Depression Care Plan

8/6/2019 Depression Care Plan

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INTRODUCTION:

. As a part of Psychiatric Nursing Clinical Posting. we are posted at NIMHANS hospital

from 01-10-2010 to 31-10-2010.As a part of Clinical rotation I was posted in Pav- I Male

closed general ward and selected the patient name Mr. goutham for my case presentation.

He was been diagnosed as Depression and to provide basic nursing care according to

priority needs

PATIENT PROFILE

Name of patient : Mr. goutham

Age : 17 years

Date of Admission : 12/1/10

Marital Status : single

Ward : child psychiatry ward

I P no : 25698

Education : PUC

Occupation : Nil

Income :

Address : kuvempunagar, Bangalore.

Religion : Hindu

Socio Economic Status: middle class Group

Diagnosis : Depression

INFORMANT : Client s mother is the informant. He is staying along with patient from birth

itself. He had good intellectual and observation ability. He had moderate degree of concern

regarding the patient.


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PRESENTING CHIEF COMPLAINTS

According to patient he had no problem for admitting him.

According to informant , Fearfulness, Social withdrawal5 months, 2 attempts of suicide 5

month back, Decreased food intake, and Decreased speech output from 1 month, Decreased

food intake. Decreased sleep. (Sound sleep), Not going for class, this all are occurring after

the death of the child s father

HISTORY OF PRESENT ILLNESS

Patient was apparently normal 2 month back. When he doing a computer course in

her town, he had joined the course 7 month back after studying 10, there he fell in love a

girl, but after a few days she left the boy. After few days he was depressed and discontinued

the course and came back to the house. After coming to the house his father was sick and

was admitted in the hospital, there after few days his father expired in Victoria hospital. As

it was sudden attack Mr.Goutham was not able to cope up with the failures of the

situations and got depressed, the child has attempted for suicide, has suicidal ideations

PAST PSYCHIATRIC & MEDICAL HISTORY

This is the first episode of illness to client. He had history of social withdrawal since 2

month and suicidal ideation before 1 month. He had no history of any major illness likehypertension, endocrine problems, metabolic problems and any other communicable or

non communicable diseases.

TREATMENT HISTORY

No treatment history available because this is the first episode.

FAMILY HISTORY

Mr.Goutham has a positive family history of mental illness. No other family history of

medical and psychiatric problems. He family is a nuclear family and all are maintaininggood IPR with each other. During this episode of illness he is withdrawn.


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FAMILY TREE

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PERSONAL HISTORY:

Prenatal history

No history of any febrile illness, medications, drugs, alcohol use, trauma to abdomen

and any physical or psychiatric illness during pregnancy. He was a wanted child. No history

about breast feeding and weaning available. The delivery was normal vaginal delivery. He

had history of measles during prenatal period. He had no birth defects.

Childhood history

Patient was brought up by his mother and father. No history available regarding

breast feeding and weaning. No history of maternal deprivation. He had temper tantrum

during his childhood period.

Educational history

He Completed SSLC and now studying a computer course. He had good relationship

with peers and teachers. He had learning problems and now had hesitance go college. He

terminated his study because he was poor in studies and was in love with a girl as she left

the place, he also discontinued his education.

Play history: Client was very happy to engage in play. He had good relationship with peergroups.

Sexual & Marital History: He had no gender identity disorder. No sexual fantasies.

Premorbid personality: Cyclothymiacs personality


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Interpersonal relationship

i. He had good IPR with family members, friends and superiors. He was introverted.

Now he has less involvement with peer group and others due to withdrawn

behavior.

ii. Use of leisure time: he had no specific hobbies and interest.

iii. Family life Not interested in family life. He was prone to anxiety and poor reaction

to stressful life events.

iv. Habit He had no habit of day dreaming. He had no specific food fads and habits.

Environmental history

House is tiled. Disposal of waste is through dumping and open drainage.

PHYSICAL & PHYSIOLOGIC ASSESSMENT

Vital Signs: Temperature Normal

Pulse 90/mt

Respiration 20/mt

BP 120/80 mm of Hg

General appearance:

State of nutrition average

Personal appearance- good

Posture straight

Emotional state- depressed

Skin and hair- child looks fair and hair is black


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Head to toe examination

BODY PARTS OBSERVATION

Skin

Nails

Hair & Scalp

Head & Skull

Face

Eye & vision

Ears

Nose

Mouth and throat

Neck

Thorax and chest

Abdomen

Upper extremities

Lower extremities

Interference

Color is normal. Dry skin

Dry Texture. Good turgor, no edema and lesion

Pink in color. Normal shape. Capillary refill good

Equal distribution of hair. No presence of alopecia and dandruff

Normal Size

No puffiness, moon face etc

Normal visual and no double vision, ocular movements are not

normal. No infection & discharges.

