Case Study for 16 Year-Old African American Female Rakira Smith Diagnosed with Psychotic Depression

Case Study for 16 Year-Old African American Female Rakira Smith Diagnosed with Psychotic Depression

History of Present Illness (HPI)

The patient in this case study is a 16 year-old African American female who presents with hypersomnia, a rebellious attitude towards her adoptive parents, sadness, engaging in impulsive and dangerous pleasurable activities, and a history of self-harm and suicidality. Her admission is on voluntary basis after being referred for inpatient treatment by the psychiatric-mental health nurse practitioner (PMHNP) who has been treating her as an outpatient. This referral came through the Community Work Incentive Co-ordinator or CWIC and it was for the treatment of the patient for depression and suicidal ideation. Her chief complaint was that her adoptive mother had “invaded” her privacy by gaining access to and reading her journal in which the mother thought she had written suicidal notes. She was accompanied by her mother who thought that she was suffering from severe depression. The week before this admission the mother reports that she had stayed out late and that is when she found her diary with a note she had written to her brother to the effect that she would harm herself or run away from home. She has a significant history of suicidality as she had attempted suicide by cutting her wrist when she was ten years old. The mother thought that she was pulling away from the family members and keeping to herself more and more.

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The patient feels that he is not happy at home and that her adoptive mother does not understand her. For instance, she cites an incident in which her cell phone was confiscated by her mother ostensibly because she had been talking to strangers. She had been coming home late and also admits to lying about her whereabouts when her parents discovered that she had a girl with her at the house. She admits to being a lesbian and feels that her mother does not approve of her sexuality and sexual orientation. She denies current suicidal or homicidal ideation as well as visual or auditory hallucinations.

The mother reported also that the patient started having psychotic symptoms last year with the patient reporting auditory and visual hallucinations. The patient agreed with the mother that she would indeed be getting visual images of scenes of tragedies or violent encounters. She also concurs that she would hear voices commanding her to do some things. Her symptoms were severe and worsening and had lasted for months. They were aggravated by attempts at parental control and relieved a bit by freedom given to her. The symptoms were present all the time any time of the day. The patient however downplayed the severity of her symptoms and thought that it was only 2/10.

Past Psychiatric History

Rakira Smith has a significant psychiatric history. She has previously been diagnosed with psychosis and put on treatment and therapy. As a matter of fact, she has been having therapy with the same therapist since she was 13 years old. As at the time of admission, she was on aripiprazole (Abilify) 5 mg at bedtime, melatonin (Melatonex) 10 mg at bedtime, and atomoxetine (Strattera) 35 mg at bedtime (Stahl 2017). She had however never been admitted to a psychiatric facility before this time.

Mental Status Exam

Appearance & Behavior

Alert and oriented

Slightly heavy build and short stature

Well groomed, neat, and attentive

Normal gait

No psychomotor agitation or retardation.

Intermittent eye contact

Cooperative with the interviewer

No physical abnormalities

Attitude towards Examiner

Attentive to questions

Giving answers to questions

Behavior & Psychomotor Activity

Piercing but shifting eye contact

No psychomotor retardation

No psychomotor agitation

No stereotypical, repetitive, or other abnormal movements

Normal gait

Speech Patterns

Rate decreased

Rhythm monotone

Volume soft

Content impoverished

Mood

Self-reported: “fantastic and elated”

Affect

Depressed, irritable, and angry (dysphoric)

Range is blunted or flat

Mood incongruent

Stability: labile

Thought Process

Denies circumstantial (unnecessary detail)

Denies loose thought process (illogical movement from topic to topic)

Denies interruption of thoughts (thought blocking)

Denies flight of ideas (movement rapidly from an idea to another)

Denies repeating phrases and words (perseveration)

Thought Content

Denies misinterpretation of some aspects of the environment (illusions)

Denies preoccupations: obsessions and compulsions; suicidal ideation

Denies misinterpretation of events thinking they are having a direct reference to her (ideas of reference)

Denies unreal feelings about the outside environment (derealization)

