Comprehensive Case Study

Psychiatric Mental Health Comprehensive Case Study

Samantha Rock

NURS 4842L: Mental Health Nursing

Due date: 4-22-22

Clinical Faculty: Bill Church

Abstract

The following case study describes the disease process of a patient with major depressive

disorder as well as the treatments and care provided for the patient. The subject of the study is

S.M., a 33-year-old Caucasian female that presented to the ED following her second suicide

attempt in two weeks. Psychiatric Mental Health issues are widespread all around the world.

However, there is such a stigma surrounding this topic, especially in the United States.

Throughout this case study, it will become more evident why this stigma is such a problem for

those actually suffering with mental illnesses. The two most common mental health diagnoses in

our country are anxiety and depression. Due to the issues surrounding mental health issues in the

U.S., many individuals will go for years undiagnosed in an effort to conceal what they’re going

through. In this paper, will discuss a patient I had and the weight that their many mental health

illnesses, including depression, has had on them.

Major Depressive Disorder: Case Study

Objective Data:

The patient I chose to do my case study on was an interesting patient. She was admitted

on April 18th, 2022, to Trumbull Regional Medical Center. I had S.M. on April 19th, 2022, as my

patient to interview and read up on. S.M. was a self-admission to the ER on the 18th after her

second unsuccessful suicide attempt by wrecking her car. On admission, S.M. was visibly upset

with her current life situation, as she was crying and saying the reason she came to the ED is

because she wants and needs help for herself and her three children. On the day of care when I

had her, she spoke of only negative thoughts. Nothing seemed to help her mood at all, and she

kept mentioning that she just wants to be dead. She was however willing to share everything that

happened leading up to her being admitted to the hospital unit. She seemed sad and was quite

tearful when sharing her story. She was especially tearful when she spoke about her feeling that

everyone is out to get her and that no one cares about her.

When I asked her about her stressors, she shared that they are the main reasons she is in

the situation she in in now. She said that her stressors are that she has not been to work since

January, so she’s scared that she’s about to lose her home and be on the streets with her kids, she

now has no car because she wrecked it, and her wallet with her food stamps card was in the car

so she was very worried about getting that to her friend who was watching her kids. Her eye

contact was moderate when we spoke with each other. She had a slouched posture and had an

unkempt appearance. She was friendly given her circumstances and said that she does not regret

trying to kill herself twice in the past. She said that if things don’t start to change, she still thinks

those thoughts will remain with her after leaving the hospital.
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The only medical diagnosis in her chart was obesity, but she stated she has undiagnosed

OCD, bipolar disorder, and ADHD. While she was in the hospital, she was on suicide

precautions due to her recent suicide attempt and ideations. Some of the safety measures include

no doors on the bathrooms, every fifteen-minute checks, no sharp objects available to her, and

shared rooms with others. At Trumbull Regional Medical Center, she was significantly safer than

being at home or on the streets because at home there’s a lot of different things she could get

access to with intent to harm herself. She was was taking the medications Trazodone Hcl 50 mg

and Zyprexa 15 mg before admission, and she states they have not been helping her. Trazodone

is a CNS depressant and anti-depressant that is used to increase total sleep time. Zyprexa is an

atypical anti-psychotic medication that is used to treat certain psychotic disorders, bipolar

disorder, and acute agitation. This drug works by producing anti-cholinergic activity.

Summarize the psychiatric diagnoses and expected common behaviors:

The criteria to be diagnosed with a psychiatric disorder is by looking at the DSM-5 which

lists the updated psychiatric disorders. The American Psychiatric Association lists all the criteria

for the psychiatric disorders for doctors to diagnose based off symptoms and behaviors. The

DSM-5 outlines the following criterion to make a diagnosis of depression. With this, “The

individual must be experiencing five or more symptoms during the same 2-week period and at

least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day.

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day,

nearly every day.

3. Significant weight loss when not dieting or weight gain or decrease or increase in appetite

nearly every day.

4. A slowing down of thought and a reduction of physical movement (observable by others,

not merely subjective feelings of restlessness or being slowed down).

5. Fatigue or loss of energy nearly every day.

6. Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

7. Diminished ability to think or concentrate, or indecisiveness, nearly every day.

8. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a

suicide attempt or a specific plan for committing suicide.

To receive a diagnosis of depression, these symptoms must cause the individual clinically

significant distress or impairment in social, occupational, or other important areas of functioning.

These symptoms must also not be a result of substance abuse or another medical condition”

(Truschel, 2022).

