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Abstract
was recently diagnosed with bipolar effective disorder, current episode manic with psychotic
symptoms. She was brought into St. Elizabeths emergency department in Youngstown, Ohio by
the police. Her mother found her at her house in a psychotic state. The police were promptly
called, and she was pink slipped to the behavioral health unit. In this paper, I will identify
objective data relating to my patients medical and nursing diagnoses, evaluation of the patients
psychiatric history, factors influencing the patients mental state, and plans for discharge.
PSYCHIATRIC NURSING CASE STUDY
Objective Data
On November 9th, during my day of clinical on the behavioral health unit at St.
Elizabeths, I spoke with A.M., who had been a patient on the unit for five days. The police pink
slipped her on November 4th after the mother called regarding her dangerous hostility and
psychotic behavior. The mother claimed she was extremely agitated, aggressive, and
incoherently talking to herself. The mother said, its as if someone slipped her something. It was
like she was drugged. Information regarding this patient was obtained by the hospital patient
records and from a one-on-one interview with the patient. She is thirty-one-year-old and has a
five-year-old daughter. She is not with the father of her child, has never been married, and
recently went through a breakup with a man she has dated intermittently over the past twelve
years. The patient grew up in Youngstown, where she currently resides. Upon admission to the
hospital, she was mumbling, agitated, and unwilling to communicate. She was oriented to time,
place, and person. She was talking to self, possibly hallucinating. Grandiose delusions were
observed, in which she stated she has multiple degrees and can get a job overseas, get whatever
she wants, and can get her attorney out of the hospital. She was refusing all medication, being
loud and aggressive, and repeatedly stated she just wanted to leave.
The patient claimed she has no psychiatric history, and that there was no history of any
psychiatric illnesses in her family. The patient also denied any medical issues. The CBC on
admission revealed abnormal blood findings. Her Hemoglobin, Hematocrit, MCV, and MCH
were all lower than normal range. The blood cell was also positive for anisocytosis,
A.M. denies any suicidal ideation, homicidal ideation, or hallucinations. Although suicidal and
PSYCHIATRIC NURSING CASE STUDY
homicidal ideation may be denied, several standard measures are maintained to provide safety to
all patients on the unit. The patient has needed forced medications on multiple occasions while
on the unit, though, due to her unruly behavior. She was given Geodon, Benadryl, and Ativan IM
in the ER to control agitation. Later that day, she was given Zyprexa 10 mg IM after becoming
uncontrollably angry while on the phone with a family member. She was also medicated on 11/5
and 11/9 with IM Vistaril, Haldol, and Ativan due to loud and disruptive behavior. The patient
has shown an immense desire to leave the hospital on many occasions and has stated multiple
times that she doesnt know why she is there. Although she has gotten disruptive, agitated, loud,
and threatening, she has not physically acted out on staff or peers.
Using the DSM IV, the patients axes are: Axis I Bipolar Effective Disorder, current
episode manic with psychotic symptoms. Axis II None identified. Axis III acute cystitis. Axis
IV assumed pregnancy, financial issues, no job, eviction notice on house door, recent end of
relationship, verbal abuse from previous boyfriend, poor support system, assisting mother with
double hip replacement, father of child unable to help due to lack of employment and on dialysis
3 times per week while on waiting list for a kidney transplant. Axis V Not charted. The patient
is currently taking cephalexin (Keflex) 500 mg three times a day to treat her acute cystitis and
Nicoderm CQ 21 mg/24 hr patch for smoking cessation. She has PRN medication orders of
Haldol 5 mg (tablet and IM injection) for agitation and Vistaril 50 mg (tablet and IM injection)
for anxiety. Her future medications will include olanzapine zydis (Zyprexa) 20 mg, which is an
antipsychotic medication to treat bipolar disorder, and valproate (Depakene) 1000 mg, which is
On the day of my care, I observed this patient discussing her issues during a group
session. She expressed her anger to the leader, stating she has been there for five days and she
PSYCHIATRIC NURSING CASE STUDY
doesnt need to be there. She kept repeating, I dont know why Im here. The doctor wont even
talk to me. She was frustrated with the doctor, claiming he walked right by her and refused to
discharge her for no reason. Although her frustration was being expressed, she continued to show
respect to the group leader. She became defensive and started arguing when another patient
brought up that she did not like all the fighting on the floor. After the group session ended, A.M.
went to the nurses desk to speak with her nurse. I approached her, introduced myself, and asked
if she would be willing to speak to me. She was very pleasant with me. She agreed to sit down
with me once she was done talking to her nurse. While we talked, the patient was very open to
communication. She was smiling and showed no aggressive behavior towards me. Her stressors
and problems were addressed, as well as general conversation about life. The problems that she
brought up in the group session were elaborated on, and she explained other problems in her life.