No infections and discharge. Good hearing capacity. No ringing in the

ears. He had not using hearing aids.

Had no frequent colds, no DNS and injury to nose or face

No halitosis, gum bleeding & hyperplasia, sore throat etc

Good range of motion. No pain and neck rigidity. Ho thyroid

enlargement.

Normal size and shape.

Chest expansion is equal and symmetric

Pale color. Soft and distended. No tenderness.

Good range of motion. No complaints of pain and stiffness of joints.

No deformities. Good range of motion. No complaints of pain and

stiffness of joints.

No specific deformities or abnormalities found during physical

examination. He had poor personal care and appearance. He was

worn shirts and 2 pants at a time during admission. No specificmedical disorders find out.


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MENTAL STATUS EXAMINATION

General appearance

Facial expression depressed

Posture stiff

Mannerism continuous picking up fingers and finger nails.

Dress poor grooming

Hygiene very poor

Motor disturbance : present (hypo activity and negativism present. Sometime patient will

do exactly opposite when asking to do something)

Disorder of thought

A. Form of thought

a) Ambivalence present ( Patient is interacting effectively sometimes and then

he become very angry towards me)

B. Disorder of content of thought.

a) Delusion present - Persecution (Patient says Somebody is trying to harm

me )

b) Obsession Present

c) Phobia Present ( Fear of death)d) Preoccupation absent

e) Fantasy absent

Remark - delusion of persecution and phobia present

Disorder of speech

1. Pressure of speech decelerated

2. Flight of ideas absent

3.

Thought block absent 4. Intensity slow

5. Pitch abnormal variation

6. Speech decreased

7. Manner inappropriate

8. Reaction time - slow


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Disorder of perception

1. Illusion absent

2. Hallucination present ( hearing voices and self talking)

Remarks auditory hallucinations present

Disorder of affect

1. Affect inappropriate

Subjective Patient says I am Happy

Objective facial expression reveals sadness

2. Pleasurable affect absent. Depressed.

3. Un pleasurable affect present

Remarks -in appropriate affect, depressed.

Disorder of memory

a. Immediate memory

Q: what you have for your breakfast?

A: Tea

b. Recent memory

Q: when did you slept during night?

A: Not answering (Looking sharply)

c. Remote memoryQ: Where did you studied?

A: Not Answering

Remarks: Patient is not responding, so it cannot be assessed.

Disorder of orientation

a. Orientation to time

Q: what is the time now? (11:00AM)

A: afternoonb. Orientation to place

Q: which place is this?

A: NIMHANS

c. Orientation to person

Q: who am I?


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A: you are coming for disturbing me

Remark: Oriented to time, place and person

Insight

Q: How are you?

A: nothing. You are coming for disturb me?

Q: for what reason you came here?

A: I don t know.

Remark: insight grade I.

Disorder of concentration

Q: Count from 100 to 10 by subtracting 10 to each

A: 100, 90, 91, 92, 93

Q: Count from 1 to 10

A: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12

Remark: Concentration is impaired

Disorder of judgment

Q: what you will do when you are in a house on firing

A: Oh, I will look and see (laughing)

Remark: Judgment is impaired.

IntelligenceQ: Who is the president of India

A: I don t know

Q: add 19 with 10

A: 29

Q: subtract 23 from 64

A: 41

Remark: Intelligence is intact. Abstract thinking Proverb

Q: tell me the meaning of barking dog seldom bite

A: not responding (looking sharply)

Similarities

Q: what is the similarity between a table and a bed?


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A: not responding (become angry)

Differences

Q: what is the difference between a apple and orange

A: apple is soft and orange is juice

Remark: abstract thinking is not elicited effectively

Disorder of sleep

Present (complaints of reduced sleep since 1 week)

Summary : Eye to eye contact was developed from the beginning itself.

General remarks

Client had delusion of grandiosity and delusion of persecution. He also had disturbance in

speech, affect and thought. He is hyperactive, over talkative and easily become angry. He

had impaired concentration and abstract thinking. His orientation is not affected. He had

reduced sleep.

Diagnosis depression.

INVESTIGATION :

SL

NO

TEST PATIENT VALUE NORMAL VALUE REMARKS

1. B Glucose 76 mg/dl 60-10 mg/dl Normal

2. B. Urea 20 mg/dl 10-50 mg/dl Normal

3. B. Creatinine 0.7 mg/dl 0.3 1.2 MG/dl Normal

4. T. Bilirubin 0.3 mg/dl Less than 1 Normal

5. ALP 72 u/L 40-129 U/L Normal

6. SCIOT 22 gm/Dl 8-40 U/l Normal

7. Sodium 147 mcg/L 135-148 MCG/L Normal

8. Potassium 4.5 mcg/l 3.5-5.2 mcg/l Normal9. Chloride 110 mcg/l 95-106 mcg/l Increased


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PROCESS RECORDING

OBJECTIVES

1. To establish good rapport.

2. To identify signs and symptoms of illness.

Nurse s response Patient s response Inference

Verbal Nonverbal

Duration 15 mts

Client lying on bed

Hello, good morning Mr.

