Danielle McMinn Case Study 1

Danielle McMinn
Case Study
Youngstown State University
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Abstract

I had the opportunity to observe and interact with a female patient today at Trumbull

Memorial Hospital that suffers from schizoaffective disorder and bipolar disorder. In the

following pages, I will explain the behaviors that I observed during clinical and any medical

conditions and treatments this patient had. I had the opportunity to explore the patients chart to

get more accurate information when needed. I will also summarize the diagnosis of this patient

and discuss any risk factors associated with this diagnosis that could potentially relate to this

patient. I will talk about this patient’s religious views that could impact her. I will address the

patient’s steps and plans for discharge from the hospital. Lastly, I will emphasize on possible

solutions for the problems that could arise in the future.

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Objective Data-

On 08/29/17 a 58-year-old Caucasian female with gray hair and bright blue eyes was

admitted to the locked psych unit involuntarily at Trumbull Memorial Hospital in Warren, Ohio

through the emergency department. She currently lives in a nursing home that she says she

doesn’t feel safe at. She presented to the emergency department due to choking another resident

at the nursing home. She appeared very agitated in ER.

This patient has been previously diagnosed with schizoaffective disorder and bipolar

disorder. She also has a medical diagnosis of hypertension, MS and hypothyroidism. She was

also diagnosed with ADHD growing up as a child. All of her vital signs as of morning were

within normal limits. Her lab values of valproic acid and TSH were within the therapeutic range.

Her t4 level was decreased at 1.3 due to hypothyroidism. Her medications are Invega 3 mg every

morning for her psychosis, Cogentin 0.5 mg twice a day for a preventive measure of EPS

symptoms and Depakote 750 mg daily for her bipolar disorder.

I provided care for this patient on Wednesday, 10/25/17. She appeared her age, and

dressed very neat, wearing long pajama pants with a blue sweater. She was alert and oriented x3.

She appeared very sad and down and out at first. She did not come out for breakfast for awhile to

eat. After she finally came out, she started to eat very slowly, and I started to communicate with

her. At this point, she did a lot of blocking and would not give me any info, stating that she

couldn’t tell me any information or details. She used a lot of simple words and kept the

conversation curt. As time passed and she gained some trust of me, she started to open up with

me and told her story of what happened and why she was there. Her facial expressions were very

animated throughout the conversation. She seemed very relaxed and was very friendly. To
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ensure the patients safety as well as the rest of the floors, safety suicide precautions and unit

restrictions were in place.

Summarize-

The patient was diagnosed with bipolar disorder. According to the DSM-5 bipolar

disorder has nine descriptors. The first is with anxious distress such as feeling keyed up or tense,

unusually restless, difficulty concentrating because of worry, or feeling on the edge of self-

control. The second is with mixed features or depressive symptoms during a manic, hypomanic

episode, or hypo/manic symptoms during a depressive episode. The third is with rapid cycling,

this means four or more episodes of any kind within a twelve-month period. Ultradian cycling is

when moods fluctuate quickly within the course of the day. The patient in this case study most

closely exhibited this set of features for bipolar disorder as she would rapidly fluctuate from

keyed-up to withdrawn and quiet. For the most part, she didn’t show a lot of symptoms of

bipolar when I was conversating with her. She made a comment that she could tell that the new

meds were working for her and she was happy about that. The rest of the descriptors were

catatonic features, psychotic features, melancholy features, atypical features, seasonal pattern, or

peripartum onset (Forbes, 2015).

This patient had ADHD when she was a child, but says as she grew older, it faded away.

She did not present any symptoms of ADHD when I observed her on clinical day. There is research

being done looking for links between childhood ADHD developing into bipolar disorder in

adulthood. According to Chen et al, “Patients with comorbid diagnoses of major depression and

ADHD had an increased risk of diagnostic conversion to bipolar disorder compared to those who

had major depression alone” (Chen, 2015). This link between the two psychiatric issues could

explain a lot of behavior and emotional issues seen in children with ADHD as they grow up, like
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the patient in this case study. Although the link between the two is in no way proven to be

correlated, it is an interesting thought since the neurotransmitters related to ADHD and bipolar

mania are the same.

Also, she is diagnosed with schizoaffective disorder. In the Diagnostic and Statistical

Manual of Mental Disorders, fifth edition, an effort is made to improve reliability of this condition

by providing more specific criteria and the concept of Schizoaffective Disorder shifts from an

episode diagnosis in DSM-IV to a life-course of the illness in DSM-5. When psychotic symptoms

occur exclusively during a Mood Episode, DSM-5 indicates that the diagnosis is the appropriate

Mood Disorder with Psychotic Features, but when such a psychotic condition includes at least a

two-week period of psychosis without prominent mood symptoms, the diagnosis may be either

Schizoaffective Disorder or Schizophrenia. In the DSM-5, the diagnosis of Schizoaffective

Disorder can be made only if full Mood Disorder episodes have been present for the majority of

the total active and residual course of illness, from the onset of psychotic symptoms up until the

current diagnosis (Elsevier, 2013).

Identify-

She was brought to the emergency department via ambulance on August 29th. She has

several life stressors, one being that her children don’t come and visit her in the nursing home.

Patient stated that she hasn’t even got to meet her grandchildren, and it really bothers her. She

stated that she has no one and has nothing anymore and nobody cares. Another stressor she claims

is that she got raped by her father when she was 9 years old and she can remember every detail of

it. These events haunt her all the time. She describes the incident at the nursing home as followed,
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“I started to barricade myself in the bathroom with forks and knives and thought about killing

myself because I have nobody, and nobody cares about me but mostly because Jesus tells me that

someone is out to get me and is going to kill me, so I thought why wait for it to happen. What

really set me off was there is a resident that lives next door to me and I choked her because Jesus

told me to do it. Jesus told me that she is evil, and she needed to die right away. I hear voices tell

me all the time that I’m going to die soon, and someone I love near is going to do it and the only

person I can think of would be my ex-husband who wants to marry me again, but I refuse to do so.

