Rachel Hart
KNH 413
3/5/2013
Depression CS
1. What is depression?
Depression is a mood state that goes well beyond temporarily feeling sad or blue.
It is a serious medical illness that affects one’s thoughts, feelings, behavior, mood
and physical health. Depression is a life-long condition in which periods of
wellness alternate with recurrences of illness. Each year depression affects 5 to 8
percent of adults in the United States. Depression occurs 70 percent more
frequently in women than in men for reasons that are not fully understood.
Without treatment, the frequency and severity of these symptoms tend to increase
over time. Major depression is also known as clinical depression, major
depressive illness, major affective disorder and unipolar mood disorder. It
involves some combination of the following symptoms: depressed mood
(sadness), poor concentration, insomnia, fatigue, appetite disturbances, excessive
guilt and thoughts of suicide. Left untreated, depression can lead to serious
impairment in daily functioning and even suicide, which is the 10th leading cause
of death in the U.S. Researchers believe that more than one-half of people who
die by suicide are experiencing depression. Devastating as this disease may be, it
is treatable in most people. The availability of effective treatments and a better
understanding of the biological basis for depression may lessen the barriers that
can prevent early detection, accurate diagnosis and the decision to seek medical
treatment (National Alliance on Mental Health, 2013).
2. Dr. Byrd has decided to treat Ms. Geitl with Zoloft, a selective serotonin
reuptake inhibitor (SSRI). Are there any pertinent nutritional
considerations when using this medication?
There are some potential nutritional considerations when taking Zoloft including,
nausea, dizziness, drowsiness, dry mouth, loss of appetite, diarrhea, upset
stomach, and weight loss. These symptoms can make it difficult to eat a healthy,
balanced diet while on the drug. If the patient reacts badly to the drug, then
nutrition intervention should be implemented (Zoloft, 2013).
3. How do selective serotonin reuptake inhibitors (SSRIs) work?
These inhibitors ease depression by affecting neurotransmitters used to
communicate between brain cells and alter the levels of one or more of these in
the brain. SSRI’s block the reabsorption of the neurotransmitter serotonin in the
brain. Changing the balance of serotonin helps the brain cells send and receive
chemical messages, which in turn boosts mood. SSRIs are called selective
because they seem to primarily affect serotonin, and not other neurotransmitters
(MayoClinic, 2013).
4. During the diet history, you ask Ms. Geitl if she uses and OTC vitamins,
minerals, or herbal supplements. She tells you her mother suggested she try
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Hypericum perforatum (St. John’s wort) because in Germany it is prescribed
to treat depression. Ms. Geitl did as her mother suggested, as it is available
without a prescription in the United States. What is St. John’s wort?
St. John’s wort is an herb with yellow flowers. It’s flowers and leaves are used to
make medicine. It can be traced as far back as ancient Greece, where they used it
to treat various nervous disorders (National Institutes of Health, 2013).
5. How is St. John’s wort used in the United States?
St. John’s wort is most commonly used for depression and conditions that can be
associated with depression such as anxiety, tiredness, loss of appetite and trouble
sleeping (NIH, 2013). St. John’s wort can be bought in a variety of forms,
including capsules, tablets, teas, and liquid extracts (NIH, 2013).
6. How does St. John’s wort work as an antidepressant?
The active therapeutic ingredients in St. John's wort are hypericin,
pseudohypericin and xanthones, although other components may support the
action of these compounds. It is not clear how St. John's wort works to treat
depression. Most likely, hypericin helps to elevate the biochemicals in the brain
that affect mood, namely dopamine and serotonin, and to reduce andrenal activity,
which is increased in depression (NIH, 2013).
7. Does St. John’s wort have any side effects?
Combining St. John’s wort and certain antidepressants can lead to a potentially
life-threatening increase in serotonin levels, a condition called serotonin
syndrome. Symptoms range from tremor and diarrhea to very dangerous
confusion, muscle stiffness, drop in body temperature, and even death. Psychosis
is a rare but possible side effect of taking St. John’s wort, particularly in people
who have or are at risk for mental health disorders, including bipolar disorder.
