Running Head: MENTAL HEALTH CASE STUDY 1

Mental Health Nursing Case Study

Marium Khan

Youngstown State University

MENTAL HEALTH CASE STUDY 2

Abstract

This paper explores the experiences of an individual who is a patient on the psychiatric unit at

Trumbull Memorial Hospital. This snapshot will include information about the patient’s

background as it was told by the patient and as it appears in his chart at Trumbull Memorial

Hospital. This report will also list and define psychiatric diagnoses pertinent to this patient and

his situation at the time immediately prior to and during admission. I will also discuss potential

diagnosis related to this individual, stressful events and patient activities that precipitated and

necessitated this admissions are identified as well. Additional areas discussed include the

patient’s history of mental illness, family members with a history of mental illness, and ethnic,

spiritual, and cultural influences that impact the patient.

MENTAL HEALTH CASE STUDY 3

Objective Data

The patient, H.A, is a thirty-six-year old male that was admitted to the psychiatric unit on

February 13, 2019 by ambulance because he was having suicidal thoughts. The patient presented

with a history of psychiatric history of depression, paranoia, and schizophrenia. Other medical

history included hyperlipidemia. Once at the hospital, the patient stated that they had been

having suicidal thoughts for the past two months with no plan prior to this current event. The

patient has had two previous attempts at suicide. The first attempt took place in 1996 where he

attempted to commit suicide but failed because he “fell out of the noose.” The second attempt

took place in 2002 where he attempted suicide in an identical manner to hang himself but failed

this time because his mother stopped him. The patient stated that these thoughts precipitated

because of his paranoia. He believes that people think negatively of him and talk negatively

about him behind his back. He thinks they are making fun of him. He states that because of his

paranoia he is constantly worried about what people think about him. The patient stated that he

hears voices telling him to hurt himself and “wrap a cord around his neck and choke himself”.

The voices not only tell him to hurt himself but to also hurt others. While reviewing the patient’s

chart for previous command hallucinations, the notes revealed that he has the urge to hurt others

that make fun of him. In the notes, it was recorded that the patient stated, “people are making fun

of me.” The voices telling him to hurt others stopped as soon as group was over. The patient

stated that he does not do well with large groups of people and feels overwhelmed. When

interviewing the patient on the psychiatric floor he states that he no longer had the thoughts of

paranoia that were leading to command hallucinations telling him to hurt himself and others. He

stated that he was feeling better today and had no intention of committing suicide again. He is

aware of this self-issue and is also aware of what needs to be done in order to get better. When
MENTAL HEALTH CASE STUDY 4

interviewing the patient on the floor, he appeared calm and relaxed, sitting with a slouch with

unkempt hair and a beard. His emotions when telling me of his history were fixed and he had a

flat affect. He had an overall friendly persona and did not exhibit any abnormal motor activity

when sitting or speaking to me. However, the patient seemed isolated during group and during

free time when they were able to socialize. The patient did have delayed speech and displayed

cognitive delay. He also repeated the use of many words when explaining his situation. He stated

that certain stressors in his life such as his parent’s death, his neighbor’s death, hearing of

celebrity deaths in the news lead to him entertaining thoughts of suicide.

The patient lives at home alone, has never been married, has one brother, and has a good

support system consisting of going to counseling. His history revealed that he had been

emotionally and verbally abused by his father. He has been compliant with his medications at

home taking his prescribed medications. At home he is prescribed several medications that he

takes currently on the psychiatric floor. On the psychiatric floor the patient was prescribed

paliperidone (Invega), an antipsychotic, 3 mg by mouth two times a day to manage his symptoms

of schizophrenia, fluoxetine HCL (Prozac), an antidepressant, 40 mg by mouth every morning to

decrease his depression, haloperidol (Haldol), and antipsychotic, 5 mg by mouth or 5 mg

intramuscularly every six hours or as needed to manage his symptoms of schizophrenia,

hydroxyzine HCL (Atarax/Vistaril), an antipsychotic, 50 mg by mouth or 50 mg intramuscularly

every six hours or as needed to decrease his anxiety, trazodone (Trazodone), an antipsychotic, 50

mg by mouth at bedtime or as needed to decrease his anxiety, and lastly paliperidone palmitate

