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Mental Health Case Study 1
Running head: MENTAL HEALTH CASE STUDY
Mental Health Case Study
Ashley Hazelwood
Nursing 4550- Caring for Clients with
Mental Health Alterations
Middle Tennessee State University
School of Nursing
November 30, 2008
Mental Health Case Study 2
Abstract
The field of mental health is a unique specialty. The nurse must focus on the psychological
wellbeing of a patient as the priority. Caring for patients with a mental health disorder can be a
challenging experience. This case study investigates the patient, M.J., who was admitted for risk
of suicide. The assessment, nursing care plan and personal reflections are discussed within this
case study.
Mental Health Case Study 3
Mental Health Case Study
The field of psychology is a unique specialty within the healthcare system. It is
important for nurses to make the switch from focusing on the physical aspects of patients to
focusing on the psychological well being of patients as the priority. Patients with a mental health
disorder can challenge a nurse’s ability to care for them, nurses must be able to respond to
certain behaviors that they may exhibit. M.J. is a female patient discussed thoroughly within this
case study, her demographics, assessment, medications, nursing plan, and personal reflections
will be discussed within this case study. M.J. suffers from bipolar disorder, post traumatic stress
disorder, and severe depression.
Bipolar disorder is a mental health disorder that causes shifts in the patient’s mood,
energy, and ability to function. According to the National Institute of Mental Health, “About 5.7
million American adults or about 2.6 percent of the population age 18 and older in any given
year have bipolar disorder” (National Institute of Mental Health [NIMH], 2008). Post traumatic
stress disorder is a type of anxiety disorder that results from living through an event that caused
or threatened harm or death to self or others. Severe depression is when the feelings the patient
experiences interferes with their daily life and routine (NIMH, 2008). All three of these mental
health disorders can disrupt an individual’s quality of life that may, at times, require inpatient
care.
Demographics
M.J. is a thirty-five year old Caucasian female, diagnosed with severe depression, bipolar
disorder, and post traumatic stress disorder. M.J. also suffers from severe COPD, asthma,
obesity, and hypertension. She is allergic to penicillin and naproxen. M.J. smokes one pack of
cigarettes a day. She owns her own house, has three children and one grandchild. She is
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unemployed, on disability and states that her mother is her main support system. Her family
history includes her mother, who has a history of depression, and her father, who had diabetes.
M.J. states the activities she enjoys include scrapbooking, painting, and making things.
Assessment
Prior to M.J.’s present hospitalization, she had been admitted in 2006 and 2007 for severe
depression and risk of suicide. She received an electroconvulsive therapy (ECT) session in
November of 2007 and was depression free until two weeks prior to her admission. M.J. was
prescribed several medications to help with her mental health disorders and was compliant with
her medication schedule. Table 1 lists her current medications.
Table 1
Current Medications for patient, M.J.
Medication
Dose Route
Schedule
Purpose
Side Effects
Teaching
Alprazolam
xanax
1mg
PO
Four Times
Daily
Benzodiazepine
used for anxiety,
panic disorders,
anxiety with
depressive
symptoms
Use caution with
activities requiring
alertness, do not
discontinue
abruptly, avoid
alcohol, rise
slowly, may be
habit forming.
Amitriptyline
150
mg
PO
Bedtime
Tricyclic
antidepressant for
major depression
Dizziness, drowsiness,
confusion, fatigue,
depression, insomnia,
hallucinations,
orthostatic
hypotension,
tachycardia, blurred
vision, dry mouth,
constipation, nausea,
vomiting, diarrhea.
Dizziness, drowsiness,
seizures, hypotension,
tachycardia,
hypertension, blurred
vision, constipation,
dry mouth, urinary
retention, hepatitis,
paralytic ilius.
Cephalexin
keflex
500
mg
PO
Four Times
Daily
Cephalosporin
(anitinfective) for
upper and lower
respiratory
infections.
Seizures, diarrhea,
anorexia,
nephrotoxicity, renal
failure
Therapeutic
effects may take
2-3 weeks, caution
with activities
requiring
alertness, avoid
alcohol, do not
discontinue
quickly, increase
fluids, and use
contraception.
Report sore throat,
bruising, bleeding,
joint pain, instruct
to take all
medication
prescribed.