Denies auditory and visual hallucinations (false sensory perceptions)

Denies a sensation of unreality about herself (depersonalization)

No obvious delusions (denies)

Passive Death Wish/Suicidal Ideation

Has a history of wishing to die (denies currently)

Has a history of suicidal ideation (denies currently)

Has a history of self-harm (denies currently)

Homicidal Ideation

No homicidal ideation (denies)

Delusions, Paranoia, & Preoccupations

Paranoid

Preoccupations present in the form of auditory and visual hallucinations (as evidenced by her admission to hearing voices commanding her and seeing scenes of violence and tragedy)

Not deluded

Distorted Perceptions

Denies as above

Orientation & Level of Consciousness

Alert and oriented in all aspects

Fully concious

Attention & Concentration

Attentive and focused

Can shift mental attention

Can sustain attentiveness

Memory

Immediate memory intact (as evidenced by her responding correctly when asked about the name of the interviewer)

Short term memory intact (as evidenced by her mentioning the type of food she had eaten the previous supper)

Long term memory intact (as evidenced by her remembering her math score in grade seven)

Ability to Abstract & Generalize

Ability to abstract and generalize present (as evidenced by her correct interpretation of the proverb “make hay while the sun shines”)

Intellect/ Fund of Knowledge

Moderately intelligent (from her responses to abstract questions)

Average fund of knowledge (she at times lacks the correct answer to questions) Case Study for 16 Year-Old African American Female Rakira Smith Diagnosed with Psychotic Depression

Insight

She agrees and concurs that indeed she requires treatment for her condition

Judgment

She can make good decisions

Neurovegetative Symptoms

Denies any pain

Reports excessive sleep

Reports normal appetite

Normal libido

Supplemental Assessment Findings

No evidence of physical illness from the laboratory findings

Columbia suicide severity rating scale (C-SSRS): Negative

C-SSRS Suicidal Ideation Intensity: Negative

Patient Diagnoses

Psychotic Depression (ICD-10: F32.A) (APA, 2013; Sadock et al., 2015)

Status: Active

Attention-Deficit/ Hyperactivity Disorder or ADHD (diagnosed in childhood)

Medical Diagnoses

Based on the HPI and the laboratory results, there is no medical diagnosis for this patient (Hammer & McPhee, 2018; Huether & McCance, 2017).

Laboratory Findings

Table 1

Laboratory values obtained

Basic Metabolic Panel (BMP)
Sodium level (139)	WNL
Potassium level (4.3)	WNL
Chloride level (103)	WNL
Carbon Dioxide (28.1)	WNL
Calcium (9.6)	WNL
Blood Urea Nitrogen or BUN (13)	WNL
Creatinine (0.88)	WNL
Glucose (86)	WNL
BUN creatinine ratio (14.8)	WNL
AST (16)	WNL
ALT (13)	WNL
Alkaline phosphatase (77.7)	WNL
Total bilirubin (0.7)	WNL
Total protein (6.9)	WNL
Albumin level (4.5)	WNL
Albumin globulin ratio result (1.88)	WNL
Globulin result (2.4)	WNL
Ionized calcium calculated (4.62)	WNL
Folate level (8.6)	WNL
HbA1c (5.3%)	WNL
Cholesterol (154.6)	WNL
Triglycerides (34.2)	WNL
HDL cholesterol (63.9)	WNL
Cholesterol HDL ratio result (2.4)	WNL
LDL cholesterol calculated (84)	WNL
Syphilis IgG/ IgM Antibody	Nonreactive
T4 Thyroxine free (1.08)	WNL
Thyroid Stimulating Hormone or TSH (0.899)	WNL
Vitamin D 25 Hydroxy (31.3)	WNL
General Hematology
White Cell Count total (3.53)	LOW
Red cell count (4.42)	WNL
Hemoglobin (13.5)	WNL
Mean Corpuscular volume result (93)	WNL
Hematocrit (40.9)	WNL
Mean Corp HGB (30.5)	WNL
Mean Corp HGB Conc Result (33.0)	WNL
RBC Dist Width (11.7)	WNL
Neutrophils Total # (1.44)	LOW
Lymphocytes Total # (1.78)	WNL
Monocytes Total # (0.27)	WNL
Eosinophils Total # (0.01)	WNL
Basophils Total # (0.02)	WNL
IGAB (0.01)	WNL
Neutrophils % (40.8)	WNL
Lymphocytes % (50.4)	WNL
Monocytes % (7.6)	WNL
Eosinophils % (0.3)	WNL
Basophils % (0.6)	WNL
IGRE % (0.3)	WNL
Platelets (269)	WNL

