Running Head: MENTAL HEALTH CASE STUDY
Mental Health Case Study
Jaclyn Rowley
Youngstown State University
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Abstract
Mental illness awareness and education has increased greatly in order to help decrease
the stigma and get patients the help they need and deserve. This case study was conducted
through observation, assessment, interview, health history, and clinical data on a mental health
patient with schizophrenia. Patient RH was admitted to Trumbull Regional Medical Center’s
Emergency Department for exacerbations of his diagnosed schizophrenia with psychosis. His
altered mental status caused him to be a harm to others which caused him to become pink slipped
and admitted to the psychiatric unit. He was diagnosed only two years ago and had been
hospitalized three times since then. The patient is having a difficult time staying at his baseline,
and continues to have heightened instances of psychosis. His baseline exhibited adequate
function of his mental and emotional health as well as good self care and lack of psychotic
events. His current medication regime is not therapeutic, and previous stressors have precipitated
his actions. The goal is to return him to baseline, enhance coping skills, and get him into a group
home to provide him with support and structure.
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Objective Data
Patient RH is a thirty one year-old schizophrenic male with psychosis. He was diagnosed
at the age of twenty-nine. He has had this condition for over two years - meaning he falls into the
bottom third of the disorder. According to the DSM-5, this diagnosis is valid because the patient
displays two or more characteristic symptoms during a one month period. These symptoms
include: delusions, hallucinations, disorganized speech, grossly disorganized behaviors, and
diminished emotional expression (Rockville 2016). During his admission, and throughout the
stay, he was exhibiting these behaviors. He was admitted on August 20th, 2019 and the dates of
care was August 27th, 2019 and September 3rd, 2019. The diagnosis was made once it started to
interfere with his level of functioning with his interpersonal relationships with his family
members, girlfriend, and self-care. It did not affect his work because the patient is unemployed
due to intellectual disabilities. On the first day of care, the patient’s severity was very high. His
Clinician-Rated Dimensions of Psychosis symptom Severity was thirty. On the second day of
care, his severity had greatly decreased. His Clinician Rated Dimensions of Psychosis Symptoms
Severity was fifteen. This shows how variant his schizophrenia progresses.
The patient was sent from Valley Counseling to the emergency department to get an
evaluation. The mother was with him upon his arrival to the emergency department stating: “He
has had three weeks of confusion, with visual and auditory hallucinations, and an unsteady gait.”
His mother is in charge of regulating his medications. He has a good support system from his
mother, step-mother, and father. Upon admission, he was actively hallucinating and displaying
emotions of rage and anger. He was uncooperative and was exhibiting racing thoughts. He was
pink slipped in the emergency department when things began to escalate and he became a threat
to himself and others. He has a history of acute kidney injury, morbid obesity, hernia repair, and
diabetes mellitus. He has an eleventh grade education and is thought to have an intellectual
disability. He denied using tobacco, drugs, and alcohol. His last admission was from September
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of 2018 to October of 2018 and was between Trumbull Regional Medical Center and St.
Elizabeth’s.
The patient is prescribed several different antipsychotics, anticonvulsants, antihistamines,
and sedatives. The patient is also a diabetic, so he is on Metformin 500mg by mouth with meals.
He is taking Depakote 250mg once a day as a mood stabilizer, as well as Cogentin 1mg by
mouth twice daily to help with side effects of Depakote. The patient is on Haldol 5 mg by mouth
at night as an antipsychotic. He has Anipiprazole ordered both as an oral medication, Abilify
10mg by mouth daily, and as an injection Aristada 882mg intramuscularly every thirty days.
Antihistamines are also ordered to help calm the patient when he is acting out or feeling anxious.
These include Atarax 50mg by mouth every six hours as needed, and Vistaril 50mg
intramuscularly every six hours as needed. These medications are all put in combination with
each other to provide a therapeutic effect for the patient and to keep his schizophrenic symptoms
to a minimum.