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Duloxetine
cymbalta
60 mg
PO
Daily
Serotonin,
norepinepherine
reuptake inhibitor
for major
depressive
disorder.
Abnormal vision,
photosensitivity,
constipation, diarrhea,
dry mouth, anorexia,
nausea, vomiting,
insomnia, fatigue
dizziness.
Quetiapine
Fumurate
seroquel
400
mg
PO
Three
Times
Daily
Atypical antipsychotic used to
treat bipolar
disorder and
schizophrenia
Trazodone
desyrel
200
mg
PO
Bedtime
Triazolopyridine
for depression.
Constipation,
drowsiness, dizziness,
stomach pain, fatigue,
weight gain,
tachycardia, and fever.
May cause tardive
dyskinesia (see Invega
effects).
Dizziness, drowsiness,
orthostatic
hypotension,
tachycardia,
hypertension, blurred
vision, diarrhea, dry
mouth, urinary
retention.
Zolpidem
Tartrate
ambien
10 mg
PO
Bedtime
Sedative,
nonbenzodiazepine, for
insomnia
Headache, lethargy,
dizziness, confusion,
nausea, vomiting,
diarrhea, constipation,
chest pain, drowsiness,
daytime sedation.
Loperimide
imodium
2 mg
PO
PRN for
Diarrhea
Antidiarrheal,
Piperidine
Derivative for
diarrhea.
Promethazine
phenergan
25 mg
Rectal
Every four
hours PRN
for nausea
Anti-histamine
used to prevent
and treat nausea
and vomiting.
Nausea, dry mouth,
vomiting, constipation,
abdominal pain,
anorexia, dizziness,
drowsiness, fatigue,
fever, toxic mega
colon, rash.
Drowsiness, dizziness,
constipation, blurred
vision, dry mouth,
tinnitus, bradycardia,
mood changes,
restlessness, tremor,
and weakness.
Source: (Roth, 2007).
Notify prescriber
if response
decreases or have
edema, do not
discontinue
abruptly, and do
not donate blood
for at least 6
months after last
dose.
May cause
dependence.
Withdrawal
reactions if drug
immediately
stopped.
Gradually reduce
dose to stop.
Caution with
activities that
require alertness,
avoid alcohol, do
not discontinue
quickly, and wear
sunscreen,
increase fluids and
bulk in diet, watch
for suicidal
ideation.
Do not use for
everyday stress or
longer than 3
months, avoid
alcohol, avoid
activities that
require alertness,
do not discontinue
abruptly.
Avoid alcohol, do
not exceed
recommended
dose, avoid OTC
products unless
directed by
prescriber.
Use caution with
activities that
require alertness
and avoid alcohol.
Photosensitivity
may occur. Wear
sunscreen.
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M.J. presented to the Parthenon Pavilion on October 12, 2008 with worsening depression
and suicidal ideation. She had a plan to cut her wrists and had written a will. She also stated she
had started cutting herself prior to admission and had not slept for three days. Her current
distress was she was still dealing with finding her thirteen year old daughter being raped by a
twenty-four year old man. Her daughter became pregnant and recently had the baby. M.J. has
been raising the baby, but now the daughter wants to take the baby and move in with her
boyfriend. During her history they found that M.J. had been physically and sexually abused as a
child and was also physically abused by her ex husband. M.J. became sexually active at the age
of twelve. Her mother is currently living with her along with her three children and grandchild,
and M.J. considers her mother her main support system. M.J. denied any alcohol or drug abuse
but was positive for marijuana.
M.J’s mental status exam revealed she was depressed with anxiety. Her concentration
and memory was poor. Her thinking was logical and goal directed and she denied any
hallucinations, delusions, or paranoia. Her affect was constricted, she endorsed suicidal
thoughts, but no homicidal thoughts were reported. M.J. was also assessed following the terms
of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Table 2 outlines M.J’s
DSM assessment.
Table 2
DSM Assessment for Patient, M.J.