Other side effects of St. John’s wort are usually minor and uncommon and may
include upset stomach and sensitivity to sunlight. Also, St. John’s wort is a
stimulant and may worsen feelings of anxiety in some people. Taking St. John’s
wort can weaken many prescription medicines, such as,
 Antidepressants
 Birth control pills
 Cyclosporine
 Digoxin
 Some HIV drugs including indinavir
 Some cancer medications including irinotecan
 Warfarin and similar medications used to thin the blood.
(NIH, 2013)
8. How is St. John’s wort regulated in the United States?
St. John’s wort is unregulated in the United States and is classified as a dietary
supplement. The Food and Drug Administration (FDA) has not approved its use
as an over-the-counter or prescription medicine for depression (NIH, 2013).
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9. How is St. John’s wort used in Europe?
St. John’s wort is used in Europe to treat depression in adults and children and
anxiety disorders. It is commonly prescribed as a prescription drug in many
countries in Europe, with great popularity in Germany (NIH, 2013).
10. Why do you think people are interested in alternative medicine and herbal
treatments?
Today, many people are interested in the used of alternative and herbal medicine
as a way to combat the large obsession with the use of prescription drugs to treat
every ailment and disease. Some of these natural agents are thought to have less
or less severe side effects than prescription drugs, which is appealing to people.
In addition, many see it as a more natural way to treat ailments and diseases since
many of these treatments have been used for centuries.
11. Because Ms. Geitl is ambulatory, you are able to measure her height and
weight. She is 5’11” tall and weighs 160 pounds. You also determine that
she is of medium frame. Because Ms. Geitl is from Germany, she is used to
reporting her weight in kilograms and her height in centimeters. Convert
her height and weight to metric numbers.
Ms. Geitl’s converted height and weight are,
 5’11” tall= 71 inches tall= 71 in x 2.54 cm/in= 180.34 centimeters
 160 pounds / 2.2 kg/lb= 72.72 kilograms
12. Is Mrs. Geitl’s recent weight loss anything to be worried about?
Ms. Geitl’s ideal body weight (IBW) is,
 Hamwi= 100 pounds + 5 x (11 inches)= 155 pounds
 A range of 140-170 is used to assess a person with a small frame to a
large frame
Since Ms. Geitl is within the normal range for her weight, and has only lost five
pounds, it is tempting to say that I would not be too concerned with her weight
loss. However, because of the eating problems she is experiencing and her low
calorie usual diet history and 24-hour food intake I am concerned with her weight
loss and malnutrition status. Also, if a large amount of weight is lost in a period
of time then her nutritional status must be addressed immediately.
13. Because Ms. Geitl is alert and cooperative, you ask her to complete a PatientGenerated Subjective Global Assessment (PG-SGA) of Nutritional Status.
How would you score her?
Sections
Box 1
Box 2
Box 3
Box 4
Weight loss section (Table 1)
Disease section (Table 2)
Score
1
2
3
2
0
0
3
Metabolic section (Table 3)
Physical section (Table 4)
0
0
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Total:
SGA Rating, select one:
A= well nourished
B= moderately nourished
(or suspected of being
malnourished)
(Nelms et al., 2011, p. A-69)
C= severely malnourished
14. Using Appendix I, how would you triage nutritional intervention?
I would estimate Ms. Geitl’s triage nutritional intervention score to be at around
eight. Because of this score, I would be sure to play a large role in Ms. Geitl’s
treatment by spending a lot of time with her on her nutritional plan. I would also
make sure to include the nurses and physician in Ms. Geitl’s nutrition plan to get a
well-rounded support group. This will aid her in her nutritional recovery, as well
as her physical and mental recovery, since they are all dependant upon one
another.
(Nelms et al., 2011, p. A-69)
15. What methods are available to estimate Ms. Geitl’s energy needs?
 Harris-Benedict equation
 Mifflin-St. Jeor equation
 Quick energy estimate equation
(Nelms et al., 2011, p. 60)
16. Calculate Ms. Geitl’s basal energy needs using one of the methods you listed
in Question 15.
