Nursing Major Depressive Disorder Case Study

Major Depressive Disorder (MDD) UNFOLDING Reasoning STUDENT Marilyn Smith, 28 years old Primary Concept Mood and Affect Interrelated Concepts (In order of emphasis) 1. 2. 3. 4. 5. 6. © 2016 Keith Rischer/www.KeithRN.com Stress Coping Clinical Judgment Communication Collaboration Patient Education History of Present Problem: Marilyn Smith is a single, African American 28-year-old female who presents to the emergency department with complaints of “feeling crummy” for the past six months. She reports that she no longer feels like doing any of the things she used to enjoy. “It all seems so pointless.” She can’t even bother to eat most days and has lost weight recently. Although she has no energy, she finds it difficult to both fall sleep and stay asleep. Even when she does manage to fall asleep, she never feels rested when she awakes. She reports having difficulty at work as a computer support person because it is so hard for her to concentrate. Last week she called in sick and spent the day in bed crying off and on all day. Last night she found herself crying again and this time she also thought about suicide, which scared her and prompted a visit to the ED. “I don’t want to live like this anymore. I feel like I will never be happy again.” Personal/Social History: Marilyn graduated from high school and obtained an associate degree in computer science. She enlisted in the Army to have an adventure and hoped the GI bill would pay for further education once she completed her service. She reports she still feels guilty about making the decision to enlist instead of marrying her high school sweetheart. She was deployed to Iraq and returned home a year ago. She enjoyed her time in the service because she felt she was doing something useful for her country. She did not see combat and did not experience any significant problems while in Iraq. When she returned home, she found out her old boyfriend had married. She recently attempted to contact local universities to explore completing her baccalaureate degree but found the process too overwhelming and just gave up. When questioned about use of alcohol or drugs, Marilyn reported that she is an occasional drinker, but recently has been drinking more in an attempt to sleep. Denies other drug use. Marilyn has no history of clinical depression. Her grandmother had periods of becoming withdrawn and not leaving the house for days. What data from the histories are RELEVANT and have clinical significance for the nurse? RELEVANT Data from Present Problem: Clinical Significance: RELEVANT Data from Social History: Clinical Significance: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment (5th VS): T: 98.8° F/37.1 (oral) Provoking/Palliative: Denies current pain P: 72 (regular) Quality: R: 12 (regular) Region/Radiation: BP: 112/66 Severity: O2 sat: 99% room air Timing: © 2016 Keith Rischer/www.KeithRN.com What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Mental Status Examination (MSE): APPEARANCE: Dressed in casual clothes, somewhat disheveled, no make-up; no body odor; appears tired and appears stated age; cooperative during interview. MOTOR BEHAVIOR: Wringing hands during interview SPEECH: Speech is a little slowed; slow to respond to questions; does not elaborate unless asked MOOD/AFFECT: Appears sad; reports feeling anxious and sad all the time. Feels like she will never be able to feel better (hopelessness). THOUGHT PROCESS: Logical and linear (thoughts make sense and are connected) THOUGHT CONTENT: Reports feelings of guilt for feeling so bad for “no reason” and for leaving her boyfriend all those years ago. Reports having ruminative thoughts that she is of no use to anyone (worthlessness). Denies delusions or paranoid thoughts when assessed No evidence of psychotic thinking or loss of contact with reality PERCEPTION: States she occasionally hears her name at night when attempting to sleep, but knows it is her imagination. Denies any other hallucinations, illusions, or depersonalization when assessed. INSIGHT/JUDGMENT: Insight – Knows she doesn’t feel “right” but does not recognize symptoms as part of clinical depression; unable to identify any precipitant. Judgement intact as evidenced by seeking help. COGNITION: Alert and Oriented x3; Recent and remote memory intact as evidenced by how she answered interview questions; Demonstrated ability to abstract when tested by asking about proverbs; Fund of knowledge and intelligence is at least average based upon vocabulary used by the patient; Patient reports difficulty concentrating. When attention span was tested using serial sevens test, patient declined to participate. INTERACTIONS: Patient reports withdrawing from friends prior to admission. Unable to assess currently. SUICIDAL/HOMICIDAL: Patient admits she thinks about suicide but would never act on it because she wouldn’t want to hurt her parents. She has no plan when she thinks about suicide. States she does have her own gun at home. Denies homicide ideation or thoughts of self-harm. What MSE assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: © 2016 Keith Rischer/www.KeithRN.com Current Assessment: GENERAL Appears somewhat tired and anxious APPEARANCE: RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, skin turgor elastic, no tenting present What PHYSICAL assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: New Medication: Medication/Dose: Mechanism of Action: Nursing Assessment/Considerations: Sertraline 50 mg PO daily Lab Results: Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Glucose (70–110 mg/dL) Creatinine (0.6–1.2 mg/dL) Current: 145 4.0 80 .8 High/Low/WNL? Previous: Not available Not available Not available Not available What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Complete Blood Count (CBC:) Current: High/Low/WNL? Previous: WBC (4.5–11.0 mm 3) 5.0 Not available Neutrophil % (42–72) 44 Not available Hgb (12–16 g/dL) 12.2 Not available Platelets (150-450 x103/µl) 150 Not available What lab results are RELEVANT and must be interpreted as clinically significant by the nurse? © 2016 Keith Rischer/www.KeithRN.com RELEVANT Lab(s): Clinical Significance: Misc. Labs: T3 (Normal range) 4.6-12 ug/dl T4 (Normal Range) 80-180 ng/dl TSH (Normal Range) 0.5-6 uU/ml Current: 4.6 82 5 TREND: Improve/Worsening/Stable: High/Low/WNL? Previous: Not available Not available Not available What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting? 2. What is the underlying cause/pathophysiology of this primary problem? Collaborative Care: Medical Management Care Provider Orders: Admit pt. to unit under voluntary admission Rationale: Initiate milieu therapy Initiate safety measures according to unit protocol VS upon admission then daily Regular diet. Monitor intake. Sertraline 50 mg PO per day Trazodone 50 mg PO PRN for sleep. May repeat x1 Lorazepam .5 mg PO PRN for acute agitation © 2016 Keith Rischer/www.KeithRN.com Expected Outcome: PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale:  Admit patient to unit under voluntary admission  Initiate milieu therapy  Initiate safety measures according to unit protocol  VS upon admission then daily  Regular diet. Monitor intake.  Sertraline 50 mg PO per day Collaborative Care: Nursing 3. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: 5. What body system(s) will you assess most thoroughly based on the primary/priority concern? 6. What is the worst possible/most likely complication to anticipate? 7. What nursing assessments will identify this complication EARLY if it develops? 8. What nursing interventions will you initiate if this complication develops? © 2016 Keith Rischer/www.KeithRN.com Expected Outcome: 9. What psychosocial needs will this patient and/or family likely have that will need to be addressed? 10. How can the nurse address these psychosocial needs? Evaluation: Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented that are listed under medical management. Two hours later… Current VS: 1200 Most Recent: 1000 Current PQRST: T: 101.6 °F/38.7 C (oral) T: 98.8° F/37.1 (oral) Provoking/Palliative: P: 100 (irregular) R: 24 (regular) BP: 150/100 O2 sat: 95% room air P: 72 (regular) R: 12 (regular) BP: 92/66 O2 sat: 99% room air Quality: Region/Radiation: Severity: Timing: Unclear what provoked the headache Complains of headache “like a band around my head” 5/10 Sudden onset Mental Status Examination: APPEARANCE: MOTOR BEHAVIOR: SPEECH: MOOD/AFFECT: THOUGHT PROCESS: THOUGHT CONTENT: PERCEPTION: INSIGHT/JUDGMENT: COGNITION: INTERACTIONS: SUICIDAL/HOMICIDAL: Disheveled Restless and agitated; mild shivering Quiet Irritable and anxious Somewhat confused Some suspiciousness Denies hallucination, illusions No change Appears confused; not sure of the day of the week. Oriented x2 only By self, but out in milieu No change Current Assessment: GENERAL Appears to be in distress; mild loss of coordination and muscle rigidity noted APPEARANCE: RESP: Breath sounds clear with equal aeration bilaterally, mildly elevated respirations CARDIAC: Pulse is elevated and irregular GI: Abdomen soft/non-tender, bowel sounds audible per auscultation in all four quadrants patient complains of abdominal pain GU: Unable to assess at this time SKIN: Goose bumps noted; diaphoresis © 2016 Keith Rischer/www.KeithRN.com 1. What clinical data are RELEVANT that must be recognized as clinically significant? RELEVANT VS Data: Clinical Significance: RELEVANT Assessment Data: Clinical Significance: 2. Has the status improved or not as expected to this point? 3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? 4. Based on your current evaluation, what are your nursing priorities and plan of care? © 2016 Keith Rischer/www.KeithRN.com Recognizing a clinical concern, the nurse contacts the on call physician and communicates the following SBAR: Situation: Name/age: BRIEF summary of primary problem: Background: Primary problem/diagnosis: RELEVANT past medical history: RELEVANT background data: Assessment: Most recent vital signs: RELEVANT body system nursing assessment data: How have you advanced the plan of care? Patient response: Recommendation: Suggestions to advance the plan of care: Education Priorities/Discharge Planning 1. What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family? 2. How can the nurse assess the effectiveness of patient and/or family teaching and discharge instructions? © 2016 Keith Rischer/www.KeithRN.com Caring and the “Art” of Nursing 1. What is the patient likely experiencing/feeling right now in this situation? 2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a person? Use Reflection to THINK Like a Nurse Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention in the moment as the events unfold to make a correct clinical judgment. 1. What did I learn from this scenario? 2. How can I use what has been learned from this scenario to improve patient care in the future? © 2016 Keith Rischer/www.KeithRN.com