Running head: COMPREHENSIVE CASE STUDY 1

Psychiatric Mental Health Comprehensive Case Study:

A bipolar adolescent

Joni Neal

Youngstown State University

N4842 Mental Health Nursing

November 28, 2016

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Abstract

This paper is a case study of a bipolar adolescent female. Her personal medical and mental

health history is reviewed as well as the spiritual and cultural influences that impact her.

Bipolar disorder is summarized along with common behaviors related to bipolar disorder from

the view of adolescent onset. Identified are the stressors and behaviors that precipitated her

current hospitalization. Nursing care provided is described and evaluated and summarized are

the plans for discharge. Actual and potential nursing diagnoses for this patient are prioritized

and reviewed.
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Objective Data

The patient is an 18 year old caucasian female admitted to the facility on 10/31/2016. The

date of care is 11/01/2016. Her diagnosis on the DSM IV-TR is as follows:

Axis 1- Bipolar disorder depressed severe without psychotic features

Axis 2- deferred

Axis 3- none reported

Axis 4- social, environmental

Axis 5- 25

The patient has no active medical conditions or treatments. She is on self harm precautions

for suicidal ideations and has contracted for safety. On admission the patient rated her

depression an 8 and her anxiety a 6. She was distracted, loud, hostile, and had a labile affect.

Her thought process was illogical, with poor judgement and insight. She was admitted with

suicidal ideations to run into traffic and homicidal ideations towards her mother. On the day of

care she was still distracted, but her speech was of a normal tone and rate. She was not hostile

but somewhat labile. She was very restless and her judgement and insight were still poor. The

patient was dressed carelessly, stating that she hadnt showered in a few days. Also she was

very sociable, particularly with men on the unit, referring to them as her friends.

The psychiatric physician ordered her Latuda 20mg 2x daily. This is an antipsychotic

medication sometimes used to treat the depressive phase of bipolar 1 and 2. She was also

ordered the standard unit PRN medications: Benadryl for EPS, Haldol for agitation, Dulcolax for

medication induced constipation, Milk of Magnesia for medication induced constipation, Ativan

for anxiety, and Tylenol for pain or fever.

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Summarize the psychiatric diagnoses and expected/common behaviors

Bipolar disorder was once called manic-depressive disorder. This previous title quickly

explained the leading characteristic of the disorder; periods of mania coupled with periods of

depression. Sometimes there is normalcy in between the periods. It affects approximately

5.7million American adults (Townsend, 2015). It is suggested that prevalence during the

adolescent years is at least that of the adult population, and may be increasing (Geller & Luby,

1997). Geller and Luby in Child and Adolescent Bipolar Disorder assert that it is

developmentally possible for childhood-onset manic depressive illness to be more severe; to

have a chronic, non episodic course; and to have mixed, rapid-cycling features (1997). The

cycling being between mania and depression.

Depression in adolescence is often characterized by feelings of sadness, loneliness,

anxiety, and hopelessness as well as inappropriately expressed anger, aggressiveness,

delinquency, substance abuse, and apathy (Townsend, 2015). They may have trouble falling

asleep and lie in bed brooding (Geller & Luby, 1997). Episodes of depression put the bipolar

adolescent at an increased risk of suicide. According to Miklowitz and Taylor in Family- focused

treatment of the suicidal bipolar patient, persons with bipolar disorder have a 15 times greater

risk of committing suicide than people in the general population. Adolescents tend to have

more depressive recurrences than manic (Miklowitz & Taylor, 2006). Data shows that high

family stress and conflict, poor parent-child communication and low perceptions of family

support, in even just the general population, are associated with completed suicides and

attempts among non bipolar adolescents. And adolescents who have been exposed to a first

degree family member committing suicide are more likely to think about or attempt suicide
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themselves (Miklowitz & Taylor, 2006). This information is concerning in that this patient has

suicidal ideations, a history of self harm, low perceptions of family support, and a first degree

relative who has committed suicide.

During a manic episode, adolescents often experience a dysphoric mood and sometimes

even irritability or aggressive behavior. Mood is often mixed and cycling (Consoli, 2007). They

could also be very elated, appearing to be the happiest people on earth (Geller & Luby, 1997).

One characteristic of the manic episode is grandiose delusions. These are firmly held beliefs

that fail to follow the laws of logic. An example of an adolescent grandiose delusion is that the

adolescent will achieve a prominent profession even when they are failing at school or might be

a rock star in the absence of musical ability (Geller & Luby, 1997). This patient stated interest in

becoming a nurse or EMT when it appears that she is a high school dropout. Pressured speech

in which the individual is difficult or impossible to interrupt, racing thoughts, and flight of ideas

are also common. The adolescent with bipolar may say that they wished they had a button on

their forehead in which to turn off their lights (Geller & Luby, 1997).