Using the Harris-Benedict equation,
 REE= 655 + (9.56 x wt (kg)) + (1.85 x ht (cm)) – (4.68 x age (yrs))
 REE= 655 + (9.56 x 72.7 kg) + (1.85 x 180.3 cm) – (4.68 x 20 yrs)
 REE= 1,590 kilocalories per day
(Nelms et al., 2011, p. 60)
17. What is Ms. Geitl’s estimated energy expenditure?
 TEE= 1,590 x 1.4 (for low activity factor)= 2,226 kilocalories per day
 Range of 2,200-2,300 kilocalories per day
 Total daily protein= .8 grams per kilogram of body weight (72.7 kg)= 58.2
grams
 Range of 55-60 kilograms of protein per day
(Nelms et al., 2011, p. 60)
18. Evaluate her usual diet history and her 24-hour recall. Is she meeting her
energy needs?
Ms. Geitl is not even close to meeting her daily energy needs. She is taking in
around 600 kilocalories per day and 25 grams of protein per day, with very little
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substantial food contribution (FitDay, 2013). I am very worried that Ms. Geitl is
becoming more malnourished with each passing day and that she is not eating to
maintain the vital nutrients that she needs to function, grow, and maintain her
existing health.
19. What would you advise?
I would strongly advise Ms. Geitl to work with me to create an eating plan with
her. I would recommend that she increase her calorie and protein intake to
eventually reach her recommended daily values. I would like to start her on a
plan that consists of eating six small meals a day to address her lack of appetite.
This will help her eat a more consistent number of calories and grams of protein
during her day, giving her more energy to do her regular activities.
20. List each factor from your nutritional assessment and then determine an
expected outcome from each.
Assessment Factor
Moderately malnourished
Expected Outcome
Replace missing and depleted nutrients
with vitamin and minerals, increase calorie
intake
Increase protein sources in diet
Increase calorie amount slowly until
desired amount is reached
Small, frequent meals about 6 times a day
Inadequate protein intake
Inadequate calorie intake
No appetite to consume food
21. What is your immediate concern regarding this patient’s use of St. John’s
wort?
My immediate concern for Ms. Geitl taking St. Johns wort is that she will be
combining it with certain antidepressants, like Zoloft, that can lead to a potentially
life-threatening increase in serotonin levels, called serotonin syndrome, as
described previously. This can have severe side effects and can even lead to
death (NIH, 2013).
22. Review the initial nutrition note written for this patient. Is this progress note
appropriate? Is it complete? Any errors? Any omissions?
Upon examining the written note, I have found many errors, omissions, and that it
is not complete in parts. First, this note is written in SOAP format and not the
standard, newer ADIME format that is recommended. Additionally, many of the
notes are written in the wrong category. For example, there is objective data,
such as diet history information, in the subjective section. Next, I suspect that her
kilocalorie count is too high at 2,600 kilocalories per day. The dietitian was not
correct in reporting that Ms. Geitl had lost five pounds in six months. The correct
timeframe for the loss was in a three-month period. Lastly, many pieces of
information are left out including, alcohol consumption, gender, temperature,
pulse, blood pressure, respiration rate, medical diagnosis, and current medical
care.
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References
Depression. (2013). MayoClinic. Retrieved from http://www.mayoclinic.com/
My fitness log. (2013). FitDay. Retrieved from http://www.fitday.com/
Nelms, M., Sucher, K. P., Lacey, K., Roth, S. L. (2011). Nutrition therapy &
pathophysiology. Belmont, CA: Wadsworth.
St. John’s wort. (2013). National Institutes of Health (NIH). Retrieved from
http://www.nlm.nih.gov/medlineplus/druginfo/natural/329.html
What is depression? (2013). National Alliance on Mental Health. Retrieved from
http://www.nami.org/Template.cfm?Section=depression
Zoloft. (2013). Zoloft: Sertraline HCl. Retrieved from http://www.zoloft.com/#isi
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