The patient told me that she was pregnant by a man she has been dating on and off for 12 years.
He verbally, emotionally, and financially abused her, then broke up with her when she told him
she was pregnant. She denied any instances of physical or sexual abuse. She did not want to have
a baby, but could not afford an abortion, so she resorted to starving herself and depriving herself
of sleep for 10 days to cause a miscarriage. She claimed when her mom came over, she was just
mad because she wanted to sleep and be left alone but the mother wouldnt leave. Several times
throughout our conversation, she stated if she had some cigarettes, a coke, and sleep, she would
be fine. A.M. does not believe she has any psychiatric issues. Despite her belief that she was
pregnant, her hCG levels (hormone produced during pregnancy) upon admission were less than
0.1 mIU/ml. The average levels of hCG in a non-pregnant woman are less than 0.5 mIU/ml.
Anything above 25 mIU/ml is considered positive for pregnancy. If she would have had a
miscarriage prior to hospitalization, her hCG levels would have been higher than 0.1 mIU/ml.
PSYCHIATRIC NURSING CASE STUDY
This patient was diagnosed with Bipolar Disorder Type 1. Her most recent episode
involved severely manic with psychotic features. Per the National Institute of Mental Health,
bipolar disorder is a disorder of that brain that initiates shift in energy, mood, activity levels, and
daily activity abilities. Bipolar I disorder is defined by manic episodes lasting at least seven days,
usually occur as well, lasting at least two weeks (National Institute of Mental Health, 2016).
People suffering from bipolar disorder usually experience stages of intense emotion, unusual
actions and manners, and changes in sleep patterns. This patient was currently in a manic
episode. Intense amounts of energy, high levels of agitation and irritability, risky behaviors, and
trouble sleeping are common in this phase. They may also have trouble sleeping, feel jumpy,
and talk faster than normal. All of these symptoms were apparent in this specific patient. She was
irritated with her doctor and her hospitalization. She required medication to calm her down on
multiple occasions. She also spoke at a very fast pace, jumping from one topic to another. I
noticed this patient walking around a lot, rather than sitting still and relaxing. In some cases,
psychotic symptoms, such as delusions or hallucinations, may occur with bipolar disorder. In this
patients case, she showed delusions of pregnancy. She kept stating she had a miscarriage, but
My patient also showed delusions of grandeur by stating she had a Masters degree, a
Bachelors degrees both in nursing and psychology. She even mentioned being able to get a job
overseas and doing whatever she wants. The fact that this patient is African American could have
an influence on her symptoms of delusions. Some studies suggest there are racial differences in
Caucasians in the Genomic Psychiatry Cohort, more African Americans have symptoms of
hallucinations and delusions. This was significantly true for cases diagnosed with bipolar
disorder and schizoaffective-bipolar disorder (Perlman, et al., 2016). It is interesting to see the
differences among African American and Caucasians when it comes to symptoms of mental
illness.
