Experienced–Based Knowled
Below is a copy of the case study that I wrote on a client at one of the facilities we went to for mental health.
Demographics M.F. is a forty-one year old married Caucasian male who came to the Parthenon Pavilion with a diagnosis of major depressive disorder (MDD) without psychotic features. His diagnosis further included post traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and substance abuse/dependence. He is allergic to codeine and hydrocodone. He is five foot eleven inches and weighs two hundred and twenty pounds. His highest level of education is a masters degree in engineering. Major Depressive Disorder Depression is increasingly causing disability in Americans. No one really knows what causes depression, but speculation is that the roots are found in psychological, biological, and/or cultural variables. The DSM-IV-TR criteria for diagnosing MDD is: represents a change in previous function, symptoms cause clinically significant distress or impair social, occupational, or other important areas of functioning. Five or more of the following occur nearly every day for most waking hours over the same 2-week period: depressed mood most of the day, nearly everyday, anhedonia, significant weight loss or gain (more than 5% of body weight in 1 month), insomnia or hypersomnia, increased or decreased motor activity, anergia (fatigue or loss of energy), feelings of worthlessness or inappropriate guilt (may be delusional), decreased concentration or indecisiveness, or recurrent thoughts of death or suicidal ideation (with or without pain) (Varcarolis, Carson, & Shoemaker, 2006). It is usually managed with a combination of counseling and communication strategies, health teaching, promotion of self-care activities, milieu management, psychotherapy, social skills training, group therapy, and psychopharmacology (Varcarolis et al., 2006). Medication M.F. is on five medications Serzone, Zanaflex, Cymbalta, Lyderm, and Zantac. Serzone is a selective serotonin reuptake inhibitor (SSRI) designed to help relieve his major depression. According to the Prentice Hall Nurse’s drug guide (2008) Serzone provides an antidepressant effect with minimal cardiovascular effects, fewer anticholinergic effects, less sedation, and less sexual dysfunction than other antidepressants. When he arrived at the Parthenon, his dose was 100 milligrams (mg) but they increased it to 250 mg on the second day of being at the Parthenon. Zanaflex is a central skeletal muscle relaxant and antispasmodic. He takes his for muscle spasms located in his back. Cymbalta is classified as a serotonin norepinephrine reuptake inhibitor (SNRI). Lyderm is a topical corticosteroid that is used to for relief of inflammation. The facility uses the Lyderm cream by putting it on a patch which is placed on his back for muscle spasms. Zantac is an antisecretory (H2-receptor antagonist) that is being used for his gastrointestinal (GI) distress. The information on the dose, route, schedule, purpose, side effects, and patient teaching for all of the medications is located in table 1. Table 1 Medication Management for M.F. Medication Dose Route Schedule Purpose Side Effects Teaching Serzone 250 mg PO BID Relieve depression Headache, dizziness, drowsiness, liver failure Report suicidal ideations. Do not use within 14 days of stopping a Monoamine oxidase inhibitor (MAOI). Zanaflex 4 mg PO HS Management of increased muscle tone associated with spasticity. Dizziness, Hypotension, bradycardia. Dry mouth Do not use alcohol. Change positions slowly Cymbalta 60 mg PO QD Treatment of major depression Insomnia. nausea, dry mouth, decreased libido Do not start within 14 days of the last dose of an MAOI’s. Do not use alcohol Lyderm 0.05% cream Topical BID Relief of inflammation Impaired wound healing, pruritus, xerosis Do not use near eyes, follow instruction of physician. Zantac 150 mg PO QD Treatment of gastroesophageal reflux disease and heartburn. Headache, malaise Do not supplement therapy with over the counter remedies for gastric distress or pain without physician's advice. Assessment and Patient History M.F. came to the Parthenon Pavilion voluntarily due to suicidal ideations and a decrease in functioning related to depression. He was admitted with a diagnosis of major depressive disorder (MDD) without psychotic features, combined with post traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and substance abuse/dependence. The DSM-IV axis system was used with this patient. The Axis I Diagnosis indicated major depression, recurrent, severe without psychotic features, PTSD, GAD, alcohol dependence, and cannabis abuse. Axis II indicated he had an antisocial personality disorder. Axis III indicated migraine headaches and GI distress. Axis IV showed severe legal, financial, relationship, and occupational problems. On Axis V his current score on the Global Assessment of Functioning (GAF) scale was a 25. This means he has serious impairment in his judgment and an inability to function in almost all areas. Physically, M.F. is at high risk for liver problems related to the amount and frequency of alcohol consumption. He reported to drinking twenty-four cans of beer a day, five or six days a week (M.F., personal communication, September 8th, 2008). He could also potentially be at risk for bedsores related to his depression and not getting out of bed or moving all day. All the stress in his life could cause him to develop a stress ulcer. There are several psycho-social problems that M.F. is encountering. After talking with him, he stated that he feels a lot of stress and anxiety related to legal, financial, relationship/family and occupational problems. He has been married for only five months and has a four month old son which compounds all of the stressors in his life. When he is released from the Parthenon, he will be required to serve forty-five days in jail for a third driving under the influence (DUI) charge. Being away from his baby for this amount of time is not something he wants to do (M.F., personal communication, September 8th, 2008). Financially and occupationally he feels stress related to having just lost