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Psychiatric Mental Health Comprehensive Case Study: Psychosis

Stephanie Smith

Youngstown State University

NURS 4842L Mental Health Nursing Laboratory

Mrs. Teresa Peck, MSN, RN

November 17, 2022

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Abstract

The following case study describes the disease process of a patient with psychosis, also called

psychotic disorder, and the treatments and care provided for the patient. The subject of study is

M.S, a 40-year-old African American male that presented to the inpatient psychiatric floor after

having a psychotic episode. M.S has a chronic history of substance abuse and is currently

working towards detoxing from the substances. The subject was studied on two different

occasions, October 27, 2022, and November 3, 2022, and the differences in symptoms,

medications, and labs are noted. Numerous academic articles were researched to augment the

information available in the patient's care. This paper highlights the manifestations of psychotic

disorder and the factors that may have led to the development of the diagnosis in this patient.
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Objective Data

Patient Identifier: M.S.

Age: 40

Sex: Male

Date of Admission: October 22, 2022

Date of Care: October 27, 2022 and November 3, 2022

Psychiatric Diagnosis: Psychosis/Psychotic Disorder

Behaviors on Admission: M.S. was brought to Youngstown St. Elizabeth's Hospital on the

morning of October 22, 2022, due to his sister calling police officials. His sister reported that the

night before, she found him standing in the kitchen holding knives and breathing rapidly. She

was able to get the knives away from him and de-escalate the situation but she was then worried

about his and her safety and contacted officials for help. Two weeks prior to this incident, M.S.

was living with friends until they kicked him out and called his sister stating that the patient “is

acting bizarre” and was found defecating in their backyard, and that's when his sister moved him

into her house.

Behaviors on Day of Care: While interviewing the patient on October 27, 2022, M.S. exhibited

multiple behaviors that are congruent with his diagnosis of psychosis. Although the patient was

calm, cooperative, and willing to speak with me, he displayed various forms of disorganized

thinking. During the conversation, the patient displayed a flight of ideas, circumstantiality,

rambling, a lack of insight, a short attention span, and poor eye contact. When the patient spoke,

his eyes would often roll into the back of his head and he appeared to be drowsy. Although the

patient didn’t display it during the interview, when questioned, he admitted to hearing voices but
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denied any other hallucinations. The patient also displayed poor memorization and time

realization for both recent and remote memory and was a poor historian. When questioned, the

patient would include a lot of unnecessary and insignificant details in the conversation, taking

away from the main point and this is known as circumstantiality. The patient also jumped

between topics and ideas frequently and this is known as a flight of ideas. At one point in the

conversation, the patient went from talking about schools and teachers to God, being Ice Ice

Baby, and then shooting up Harvard and going to jail. He would often answer a question and

then right after say something that contradicts the first answer he gave.

When the patient was interviewed again on November 3, 2022, the same questions were

asked and many of the answers differed from the previous interview. During the second

interview, the patient still displayed a flight of ideas, circumstantiality, rambling, a lack of

insight, and poor attention span but also displayed a large amount of grandiose delusions.

Grandiose delusions are inaccurate beliefs that one has special powers, wealth, mission, or

identity. When asked if the patient was employed, he responded that he has never had a job

because he has too much money from being an actor and doing movies, and completing missions

in the army. At another point in the conversation, the patient stated that he went to space with

Father Mike, where they attended a Michael Jackson concert in the galaxy, and then they

exploded and turned into white men. He also said he played NFL football for the Denver

Broncos. During this interview, the patient began laughing out of nowhere and mumbling. When

questioned, he stated that his friend was whispering in his ear like Casper the ghost. I asked him

if his auditory hallucinations have been getting better during his time in the psychiatric unit and

he responded yes but the notes in the chart explained that the patient is often seen talking to

unseen others and often becomes aggressive, needing a PRN dose of Haldol to calm him down.
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The patient's eye contact during this interview was much better than the first and he was less

drowsy but there didn’t seem to be a difference in his disturbed thought process, even after being

on medication during this time.

During both interviews, the patient was questioned on what brought him into the

psychiatric unit and his answer both times was “to get off drugs.” He was unaware of his actions

before admission which led his sister to call police officials. When asked about his substance

abuse, the patient admitted to his history of using heroin, cocaine, and fentanyl and denied any

use of alcohol. He was very aware of how his drug use began, the issues it was causing in his

life, and the fact that he needed help and was on the right track by being in the psychiatric unit.

He explained that his history of drug use began when he was young and he uses it as a way of

coping with stress.

