Case Study Depression ANDREA BERTHEAUD, MSN, RN-BC MENTAL HEALTH- NUR 3406 Questions you ask yourself Ask yourself when listening to report: Write it down What is the environment? Are there cultural considerations? Knowledge about Dx What stands out? What is important? Acute VS. Chronic? What action is first? What is relevant S&S? Do I need to delegate? To who? Do I need to report? To who? Patient https://www.youtube.com/watch?v=Gm3FLGxb2ZU Case Study 4-to 10 rows, 2 to 3 columns, each row must have a key H&P NN VS Diagnostic Laboratory MAR results results I&O Physical exam Case Study History and physical Tony Jones (TJ) has been admitted to a psychiatric inpatient unit and he is your new admission. TJ was referred to the emergency room last night and now is your patient. C/C suicidal ideation, persistent thoughts of suicide with no plan. “I will I was not here” 18 year old male with a prior history of MDD and one attempt to overdose on Tylenol 2 years ago, their girlfriend broke up with them. Their father committed suicide when TJ was 5 years old In the emergency room his vital signs BP 130/80, HR 90, RR 18, SAT 97%, Temp 98.4 (Tympanic), Blunted affect, Indecisiveness at times, Poor appetite, loss 10 pounds over the last 2 months, c/o Anhedonia- without pleasure, intermittent periods of anger, c/o Loss of control, Anergialack of energy, speech normal cadence, soft spoken, good eye contact, steady slow gait, Case study History and Physical Time 9AM RR- 18 SAT- 98% HR- 92 BP- 128/66 Temperature 98.0 Vital signs Lab Results Case Study H&P Labs and Dx results VS Urine Toxicity positive for cannabis negative for opioids negative for cocaine Electrolytes Na K Cl bicarb phosphorus Hematocrit 42% Hemoglobin 14 grams (three times) 138 4.0 98 25 2 normal ranges 135 - 145 3.5 - 5 96 - 106 24-30 1.8-2.3 Male normal range 41 to 48% normal range 13.2 to 16.6 grams per deciliter How was TJ treating himself over the last 2 months? St John’s Wort herbal pill daily (OTC) Smoking Cannabis severe times a day Smoking tobacco 1 pack daily Staying away from people and old girlfriend Occasionally drinking beer What is a consider relevant info? Important relevant information What is an affective disorder? What is suicide? What is suicidal ideation? Who is most likely to complete suicide? Is it better or worst to have a plan? Why and why not? Does his father’s suicide put TJ at a higher risk? Suicidal If they have a plan more likely to act on it 10th leading cause of U.S. deaths 2nd leading cause of death for ages10–34 What is an affective disorder? MOOD disorder like depression and bipolar disorder Suicide: Intentional act of killing oneself by any means Suicidal ideation: persistent thoughts of suicide, Thinking about killing oneself Completed suicide: Suicide successfully resulting in death Non-suicidal self-injury: Self-injury directed to the surface of the body to induce relief from a negative feeling/cognitive state or to achieve a positive mood state Recognize cues of MDD Which of the following finding require follow-up by the nurse? Select all that apply Blunted affect YES NO MAYBE Suicidal thoughts irritability Speechslow cadence Plan to hang himself Sadness, Impaired emptiness thinking Euphoria Analyze Cues form Dx MDD Disruptive Mood Dysregulation D/O Extreme sadness seen in children Delusions or hallucinations Suicidal low energy, difficulty thinking, hopelessness Manic or hypomanic Sleep disturbances Each column must have at least one selected Bipolar 1 Analyze Cues What happens with MDD? What might be medications needed? Medications 5 Categories of antidepressant medications • SSRI • SNRI, • Tricyclics, • MAOIs, • Atypical What are the most common medication prescribed? • SSRI • SNRI, • Tricyclics, • MAOIs, • Atypical TJ is ordered Sertraline 25 mg po daily example of SSRI Mechanism of actions: Is the medication working? What happens when it does? Outcomes How long does it take to work? Is there an increase risk of suicide? In teenagers? When? SSRI- SSRIs are the most common class of antidepressants in the U.S. and are believed to be safer and generally cause fewer side effects than other antidepressants. SSRIs are prescribed to treat depression, anxiety disorders, panic attacks and personality disorders. Selective serotonin reuptake inhibitors, Citalopram/Celexa Escitalopram/Lexapro Fluoxetine, Prozac Fluvoamine/Luvox Paroxetine/ Paxil Sertraline/ Zoloft SNRI Venlafaxine/EffexorXR Desvenlafaxine/Pristiq Duloxetine/Cymbalta Levomilnacipran/Fetzima SNRI From the previous scenario, what precaution should the nurse utilize prior to administering the Venlafaxine? Check the client’s blood pressure Check the client’s apical pulse Check the client’s temperature Check the client’s blood sugar What is a fatal potential adverse effect of antidepressants? What causes it? When does it occur? Can it be fatal? What are the S&S? serotonin syndrome can be fatal medications cause high levels of the chemical serotonin. May occur- increase the dose or add a new drug SEROTONIN SYNDROME: Serotonin is a chemical your body produces that's needed for your nerve cells and brain to