Nursing Diagnosis

A disturbance os sleep pattern related to the feeling of loneliness as evidenced by the mother’s admission to the client’s changed sleep patterns (Herdman & Kamitsuru, 2018).
Risk of self-harm related to self-inflicted injuries and suicidality as evidenced by her previous attempt at taking her own life (Herdman & Kamitsuru, 2018).

Patient Treatment Plan

Appendix A – Medication Table

Appendix B – Nursing Care Plan

Reflection

This case is one of the very special cases to me as a professional. This is because it is a case that I handled following all the protocols as they are supposed to be done. For instance, I conducted this initial psychiatric admission interview as per the laid down guidelines (Carlat, 2017). The confidentiality of the patient was respected as were other ethical principles such as fidelity, autonomy (informed consent), beneficence, and nonmaleficence (Haswell, 2019). I gave health education to the mother as well as to the patient. I also suggested to the mother that they attend family therapy as this would help her and the rest of the family cope with their daughter’s condition (Wheeler, 2020). The feedback that I got from the patient and her mother was overwhelmingly positive and it is my hope that the outcome of the management of her condition will be good and satisfactory.

The case was an opportunity for me to practice my interviewing skills as well as matters to do with practical application of knowledge gained in the cognitive domain in class. For instance, it was an opportunity for me to create a rapport that is therapeutic with the patient and to strike a lasting therapeutic bond with them. It was also an opportunity for me to practice and apply the assessment tests for depression as has been documented above. If I were to be the one following up this patient, I would have taken them also through cognitive behavioral therapy (CBT) and combined it with medications for the best of results.

Appendix I

Psychiatric Medications

Medication Name, Class, & MOA	Dose instructions with Indication	Side Effects	Patient Education
Aripiprazole (Abilify)	5 mg orally at bedtime indicated for the psychosis (Stahl, 2017)	Akathisia, insomnia, dizziness, vomiting, orthostatic hypotension, asthenia, headache amongst others (Stahl, 2017).	Look for possible weight gain especially if not overweight or obese (Stahl, 2017)
Naloxone (Narcan)	4 mg/0.1 ml intranasal STAT and prn. Indicated for respiratory depression.	Sweating, runny nose, sneezing, goose bumps, yawning, weakness, shivering or trembling, nervousness, restlessness or irritability, diarrhea, nausea or vomiting, stomach cramps, tachycardia amongst others (Stahl, 2017)	Report side effects promptly. Particularly look out for sedation and take appropriate action (Stahl, 2017)
Melatonin (Melatonex)	9 mg orally at bedtime. Indicated for the insomnia (Stahl, 2017).	Depression, anxiety, cramps, disorientation, irritability, and low blood pressure amongst others.	Causes daytime drowsiness so do not drive or operate machinery. Care must be taken on reporting side effects.
Atomoxetine (Strattera)	35 mg orally at bedtime. Indicated for ADHD.	Sedation, dry mouth, decreased appetite, constipation, dyspepsia amongst others.	Watch for side effects and teach on compliance.

