Assignment Review

Student Name: Abimbola Adekunle

Week: 6

Dates of Care: 07/24/2021

Demographics and Brief History

Patient Initials:

A. K

Sex

M

Age

32y/o

Room

0619

Admitting Date

07/24/2021

Admitting Chief Complaint: What symptoms cause the patient to come to the hospital?

Depression: suicide Ideation with plan to take pills and sexual paranoia.

Attending physician/Treatment team:

Mitchell L Glaser, MD

Precautions:

Suicide precaution, assault/ homicide precaution.

Primary Diagnosis:

Suicidal Ideation

Co-morbidities:

Disruptive mood dysregulation disorder.

Allergies:

None Reported

Code Status:

Full Code

Isolation: (type and reason)

Standard precaution because patient does not have any condition that required him to be placed on isolation.

Admission Height:

5’3.39’’

Admission Weight:

67.2 kg

Arm Band Location (colors & reasons)

White arm band on the left wrist for identification purposes.

Past Medical History: (pertinent & how managed)

Patient has a medical history of anxiety & depression. No pertinent surgical history.

Significant Events during this hospitalization but not during this clinical time: (examples include restrictive interventions or any medical emergencies. Include date, event and outcome)

On 07/24/2021, patient stated “I don’t want to leave my room; I need to sleep.

Physical Assessments and Interventions: (Include all pertinent data)

Vital signs:

General Appearance

· Grooming/Clothing

· Well Groom, dress in hospital gown and pairs of socks.

· Hygiene

· Well-kept hygiene, no foul odor present

· Posture

· Sitting, upright

· Gait

· Smooth and steady

· Obese/average or normal/ underweight

· Normal weight for his stated age

· Evidence of scars/ abrasions/ bruises/ tattoos/ or other physical markings

· None Observed at this moment.

Activities of Daily Living

· Sleep/rest

· No naps: but improved with, 8 hours of sleep reported

· Diet

· General diet

· Exercise/mobility

· Patient states he takes a walk around the facility.

· Elimination

· Normal elimination patterns.

· Hygiene

· Well kept

GI

Diet:

Blood Glucose (time & date):

Last bowel movement (time & date):

Pertinent Labs/Test:

Assessments:

· Stool

· Soft, normal BM pattern

· Bowel sounds

· Normoactive

· Tenderness, distention

· No distension, during palpation

· Appetite, nausea, vomiting

· Appetite is good, no nausea or vomiting reported

Interventions:

Respiratory:

Assessments:

· Lung sounds

· Clear breath sounds, bilaterally

· Cough, sputum

· None reported

· SOB

· None reported at the time.

Interventions:

Neurosensory:

Alert & Orientated:

Follows commands:

Speech Comprehensible:

Pertinent Labs/Test:

Assessments:

· LOC

· A & O 4x

· Pupils

· PERRLA

· Glasgow Coma Scale

· 15

· Dizziness

· Patient refuses

· Headaches

· Patient refuses

· Tremors

· Patient refuses

· Tingling, weakness, paralysis, or numbness

· Patient refuses

Interventions:

Cardiovascular:

Pertinent Labs/Test:

Assessments

· Peripheral pulses

· + 2 normal strengths and rhythm, bilaterally.

· Heart sounds (murmurs or bruits)

· Si & S2 present, no abnormal sound or bruits present.

· Edema

· No sign of edema

· Chest pain, discomfort, palpitations

· Patient refuses

Interventions:

None taken at the time of assessment as patient responded appropriate.

Musculoskeletal:

Activity:

Casts/Slings:

Assessments:

· Strength, weakness

· Strong equal on both sides

· ROM

· Full ROM of all extremities.

· Gait (documented under appearance)

· Pain

· None reported

· Fractures, amputations, or transfers

· N/A

Interventions:

Renal:

Pertinent Labs/Test:

Assessments:

· Bruit, thrill, location

· No bruit or thrill

· Urine-quality

· Clear, yellow

· Burning with urination, hematuria

· None reported

· Incontinent, continent, I & O

· Continent

Interventions:

N/A

Skin:

Braden Score:

Pertinent Labs/Test:

Assessments

· Bruising, wounds, drains

· None observed

· Turgor

· Normal skin turgor. No sign of dehydration

· Surgical incisions

· None

· Finger & toenails

· Well maintained, no abnormalities present.