function. But too much serotonin causes symptoms MILD_(shivering and diarrhea) to severe (muscle rigidity, fever) Milder forms of serotonin syndrome may go away within a day of stopping the medications that cause symptoms and, sometimes, taking drugs that block serotonin Severe S&S: mental changes [agitation, hallucinations, coma], autonomic instability [tachycardia, labile blood pressure, hyperthermia], neuromuscular aberrations [hyperreflexia, incoordination], and/or GI symptoms [nausea, vomiting, diarrhea]) Prioritize Hypotheses Which action is first? Complete the sentence: drop down Which action should the nurse perform first when your patient is depressed? Assess if the patient for risk of suicide Discussion on ECT Discuss the issues causing the depression Teach coping strategies Discussion on social isolation Assess milieu Discussion on CBT Prioritize Hypotheses Complete the sentence: drop down Which are appropriate potential treatment for depression? Electroconvulsive therapy ECT Transcranial magnetic stimulation TMS Light therapy Exercise Venlafaxine Vagus nerve stimulation VNS Naxolone YES NO Environmental facts What are safety considerations? What is Milieu therapy? What is CBT? What is ECT? Communication Communication facts Can you ask a patient if they are having thoughts to kill themselves? Why? When? What puts them at risk? What is active listening? Therapeutic communication Friends use Initiated for the purpose of friendship, socialization, enjoyment, or accomplishment of a task Mutual needs are met Communication to give advice, give, or ask for help Content of communication superficial Professional Nurses use Patient centered Goal directed One-way benefits towards the patient Social relationship Therapeutic relationship Tools for enhancing communication Projective Questions What if…? Questioning Active listening Clarifying techniques Paraphrasing , restating, reflecting, Closedended questions Openended questions Being present & attentive The “Miracle” question what would be different? exploring Tools for enhancing communication Active listening, being present & attentive Questioning Open-ended Closed questions ended questions Projective Clarifying Questions What if…? techniques Paraphrasing, restating, reflecting, exploring (give me an example of…) The “Miracle” question what would be different? Communicationopen ended questions “Tell me what brought you here.” “What’s on your mind today?” or “What would you like to talk about?” Tell me about yourself, What is going on today? What are your goals today? “How have you been feeling lately?” “What brought you to the hospital?” “Can you tell me how it is for you?” “Perhaps you would like to talk about….” “Would it help to discuss your feelings?” “Where would you like to begin?” “And then what?” “I’d like to hear more about that.” “Tell me about….” “What is you opinion?” “You said you were frightened yesterday. How do you feel now?” “I’m not sure I understand that, can you tell me more?” “Would you tell me more?” “During the past hour we have talked about…” Generate solutions Potential Orders Buprenorphine/naloxone daily Daily 4 ounce of wine at dinner Group therapy to develop coping skills Interpersonal therapy IPT Tricyclic antidepressants Anti-smoking cessation medication Continue St John’s Wort herbal treatment when starting sertraline Anticipated Non-essential Contraindicated Get better, the same or worse? Evaluate History And Physical Specify if assessment finding indicate client’s health is: NN VS Labs 9:00 AM alert, oriented times three, blunted affect, speech normal cadence and good eye contact stated he had thought about hanging himself with a sheet” given one to one support for 10 minutes then went to a coping skill group, VS 136/82, HR 95, Temp 98.1, SAT 98%, RR 16, 11:55 AM alert, oriented to person, confusion to time and place, c/o shivering, mild stiffness and rigidity in arms noted, c/o nausea, noted diarrhea times one, BP 146/90, HR 110, Temp 102.2, SAT 95%, RR22, Assessment Finding Confusion alert Rigidity nausea Increased temp Increased HR Increased BP Improved Unchanged or the same Declined or worse Evaluate potential issue? Improved Same Declined Confusion alert Rigidity nausea Increased temp Increased HR Increased BP Evaluate H&P NN VS Labs 11:55 AM alert, oriented to person, confusion to time and place, c/o shivering, mild stiffness and rigidity in arms noted, c/o nausea, noted diarrhea times one, BP 146/90, HR 110, Temp 102.2F, SAT 95%, RR22, 12:10 PM increased confusion, able to state his name given cyproheptadine 12 mg tablet po STAT, discontinue St John’s wort and sertraline, and IV started in right hand w/ D5½NS at 100 cc/hr, transfer to the ICU at 12:15, BP 90/50, HR 110, temp 104 F, RR 24, hand and arms tremor noted Assessment finding Arms and legs tremors BP 90/50 HR 110 Temp 104 Increased Confusion Improved Same Worse Evaluate potential Serotonin syndrome Improved Same Declined Arms and legs tremors BP 90/50 HR 110 Temp 104 Increased Confusion Why? Cyproheptadine 12 mg Discontinue St John’s wort and sertraline STAT D5½NS at 100 cc/hr transfer to the ICU