Appendix B

Nursing Care Plan

Nursing Diagnosis	Goal	Intervention with Rationale	Evaluation
A disturbance os sleep pattern related to the feeling of loneliness as evidenced by the mother’s admission to the client’s changed sleep patterns (Herdman & Kamitsuru, 2018).	Short-Term: The patient will start to get some time without feeling sleepy by the end of the day and get sleep only during the night. Case Study for 16 Year-Old African American Female Rakira Smith Diagnosed with Psychotic Depression	1. The nurse will administer prescribed medications as per the dose and frequency without fail. (Stahl, 2017). 2. The nurse will counsel the patient and reinforce therapy (Wheeler, 2020).	This goal was achieved by the end of the following day.
	Long-Term: The patient will be able to sleep without any problems at night and be active during the day.	1. The nurse will continue with the follow up treatment and heath education in furtherance of the nursing care plan (Toney-Butler & Thayer (2021) 2. The nurse will play multidisciplinary role and coordinate care of this patient by bringing the efforts of the PMHNP and the therapist together (Sadock et al., 2015).	This goal is expected to be achieved by the time the patient is discharged to go home.
Risk of self-harm related to self-inflicted injuries and suicidality as evidenced by her previous attempt at taking her own life (Herdman & Kamitsuru, 2018).	Short-Term: The patient will be dissuaded from wanting to take their own life.	1. The nurse will offer psychoeducation in reinforcement of the therapy given by the therapist to make the patient love themselves again (Sadock et al., 2015). 2. The nurse will effectively monitor the patient for any signs of suicidality (Sadock et al., 2015).	This goal was achieved by the second night of admission.
	Long-Term: There will be no disturbance in sleep patterns by the time of discharge.	1. The nurse will create favorable conditions and encourage the family to do so in the long term to make the young lady feel loved and comfortable at home (Wheeler, 2020) 2. The nurse will be doing follow up visitations and giving additional psychoeducation and counseling (Wheeler, 2020).	This goal is expected to be achieved by the time of discharge.

History of Present Illness (HPI)

The patient is a 30-year-old Caucasian female who presents with psychotic symptoms, insomnia, restlessness, anxiety, and hyperactivity. She presents with grandiose, referential, and persecutory delusions as well as auditory hallucinations and admits to a past history of the current symptoms which occurred a few weeks ago. She is admitted involuntarily by emergency petition by police after causing a scene at the airport claiming that she had a flight to catch to Alaska. The symptoms are in her mind and thought process, they last for a few days’ duration before waning. Characteristically the symptoms are intense, compulsive, and persistent. They are aggravated by opposition from reasonably thinking persons. Relief is from reassurance and listening to what she has to say without being overly judgmental. She notices these symptoms all day and night and on a scale of 1-10 the severity of the symptoms is rated at 8/10.

Past Psychiatric History

Her past psychiatric history is significant in that she has been diagnosed with bipolar disorder before and placed on lithium (Eskalith). She stopped taking the lithium because she claims they were making her gain weight but also “preventing Mother Nature from talking to her”. She does not provide information about the presence of psychiatric history in her family.

Mental Status Exam

As indicated on Case 1 Reviewed, this should be words and phrases – no paragraphs- complete sentences not needed. Highlighted words are all that is needed

Appearance & Behaviour

The patient is dishevelled in appearance and wears a tank top with bright-colored lipsticks. Her hair is messy and she is wearing a lot of jewellery. She is of medium build with an upright posture. There are no prominent physical abnormalities noticed in the patient. She is alert and hyperactive all the time. Psychomotor agitation is evident as well as an excited facial expression. She is a bit uncooperative towards the examiner but answers the questions asked without maintaining good limited eye contact all the time. There is no hand wringing or abnormal gait. There are also no tremors or any other abnormal movements.

Attitude towards Examiner

She is cooperative with the examiner albeit reluctantly because she did not see the reason why she should be admitted in the first place.

Behaviour & Psychomotor Activity Repetitive

There is poor eye contact as she keeps wandering with her eyes around the room. Psychomotor agitation is evident because she keeps fidgeting all the time as though there are pins on the chair that she is sitting on. There are no stereotypical movements noted.

Speech

The rate of her speech is pressured and her prosody (rhythm is ?, intonation, and stress) denotes an emotionally charged individual full of energy and wanting to engage in activity. The volume of her speech is loud and she is also loquacious, voluble, and garrulous. She cannot stop talking about “Mother Earth” and her belief in her “investors” with whom she had intended to meet in Alaska. Her discussions with “Mother Earth” and the fact that she has a special relationship with her dominate her speech. She is also keen on letting the examiner know that she has some special powers.

