During my clinical rotation for Caring for Clients with Mental Health Alterations, NURS-4560, I was able to do my clinical work at the Parthenon Pavilion in Nashville, TN. As a requirement for this clinical, I developed a research case study for a client that suffered from Recurrent Depressive Disorder. The case study is attached.

Abstract

This case study focuses on a 56 year old female diagnosed with recurrent depression, suicidal ideation, migraines, and insomnia. Subjective and objective data, assessment, medications, and pertinent research related to the patient’s condition are included. Nursing interventions and patient goals are discussed. The role of the nurse taking care of a patient with recurrent depression and his/her responsibilities to promote a successful outcome is also discussed.

                                                                    Demographics

            P.A. is a 56 year old Caucasian female who is diagnosed with recurrent depressive disorder, suicidal ideation, migraines, and insomnia. P.A. has no known food or drug allergies. She weighs 172 pounds, stands at 5’7, and has a body mass index of 26.9. She currently smokes about a half a pack of cigarettes per day. She has two adult children and is currently going through her second divorce.

Assessment

            P.A. initially presented to Williamson Medical Center via an ambulance. Her co-workers called for the ambulance because P.A. had become extremely upset and tearful while at work and was inconsolable. Upon her assessment at the hospital, she stated that she “had nothing to live for” and that she “had no desire to live”. She was later transferred to the Parthenon Pavilion and was accompanied by a police officer. During her admission assessment, P.A. was coherent and cooperative, but did not maintain good eye contact. All of her vitals were within normal limits. Her skin assessment and her cranial nerve assessment were also within normal limits.

            The DSM-IV diagnosis criterion for P.A. was based on five axes. The Axis I diagnosis for P.A. was Recurrent Depressive Disorder. Axis II indicated that she suffered from suicidal ideation and the inability to function due to mood disturbance and Axis III showed that P.A. suffered from migraines and insomnia. Axis IV revealed that P.A. has stressful living conditions and a limited support system. Lastly, Axis V yielded a Global Assessment of Functioning (GAF) value of 30, which indicates that she has an inability to function in almost all areas (e.g. stays in bed all day), (Varcarolis, 2006).

            Physically, P.A. is at risk for cardiovascular and respiratory problems due to the fact that she smokes. She currently suffers from migraine headaches and her sleep pattern varies each night. She stated that it has been two or three years since she last slept through the night. (P.A., personal communication, September 2, 2008).

            A psychosocial assessment of P.A. indicates that she is not within normal limits. Although she does not suffer from delusions or hallucinations, she has had suicidal ideations. P.A.’s suicide plan consists of shooting herself in the head. She has not attempted suicide in the past. P.A. claims that she was sexually abused by a male neighbor at age seven, and physically abused by her first husband. P.A. has a long history of depression with poor treatment compliance (stops taking her medication when she feels better). She denies drug and alcohol use.

            P.A. does not have a known family history of mental illness. She has reported a decreased appetite, loneliness, stress, lack of motivation, hopelessness, and helplessness. She currently works full time, but lives with a new roommate who refuses to pay his portion of the rent. He told her that she will “just have to get him evicted”. (P.A., personal communication, September, 2, 2008). P.A. enjoys reading and swimming, and her stress management involves praying and taking hot baths. Her two sons live out of state and both of her parents are deceased. She has a limited support system. P.A. is aware of her illness and wants to “learn how to take better care of herself so she doesn’t end back up in the hospital”. (P.A., personal communication, September 2, 2008).

Medications

            Many different types of medications are used to treat depression, all of which target specific neurotransmitters within the brain or its respected receptor sites. P.A. currently takes a newer antidepressant medication called Wellbutrin, which is a norepinephrine dopamine reuptake inhibitor, (NDRI), and it is further explained in Table 1.

Table 1

Psychiatric Medications for P.A.

(Skidmore-Roth, 2007).

            According to Mahmoud et al, depression is the leading cause of disability worldwide, affecting more than 121 million people. Interestingly, despite a sufficient dose and duration of antidepressant treatment, symptoms do not resolve in 30% to 40% of patients. Remission, defined as the virtual absence of depressive symptoms, is important because it is associated with improved patient prognosis and functioning (Mahmoud et al, 2007).

            According to the study performed by Mahmoud et al, risperidone therapy in conjunction with antidepressant therapy reduces depressive symptoms and disability, increases response to antidepressant therapy, and increases remission rates. Additional research is needed to define the dose, duration, and treatment strategy for risperidone therapy in practice so that the many depressed people in society, like P.A., can get some relief.

Nursing Diagnoses

            P.A. is at risk for suicide related to recent divorce, stressful living environment, and limited support system as evidenced by recent suicidal ideations, suicide plan, and recurrent depressive disorder diagnosis (Varcarolis, 2006). She also suffers from situational low self-esteem related to recent divorce as evidenced by feelings of worthlessness, poor self-image, and negative sense of self (Varcarolis, 2006). In addition, P.A. also suffers from self-care deficit related to her current decline in mood as evidenced by impaired Activities of Daily Living (ADL’s), such as decreased bathing, grooming, cooking, and financial management (Varcarolis, 2006).

