Running head: CASE STUDY T.G.

Case Study T.G.

Emily Evans

Nursing Department, Youngstown State University

NURS 4842 Mental Health Lab

Professor Peck

March 18, 2021

Abstract

A family history of mental illness and a history of childhood trauma are huge contributors to

having a mental illness in the future. My patient T.G. had both and have many different

diagnosis, many of which, trauma and family history predispose people to having them. T.G. has

been seeing a counselor for 8 years and has had two total inpatient psychiatric visits. This paper

talks about the heritability of the different diagnosis that T.G. has a family history of, the

relationship trauma has with mental illnesses, and different nursing diagnosis along with

interventions for T.G. As well as mentions the importance of milieu therapy in the clinical

setting.
Running head: CASE STUDY T.G. 3

Objective Data

T.G. was admitted on March 15, 2021 for a suicide attempt. This was the patient’s second

suicide attempt, the first being back in 2019. The patient has a two year old daughter that would

have been born in 2019, which may be related to that stay, because it very possibly could have

been postpartum depression or have been triggered from the pregnancy itself. The chart did not

give details on the stay. The patient had a history of verbal and emotional abuse from her mother

and a history of sexual and physical abuse from her mother’s many boyfriends growing up. The

patient’s psychiatric diagnosis that was related to her admission was depression, her other

diagnoses are post-traumatic stress disorder, panic disorder, agoraphobia, mixed bipolar 2

disorder, cluster B personality disorder, cannabis abuse and diabetes mellitus type 2. The patient

also has a history of hallucinations. Important labs include the patients QTC, CBC, and a covid

test which was all within normal range. The patient triglycerides were elevated in her lipid panel

which could be caused by the patients obesity, or antipsychotics can elevate triglycerides. The

urine drug screen was positive for cannabis and the blood sugar was 104. The TSH and T4 were

also within normal range. During the patient interview the patient was initially agitated due to

just signing herself as voluntary after her three day involuntary pink slip ended. The patient

hoped to leave and felt she did not have any choice but to sign herself as voluntary. After

validating the patient’s feelings she became more open and talkative. The patient appeared well

dressed but her hair looked unwashed and greasy. The patients mood and affect were normal.

The patient’s has good judgement and memory and there was no disturbance in thought. The

patient is currently unemployed, the patient states the reason for this is because of her frequent

panic attacks. She was working as a phlebotomist at St. Elizabeth’s hospital and was attending

nursing school. The patient was having at least one panic attack a week at work and they
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eventually let her go. As for nursing school, she was “Let go from the program because the

patient was deemed mentally unfit for the program”. The patient is currently prescribed

Oxcarbazepine, Metformin, and Citalopram daily. The patient is also prescribed Haldol, nicotine

gum, and different medications to be used as needed.

Summarize the psychiatric diagnosis

Depression occurs when adaptation is ineffective. Depression is an alteration in mood that is

expressed by feelings of sadness, despair, pessimism and loss of interest in activities causing

significant impairment in daily life. May affect sleep patterns, appetite, energy level,

concentration, daily behavior, and self-esteem.

Mixed bipolar disorder is when a patient’s cycles alternate between periods of mania, normal

mood, depression, normal mood mania and so forth.

A person diagnosed with Cluster B personality disorder has difficulties regulating their emotions

and behavior. Others may consider their behavior dramatic, emotional, or erratic. There are four

cluster B disorders: antisocial, borderline, histrionic, and narcissistic personality disorders. Being

diagnosed with just Cluster B means they have traits if all four along with enough traits of a

single one to but is not considered just one. Some traits that I noticed in T.G., whether she

expressed it in the interview or showed traits of it through her stories and in her chart include

impulsive behavior, unstable relationships that shift from extreme adoration to extreme dislike,

impulsive harmful behaviors, and envy of others. I noticed most of those traits while T.G. was

talking about her relationships with her family and what she thinks of her brother’s girlfriend.