Mood

Her self-reported mood is “excited” and “fantastic”. She animatedly informs the examiner that she has been feeling very good and elated these past few weeks. She says that it is “Mother Earth” who has been giving her the energy to feel the way she does.

Affect

The observed emotional state is euphoric, meaning that the mood and the affect are congruent with mood. The affect is not stable but labile.

Thought Process

This patient displays racing thoughts and a degree of flight of ideas as she shifts from one idea to another. She also does not answer the questions she is asked directly but launches into her fantasies and delusions about “Mother Earth” and the type of relationship she has with her. Even though her ideas are connected, some of them are outrageous and based solely on fantasy and false beliefs. Word salad is apparent and she also displays flight of ideas; shifting from one thought to another midstream. Her thought process is also clearly circumstantial because she often provides unnecessary details before getting to the point.

Thought Content

Her thought content is characterized by hallucination and delusions. There are clear perceptual disturbances as the patient claims to hear people talking to her. These are her “investors” and “Mother Earth”. She has preoccupations in terms of obsessions and compulsions. For instance she felt strongly that she had to travel by plane to Alaska because she believed that her “investors” were waiting to meet her there. She is also obsessed with the real issue of climate change and believes there are people who are intent on preventing her from preventing the occurrence of global warming.

She is also having illusions as she misinterprets the events that are happening in the environment. This is confirmed by her manifestation of ideas of reference. She is definitely misinterpreting events that are occurring in the outside world and assuming that they are having a direct personal reference to her. A case in point is her reference to the “Big Oil” companies that are ostensibly antagonizing her efforts at fighting climate change. She is also having hallucinations or false sensory perceptions and the most obvious ones are auditory and visual hallucinations.

There is also evidence that she feels that the outside environment is unreal. This is derealization. Also, she has a sense of unreality about herself or parts of herself. This is depersonalization. The patient also has some fixed false beliefs that she continues to firmly hold despite there being clear and reasonable contradictory evidence. These are delusions and the most prominent ones that she is displaying are grandiose delusions, persecutory delusions, and referential delusions. This patient strongly believes that she possesses some special powers and that is why she is able to communicate with “Mother Earth” on matters concerning her such as global warming. She also believes some people are out to persecute her because of the good work she is doing to save “Mother Earth.” In her world, the happenings around her with regard to nature and environmental conservation are referring to her.

Passive Death Wish/Suicidal Ideation

Denied

Homicidal Ideation

Denied

Delusions, Paranoia, & Preoccupations

As stated above, she has referential, persecutory,e.g. being watched and grandiose delusions e.g. must save Mother Earth. She also has preoccupations in the form of obsessions and compulsions to act irrationally, carelessly, and dangerously.

Perceptions

These are in the form of hallucinations and she displays both auditory and visual hallucinations e.g. ? as evidenced by her speech.

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Consciousness/Orientation

She is alert and fully conscious. The patient is oriented in space, time, and place. However, she shows some disorientation in person and event. Case Study for 16 Year-Old African American Female Rakira Smith Diagnosed with Psychotic Depression

Concentration/Attention

She lacks the ability to focus, sustain the concentration, and appropriately shift her mental attention.

Memory

The patient shows that her immediate, short- and long-term memory is are intact.Give examples of each She is not showing any form of amnesia during the psychiatric interview.

Ability to Abstract & Generalize

She has however lost the ability to abstract and generalize. For instance she is unable to interpret some simple proverbs said to her such as “blood is thicker than water.” What was her response?

Intellect/Fund of Knowledge

She can provide information as demanded ??and is clearly quite intelligent ???. How do you know that? However, it is her altered sense of proper reasoning that makes her radiate outrageous intelligence.

Insight

Her insight is poor because she clearly does not think she is sick and requires help. hospitalization This is why she is being admitted on an involuntary basis.

