1

Mental Health Nursing Case Study

Mental Health Nursing Case Study

Ryan Thompson

Youngstown State University

November 25, 2022

Abstract

Psychiatric nursing is a field of study that you could potentially run into a lot of

diagnoses. Of those diagnoses, many of them could potentially join together in their signs and

symptoms. Today, being discussed will be Bipolar Disorder, and the breakdown of the disease in

itself. Patient also presented with a specific type which was hypermania in her thinking and even

current actions. In this case study the disease will be broken down, the clients stay on the psych

unit will be discussed and plans for discharge home.

Objective Data

Patient M.W. presented to the emergency room on 9/12/22 on a police hold because of a

situation that was not yet elaborated to us upon this interview. The patient was said to have a

manic break, and that is what eventually led to her being picked up and brought into the

emergency room because that patient has past issues of psychiatric issues within her community

while she is non-compliant on medications. With this past known psychiatric diagnosis of type 1

Bipolar, that patient went through many different medications and eventually ended up on

Lithium. Lithium has one of the highest med compliance rates because of how small the

therapeutic range is (0.6-1.2), so it is not uncommon to see a patient present with non-

compliance. The required blood tests for Lithium are as followed, every 3-5 days for 2 months

their level must be checked, every month their creatinine concentrations and thyroid hormones

must be monitored, and a CBC every 6 months.

As mentioned before the patient presented with Type 1 Bipolar Disorder as well as

underlying medical diagnoses such as GERD, Nephrolithiasis as well as Hyperglycemia. The

labs that need to be closely monitored are as followed for this patient, QTC, Sodium, BUN,

Creatinine, Blood Glucose, AST/ALT as well as the patients Lithium level.

QTC was within normal limits and 450, this needs checked because of the patient being

on antipsychotics such as Zyprexa and Haldol which can lead to increased QTC times. Sodium

was within normal limits at 141 which Lithium has tended to show a decrease in sodium levels.

BUN was slightly decreased at 6, but Creatinine was within normal limits at 0.55. Those tests

reflect kidney function and are prioritized due to Lithium being nephrotoxic. Glucose needed
4
Mental Health Nursing Case Study

monitored as well due to patient being on Zyprexa which is an antipsychotic which led to blood

sugar increases. Her sugar was slightly high at 104, but that is a manageable range to be in.

Lithium level was not yet resulted at the time of care. The last labs that need close monitoring

are AST/ALT due to chronic drug use from the patient. AST presented at 18, ALT presented at

35, which both of those falls within the normal range.

The patient had a psychiatric hold as I mentioned but was on per unit privileges. The

patient did not present with any suicidal/ homicidal ideation so had no restrictions. Although, the

patient was withheld from group therapy sessions due to being hyperverbal and it would not be

beneficial for the other patients if she was in that group setting. The patient was only on a few

psychiatric medications such as, Haldol and Zyprexa for any agitation or delusions. Patient was

given Atarax and Trazadone for sleeping aid which was necessary because while in mania it is

very hard for the patient to sleep. The main medication given was Lithium, this was to treat the

type 1 bipolar disorder and the manic episodes, this is a mood stabilizer.

Summarize the psychiatric diagnoses

As mentioned before, the patient presented on the date of care with type 1 Bipolar

disorder. Bipolar Disorder is, “a mental illness that causes unusual shifts in mood, energy,

activity levels, concentration, and the ability to carry out day-to-day tasks (National Institute of

Mental Health, 2022).” There is one definition as written in the DSM-5 and that is, “Bipolar 1

disorder is defined by manic episodes that last at least 7 days, (most of the day, nearly every day)

or by manic symptoms that are so severe that the person needs immediate hospital care.
5
Mental Health Nursing Case Study

(National Institute of Mental Health, 2022).” This patient presented with the second half of that

definition, she had symptoms so severe that it required a hospital stay this time around.

The signs and symptoms of mania is described as “Abnormally upbeat, jumpy or wired,

increased activity, energy or agitation, exaggerated sense of well-being and self-confidence

(euphoria), decreased need for sleep, unusual talkativeness, racing thoughts, distractibility and

poor decision-making. (Mayo Clinic, 2022).” The patient had presented with almost everyone of

those signs and symptoms on day of care. Also, according to Hopkins Medicine, “Common

psychiatric comorbidities include alcohol use disorder and other substance use disorders. (Johns

Hopkins Psychiatry Guide, 2017).” As mentioned, the patient presented with also history of

substance abuse, while also testing positive upon time of admission for amphetamines and pot.