The patient stated that he was sleeping well throughout the night and getting a good

number of hours of sleep. However, the notes in the chart state that the patient is up most of the

night talking to unseen others and usually only gets three hours of sleep a night.

During both dates of care with the patient, he attended group therapy sessions, although

he slept through most of the one on October 27, 2022. During the other therapy session on

November 3, 2022, the patient verbalized clang, which is the rhyming of words, where he said

“It’s like the potion in the ocean.”

Laboratory Results (October 22, 2022)

Potassium (3.5-5.0) 3.6

Sodium (132-146) 142

Glucose (74-99) 82

Blood Urea Nitrogen/BUN (6-20) 11

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Creatinine (0.7-1.2) 1.1

Red Blood Cells (3.8-5.8) 5.12

Hemoglobin (12.5-16.5)/Hematocrit (37-54) 15.4 / 47

White Blood Cells (4.5-11.5) 14

AST (0-39) / ALT (0-40) 18 / 15

TSH (0.270-4.2) / T4 (4.5-11.7) Not Drawn

Drug Toxicity (+) Fentanyl

U.A. Alcohol Level Negative

QTC (<440) / ECG 455/Normal ECG

Total CK (20-200) 261

Total Protein (6.4-13) 8.8

Ammonia Levels Normal

Laboratory Results (October 29, 2022)

Valproic Acid (50-100) 59

QTC (<440) 441

Psychiatric Medications as of October 27, 2022

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

Sodium valproate Depakote Anticonvulsant 500 mg Q12 hours Mood stabilizer

Risperidone Risperdal Atypical Antipsychotic 2 mg Q12 hours Psychosis

Haloperidol Haldol Typical Antipsychotic 5 mg Q6 PRN Agitation

Psychiatric Medications as of November 3, 2022

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

Sodium valproate Depakote Anticonvulsant 750 mg Q12 hours Mood stabilizer

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Risperidone Risperdal Atypical Antipsychotic 3 mg Q12 hours Psychosis

Haloperidol Haldol Typical Antipsychotic 5 mg Q6 PRN Agitation

Benztropine Cogentin Anti-Parkinsonism 1 mg Q12 hours EPS/Tremors

Olanzapine Zyprexa Atypical Antipsychotic 5 mg Q12 hours Psychosis

M.S. is taking several medications to help with his diagnosis of psychosis. During the

first interaction with the patient, he was taking 500 mg of Depakote twice daily, 2 mg of

Risperdal twice daily, and a PRN dose of 5 mg of Haldol for agitation. During the second

interaction with the patient, the PRN dose of Haldol remained the same and his dosage of

Depakote increased to 750 mg and his dosage of Risperdal increased to 3 mg. He was also placed

on Olanzapine 5 mg twice daily and Cogentin 1 mg twice daily due to the development of

extrapyramidal side effects (EPS) from his antipsychotic medications. The increase in doses of

Depakote and Risperdal and the addition of Olanzapine are because his psychotic symptoms

were not improving.

Labs were assessed and the importance of each were noted. The patient's glucose levels

were within normal range and the QTC was slightly elevated. These levels are important to

monitor as the patient is on antipsychotic medications, Risperdal and Olanzapine, which can

raise blood glucose levels and over time cause the patient to develop Type II Diabetes and can

also prolong the QT interval, causing a fatal cardiac dysrhythmia called Torsades de Pointes.

Another QTC was drawn on October 29, 2022 and the levels were getting closer to being within

the normal range. The patient's BUN and creatinine levels were also within normal range which

are important to check because antipsychotic medications are nephrotoxic and can not be taken

in those with kidney failure. The patient’s AST and ALT levels were within normal range, along
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with the ammonia levels. The liver enzymes, AST and ALT, are important to monitor, not only

because the patient has a history of chronic substance abuse, but also because Depakote is

hepatotoxic. The ammonia levels were checked because if the liver were damaged, it would

cause a decrease in the excretion of ammonia which in return can cause a build-up of ammonia

and can lead to the development of hepatic encephalopathy. During the first interaction, the

patient's valproic acid levels had not yet been drawn because it was too soon but the levels were

drawn on October 29, 2022 and were within the therapeutic range. The patient's white blood cell

count was high but should be monitored as Depakote can diminish white blood cells in the body.

The red blood cells and hemoglobin/hematocrit were also within normal range but are important

to monitor because Depakote can lower levels. The patient's total protein levels and total CK

enzymes were high, indicating that the patient may have rhabdomyolysis.

