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MDD case study...

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Major Depressive Disorder (MDD) UNFOLDING Reasoning STUDENT

Marilyn Smith, 28 years old

Primary Concept Mood and Affect Interrelated Concepts (In order of emphasis) 1. Stress 2. Coping 3. Clinical Judgment 4. Communication 5. Collaboration 6. Patient Education

© 2016 Keith Rischer/www.KeithRN.com

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 Her grandmother had periods of becoming withdrawn and not leaving the house for days.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: Female Pt is not eating, has had recent weight loss Pt has no energy, has difficulty sleeping and never feels rested, Pt has difficulty concentrating, crying on and off Pt states, “I don’t want to live like this anymore. I feel like I will never be happy again.” Thoughts of suicide

MDD is more diagnosed in females, higher risk in females Hallmarks for MDD weight loss, insomnia, fatigue or loss of energy nearly every day, feelings of worthlessness or excessive or inappropriate guilt, depressed mood most of the day, diminished interest

RELEVANT Data from Social History: Army Feels Guilty, Pt states “feeling crummy” No combat in Military when she was in the army Overwhelmed by normal daily task Drinking to sleep Pt’s Grandmother has history of being withdrawn, may be depression

Clinical Significance: VA Assistance may be available Signs of MDD Lessens risk of other trauma related disorders May be related to lack of sleep and depression Bad habit but needs to be monitored to make sure its not worse than patient claims Possible genetic link to disease

© 2016 Keith Rischer/www.KeithRN.com

Need to do suicide assessment regularly and monitor for continuing thoughts/planning of suicide.

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: What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: All vitals are normal No underlying issue with the patient and gives baseline for future assessments of the patient.

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) Reports feelings of guilt for feeling so bad for “no reason” and for leaving her boyfriend all THOUGHT CONTENT: 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 does not 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: Patient may have lack of energy to care for appearance Pt appears somewhat disheveled, appears tired Willing to talk but may not be in a mental space where she can explain what Speech a little slow, reluctant to exactly she feels is wrong just that “something” is wrong. elaborate on questions Feelings of guilt or feeling guilty is a sign of MDD Appears sad, Feels “anxious and tired” May be a sign that her disease is progressing, needs to be watched closely © 2016 Keith Rischer/www.KeithRN.com

all the time Feels guilty and occasionally thinks she is “of no use to anyone” Hears her name when trying to sleep Denies hallucinations Does not feel “right” and cannot figure out the cause Difficulty concentrating States she would not commit suicide but owns a gun Judgement is intact willing to seek help

May also be due to sleep deprivation, lack of energy People with depression process information in negative ways, and tend to ignore positive aspects of their lives Relating back to feeling sad and anxious she may just not have the energy to look within herself and figure out what exactly it is that may be wrong. Another common side effect of MDD Patient has had thoughts of suicide so even though she says she wouldn’t carry it out Need to want to watch closely and regularly do the suicide assessment if change in status occurs Gun could be a tool, should monitor any changes in behavior, or see if family member can hold on to gun in the meantime once symptoms improve outpatient care Knows there is something wrong, willing to involuntarily come to hospital to get help

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: Somewhat tired and anxious in May be due to lack of sleep, may be from not be getting enough nutrition appearance from weight loss, anxious mood may be from being out of her normal environment, being in the hospital, and unsure of what to expect with treatment

New Medication: Medication/Dose: Sertraline 50 mg PO daily

Mechanism of Action: Inhibits neuronal uptake of serotonin in the CNS, thus potentiating the activity of serotonin. Has little effect on norepinephrine or dopamine.

Nursing Assessment/Considerations: Nurse needs to assess for suicidal tendencies, Monitor appetite and nutritional intake, Monitor mood changes. Notify prescriber is there is significant increase in anxiety, nervousness, or insomnia (can be adverse effect from medication)

Lab Results: Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Previous: Sodium (135–145 mEq/L) 145 WNL Not available Potassium (3.5–5.0 mEq/L) 4.0 WNL Not available Glucose (70–110 mg/dL) 80 WNL Not available Creatinine (0.6–1.2 mg/dL) .8 WNL 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: Labs are all within normal Shows that there is no major issue that needs to There are no previous labs to compare limits be addressed right away as far as labs go. Labs to, but we now have a baseline to © 2016 Keith Rischer/www.KeithRN.com

give baseline for future labs

compare future labs.

