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Running Head: CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Amber Wilson

Youngstown State University

NURS 4842L Mental Health Nursing Laboratory

Mrs. Teresa Peck, MSN, RN

September 23, 2022

C.T. is a forty-nine-year-old Caucasian female who was admitted to the Behavior Health unit due

to a manic episode that contained multiple suicidal comments. Upon admission, she only had a

history of anxiety and fibromyalgia. Staff was also informed that she had an active Xanax

addiction, which was confirmed through labs as well as marijuana abuse. She was diagnosed

with Bipolar 1 disorder, mania once admitted. Lithium, a mood stabilizer, and Risperdal, an

atypical antipsychotic, were prescribed to reduce her mania and prevent as intense of episodes in

the future. She was refusing medications for the first day, but started to be compliant and

understand the circumstances that she was in. Other nursing care provided on the unit for C.T.

was suicide precautions, for her safety, and two group therapy sessions a day.
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Objective Data

C.T. is a forty-nine-year-old female who came into the hospital through the Emergency

Department on September 22, 2022. She was brought in due to a manic episode with suicidal

comments that ended with her crashing her car into a pole. She was aggressive, both verbally and

physically, and denied any suicidal ideation. The only past medical history of mental health

diagnoses was anxiety. But her sisters stated that these episodes occur often when she and her on

and off again significant other go through break-ups. It was also noted that she has an active

Xanax addiction. Once she was transferred to the Behavioral Health unit her mood and behaviors

were the same as in the Emergency Department. She was placed on suicide precautions and was

diagnosed with Bipolar 1 Disorder and mania. To keep her suicide precautions secure there were

no belts, shoelaces, hoodie strings, sharp or glass objects in her environment.

I interviewed C.T. on September 23, 2022. On appearance, C.T. appears younger than her

age. Her grooming was difficult to tell because she was in a hospital gown and pants. But there

was what appeared to be blood on her pants. Her hair was unwashed to the point it was matted

into a braid, this showed she did not have the best hygiene practices. She had high energy, was

very talkative, and even tried to crack jokes. Her mood was almost euphoric, and she was very

cooperative and friendly, which was completely different than the night prior when she was

admitted. Which was congruent with her affect which was bright and positive. Her mood and

affect were evidenced by her stating she was “happy to finally be feeling her feelings.”

Talking with C.T. I learned a lot about her past and current life. She is a divorced mom

with a nineteen-year-old daughter, but she has a significant other. She used to be a medical

assistant until her diagnosis of fibromyalgia, and she kept getting bulging discs and refused

surgery. This caused her to switch her career to being a baker because it is easier on her body.
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Her three sisters are her support systems, and she is currently living alone in an apartment. She

stated her daughter used to live with her and be a big part of her support. But her daughter just

eloped and moved out of state. When her daughter told her she was going to move and marry this

man C.T. told her that “she could just be a sinner” and did not have to marry him yet. This shows

that she can have a poor sense of judgment and impulse control. When her daughter did leave

and got married was when her manic episode began. She admitted she made suicidal comments

“for attention” because her daughter left her. When asked if she still had those suicidal thoughts,

she denied them.

At the beginning of the patient interview, C.T. was hyper-fixated on her medications. She

has two new medications prescribed, Lithium and Risperdal. She had Lithium 150 mg twice

daily and Risperdal 0.5 mg daily both by mouth. Both information sheets were printed out on her

desk with words, lines, and circles drawn all of them where she had questions. She stated that she

did not understand why she was on these medications and what they were for. When the nurse

tried to give her morning medications, she refused both. Her main concerns were the reason she

was on them and the side effects. She stated the side effects would worsen her fibromyalgia and

anxiety. This was when she said her anxiety was so bad that “Xanax is the only thing that calms

me.” Her addiction shows her lack of good decision-making, problem-solving, and healthy

coping mechanisms. She was also a cigarette smoker and was prescribed nicotine transdermal

patches of 21 mg for 24 hours. She also was not wanting to take her medications because she

thought they were trying to “drug her.” This goes to show she had paranoia. Her paranoia also

showed with her lack of sleep. She stated she had not slept the entire night due to the door

opening and her “not trusting anyone.”

span and ability to concentrate were shown through her conversation ability. She was able to

have a conversation about one topic for long periods. There was no evidence of delusions,

hallucinations, or illusions. She was alert and oriented to person, place, and time. Verbally, she

understood the circumstances she was in by the end of the day, but her mood and affect seemed

inappropriate for these circumstances. Her memory was clear and intact, this was shown by the

many stories from her past she was telling.

