Running head: CASE STUDY 1

Belmont Pines Acute Care: Case Study

Kirsten Hurd

Youngstown State University

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Abstract

On October 1, 2019, I began my investigation on a nine-year-old female for my case study in this

clinical. A.L. was admitted to Belmont Pines Acute Care Center after being discharged three-

days prior to admission. She has a family history of psychiatric illness and also has a few

psychiatric diagnoses of her own to contribute. Her mother has reported that the patient has

verbalized thoughts of suicide and performs self-harm behaviors, i.e. ripping out hair and

banging head against the wall, on herself. Being so young, finding the proper treatment for this

patient is more difficult than that of an adult. The treatment team must review her previous

discharge goals and identify what needs to be changed with the current admission related to new

as well as old reports of behavior changes.

Keywords: bipolar disorder, autism spectrum disorder, ADHD, impulsiveness.

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Belmont Pines Acute Care: Case Study

A.L. is a nine-year-old Caucasian female that was admitted to Belmont Pines Acute Care

center on September 30, 2019. She comes from a family consisting of her biological mother,

father and one younger brother. The patient was previously discharged on September 27, 2019,

so A.L. was brought back by her parents after being home with her family for less than three

days. Day of care took place from 9:00 a.m. to 3:00 p.m. on October 1, 2019. A.L. has been

diagnosed with early Bipolar Disorder, Attention Deficit Hyperactivity (ADHD) and Autism

Spectrum Disorder. The patient was readmitted due to a suicidal risk behavior as the patients’

mother stated that A.L. verbalized a death wish upon herself while her mother had to restrain

A.L. on September 29, 2019. Admission criteria for this patient consisted of danger to herself

and others, severe incapacitation and requiring continuous evaluation. A.L. was aggressive with

her mother, tried to stab her younger brother and created property destruction. She also has a

history of banging her head against the wall, pulling out clumps of her hair and viciously

scratching her face.

On day of care, A.L. was placed on assaultive behavior hold at 8:45 a.m., before I was

scheduled to be at the clinical site. It was difficult to get an interview with the patient during this

shift. The patient was behaving well during her group therapy session and did not want to leave it

to talk a nursing student. However, at 10:15 a.m., she did agree to spend a few minutes with me

at 11:00 a.m. when the group therapy session was done. This gave the patient about forty-five-

minutes to spend time with the group and it also gave myself some time to search through her old

admission file. A.L.’s new admission file did not have enough information about her new

treatment plan because the patient had only been there for less than a day, so Mr. Bill and myself

went to the office to gain access to her file from her previous stay. After searching through her
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file, I learned that A.L. enjoyed talking about her favorite teacher from school, Ms. Figley, and

also her teacher’s assistant named Krissy. In order to gain trust with the patient, I planned to

bring these people up in our interview before asking about more sensitive subjects.

After group therapy, I was able to get A.L. to talk with me. To say the slightest, I did not

get any information from the patient that I could not get from her chart. My whole plan to talk

about Ms. Figley and Krissy completely back-fired on me. I asked the patient about school and

what subjects she enjoyed to learn about, which she answered that science and art were her

favorite classes. I then tried to incorporate Ms. Figley and Krissy into the conversation and

immediately the patient stated, “They are fucking stupid. Krissy never gives us any snacks and

Ms. Figley is annoying”. Following, I changed to subject and asked about her life at home and if

she had any pets. Her response was, “I have 2 dogs. The old fat one is a piece of shit and is

probably going to die soon. The other one shits everywhere in the house and stinks”. Again,

trying to get more detail on her relationship with her mother, I asked A.L. if her and her mother

get along. She responded with, “Sometimes”. That was all she would tell me about her mother.

After that, A.L. was very easily distracted during the interview. We were standing in the hallway

near the daily activity schedule and all A.L. wanted to know is if they were going to have an art

therapy session later on in the day. When I told her I was unsure what was on the agenda for the

day, she stated, “I am done with this stupid talking”, and went back into the room for the next

group therapy session.