A.M. denied any history of medical problems, but her CBC levels on admission were
abnormal. Her hemoglobin was 10.5 (normal 12-16), hematocrit 32.7 (normal 34.9-44.5), MCV
78.5 (normal 80-96), MCH 25.3 (normal 27-33), and RDW 16.1 (normal 11.5-14.5). The blood
ovalocytes, and target cells positive. These results suggest she suffers from a hematological
problem, such as anemia. Seeing these results prompted me to look at the relationship between
patients, Korkmaz et al. (2015) performed a study looking at the frequency of anemia in chronic
psychiatric patients. When anemia is left untreated, it can cause multiple complications,
including fatigue, exhaustion, heart palpitation, and psychiatric symptoms, such as depression
and cognitive function disorders. This study states that there is may be a correlation with anemia
and an increase in the severity of preexisting diseases. It was determined that 25.4% of the
psychiatric patients had anemia as well. Anemia was noted in 25% of the bipolar disorder
patients. Results of this study showed that anemia was more prevalent in chromic psychiatric
As mentioned earlier, the patient spoke with me about multiple stressors occurring in her
life that have led her to be in the mental state she is now. First, she stated she has a five-year-old
daughter that she raises herself. The father of her child is facing his own health issues, doesnt
work, and doesnt take any part in caring for their daughter. The patient also claimed she was in
school. She mentioned to me that she was majoring in psychology and minoring in business
management. She says she must work hard to keep 4.0 GPA. She is currently unemployed, so
financial issues are a problem in her life. There is an eviction notice on her door and she doesnt
know where she will be living. Her recent off-an-on relationship is toxic and unstable. The
patient said he stresses her out, takes her money, and causes too much drama.
A.M.s support system is very limited. She has a mother, sister, and brother that she does
not get along with because they are in her business too much. The patient said her mother is too
nosy and around too much. Her siblings and cousins always ask her for help, but never return the
help when she needs it. She claims she still helps them when they need it. Her mother recently
had a double hip replacement and needs help around her house. She also takes care of her other
family members. The patient said a few times, I feel like Im doing 30 things a day and never
get a chance to rest. A.M. declared she doesnt get along with a lot of people because they are
always testing her, using her, and always on some type of bull****. She mentioned a few
friends that she said she liked to party with, but she doesnt trust any of them. In an article titled,
The role of social relationships in bipolar disorder: A review, it stated that individuals with
bipolar disorder have a more difficult time forming social relationships and attachment to other
individuals as compared to people with other mood disorders and normal controls (Greenberg,
Rosenblum, McInnis, Muzik, 2014). The authors also mentioned that individuals with bipolar
PSYCHIATRIC NURSING CASE STUDY
disorder have a higher likeliness to be living alone, more poor, less educated, or unemployed
compared to others with major depression or no affective disorder. Several studies performed
determined that a relationship is shown with lower levels of perceived social support and
extremely true with this patient. Her ability to form relationships with friends and family is
inadequate, causing her to feel alone. She also lives alone, has no job, and is very poor.
The biggest stressor in in A.M.s life was her belief that she was pregnant. She was
definite on not wanting a baby, but could not afford an abortion. When desperate times call for
desperate measures, she resorted to not eating and not sleeping for multiple days to cause a
miscarriage. Her mother came over to check on her after the patient made a Facebook status and
the mother thought the daughter was going to commit suicide. She said she just wanted to be left
alone for a few days, but her mother wouldnt respect her wishes. The patient was apparently
rambling nonsensical sentences, yelling at everyone, and unreceptive. This led to the mother
calling the cops, in which they came and pink slipped her for psychotic behavior.
When discussing the patient about her mental history, she denied any past issues. She
even said she has been going to the same doctor her whole life and he would never believe she
was diagnosed with Bipolar Disorder. She boldly stated she doesnt fit in with the koo-koos
that are in the behavioral health unit and that she isnt crazy. This patient did not comprehend
why she was in the hospital. When I asked the patient about her familys history of mental
illness, she did not recall any information. There was no family history of mental illness noted in
on the behavioral health unit. The most important technique is to provide a safe environment for
everyone. This is accomplished by having staff make rounds every fifteen minutes, or safety
checks, checking off each patient that is on the floor. It is important to ensure no patient is doing
something inappropriate, trying to harm themselves, or causing problems. The furniture on the
floor are also weighted to make it more difficult to be picked up and thrown. The doors are
angled and have sensors on them to prevent any hanging. The rooms and bathrooms are
strategically constructed so the patients cant make sharp objects out of any item. The mirrors are