Labs were assessed and multiple items were out of the normal range. She tested positive

for cannabinoids and benzodiazepines; this was evidence of her Xanax addiction and showed

that she was abusing marijuana as well. BUN and Creatinine levels were both slightly elevated,

which are related to the kidneys. Her white blood cells were also elevated, as well as her glucose

at 100. Some labs that came back within the normal range included sodium, potassium, red blood

cells, hemoglobin, and hematocrit. The liver enzymes, AST and ALT were tested and came back

normal indicating that the liver is healthy. An ECG was also taken and indicated normal sinus

rhythm.

Summary Of Psychiatric Diagnoses

Psychiatric-Mental Health Nursing Eight Edition (Videbeck, 2020), explains anxiety as

“a vague feeling of dread or apprehension; it is a response to external or internal stimuli that can

have behavioral, emotional, cognitive and physical symptoms.” Anxiety has different levels, for

example, most people have felt mild anxiety, which can have a positive effect and be

motivational. But when anxiety gets to moderate, severe, or panic levels is when it becomes

dangerous and unsafe. The higher levels of anxiety can decrease attention and cause a loss of

reality. (Videbeck, 2020). When anxiety no longer becomes positive or at a mild level is when
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anxiety disorders are a possible explanation. Types of anxiety disorder include agoraphobia,

panic disorder, specific phobia, social anxiety disorder or social phobia, and generalized anxiety

disorder. (Videbeck, 2020). One of the most common anxiety treatments is Xanax or

Alprazolam, a benzodiazepine, which is what C.T. is known to abuse.

C.T. received the diagnosis of Bipolar 1 disorder on the Behavior Health unit. Bipolar 1

disorder is defined by the National Institute of Mental Health (2022) as:

“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. Usually,

depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of

depression with mixed features (having depressive symptoms and manic symptoms at the

same time) are also possible.”

When in a manic episode clients feel high, elated, wired, more active, have a decreased need for

sleep, and talk fast about many things. Compared to depressive episodes which cause feelings of

sadness, anxiety, trouble falling asleep or sleeping too much, and inability to find anything to say

(NIMH, 2022). C.T. was in a manic episode when brought into the hospital and was coming

down from that mania during the patient interview. She did explain she had a decreased need for

sleep, she did not sleep last night due to paranoia but was still not tired. Throughout the time

talking with her she was trying to make jokes and was very elated or high. There was also

evidence she was more active just by her hyper-fixation on her medications. Her information

sheets were covered in writing and she had questions about both medications. The symptoms that

C.T. showed through her manic episode are congruent with mania according to the Cleveland

Clinic (2021) being “a condition in which you have a period of abnormally elevated, extreme

changes in your mood or emotions, energy or activity level.”

Stressors and Behaviors Precipitating Current Hospitalization

During the patient interview with C.T., her daughter’s eloping and moving to South

Carolina was a big influence on her episode beginning. She said that she was aware of the plan

when her daughter told her back in January of this year. C.T. did not agree with it or believe it,

evening tell her daughter to “just be a sinner” and not marry him. This entire time she did not

think her daughter was going through with this plan and then she did it. It affected C.T. badly

because she has felt that her life these past nineteen years has been lived for her daughter. Mixed

with the feeling of her daughter leaving, she and her significant other of twelve years also got in

a fight and broke up. Her sisters stated that this has been going on for a while and they are off

and on. But every time that it happens these episodes end up occurring.

These two stressors added onto one another made her feel abandoned and she does not

have healthy coping mechanisms. Her first way of coping is Xanax for her anxiety. She abuses

Xanax because she thinks it is the only thing that can calm her down. Without having any prior

mental health diagnoses except anxiety, she did not have the correct medications to help regulate

her emotions. This is could have been a big influence on her need to self-medicate and abuse

Xanax for anxiety. She also smokes cigarettes daily for stress. It was then found through labs that

she abuses marijuana. When her usual coping mechanisms failed, she began making suicidal

comments “for attention.”

