Purpose
           The purpose of this case study is two-fold: (1) To allow the student the opportunity to collect and analyze assessment data and (2) to propose nursing interventions for a patient admitted to an inpatient psychiatric hospital based on sound nursing knowledge.  The assessment will focus on the major function areas: affect, speech, thought, perception, cognition, and social functioning.  Students will incorporate nursing research, which supports at least one nursing intervention, into their discussion

 

Student Approach
          The patient at the center of this case study was admitted for self-harm and suicidal ideation and was diagnosed with Bipolar Mood Disorder. During the assessment of the patient, she reported feeling overwhelmed at school and home, which had led her self-harm in order to cope with stressors. This study has allowed me to learn how social, environmental, and physical factors affect mental health.
    
Reason for Inclusion 
          This assignment is included to showcase my ability to perform an assessment and develop a nursing plan of care for an acute mental health patient. In addition, it integrates a variety of end of program behaviors that are listed below:

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• Critical Thinking

  • ​Uses decision-making skills in making clinical or professional judgment

    • Example: After assessing the patient, I formulated a nursing plan of care and decided to prioritize the nursing diagnosis of Self-Mutilation. Two other nursing diagnoses that I had come up with were Risk for Suicide and Compromised Family Coping. I decided to prioritize Self-Mutilation because it is an actual problem as opposed to just a risk and, according to Maslow’s Hierarchy of Needs, safety is the most basic of human needs.

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• Nursing Practice

  • Performs therapeutic interventions that incorporate the principles of quality management and proper safety techniques.

    • Example: In order to maintain quality management and safety, I discussed the implementation of therapeutic interventions such as educating and helping the patient to develop coping skills, offering self, keeping the patient within line of sight, and ensuring the patient did not have access to any equipment that could be used for self-harm. 

  • Implements traditional nursing care practices as appropriate to provide holistic health care to diverse populations across the lifespan

    • Example:  My patient was a 13-year-old Caucasian female in the pediatric mental health ward.  I provided holistic, traditional nursing care practice by assessing her school and home life and by helping her to develop coping skills. She mentioned that she enjoyed writing, so I suggested that she use a journal to write out her thoughts and feelings. She has a large family whom she is often around, so her plan of care included speaking to her family and educating them on her medication regimen and how to mediate conflicts.

 

• Communication

  • Uses therapeutic communication within the nurse-patient relationship

    • Example: Therapeutic communication, which included the use of open-ended questions, clarification, and offering of self, was utilized during the assessment of the patient.

 

• Teaching

  • ​Provides relevant and sensitive health education information and counseling to patients, and families, in a variety of situations and settings..

    • ​Example: The patient and family were informed on the patient’s treatment, goals, and expectations. They were also educated on the patient’s medication and administration regimen. The patient was counseled on developing coping skills that will help her during stressful situations and coping methods that can be utilized in place of cutting.