made of aluminum instead of glass, toilet paper rolls holders are eliminated, the toilet flusher is a
button rather than a handle, and furniture drawers are not allowed. The behavioral health unit is
locked down so patients cant get out. This also prevents unauthorized visitors from coming onto
the floor. All personal belongings are taken and searched upon arrival on the floor. Most clothing
items are allowed, but certain items, such as shoe laces, pocketknives, jewelry, and anything
deemed to be potentially dangerous, are prohibited. Meals are served on plastic with plastic
utensils and counted after the patient has finished the meal. Medication administration is also
It is vital to guarantee a patient is taking their medication rather than pocketing it in their
cheek or spitting it out. Along with guaranteeing medication is being taken, monitoring the
patients for adverse effects is a critical part in nursing care. Side effects to some of the drugs
used on the floor could potentially be life threatening. For instance, Clozaril, an antipsychotic,
can cause agranulocytosis. This medication requires regular blood test monitoring. Geodon,
another antipsychotic, can cause neuroleptic malignant syndrome. Lamictal use may cause a life-
PSYCHIATRIC NURSING CASE STUDY
threatening rash. These medications may lead to EPS, or extrapyramidal symptoms. Examples
dyskinesia happens later in drug therapy and is irreversible. Any signs of this side effect prompts
immediate discontinuation of medication. The nurses on this floor must be well educated on
Nursing care on the behavioral health unit involves a positive milieu. The goal of milieu
therapy is to provide an environment that is considered therapeutic. A patient will recover best in
a nonjudgmental, hostile-free, relaxing environment. Patients feel safe and independent. The staff
should also make sure the patient feels respected and supported. Increasing their self-esteem and
confidence while avoiding any belittling of the patient is important in nursing care. Certain
events, such as group discussions, allow the patients to voice their opinions and concerns. The
individuals are also allowed to engage in activities such as playing card games, watching
television, and exercising during their free time. Nurses must provide a safe and therapeutic
During my interview with my patient, A.M. told me she has no religious beliefs. She said
she used to believe in God, but hasnt gone to church since she was a teenager. There were no
Although the patient does not feel she needs to be hospitalized anymore, it is evident she
still needs help. The patient had made progress since her admission five days before my day of
care in certain aspects. For example, she is no longer having delusions or talking to herself. She
PSYCHIATRIC NURSING CASE STUDY
was more approachable, talkative, and understanding. She still has not achieved the goal of being
able to express her anger through appropriate verbalization and healthy physical outlets, though.
A few hours before my shift, she required IM administration of Vistaril, Haldol, and Ativan
because of an angry outburst. She was able to achieve the goal of acknowledging positive coping
patterns, but she did not practice them. She also achieved the goal of successfully competing
activities of ADLs. She was well groomed, recently showered, and dressed appropriately on my
day of care. A.M. achieved adequate nutritional intake as well as adequate sleep during her stay
on the unit. She is progressing well, but still requires additional days in the unit.
A.M. has been on the floor for five days. Right now, there is not a specific discharge date.
Discharge planning begins on admission to the hospital. This helps in goal planning and an easier
discharge. Depending on the patients progress, additional days may be necessary. Because of the
most recent episode of needing medicated, my patient will probably require a longer stay.
Turning Point Counseling in Youngstown was notified of the patients situation. She will have an
aggressive behavior
Disturbed thought processes related to as evidenced by tangentiality of ideas and speech
Deficient knowledge related to lack of interest in learning as evidenced by denial of
psychiatric illness
PSYCHIATRIC NURSING CASE STUDY
Risk of self harm related to feelings of loneliness and helplessness as evidenced by lack
of support
Risk for imbalanced nutrition related to failure to eat as evidenced by patient verbalized
Conclusion
Upon admission, she was in a manic episode with psychotic symptoms. She has no known
medical disorders, and this is her first hospitalization regarding psychiatric issues. She has a
multitude of stressors in her life that have been altering her mental health. This patient has a poor
support system, financial issues, and a denial of her illness as well. It is important for her to
remain hospitalized in order to have a better understanding of her illness and learn methods to
control her angry outbursts. Although her explosions have not led to self-harm or harm to others,
there is a chance it could occur in the future. Medication compliance and outpatient counseling
References
Greenberg, S., Rosenblum, K. L., McInnis, M. G., & Muzik, M. (2014). The role of
doi:10.1016/j.psychres.2014.05.047
Korkmaz, S., Yildiz, S., Korucu, T., Gundogan, B., Sumbul, Z. E., Korkmaz, H., & Atmaca, M.
National Institute of Mental Health. Bipolar Disorder. (2016, April). Retrieved November 16,
Perlman, G., Kotov, R., Fu, J., Bromet, E. J., Fochtmann, L. J., Medeiros, H., . . . Pato, C. N.