiamine (Vitamin B), although not a psychiatric drug it was

prescribed to MM because of his alcohol abuse which is a mental illness. Thiamine (Vitamin B)

is required in our bodies to properly use carbohydrates and prevents brain disorders in

individuals with alcoholism. Alcoholism usually results in poor diets, where we find Vitamin B,

therefore it must be supplemented. (Pedersen, 2017)

Summarize the psychiatric diagnoses and expected/common behaviors with citations


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Major depressive disorder, also known as clinical depression, is one of the most common

mental illnesses in the United States. Major depressive disorder is persistent and intense feelings

of sadness for an extended period, effecting the mood, behavior, and physical function like

sleeping, eating and other activities of daily life. With major depressive disorder the individual

will feel sad or irritable majority of the day, more days often than not, will lose interest in

activities they once enjoyed, will suddenly lose or gain weight, will have a change in appetite,

will have insomnia or hypersomnia, will feel restless, will lack energy to complete tasks, will

have feelings of worthlessness and/or hopelessness, will have difficulty concentrating, thinking,

and making decisions, will have thoughts about harming oneself or committing suicide. The

individual will have five or more of the above symptoms for more than two weeks to be

diagnosed with major depressive disorder. (Kerr & Legg, PhD, 2017)

Alcohol use disorder is described as chronic relapse of alcohol use with loss of control of

alcohol consumption and negative emotional state while using alcohol. Alcohol use disorder can

be diagnosed by experiencing any two or more of the following symptoms; drinking more or

longer than you planned to, tried to cut back or quit drinking with no success, spent long period

of time drinking, spent a long period of time feeling sick after drinking, experience a craving for

alcohol, drinking interfered with school, work, or family, continued drinking even though

drinking was causing problems with school, work, or family, cut back on activities you enjoyed

because of drinking, being in a situation of increased risk for injury because of drinking,

continued to drink even though you felt depressed or anxious, have had to increase the amount of

alcohol consumed to receive desired effect, or had feelings of withdrawal symptoms after

drinking. Mild, moderate or severe alcohol abuse coordinates with how many symptoms the

individual is experiencing. (“Alcohol Use Disorder”)


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PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

Bipolar is a mental health illness characterized by periods of extreme high moods and

extreme moods called mania and depression. Mania is a period of extremely elevated moods that

must last at least one week and have at least three of the following symptoms; high self-esteem,

insomnia, rapid speech, flight of ideas, distracted easily, increased interest in goals or activities,

akathisia, or reckless, dangerous behavior. Depression is a period of extremely low moods that

must last at least two weeks and at least four of the following symptoms; weight gain or loss,

changes in appetite, insomnia or hypersomnia, akathisia or akinesia, decreased energy, feelings

of worthlessness or hopelessness, difficulty concentrating or making decisions, thoughts of self-

harm or suicidal ideation. Bipolar II is when the individual with bipolar has more depressive

moods than they do manic moods or have hypomanic moods which are less extreme than mania.

(Krans & Legg, PhD, 2017)

Generalized anxiety disorder is severe, ongoing anxiety that affects activities of daily life.

To be diagnosed with generalized anxiety disorder, excessive anxiety and worry about a variety

of topics, events, or activities must be present. The excessive worrying occurs more often than

not for at least 6 months and is clearly more excessive than everyday worrying. The worrying in

generalized anxiety disorder is hard to control and may shift from one subject to another easily.

To be diagnosed with generalized anxiety disorder the individual must also present with at least

three or more of these symptoms; edginess or restlessness, more fatigued than normal, difficulty

concentrating, irritability, increase in muscle aches from tenseness, and insomnia. (Glasofer,

PhD, 2018)

Identify the stressors and behaviors that precipitated current hospitalization

MM has had multiple psychiatric commitments throughout his life, many of which were
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for alcohol and substance abuse, extreme depression, and suicide attempts with his last

hospitalization prior to the current one being September 2018. This specific hospitalization was

for another failed suicide attempt. MM has suffered from epilepsy since childhood, in May 2017

MM underwent a craniotomy performed at the Cleveland Clinic in attempts to end his seizures.