The patient did not display too many abnormal lab values. His urine ketones showed 5A
due to his diabetes, salicylates were extremely low at 1.7 to show that he did not attempt suicide,
and acetaminophen was below therapeutic range. This could be the reason for the exacerbation
of symptoms. The goal is to get him into the therapeutic range. The patient is on Depakote and
his valproic acid was 44.1 mcg/mL-which is below the therapeutic range of 50-125 mcg/mL. His
drug screens were all negative. His complete blood count was all within normal limits. His TSH
and T4 were not drawn at this time. He did not have ammonia levels, AST, or ALT labs drawn.
His glucose was 128, which is lower than his average of 142. The majority of his lab results were
within normal or therapeutic range.
On the first day of care, the patient was not oriented. His hygiene and appearance was not
well kept; his hair was greasy, his beard was not well kept, he had stains on shirt and pants, and
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he had holes in his socks. His answers to questions were commonly jumbled and did not make
any sense or have any correlation to the topic that was asked about. He could not keep eye
contact during the interview, was soft spoken, and constantly reacting to his internal and external
stimuli. The patient was exhibiting active hallucinations and delusional thinking. He would look
down and to the right when he was hearing voices. When asked what he was hearing he replied:
“Oh, just normal stuff; nothing really important.” He then started to stare at the ceiling stating:
“Those clouds up there are pretty.” When asked to explain the clouds, he drew them with his
fingers. He was constantly tapping his toes, counting on his fingers, and continuously mumbling
under his breath. When asked questions about himself, he was unable to answer with valid
answers. He displayed two illusions during my encounter with him. He saw a nurse’s computer
cart as a dog, and thought the door slamming was a man stomping towards him. He was very
tense, restless, and had racing thoughts. During group, he was unable to truly focus on the paper
and was writing random words for each question. His movements were shaky. He would get very
upset if he was unable to explain himself, and his racing thoughts enhanced. The patient was
only able to get three and a half hours of sleep. Very minimal information was received
throughout my first day of care, but he did state that his mother and girlfriend are a great means
for support.
The second date of care was exceptionally different. His hair, and beard were well kept,
and his clothes were clean and matched. He was able to form coherent sentences. He displayed a
sense of humor and could carry on a conversation without any issues of distraction or racing
thoughts. He was able to talk about his support system. He explained: “When my mom doesn’t
support me as much, I know I deserve it.” His mother was very adamant on getting him into a
group home to give him more interactions with others. The patient talked about his siblings, his
dogs, and his favorite places to get a bite to eat. He was relaxed, animated, well dressed, and
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friendly. During groupm he was easily able to answer questions and participate in the activities.
He displayed minimal instances of hallucinations or delusional thinking. He denied any suicidal
or homicidal ideations, and his anxiety and depression were minimal. The patient was still not
able to rest well at night. Overall, he made a total turn around and was doing well on his
medication regime. He stated, “The unit does a great job here. This is the best I have felt in like
four days.” His actions, mannerisms, and communications had greatly improved within a week
period.
Summarize
The patient’s psychiatric diagnosis is schizophrenia with psychosis. Schizophrenia is a
brain disorder that distorts the way a person thinks, acts, expresses emotions, relates to others,
and perceives reality (NAMI 2019). Eugen Bleuler coined the term “schizophrenia” in Greek; it
translates to “split mind.” Schizophrenia is the cause for longer hospital stays, greater family
issues, increased cost to manage, and a larger fear and stigma than others. Causative factors
include genetic predispositions, biochemical dysfunction, physiological factors and psychosocial
stress (Townsend and Morgan 2017). RH is caused by a mixture of biochemical dysfunction,
physiological factors, and psychosocial stress. This illness is commonly diagnosed in a person’s
twenties, which is the case for RH (NAMI 2019). There are four phases: the premorbid phase,
which is just distinctive changes in personality traits or behaviors, the prodromal phase, that has
more clearly manifestes signs of the disease, schizophrenia, which is the active phase of the
disorder with psychotic symptoms, and then the residual phase which is characterized by times
of remission and exacerbation (Townsend and Morgan 2017). During admission, RH was in the
schizophrenia stage. He stayed in the residual phase, going in and out of remission and
exacerbation, throughout his stay. Drug abuse can also be a factor with schizophrenia, but not in
RH’s case. There are also forms of positive symptoms (which include delusions and
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hallucinations) and negative symptoms (which affect a person's affect, emotions, and
interpersonal functioning) (Townsend and Morgan 2017). RH has schizophrenia with psychosis.