Major depressive disorder is associated with high mortality rates, much of which is

accounted for by suicide. Because of this, as a nurse and in general, it is important to know the

warning signs of suicide and to take suicidal statements extremely seriously. “Depressed

individuals also may present with irritability, brooding, and obsessive rumination, and report

anxiety, phobias, excessive worry over physical health, and complain of pain. It is also possible

for major depressive disorder to occur in addition to sadness resulting from a significant loss,

such as bereavement, financial ruin, or a serious medical illness” (Truschel, 2022)

Identify the stressors and behaviors that precipitated current hospitalization:

My patient had quite a few stressors involved in the precipitating factors to being at

Trumbull Regional Medical Center. Chronic stress can lead to a lot of mental health issues like

anxiety and depression. S.M.’s admission began when she purposely wrecked her car for the

second time in two weeks to try and kill herself. She was a self-admission to the ED and

explained that she was trying to reach out for help by doing this. She seems to have some

understanding of her mental illness and situation and that she needs help but does not have the

means to solve every problem on her own. This is quite common with mental health patients, as

many of them do not have stable jobs due to their conditions and cognitive abilities. With this,

S.M. has also expressed concern about her not working since January and is terrified she will end

up homeless, and with her having kids it makes it even more stressful. Along with the financial

situation, she is also on government benefits in order to support her children. She now no longer

has a car due to her totaling it from her recent suicide attempts and does not have enough money

to buy another one, which complicates all of these matters further.

Discuss patient and family history of mental illness:

When it comes to family history of mental illness, I’d say it plays a major role in the

development of certain disorders. Her mother and father both suffer from anxiety and depression,

and her maternal grandmother also had depression. This means that depression runs in the family

on both sides, greatly increasing the risk to pass it onto children. When a first degree relative has

a mental illness like depression it appears the child is two to three times at a greater risk of

having the condition as well. There was no other known history of mental illness in her family,

but that doesn’t mean there aren’t mental illnesses that have gone undiagnosed. Many people

with mental illnesses go undiagnosed because it doesn’t affect their life enough to get the help
Comprehensive Case Study

they may need for that illness. Plus, due to the huge stigma, most people don’t even want to

mention it. Their activities of daily life like eating and bathing for example aren’t altered

necessarily and are able to lead somewhat normal lives. Some people with depression go

unnoticed until they present critical issues like trying to commit suicide.

Describe the psychiatric evidence-based nursing care provided:

The psychiatric evidence-based nursing care that was provided was based on her major

depressive disorder and multiple recent suicide attempts with current suicidal ideations. An

important thing for the nurses to do when caring for this patient is to be an open and active

listener. It’s also important to be non-judgmental of these patient’s situations. People that are in a

depressive or manic state are known to be very emotionally labile and may take something that

was said the wrong way or out of context. This is not good for their physical and mental state, so

being able to create rapport with these patients is crucial. All patients should be treated fairly no

matter what their gender, race, socioeconomic background is. Professionals like nurses that work

in the health care field should use evidence-based nursing care by using the best and newest

information available to best provide care for their patients.

“Milieu therapy is based on five components that helps make the environment therapeutic

for the patient. An important characteristic of milieu therapy is having the support of loved ones

and the healthcare personnel” (NIMH, 2021). One major thing that the hospital did with my

patient was interviewing her about her current treatment plan and goals. The nurse practitioner

and social worker sat down with her and interviewed her about her current admission, how her

medications are working, and just her general thoughts and feeling on the current situation she’s

in. Another important part of milieu therapy is having structure, which was implemented at the
Comprehensive Case Study

hospital by them following the same schedule every day. They had group therapy multiple times

a day, had a certain time to go to bed, and had specific times they ate. Everything was very

structured in the hospital for them, which may or may not provide patients with things to look

forward to during the day, such as mealtimes and learning opportunities. Being on a routine can

also take some of the stress away from life as well so they can focus on their mental illness and

getting better. “Milieu therapy is very therapeutic because it provides a safe and welcoming

space to talk and develop a trusting professional relationship with the nurses” (NIMH, 2021).

Often people feel vulnerable when being in a new setting so, group therapies and individual

therapies encourage them to open up and hopefully develop therapeutic relationships when it

comes to healing. The group therapy promotes them to get involved with socialization with

others. They aren’t supposed to be developing friendships while on the psychiatric floor, but it is

important to hear other stories that may be going through the same thing. When they hear they

aren’t alone in their problems they may feel a sense of comfort. Another important part of milieu

therapy is a focus on self-care for the patients. By having them do their own hygiene and self-

care activities, this will potentially create a sense of willingness to fix other issues in life.

Analyze ethnic, spiritual, and cultural influences that impact the patient:

S.M. did not specify whether she had any cultural or religious backgrounds and/or

preferences. At no point during our interview did she mention anything related to religion or

culture, nor was it indicated at all in her chart data.

Evaluate the patient outcomes:

Patient outcomes involved in her care involved her functional status, her safety status,

and her satisfaction with care. A very important outcome for her was to state 1-2 positive
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comments about herself or what she has accomplished during her stay. It was also important to

identify positive coping mechanisms she was willing to try to improve her mental health status.

She was able to develop a couple positive coping strategies that involved writing and spending

time with friends. She stated that she will ‘do her best’ to report self-harm thoughts to staff when

they arise, but that this will be hard for her to do at first. This is a very important outcome

because it means she’s willing to get help when having those bad thoughts. With the use of group

therapy and individual therapy she will have improved outcomes when it comes to her mental

health. An important outcome is to have the desired effect of his new medication. She had stated

previously that her current medications are not helping her, so getting her regulated on the right

medication and dosage is critical. She will show an improvement in her mood regarding his

depression and should be able to identify her positive progress towards the end goal.

