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Mental Health Case Study
Marc Manucal
00844835
On Campus
Submitted in partial fulfillment of the requirements in the course
N351: Psychiatric and Mental Health Nursing
in the School of Nursing
Old Dominion University
NORFOLK, VIRGINIA
Spring, 2011
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Psychosocial Assessment
Client S.B. is a 26 y/o female self admitted to the Virginia Beach Psychiatric Center
(VBPC) for bipolar disorder and depression. She has had a previous hospitalization for a
forearm fracture at the age of 19. Client has not had any previous hospitalizations for mental
health disorder. Her educational background consists of a high school diploma and a
baccalaureate degree in education from the University of North Carolina. Client had a job as a
3rd grade teacher after earning her degree in education. She recently lost her job as a teacher
because of her inability to function at school.
Client is currently unemployed and lives with her mother. She considers her mother and
sister as her support system. She denies having any true friendships and claims to have
difficulties maintaining intimate relationships. A typical day for S.B. after losing her job
consists of staying at home and being very sedentary. Client did not disclose any information on
her sexual patterns or if she were sexually active. Her interests include yoga, reading and
journaling. Client denies any use of illicit or recreational drugs. She drinks alcohol socially,
having 1-2 drinks a week depending on what she is doing. Prescription medications include
Lithium Carbonate, Bupropion, Adderall, Miralax and Prilosec. Over the counter medications
include Tylenol for minor aches and pains. Denies any herbal remedy usage.
Client states that she has difficulty coping with her stress and depression. She states that
her family only compounds her problems. Her mother denies that she has a problem and
frequently asks why she needs to seek treatment. Her sister will only support her if she is able to
support herself stating that client needs a stable job before she can help her. Her coping abilities
that work are yoga and journaling. Breathing exercises also help her with anxiety and relieving
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stress. Being involved in group therapy also helps to get her feelings out which help her to
relieve stress. Client believes in a higher power and feels that she can turn to her spirituality as a
way to cope with her problems.
Mental Status Examination
S.B. is a 26 y/o Caucasian female. Client is clean and well kept, wearing appropriate
attire for psychiatric facility. Gait is rhythmic with upright posture and good eye contact. Client
is well developed according to age. Immediate, recent and remote memory intact. Alert and
oriented to person, place, time and situation. Intellectual function is above average.
Concentration and calculation are good. Affect and mood are congruent. Affect was blunted
and mood was happy. Denies at present any suicidal or homicidal ideation. Denies having
hallucinations. No delusions noted. Speech is clear and coherent with no noted FOI or LOA.
Insight into problems is good. Judgment was deliberate and good.
Analysis in the Case Study
S.B. is a 26 y/o female admitted to the Virginia Beach Psychiatric Center on September
25, 2011 for bipolar disorder and depression. S.B. self admitted herself to the VBPC because she
stated she was “unable to function” due to her depression. S.B. has been seen in an outpatient
setting in North Carolina in which she was being treated for bipolar disorder. She is currently
living with her mother in Virginia Beach. She has lost her job as a teacher and does not have an
adequate support structure in place to help her mental health disorder. She has difficulty
maintaining intimate relationships and states that she feels “depressed and alone” when not in an
intimate relationship.
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The priority patient problem for client S.B. is ineffective coping skills. Ineffective
coping is evidenced by her inability to meet basic needs, inability to meet role expectations,
alteration in social perception and impairment of usual patterns of communication (Varcarolis
and Halter, 2010). Evidence of client not being able to meet basic needs is seen in her inability
to maintain an adequate household. Client stated that she rarely ate or exercised and that she
rarely cleaned and maintained her apartment forcing her to move in with her mother. Losing her
job as a teacher is evidence of her inability to meet her role expectations as an educator and
productive member of society. Alterations in her social perception are her feelings of being
alone and worthless when not in an intimate relationship. Another alteration in social perception
is her lack of a support system and friendships. Client states that she stays in her home for most
of the day and does not communicate with other people displaying an impairment in patterns of
communication.