One of the possible side effects of the craniotomy was loss of vision, because of the surgery MM

suffered loss of peripheral vision in his left eyeball. With the loss of vision, MM has had a

decrease in the quality of his life and loss of independence as he has not been able to work since

the surgery. The loss of independence and quality of life has greatly increased his depressive

state of mind. Prior to the suicide attempt on October 17th, 2018, MM states that he had not left

his residence in two weeks due to his depression. In that two weeks he claims that he had little

to nothing to eat and when he tried to contact his sister for help she did not want him contacting

her. MM decided that he would take his life by overdosing on the Tegretol (Carbamazepine) he

was prescribed for his epilepsy and mood stabilization. MM woke up from the Tegretol

(Carbamazepine) overdose, crawled over to his neighbor’s front porch and waited three hours for

him return from work. When the neighbor got home from work he called 911, police arrived,

and he was taken to Trumbull Memorial Hospital to be committed to the psychiatric unit.

Discuss patient and family history of mental illness

MM has presented to the psychiatric floor numerous times throughout his life with a

history of thirty day readmits, he is well known to the staff at Trumbull Memorial Hospital.

MM’s alcohol abuse began when he was a young teenager caving into peer pressure and

believing drinking would make him popular with the older kids. Having had epilepsy since

childhood, MM was never able to legally drive, resulting in many driving without license and
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PSYCHIATRIC MENTAL HEALTH COMPREHENSIVE CASE STUDY

driving under the influence arrests. MM told a story of the last time he drove drunk, after a night

of drinking MM was driving home when he wrecked his vehicle and flipped the vehicle into

someone’s front yard. A passerby stopped to check on MM when MM asked for a ride home to

his house a couple miles down the road where he called the police and reported the vehicle

stolen. When police arrived at MM’s house they noticed blood on his face, MM lied to the

police and told them that he had been hit in the face with a rock by his nephew. MM claims he

got away with the stolen vehicle report but that was the last time he had drove. MM was very

remorseful about the situation and always wonders what he would feel like if there had been

children playing in that front yard. The accident was enough to scare MM into never driving

again but the drinking continued until his recent sobriety of 3 weeks, the longest he has ever been

clean of alcohol and drugs.

MM has been married and divorced twice in his life with no children. His mother

recently passed away in January of 2018, a woman he was very close to. MM’s alcohol abuse

and poor decisions has driven away his two sisters and hindered the relationships with his

nephew. These losses and isolations have pushed MM deeper into his depression every time,

causing more alcohol use and more poor decisions. MM states he is the only one in his family

with a mental illness, contributing to his isolation from the family.

Describe the psychiatric evidence-based nursing care provided and milieu activities

attended

Upon admission, MM was evaluated, and his needs were assessed. Based upon his

current needs for this admission, MM’s physician made a plan to stabilize MM on his

medications, address his suicidal ideations, depression, and anxiety, and to prepare MM for
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future discharge. Since MM was sober, he will be encouraged to reach out to his sisters for

support and will be encouraged to attend AA meetings to be with like peers once discharged.

Milieu therapy is a psychotherapy in which the patient's social environment is controlled

or manipulated with a view to preventing self-destructive behavior. Patients are involved with

their decision making about their treatment, family visitation is encouraged, provides a

comfortable setting, the rooms are not over stimulating, and communication is encouraged in

group therapy. Group therapies are beneficial to psychiatric patients as it lets the individuals

know that they are not alone in what they are feeling, it promotes improving social skills and it

provides a safe place to share your feelings and thoughts. MM attended all group therapies on the

floor with the other patients and participated eagerly and appropriately. MM was out on the

floor in the common area, trying to engage in conversation with the other patients and staff

members. It is clear that MM does not have support outside of the psychiatric unit, so he uses

his hospitalizations and the staff members as his means of support and socialization.

Analyze ethnic, spiritual and cultural influences that impact the patient

MM is white, middle aged man who has had a long career in the chef business working

for many of the big local area restaurants and catering businesses. He has been lucky enough to

own his own home since his twenty’s and has been financially stable since his surgery. MM

made no mention of any spiritual beliefs that he or his family participated in, when asked about

spirituality and religion MM replied, “I believe there is a God, but I do not attend church or

worship on my own.”.