Patient and Family History of Mental Illness

When C.T. was asked if there was anyone else in her family with mental health diagnoses

in the past she denied it. She, however, did have a history with her diagnosis of anxiety. It was

also stated during our interview that she was admitted to another psychiatric facility earlier this
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year. The diagnosis, if any, from that visit is unclear due to no evidence of a diagnosis in the

chart and her saying that she was not diagnosed with any mental illnesses. She also has a history

of substance abuse which is seen in her labs with cannabinoids and benzodiazepines. In the chart

for C.T., there was a note from the Emergency Department about information her sisters gave

them. Both of her sisters also denied any family members a having history of mental illness but

confirmed history of anxiety and substance abuse for C.T.

Psychiatric Evidence-Based Nursing Care Provided

On the Behavioral Health unit, the environment was full of evidence-based nursing care.

To keep C.T. on her suicide precautions she was provided a hospital gown and pants, her clothes

were confiscated to make sure there were no belts, shoelaces, or hoodie string on her person. On

the unit, there was no glass or mirrored objects for clients to harm themselves or others. There

were two group therapy sessions throughout the day for the clients to attend. The first was

cognitive behavioral therapy and the second was a psychotherapy session. Both therapies have

been shown to have positive impacts on clients with bipolar disorders. C.T. attended both

sessions to a point, during the first session she was present and attentive, but was not openly

participating. During the second session, she did end up leaving due to her hyper-fixation of her

medications and requested the nurse practitioner to talk with her.

She has been prescribed two new medications for her diagnosis of Bipolar 1 disorder,

Lithium and Risperdal. Lithium is a mood stabilizer for the highs and lows that accompany

bipolar disorder. In the past seventy years, lithium has been the medication of choice for the

treatment of bipolar disorders (Volkmann et al., 2020). According to the National Library of

Medicine, this is due to the prevention of manic episodes and the suicidal preventing effects that

have been observed with 82% fewer suicides during lithium treatments. Therefore, lithium is
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usually the first-line therapy for manic episodes, as C.T. was in, and bipolar disorders overall.

Risperdal, also known as Risperidone, is an atypical antipsychotic. According to the National

Alliance of Mental Illness (2016), it is usually used for schizophrenia, but the FDA approved it

for the acute and long-term treatments of manic episodes and bipolar disorders.

Ethnic, Spiritual, and Cultural Influences

C.T. is a forty-nine-year-old Caucasian female, who is divorced but has had a significant

other for twelve years off and on. Though she did not specifically state a religion she follows,

there were multiple references to Christianity throughout the interview. For example, she told her

daughter she could be a sinner and have premarital intercourse. C.T. holds a full-time job, which

allows her to have her apartment to support herself and her cats. But a specific socioeconomic

status was not mentioned. The main influence for this episode and in a shown pattern is

abandonment. This pattern has commonly been related to her significant other in the past but in

this situation, it involves not just her significant other, but also her daughter.

Patient Outcomes

Throughout C.T.’s admission to the Behavioral Health unit, many improvements were

made. The biggest improvement witnessed was her accepting her diagnosis and taking her

medications. At the beginning of the day, she was hyper-fixated on why she needed to take her

new prescriptions and what they were for. She was even in denial that she had Bipolar 1

disorder. After sitting down with her and going through her diagnosis and medications one-on-

one she was more accepting of everything, but she still wanted to meet with her nurse

practitioner. After meeting with her nurse practitioner, she ended up taking both medications and

seemed to be more accepting. She planned on continuing to be compliant with the medications as
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well, on the basis that they did not affect her anxiety or fibromyalgia. After cognitive behavioral

therapy, she stated, “it is not good for me to push my emotions down until I get to this point.”

The recreational therapist and C.T. met and made a plan to continue going to both therapy

sessions each day throughout her admission with hopes to start participating as well. She

accepted the fact that she was admitted and said that she was feeling better, which was evidenced

by her not being angry at the staff anymore. As well, she wanted to shower and change, which

also showed improvement after taking her medication.