The DSM-IV criteria for client S.B. states that Axis 1 is Bipolar Disorder, Axis 2 is
passive dependent personality disorder, Axis 3 has no diagnosis, Axis 4 states severe difficulty
with interpersonal relationships, difficulty with primary support group, occupational and
financial problems and Axis 5 is a GAF of 35 with a past year GAF of 50.
Bipolar disorder is the first diagnosis in Axis 1. One criteria for bipolar disorder states
that “A distinct period of abnormality and persistently elevated, expansive, or irritable mood for
at least 4 days of hypomania or 1 week of mania” (Varcarolis and Halter, 2010, pg 282).
Hypomania is characterized by a change in functioning that is uncharacteristic of the patient, a
disturbance in mood which is noticeable to others, no hospitalizations needed and no symptoms
are caused by substance use (Varcarolis and Halter, 2010). Not showing up to work, lack of
interest and attentiveness to the children she taught when at work, irritability at work were
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indications of a change in function of the patient. Her depressed mood, lack of interest during
work and irritability with colleagues were all noticeable changes in the behavior of S.B. Her
hypomanic state did not require her to be hospitalized and client denied taking any recreational
drugs which may have contributed to her behavior changes.
Mania is characterized by impairment of occupational or social activities, as well as
impairment of relationships, requires hospitalization to prevent harm to self or others and is not
due to use of medications or underlying medical conditions (Varcarolis and Halter, 2010). Client
displayed manic episodes at work by becoming very short tempered with colleagues, inability to
focus on one task at a time when teaching and her feelings of needing to be a “perfectionist”
were all displayed in the client. She also claims to have difficulty maintaining intimate
relationships with men because she always finds flaws in them. She stated that she “feels like
she pushes guys away” but is unsure how she does it. She also stated that “she feels the need to
be in a relationship even when she knows that it is a bad situation.”
Other criteria for bipolar disorder is that the client has to have a decreased need for sleep,
flight of ideas or racing thoughts, easily distracted, increase in psychomotor activity and
excessive involvement in activities that produce negative consequences. Client stated that
“being admitted has given her the most sleep she has had in months”. Client is used to getting 23 hours of sleep per day claiming that her mind was constantly thinking about something.
Concentrating on one task was difficult for her in the past. She was unable to stay focused on
her job nor was she able to focus on taking care of herself. Increased psychomotor activity was
evident in her constant twirling of her pencil or constant tapping of her foot. She also has
financial troubles that stem from losing her job but also due to excessive spending while
shopping.
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Axis 2 states that S.B. has a passive dependent personality disorder. This is characterized
by her feelings of needing to be in a relationship. The client would rather be in a relationship
that was unfruitful than be alone. Her relationship with her mother is another aspect of her
passive dependent personality disorder. She claims that her mother stresses her out because she
does not support her claim that she needs mental health help. Although her mother is a negative
factor in her treatment, she still refuses to leave her and continues to stay within her household.
Axis 3 has no diagnosis.
Axis 4 is evident in the dysfunctional relationships she has had with significant others.
She has become very agitated with her boyfriends in the past for no reason. She has always been
in a relationship and states that she has been single for only a few weeks since being admitted.
Many of her relationships in the past were very unhealthy and yet she would always find a way
to stay in the relationship. The difficulties with her primary support group start with her mother.
Her mother is allowing the client to live with her but does not support her seeking mental health
treatment. Her sister has told the client that she can help S.B. only if she gets her act together
and gets a job. Occupational and financial problems began with the loss of her job. She has no
income coming in and has maxed out her credit cards due to frivolous shopping sprees. Her Axis
5 GAF score is 35, which is less than what she was the past year. Her inability to manage her
life, losing her job and inability to cope with her stress have contributed to her decreased GAF
score.
Laboratory Diagnostic Testing
The laboratory tests ordered for the client were a CBC with differential, metabolic panel
and a Thyroid Stimulating Hormone test. The CBC was within normal limits. The metabolic
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panel was also within normal limits except for the globulin, which was low at a 1.9g/Dl. Low
globulin protein levels can be attributed to the patient’s malnutrition from manic episodes or
depression. There were no radiological or other tests ordered.