Santhosh.

How are you?

Why are you lying in this bed

constantly? Just go to out side

of this ward.

Are you happy here?

Oh, you just leave that. Did you

taken your breakfast?

How was your sleep?

Ok. When did you slept

yesterday?

Who all are your family

members?

In which person you have more

Good morning

Fine.

Oh, I will go later.

I don t like thisplace.

Yes. Idly .

It was nice.

Yes it was ok.

8 o clock and waken

on morning 5

o clock.

Father, mother , one

sister and brother.

Smiling

Sitting on bed.

Smiling

Face became

tightened.

Smiling

Smiling

Smiling

Smiling

Eye contact

developed.

Verbal

communication

adequate

Eye contact.

Irritated

happy

immediate and

recent memory

intact.


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Henderson s Basic Needs Patient Picture Application of theory

1. Breathe normally Mr. goutham breaths normally

2. Eat and drink adequately

Mr. goutham is not interestedin eating the food

y Assess the likes and dislikes y Provide food in an attractivey Advise the mother to provide

and dislikesy Advise the mother to providy Advise the child s mother to

attractive mannery Advise the child s mother tovegetables to increase the bo

3. Eliminate the body waste Eliminates the body waste

4. Move and maintaindesirable positions

Moves and maintains desirablepositions

-

5. Sleep and rest Mr. goutham looks sleeplessand restless to the newhospital environment.

y Provide orientation of the hoy Provide warm milk at night.y Provide warm bath at night y Provide clean and calm envir

6. Maintain bodytemperature

The child is maintaining thenormal body temperature


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7.Select suitable clothing Mr. goutham is able to select the clothes and removes dressand but do not know to wear.

_

8. Maintain bodilycleanliness and grooming

Is able to maintain cleanlinessalone needs help andassistance

9. Avoid dangers in theenvironment

Mr. goutham d is consciousabout the dangers of theenvironment

10. Communicate with othersto express emotions, needsfears or opinions

Mr. goutham is showingreaction towardshospitalization and she is

scared of personnel withapron.

y Develop good rapport with y Use calm and soothening ap

childy

Avoid speaking loudly, avoi


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NURSING DIAGNOSIS

1. High risk for self harm related to depressed mood, feelings of worthlessness,

anger turned inward to self .

2. Dy sfunctional grieving related to real or perceived loss, bereavement over

loads .

3. Low self esteem related to learned helplessness, feelings of abandonment b y

significant others .

4. Powerlessness related to d ysfunctional grieving process, life st yle of

helplessness .

5. S piritual distress related to d ysfunctional grieving over loss of valued object .

6. Alteration in sleeping pattern related to suicidal thoughts

7. Alteration in nutrition less than bod y requirement related to loss of appetite .


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ASSESSMENT NURSING DIAGNOSIS

GOAL PLANNING RATIONALE

SUBJECTIVE DATA C lient , told that hedoesnt want tolive, because hislife is useless andworthless .

OBJECTIVE DATA C lient looks ver y sad and depressive

mood .

SUBJECTIVE DATA Patient sa ys that heis separated fromhis parents becauseof illness and feelsdepressed . He sa ysthat his

R isk for suiciderelaxed todepressed mood,feelings of worthlessness,anger turned inward on the self .

Low self esteemrelated learnedhelplessness,feeling of abandonment b y significant others .

R educe therisk of self harm or injur y.

Improve theC lients self esteem .

---Ask C lient directl y haveyou though about harming your self in an y way? If so what doyou plan to do ? Do you have themeans to carr y out this plan ?

---Create a safe environment for the C lient .

---Formulate a short term verbalor written contract that theC lient will not harm self .

---Maintain a close observationof C lient .

---Encourage the client to become involved with staff andother clients in the therap y through interactions andcompletion of responsibilities . ---G ive the C lient positive feed

back for completion of responsibilities .

---The risk of suicidis greatl y increaif the C lient hasdeveloped a plan and

particularl y it meanexist for the C lient execute the plan . --- Client safel y is anursing priorit y. --- A degree of theresponsibilit y for hor her safet y is give

to client . --- O bservation helpsto find out an y suicidal behavior .

--- Involvement ininteraction helps to

build self-esteem .

