Concept map (2) depression PDF

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CONCEP MAP...

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Psychiatric Dx: Diagnosis Classification:  Social

Assessment Data Subjective  Anergia- Patient states he feels fatigue, lack of energy.  Hopelessness. Patient states he does not care removing his IV which is important to administer fluid, medication to the patient.  Helplessness. Patient states nobody cares about me.  Suicidal ideation. Patient states he wishes to be with his dead wife.  Anhedonia. Patient states he has a lack of interest in activities he used to enjoy doing like going to church.  Sleeplessness. Patients states he barely sleeps and used maladaptive behaviors like drinking alcohol to help him go fall asleep.  Sadness-Patient states he feels sad because he lost his wife.  Lack of motivation- Patient does feel like to try anything that can help manage his depression and sand states he spends most of the time in bed. Objective  Flat affect -Patient show a reduction in emotional expressiveness  Poor eye contact -Patient was not able to establish eye contact when she answers interview questions.

Major depression Medical DX: No Known medical problem.

Priority Nsg Dx Risk for self-harm related to feeling of helplessness, loneliness or hopelessness secondary to psychiatric disorder depression disorder as evidenced by patient states “I wish to be with my dead wife”

Short Term Goal: Patient will refrain from attempting suicide during hospitalization. Nursing Interventions:  Implement one-on-one observation Rationale: a client with a suicidal ideation will require a constant supervision and a safe environment.  Implement a written no- suicide contract. Rationale: Reinforce action the client can take when feeling suicidal:  Encourage patient to express feelings (anger, guilt, sadness) and come up with alternative ways to handle

Psychiatric Meds: Prozac 10 mg stat q daily 9 am...