Medical Orders
The client was on a diet as tolerated order. Activity orders were also as tolerated with off
ward privileges. The medications the client was taking are Lithium Carbonate, Adderall-XR,
Bupropion, Prilosec and Miralax. The client was placed on Lithium to help control her bipolar
disorder, particularly her manic episodes (Hodgson and Kizior, 2012). Client is taking AdderallXR, an amphetamine and CNS stimulant, to treat her attention deficit disorder (Hodgson and
Kizior, 2012). Bupropion is a aminoketone, antidepressant and smoking cessation aid, which
was used to treat her depression (Hodgson and Kizior, 2012). It may have also been used to help
curb her appetite for cigarettes since it also was used as a smoking cessation aid (Hodgson and
Kizior, 2012). Prilosec is a gastric acid pump inhibitor, which was taken because she had a
history of GERD. Miralax, a laxative, was given to combat the side effect of constipation seen
when a client takes Bupropion (Hodgson and Kizior, 2012). Treatment modalities include
speaking with attending psychiatrist daily and attending group therapy. Speaking with
psychiatry helps her to focus her treatment plan, discuss any negative feelings she may be
experiencing, learn new coping skills and is a way to monitor her progression through treatment.
Group therapy provides a milieu environment in which she can develop communication skills
and build bonds with other people going through the same experiences that she has.
Nursing Interventions
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2 outcomes for client S.B. include injury prevention and relapse prevention. Injury
prevention, primarily in the acute phase of bipolar disorder, is to prevent harm to the client
and/or others (Varcarolis and Halter, 2010). When the client experiences mania or hypomania in
the acute phase, they are in constant motion with frequent flight of ideas (Varcarolis and Halter,
2010). They may get little to no rest and may not eat during this time period which can result in
physical exhaustion and death (Varcarolis and Halter, 2010). 2 nursing interventions that can be
used for injury prevention are to keep the client well hydrated and for the client to get sufficient
sleep and rest (Varcarolis and Halter, 2010). The body needs food and water to survive and rest
so that the body can recover. Both issues are absent during a manic state.
The other nursing outcome is relapse prevention which is part of the continuation phase
of bipolar disorder and lasts approximately 4-9 months (Varcarolis and Halter, 2010). 2 nursing
interventions for relapse prevention include getting involved in support groups or therapy and
communication and problem-solving skills training (Varcarolis and Halter, 2010). Group
therapy enables the client to express her feelings of agitation or depression in a controlled
environment that can be therapeutic. Group therapy also provides a support group in which she
can seek guidance and help on how they deal with their manic episodes.
Sufficient sleep and rest is very important in the bipolar disorder client. The qualitative
research article “Self-Management Strategies Used by ‘High Functioning’ Individuals with
Bipolar Disorder: From Research to Practice” places a high importance on adequate sleep and
rest. Their study suggests that a lack of sleep and a disruption in Circadian rhythms correlate
with the development of bipolar disorder symptoms (Murray et al, 2010). Maintaining good
sleeping habits also has a benefit in that it usually does not require a pharmacological
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intervention (Murray et al, 2010). Clients can control their symptoms through empowering
themselves and abiding by a sleep schedule.
A diagnosis of bipolar disorder can be a difficult, life changing event. S.B. has
experienced many life changing events since being diagnosed with bipolar disorder. Her
decision to self-admit and seek help put her on the right path to becoming a high functioning
member of society. With proper care and adherence to medical regimens, along with strict
adherence to medication orders, S.B. can increase her independence and functional ability and
become a productive member of society once again.
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References
Murray, G., Suto, M., Hole, R., Hale, S., Amari, E., & Michalak, E.E. (2011). Self-management
strategies used by ‘high functioning’ individuals with bipolar disorder: from research to
clinical practice. Clinical Psychology & Psychotherapy, 18(2), 95-109. doi:
10.1002/cpp.710
Hodgson, B.B & Kizior, R. J. (2012). Nursing Drug Handbook 2012. St. Louis, MO. Elsevier.
Varcarolis, E. M & Halter, M. J. (2010). Foundations of Psychiatric Mental Health Nursing (6th
ed.). St. Louis, MO: Elsevier