Another characteristic of mania is involvement in pleasurable activities with a high level

of danger. These are manifested in age-specific behaviors (Geller & Luby, 1997). Older

adolescents will have multiple sexual partners with unprotected sexual behaviors. They may

develop romantic fantasies and delusions about teachers (Geller & Luby, 1997). Also they may

take more dares or drive wildly.

In bipolar disorder, there is potential for comorbidities. Some studies suggest that

nearly 30% of adolescents with bipolar disorder also have ADHD (Geller & Luby, 1997).

Approximately 18% have conduct disorder which manifests itself in poor judgement and
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grandiosity (Geller & Luby, 1997). Bipolar patients also can have anxiety disorders, accounting

for 12% of adolescents (Geller & Luby, 1997). And especially significant in adolescence is the

occurrence of substance abuse. In adolescence, substance abuse is pleasurable activity with a

high amount of danger that can be easily accessible and may help the adolescent cope with

their disorder. It is important to disassociate mood disturbances caused by substance use from

the mood disturbances of bipolar disorder. Geller and Luby (1997) describe that an adolescent

using marijuana may appear manic from their laughing fits and elation and the adolescent using

an amphetamine may appear to have very rapid cycling followed by crashes. Also that

hallucinogens can mimic bipolar perceptual distortions.

Identify the stressors and behaviors that precipitated current hospitalization

The stressors and behaviors that precipitated the current hospitalization included a big life

change and a strained relationship with her biological mother. The patient recently made the

transition from minor to adult. She moved out of the group home where she has resided for

the past four years and moved in with her biological mother. The patient had stated that her

mother is 32 years old and has five other children living in the home. Her mother expects her

to help out a lot with the other children. The patient is also attending high school currently,

although not in person or online, which may be causing some sort of stress either from the

work needed or from not having a high school diploma.

Most recently the patient was staying at her uncles house and needed her mother to

pick her up. When she called her mother, her mother became agitated and yelled at the

patient. She told the patient that she was done with everything and done with her and that she
 COMPREHENSIVE CASE STUDY 7

was kicking her out. The patient then grabbed her stuff and began walking. The patients

mother sent out friends of hers to look for the patient and then had them call her when they

found the patient. At that time her mother came to where she was and began to berate her

about coming home. The patient refused to come home. The argument escalated into a

physical altercation; the patient claimed that her mother hit her first and she then slammed her

mother to the ground. The police were then called at which time her mother started to taunt

her that she should just kill herself and she started screaming at her mother that if she

wanted her dead she would just kill herself, she would just jump into traffic. She also stated

that she was having homicidal thoughts towards her mother. This prompted the police to

remove the patient from the situation and bring her to the hospital. The patient stated that

this sort of thing happens relatively frequently with her mother. That her mother often tells

her that she is horrible and should just kill herself. The relationship seems relatively toxic and

stress inducing.

Discuss patient and family history of mental illness

This patient has a long psychiatric history. Her father committed suicide. At the age of 5 she

was in a house fire in which she was burned and has some scarring from. Subsequently, she

was removed from her biological mothers custody and placed in the system. At the age of 14

she was placed in a group home and she remained in the system until she turned 18. This was

one month prior to her admission, at which time she moved in with her biological mother.

The patient reported a history of sexual abuse, but the timing and degree of abuse is unknown.

She also reported minimal physical abuse. There are scars from self inflicted cutting on her left
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arm. The patient also reported that this is at least her 8th psychiatric hospitalization; this being

her first time on the adult inpatient unit. She has been admitted to Belmont Pines and St.

Elizabeths previously. Her most recent admission was two months ago to St. Elizabeths. The

patient also reported that she smokes cigarettes, although not regularly, and smokes marijuana

occasionally with her mother. She reported that she has been prescribed medication but stops

the medication when she feels better. Her current coping strategies include working out,

reading, and listening to music and she reported a fear of suicide/death.

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

The patient is in a semi private room on the inpatient mental health unit. She is able to move

freely about the unit and shower when she desires. There is a common room with a small,

enclosed room for group therapy attached. The common room has two phone stations that are

open for use for local calls. There are also games, coloring pages, word searches, and two

televisions available. Meals are eaten in the common room. Lights are kept dim and uplifting

music plays softly on the intercom. Patients are encouraged to be out on the unit and

participate in group but are not restricted from staying in their rooms or sleeping during the

day, unless specifically ordered by the psychiatrist.

