Mental Health Case Study 1

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

MiddleTennesseeStateUniversity

School of Nursing

November 30, 2008

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

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 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 / Dizziness, drowsiness, confusion, fatigue, depression, insomnia, hallucinations, orthostatic hypotension, tachycardia, blurred vision, dry mouth, constipation, nausea, vomiting, diarrhea. / 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, seizures, hypotension, tachycardia, hypertension, blurred vision, constipation, dry mouth, urinary retention, hepatitis, paralytic ilius. / Therapeutic effects may take 2-3 weeks, caution with activities requiring alertness, avoid alcohol, do not discontinue quickly, increase fluids, and use contraception.
Cephalexin keflex / 500 mg / PO / Four Times Daily / Cephalosporin (anitinfective) for upper and lower respiratory infections. / Seizures, diarrhea, anorexia, nephrotoxicity, renal failure / Report sore throat, bruising, bleeding, joint pain, instruct to take all medication prescribed.
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. / 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.
Quetiapine Fumurate seroquel / 400 mg / PO / Three Times Daily / Atypical anti-psychotic used to treat bipolar disorder and schizophrenia / Constipation, drowsiness, dizziness, stomach pain, fatigue, weight gain, tachycardia, and fever. May cause tardive dyskinesia (see Invega effects). / May cause dependence. Withdrawal reactions if drug immediately stopped. Gradually reduce dose to stop.
Trazodone desyrel / 200 mg / PO / Bedtime / Triazolopyridine for depression. / Dizziness, drowsiness, orthostatic hypotension, tachycardia, hypertension, blurred vision, diarrhea, dry mouth, urinary retention. / 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.
Zolpidem Tartrate
ambien / 10 mg / PO / Bedtime / Sedative, nonbenz-odiazepine, for insomnia / Headache, lethargy, dizziness, confusion, nausea, vomiting, diarrhea, constipation, chest pain, drowsiness, daytime sedation. / Do not use for everyday stress or longer than 3 months, avoid alcohol, avoid activities that require alertness, do not discontinue abruptly.
Loperimide imodium / 2 mg / PO / PRN for Diarrhea / Antidiarrheal, Piperidine Derivative for diarrhea. / Nausea, dry mouth, vomiting, constipation, abdominal pain, anorexia, dizziness, drowsiness, fatigue, fever, toxic mega colon, rash. / Avoid alcohol, do not exceed recommended dose, avoid OTC products unless directed by prescriber.
Promethazine phenergan / 25 mg / Rectal / Every four hours PRN for nausea / Anti-histamine used to prevent and treat nausea and vomiting. / Drowsiness, dizziness, constipation, blurred vision, dry mouth, tinnitus, bradycardia, mood changes, restlessness, tremor, and weakness. / Use caution with activities that require alertness and avoid alcohol. Photosensitivity may occur. Wear sunscreen.

Source: (Roth, 2007).

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 / Bipolar Affective Disorder Type 2, Severe Depression, Post Traumatic Stress Disorder
Axis II / Deferred
Axis III / Chronic Obstructive Pulmonary Disorder, Migraines
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 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 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.

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 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 bystating 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.