Interventions:

N/A

Pain:

Pain score: 0

Assessments/Interventions:

· Scale used

· Pain scale of 0-10

· Location, duration, intensity, character

· N/A

· Exacerbation, relief

· N/A

Interventions:

· N/A

Gyn:

Gravida/Para: N/A

LMP: N/A

Last Pap: N/A

Breast exam: N/A

Pertinent Labs/Test: N/A

Assessment

· Bleeding

· N/A

· Discharge

· N/A

Interventions:

N/A

Safety:

Bed Rails: UP

Bed alarms: None

Fall risk: N/A

Assistive Devices: None

Interventions:

· N/A

Advance Directives/Ethical considerations:

AD: N/A

POA: N/A

Please add lab values for any medications that may require a blood draw (e.g., Lithium, Lamotrigine, Carbamazepine, Oxcarbazepine, Sodium valproate/divalproex sodium)

10 Panel Toxicology/Drug Screen: if available

Blood Alcohol Level/Ethyl Serum Level: if available

Psycho/Social Assessment

· Level of education

· Senior at Chamberlain University

· Occupation

· None

· Race/Ethnic Background or Identification

· Asian

· Religion/Spiritual Beliefs

· Catholic

· Communication needs: (verbal, nonverbal, barriers, languages)

· Verbal communication

· Special Talents/Interests/Skills

· Interested in communication and arts.

· Environment (home and community)

· Living with parents.

· Family Structure/History: Single

Stage of Development: (Erikson’s Stage of Development, describe the current stage of the client and previous stages that the client may not have successfully completed)

Patient is in early adulthood, a stage of Intimacy vs. Isolation. This is a development stage that is characterize with love relationship seeking. According to Erikson, at this stage success mean fulfilling relationship while failure means isolation. Struggle at this stage may leads to depression, anxiety, and substance abuse, which may be relevant with this patient.

The previous stage the patient may not have successfully completed is adolescence stage, Identity vs. role confusion. Most people at this stage may struggle with who they are or want to be. This stage is one of most critical developmental stages.

Support System:

Patient stays with mum and siblings as support system.

Stressors/Stress Management Practices:

Stressor according to the patient was due to too much schoolwork, patients is an undergraduate with dual majors. Another stressor may be paranoia thoughts. Patient stated that education is important to him.

Pathophysiological Discussion: One scholarly article must be cited using APA format in this section. The textbook may also be used as a secondary source. The reference list should be included with the summary of the article.

Discuss the current disease process:

Neurotransmitters are naturally occurring in the brain that causes chemicals that’s likely to play a role in major depressive disorder. Research indicates that changes in the function and effect of these neurotransmitters and how they interact with neurocircuits involves in maintaining mood stability that may play a significant role in depression and its treatment. Traumatic or stressful events such as physical, sexual abuse, death of a family member may trigger depression.

Patient with major depressive disorder often show symptoms of anhedonia and anxiety may cause physiological changes like insomnia. Significant disturbance in cognitive function associated with lack of coherent thinking as well as morbid preoccupation by thought of self-arm and suicide Ideation.

Discuss the etiology of the patient’s illness:

In the case of this patient, major depressive disorder can be associate with not meeting up with schoolwork. Also, patient stated that he is been overwhelmed with school studies because patient is taking dual major courses. In a stressful situation as such, these feeling of stress could also triggers acute depression.

Also note the complications that may occur with treatments and patient’s overall prognosis:

Certain types of complication may arise and cause exacerbation of symptoms, traumatizing event may also trigger symptoms. Lack of therapeutic effect of medications and late diagnosis may occur.

Attach a research article pertaining to diagnosis of patient. Write a summary about the article below and include a reference list:

Depression is a common and serious medical illness that negatively affect one’s thoughts, mood, emotions, and physical health. This dysfunction may happen due to hormonal imbalance in the CNS. Especially in the brain. The exhaustion of neurotransmitters such as dopamine and serotonin in the brain has been linked to feeling of sadness and loss of interest and this can interfere with daily life functioning. Certain events in life may also cause major depressive disorder.

Major depressive disorder is anxiety and anhedonia, these symptoms accompany with other psychophysiological symptoms like feeling of sadness, misery, and recurrent thoughts of committing suicide. These are the evident found in the patient diagnosis.

Types, treatments, complications, management, of depression are detailed in this article. According to the authors, there were establishments that explains that even though there are several medications for these treatments, and therapeutic management to relief depression, some of the patients may develop treatment resistant whereby they fail to respond to available medications and other therapeutic approach presented.

.

References

Fedaku, N., Shibeshi, W., Engidawork, E. (2017). Major Depressive Disorder: Pathophysiology and Clinical Management. Journal of Depression and Anxiety, 06(01). https://doi.org/10.4172/2167-1044.1000255

Medications

Classification

Dose

Route

Freq

Purpose/Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Lorazepam (Ativan)

Benzodiazepine

1 mg

PO

q.d

prn

For anxiety/it enhance inhibitory effects of GABA within the CNS.

