Depression

A patient was admitted into the hospital for a diabetic foot ulcer with osteomyelitis. She
previously was admitted into the hospital, but left against medical advice. The patient is single
mother, also caring for ill parents. She is currently taking Nortriptyline for depression. The
Burns Depression Checklist was chosen to assess the patient because she is unhappy that she
needs to remain in the hospital for four weeks of antibiotic treatment.
Initially, I was reluctant to ask questions about depression. I felt uncomfortable to probe,
but she actually did not mind. The Burns Depression Checklist score was a 6 out of 45. The
patient was classified as borderline depression, normal but unhappy.
It was not a surprise since the patient was talkative, in a good mood, and counting the
days till she could leave. But again, she could simply enjoy having a student nurse to converse
with, putting her in a pleasant mood. I wondered what the patients mood was like prior to being
medicated with Nortriptyline.
The manifestations of depression observed were the inability to sleep and lack of
motivation to improve her health. Risk factors she encompassed were stressful social factors
including lack of an intimate, confiding relationship with a significant other, having three or
more children at home, and being unemployed. She had three of the four social risk factors
stated in our textbook. This probably contributes greatly to her depression. The patient is also
female, who are twice as likely than men to develop depression. She also lives in public
housing. Lower socioeconomic classes see more depression disorders. I wondered if her
parents, whom she is very close to, also suffered from depression. Patients with a first-degree
relative suffering from depression have a great risk of developing it themselves.
I was able to apply several nursing interventions. Maintaining a safe environment, I daily
cleaned and straightened up her room. I established a good rapport with her, as she opened up,
sharing her thoughts and feelings of the hospital, the social worker, and her family. I was able to
identify her support system, which was not sufficient for her condition. The social worker was
aware of it, and working to help her.
There was a good outcome, as the patient understood and verbalized the importance of
remaining in the hospital to complete treatment. She is not a risk for suicide at this time. She
was ecstatic to be transferred to the progressive care unit at the hospital, rather than the longterm care facility, thus being closer to her family.

Alcohol Withdrawal
For my second patient I selected the Clinical Institute Withdrawal Assessment-Alcohol
revised (CIWA-Ar) tool. I chose this assessment guide for several reasons. The obvious reason
was that the patient was admitted into the hospital for alcohol withdrawal, esophageal varices,
alcoholic cirrhosis, ascites, and alcoholic hepatitis.
Secondly, it is simple, being refined from 30 questions to 10. This was important since
the patient was difficult and required a lot of attention. It allowed me to take a quick assessment
every four hours.
The third reason was the assessment had follow up procedures written on the assessment,
which helped me decide what action to take according to the patients score at any given time.
His mood and level of consciousness would range widely throughout the day. The nurses
reported the patient trying to leave the room, hitting a nurse and security being called.
Lastly I chose this assessment because it is the most studied scale for alcohol withdrawal.
It has been researched, validated, and most importantly the results have been reproduced.
I assessed the patient twice each day, during my initial morning assessment, and with the
last set of vital signs when reporting off the floor. The test has a possible 67 points. He
regularly scored low, between 5-7 points, which is classified as minimal withdrawal. Any score
above 8 may require action of administering PRN medications, Diazepam or Lorazepam. He did
not have any PRN medications ordered, though Diazepam was previously ordered as a PRN last
week. My analysis for his low score is because he has been in the hospital for two weeks, thus
the care and medications has been improving his condition. Also he is taking Chlordiazepoxide
25mg twice a day. This is a long acting benzodiazepine similar to Diazepam; both are used
regularly to treat alcohol withdrawal. He is being administered 25mg, which is a low dose.
Usually 50-100mg is prescribed during withdrawal periods.
I am assuming that the patient had a higher score on the CIWA-Ar during the afternoon
and late night, as those are the reported times that security was called. He also had episodes of
paroxysmal sweats, tactile and auditory disturbances in the previous weeks, which would
increase his score. So the medication is working and his condition is improving.
Nursing interventions were implemented for this alcohol withdrawal patient. Foremost
was fall precaution. He constantly wanted to get out of bed, but had a very unsteady gait, and
did not use the walker unless told to. He was moved to a room in front of the nurses station
since hourly roundings were not sufficient. He had a bed and chair alarm, a chair belt, and 4 bed
rails remained up.
Aspiration precaution was also put into effect. He was ordered a dysphagia diet, with
nectar liquids. He also had to sit in the high back chair during meals, and kept upright for one
hour after each meal. He strongly disliked the thickening powder for nectar drinks, so I always
mixed his liquids out of his room.
Also his diet was supplemented with folic acid, thiamine, and multivitamin to combat
malabsorption and emotional disturbances.
The outcome for this patient thus far is favorable. He has not sustained any falls, his
mental and physical states are responding to treatment, and he does not have access to alcohol
while in the hospital. He still remains in the hospital, awaiting placement in a foster home.