DSM Assessment
Axis I
Axis II
Bipolar Affective Disorder Type 2, Severe Depression, Post Traumatic
Stress Disorder
Deferred
Axis III
Chronic Obstructive Pulmonary Disorder, Migraines
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Axis IV
Primary Support and Family Distress
Axis V
Global Assessment of thirty
The axes are five different categories that the Diagnostic and Statistical Manual of
Mental Disorders uses to categorize mental health disorders. This system forces the health care
provider to examine a broad range of information. Axis one are the signs and symptoms that
make up a disorder, axis two is personality disorders and mental retardation, axis three is any
general medical conditions relevant to the mental health disorder, axis four is psychosocial and
environmental problems, and axis five is the Global Assessment of Functioning (GAF) which
gives the person’s best level of psychological, social, and occupational functioning on a scale of
one to one hundred (Carson, Shoemaker, and Varcarolis, 2006). M.J. had a GAF score of thirty,
which indicates that “behavior is considerably influenced by delusions of hallucinations or
serious impairment in communication or judgment or inability to function in almost all areas
(Carson, et al., 2006). The treatment plan for M.J. included continuing her current medications
and receiving inpatient and outpatient electroconvulsive therapy treatments (ECT).
Nursing Diagnosis One
The three nursing diagnoses that were chosen for M.J. are risk for suicide, ineffective
coping, and disturbed sleep pattern. The priority diagnosis is risk for suicide related to feelings
of hopelessness as evidenced by her verbalization to “cut her wrists”, writing out a will, and she
stated “having a hard time for several weeks and have began cutting myself.” This diagnosis is
the most serious and needs immediate attention from the nurses.
In order to help M.J. the nurse must develop short and long term goals. The first short
term goal is that M.J. will remain free of self inflicted injury during her hospitalization. This is a
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major goal because without her safety M.J.’s other issues cannot be addressed. The second short
term goal is that M.J. can report changes in symptoms to the health care provider by the third day
of hospitalization. This needs to be achieved considering the reason for hospitalization was
suicidal ideation. A third short term goal is that M.J. will be able to identify precursors for her
depression by her date of discharge. M.J. can obtain much of this information by attending
group sessions during her hospital stay. She will also be able to attain many resources for future
use during these group sessions.
M.J. also needed long term goals to help her when she returns to the community. The
first long term goal is for M.J. to adhere to her therapy schedule and follow her treatment plan
following her discharge. This includes receiving her ECT treatments as scheduled and attending
therapy sessions. The second long term goal involves M.J. continuing to be compliant with her
medications and taking them all as prescribed. Medication compliance plays a major role in
helping M.J. maintain a higher level of functioning within the community. A third long term goal
is that M.J. will remain free from suicidal thoughts and from harming herself after discharge
from the hospital.
In order for M.J. to obtain her goals the nurse must develop interventions that will assist
the patient. A major intervention for suicidal patients is implementing suicide precautions by
using the milieu therapy. Suicide precautions include one to one nursing observation and
interaction twenty-four hours a day, maintain arms length at all times, chart a clients status every
fifteen to thirty minutes, make sure meal trays have no glass or metal silverware, hands should
always be in view and not under the covers, watch client swallow every dose of medication, and
explain to the client what you are doing, why, and document (Carson, et al., 2006). Other basic
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level interventions for a client at risk for suicide includes counseling, health teaching, case
management, and carefully administering all medications.
Evaluation of a suicidal client is a continuous effort. It is important for the nurse to
constantly watch for changes in the client’s mood, thinking, and behavior. Signs that the patient
may be at risk is a sudden change in behavior and a sudden burst of energy to carry out their
plan. The nurse should also observe signs that the patient is communicating more effectively and
able to function within the community. The nursing student was unable to implement
interventions or evaluate M.J. because she was unable to spend any time with the patient.
One research article that was reviewed examined suicide risk factors in major psychiatric
disorders. The article found that the influence of certain risk factors were different for each
diagnosis. The ten most significant suicide risk factors for bipolar disorder include: method of
last attempt, GAF of 20-30, academic work, 20-37 years of age, stress, manual labor, number of
previous suicide attempts, unemployment, delusions, and number of suicides in first degree
relatives. (Goldberg, Goldish, Kuperman, et.al., 2004).
Nursing Diagnosis Two
The second nursing diagnosis that is a priority for M.J. is ineffective coping related to
situational crisis as evidenced by statements such as “I bottle it up inside,” “I hide from my
children,” “ I have been having a hard time for several weeks and began cutting myself this
week,” “ I am severely stressed and sometimes feel like choking the kids.” Other signs of
ineffective coping include suicidal ideation, no sleep for three days prior to admission, chronic
medical conditions, unemployed, poor concentration, GAF score of thirty, and testing positive
for marijuana.