Plans for discharge:

Her plans for discharge include meeting her desired inpatient outcomes as previously

discussed. She will be interviewed by a social worker, who will determine what additional

resources are able to be allocated for her when she leaves. Once a solid plan is in place with the

multidisciplinary team, she will be discharged to home. She will start her medication plan that

was created for her severe state of depression, which is Prozac 20 mg. She will also continue to

take her Trazodone 50 mg and Zyprexa 15 mg every day. She was also ordered Melatonin 5 mg

every night PRN. After discharge she will continue to go to therapy and talk to a psychiatrist

once a week. This will help her get her feelings out on the table about stressors, and she will

have someone to talk to if the suicidal ideations come back.

Actual Nursing diagnoses using NANDA format:

“Nursing care plan goals for patients with major depression includes determining a

degree of impairment, assessing the client’s coping abilities, assisting the client to deal with the

current situation, providing for meeting psychological needs, and promote health and wellness”

(Martin, 2022). Risk for self-directed violence related to anhedonia as evidenced by clear and

specific suicidal plan and multiple suicide attempts. Impaired social interaction related to

feelings of worthlessness as evidenced by dysfunctional interaction with family, peers, and/or

others. Chronic low self-esteem related to feelings of shame and guilt about self as evidenced by

negative view of self and abilities, repeated expression of worthlessness and self-negating

verbalizations. Self-care deficit related to anergia (decreased or lack of motivation) as evidenced

by persistent insomnia or hypersomnia. She has a lot of nursing diagnoses that fit her situation as

you can see above. Many of these problems are due to her severe state of depression and anxiety

like risk for self-injury, ineffective coping, disturbed sleep pattern, hopelessness, and fatigue. It’s

important to work through his depression with therapies whether group or individual and

medications she is on.

Potential nursing diagnoses:

Readiness for enhanced coping related to getting help after suicide attempts and sharing her story

as evidenced by expressing desire to enhance knowledge of stress management strategies,

expresses desire to enhance management of stressors, and expresses desire to enhance use of

problem-oriented strategies. Risk for loneliness related to life choices as evidenced by family’s

lack of support, little to no social life and depression. Readiness for enhanced self-concept

related to becoming comfortable with self as evidenced by feeling comfortable in her own body,
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being able to recognize her own strengths, and wanting to improve her attitude. Risk for

situational low self-esteem related to depression as evidenced by being unhappy with personal

appearance by verbalization. Risk for suicide related to threats of killing self previously as

evidenced by past suicide attempts and self-harm tendencies. There’s always a potential for

different nursing diagnoses but these are some that are especially relative to S.M. Risk for

suicide is a top priority because its life or death. They can prevent this by doing every fifteen-

minute checks, no doors, and one to one if the patient becomes a threat to themselves.

Conclusion:

Mental disorders can have a huge effect on peoples lives. Every little thing that happens

in someone’s day to day experience is important in shaping their mental health. S.M. has had a

lot of different stressors in her life that have affected her and how she copes today. Everyone

copes differently, but how someone is brought up and taught to cope makes a huge impact on

how they handle things. If you grew up watching your parents smoke cigarettes and drink

alcohol all the time to deal with their problems, that’s most likely what you will do as well

because that’s all you’ve known. She has a huge number of personal stressors and doesn’t have a

lot of support from her family or friends. She does seem to have one good friend that is there for

her and us willing to watch her kids while she’s focusing on her mental health. Learning good

coping strategies, gaining support of others, and finding her own sense of self-esteem are all

important goals to work towards.

References

Betty J. Ackley, Gail B. Ladwig. (2008). Nursing diagnosis handbook: an evidence-based guide

to planning care. St. Louis, Mo: Mosby Elsevier.

Martin, P. (2022, March 18). 9 major depression nursing care plans. Nurseslabs. Retrieved April

21, 2022, from https://nurseslabs.com/major-depression-nursing-care-plans/

National Action Alliance for Suicide Prevention. (2019). Best Practices in Care Transitions for

Individuals with Suicide Risk: INPATIENT CARE TO OUTPATIENT CARE. (2019).

https://www.samhsa.gov/sites/default/files/suicide-risk-practices-in-care-transitions-

11192019.pdf

National Institute of Mental Health. Disruptive Mood Dysregulation Disorder: The Basics.

(2021). Www.nimh.nih.gov. https://www.nimh.nih.gov/health/publications/disruptive-

mood-dysregulation-disorder

Truschel J., (2020, September 25). Depression definition and DSM-5 diagnostic criteria.

Psycom.net - Mental Health Treatment Resource Since 1996. Retrieved April 21, 2022,

from https://www.psycom.net/depression-definition-dsm-5-diagnostic-criteria/#dsm-

5diagnosticcriteria