T.G. also has Panic disorder, onset of a panic attack is often unpredictable and can happen at any

time. A panic attack is manifested by intense apprehension, great feelings of fear and terror, and
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the heart may be pounding. They also may be experiencing shortness of breath, lightheaded,

dizzy, sweaty, trembling, shaking, and sick.

Agoraphobia is an anxiety disorder that develops after one or more panic attacks. It is closely

associated with panic disorder. Those diagnosed with agoraphobia avoid conditions where they

lack control or safety. At its most severe people can become housebound.

Post-traumatic stress disorder is a condition of persistent mental and environmental stress

occurring as a result of a severe psychological shock.

Identify the stressors and behaviors

The patient took a cocktail of pill which included fourteen – 100 mg Zoloft (1400mg total of

Zoloft), two tablets of Buspar, two tablets of metformin, and two shots of alcohol (not specified).

The patient expressed they did not intend to kill themselves but “ intended to sleep and not wake

up”. E.D. called poison control and was warned to watch for Serotonin Syndrome related to the

high dose of Zoloft. Recent stressors includes the patients grandmother recently passed away,

who of which was a huge support system in T.G’s life. The patient expressed that she does not

have any coping mechanisms other than attending counseling. The patient has been seeing a

counselor for the past eight years.

Serotonin syndrome occurs when there is too much serotonin, which can be caused by MAOIs

and SSRIs. According to Videbeck the signs and symptoms are, change in mental state and

neuromuscular excitement which can be presented as muscle rigidity, weakness sluggish pupils

and tremors. Another symptom is autonomic abnormalities which includes hyperthermia,

tachypnea, hypersalivation, and diaphoresis.

Discuss patient and family history of mental illness

The patients mother has “multiple mental disorders” including schizophrenia, borderline

personality disorder, bipolar disorder, and dissociative identity disorder. A study by Jennifer

Chapman, Radia T. Jamil, and Carl Fleisher suggest that 70% of people with borderline

personality disorder have experienced physical abuse, sexual abuse, or neglect during childhood.

That same study by Jennifer Chapman, Radia T. Jamil, and Carl Fleisher also suggests that there

is a genetic predisposition evidenced by twin studies done by researchers from France. The twin

studies concluded there is over 50% heritability, which is greater than major depression. T.G had

both physical and sexual abuse growing up along with the hereditability of the disorder, it is not

surprising she is diagnosed with cluster B and her behavior resembles borderline personality

disorder. Behavior like knowing exactly what pills she took and the exact amount before she

tried to harm herself and calling her brother prior, so someone could alert authorities.

Schizophrenia is a disorder that affects a person’s ability to think, feel and behave clearly.

Psychotic symptoms include delusions, hallucinations and impairment in work, social relations

and self-care. To be diagnosed with schizophrenia they must have two of the following;

delusions, hallucinations, disorganized speech, grossly disorganized behavior and negative

symptoms and the symptoms must be present for a significant amount of time. The mother of

T.G. also has an unspecified type of bipolar disorder, a mood disorder characterized by episodes

of mania and depression. T.G. is also diagnosed with bipolar disorder. According to Barrett and

Smoller, “ Studied estimated the heritability of bipolar disorder to be 79-93%, substantially

higher than even medical disorders such as breast cancer for which specific susceptibility has

been identified.” The same study by Barrett and Smoller stated that “The recurrence risk for

bipolar disorder in first-degree relatives of bipolar disorder patients in approximately 9%” that is
Running head: CASE STUDY T.G. 7

almost ten times greater than that of the general population. T.G’s mother also has dissociative

identity disorder, previously known as multiple personality disorder. Dissociative identity

disorder can present itself in two different ways. The first is where the person maintains at least

two distinct and different personality states. This leaves the patient with memory gaps that would

go further beyond just being forgetful. For the first presentation one of the goals of treatment is

to make the personalities aware of each other. The second presentation is where the person can

dissociate from their own body and feel as though they are watching themselves do thing from

outside their body. T.G. did not specify how dissociative identity disorder presents in her mother.

According to Slogar, “Studies on genetic finding contributing to dissociative identity disorder

present mixed findings” However that same journal cited a study from Waller and Ross

attributing Dissociative identity disorder solely to environment and stated that heritability had no

effect.