I really think people are out to get me and I don’t know why. This is all what led me here”.

When questioned about what kind of coping strategies she used or plans to use to prevent re-

admission she responded with music. This began to make her very happy because it is something

that she loves. Country and Gospel are her two favorites to listen to. She states that hearing

something she loves relaxes her and calms her down. She also stated that she loved to walk and

take deep breaths when walking. She states that these three coping mechanisms have helped her

in the past and she continues to use them in the future. The combination of trauma as a child with

rape, stress from her family that doesn’t visit her combined with a history of a bipolar disorder,

schizoaffective disorder, and auditory hallucinations/delusions (paranoid & religious) led to the

incident that resulted in her stay at this facility.

Patient/Family History-

The patient had very little family history in her chart, however I got a lot of information

from her directly. Both mother and father have a history of hypertension and cardiac disease. Her

father was also diagnosed with bipolar disorder. She stated that she grew up in a childhood
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watching her father beat her mother for years upon years. Patient also states that she got raped by

her father at 9 years old in a garage and she remembered every detail and believes she is scarred

for the rest of her life from that. Patient has a history of bipolar disorder, ADHD when a child and

schizoaffective disorder. Patient currently lives in a nursing home in Mineral Ridge, however due

to the incident, she is no longer permitted back there and currently social services is searching for

a nursing home with an open bed, which is why she has been there so long. Patient is currently

unemployed and received Social Security. Her highest education is college with an associate’s

degree in English. She used to be an English teacher. Patient is divorced x2, however states that

her recent ex husband wants to get remarried in November.

Describe Psychiatric Evidence-

Psychiatric care on the floor includes a doctor who oversees the whole floor, nurse

practitioners, a milieu therapist, nurses, health care associates, activities directors, and a dietician

if needed since many psychiatric medications can cause weight gain. The milieu therapy on the

floor includes plastic silverware that does not include a butter knife and it gets counted after each

patient’s meal. The rooms all have beds that are low to the ground and bolted down so the patients

cannot lift them or hurt themselves by falling out of them. The mirrors in the room are not made

of glass so they cannot shatter them to cut themselves or other patients with it. There plastic bags,

only brown paper bags, for the trashcans so they cannot suffocate themselves with the bags. The

closets in the room are not tall enough to hang themselves from. There is also rounding every

fifteen minutes by either a health care associate or a nurse to ensure that the patients are all safe if

they are not in the common area which has cameras to monitor what the patients are doing. In the

common area there are plants for the patients to water and enjoy. There are also coloring pages,
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checkers, Uno, puzzles, two televisions, and word searches to help calm the patients and occupy

their minds while on the floor. There is also an outdoor patio with very high walls so there is no

risk to the patients when they are enjoying the weather. On this floor they also provide several

different types of group therapies run by the nurses to answer questions and educate about

medications and diagnosis, groups run by the activity director to go over different topics like

coping skills, stress management, assertiveness training, etc. and finally they offer spiritual

counseling for those who want it. On the day of care the patient attended the one group run by the

activities director about coping skills and my patient was very into it because the activity director

put on some country music while they were filling out their papers and she sang along and looked

like the happiest woman alive!

Analyze Influences on Patient-

Although she is no longer a practicing member of the Catholic church, she still attends a service

that is provided at the nursing home, along with mass. She grew up in the church and when she had children,

she stopped going due to life getting in the way, however after her kids got older, they all went together.

Her views on mental health are that her childhood has a lot to do with it, as well as her father’s history.

Evaluate Patient Outcomes-

The goal of all nursing treatment is to reduce, or control symptoms associated with

disorder, improve function, and avoid relapse. Nursing priority care is patient safety due to suicide

ideation of forks and knives in the bathroom. Her anger issues would need to get in control, but it

is not something she could not do if she was putting effort into it; patient stated that she feels very
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much better and she can tell that her meds are working for her for her bipolar and thought process

(schizoaffective).

Summarize Discharge Plan-

The patient will be discharged back to a new nursing home where they will give her

medications. She will be under the care of a psychiatrist who will continue to prescribe her Invega

and Depakote which are both PO. Further group therapy would be helpful especially regarding

anger. The patients plan for discharge include taking my medications as prescribed, doing a lot of

the coping skills that I learned in group here and hopefully to stay the way I feel now, which is

happy!

Prioritized List of Actual Diagnoses-

Impaired coping related to excessive hyperactivity and agitation

Impairment of social interaction related to social interaction skills

Disturbed sleep pattern related to hyperactivity

Altered thought/sensory process related to inability to evaluate reality

Potential Diagnoses-

Risk for injury

Risk for imbalanced nutrition less than body requirements

Self-care deficit
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References

Chen. (2015). Comorbidity of ADHD and subsequent bipolar disorder among adolescents and young adults

with major depression: a nationwide longitudinal study. International Journal of Psychiatry and

Nuerosciences, 315-322.

Elsevier. (2013). Diagnostic criteria for 295.70 Schizoaffective Disorder [Abstract]. Diagnostic

and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR),

21-25. doi:10.1176/appi.books.9780890423349.9152

Forbes, E. (2015, June 1). 9 Descriptions for Bipolar Disorder (According to the DSM-5).

Retrieved from Bphope.com: https://www.bphope.com/9-add-on-descriptions-for-

bipolar-disorder-according-to-the-dsm-5/