Judgment

Her judgment is good. This is because when asked what she will do in the event that she falls into a hole; she responded is this a quote? If so use quotation marks that she would call out for help and at the same time attempt to get out.

Neurovegetative Symptoms

She reports weight loss and a disturbance of her normal sleep patterns. She has not been sleeping well in the past several weeks because of her hyperactivity and high levels of energy. Appetite, pain, libido?

Supplemental Assessment Findings

MMSE results

There are no obvious signs of traumatic brain injury that could explain the symptoms displayed by this patient.

Mini-Mental Status Exam (MMSE): She successfully completed the MMSE and scored 30/30.

Patient Diagnoses

Psychiatric Diagnosis(es) Listing the Psychiatric diagnoses that she has already received from a doctor is all that is needed. No additional possible diagnoses, explanations or paragraphs should be included here

Bipolar I Disorder with psychotic Features: 296.44 (F31.2)

This patient has a previous history of Bipolar I Disorder. It follows that the possibility that this is an exacerbation or recurrence is high. Given that the patient's symptoms are highly similar to the diagnostic criteria (for bipolar I disorder) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, this is the most likely primary diagnosis (APA, 2013; Sadock et al., 2015). The diagnosis of bipolar I disorder is given when a patient has had at least one manic episode in their lifetime, according to the American Psychological Association (APA, 2013). This 30-year-old female patient comes with disturbed in sleep patterns (insomnia), exaggerated self-importance, distractibility, euphoria, racing thoughts or tangential thinking, hyperactivity, talkativeness, and agitation amongst others. These symptoms are those of bipolar I disorder and fulfil the DSM-5 diagnostic criteria perfectly. They show that she is in the manic phase of bipolar I disorder.

At least some or majority of the DSM-5 diagnostic criteria that must be met for the diagnosis of bipolar I disorder to be made, just as in the case of this patient. During the manic episode such as the one in which this patient is presenting with, there must be: delusions of grandeur; psychomotor agitation; flight of ideas; abnormally increased intensity in goal-directed activity; reckless and risky behaviour; impairment in social, self, and occupational functioning; and the impossibility of attributing the symptoms to the effects of a substance/ drug or another medical condition (APA, 2013; Sadock et al., 2015). This is specifically Bipolar I Disorder with mood-congruent psychotic features according to the DSM-5. During manic episodes, the subject matter of all delusions and hallucinations is consistent with typical manic themes of grandiosity, invulnerability, and so on; but may also include themes of suspiciousness or paranoia. This is particularly in relation to others' misgivings about the patient's abilities, achievements, and so on.

Substance-Induced Psychotic Disorder: 9 (F19.259) Has a doctor diagnosed this??

During the laboratory testing for this client, a urine drug screen was performed. The results showed that she is using cannabis and cocaine as these were positive. This patient has therefore been using and abusing substances for a while, especially cannabis and cocaine. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5, the symptomatology of this diagnostic closely mimics that of schizophrenia in every regard. In reality, cannabis usage, especially during youth and early adulthood, has been linked to the later development of psychosis (APA, 2013; Sadock et al., 2015; Stahl, 2013).

Paranoid Schizophrenia: 90 (F20.9)

Paranoid schizophrenia is the second most likely alternate diagnosis for the client. She is presenting with hallucinations and persecutory delusions that conform to the DSM-5 diagnostic criteria for paranoid schizophrenia. Because the symptoms presenting fulfill the DSM-5 diagnostic criteria for paranoid schizophrenia, this is the situation. At least two of the following signs must be present, according to the DSM-5, for a diagnosis of schizophrenia to be made: hallucinations and/ or delusions (positive symptoms), catatonia, and negative symptoms (like disorganized speech, avolition or lack of motivation, and anhedonia or inability to enjoy happiness. In addition, the symptoms must have considerably reduced functioning in at least one area, such as self-care or occupation, and the disruption must have persisted at least six months (APA, 2013; Leucht et al., 2019; Sadock et al., 2015). The symptoms for this patient are only weeks old. This is what appears to rule this diagnosis of schizophrenia out for the moment.