Describe the psychiatric evidence based nursing care provided

Milieu therapy is a form of psychotherapy that involves the environment and how it is controlled

to affect patient behavior as well as improving patient’s psychological health and functioning.

Milieu therapy can include anything from the paint on the walls to the buttons on the clothes

instead of strings. Milieu therapy keeps the patents safe from harm as well as making a

structured environment that supports the individual towards recovery and wellness. One

important part of milieu therapy is having a strict schedule and following it every day. This

aspect is also an important factor that the patient must include into their daily life once they get

discharged. Another aspect is cohesion, providing the patients exposure to good role models by

the staff modeling how the patients should act. The patients should feel comfortable enough to be
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vulnerable with the nurses, doctors and everyone on their care team as well as feel supported.

Privacy should be provided and the patients room should be able to be their safe place during

their stay at the inpatient hospital. The patients expectations should also be clearly stated.

Another very important aspect of milieu therapy is safety. There are many different aspects of

the floor that promotes safety. First, the garbage bags are paper bags instead of plastic, and the

beds are wooden boxes on the ground. Also the patients clothes have buttons instead of strings

and the shower rooms do not have curtains. Another example is that the windows do not open

and the blinds are built into the window. Another aspect is the doors, the individual bathroom

doors are slated so the patient cannot hang anything off them and the bedroom doors have weight

sensors on them. There are so many safety features on the floor at St. Elizabeth’s downtown it is

shocking, another aspect is the mirrors in the bathrooms, the mirrors are made of polished steel

instead of regular mirror material as well as the plumbing in the bathroom, which is built into the

walls so the patients cannot mess with that. The furniture on the floor is even included in milieu

therapy, the chairs in the patients individual rooms are much heavier than normal chairs so

patients cannot throw them when they get angry. Repetition is also an important aspect of milieu

therapy, which helps give the patient a sense of structure. Repetition can be achieved by again

having a schedule to follow and sticking to it. One paint color as previously mentioned that is a

part of milieu therapy is lavender which is supposed to have a calming effect. According to a

study by Mancil, Conroy and Haydon “Results indicate that aberrant behavior decreased

concurrent with an increase in total percentage of communication responses. The children

maintained communication and low rates of aberrant behavior, and generalized their

communication from the home to the classroom.”

Analyze ethnic, spiritual and cultural influences

The patient was a Caucasian female who expressed that she does not have a strong relationship

to religion. She does not practice any spiritual coping mechanisms which includes but is not

limited to meditation yoga and mindfulness. When asked, T.G. expressed that she believes in

God but she does not practice religion and she does not attend church. T.G. does attend spiritual

group therapy sometimes but did state that she questions religion often and doesn’t not have

strong beliefs.

Evaluate the patient outcomes

The patient met none of her nursing diagnosis on epic, because of this the patient was asked to

sign in as voluntary. The treatment team believes they need more time to get T.G. stabilized. The

patient was prescribed new medications, Trileptal and Cilexa and was taken off Zoloft, the

medication T.G. tried to kill herself with. After three days of treatment T.G. still denies she tried

to kill herself and states she was just trying to sleep for a really long time. During the interview

T.G. talked as if she shouldn’t even be admitted to the hospital and everything is just a big

misunderstanding. One goals of treatment is that T.G. can verbalize why she was admitted in the

first place.

Summarize discharge plans

The patient plans to go home to her fiancé and two year old daughter. The patient was admitted

on a pink slip and her pink slip ended the date of care on March 18, 2021. On March 18, 2021

T.G. signed the voluntary form to stay longer. Her support systems include her fiancé and family

members and a few close friends. Discharge plans include new medications and continued
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counseling. T.G. will no longer be prescribed Zoloft and is now taking Trileptal and Cilexa. The

counseling with change from every other week to more often being weekly at the counselor’s

discretion.

List of potential nursing diagnosis

1. Impaired ability to cope related to no coping mechanisms

Interventions: Have the patient continue to attend counseling, teach the patient different coping

skills, and have client attend group therapy.