Plans for Discharge

C.T. planned on being discharged following her seventy-two-hour hold, which would

have been within the next two days. Upon discharge, she planned to go back to her apartment

with her cats and continue to live on her own. She does plan on continuing her full-time job at

the bakery, it gives her a purpose and is something she enjoys taking pride in. C.T. did make

comments about needing better coping mechanisms, including that she cannot push her emotions

down because they always build up and cause more issues once built up. With her daughter

being gone she also knows she must start living her life for herself, even if for the past nineteen

years she has been living it for her daughter. She knows both are going to be challenges but she

is willing to work on them. C.T. also was unsure about her medications at the beginning of the

day of care, but after discussion was more accepting and did take them. She stated she was going

to see how they made her anxiety and fibromyalgia feel but did not specify if her compliance

would last after discharge. A barrier to her compliance is her history of abusing Xanax and

marijuana for anxiety. Once again, she did not mention specifically if she was willing to quit

these substances and stay clean upon discharge. Education given on the benefits of her new
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medications and the consequences of her addiction was given by the nurse, nursing student, and

nurse practitioner.

Prioritized Diagnoses of Actual Nursing Diagnoses

Listed below are the prioritized nursing diagnoses for C.T.:

1. Risk of Suicide related to previous suicidal ideation and possible attempt with crashing

her car.

2. Risk for Injury related to substance abuse and crashing her car into a pole.

3. Risk for Violence; Self-Directed or Other-Directed related to aggression against staff

members when admitted and suicide precautions.

4. Ineffective Coping secondary to anxiety related to substance abuse of Xanax and

marijuana.

5. Disturbed Thought Processes related to anxiety and substance abuse.

6. Interrupted Family Processes related to family crises and changes in roles.

7. Disturbed Sleep Pattern related to lack of sleep from paranoia.

Potential Nursing Diagnoses

The following are potential nursing diagnoses for C.T.:

Self-Care Deficit

Risk for Loneliness

Impaired Social Interaction

Ineffective Impulse Control

Impaired Individual Resilience

Risk for Low Self-Esteem

Conclusion

Bipolar 1 Disorder is a mental health disorder with more commonly extreme highs,

mania, that can be followed by extreme lows, depression, or a mix of highs and lows at the same

time. During manic episodes, clients can be dangerous to themselves or others and may need

immediate hospitalization for safety. They can have a wired mood and activity leading to

impulsivity, lack of sleep, and self-care. Depressive episodes are evidenced by low energy.

Without medication, C.T. was unable to regulate these emotions and leaned towards substance

abuse as her coping mechanism. This caused less impulse control making her a higher danger

risk to herself and others.

Going forward with her medication regimen and group therapy sessions inpatient, I

believe will help C.T. evaluate her emotions and coping mechanisms better. Once discharged

though she is going to need collaboration and support in her life while she adjusts. Her new

medications are important to stay compliant with, but she is going to need to be reminded of

why. As well, coping with the use of Xanax and marijuana is unhealthy and is going to need to

stop. C.T. will need support to make that decision and take the steps to get sober. She is also

going to need social support not having her daughter in the state, which is the reason this crisis

truly began. For C.T. to stay on track with her treatment the right support and guidance are going

to be needed to get her to and keep her at optimal functioning.

Mania: What is it, Causes, Triggers, Symptoms & Treatment. Cleveland Clinic. (2021,
September 14). Retrieved October 6, 2022, from
https://my.clevelandclinic.org/health/diseases/21603-mania 

Risperidone (Risperdal). NAMI. (2016, January). Retrieved September 25, 2022, from
https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/
Types-of-Medication/Risperidone-(Risperdal) 

U.S. Department of Health and Human Services. (2022). Bipolar Disorder. National Institute of
Mental Health. Retrieved October 1, 2022, from
https://www.nimh.nih.gov/health/topics/bipolar-disorder 

Videbeck, S. L., & Miller, C. J. (2020). 14. In Psychiatric-Mental Health Nursing (p. 517).
essay, Wolters Kluwer. 

Volkmann, C., Bschor, T., & Köhler, S. (2020, May 7). Lithium Treatment Over the Lifespan in
Bipolar Disorders. National Library of Medicine. Retrieved September 25, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7221175/