This is a severe mental condition in which there is disorganization of the personality,
deterioration in social functioning, and loss of contact with reality (Townsend and Morgan
2017). RH shows psychosis when he continually has delusions and hallucinations and is in his
own little world. Schizophrenia is not a treatable disease, but it is a manageable disease that
causes a need for compliance for a lifetime. Patients may need rehabilitation, constant
psychosocial care, family therapy, and pharmacotherapy (Townsend and Morgan 2017).
Potential for suicide is a major concern for these patients, but RH denies any suicidal or
homocidal ideations. He calls himself “a happy little schizophrenic.”
Identify
RH was admitted to the hospital due to exacerbations of delusions, hallucinations, and
loss of reality. He lost the ability to take care of himself, became agitated, and began to act out.
His mother takes care of him at home and helps him with medication compliance. The patient’s
stressors that have precipitated his current admission is his parents’ divorce, change in housing
arrangements, and upset from previous counseling sessions.
The patient was not pleased with his parents’ divorce, but loves his mother, father, and
step-mother. This stressor was brought up several times during the second day of care. He has
not fully coped with the fact that his parents were separated and he feels guilty that his mom has
not found a significant other. The patient stated: “I know I’m the reason she can’t find love. She
cares too much for me and puts me before herself.” This amount of guilt heightens his emotions.
In return, this is increasing his internal stimulation and causes him to have exacerbations of his
schizophrenia and psychosis (Cocoran and Malaspina 2008). Enhancing his coping techniques
will help him to avoid exacerbations of his condition.
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The patient is also back and forth between his father's house, mother’s house, and in and
out of group homes. He has recently tried to stay at his dad’s house more often to allow his
mother to have a more social life. His father is not as supportive as his mother. The step-mother
has done her best to support him and keep up with his medications, but this transition has been
difficult for the patient and the family. If medications are not taken properly, it can cause an
exacerbation of schizophrenic symptoms which lead him to this admission. His mother wanted
more independence for him and tried getting him into a group home - which is also a big
adjustment for a schizophrenic patient. The mother admits that he did very well in a group home
and wants him to be discharged into a group home.
The patient was sent to the emergency department from a counseling session with Valley
Counseling. The counseling session can bring up instances that stress the patient out as well. If
the patient becomes triggered during this session, it can cause him to shut down and go into
psychosis. I was unable to ask what information was discussed during the last counseling
session. The patient’s coping mechanisms have many faults that make it hard for him to deal
with stressors (Cocoran and Malaspina 2008). It is important during this stay to enhance his
coping skills and to address these stressors.
Discuss
The patient has only been diagnosed with schizophrenia with psychosis for two years.
This is a pretty new diagnosis for the patient. This is the third time he has been hospitalized for
this illness. Although he has only been diagnosed for two years, there has been evidence showing
he may have had altered thought processes in the past. He struggled in school because he
constantly wanted to “mess around with friends.” His actions throughout high school mirror the
symptoms of compulsive behaviors, disorganized behavior, and excitability. He also did not
graduate from school and is thought to be intellectually challenged which exhibits the symptoms
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of confusion, memory loss, incoherent speech, and poor thought process. He also explains how,
in high school, he would get in fights and arguments with teachers - often displaying anger,
elevated mood, and inappropriate emotional response. This could be considered the premorbid or
prodromal phase. These may have been signs of negative symptoms of schizophrenia that then
caused the transition into positive symptoms of hallucinations and delusions. A diagnosis of
mental illness is not made until it affects a person's physical, mental, or emotional function.
These symptoms were interfering with his school work, his interactions with others, and his
emotional stability.