Medical Diagnosis(es) Listing the Medical diagnoses that she has already received from a doctor is all that is needed. Based on your HPI and MSE, the patient does not have any Medical Diagnoses

Infection

Assessment and investigation of this patient showed no significant physical abnormalities. However, the laboratory tests on the white blood cell count revealed that the patient has a leukocytosis. This may mean that there is an infectious process going on in the patient (Hammer & McPhee, 2018; Huether & McCance, 2017). The presence of an infection requires the administration of broad-spectrum antibiotics.

Dehydration

Another finding on the performance of a full blood count in the laboratory was that of an elevated hemoglobin level and hematocrit. This could clinically mean that this patient is suffering from dehydration (Hammer & McPhee, 2018; Huether & McCance, 2017). This is a plausible scenario because this patient is not sleeping and is hyperactive. The chances of getting dehydrated are therefore very high.

Table 1

Pertinent Lab Values

Basic Metabolic Panel (BMP)
Sodium	WNL
Potassium	WNL
Chloride	WNL
Bicarbonate	WNL
Blood Urea Nitrogen (BUN)	WNL
Creatinine	WNL
Glucose	WNL
Complete Blood Count
Hemoglobin	Elevated
Hematocrit	Elevated
Platelets	WNL
White Blood Cells (WBC)	Elevated
Blood Alcohol Level (BAL)
Ethanol	0.04% (WNL)
Urine Drug Screen (UDS)
Cannabinoids	Positive
Cocaine	Positive
Other Laboratory Tests
Lithium	0.0 ml/Eq

Nursing Diagnosis(es)

The following are five of the most important nursing diagnoses that address the patient’s needs and relate to their psychiatric-mental health condition (Herdman & Kamitsuru, 2018): Citation should follow each diagnosis

Disturbed sleep pattern related to hyperactivity and agitation as evidenced by the patient’s statement that “Mother Earth” has talked to her to work hard and save the Planet. Case Study for 16 Year-Old African American Female Rakira Smith Diagnosed with Psychotic Depression

Self-care deficit related to an altered sense of appreciation of reality as evidenced by the patient’s dishevelled appearance and unkempt hair.
Ineffective impulse control related to the preoccupations of obsession and compulsion to act recklessly, as evidenced by her going to the airport to board a plane to Alaska without booking.

Dysfunctional family processes related to social and interpersonal dysfunction as evidenced by the patient’s unwillingness to find out about her husband and be with him.

Ineffective sexual pattern related to recklessness and hyperactivity as evidenced by the patient’s admission that she is not getting enough sex.

Patient Treatment Plan

Appendix A – Medication Table

Appendix B – Nursing Care Plan

This patient’s treatment plan will comprise of medications and psychotherapy. The medications prescribed for her are olanzapine (Zyprexa), lithium carbonate (Eskalith), and lorazepam or Ativan (Stahl, 2017). Psychotherapy will involve individual sessions of cognitive Behavioral therapy or CBT for cognitive remodelling and restructuring (Corrigan, 2016; Wheeler, 2020).

Reflection

This interview with the 30-year-old Caucasian female patient is an exercise that I performed to satisfaction. This is because I made sure that all the guidelines on the psychiatric interview were followed (Carlat, 2017). I asked for informed consent all the time before performing anything on the patient. This part of the bioethical principle of autonomy (Haswell, 2019) is very important even though the patient’s insight is impaired. My perceptions of mental and Behavioral health changes since the beginning of the semester have changed tremendously. I am now more competent in terms of the psychomotor and affective domains of learning with regard to my specialty. What feedback did you receive from the standardized patient?

I have been able to apply what I learnt in lectures (cognitive domain) in many instances in the clinical setting. For instance, I have been able to interview patients such as Maryanne Murphy never use a patient’s name and admit them as the student admitting nurse. This has given me the opportunity to sharpen my skills and develop the confidence required for me to be an effective professional after graduation. I have also been able to apply what was learnt in theory by performing assessment tests such as the Beck Depression Inventory (BDI-II), the Patient Health Questionnaire or PHQ-9, and the positive and negative symptom scale or PANSS score.