Due to my inability to learn any new information from the patient, I resided to reading

both her new and old chart for my case study. Related to her psychiatric diagnoses, A.L. has been

prescribed Latuda 40 mg by mouth every evening and Trileptal 150 mg by mouth twice daily

Both of these medications have been prescribed for mood swings. A family history of psychiatric
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occurrences is also present. The patients’ maternal uncle was diagnosed with PTSD, her maternal

great uncle killed his wife and also killed himself. Lastly, A.L.’s paternal grandparents both have

a history of alcohol and drug abuse. It is unknown if the patient is aware of the family history.

Although the A.L.’s chart stated the family is Presbyterian, it is unknown if the family follows

the faith or attends church ceremonies.

After researching her current psychiatric diagnoses, bipolar disorder, “… is characterized

by mood swings from profound depression to extreme euphoria (mania), with intervening

periods of normalcy” (Ball, 2019). I was able to witness these changes in the patient’s behavior

on day of care. The patient would be calm and open to talking to me for the interview, but then

she would be angry and easily triggered within a few seconds difference. Next, ADHD is a

common disorder found in children. The child with ADHD is said to have behavioral patterns of,

“… inattention and/or hyperactivity and impulsivity” (Ball, 2019). The patients’ ability to

become easily distracted during our interview was a perfect example of behavior in a child with

ADHD. However, the behavior of impulsivity seems to be high in A.L. Impulsiveness is defined

as, “The trait of acting without reflection and without thought of the consequences of the

behavior” (Ball, 2019). A.L., in other words, seems to have a history of acting impulsively,

especially when it comes to being aggressive with family members at home. Lastly, A.L. has

been diagnosed with autism spectrum disorder and it is characterized by, “… a withdrawal of the

child into the self and into a fantasy world of his or her own creation” (Ball, 2019). I understand

this to mean that a patient lives in their own reality and withdraws from others. Based on the

patients’ chart, it seems as if A.L. does not like to be in big crowds and is a trigger for her temper

tantrums.
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Being only 9-years-old, the patient does not have many medical diagnoses to date.

However, the patient does have a diagnosis of early insomnia, meaning she has trouble falling

asleep, but when she does, the patient is able to stay asleep. Due to this, the patient gets less than

6-7 hours of sleep per night. This is a concern for her wellbeing because at the age of 9, the

average child should get a minimum of 8-9 hours of sleep each night in order for the body to

replenish itself for the next day (Townsend, 2017). The patients lack of proper sleep can be the

reason for barriers towards treatment. A.L. has a history of barriers, including poor motivation

and poor impulse. The patients mother reported that A.L. is very manipulative, an incredible liar

and rather profane. A.L.’s mother also reported that these characteristics increase when the

patient is trying to get something that she wants. The treatment team also relates A.L.’s

psychiatric and medical diagnoses to having lack of fetal movement in utero, causing the mother

to receives numerous non-stress tests (NST’s) during pregnancy.

A.L. has verbalized to social work and therapists that there are specific triggers to her bad

behavior. These triggers include being yelled at, loud noises, being told “no”, overcrowding,

being teased by others and not getting what she wants. When the patient gets angry, her behavior

includes an increase in swearing, grinding her teeth, clenching her jaw and fists. A.L. stated

when she is upset, she does not like to be touched, being overcrowded and getting things taken

away from her. However, the patient does have activities she likes to do to cope and feel better

when she is upset. These activities, include drawing/coloring, swimming, telling jokes/being

funny, laying with her favorite blanket and practicing Tai Kwando. A fun fact about A.L. is that

she has a blue belt in Tai Kwando and wants to be a veterinarian when she grows up. I did

attempt to talk to the patient about her Tai Kwando class and her favorite things to draw, but she
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was not in the mood to talk about them at the time. It was important for me not to continue to

push the subjects in order to prevent an outburst and cause the patient to become aggressive.

On day of care, I was able to sit for the last couple of minutes of the group therapy

session before my interview with the patient. Upon my observation, A.L. was having a fun time

with the other kids and was acting appropriately. The person in charge of group therapy that day

made the session fun and kid-friendly by incorporating newer Disney movies, such as frozen,

into the lesson. I believe the milieu activity being provided was helpful in the therapeutic plan

for A.L. because she was able to move around and play like a normal kid rather than being

expected to sit still in a chair and be quiet for the entire session. Due to her diagnosis of ADHD,

a quiet environment would not be therapeutic for the patient. A child with ADHD already has a

short attention span and does not have the ability to sit still for a long period of time. Some may

see this behavior as acting-out and put this in the patients’ chart for the rest of the treatment team

to see. This would then contribute to a false occurrence of misbehavior and lead the treatment

team to believe no progress is being made.