Complete Blood Count (CBC:) Current: High/Low/WNL?

Previous: WBC (4.5–11.0 mm 3) 5.0 WNL Not available Neutrophil % (42–72) 44 WNL Not available Hgb (12–16 g/dL) 12.2 WNL Not available Platelets (150-450 x103/µl) 150 WNL 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:

All bloodwork came back within normal limits.

© 2016 Keith Rischer/www.KeithRN.com

Shows that there is no major issue that needs to be addressed right away as far as labs go. But these labs do give us baseline values to look at in the future.

There are no previous labs to compare to, but we now have a baseline to compare future labs. Misc. Labs: Current: High/Low/WNL? Previous:

T3 (Normal range) 4.6-12 ug/dl 4.6 WNL Not available

T4 (Normal Range) 80-180 ng/dl 82 WNL Not available

TSH (Normal Range) 0.5-6 uU/ml 5 WNL Not available

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? Clinical Significance: TREND: Improve/Worsening/Stable: All lab within normal limits Shows that there is no major issue that needs There are no previous labs to compare to, to be addressed right away as far as labs go. but we now have a baseline to compare But these labs do give us baseline values to future labs. look at in the future.

RELEVANT Lab(s):

Clinical Reasoning Begins… 1. What is the primary problem that your patient is most likely presenting? Patient seems to present with a new onset of Major Depressive Disorder 2.

What is the underlying cause/pathophysiology of this primary problem?

© 2016 Keith Rischer/www.KeithRN.com

Major depressive disorder is a medical disorder affecting how you feel, think, and behave which can cause persistent feelings of sadness, hopelessness, loss of interest in previously enjoyed activities. Often there are disturbances in the regulation of mood, behavior, and affect that go beyond the normal fluctuations that most people experience. Exact pathophysiology unknown but involves chemical changes within the brain with neurotransmitters

Collaborative Care: Medical Management Care Provider Orders: Admit pt. to unit under voluntary admission

Rationale: Allows patient to feel in control of their care while still feeling in charge of their care.

The therapeutic environment may be helpful to show the patient what kind of environment would Initiate safety measures according be best for her condition, may give her opportunity to socialize with others and staff, improving her to unit protocol mood VS upon admission then daily Keeps the patient and all others safe while in residence. Diminishes the risk of suicide once Regular diet. Monitor intake. medications have been started.

Expected Outcome: Patient will remain in unit until they feel they are safe to go home.

Initiate milieu therapy

Shows the patient’s trends and will show if the patient is getting better or worse. Patients with MDD tend to skip meals and lose weight so this will help keep the patient on a schedule and help them gain the weight back that they lost.

Sertraline 50 mg PO per day Trazodone 50 mg PO PRN for sleep. May repeat x1 Lorazepam .5 mg PO PRN for acute agitation

Works as an anti-depressant to begin treatment of MDD to begin maintenance therapy. Help the patient with insomnia/inability to sleep at night. Helps the patient to relax so that they can focus on therapy and getting better.

Patient will be able to socialize and interact with others in a therapeutic environment Patient and others will remain free from injury during their stay in the unit. Patient will have labs stay WNL for duration of stay. Patient will maintain healthy BMI and continue to eat regularly. Patient will report less feelings of helplessness, depression, and elevated mood. Patient will report easier time falling and staying asleep. Patient will also report feeling rested after a full night’s sleep. Patient will report feeling calmer and less anxious throughout the day.