Summary of Psychiatric Diagnosis

The word psychosis is used to describe conditions that affect the mind, where there has

been some loss of contact with reality (National Institute of Mental Health, n.d.). According to

the National Institute of Mental Health, during a period of psychosis, a person's thoughts and

perceptions are disturbed, and the individual may find it difficult to differentiate between what is

real and what is not. Psychosis is often accompanied by symptoms such as a disorganized

thought process, delusions, hallucinations, illusions, and incoherent or nonsense speech that is

inappropriate for the situation they are in (National Institute of Mental Health, n.d.).

Hallucinations are false sensory perceptions or experiences that are not associated with real

external stimuli and can involve any of the five senses (Videbeck, 2020). These include auditory,

visual, tactile, olfactory, and gustatory hallucinations where a person can hear voices or sounds,

see images, feel sensations, smell odors, and taste things that are not present. Delusions are when
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a person believes things that are untrue, even when examined and proven to be untrue. Illusions

are misperceptions of real external stimuli when a person sees an object as something completely

different. Along with those symptoms, a person with psychosis may also have problems with

sleeping, experience a lack of motivation, become socially withdrawn, have difficulty

functioning overall, and may experience depression, and anxiety (National Institute of Mental

Health, n.d.).

According to the National Institute of Mental Health, psychosis can affect anyone and

may be triggered by things that include trauma, stress, sleep deprivation, general medical

conditions such as brain tumors, certain prescription medications, and the misuse of alcohol or

other drugs. The Psychiatric-Mental Health Nursing book states that the use of substances can

induce symptoms that are similar to other mental illness diagnoses, such as anxiety, psychosis, or

mood disorders, and they are called substance-induced anxiety, substance-induced psychosis,

and so forth. The book also states that the symptoms may subside once the substance is

eliminated from the body, but this may not always be the case if the substances have caused

brain damage (Videbeck, 2020, p. 812). This information relates well to M.S. and may be a

reason he is displaying psychosis as he has a chronic history of substance abuse, which may lead

to brain damage.

According to research, there are a variety of treatments available for those with psychosis

which include medication management, individual or group psychotherapy, family support and

education, and supported employment and education services (National Institute of Mental

Health, n.d.). Just like any other health condition, individuals with psychosis should be involved

in planning their treatment and goals to help them stay engaged and focused on their recovery

path, allowing them to improve their quality of life.

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Identification of Stressors and Behaviors

M.S. is originally from Chicago, Illinois but has been living in Youngstown, Ohio for the

past two years with a group of friends until two weeks prior to admission when he moved in with

his sister. The patient is a chronic substance abuser and states that he has been using and dealing

heroin and crack for the past 20 years. When questioned on how his substance use began, he

stated that he grew up with guns, violence, and drugs in the home and it just became his way of

living. He is unemployed and has a low support system, as his sister was the only one mentioned

during the interview and also in the charting system. The patient wasn’t sleeping at night as his

auditory hallucinations and drug use kept him awake. All of these factors could contribute to his

diagnosis of psychosis.

Patient and Family History of Mental Illness

Prior to admission, M.S. was not taking any medications for a psychiatric illness.

According to the notes in the chart, his sister stated that he has never had a history of psychiatric

illness, although he has been struggling with substance use for 20 years. She stated that the

patient was “slipped a mickey” two years ago and has never been the same since. Neither M.S.

nor the charting system mentioned anything about a history of mental illness in the family.

Milieu therapy and Psychiatric Evidence-Based Nursing Care

During his stay in the inpatient psychiatric unit, M.S. received evidence-based nursing

care as well as milieu therapy. Initially, dangerous items were removed from the patient and his

environment to ensure the safety of himself and others. These items include belts, shoelaces, ties,

smoking materials, and any other potentially dangerous objects. Group therapy sessions occurred
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daily and the patient was encouraged to attend each. On the first day of care, M.S. attended a

group therapy session but fell asleep at the beginning and did not wake up until the end. On the

other day of care, M.S. was only present for the end of the session. Although the patient was not

attentive to group therapy on the days of care, several notes prior said that the patient was active

and present in many group therapy sessions during his stay.