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To help M.J. develop proper coping skills the nurse needs to develop short term goals.
One short term goal for M.J. includes communicating feelings about her present situation by day
two of her hospital stay. This will help her identify the stressors she is having a difficult time
coping with. The second short term goal is M.J. will attend the group therapy sessions
throughout her hospital stay. This will provide her with the tools to develop new coping skills.
This will also enable her to become a part of planning her own care.
M.J. also needs long term goals to help her cope past her discharge from inpatient care.
The first long term goal includes M.J. utilizing available support systems such as family and
friends to aid in coping after being discharged. The second long term goal is that M.J. will
identify and demonstrate ability to use at least two health coping behaviors after attending
therapy sessions.
There are many interventions that apply to the nursing diagnosis of ineffective coping.
Interventions that help build the therapeutic relationship and help the patient feel safe include:
arranging to spend uninterrupted periods of time with patient, encouraging expression of
feelings, accepting what the patient says, trying to indentify factors that exacerbate patient’s
inability to cope, identifying and reducing unnecessary stimuli in the environment, and
explaining all procedures and treatments and answer questions the patient has. Other
interventions include encouraging patient to make decisions about care, having patient increase
self-care performance levels gradually, helping patient to look at current situation and evaluate
various coping behaviors, and encouraging the patient to try the coping mechanisms.
Evaluation of the patient includes observing M.J. for signs that she has met her short term
goals while in the hospital. M.J. should have been able to openly communicate about her present
situation. M.J. should have also attended most of the group therapy sessions to help develop new
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coping skills. Another important evaluation that must be made is reporting from M.J. about new
coping skills she has developed and how well they work for her situation. Once again, the
student was not able to implement interventions or evaluate the outcome of M.J. because she did
not get the chance to actually speak to the patient.
Nursing Diagnosis Three
The third nursing diagnosis the nursing student developed for M.J. was disturbed sleep
pattern related to internal factors as evidenced by stating having no sleep for three days before
admission, insomnia, mental illnesses such as PTSD, bipolar disorder, and severe depression,
and the medical condition COPD. Sleep disturbance is a major issue when dealing with bipolar
disorder. According to Plante and Winkelman in an article examining sleep disturbances in
bipolar patients, “Careful assessment of the quality and quantity of sleep, thoughtful application
of behavioral and pharmacological therapy to improve sleep, and screening for co-occurring
sleep disorders are critical in the management of this patient population.”
The nurse must develop short term goals to help promote sleep and well being for M.J.
The first short term goal is for M.J. to identify factors that prevent or disrupt sleep by the second
day of hospitalization. Before M.J. can solve her sleeping disturbances, she must identify the
factors that cause the disturbance, without doing this she will not accomplish anything during her
therapy. The second short term goal for M.J. is for her to perform relaxation techniques prior to
going to sleep by the second day of hospitalization. These techniques can be taught during group
therapy sessions and may help reduce M.J.’s insomnia she experiences. A third short term goal
is for M.J. to develop a sleep routine by the date of discharge. A routine will help develop
stability in M.J.’s life.
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M.J. also needs long term goals to help her disturbed sleep pattern. The first long term
goal includes sleeping through the night consistently by the last two days of inpatient care. This
will significantly improve how M.J. feels and help her cope much better. A second long term
goal is for M.J. to slowly become non dependent upon sleep aids throughout the year. Staying
dependent on sleep aids will only worsen her sleep issues and affect her circadian rhythm further.
Interventions that help alleviate sleep disturbances include allowing M.J. to discuss any
concerns that may be preventing sleep, create a quiet environment conducive to sleep, administer
medications that promote sleep as ordered, and educate M.J. in relaxation techniques such as
guided imagery, progressive muscle relaxation, and meditation. The article by Plante and
Winkelman that examined sleep disturbances in bipolar disorder discusses the management of
insomnia in bipolar patients. This is an important aspect of treatment for bipolar patients
because insomnia can cause morbidity, functional impairment, and an increase in health care
costs. The article states that the two methods to manage insomnia are cognitive-behavioral
therapy (CBT) for insomnia and using medications such as benzodiazepines, benzodiazepine
receptor agonists, sedating antidepressants, anticonvulsants, sedating antipsychotics,
anticonvulsants, and melatonin receptor agonists. Strategies for CBT include sleep restriction
therapy, sleep hygiene education, stimulus control therapy, and relaxation training (Plante,
Winkelman, 2008).
