Mental Health Case Study

 

Chassie E. Turnbow

 

Middle Tennessee State University

 

 

Abstract

 

This is a case study on a patient, D.R., who was diagnosed with major depressive disorder at a young age. Her background information and history are integrated within this paper. Major depressive disorder is a very serious and life altering mental disorder. The study discusses patient assessment, patient history, medications, goals, interventions, and evaluation of nursing care.

Introduction

            Major depressive disorder (MDD) is characterized by one or more depressive episodes and no history of manic or hypomanic episodes. (Carson, Shoemaker & Varcarolis, 2006). It can affect a person by interfering with their social and physical health. Major depressive disorder (MDD) may or may not have psychotic features.

Demographical Data

            D.R. was admitted to the hospital on September 12^th, 2007 with a diagnosis of major depressive disorder (MDD) with psychotic features, suicidal ideation with plan and auditory hallucinations. D.R. is a twenty-two year old Caucasian female with a twelfth grade education. She weighs three hundred thirty pounds and is four feet five inches. The patient had a body mass index of eight-three. She is Pentecostal and attends church on a regular basis. D.R. has a drug allergy to Topamax, which caused a red rash. D.R. (Personal Communication September 23, 2007).

Medications

Practice guidelines for major depressive disorder include medication and psychotherapy combined as a first line treatment. It is recommended that patients receive antidepressant medications for a minimum of six to twelve months at a consistent dose after resolution of an acute attack. The recommended antidepressant medications are selective serotonin reuptake inhibitor (SSRI), tricyclic antidepressant (TCA), serotonin norepinephrine reuptake inhibitor (SNRI), norepinephrine reuptake inhibitor (NRI), or dopamine agonist (DA) can be prescribed as first-line treatment of MDD. Patients diagnosised with major depressive disorder (MDD) expressing suicidal ideation and plan should be referred to specialist before certain medications are prescribed.             National Guideline Clearinghouse (2008). Refer to table 1 for dosage, purpose, frequency, side effects and patient/nurse teaching for patient’s current medications.

Assessment Data

D.R. had a history of admissions to the Parthenon and was admitted, prior to current admission, in July and discharged. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) was used to manage and address the patient’s physical and mental problems. The manual helps to classify mental disorders by constructing five separate diagnostic categories or axis. The patient’s Axis I diagnosis was major depressive disorder, severe, recurrent, with psychotic features. Axis II was deferred. Axis III indicated that the patient suffered from achondroplasia, hypertension, history of tachycardia, acid reflux and morbid obesity. Axis IV revealed a lack of primary support for the patient. Axis V was a global assessment of functioning score of twenty-five indicating that the patient was a danger to herself and was influenced by auditory hallucinations.

The psychosocial assessment of the patient was not within normal limits. The mental status examination of the patient revealed an overall poor appearance. The patient was not participating in self-care, her posture was poor, she avoided eye contact and appeared insecure. She had a flat affect and was very depressed. D.R. currently lives with her adoptive mother and sister and has never been married. She calms to be verbally abused by her adoptive mother. She denied alcohol and drug abuse. Her mother committed suicide, when she was one year of age, by a self-inflicted gunshot wound. She has a history of suicidal attempts and was eighteen the first time. The patient had cut herself on two different occasions and had overdosed once. She calmed to hear voices telling her to kill herself. She is currently on disability and does not have a job. She did not express concern about her morbid obesity and felt it was pointless to care for her health. The patient is physically at risk for a number of diseases. Her weight, lack of exercise, and overall poor health puts her at risk for diabetes, heart disease, cancer, stroke and a number of life threatening diseases. The source of history was the patient and patient’s chart. Current treatments and therapies included group activities and medications. D.R. (Personal Communication September 23, 2007).