--- Positive feedbackhelps to identif y

meaning in behavior


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relatives make funof him and feelsshame to sta y in thehospital . He sa ysthat he needs othershelp .

Objective data . C lient is not doingactivities in anormal pattern .

Subjective dataC lient sa ys god ischeating me

Subjective data:The C lient told, thatshe is not interestedin eating food .

Dy sfunctionalgrieving related toreal or perceivedloss, overloads .

Improve theC lientsfunctionalabilities andshould

behavenormalit y.

---Encourage Client to recognizeareas to change and provideassistances towards theseefforts . ---Teach assertiveness andcommunication technique . ---Promote attendances intherap y groups that offer C lientsimple methods of accomplishment .

---Assess stages of fixation ingrief process .

---Develop trust, show empath y concern and unconditional

positive regard .

---Help C lient with honestreview of relationship with lostobject .

---Teach normal behavior associated with grieving .

---it will helps for effective interaction

---it is a form of reinforcement for thclient .

--- Accurate baseline

data is required inorder to plan accuratcare . ---- Developing trust

provide the basic fortherapeuticrelationships . --- Only when theC lient is able to see

both positive andnegative aspectsrelated to the lostobjects . ---To develop the

positive attitude .


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Subjective dataC lient , told that hedoesnt want tolive, because her life is useless andworthless .

Objective dataC lient looks ver y sad and depressivemood .

Subjective dataC lient , told that hedoesnt want tolive, because hislife is useless andworthless .

Powerlessnessrelated todysfunctionalgrieving processlife st yle of helplessness .

S piritual distressrelated todysfunctionalgrieving over lossof valued object .

Improve theC lients

problemsolvingabilities .

R educeclientsspiritualdistress .

---A llow C lient in participate ingoal setting and decisionmaking regarding own care . ---Ensure the goals are realisticand the C lient is able to identif y areas of life situation that arerealisticall y under control---- Encourage C lient toverbalize feelings about areasthat are not within her abilit y tocontrol .

---Be accepting and non- judgmental when C lient expressanger and bitterness toward god,sta y with C lient .

---Encourage the client toventilate feelings related tomeaning of own existence in theface of current . ---Ensure the client that he or she is not alone when feelinginadequate in the search of lifes

--- Providing C lientwith choices willincrease the feelingsof control . --- R ealistic goals wavoid setting C lienfor further failure . --- It ma y help C lieto accept what canno

be changed . --- To promote trustrelationship .

--- Catharsis can provide relief and pulife back into realisti

perspective . ---increases spiritualwell being .


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Objective dataC lient looks ver y sad and depressivemood .

Subjective data:C lient sa ys I amfeeling not well . I have fatigue andnot able to do an y thing . Objective data:Look weak Poor food intakeDr y mouth andtongue .

Alteration innutrition less than

bod y requirementrelated to loss of appetite .

Maintain theC lientsnutritionaland fluidstatus .

answer .

---Provide food in a smallquantit y and at a time butfrequentl y.

---Ask choice of food and servein an attractive manner . ---Serve food when ever y one iseating . ---Be with the patient when he iseating food . ---Talk about his success andgood behavior while the patientis eating . ---Pursue the patient to eat fullmeal .

increase digestion an palatabilit y.

---serving in attractivmanner improveattitude .

---to ensure whetherclient is taken food---improve self esteem .


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---G ive plent y of fluids androughage, green leaf y vegetables and salad .

---to ensurerecommended dailintake . ---To maintainnutritional status .


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P SYCHO EDUCATION & REHABILITATION

Explained the patient regarding various measures to do at home

DIET

Explained him about the importance of balanced diet & explained to him about the

diet pattern which should be followed

Explained to his relatives to give diet according to the choice of the patient and if

he is unable to take food help him to eat

DRUG

Explain to him and to his family members regarding the importance of drug therapy

Explained to the relatives about the drug how often it should be given and about the

action of each drug

Explain to him and to his relatives not to stop the drug without the prescription of

doctor and to continue drug as prescribed by doctors.

FAMILY SUPPORT

Explain to family members about the king of illness the patient is suffering from and

about his social productive abilities

Educate the relatives to persuade the patient to maintain his personal hygiene, take

diet, participate in daily care activities and to accept the treatment

Explain about the types of jobs the client can perform Encouraged the relatives to keep supportive the patient and not to over protect and

show rejection towards patient

SOCIALIZATION Encourage him to go day care center and to interact with others Allowed him to sit with others and encouraged him to talk to neighbor patients Encourage his good performance in the group Encourage him to spend more time with others


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FOLLOW UP

Explain to the patient that the disease can t be cured completely. Only we have to control

this. So you must continue drugs as prescribed by doctor and come for follow up regularly

as prescribed by doctor.

Depression Care Plan

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