(Invega Sustenna), an antipsychotic, 234 mg intramuscularly every 30 days to manage his

symptoms of schizophrenia. When talking to the patient, he stated that he had multiple coping

mechanisms to distract him from the hallucinations he has. Some of his coping mechanisms were
MENTAL HEALTH CASE STUDY 5

writing Bible study notes, listening to jazz music, watching tv shows and movies, attending

church and is a part of the church choir. This patient has also had previous psychiatric

hospitalizations before at Trumbull Memorial Hospital, St. Elizabeth, Windsor Laurelwood, and

at Riverbend Center.
MENTAL HEALTH CASE STUDY 6

Summarize

The patient, H. A., was diagnosed with Schizophrenia, paranoia, and depressive disorder.

Schizophrenia is defined as “a severe and chronic mental disorder characterized by disturbances

in thought, perception and behavior” (Hurley, 2018). Paranoia is defined as “a term that implies

extreme suspiciousness. In schizophrenia, paranoia is characterized by persecutory delusions and

hallucinations of a threatening nature” (Townsend, 2018). Lastly, depression is defined as “an

alteration in mood that is expressed by feelings of sadness, despair, and pessimism. There is a

loss of interest in usual activities, and somatic symptoms may be evident. Changes in appetite

and sleep patterns are common” (Townsend, 2018). The symptoms common with schizophrenia

are broken into two categories, positive and negative symptoms. Positive symptoms of

schizophrenia include delusions or hallucinations. Negative symptoms of schizophrenia take

away a feeling or ability that is normally present in most people, but is now missing. These

negative symptoms include avolition (lack of motivation), anhedonia (inability to experience

pleasure), apathy (lack of concern for self or others), alogia (reduction in speech), and affective

flattening (absence of emotional expression) (Cagliostro, 2019). My patient presented with both

negative and positive symptoms of Schizophrenia. When interviewing the patient I was able to

see negative symptoms such as the flat affect he had when describing his past suicidal efforts as

well as his parent’s death. He also presented with positive symptoms. In his chart it was recorded

that the patient had command hallucinations to hurt himself and others around him that were

making fun of him. In a research study conducted by Fusar-Poli et al in 2014, they were trying to

determine if the current treatment strategies that are available for schizophrenia today can also

combat the negative symptoms. The positive symptoms of schizophrenia are more readily treated

by medication available today, but the negative symptoms are much harder to treat.
MENTAL HEALTH CASE STUDY 7

Unfortunately, their research found that there are still no clinically effective treatments for

negative symptoms, which are when paired together with cognitive impairment, the most

disabling features of schizophrenia (Fusar-Poli et al, 2014).

Schizophrenia can be caused by many things and in my patient’s charts, it was stated that

he had a history of smoking. A study was conducted to determine if there was any correlation

between smoking and developing schizophrenia. There have been reports of psychotic symptoms

developing from the use of cigarettes, but it was assumed that people take up smoking as a

coping mechanism for the psychiatric symptoms that they are dealing with otherwise. In the

study, it was founded that “57% of people having a first episode of psychosis were smokers”

(Hawkes, 2015). There was also an increased risk of schizophrenia in daily smokers. While the

patient did not disclose how often he smoked or whether he had quit smoking, it was interesting

to see the correlation between the two factors.