During her previous admission from September 18th – September 27th, the patient long-

term outcomes related to care was to improve mood, behavior and thinking before discharge. A

long-term concern for the treatment team related to care was the bad relationship between A.L.

and her brother. The long-term concern of the patients’ relationship with her brother will be an

on-going worry until the patient has found a stable method of treatment regarding medications

that work well for her and what non-pharmacological ways the patient can use to cope with times

of stress.

The treatment team also constructed a few short-term goals for the patient to meet before

discharge. These short-term goals included:

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1. List two things that make her mad by discussing stressors and when she feels

overwhelmed for 30-45 minutes per day.

2. Verbalize two positive activities to remain safe/calm/in control when

frustrated by using games for at least 1-hour per day.

3. Express anger to doctor/thoughts of any self-harm or harm to others in order

to identify the need for new medications (i.e. Prozac, Strattera and Lamictal)

for 15 minutes per day.

Before discharge on September 27, 2019, the patient did meet the stated goals set by the

treatment team. However, the patient did not last long when she returned home to her family as

she was readmitted on September 30, 2019, less than three-days after discharge.

Since A.L. has only been admitted for about 24-hours on day of care, there was no set

treatment plan for patient at that time. Nonetheless, I believe the treatment plan for A.L. will

remain the same with the overall goal for the patient to return home to her family. From my

observation and research, there needs to be more investigation regarding the patients’

relationship with her brother and mother. Upon readmission, the patient was brought back by her

mother due to aggression and assault. So, the questions remain: what about her brother makes

her angry? What are her specific triggers for wanting to hurt herself and others at home? What

causes the patient to be aggressive towards her mother? These questions need to be further

investigated in order to fully comprehend the actions of the patient.

The first priority for A.L. is risk of suicide related to history of self-harm. A.L. has

verbalized thoughts of hurting herself and others. Her mother reported that the patient verbalized

a death wish upon herself on September 29, 2019. It is important that the treatment team

investigate these thoughts of hurting herself and others while prevent access to objects that can
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aid in such behaviors. These objects may include self-care items, sharp objects, writing utensils,

metal silverware for meals and shower curtains. The patient must report suicidal thoughts, report

thoughts of hurting others and verbalize thoughts during times of stress and frustration to staff

members during hospitalization.

Some possible nursing diagnoses for A.L. include:

1. Impaired social interaction related to neurological alterations as evidenced by

lack of interest in people (Ball, 2019).

2. Impaired verbal communication related to withdrawal into self as evidenced

by unwillingness to speak to nursing student (Townsend, 2017).

3. Risk for injury related to impulsiveness and extreme hyperactivity (Ball,

2019).

4. Impaired social interaction related to underdeveloped ego and low self-esteem

as evidenced by inability to develop satisfying relationships and manipulation

of others for own desires (Townsend, 2017).

In conclusion, A.L. has behaviors that will continue to be an on-going investigation for

the treatment team and her family. Even thought A.L. met all of her short-term goals during her

previous hospitalization, she was readmitted a few days after being discharged. It is important to

investigate the causes for A.L.’s aggression towards members of the family as well as the

thoughts of suicide. It is also essential for the doctor to identify medications that can help with

A.L.’s treatment in order to create a stability in her mood changes. Those involved in her

treatment must be able to identify actions done by the patient that may be a warning that she is

angry and could become aggressive. I do wish I could have contracted more information from
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A.L. herself, but I did not want to push her into talking to me and trigger an outburst in her

behavior.
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References

Ball, J., Bindler, R. M. G., Cowen, K. J., & Shaw, M. R. (2019). Child health

nursing: partnering with children & families (3rd ed.). New York, NY: Pearson.

Parekh, R. (Ed.). (2017, July). What is ADHD? Retrieved from https://www.psychiatry.org/patients-

families/adhd/what-is-adhd.

Townsend, M. C., & Morgan, K. I. (2017). Essentials of psychiatric mental health

nursing: concepts of care in evidence-based practice (7th ed.). Philadelphia, PA:

F.A. Davis Company.