Appendix A

Psychiatric Medications

Medication Name, Class, & MOA	Dose instructions with Indication	Side Effects	Patient Education
Olanzapine (Zyprexa)	10 mg orally BID. Indicated for reduction of the manic symptoms and as an adjunctive treatment to lithium (Stahl, 2017)	Restlessness, depression, weakness, ataxia, unusual behaviour, dizziness, and constipation amongst others (Stahl, 2017).	Expect problematic weight gain. It is better to start exercise and dieting early. It also commonly causes sedation but this is temporary (Stahl, 2017)
Lithium carbonate (Eskalith)	300 mg orally TID. Indicated as the main treatment for the mania.	Thirst, fine tremors, drowsiness, fatigue, increased frequency of micturition, dizziness, and weight gain amongst others (Stahl, 2017)	Report side effects promptly. The drug commonly causes weight gain and so this should be expected. Exercise and diet can help. Also expect sedation but this will wear off with time (Stahl, 2017)
Lorazepam (Ativan)	1 mg orally 4 hourly as required for anxiety and agitation	Dry mouth, weakness, nausea, diarrhea, dizziness, amongst others.	There is great potential for abuse. Care must be taken.

Appendix B

Nursing Care Plan

Toney-Butler and Thayer (2021)

Nursing Diagnosis	Goal	Intervention with Rationale	Evaluation
Ineffective impulse control related to the preoccupations of obsession and compulsion to act recklessly, as evidenced by her going to the airport to board a plane to Alaska without booking.	Short-Term: The patient will start settling down by the end of the shift. Case Study for 16 Year-Old African American Female Rakira Smith Diagnosed with Psychotic Depression	1. The nurse will administer prescribed medications as per the dose and frequency without fail. The lithium and olanzapine are the main medications that will enable remission of symptoms (Stahl, 2017). 2. The nurse will offer psychoeducation to the patient. Counselling is helpful as it enables the patient to see what is wrong with them (Wheeler, 2020).	This goal was achieved by the end of the shift.
	Long-Term: the patient will have no hyperactivity and psychomotor agitation demonstrate predicable behaviour patterns by discharge. the time she will be getting discharged. Goals should be written as to what the desired outcome will be - what the patient will do to achieve the outcome	1. The nurse will conduct home visitations to continue care despite the care transition to the home environment. Home visits enable the nurse to correct social determinants that may affect treatment continuity (Toney-Butler & Thayer (2021) 2. The nurse will partner with the home caregivers, the social worker, and other interprofessional team members to see that the patient remains in remission. To realize steady remission there must be continuity of care in a multidisciplinary manner (Sadock et al., 2015).	This goal was also achieved by the time the patient was transitioning home.
Disturbed sleep pattern related to hyperactivity and agitation as evidenced by the patient’s statement that “Mother Earth” has talked to her to work hard and save the Planet.	Short-Term: The patient will get some sleep during the first night. Increase her preadmission hours of sleep by 1 hour.	1. The nurse will encourage the patient not to sleep during the day but only at night. Many patients who experience insomnia often feel sleepy during the day (Sadock et al., 2015). 2. The nurse will advocate for sleep hygiene. Many people who have insomnia cause it or worsen it by for instance taking coffee, listening to music, or watching movies till late before sleeping (Sadock et al., 2015).	This goal was achieved on the first night albeit with some difficulty at first.
	Long-Term: There will be no disturbance in sleep patterns by the time of discharge. Patient will go to be at a consistent time, sleep through the night and wake up at a consistant time in the morning.	1. The nurse will assist the patient with sleep hygiene every night until the patient is used to creating the conditions necessary for sleep. 2. The nurse will be conducting hourly rounds to help the patient with problems that may be keeping them awake. Most of the time psychological issues may keep a patient awake at night and giving a listening ear and empathy can reassure the patient and help them sleep (Wheeler, 2020).	This goal was achieved with a lot of success.

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