The nurse brings the medications to the patients. The nurse will review the names of

the medications and describe their purpose when needed. She will also teach about side

effects. The nurse talks with the patients using therapeutic techniques and performs a risk

assessment. It is the nurses duty to assess and document the presence of depressive

symptoms during her shift, monitor side effects of medications, educate the patient on the
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disease process, and direct/assist the patient to group. During the day the patient has been

attending groups. In the first group the patients filled out a paper about their personal

qualities: the things they like and what they think people like about them. She also attended

the spirituality group.

Analyze ethnic, spiritual and cultural influences that impact the patient

The patient stated that she does believe in God and was recently baptized but does not attend

church because her mother doesnt let her. She did not go in depth into her religious history or

explain what she meant by her mother doesnt let her. She just maintained that she does

believe in God. The patient doesnt have any specific ethnic influences. The patient was raised

in the system moving from foster family to foster family and eventually moving to the group

home. I did not have enough of a rapport with the patient to get in depth about the various

environments she was raised in, but I have to think that the lack of structure from moving

around effected her some. Furthermore, her mother is a 32 year old single mother of 5. She

works at a University as a housekeeper and more than likely she is low income. There has yet

to be proven causation in the socioeconomic status-mental illness relationship but the results

of studies have indicated that low socioeconomic status leads to an increase in reports of

depression (Townsend, 2015). So it is possible the low socioeconomic status has some impact

on the patient.

Evaluate the patient outcomes related to care

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The patient has met some of the outcome criteria identified for her, but still has more work to

do. She has not harmed herself or others in any way. She can identify at least one community

resource to help her. Although her insight is still relatively poor, she is willing to participate in

treatment and expressed interest in restarting medication. She eats a well balanced diet and

sleeps well at night. The patient is still currently easily agitated and prone to aggression. It

doesnt appear that she accepts responsibility for her own actions. It is uncertain whether she

manipulates others or interacts appropriately with others. She is not setting realistic goals for

herself and has not showered in a few days. It appears as though she has quickly acclimated to

the environment and she had no complaints about her care. She attends and participates in

group and is out of her room most of the day. She is expected to remain admitted for 5 to 7

days.

Summarize the plans for discharge

The patient must resolve current precipitating factors of admission, contract for safety/adhere

to a safety plan, have no symptoms of psychosis, and be clinically stable for discharge. She also

needs to state to staff that her depressive symptoms are under control and demonstrate ability

to recognize, accept, and cope with symptoms of depression. The patient should be able to

identify community resources that she could use to decrease depressive symptoms and be able

to identify her triggers. The plan is for the patient to go to the local AWARE shelter or the

mission and not to return home to her mother. I asked the patient about getting a restraining

order against her mother. She said that if she got one against her mother then her mother

would get one against her. I asked her if that would be a bad thing and she stated that she
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guessed it wouldnt be. But later in the day I believe the patient was trying to call her mother.

She was being evasive about a phone call she was trying to make, when asked who she was

trying to get ahold of. I also discussed with the patient her general plans for the future. She

stated that she is interested in being an EMT or maybe even a nurse.

Prioritized list of all actual diagnoses using individualized NANDA format

Risk prone health behavior R/T inadequate comprehension of disease process AEB substance

abuse

Ineffective health maintenance R/T inability to make appropriate judgements AEB

noncompliance with meds

Readiness for enhanced self-health management R/T willingness to participate in treatment

AEB verbalization of need for help

Self neglect R/T disease process AEB unkempt appearance

Chronic low self-esteem R/T inadequate coping skills AEB feelings of helplessness

Impaired social interaction R/T underdeveloped ego and low self esteem AEB manipulation of

others for own desires

List of potential nursing diagnoses

Risk for self-directed violence R/T depressed mood, hopelessness

Risk for loneliness R/T change in living arrangement

Risk for other directed violence R/T feelings of anger and aggression towards mother

Risk for suicide R/T depressed mood and initiation of antidepressants

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References

Consoli, A., Deniau, E., Huynh C., Purper, D., & Cohen, D. (2007). Treatments in child and

adolescent bipolar disorders. European Child & Adolescent Psychiatry. 16(3), 187-198.

doi: 10.1007/S00787-006-0587-7

Geller, B., M.D., & Luby, J., M.D. (1997). Child and Adolescent Bipolar Disorder: A Review of the

Past 10 Years. Journal of the American Academy of Child & Adolescent Psychiatry, 36(9),

1168-1176. doi: 10.1097/00004583-19970900-00008

Miklowitz, D.J., & Taylor, D. O. (2006). Family-focused treatment of the suicidal bipolar patient.

Bipolar Disorders, 8(5p2), 640-651. doi: 10.1111/J.1399-5618.2006.00320.X

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

Practice (8th ed.). Philadelphia, PA: F.A. Davis Company.