Antipsychotic pharmacological therapy of Risperidone, Olanzapine, and Haldol were

administered as ordered. During the patient's stay on the unit and his compliance with taking

these antipsychotic medications, the patient developed tremors or extrapyramidal side effects

(EPS). According to D’Souza & Hooten, extrapyramidal side effects which are commonly

referred to as drug-induced movement disorders, are among the most common adverse effects

patients experience when taking dopamine-receptor-blocking agents or antipsychotics. The

symptoms that come along with EPS can be debilitating and interfere with social functioning and

communication, motor tasks, normal activities of daily living, and may cause a patient to

abandon their medication regimen, resulting in disease relapse and re-hospitalization (D’Souza &

Hooten, 2019). Studies have found that a patient experiencing EPS from antipsychotic

medications can be given an AntiParkinsonism agent such as benztropine (Cogentin) to relieve

those side effects and help the patient to be compliant with their medication regimen and prevent

disease relapse and re-hospitalization (D’Souza & Hooten, 2019). After realizing that the patient

was experiencing EPS as a side effect of the antipsychotics, the doctor placed him on 1 mg of

benztropine (Cogentin) two times daily.

Ethnic, Spiritual, and Cultural Influences

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M.S. is an African American single male from a lower-middle-class family who did not

talk about any cultural background. When asked about his spiritual beliefs or religion, he

responded “I believe in Jesus and God” but did not go on to further talk about the subject.

Evaluation of Patient Outcomes

Some of the outcomes that are desired for a patient experiencing psychosis include

remaining free from harming themselves and others, perceiving themselves in a realistic manner,

performing self-care activities appropriately, and recognizing distortions in their reality. Other

outcomes for M.S include finding a facility of ongoing treatment for recovery after discharge,

preventing relapse, enhancing his quality of life, complying with his medication regimen, and

minimizing the side effects of medications.

On both days of care, M.S. performed self-care activities by showering and eating

appropriately. He also remained free from any harm, was compliant with taking his medications,

and discharge to a rehabilitation facility was set in stone. His ability to recognize distortions in

his reality was only partially met on the days of care, as M.S. was still experiencing auditory

hallucinations and was seen talking to unseen others in his room.

Plans for Discharge

The patient's plan for discharge is to Midwest Center at Youngstown. This is a facility

that offers behavioral health services to those struggling with addiction and are ready for

renewal, restoration, and recovery. The facility focuses on sobriety and amenities to help heal the

body, mind, and spirit. Originally, the patient was planned to discharge back to his sister's house

but she later stated that the patient needed to attend a 30-day rehabilitation program before she

was willing to accept M.S. back into her home.

Prioritized Nursing Diagnosis

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The following are prioritized nursing diagnoses for the patient:

1. Impaired thought process related to psychosis as manifested by false beliefs,

memory deficits, a flight of ideas, circumstantiality, and clang.

2. Ineffective coping related to negative role modeling as evidenced by impaired

adaptive behavior, employment difficulties, and a history of substance abuse.

3. Altered sensory perception related to the inability to focus as manifested by

auditory hallucinations and delusional thinking.

4. Impaired social interaction related to disturbed thought processes as manifested

by poor eye contact, disorganized speech and thoughts, and contradicting

answers.

5. Risk for self/other-directed harm related to hallucinations and delusions.

Potential Nursing Diagnoses

1. Self-care deficit

2. Ineffective health maintenance

3. Fear

4. Hopelessness

5. Impaired memory

6. Ineffective impulse control

7. Risk for suicide

8. Social isolation

Conclusion

Psychosis is a complex process that has remissions and exacerbations of symptoms, often

complicated by stress and non-compliance to medications. I believe that if the patient remains
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compliant with his medication regimen and rehabilitation process for his substance abuse, he will

have a decrease in exacerbations throughout his lifetime. His sister will play an important role in

his life by providing him with added support through this process and ensuring that he is

compliant with his treatment plan. As M.S. progresses forward, a collaborative effort will be

necessary to ensure he is functioning at his optimal level physically, psychologically, and

socially.
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References

D’Souza, R. S., & Hooten, W. M. (2019, January 9). Extrapyramidal Symptoms (EPS). Nih.gov;

StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK534115/

National Institute of Mental Health. (n.d.). NIMH» Understanding Psychosis.

Www.nimh.nih.gov. https://www.nimh.nih.gov/health/publications/understanding-

psychosis

Videbeck, S. L. (2020). Psychiatric-mental health nursing (8th ed.). Wolters Kluwer.

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Case Study Comment Sheet 4842 (Turn in with Case Study)

Student Name_____________________________________

Pt Identifier______________

Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

___________ Patient education required (based on symptoms, diagnosis, medications, labs,

safety, etc.)

___________ Priority patient needs (day of care and discharge)

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format

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