His family does not have any history of mental illness. No family members have ever had
a drug or alcohol addiction, nor used drugs or alcohol as a means for coping. His parents do not
display good coping skills. His father is not very supportive to the patient and his mother is
unable to move on after her divorce. This proves there are some coping issues. His father
displays a stigma towards mental illness. The patient’s siblings interact with him well and are
very supportive to him. His grandparents are deceased and he did not speak of any aunts, uncles,
or cousins. It is unknown if mental health is present in any distant family members.
Describe
The main goal for a psychiatric unit is to keep the patients and staff members safe. The
patient was kept on a locked down psych unit. Fifteen minute checks were done continuously
and elopement risk precautions were put into effect, along with both low and high risk suicide
precautions depending on the escalation of his condition. He was also under a generalized
psychiatric precautions ensuring safety throughout the whole unit. All doors on the units are
locked. All knobs, shower nozzles and faucets are angled so a patient cannot hang themselves on
them. The doors are soft magnetic doors that fall off when weight is applied to them. All
windows are screened in, the toilets are blocked in, the mirrors are made of polished steel, the
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beds are secured into the floor, the call light does not have a long cord, there are no pictures
hanging on the walls, the nurses station is windowed in with bullet proof glass, and all patients’
belongings are gone through. Patients are not allowed to have any strings, sharp objects, large
shower care bottles they can hide things in, or anything that can be a weapon or a threat to the
patient themselves or others.
The nursing care provided is based on assessment, medication passes, and observation.
Nurses assess patients every shift to note any changes in a patient's status. Nurses ask if they are
currently feeling suicidal or homicidal, what level their anxiety and depression is, and if they
have any questions and concerns about their plan of care. The nurse helps to regulate
medications and keep the patient therapeutic. If the patient starts to act out, they have the right to
force meds to ensure the patient’s safety and the safety of others. The nurse must continuously be
observing all the patients and spotting tensions and issues in the early stages to prevent them
from growing out of proportion. Observation is the biggest part of psychiatric nursing. Nurses
look for how patients interact with each other, as well as how they walk, speak, and present
themselves.They observe how much they sleep, search for present external stimuli, and see if
they are displaying some anxiety or isolation. Psych nurses are the encourager to make sure
patients are staying on track, going to group, learning good coping techniques, and making good
decisions. They also are the biggest advocates to do and provide what is best and right for each
individual patient. The nurses also work alongside the doctors, therapists, and social workers to
ensure they are getting all the appropriate information they need. The nursing staff is what makes
the psych unit so therapeutic and helps the patients learn skills and the decision-making that will
allow them to be discharged.
The milieu therapy of the unit includes warm, beige colored walls and carpeting to feel
more homey. There is a large common space that allows for patients to interact with others, or to
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be alone doing activities by themselves. The area also has a large amount of windows which
provides light to help increase good moods. The patio is enclosed for safety, but on nice days
allows patients to get fresh air and natural sunlight for vitamin D. The PICU is available to
ensure the safety of the patients, but is only locked down when absolutely necessary to allow for
patients to interact with others as much as possible. There are many things for the patients to do
such as games, puzzles, televisions, coloring books, novels, and going to groups. They keep a
nice schedule which helps patients stay task-oriented and gives them structure. Groups allow
patients to have a therapeutic environment to learn new skills such as coping mechanisms, and
communication skills, while also giving patients a sense of belonging. The whole tone of the unit
sets how patients will act, and how they will get better.
Analyze
RH is a thirty one-year-old German, Caucasion male. The patient’s spirituality and
ethnicity do not affect his diagnosis, but his gender plays a slight role. Schizophrenia is more
common in males. The patient did not elaborate much about ethnicity. He did not state any other
ethnicities he could be, but he did state: “I wish I was Italian. I love their food.” He was able to
talk about Italian culture and cuisine with ease and connected greatly with the Italian culture and
ethnic background. Spiritually, he did not state that he was a religious person but he did admit
that he believes in a higher power, such as God, and was born and raised Catholic. He does not
go to church or mass regularly and stated, “I should probably get back to that.” Culturally, he is
strongly swayed towards American societal standards. He is very into watching football on the
weekends, among other sports as well. He believes that freedom is very important and that
religion plays a huge role in how people act and think. He displays a good moral compass such
as disagreeing to anyone using drugs or alcohol as a way to feel better, and says “You should
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always treat people nice.” The patient uses most of his beliefs to help him cope, and “stay on the
right path.”