The medication regimen that the patient is on is to help him control the symptoms of

schizophrenia to lead a somewhat normal life. An interesting drug that the patient is on currently

while admitted to the psychiatric unit and while at home is paliperidone palmitate (Invega

Sustenna), an antipsychotic, 234 mg intramuscularly every 30 days to manage his symptoms of

schizophrenia. This is considered a long-acting injectable antipsychotic. They have many

advantages which include “not having to remember to take the drug daily, reducing the risk of

unintentional or deliberate overdose, and transparency of adherence” (Brissos et al, 2014). There

are disadvantages to giving a long-acting injectable antipsychotic, such as a slow dose titration

and the long time required to achieve steady state levels (Brissos et al, 2014). These

disadvantages mostly affect acutely ill patients. During the interview process with the patient, he

states that he was compliant with all his medication. This type of administration route is reserved
MENTAL HEALTH CASE STUDY 8

to keep compliance with patients that have a habit of discontinuing their medications themselves.

Along with the intramuscular version of Invega, a long-acting injectable antipsychotic, the

patient was also prescribed the oral route. Through this research, it was concluded that long-

acting injectable antipsychotics are more adventitious than the oral version of the same

medication, was that there was a decreased risk of relapse and dropout for inefficacy (Brissos et

al, 2014).

Suicide is a relevant leading cause of death among patients affected by schizophrenia.

The patient was admitted to the psychiatric unit for risk of suicidal thoughts. He had had 2

previous attempts at suicide all attempted in identical ways. The suicidal thoughts plaguing the

patient this time were identical to the last 2 attempts. According to the research conducted by

Ventriglio et al in 2016, they identified several psychotic symptoms such as suspiciousness,

paranoid delusion, mental disintegration and agitation, negative schizophrenic symptoms,

depression and hopelessness, and command hallucinations to be associated with higher risks of

suicide. The patient has a history of paranoia and command hallucinations. This puts him at an

increased suicidal risk. The research went on to state that patients that had auditory

hallucinations, such as this patient, their risk for suicidal ideation is associated with twofold the

risk. The patient had attempted suicide once in 1996 where he was unsuccessful because he fell

out of the noose, and again in 2002 where was unsuccessful because his mother stopped him.

Recently he had suicidal thoughts but no plan of action other than command hallucinations

telling him to “wrap a cord around his neck and choke himself.” He also had the thoughts of

hurting others who talked negatively about him during group sessions. He was very

uncomfortable during these group session because he believed that people were making fun of

him. The research journal explains that patients with a history of suicidal attempts suggests an
MENTAL HEALTH CASE STUDY 9

increased risk of suicide since it is supposed to be a strong predictor of later attempted or

completed suicides (Ventriglio, 2016). Furthermore, the research study states that negative

symptoms [of schizophrenia] may increase suicidal ideation. There are other factors that

predispose a patient to an increased risk to suicidal ideation and an attempt at suicide. The

research conducted found that “83% of these patients had been exposed to at least one stressful

event during their lifetime and 34% of them to physical and/or sexual abuse” (Ventriglio, 2016).

The patient, H. A., has suffered from emotional and verbal abuse from his father as a young

child. This also contributed to the increased risk of attempting suicide.

MENTAL HEALTH CASE STUDY 10

Identify

Upon questioning the patient about the stressors in his life, he listed several issues

revolving around one common theme: death. The patient was stressed about multiple deaths

occurring too close to each other and in turn he did not have the appropriate time to grieve for

one death before another would occur. He stated that he had lost his parents, his mother was a

big support in his life before she passed away. Not too long after his parent’s death, his

neighbors passed away. This led to more grief the patient had to deal with paired with grief that

he had not yet resolved. Celebrity deaths on the news also affected him to have an increase in

suicidal thoughts. The patient was in grief overload and had no way to deal with all the grief he

was exposed to. This led him to call for an ambulance to be taken to the hospital to help him for

having the suicidal thoughts he was having.