PRIORITY Setting: Which Orders Do You Implement First and Why? Care Provider Orders: Order of Priority: Rationale: Safety within the unit is very important so once the patient Second Priority • Admit patient to unit under voluntary is admitted safety would be the first priority. Safety for the admission patient and staff is always first priority •

Initiate milieu therapy

Last Priority

•

Initiate safety measures

First Priority

© 2016 Keith Rischer/www.KeithRN.com

Makes it so that the patient is in a situation where they can begin treatment, encourage Pt. with therapeutic communication and encourage healthier ways of thinking and behavior, adaptive coping skills, thought processes

according to unit protocol •

VS upon admission then daily

Third Priority

•

Regular diet. Monitor intake.

Fifth Priority

•

Sertraline 50 mg PO per day

Fourth Priority

This gives the unit a baseline for the patient’s health and should be done before any medication is given so that there is no skew to the data. Adequate nutrition and fluid intake is important for getting enough energy into the cells and body, appetite may slowly increase once in hospital, opposed to being at home Beginning medication therapy is important so that the patient can begin to focus on other aspects of their care with enough energy and emotion, also to monitor for adverse sings and symptoms and maybe another medication may be more appropriate

Collaborative Care: Nursing What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) Risk for suicide Hopelessness Ineffective coping Deficient knowledge about illness and treatment options 4. What interventions will you initiate based on this priority? Nursing Interventions: Rationale: Expected Outcome: 3.

Risk for self-directed suicide and violence

Be alert for warning signs of suicide: making statements such as, “I can't go on,” “Nothing matters anymore,” “I wish I were dead”; becoming depressed or withdrawn; behaving recklessly; getting affairs in order and giving away valued possessions; showing a marked change in behavior, attitudes, or appearance; abusing drugs or alcohol; suffering a major loss or life change. Be f or ei mpl e ment i ngi nt er ve nt i onsi nt hef ac eof s ui c i dalbe ha vi or ,nur s e ss houl de xami net he i rown e mot i onalr es pons e st oi nc i dent sofs ui c i det o e ns ur et ha ti nt e r ve nt i onswi l lnotbebas e don c ount er t r ans f er e nc er e ac t i ons .Re moveanyt hi ng t ha tt heptc anus et opot ent i al l yhar m Re moveptoutofERi nt opr ope runi t

Hopelessness is a potential predictor for depressive and suicidal symptoms (Wang et al, 2013). Hopelessness related to depression

Physical assessment, MSE, neurological, nutrition, sleep pattern

Having a baseline of assessment can better address care of plan for patient

© 2016 Keith Rischer/www.KeithRN.com

Patient will ask for help when experiencing self-destructive impulses Pt will be thought process will change and improve from negative talks, to more positive ones stating things pt enjoys in her life Express decreased anxiety and control of impulses Pt will talk about feelings; express anger appropriately Pt will refrain from using mood-altering substances Pt will obtain no access to harmful objects

Patient will demonstrate independent problem-solving techniques to take control over life and does not verbalize or demonstrate suicidality. Pt will Expresses hope for a positive future, believes that personal actions impact outcomes, demonstrates optimism and

Nurse should identify Suicidal Ideation Severity, risk factors, behavior, specific questions Nurse will make rounds every 15 minutes Safe- T- Test

Ineffective coping

Use verbal and nonverbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client and family to express emotions such as sadness, guilt, and anger (within appropriate limits); verbalize fears and concerns; and set goals. - Collaborate with the client to identify strengths such as the ability to relate the facts and to recognize the source of stressors.

describes plans - Therapeutic communication, socialization mileu will begin -Nurse will establish baseline assessments and gauge what actions will need to be done -Pt sleep patterns will improve -Nurse will establish pt score for test and rate Pts risk, low and moderate to severe -Pt will verbalize contract to not self harm for shift Pt get started on meds, to improve feelings of hopelessness and watch for adverse effects -Pt identify responses that may be harmful Pt will acknowledge and accept the need for assistance with circumstances

Findings from a cross-sectional study support the notion that health literacy, as a “sixth vital sign” be addressed in all settings because health literacy can vary depending on the situation and complexities of a chronic condition (Heinrich, 2012) Deficient Knowledge

Pt will use effective coping strategies Use behaviors to decrease stress Remain free of destructive behavior toward self or others Report decrease in physic...