Running head: Depression Case Study

Depression Case Study

Kailee Engel
Mental Health Nursing
Youngstown State University
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Abstract

This case study explores the case of a 34-year-old man with depression. The purpose is to address

care for this client in the most efficient way through a thorough understanding of the individual's case. In

the study the focus is on mental health history, current presentation, spiritual concerns, ethical concerns,

nursing care, stressors involved, nursing diagnosis, and potential nursing diagnoses.

1. Objective

R.P. is a 34-year-old, Caucasian male who presented with an overdose of Seroquel, 9 grams,

after getting into an argument with his mother and his mother threatening to kick him out of the house.

He was brought into the emergency room by EMS after his mother called 911. He spent several days in

the ICU intubated, after which he was pink slipped and sent to the mental health floor once medically

stable. His DSM I state Major Depressive Disorder. DSM Il-IV are undocumented in the electronic

medical record. He has a history of anxiety, PTSD, bipolar I disorder, ADHD, schizoaffective disorder,

hypertension, gout, hypothyroidism, fibromyalgia, and vitamin D deficiency. The patient is on

paliperidone (Invega) for schizoaffective disorder, 3mg daily. He takes clonazepam (Klonopin) for

PTSD, 0.5mg as needed. He also takes divalproex (Depakote) for bipolar I disorder, 250mg BID.
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Upon date of care (February 20, 2018), the patient was dressed in his regular clothes with

unkempt hair. He slouches forward and displays a sad look and does not change emotional status when

talking. He often looked down and away when asking about problems he may have. Throughout the

conversation he often diverted blame from himself and said that all of his issues came from his mother.

He reported that he has never been married and that his longest relationship failed due to his drug

problems and issues with his mother. In the admitting note he reported that he attempted suicide

because he was depressed and did not want to live anymore with no specific reasoning behind why he

attempted suicide. Later, he did admit that he was just trying to "get a rise" out of his mother and make

her feel bad for wanting to kick him out of the house. He reports that he is a great uncle to his nieces

and nephews stating, "I'm the only father figure in their life" while in the notes he has been reported

saying that his sisters are married with the father still in their children's lives.

2. Summarize

The client has a diagnosis of depression which is defined by Mary C. Townsend in

Psychiatric Mental Health Nursing as "An alteration in mood that is expressed by feelings of

despair, sadness, and pessimism. There is a loss of interest in usual activities, and somatic

symptoms may be evident. Changes in appetite and sleep patterns are common. The diagnosis of

anxiety is defined by Townsend as "An emotional response to anticipation of danger, the source of

which is largely unknown or unrecognized. Anxiety may be regarded as pathologic when it

interferes with effectiveness in living, achievement of desired goals or satisfaction, or reasonable

emotional comfort." Anxious patients usually exhibit signs of restlessness, apprehension, tension,

or uneasiness.
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3. Identify
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4. As with everyone there are several reasons for stress in a person's life. He is
unemployed and living in a low socioeconomic region. These are two very
large stressors that would contribute to a feeling of worthlessness, often
associated with depression which the patient has been diagnosed. He abuses
drugs and alcohol as a coping mechanism which can be an additional stressor
to the life. The events that led up to his hospitalization and reasons behind his
behavior is always falling back onto his mother. The main stress in his life
stems from a difficult relationship with his mother. He continually blames her
for everything in his life as her wrong doing but also turns around to say that
he would do anything for her and would never leave her behind.Discuss

The patient was reluctant to reveal much information about his troubled history but was very

upfront about his drug abuse. He said that this was the first time he had ever been admitted for a

psychiatric illness but he has made threats in the past about trying to take his life. He stated

"I just took it too far this time" further stating "even my mother thinks that I was just Wing to get

attention and I went too far." Upon review of record I found that the patient's mother had not had

contact with him but only called into the nurses to tell them that she would be pressing charges

against him for the attack he made on her. The patient believes that he still has a good relationship

with his mother and believes that they have reconciled when in fact they have not according to the

patient's mother.

Patient also discussed how he was abused as a child by his stepfather who was a pastor.

He described a long history of abuse and neglect on the behalf of his mother who frequently married

after the deaths of multiple husbands. He described that his biological father was abusive and

sexually assaulted him as a small child and the abuse continued after his father died. He continued

to talk about how he has been abused by three different men in his life which is what made him

decide to abuse drugs. He continually blamed others for his addiction and bad habits. He also

mentioned that his mother is a drug addict and they have used drugs together as bonding

experiences which she eventually saw was a bad thing and he reports that his mother has been clean
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for one year. He states that he made his mother relapse last year because he continually brought the

substances in the house but then turned around to say it was her fault that she did not stop him from

making these decisions. It was written in the client's chart that he threatened to kill his mother

because she had planned to kick him out of the house but the patient continued to deny this fact in

the interview process. He said that his mother took him wrong and misunderstood what he was

saying continuing to place blame on others.

5. Describe

Patient safety is at the front of psychiatric nursing care. The first thing a nurse should

ensure is a safe and caring environment for the patient. This also includes removing all potentially

harmful objects from the client's access, while supervising carefully during meals and medication

administration. Maintaining a close observation of the client to prevent further attempts of suicide

is also very important. Another aspect of care is encouraging honest feelings through several

therapeutic communication techniques, to allow a discussion of stressing triggers and other

potential causes contributing to the client's diagnosis. As a nurse, the actions should be directed at

empowering and allowing the patient to have self-work to blossom as well as providing a

nurturing environment for self-esteem free of degradation. Prevention of powerlessness is a very

high priority in a depressed patient which can be hard to prevent in such an environment such as a

psychiatric unit. In order to complete and achieve all of these interventions one should encourage

the client to take responsibility as much as possibly by allowing the client to determine goals for

himself and providing the client with as much privacy as earned within safe reason. Identifying

areas of the life the patient can control are important as well and enabling him to identify things
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that can change and cannot change are both important abilities in dealing with the powerlessness

that can be felt. Identifying strengths and weaknesses of the client allows the nursing staff to

appraise the efficiency of the care plan in place. By focusing on the strengths of the client, the

nurse provides a fostering environment for an upliftment of self-esteem.