Role of Nurse Agency

            The care plan for the patient addressed the most significant compliant which was major depressive disorder. The patient had complaints of depression, low self-esteem, lack of motivation and voices telling her to kill herself. The priority nursing diagnosis, for the patient, was risk for suicide related to depression as evidenced by suicide attempt and verbalization of intent and plan. The short-term goals for the patient were to seek help when feeling self-destructive, for the patient to express painful feelings, and for the patient to identify three non-pharmacological stress relievers. All goals were to be meet by the end of the second day with the patient. The long-term goals for the patient were to consistently use suicide prevention and social support groups in the community. The first intervention for the patient was to assess suicide status and make a future plan. The second intervention addressed helping the patient refocus and giving the patient opportunities to express feelings. The third intervention was to help the patient identify three non-pharmacological measures that helped with the pain. The first intervention was successful because the patient agreed to talk about suicidal thoughts, made a verbal agreement not to hurt herself, and agreed to call a help line if she found herself in a crisis. The second intervention was not successful because the patient was not active in her plan for the future and felt it was waste of time. The third intervention was somewhat successful. She began to look at alternative measures of stress relief. The long-term goals were not yet met but the patient was given information on local support groups and numbers for the suicide crisis line and for the suicide prevention center.

Personal Reflection

Conclusion

In conclusion, the patient suffered both mentally and physically with her condition. She expressed dissatisfaction with the care she received because she felt that she was nothing more than a days work. Caregivers had to reassess the patient’s situation and restructure her plan of care. The little things are vital to patient care standards and patient satisfaction. Taking the time to be empathic and listen is sometimes the most important aspect to a care plan.

References

Carson, V.B., Shoemaker, N.C. & Varcarolis, E.M. (2006). Mood Disorders: Depression.

Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. (5^th ed.). (pp.326-357) St. Louis, MO: Saunders.

National Guideline Clearinghouse. (2008). Practice Guidelines for Management of

Major Depressive Disorder. Retrieved October 6, 2008, from National Guideline Clearinghouse Web Site: http://www.guideline.gov/summary/summary.aspx?doc_

id=9632&mode=full&ss=15#s23.

Skidmore-Roth, L. (2007). Mosby’s drug guide for nurses, (7^th ed). St. Louis, MO:

Mosby.

 

Table 1      

Medication	Dose	Route	Schedule	Purpose	Side Effects	Teaching
benztropine (Cogentin)	0.5mg	PO	H.S.	Decrease involuntary movements	Confusion, anxiety, dizziness, tachycardia, dry mouth, muscular weakness, cramping, heat stroke	Use caution in hot weather. Do not abruptly discontinue. Do not drive. Maintain good oral hygiene. Hard candy and sips of water to help with dry mouth.
carbamazepine (Tegratol XR)	400mg	PO	B.I.D.	Absence of seizures and decrease neuralgia pain	Drowsiness, fatigue, paralysis, hypertension, thrombocytopenia, renal failure, aplastic anemia	Monitor B/P, Blood studies and liver function. Wear medical alert bracelet. Do not drive or discontinue abruptly. Report chills, rash, abdominal pain, blurred vision or dizziness.
lorazepam	0.5mg	PO	T.I.D./ PRN	Relieve Anxiety, Induce Sleep, Relaxation	Dizziness, Drowsiness, Confusion, Orthostatic hypotension, ECG changes, tachycardia, apnea, dry mouth, constipation	Give with food or milk. Avoid OTC medication. Do not discontinue abruptly. Stand slowly dizziness may occur.
olanzapine (Zyprexa)	20mg	PO	H.S.	Decreases psychotic symptoms	Extrapyramidal symptoms, seizures, headache, drowsiness, fatigue, hypotension, tachycardia, urinary retention, cough, muscle twitching.	Assess mental status. Monitor I&O, bilirubin, CBC, urinalysis. Teach patient to use good oral hygiene. Avoid hazardous activities. Avoid hot tubes, hot showers or baths since hypotension may occur. Do not abruptly discontinue.
sertraline (Zoloft)	200mg	PO	Q.D.	Relief of depression	Insomnia, agitation, dizziness, headache, tremor, fatigue, diarrhea, nausea, dry mouth, flatulence.	Assess mental status and suicidal tendencies. Do not take with alcohol. Therapeutic effects may take 1 week. Do not discontinue with out consulting doctor. Increase fluids. Wear sunscreen.
ziprasidone (Geodon)	160mg	PO	Take with supper	Decreases signs and symptoms of psychosis.	Extrapyramidal symptoms, drowsiness, insomnia, agitation, anxiety, headache, seizures, tachycardia, prolonged QT/QTc, sudden death, weight gain.	Assess mental status before administration. Assess for Extrapyramidal symptoms. Teach patient and family hypotension may occur, do not discontinue abruptly, increase fluids, report blurred vision, do not drink alcohol.