Evaluate
On the first date of care, the patient displayed hallucinations, illusions, and delusions. He
had multiple internal stimuli, and was in his own reality. He was unable to coherently speak, take
care of himself, or communicate with others. He was very isolated, sitting in the corner of the
group room by himself for the majority of the day. He would go to groups, but was unable to
participate because he could not focus on what was going on. He took his meds, but the regime
was not therapeutic at that time. He could not answer questions and did not make any sense. He
was quiet, and unable to make eye contact during his interview. He has a very flat affect and not
much information was extracted from him.
On the second day of care, he was feeling much better. He was able to answer questions,
make eye contact, speak clearly, and made sense in his answers. Internal stimulation was
minimal, and hallucinations and delusional thinking were kept at an acceptable level. If he was
having a delusional thought or a hallucination, he was easily reoriented back to the conversation,
or real time. He was more social and talked to other patients. His medications started reaching a
therapeutic effect. He was very pleasant to talk to and had a good sense of humor. He was
animated and displaying joy. The patient was feeling better, able to take care of himself
independently, and displayed decrease instances of hallucinations and delusions.
Summarize
The goal for discharge is to get him into a group home. It is important for him to sustain a
sense of independence, but he also needs structure to stop him from cycling back though his
exacerbated phase. The mother believes a group home is best for him. Discharge education needs
to amplify medication compliance, and promote good coping skills. He will continue on his
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disability, and will need extra support from his mother, father, and step-mother. The patient has
been in the hospital for an extended period of time, so he may need to be reoriented to the
outside world, and explain that structure is even more important with all the excess freedom he
will have. Hopefully the medications will continue to work and stay therapeutic so he does not
have another exhibition of exacerbated symptoms.
Prioritize
1. Disturbed Sensory Perception: visual and auditory related to psychological stress as
manifested by altered communication pattern, changes in problem solving, hallucinations,
inappropriate responses, frequent blinking of the eyes, and mumbling to self.
2. Risk for injury related to loss of reality and poor judgment.
3. Anxiety related to stress as manifested by feelings of inadequacy, restlessness and
insomnia.
4. Social isolation related to changes in mental status as manifested by lack of support from
father, emotionally sad, concerns with one's own thoughts, withdrawn, no
communications, and no eye contact.
5. Dressing or grooming self-care deficit related to perceptual impairment as manifested by
poor personal hygiene, inability to bathe and groom self independently, and disorderly
appearance.
List
● Disabled family coping related to unexpressed feelings of guilt as manifested by
depression, hostility, and neglectful relationship with father.
● Disturbed sleep pattern related to excessive stimulation as manifested by lack of energy,
irritability, tiredness, verbal reports of difficulty falling asleep, and problems with
memory and concentration.
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● Disturbed thought process related to mental disorders as manifested by hallucinations,
delusions, inappropriate social behaviors, confusion and cognitive deficit.
● Risk for self-directed violence related to altered thought process.
Conclusion
RH, a thirty-one year-old male diagnosed with schizophrenia with psychosis was
admitted to the emergency department due to exacerbations in his psychosis. He was kept safe on
the unit in order to provide care and therapy to get him back to his baseline. He was taught ways
to cope with stressors that cause a heightened stimuli, and how to cope with future stressors that
may come his way. His medications were regulated and put in combination to not only be
therapeutic but also to avoid problems from occurring in the future. He has good days, and bad
days and he needs to keep up with medication compliance, stay in his group home upon
discharge, keep his support system of his family, and continue with his counseling therapy.
Education should be provided to the family and group home to bring him into the hospital at the
first sign of elevated symptoms instead of waiting for a few weeks. Overall, if he sticks to the
schedule, and medication regime he is on right now he should be on the path for better mental
health.
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Rockville (MD) (2016). Substance Abuse and Mental Health Services Administration (US);
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