6. Analyze

The patient is a Northern European, American, and this indicated many cultural phenomena

that a nurse should learn and know. Communication techniques will be more verbal than nonverbal

in this culture. The nurse should also be aware that personal space is very important with about 18-

inches to 3-feet distance being appropriate for the Northern European American. Personal gestures

like touching is not well received in this culture. Future orientation is important in planning

outcomes and therapeutic interventions. The client states that he is not very spiritual but he is trying

to be more spiritual because his mother is a pastor. He states that he does d ry to attend his mother's

church on a weekly basis which he used to do when he was younger with his entire family. He did

say that he has not been open about his drug use in the church setting so they may not be a type of

support system that he can count on when he is released. Spirituality is important because it can

often give a certain meaning to life which is generally very important in patients with depression.

7. Evaluate

The outcomes for this patient should be focused on and around communication and

establishing an effective rapport with the patient's mother using milieu therapy. This will allow for

treatment of a stressor in the patient's to evaluated for the best possible outcome. However, a
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potentially more important goal for the client is based around prevention of future suicide attempts.

Outcomes can include: client will seek out staff when feelings of harming self-begin to become

evident with oneself, and even more importantly, client will not harm self. Dealing with the

potential loss of an important relationship such as a mother-son relationship can affect the progress

made with the client. An outcome relating to grieving loss includes; client will express anger about

the loss, client will verbalize normal behaviors related to grieving, and a long-term goal is that the

client can place himself in the spectrum of grieving while progressing towards the resolution of the

grieving process.

8. Summarize

Before the client can be discharged he must verbalize an understanding of the situation. He

must be able to identify the actions as an attempted suicide and accept responsibility. He must be

free of delusions of grandeur thus allowing himself to resume life in reality and accept

responsibility for his mistakes both currently and in the past. Client must be able to identify

healthy ways of dealing with stress, as well as properly determine the stressors in his life and toxic

relationships. The client's medications should be reviewed and possibly adjusted and/or changed.

The suicide attempt may have been because of the medication and thus need reviewed prior to

discharge. A healthy support system and close follow up should be well established prior to

discharge of the client. The support system should be contacted by the Social Worker prior to the

patient being discharged to ensure that everyone is on the same page with treatment. Education for

the client and support system should be done to address the importance of medication compliance

as well as what to look for if the medications are not doing their job.

9. Prioritized List
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 Ineffective Coping related to disturbance in tension release as evidenced by poor

judgment.

o Provide a list of coping mechanisms

o Maintain neutrality in each situation

 Risk for Suicide related to attempt on life as evidenced by overdose on Seroquel.

o Identify stressors that make client feel suicidal

o Remove all objects that could potentially harm the patient

 Interrupted family process related to explosive outburst behavior as evidenced by

attempted homicide and suicide.

o Avoid conflict

o Maintain neutrality when identifying family issues

 Impaired social interaction related to difficulty communicating as evidenced by

spending much of his time alone.

o Positive encouragement

o Encourage as much independence as possible and responsibilities to help

those who will accept the help

10. Nursing Diagnosis

 Risk for suicide

 Complicated grieving
 Low self-esteem
 Powerlessness
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 Spiritual distress
 Disturbed thought process
 Imbalanced nutrition: less than body requirements
 Insomnia
 Self-care deficit
 Panic anxiety
 Fear
 Ineffective coping
 Ineffective role performance
 Ineffective denial
 Risk for infection
 Risk for injury
 Deficient knowledge

11. Conclusion

This case study allowed me to develop my care plan skills on a deeper level. It required a lot

of information of which I did not know, even from class. Taking little information to create a nursing

diagnosis, care plan, and interventions to help a patient in a quick amount of time. One of the major

skills developed through this case study was how to complete a Mini-Mental Health State

Examination (MMSE). The exam is as follows: Orientations was a 5/5 on both subgroups,

registration was a 3/3, attention and calculation was a 4/5, recall a 3/3, naming a 2/2, repetition a 1/1,

three-stage command was a 3/3, reading a 1/1, writing 1/1, and copying 1/1 for a total score of 29/30.

This score means that he had mild to no cognitive impairment. Additionally, I learned that mental

health patients have a high tendency of returning for treatment due to noncompliance. The goal of

any hospital is to prevent readmission and identifying these potential causes for readmission can

greatly better outcomes. This plan helped myself identify possible ways to prevent those

readmissions.
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References

Ackley, B.J. Ladwig, G. B. (2014) Nursing diagnosis handbook: an evidence based guide to planning

care (10th ed.). Elsevier Publishing. Maryland Heights, MO.

Current Nursing. (2013, September 19). Nurse's Role in Milieu Therapy. Retrieved March 24,

2018, from http://currentnursing.com/pn/milieu_therapy.html

National Institute of Mental Health. (2017, December). Depression. Retrieved March 24, 2018, from

https://www.nimh.nih.gov/health/topics/depression/index.shünl

Paley, G & Shapiro, D. (2016, January 18). Evidence-based psychological interventions in mental

health nursing. Retrieved March 24, 2018 from https://www.nursingtimes.net/roles/mental-

health-nurses/evidence-based-psychologicalinterventions-in-mental-health-

nursing/206109.article

Townsend, M. C., & Morgan, K. I. (2018). Psychiatric mental health nursing: Concepts of care in

evidence-based practice. Philadelphia, PA: F.A. Davis Company.

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