Nursing Planning

            Due to the fact that P.A. is suicidal, many things must be done in order to ensure that she does not harm herself while she is in the hospital, or when she is discharged. Two-short term goals that were made for P.A. in reference to her diagnosis of risk for suicide were as follows: she would express at least one reason to live by day two of her hospitalization and she will identify two outside supports that she can call upon if she feels suicidal in the future. Two-long term goals in reference to this diagnosis were as follows: P.A. will continue to take her medications as scheduled once she is discharged from the hospital and she will stay in contact with her psychiatrist and will report any suicidal thoughts that she may have to him/her in the future. Appropriate nursing interventions for this diagnosis would be to remove all dangerous objects from P.A., spend regularly scheduled periods of time with her throughout the day while conveying a compassionate and caring attitude towards her, encourage her to attend group sessions, and to suggest a number of community-based support groups that she might wish to visit upon discharge (Varcarolis, 2006).

Situational low self-esteem plays a major role in P.A.’s depression status; therefore, it is extremely important that she expresses better feelings about herself during her hospitalization. Two short-term goals that are appropriate for P.A. in regards to this diagnosis are: she will be able to name three things that she likes about herself by day two of her hospitalization and she will describe at least one of her strengths by day two of her hospitalization. Two-long term goals in reference to this diagnosis are as follows: During hospitalization, P.A. will be instructed to keep a journal, and for each day, she will log at least two things that she liked about herself during that day. She will be instructed to continue journaling upon discharge. P.A. will also spend at least one night out of her work week doing something that she enjoys, rather that just laying in the bed and watching television. Appropriate nursing interventions for this diagnosis are: encourage P.A. to engage in activities that raise her self-esteem, such as participating in extracurricular activities that she enjoys, encourage P.A. to exercise, such as yoga or Pilates, and to encourage formation of supportive relationships, such as therapy and peer support (Varcarolis, 2006).

Due to the fact that P.A. suffers from self-care deficit, it is vital that she understands the importance of taking care of herself. Two short-term goals for this diagnosis are: P.A. will bathe and groom herself without having to be told to do so before discharge and P.A. will explain the importance of performing her own Activities of Daily Living (ADL’s) before discharge. Two long-term goals for this diagnosis are: P.A. will continue to bathe and groom herself daily after discharge and P.A. will get the right amount of sleep and nutrition recommended after discharge. Nursing interventions for this diagnosis include offering frequent high-calorie and high-protein snacks throughout the day and evening, encouraging P.A. to get up and dress and stay out of bed during the day, encourage P.A. to use the toothbrush, make-up, etc. when beginning her day, and to encourage the intake of fluids.

Nursing Implementation

The nurses responsible for the care of P.A. removed all dangerous objects from her, obtained a “no self harm” contract with her for a specific period of time, and assisted her in evaluating positive and negative aspects of her life. They also encouraged the appropriate expression of her feelings, and explored usual coping behaviors. The nurses also suggested community based support groups that she could visit upon discharge. P.A. was encouraged to participate in all group sessions and to exercise. She was also encouraged to keep a daily log of her activities and feelings for each day. P.A.’s nurses spent time with her each day and explored her feelings while conveying a compassionate and caring attitude towards her. P.A. was also taught the importance of medication compliance and was encouraged to ask any questions that she had concerning her medications.  She was also encouraged to bathe regularly, and to snack if she was hungry. The nursing staff also made a point to compliment her when she looked nice. P.A. was encouraged to contact her psychiatrist or any other healthcare professional if she had any thoughts of suicide in the future.

Nursing Evaluation

I was unable to assess the progress towards the long-term goals that were established for P.A. because I was unable to see her discharged. However, I was able to assess her short-term goal progress. P.A.’s short-term goals in reference to her diagnosis for risk for suicide were met; therefore, there was no need for change. She stated that she no longer wanted to commit suicide, but, if she did feel that she wanted to in the future, that she would contact her psychiatrist. Her short term goals were also met for her diagnosis of situational low self-esteem, so again, no changes needed to be made for this plan of care. She kept a daily journal, and she was able to list qualities about herself that she liked and numerous strengths that she possessed. With regards to her self-care deficit diagnosis, she was also able to meet the short-term goals that were established; therefore, no changes needed to be made. She bathed and groomed herself appropriately, ate when she was hungry, and stayed out of bed during the day.

Personal Reflection

The care plan that was implemented for P.A. is important because it guides the healthcare team involved in her care towards meeting her short-term and long-term goals. It is vital that the team taking care of P.A. recognizes the importance of the care plan and enforces it to the best of their ability. I believe that this plan of care will definitely yield good outcomes for P.A. if it is adhered to because P.A. is already showing signs of improvement. Mental illness is very difficult for people to understand; therefore, it is important that the healthcare providers who care for the mentally ill keep an open mind and do their best to research the different illnesses that they are expected to help treat. I do believe that P.A. will recover and have a better quality of life if she works to meet her long-term goals and has a stronger support system.

                                                                    References

Mahmoud, R. A., Pandina, G. J., Turkoz, I., Gonzalez, C., Canuso, C., Kujawa, M., & Geribaldi, G. (2007). Risperidone for treatment-refractory major depressive disorder: A randomized trial. Annals of Internal Medicine, 147(9), 593-602. Retrieved September 29, 2008, from CINAHL database.

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

Varcarolis, E., Carson, V. B., & Shoemaker, N. C. (2006). Foundations of psychiatric mental health nursing: A clinical approach. (5^th ed). St. Louis, MO: Saunders Elsevier.