Evaluate the patient outcomes related to care


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The outcomes for MM on this hospitalization were to get him past the suicidal crisis, ease

the thoughts of suicide, restart and get stabilized on medication, continue sobriety, try to

reestablish family support and outside socialization, begin government assisted programs for

income and increase coping skills.

Summarize the plans for discharge

On the date of care MM was having a court hearing at the Trumbull Memorial Hospital to

be appointed a guardian by the state. A guard who has guardianship over a mental health patient

will make all decisions on behalf of the patient, the patients needs and wishes will be considered

by the guardian. Not only will the guardian make all decisions like where the patient will go

upon discharge, the guardian will be in charge of the patient’s financials. MM was being

appointed a guardian for his history of poor decision making, noncompliance, his financial

situation, and his recent short-term memory loss. MM voiced that he would like to be discharged

to a group home or even a skilled nursing home. A group home or skilled nursing home would

provide socialization and a structured routine with some personal freedoms in which MM would

thrive in with the support. MM also said he would like to return to attending AA meetings. AA

meetings provide camaraderie for those recovering for alcoholism and will be another avenue of

socialization. MM expressed a wish for trying canine therapy since he grew up owning dogs and

has always been around dogs, he believes canine therapy would improve his mood and be

beneficial.

Prioritized list of all actual diagnoses using individualized NANDA format.

1. Ineffective individual coping related to depression as evidenced by suicide attempt by

overdose
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2. Risk for self-directed violence related to feelings of worthlessness as evidenced by

verbalization of suicidal ideation

3. Self-care deficit related to loss of peripheral vision as evidenced by decreased ability to

cook, clean and walk without difficulty.

4. Complicated grieving related to loss of mother as evidenced by prolonged difficulty

coping following a loss

5. Low self esteem related to feelings of failure related to difficulty accepting loss of vision

6. Social isolation related to absence of significant others as evidenced by expression of

feelings of aloneness

7. Powerlessness related to loss of ability for self-care as evidenced by verbal expression of

having no control over situation

List of potential nursing diagnoses

1. Imbalanced nutrition, less than body requirements, related to inability to pay for food

as evidenced by loss of weight

2. Disturbed sleep patterns related to anxiety as evidenced by awakening earlier than

desired

3. Ineffective health maintenance related to substance abuse as evidenced by

verbalization of lifelong alcoholism and drug use

4. Noncompliance related to substance abuse and financial issues as evidenced by

verbalizing not taking medications and progression of depression

Conclusion paragraph

Having MM as a patient gives one better insight into the life of an individual who suffers
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from lifelong mental illnesses like substance abuse and major depressive disorder. MM is the

prime example of noncompliance and the consequences that arise from noncompliance and

substance abuse. MM has pushed his only family away that is only support he has now is the

support he finds within the psychiatric unit at Trumbull Memorial Hospital and will possibly

have all rights taken away from him when he is appointed a guardian. From report, MM appears

to be on a better path now than previous hospitalization, with three-week sobriety and wishful

discharge to a group home, the nurses at Trumbull Memorial Hospital can only hope that MM

continues this sobriety and continued work towards acceptance of his vision loss.
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Works Cited

Alcohol Use Disorder. (n.d.). Retrieved November 1, 2018, from

https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-

disorders

Depression Definition and DSM-5 Diagnostic Criteria. (n.d.). Retrieved October 31, 2018, from

https://www.psycom.net/depression-definition-dsm-5-diagnostic-criteria

Glasofer, PhD, D. R. (2018, September 20). Generalized Anxiety Disorder: Symptoms and

Diagnosis. Retrieved November 1, 2018, from https://www.verywellmind.com/dsm-5-

criteria-for-generalized-anxiety-disorder-1393147

Kerr, M., & Legg, PhD, T. J. (2017, June 27). Major Depressive Disorder (Clinical Depression).

Retrieved November 1, 2018, from https://www.healthline.com/health/clinical-depression

Krans, B., & Legg, PhD, T. (2017, September 25). Diagnosis Guide for Bipolar Disorder.

Retrieved November 1, 2018, from https://www.healthline.com/health/bipolar-

disorder/bipolar-diagnosis-guide#mental-health-evaluation

Pedersen, D. D. (2017). Psychnotes: Clinical pocket guide (5th ed.). Philadelphia, PA: F A

Davis.

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