his job because he had to take so many unexpected days off related to his wife’s post-partum depression and mental problems (M.F., personal communication, September 8th, 2008). He claims that his wife is “crazy”. He alleged she smashed a four thousand dollar guitar of his because she got mad, left a goldfish in the sink to die because she did not like the way it was bullying the other fish, and tried to stab him because he was ten minutes late coming home from the store (M.F., personal communication, September 8th, 2008). He said that “he would not be surprised if she stabbed him in the back one night while he was sleeping” (M.F., personal communication, September 8th, 2008). He voiced concern for the well-being of his son while he is at the Parthenon. Currently, the baby is staying with his wife’s parents, who he maintains are also crazy (M.F., personal communication, September 8th, 2008). He planned to commit suicide by taking an overdose of forty Tylenol PM capsules. He also stated that he has a gun in the house. He claims that he is not sure he could ever follow through with his plan because he worries about what would happen to his son (M.F., personal communication, September 8th, 2008). M.F. has a family history of mental disease, with his two brothers, mother, and maternal grandparents all having major depression. His paternal grandmother was a paranoid schizophrenic. Alcoholism runs on his father’s side, affecting his father and five uncles, all of whom have committed suicide. At the age of nineteen, he started drinking. The amount and frequency has increased gradually over the years (M.F., personal communication, September 8th, 2008). He is aware of his illness and is trying to get to the point where he can function “normally” and take care of his family (M.F., personal communication, September 8th, 2008). His depression is the result of ten years of verbal, sexual and physical abuse by his father, he believes (M.F., personal communication, September 8th, 2008). He considers some of the obstacles in his path to recovery to be having no support system and excessive drinking habits. He expresses feelings of isolation because both of his parents are dead, he has no family nearby, and he has no friends. M.F. lives with his wife and four month old son in a two bedroom house and he got fired from his job a month ago. Coping strategies he employs are running, sleeping a lot, and drinking alcohol (M.F., personal communication, September 8th, 2008). His highest priorities are finding another job, properly raising his son, and helping his wife receive psychiatric help. Currently he is being treated with medication and group therapy. Nursing Diagnosis The top three nursing diagnoses for M.F. are risk for suicide, ineffective coping, and bathing/hygiene self-care deficit. M.F. has a risk for suicide related to suicidal ideations, an actual plan, feelings of anger, hopelessness, and anxiety, sleep disturbance, problems with depression, and substance abuse. He exhibits ineffective coping related to situational crisis as evidenced by suicidal ideas, feelings of despair, hopelessness, guilt, and anxiety, not going to group therapy, sleeping all day, not going down to the cafeteria to eat, and not going to the gym. He experiences bathing/hygiene self-care deficit related to feelings of worthlessness and hopelessness as evidenced by not bathing or brushing his teeth for two days, and a slight odor (Schultz & Videbeck 2005). Plan Two short-term goals to aid in reducing the risk for suicide are that he will not harm himself while at the Parthenon and he will report a decrease in suicidal ideations. To accomplish these goals, the nursing interventions would be to make sure all items that could be used for harm are out of his environment and assess by asking him twice a day if he is having any suicidal ideations (Schultz & Videbeck, 2005). Two long-term goals would be that after discharge, M.F. will attend a therapy session once a week with a mental health professional and maintain safety by keeping all dangerous objects out of the house. To achieve these goals, an intervention will be to give the client the phone numbers of mental health professionals and crisis hotlines. Another intervention will be a recommendation that guns and knives are taken out of the house as soon as possible (Schultz & Videbeck, 2005). To assist M.F. with his difficulty with ineffective coping, short-term goals for him will be to vocalize feelings of hope and alternative ways of dealing with stress and emotional problems by the time he is discharged. The nursing interventions implemented will be to encourage him to vocalize each day one positive strategy to deal with stress and problems, to have a member of the healthcare team set aside at least fifteen minutes each shift to talk with M.F., utilizing true presence, or just be present with him if he does not feel like talking, and to encourage him to attend at least one group therapy session a day. Long-term goals will be that he will stop using alcohol to cope, keep taking his medications as prescribed by his physician, attend at least one depression support group a week, and employ one positive new coping strategy. To support these goals he will be given the days and times of Alcoholics Anonymous (AA) meetings, the names and phone numbers of depression support groups, and be instructed to see his physician if he feels like the medication is not being effective (Schultz & Videbeck 2005). Due to feeling very depressed and unmotivated to do anything, bathing/hygiene self-care deficit became a problem. Short-term goals are he will take at least one shower a day and he will brush his teeth at least twice a day while he is at Parthenon. Three interventions will be to give him two shower times and let him chose which one he would like, give him the choice of which toothpaste to use (either the gel or paste) and make sure he takes his Serzone and Cymbalta as ordered by his physician. Long-term goals will be to maintain a daily routine that meets his physiologic and personal needs and to take his antidepressants as prescribed. To support these goals, a healthcare