Evaluation is based on whether the patient is experiencing an increase in improved
sleeping patterns. In a perfect setting the patient will experience decreased time to fall asleep
initially, fewer awakenings, and a shorter time to fall asleep after awakening. This can be
accomplished through observation of the patient, patient reports, and having the patient develop
a sleep journal. The most important evaluation technique is to receive the patient’s perception of
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improvement of sleep patterns. Once again the student nurse was not able to implement
interventions or evaluate the outcomes for M.J.
Personal Reflections
Nurses have a challenging role when caring for patients with mental illnesses. The
number of mental illnesses within the United States is outstanding with about 57.7 million
Americans suffering from a mental disorder. This number proves that nurses in every field will
at some point have to care for a patient with a mental illness and it is important for nurses to be
able to identify signs associated with certain disorders. Mental disorders are the leading cause of
disability in the United States, and can disrupt a patient’s quality of life to the extreme.
In dealing with M.J., she suffers from severe depression, bipolar disorder, and post
traumatic disorder. Major depressive disorder accounts for 14.8 million American adults with a
median age of onset at thirty-two, bipolar disorder affects around 5.7 million American adults
with a median age of onset at 25 years, and post traumatic stress disorder affects approximately
7.7 million American adults with a median age of onset at 23 years (NIMH, 20008). M.J. also
suffers from suicidal ideation with a well thought out plan. Suicide is a major issue within our
country, approximately 32,439 people died in 2004 by suicide, and more than 90% of people
who commit suicide have a mental disorder (NIMH, 2008). Nurses must be able to recognize
signs of suicide in all of their patients no matter what type of healthcare setting they are in.
Dealing with patients with mental illnesses was a new experience for me, and this
assignment helped me look at nursing from a different perspective. Being able to experience
group therapy sessions and ECT treatments was something I have not seen in any other clinical
before. I learned that mental illnesses can affect every aspect of the patient’s life which
emphasizes the need for holistic care of the patient. I also learned the importance of milieu
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therapy within the psychiatric unit. This type of environment is completely different from what I
have experienced on a medical surgical unit. The milieu therapy provides structure and
boundaries for the patients to help keep situations from escalating.
It is important to care for the patient from every aspect such as psychological,
psychosocial, emotional, spiritual, and physical well being. When caring for any patients,
whether they are psychiatric patients or not, the nurse must develop a care plan. The care plan
allows the actions needed to be clearly organized and when carried out appropriately helps
patients obtain the best outcomes during their inpatient care. Within the care plan the nurse must
identify priority nursing diagnoses, goals, interventions and evaluation of the care plan. I feel
this assignment will help me to care for my patients more successfully no matter what field I
choose to practice.
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References
Carson, V.B, Shoemaker, N.C., & Varcarolis E.M. (2006). Foundations of psychiatric mental health
nursing: A clinical approach. (5th ed.). St. Louis, MI: Elsevier.
Modai, I., Kuperman, J., Goldberg, I., Goldish, M., & Mendel, S. (2004, March). Suicide risk factors
and suicide vulnerability in various major psychiatric disorders. Medical Informatics & the
Internet in Medicine, 29(1), 65-74. Retrieved November 30, 2008, from CINAHL with Full Text
database.
National Institute of Mental Health (2008). The numbers count: mental disorders in america. Retrieved
November 26, 2008, from http://www.nimh.nih.gov/health/publications/the-numbers-count
mental-disorders-in-america.shtml.
Plante, D., & Winkelman, J. (2008, July). Sleep disturbance in bipolar disorder: therapeutic
implications. American Journal of Psychiatry, 165(7), 830-843. Retrieved November 30, 2008,
from CINAHL with Full Text database.
Ralph, S.S., & Taylor, C.M. (2005). Sparks and Taylor’s nursing diagnosis reference
manual, (6th ed). Ambler, PA: Lippincott Williams & Wilkins.
Skidmore-Roth, L. (2007). Mosby’s drug guide for nurses, (7th ed.). St. Louis, MO: Mosby.