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Running head: MENTAL HEALTH CASE STUDY

Mental Health Case Study

Joshua Danko YSU SN
Youngstown State University
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MENTAL HEALTH CASE STUDY

Mental Health Case Study

Abstract

Pt. diagnosed with depression and had vague suicidal ideation with no plan.

Pt had stated wanting to die to one of his close friends after a long night of

drinking alcohol and partying. Pt. was taken to emergency department by his

friend based on claims of suicide. Pt. states not remembering everything

from that night. Pt. Verbalizes many stressors in current life. Pt. is awaiting

discharge.

Objective Data

Admission date 9/27/16, date of care 9/29/16, Axes I: Pt. diagnosed

with depression, Axes II: suicidal ideation with no plan, Axes III: ADD and

ADHD, Axes IV: Pt. states stressors as thinking, family problems, college,

future, Axes V: N/A, pt. on suicide precautions, pt. allergic to codeine, Meds

taken by pt. are the following: Seroquel (Antipsychotic/Agitation), Vyvanse

(ADHD), Adderall (ADD).

Summarize

Depression is a disorder that can affect ones behavior on a daily basis.

According to the National Institute of Mental Health, depression is identified

as a mood disorder that can affect how one feels, thinks, and handles daily

activities (2016). People dealing with depression have a tough time handling

daily activities as they continuously have negative thoughts and feelings.

According to Medline Plus, some of the symptoms of depression include the

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MENTAL HEALTH CASE STUDY

feeling of being sad or empty, loss of interest in favorite activities,

overeating, or not wanting to eat at all, not being able to sleep, or sleep too

much, feeling very tired, feeling hopeless, irritable, anxious, guilty, aches,

pains, headaches, cramps, or digestive problems, or thoughts of death or

suicide (2016). The symptoms of depression are extremely vague and can

manifest themselves in many ways. According to the CDC, 1 out of every 20

Americans aged 12 and older have reported depression from 2009 to 2012

(2016). Depression is a very common problem in America and many

Americans struggle with it every day. Depression is a very serious disorder

that can have major negative implications on ones life.

Identify

Pt. talked about the events that led up to hospitalization on day of care. Pt.

had recently went to see biological family to get answers that he was looking

for. Pt. then had got in an argument with his adoptive mother. The adoptive

mother packed his bags and sent him to the rescue mission to live there. Pt.

then talked about events that lead directly up to hospitalization. Pt. stated

being downtown at a bar where he was drinking with his friends. Pt. sated

drinking several different types of heavy liquor and also drinking beer with

that. Pt. had been drinking all night and stated all he remembered was

saying to one of his friends that he just wanted to die. Pt said that he did

not remember anything after this but knows he was taken to the hospital by

one of his close friends that was with him that night. Pt. stated stressors as
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just thinking. Pt. also talked about how his adoptive mother can be a

stressor in his life. Pt. states a conflict between him and her as him wanting

to play football and his mother wanting him to quit football and focus on

school. Also his father wants him to play football as he did in college. Pt.

stated college as being difficult to adapt to as he is used to being the man

as he said he was in high school. Pt. talked about how much different college

is from high school and that he is having trouble dealing with that.

Discuss

Pt. suffers from a past history of depression and also ADD/ ADHD. Pt. now is

diagnosed with vague suicidal ideation. Pt. was adopted but does know who

his biological mother is. There is no documented history of mental illness in

the pt.s family. Pt. did describe family as a stressor in his life.

Describe

Pt. had been a part of milieu therapy that is available to all pt.s on the

psychiatric floor. On day of care pt. attended group therapy. Although unable

to observe group therapy pt. had attended. Also the open communication to

other pt.s was conducive to milieu therapy as patient had connected with

another patient there. Psychiatric evidence based nursing care was provided

for this patient in many ways. Pt.s ability to verbalize adaptive coping

strategies to use when suicidal feelings occur. Pt. was encouraged to

verbalize feelings. Nurses used therapeutic communication skills to develop

a trusting relationship. Pt. was encouraged to explore available resources

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and support systems. Nurses promote pt. and family participation. Pt. is to

verbalize acceptance of life and situations over which he has no control.

Analyze

Pt. was an African American male that was also homosexual. Pt. had not

discussed or have any spiritual ties documented. Pt.s ethnic and also

cultural influences could have an impact on pt.s behavior. These two ethnic

and cultural backgrounds are considered minorities. Also pt.s lack of spiritual

support may negatively influence his behavior and not hinder any thoughts

or actions of suicide.

Evaluate

The care of the psychiatric pt. is in therapeutic communication used by the

nurse. Also observing behavior for a suicidal pt. is very important in

preventing an attempt against the pt.s life. During the day of care pt. stated

having trouble coming up with effective coping strategies in dealing with his

stressors. Pt. was effective in verbalizing his thoughts and feelings. Pt. had

relayed what was going on in his mind. Pt. was open and cooperative during

period of communication between nurse and pt. Pt. had identified support

systems as his family. Pt. stated having knowing his biological mother but her

not being a part of his life. Pt. had an adoptive mother that he considered to

be a stressor in his life but that she was very supportive and a positive

influence on his life. Pt. had stated a father as being there to support him in

his life through football. Pt. had stated living with five other brothers and
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sisters. Pt. said he was the only adopted child and the others were birthed by

his step mother. Pt. stated his best friend who is a football player is helpful in

his life. Pt. talked about how he does not feel his suicidal episode was very

serious and considers it a mistake and a moment of weakness. Pt. says he

has talked to his football coach about him being there and also is not worried

about missing class time. Pt. believes that he should be getting discharged

soon to go home and that he is in a mindset fit to be discharged.

Summarize

Pt.s plans for discharge would include pt. being able to verbalize acceptance

of life and also situations in his life that he has no control over. Pt. must be

able verbalize effective coping techniques when pt. is feeling depressed. Pt.

must also be aware of available support systems and resources. Also pt.

must know to report any thought of suicide. Pt. must be free of any signs of

suicidal behavior.

Prioritized

Risk for suicide

List

Ineffective individual coping strategies

Disturbance of self- esteem

Disturbance of personal identity

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Loss of Hope

Anxiety

Spiritual Distress

Disruption of sexuality

Stress Overload

Impaired Resilience

Feelings of powerlessness

Risk of Violence against self or to others

References

Depression: NIMH. (2016, May). Retrieved October 12, 2016, from

[Link]

Depression: MedlinePlus. (2016, October 12). Retrieved October 12, 2016,

from [Link]

Depression: CDC. (2016, March 30). Retrieved October 12, 2016, from
[Link]