member will explain to him the long term importance and benefits of good hygiene and a regular medication schedule (Schultz & Videbeck 2005). Implementation M.F. had all harmful items such as razors, belts, and sharp objects kept away from him to help prevent him from inflicting harm on himself. He was asked twice daily to fill out a questionnaire on his mood and was assessed by a nurse who asked if he was having any thoughts of suicide. Names and phone numbers of a couple of psychiatrists in the area and the suicide hotline phone number were offered to him. He was instructed to come back to the Parthenon if he started having further suicidal thoughts. Recommendations were made to him that he take all guns and knives out of the house after being discharged. He was encouraged to take a few moments a couple times a day to identify a positive way to deal with stress and problems and was given suggestions if he requested help. Teaching of deep breathing techniques was performed when he started to feel overwhelmed. A member of the health care team sat down with him for fifteen minutes and gave him a chance to talk about whatever topic he chose or just be present if he chose not to talk. He was also encouraged to go to at least one group session a day. Due to M.F. voicing a desire to quit drinking and needing support, he was given a list of AA meetings and depression support groups with times and days that worked best for his schedule and were near enough that he could attend when he was discharged. He was reminded that he would need to see his regular physician if he felt like the medication was not being effective. A choice was given whether he wanted to shower in the morning or the evening and what kind of toothpaste he wanted to use. This was done so that he could participate as much as possible in his plan of care. He was informed when it was time for his two antidepressants and the nurse made sure he swallowed them. Education was done as to some of the long term benefits (healthy skin, smell good, clean hair, and good breath) of good hygiene and some of the consequences (teeth could rot, people might not want to be around you if you smell, and appearing dirty) of not following a good healthy routine. He was taught that if he did not keep taking his medication regularly, he could possibly have to come back to the Parthenon, which would be time away from his son. Evaluation M.F. was very open to all the interventions and suggestions. He denied having any suicidal ideations. In response to being offered suggestions of some mental health professionals, he did vocalize that he would schedule an appointment at discharge with a psychiatrist that he liked and who had helped him in the past. He also agreed to remove the gun and sharp knives from the house. By the second day, M.F. was receptive to talking about some positive ways to deal with his stress and problems. He stated that he would find a good friend that he could talk honestly and openly with and continue his running to help him deal positively with the stress in his life (M.F., personal communication, September 8th, 2008). When engaged in fifteen minutes of true presence, he wanted to talk about his son. He said that he liked talking about him because it helped him feel hopeful about the future and gave him a reason to try to cope with the stress and negative things in his life (M.F., personal communication, September 8th, 2008). He decided to go to the last group therapy session of the day. He happily took the list of support groups and AA meetings so that he could attend them after discharge (M.F., personal communication, September 8th, 2008). He repeated back his understanding that he would need to see his doctor if he started to feel very depressed again. The first day he refused to take a shower or brush his teeth stating that he did not want to or have the energy to do so (M.F., personal communication, September 8th, 2008). The second day he was more cooperative and chose to take his shower in the evening and use the gel type toothpaste. He took his pills both days, as scheduled, and swallowed them. He agreed to follow a good, regular routine to care for himself. He expressed a desire to stay healthy for his family. All of the short-term goals were met and no changes need to be made. Due to him not being discharged before I left, I can not evaluate the success of the long-term goals, but he did vocalize that he would follow through with all of them. He appeared very open to suggestions and interventions that I believe he will follow through with and no changes will need to be made. Personal Reflection The care plan is important because it gives a physical document that everyone can look at so that the continuum of care is being consistently followed on all shifts. Goals should be identified so everyone can work together on them. Care plans give clear interventions and goals that can be evaluated and changed if not working. I have learned from this assignment a couple of things. I learned that the clients in psychiatric hospitals need rules and structure more so than normal hospital patients. You can not be their friend and you must establish and maintain boundaries. It taught me that psych patients are complex and you may need to try several different interventions until you find one that works. I believe that my plan of care will yield good outcomes for M.F. He was very receptive while I was there and he met all the short-term goals. M.F. was making progress everyday. I believe that his desire to be a positive force in his son’s life will be the motivating factor for M.F. to continue with his plan of care and follow it through to a positive outcome. References Carson, V.B, Shoemaker, N.C., & Varcarolis E.M.(2006). Foundations of psychiatric mental health nursing: A clinical approach. (5th ed.). St. Louis, MI: Elsevier. Schultz, J. M., & Videbeck, S.M. (2005). Lippincott’s Manual of Psychiatric Nursing Care Plans, (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Shannon, M.T., Shields, K.M., Stang, C.L., & Wilson, B.A. (2008). Prentice Hall Nurse’s Drug Guide,. Upper Saddle River, NJ: Pearson Prentice Hall.