Identify the stressors and behaviors

M.W. did not discuss many stressors within her life at the time of the interview d/t the

patient being in that state of euphoria. With that being said, she did mention that she had a past

traumatic childhood but chose not to speak on it due to that being “her old testament.” One issue

that she has been having is her mother has primary custody of her children. Due to her and her

spouse’s psychiatric diagnoses and the need for constant hospitalization, they were unable to

gain custody of her children. So, they were placed in the home of her mother where M.W. has

visiting rights whenever she is complaint on her medications and not in a state of mania.

Some behaviors that could have led to this is her persistent drug use. Amphetamines are a

stimulant, so in the situation where a manic break occurs, stimulants are a very risky behavior for

the patient even more so. The main behavior for this hospitalization is medication non-
6
Mental Health Nursing Case Study

compliance. With the patient admitting to not taking her medication, even though a lithium level

was not drawn it is within reason to assume that her lithium level would be too low or outside of

the therapeutic range.

Discuss patient and family history of mental illness

The patient refused to speak on her family history as she was in her “new testament and

not the old one” so it was difficult to gain a full family history. In the chart, it mentioned the

patient was diagnosed with Bipolar disorder at the age of 25, so this had been an ongoing factor

because the patient now is 29 y.o. She does not show any signs of hallucinations in the interview,

only very many signs of delusions which is concurrent with the diagnosis of Type 1 Bipolar

which is the manic phase.

Her boyfriend she was very set focused on upon the time of the interview. Her boyfriend

also presents with manic symptoms at times and has been in the psychiatric unit multiple times

as well. This is something that the patient says aids her in dealing with her diagnosis because the

boyfriend tries to help her stay complaint with her medications.

Describe the psychiatric evidence-based care provided

The nursing care provided mainly to this patient today from myself was therapeutic

communication and listening skills. The patient had a lot to say, which I listened to and was even

able to redirect her at times and bring her out of a manic phase for a brief moment in order to

have a true conversation. She was able to briefly attend a group therapy session but then was
7
Mental Health Nursing Case Study

escorted out, because of being hyperverbal. Another example of milieu therapy throughout the

day used was the colors of the walls on the psychiatric unit are very calming and warm, so they

could have potentially helped calm her down as well.

Analyze ethnic, spiritual and cultural influences

M.W. was in a state of mania at the time of the interview, which led to very many

grandiose delusions. When asked about her religion, the patient stated that she “has her own

religion.” When asked to elaborate, she mentioned that she was the sun and that her boyfriend

was the heart of the sea. On the day of the interview, it was a rather cold and rainy day outside

and she noticed that and mentioned that her being in the psychiatric unit was the reason it was

cold outside because she wasn’t outside to make it warm.

This also is where it should be mentioned about her visons of her life being split into the

new and old testaments. The patient has some history of past trauma, and the father being that

main source of trauma. She chose to split her life into two different parts upon her religion from

where she had met her boyfriend because she stated that is where her life completely turned

around.

When it comes to gender, Type 1 Bipolar disorder does not have a distinction, other than

when it comes to rapid cycling of mania, that is more common in females. Upon research it is

also more common in Asians and Latinos. This is irrelevant in this case because the patient

presented as a Caucasian female.

“Culture is a complex and personal biopsychosocial phenomenon that provides meaning

within life for an induvial, a group, or a community. (PubMed 2007)” With this textbook

definition it is hard to say that it would have an overall impact on the initial diagnosis of type 1

Bipolar, but it could have something to do with the aggravation of symptoms. In this interview it

was difficult to get a baseline d/t the patient already presenting with mania, but from how it was

described her cultural expectations were not outside the normal for age and race. Socioeconomic

factors may play a part though as she has stated that there are some problems in paying for the

medication and she also mentioned not having a job and not knowing the last time she had

worked.