Dizziness, drowsiness, orthostatic hypotension, blurred vision, headache, dry mouth, rash, disorientation.

Monitor respiratory status, heart rate, BP, and level of sedation

Haloperidol

Antipsychotics

5 mg

PO

b.i.d

prn

Prevents suicide ideation/blocks dopamine D2 receptor in the brain.

Tachycardia, urinary retention, hypotension, impotence, dry mouth, extrapyramidal symptoms, confusion, rash

Be alert for symptoms of seizure, assess & monitor motor function like tardive dyskinesia.

Zolpidem

Sedative-hypnotics

5mg

PO

q.d

prn

For sleep, treat insomnia/It increases GABA effects in the CNS by binding GABA receptors in the CNS

Headache, drowsiness, dizziness, diarrhea, rash, sinusitis, lethargy, double vision. Nausea, vomiting

Assess respiratory function, monitor for signs & symptoms of increase depression, as well as motor function.

Priority

Nursing Diagnosis

Related to

As Evidence By

Rationale (reason for priority)

1

Anxiety

Maturational crises, Persistence feeling of guilt

Negative rumination of not meeting up with studies.

Patient is in early adulthood developmental stage. Negative rumination of not meeting up with studies, hence causes stress and increase anxiety.

2

Ineffective coping

Major depressive disorder. Anxiety

Suicide Ideation with plan, self-harm.

Psychologic trauma and stress may lead to major depressive disorder. Patient expressed he is overwhelmed with school, and he is feeling helpless and hopeless.

3

Ineffective health maintenance

Substance abuse

Underlying fear and anxiety, acute psychosis

Substance abuse may cause acute psychosis, anxiety and other physiologic effects like tachycardia, hypotension.

4

Risk for self-direct violent

Suicide ideation

Repressed fears

Patient diagnose with major depressive disorder to self. Patient stated plan to take commit harm to self.

Table for Nursing Diagnosis Number 1

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

Objective:

Patient displays pressured speech during communication when interviewed.

Increased breath during assessment, demonstrate discomfort.

Subjective:

Patient stated I feel like I’m not doing enough, I want to make my mum and siblings proud, I’m not doing anything positive with my life.

Patient stated feeling hopeless as being concern with college due to stress and anxiety. Stated “I feel overwhelmed.”

Patient will be verbalizing his own coping patterns and anxiety.

Patient will express feeling in a coherent, logical manner.

Patient will express satisfaction with social circumstances and achievements of life goals.

Patient will relate high rate of psychological and physiologic comfort.

Make sure environment is calm and free of stimuli.

Keep voice tone and rhythm in a calm manner when addressing the patient.

Plan short, frequent periods with patient every day.

Encourage family and friends of patient to provide support as much as possible.

Encourage patient to engage more in pleasurable activities that will promote coping skills.

Patient was able to verbalize awareness of own coping abilities and congruent with behavior.

Patient was able to withdraw from substance use successfully.

Patient verbalize signs and symptoms of escalating anxiety.

Table for Nursing Diagnosis Number 2

Assessment

· Signs and symptoms relative to the nursing diagnosis, as evidence by

· 2 objective

· 2 subjective

Patient Outcome

· SMART

· Specific

· Measurable

· Attainable

· Realistic

· Timely

Interventions/Implementations

· Includes interventions/ nursing actions directly relating to pt. outcomes

· Specific in action, frequency and contain rationale

· Minimum of 3 interventions appropriate to help pt./ family meet their outcomes

Evaluation

· Includes all data that is listed as criteria in outcomes

· Outcomes are determined to be met, partially met, or not met

· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

Objective:

Patient displayed physiological stress upon assessment, patient appeared tired, bored, display loss of interest in surroundings.

Dysphoric mood and anhedonia observed

Subjective:

Patient stated feeling sad about recent friend’s death. Sometimes feel like harming self.

Patient complain of insomnia, not being able to focus, helplessness, and loss of hope.

Patient will express their goals and feelings in a reasonable and logical manner.

Patient will ask for help when experiencing self-destructive moments.

Patient will have satisfaction with social circumstances and achievement of life goal.

Patient will demonstrate a stress reduction technique.

By Identifying the level of suicide precautions needed.

Implementation of no suicide contract.

Help patient to recognize a distorted perceptions linkage to depression.

Encourage patient to participate more often in group therapy.

Encourage patient to identify problem happening in patient life and explore ways substance use may intensify those problem.

Compliance with medication need for the relieve of stress.

Provide family the important reason to contact the provider when there is any sign of relapse is seen.

The patient’s ability to identify ineffective coping behavior and outcome.

Patient will meet up with physiological need as evidence by pertinent expression of self-feelings and use of resources.

Patient’s ability to evaluate current situation precisely.