2. Interrupted family processes related to depression

Interventions encourage the family to attend family therapy so the fiancé can learn about the

different diagnosis, encourage family members to list their strengths, and encourage family to

talk openly about patients diagnoses.

3. Risk for suicide related to physically self-damaging acts

Interventions have the patient comfortable enough to be able to talk openly about her suicide

attempt, have the patient with a one-on-one nurse until they’re deemed safe enough, and develop

a positive therapeutic relationship with the client.

4. Social isolation related agoraphobia

Interventions teach the patient coping mechanisms related to panic attacks for example to breathe

deeply, practice mindfulness, focusing on a single object, using muscle relaxation, and repeating

mantras. Another intervention is to join a support group and attend group therapy.

5. Risk for injury related to impulsivity

Interventions include using verbal intervention, assess safety of room and remove any dangerous

belongings.
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6. Risk prone health behavior related to cannabis abuse

Interventions include using open ended questions to allow for the patient to have free expression

and encourage participation in appropriate wellness programs.

7. Impaired individual resilience related to dropping out of nursing school

Interventions include having the patient identify their support systems and promote engagement

in positive activities.

8. Risk for unstable blood glucose control related to diabetes mellitus type 2

Interventions include checking blood sugars daily and administering client’s metformin.

9. Self-neglect as evidenced by greasy hair related to mental illness

Interventions include offering client encouragement to perform self-care activities, being the

client the materials needed to perform self-care activities, and give the patient a bathing schedule

to give them a sense of structure.

Prioritized list of all nursing diagnoses

i. Risk for suicide related to physically self-damaging acts

ii. Risk for injury related to impulsivity

iii. Risk for unstable blood glucose control related diabetes mellitus type 2

iv. Risk prone health behavior related to cannabis abuse

v. Self-neglect related to mental illnesses.

vi. Impaired ability to cope related to no coping mechanisms

vii. Interrupted family processes

viii. Social isolation

ix. Impaired individual resilience related to dropping out of nursing school

Conclusion

In conclusion, T.G.s childhood experiences and the heritability of different mental illnesses have

put her at a very high risk for having mental illness in her adulthood. Also her mental illness

exacerbating due to her grandmothers death is not surprising especially because T.G. considered

her grandma as a huge supporter in her life and was very close with her. The nursing diagnosis

mentioned are all appropriate in relation to T.G’s many diagnoses as well as the prioritized list.

The discharge plans and outcomes are both appropriate because they related to the plan of care in

her chart. Also milieu therapy is a very important aspect that is included in the treatment pf

patients at inpatient hospitals. Milieu therapy promotes safety, gives the patient structure, and

promotes wellness thru many different aspects included into the patients daily lives during their

stay and many of which is encouraged to continue many aspects after their stay.
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References

Barnett, J. H., & Smoller, J. W. (2009). The genetics of bipolar disorder. Neuroscience, 164(1),

331–343. https://doi.org/10.1016/j.neuroscience.2009.03.080

Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3637882/

Chapman J, Jamil RT, Fleisher C. Borderline Personality Disorder. [Updated 2020 Nov 30].

In:

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

Available from: https://www.ncbi.nlm.nih.gov/books/NBK430883/

Mancil, G.R., Conroy, M.A. & Haydon, T.F. Effects of a Modified Milieu Therapy

Intervention on the Social Communicative Behaviors of Young Children with Autism

Spectrum Disorders. J Autism Dev Disord 39, 149 (2009).

https://doi.org/10.1007/s10803-008-0613-3

Available from: https://link.springer.com/article/10.1007%2Fs10803-008-0613-

3#citeas

Slogar, S. M. (2011). Dissociative Identity Disorder: Overview and Current

Research. Inquiries Journal/Student Pulse,3(5).

Available from: http://www.inquiriesjournal.com/articles/525/dissociative-identity-disorder-

overview-and-current-research
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Videbeck, S. L. (2020). Psychiatric-mental health nursing(8th ed.). Philadelphia: Wolters

Kluwer.