The episode is not attributable to the physiological effects of a substance or to another medical condition.
- Patient reports no etoh or illicit drug use
The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- Patient reported that symptoms often leave him unable to function, leaving him "feeling like a zombie".
- Patient's impulsive violent outbursts have caused his relationship with his father and brother to be strained.
- Patient stated his grades have been unaffected.
How About A Little Insight?
http://tiny.cc/ImGoodLuv-Enjoy
There has never been a manic episode or a hypomanic episode.
- Patient has no history of manic episodes at home or on unit
Psychosocial History
Drug 2: Tylenol (Acetaminophen) 325 mg x2 q4H (PRN)
i) Drug Category: Antipyretic
ii) Reason for Taking: Discomfort
iii) Standard Safe Adult Range & Frequency: 325–650 mg q 4–6 hr or 1 g 3–4 times daily or 1300 mg q 8 hr
iv) Common Side Effects: agitation, anxiety, hepatotoxicity, insomnia, headache, fatigue, N/V
v) Nursing Implications: Assess type, location and intensity of paint prior to admin of drug. Record vital signs before admin of drug to obtain baseline for comparison to after drug admin.
Meet "Scott"
- Age : 17
- Male
- Caucasian
- Unemployed
- Single
- Lives with parents and older brother
- Time on unit : 48 hours
- No reported ETOH or illegal drug use
Drug 3: Milk of Mag. (Magnesium hydroxide) 10 ml q4H (PRN)
i) Drug Category: mineral and electrolyte replacement/supplement, laxatives.
ii) Reason for Taking: Indigestion
iii) Standard Safe Adult Range & Frequency: 5–15 mL/dose up to 4 times/day as liquid or 2.5–7.5 mL/dose up to 4 times/day
iv) Common Side Effects: diarrhea, flushing, sweating
Nursing Implications: Monitor patient I/Os, keep patient hydrated providing water and ice as necessary. Do not admin within 2 hours of patient taking other medications.
- Chronic depression (>3 Months)
- Violent outbursts
- destroying property
- impulsivity
- impaired problem solving
- Previously baker acted 4 years ago
- No hx of previous suicide attempts
Interventions
- Carry out and review daily food dairy. Rationale: Provides opportunity for the individual to focus on a realistic picture of the amount of food ingested and corresponding eating habits and feelings. Identifies patterns requiring change or a base on which to tailor the dietary program.
- Determine the patient’s readiness to initiate a weight loss regimen Rationale: More specific directions regarding weight loss can be addressed if the patient is in the preparation or action stages.
- Review patient’s current exercise level. With patient and primary healthcare provider, design a long-term exercise program. Rationale: Exercise is vital for increased energy expenditure, for maintenance of lean body mass, and as component of a total change in lifestyle.
Planning begun upon admission, Patient was a BA-52 Involuntary admission
(1) Parents signed consent for treatment
ii) Court mandated family therapy and 1:1 therapy pending evaluation of patient assessment.
iii) Daily psychiatric evaluation for a total of at least 3
iv) Patient received 2 of 3 and is on par for discharge pending outcome of final evaluation.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day(not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan,or a suicide attempt or a specific plan for committing suicide
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (subjective)
- Depressed mood most of the day, nearly every day, as indicated by subjective report
Assessment data
Medical history
- Loc: alert and oriented x 4
- Behavior : Passive, moderate level of activity. Instances of
depressive episodes.
- speech : Clear, well thought out
- visual interpretation : Clean, well kept
- Mood : alternates from happy to depressed as reported by patient
- affect: appears positive during most points of contact during
the day until depressive episodes came
- Concentration : Able to maintain focus well
- Hallucinations/Delusions: NOne
- Memory : No abnormalities observed
- Morbid obesity : Patient weighs 405lbs at 6 feet with a
bmi of 54.9, more than 220lbs over the normal limits
to be considered "healthy" by bmi standards.
- Forearm cutting (patient states)
- Unable to Obtain a complete Medical history
Major Depressive disorder
A Presentation by Maurice Reynolds
Drug 1: Benadryl (Diphenhydramine) 50 mg qHS (PRN)
i) Drug Category: Antihistamines, antitussives
ii) Reason for Taking: Insomnia/anxiety
iii) Standard Safe Adult Range & Frequency: 25-50 mg q4-6H, not to exceed 300mg/day
iv) Common Side Effects: Drowsiness, dizziness, headache, blurred vision, tinnitus, hypotension, anorexia, dry mouth, constipation, nausea.
v) Nursing Implications: may cause sedation, patient cannot operate machinery, risk for falls r/t drowsiness, monitor vitals.