Another stressor identified by the patient was people. He stated that he was

uncomfortable around people and did not do too well in large groups. He suffers from paranoia,

so he tends to think that people are making fun of him and do not value his input in group

discussions. When posed with group activities, he tends to isolate himself and remain quiet. In

the patient’s chart, when he was first admitted and attended group, he admitted to wanting to hurt

those who made fun of him. On the time of care and when I interviewed the patient, I spoke with

him about his paranoia and he replied that he was doing much better and no longer felt anxious

going to group. He no longer felt as if people were making fun of him.

The patient did state the he has many coping mechanisms such as writing bible study

notes, listening to jazz music, watching TV and movies, and attending church.
MENTAL HEALTH CASE STUDY 11

Discuss

As mentioned in a previous section, the patient suffers from schizophrenia, paranoia, and

depressive disorders. The patient’s chart stated that he was also hyperlipidemic for which he was

taking atorvastatin 20 mg by mouth every day for management of the symptoms. The patient has

depression and he stated that being depressed makes him feel “kind of like a roller coaster.” He

is very paranoid about what other people think about him.

The patient’s parents are dead and only his brother remains. He used to live with his

mother before she passed away. He does not keep in touch with his brother. His mother had a

history of diabetes mellitus and his father had a history of hypertension and suffered a

myocardial infarction. The patient has never been married. He states he is currently retired. His

chart history revealed that he attended college for two years but dropped out for unmentioned

reasons.

The patient was aware of his diagnosis and was also aware of what needed to be done in

order to get better. He stated he had plans upon discharge to go back to church and even try to

attend school again to become a minister for his church. He had goals in mind for himself and

told me that he knew he had to be compliant with the medication in order to control his

schizophrenic symptoms.
MENTAL HEALTH CASE STUDY 12

Describe

The patient attended group therapy that was conducted by a nurse. During group therapy,

the patient remained in his seat and was quiet throughout the session. The group therapy session

that he attended was focused on short and long-term goals that they had. He stated that he did

not share his goals with the rest of the group attendees. When I talked to him afterwards, he

talked freely to me about his future goals and what he wanted to accomplish. Later, when I

looked in his chart, I was able to see how well he performed in group therapy sessions in the

past. When the patient was first admitted onto the psychiatric unit, he was very antisocial and

isolated. He had the idea that people in group were talking about him. He had the urge to hurt

those that talked bad about him. As his stay in the psychiatric unit progressed, he became more

and more comfortable with attending group and the day prior to the date I took care of him, he

stated to that he no longer felt anxious attending group sessions. He was able to sit through group

without feeling like “people were out to get him.”

Evidence based nursing care provided for the patient was keeping him compliant with his

medication routine. He has stayed compliant in taking his medication while on the psychiatric

unit and has been known to be compliant with his medication at home as well. Also, because this

patient has expressed past suicidal attempts and this admission was based on his increased risk

for suicide, frequent visualizations and behavior contracts may be extremely efficient in caring

for this patient.

MENTAL HEALTH CASE STUDY 13

Analyze

The patient is an African American male. He is very spiritually oriented and listed going

to church as one of his coping mechanisms along with writing down Bible study notes. He

expressed his future goals of going back to school and pursuing a degree in religious studies to

become a church minister. He identified this as one of his support systems and refers to the Bible

frequently.

Evaluate

The main goal set for the patient on the day of care was that he would be kind to others

and refrain from having suicidal thoughts. The patient was able to socialize with another patient

during lunch time as I was leaving for the day. As I was leaving for the shift, I asked the patient

how he was feeling socializing and eating his lunch and he stated that he “felt better than

yesterday.” The patient was also under frequent visualization. Therefore, the goal was met for

the day. The patient was able to be kind to others by socializing with one other patient during

lunch time and refrained from having suicidal thoughts when I checked on him as I was leaving.

Summarize

Upon caring for this patient, discharge planning had begun. The patient was referred to

go to Riverbend, a residential facility that provides crisis stabilization for persons experiencing

or recovering from a mental health crisis and is in need of an intermediate level of care.