Evaluate the patient outcomes

Upon the day of the interview evaluating the patient total outcomes was not able to

happen. After talking to staff her outcomes typically end up very well. She has her dose of

lithium adjusted to get in a therapeutic range, then reverts back to baseline. Now all of this can

still be altered without compliance, there was breaks in the psychosis though, where the patient

was very willing to get help. Without her support system around her, hopefully it will be another

favorable outcome in her treatment. Even a day later M.W. was able to sleep 5 hours, which in

the state she was in, that is very much considered a positive. That is with the help of medication,

but some sleep is better than none in this circumstance, not matter how it may come.
9
Mental Health Nursing Case Study

Plans for Discharge

The plan for discharge is to eventually send this patient home once within the therapeutic

range for her lithium levels. Once a therapeutic dose is once again established, she will proceed

to live with her boyfriend, and stay medication requirement. In the meantime, the patient must

show signs that she is improving by her mania not interfering with her activities of daily living.

One thing that needs to be monitored closely while on the unit is her total nutritional intake, due

to walking and taking so much she becomes at risk for impaired nutrition. Also, once therapeutic

range is established and mood is stabilized, she may visit with her kids because that plays an

important part in her life with her discussing the love for her kids very frequently. The mother

had been in contact with the social worker discussing that it may be possible for her to come live

with herself and the kids to even try to more so increase medication compliance. She shows

interest in her care and knowing that she has a safe space to stay after discharge is very crucial

when sending somebody home.

Prioritized list of all actual diagnoses

Risk for Injury- Patient is at a risk for injury d/t drug use and impulsivity symptoms of mania.

Imbalanced Nutrition- Patient is at risk for imbalanced nutrition due to constantly moving around

unit and talking, which allows less time for the patient to eat and drink, so she can potentially

become malnourished or dehydrated.

Impaired Social Interaction- This ranks highly on this list because with the hyperverbal and

hypersexual comments throughout conversation, no social interaction ranks highly on Maslow’s

scale.

Total Self-Care Deficit- On the day of the interview, the patient was not well groomed and that

can play a part into the impaired social interaction diagnoses mentioned previously.

Disturbed sensory perception- This is very relevant in this case because with the sleep

deprivation, psychosis can even potentially get worse in that sense, by the patient becoming

delirious and manic at the same time.

List of potential nursing diagnoses

Risk for self-harm

Impaired coping

Altered thought processes

Risk prone health behavior

Sleep deprivation

Labile emotional control

Risk for acute confusion

Risk for electrolyte imbalance

Conclusion

In conclusion, this patient has the opportunity for a very successful outcome. It will take

some help from family members and herself, but medication compliance is a very tricky thing to

overcome at first, but the situation needs to be addressed. Explaining that to the patient in order

to remain with her family and out of a psychiatric unit, she needs to do this for herself and her

family. Getting out of that manic break and staying hydrated and well fed will need to be the

priority interventions at this point in time. Lithium levels will need to be monitored for at least

two weeks in the unit but, after that the resources will be utilized and given to M.W. to try to

avoid this bad of a manic break from happening again.

Reference Page

Lee, J., & Swartz, K. L. (2017, October 29). Bipolar I disorder: Johns Hopkins Psychiatry
Guide. Bipolar I Disorder | Johns Hopkins Psychiatry Guide. Retrieved November 25,
2022, from
https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/
787045/all/Bipolar_I_Disorder 

Mayo Foundation for Medical Education and Research. (2021, February 16). Bipolar disorder.
Mayo Clinic. Retrieved November 25, 2022, from https://www.mayoclinic.org/diseases-
conditions/bipolar-disorder/symptoms-causes/syc-20355955 

U.S. Department of Health and Human Services. (n.d.). Bipolar disorder. National Institute of
Mental Health. Retrieved November 25, 2022, from
https://www.nimh.nih.gov/health/topics/bipolar-disorder 

Warren, B. J. (n.d.). Cultural aspects of bipolar disorder: Interpersonal meaning for clients &
Psychiatric Nurses. Journal of psychosocial nursing and mental health services. Retrieved
November 25, 2022, from https://pubmed.ncbi.nlm.nih.gov/17679314/ 
13
Mental Health Nursing Case Study

Case Study Comment Sheet 4842

Student Name: Ryan Thompson

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the
patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format