Potter, P. A., Perry, A. G., Stockert, P. A., Hall, A., & Peterson, V. (2014). Fundamentals
of nursing. St. Louis: Mosby.
Reynolds, C. R., Ph.D, & Kamphaus, R. W., Ph.D. (2013). BASC3: MAJOR DEPRESSIVE DISORDER.
DSM5 Diagnostic Criteria Major Depressive Disorder, 1-3. Retrieved June 25,
2018, from https://images.pearsonclinical.com/images/assets/basc-3/
basc3resources/DSM5_DiagnosticCriteria_MajorDepressiveDisorder.pdf.
Interventions
- Encourage patient to express feelings and come up with alternative ways to handle anger and frustration. Rationale: Clients can learn alternative ways of dealing with overwhelming emotions and gain a sense of control over his/her life
- Implement a written no-suicide contract. Rationale: Reinforces action the client can take when feeling suicidal.
- Contact the family, arrange for crisis counseling. Activate links to self-help groups. Rationale: Clients need a network of resources to help diminish personal feelings of helplessness, worthlessness, and isolation.
Goal
Nursing Diagnosis No.1
Patient will demonstrate a change in eating pattern and make healthier meal choices before discharge.
Risk for self-directed violence r/t depression, history of self-mutilation, reported feelings of helplessness and loneliness
Evaluation
Client goal
Goal partially met, patient began developing alternative strategies to deal with emotional stress and anger. It is unknown how effective the coping mechanisms are without subsequent follow up evaluations.
Patient will demonstrate to the nurses, three alternative ways to deal with emotional stress and negative feelings before the end of shift
nursing Diagnosis No.2
implementation
Patient reported feeling lonely and depressed, stating, “I feel like nobody understands me or cares”.
Patient was unable to discuss feelings without having a depressive episode
When depressed, patient isolated himself and did not speak.
Patient has a history of self-mutilation.
- Directed patient to create inventive coping strategies to overcome bouts of rage and frustration. Patient fond of drawing a writing as an adequate form of expression.
- Patient was tasked with writing and signing a "no suicide" contract to essentially reflect upon during instances of depression and suicide ideations.
- Parents were contacted by attending nurse for referral to outpatient family therapy
Impaired nutrition: More than body requirements r/t food intake that exceeds body needs aeb current weight over 20% of optimum body weight.
Patient stated, “I really love food’
Patient weights 405lbs at 6 feet tall
Assessment
Objective
Subjective
Patient verbalized “I don’t know what will happen to me when I go back home”.
“I don’t want to see my dad or brother”
“I don’t want to go back home”
Patient has depressive episodes where he isolates himself.
Patient flirts with idea of dying during depressive episodes (gesturing)
Nursing Diagnosis No.3
- Disturbed thought process r/t feelings of extreme anxiety, suicide ideation, depressed mood aeb, inability to contract for safety outside of hospital, violent outbursts at home.
Implementation
Evaluation
- Patient’s meal choices were monitored by technicians and recorded, essentially recording the patient’s food choices over time.
- Patient was asked questions such as "do you think you are ready to lose weight?" and "are you willing to make the necessary changes?" (Patient said nah)
- Discussed patient's exercise regimen at home, there was no regimen. Patient likes his snacks.
- Goal partially met, patient began making better dietary decisions when ordering meals, often opting for healthier choices such as fruit and vegetables instead of carbs and starches...... The boy still loves his honey buns though...
Implementation
- Attending nurse met with family members (mother, father, brother) to obtain baseline cognitive functioning of patient.
- Encouraged patient to write out negative self thoughts and describe at least three reasons why they are untrue.
- Encouraged patient to write 5 positive things about himself to read when feeling depressed.
It is unknown if the goal has yet been met, however, patient progress would indicate a strong likelihood of success.
Client goal
Patient will identify negative thoughts and rationally counter them and/or re-frame them in a positive manner within 2 weeks.
Interventions
- Determine the client’s previous level of cognitive functioning Rationale: Establishing a baseline data allows for evaluation of client’s progress.
- Help the client identify negative thinking/thoughts. Teach the client to re-frame and/or refute negative thoughts. Rationale: Negative ruminations add to feelings of hopelessness and are part of a depressed person’s faulty thought processes. Intervening in this process helps in healthier and more useful outlook in life.