However, the patient stated that he does not want to go to Riverbend and instead would like to go

back home where he was living alone prior to admission. The patient is already familiar with the

medications he has been receiving on the unit and has been prescribed them for home use in the

past. Discharge will now solely be decided on the patient’s participation in group therapy.
MENTAL HEALTH CASE STUDY 14

Prioritize

Because of this several different diagnoses of the patient, there's also a substantial

amount of nursing diagnoses applicable to caring for this individual. Following will be a

prioritized list of those diagnoses from highest priority to lowest.

1. Risk for self-harm related to recent suicide attempt as evidenced by vocalized intent,

command hallucinations, and previous attempts to do so.

2. Altered sensory perception related to hallucinations as evidence by command

hallucinations to self-harm and harm others.

3. Risk for behavior that patient can be physically harmful test self, related to depressed

mood as evidenced by suicidal ideations.

4. Anxiety related to situational crises as evidenced by verbalizing paranoia when

attending group activities.

5. Ineffective coping related to self-harm activities as evidenced by command

hallucinations to self-harm and hang oneself.

6. Social isolation related to paranoid negative thinking as evidenced by delusional

thinking and come and hallucinations to hurt self and others

7. Hopelessness related to loss of significant support systems as evidenced by loss of

parents, neighbors, and other significant deaths.

MENTAL HEALTH CASE STUDY 15

List

Potential nursing diagnosis not listed above would be those affiliated with schizophrenia

and depressive disorders.

1. Risk for self-inflicted life-threatening injury related to depressed mood and

schizophrenia as evidenced by suicidal ideations

2. Anxiety related to diagnosis of schizophrenia as evidenced by paranoia

Conclusion

Upon ending the day of care with this patient, it was clear that the patient understood for

what purpose he was ther and what he would need to do in order to achieve his long-term goals

and get his disorder under control. The most important aspect of his care aside from suicide

prevention was to reintegrate him into a social setting. He was isolated during his stay on the

psychiatric unit and was solely starting to get back out of his shell on the say I was leaving. It is

important to reintegrate him into a social setting so that he can expand his circle of support

systems and prevent the cycle of loneliness. If the patient builds is stronger support system by

socializing, he can receive extra help to keep up with his medications, his counseling, and see

some progression in maintaining his condition.

MENTAL HEALTH CASE STUDY 16

Reference Page

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injectable antipsychotics in schizophrenia: A critical appraisal. Therapeutic Advances in

Psychopharmacology,4(5), 198-219. doi:10.1177/2045125314540297

Cagliostro, D., PhD. (2019). Schizophrenia Symptoms and Diagnosis. Retrieved from

https://www.psycom.net/schizophrenia-symptoms-diagnosis

Fusar-Poli, P., Papanastasiou, E., Stahl, D., Rocchetti, M., Carpenter, W., Shergill, S., &

Mcguire, P. (2014). Treatments of Negative Symptoms in Schizophrenia: Meta-Analysis

of 168 Randomized Placebo-Controlled Trials. Schizophrenia Bulletin,41(4), 892-899.

doi:10.1093/schbul/sbu170

Hawkes, N. (2015). Smoking cigarettes may increase risk of schizophrenia, study shows:. Bmj.

doi:10.1136/bmj.h3773why doesn't say 17 when I only have 610

Hurley, K., LCSW. (2018). What is Schizophrenia? DSM-5 Schizophrenia Definition &

Symptoms. Retrieved from https://www.psycom.net/schizophrenia-dsm-5-definition/

Townsend, M. C., & Morgan, K. I. (2018). Psychiatric mental health nursing: Concepts of care

in evidence-based practice (8th ed.). Philadelphia, PA: F.A. Davis Company.

Ventriglio, A., Gentile, A., Bonfitto, I., Stella, E., Mari, M., Steardo, L., & Bellomo, A. (2016).

Suicide in the Early Stage of Schizophrenia. Frontiers in Psychiatry,7.

doi:10.3389/fpsyt.2016.00116