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Running Head: MAJOR DEPRESSIVE DISORDER

Psychiatric Mental Health Comprehensive Case Study

Major Depressive Disorder

Kirstie Lynne Lewis

Youngstown State University

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MAJOR DEPRESSIVE DISORDER
Abstract

The following is a case study regarding the nursing care of a patient admitted to a mental health

unit. Multiple pieces of the patient’s disease, background and care will be discussed – including

objective data, summarization of diagnosis, identification of stressors, history of mental illness,

psychiatric evidence, analyzation of influences, evaluation of patient outcomes, summarization

of discharge plans and NANDA nursing diagnoses.

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Objective Data

The patient within this case study is a thirty-year-old female from Youngstown, OH. On

October 3rd, 2017 the patient voluntarily admitted herself onto an in-patient mental health unit

due to increasing depressive mood and suicidal thoughts. The nursing care from within this study

was completed on October 5th, 2017. The patient was admitted with a diagnosis of “Recurrent

Major Depressive Episode”. As explained by Townsend (2015), a Major Depressive Episode

occurs when an individual experiences persistent emotional depression. The specific criteria are

that the person must have experienced five or more specific symptoms for at least a two-week

period. Examples of these specific symptoms include a depressed mood for most of the day,

diminished interest in activities, weight loss or gain, insomnia or hypersomnia, psychomotor

agitation, fatigue, feelings of worthlessness, diminished concentration, recurrent thoughts of

death, etc (p. 462). While also reviewing the patients chart, it was found that she had a

psychiatric history of Generalized Anxiety Disorder and Bipolar Disorder. Anxiety is a condition

that occurs when one has excessive uneasiness from which the source largely unknown and

bipolar disorder consists of alternating manic and depressive episodes (Townsend, 2015, p. 529).

The patient also had a medical health history of morbid obesity, restless leg syndrome,

hypertension, carpal tunnel syndrome, cellulitis, and diabetes. Upon the patient’s admission, she

was documented to have been pleasant, but extremely emotional. During the admission process

and day of nursing care, the patient was tearful, but denied knowing of any acute or chronic

stressors that may have contributed to her depressive episode. The patient denied any abuse of

illicit drugs or alcohol, but admitted to the use of smoking tobacco since age fifteen. As I

personally spent more time with the patient, I was able to help her identify multiple life stressors,
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which will be discussed further in this study. The following is a list of medications that the

patient is taking:

1. fluoxetine (Prozac) 60mg QID  SSRI to treat depression

2. quetiapine (Seroquel) 60mg QID  antipsychotic to treat bipolar disorder

3. trazadone (Desyrel) 300mg q night  antidepressant to treat depression and anxiety

4. pramipexole (Mirapex) 2mg q night  antiparkinsonian to treat bipolar disorder

Summarization of Psychiatric Diagnoses

According to Steve Bressert (2017), Major Depressive Episode is described as, “an

overwhelming feeling of sadness, isolation, and despair that lasts two weeks or longer at a time”.

Some of the expected symptoms of this diagnosis include, diminished interest in activities,

weight loss or gain, insomnia, fatigue, difficulty concentrating, recurrent thoughts of death and

much more (para. 1). While interacting with the patient in this study, she visibly and verbally

expressed sadness, weight gain, fatigue and carelessness regarding hygiene. Regarding the

patients Generalized Anxiety Disorder, the National Institute of Mental Health (2016) describes

it as excessive worry for months including feeling on edge, fatigued, difficulty concentrating and

more (para. 2). The third diagnosis found in this patient’s history is bipolar disorder. As also

explained by the NIMH (2016), this disease is known as “manic-depressive illness” and an

individual experiencing it goes through both euphoric and depressive episodes. Some signs and

symptoms that occur while an individual is experiencing a manic state are increased energy

levels, increased activity, trouble sleeping, racing thoughts, fast speech and risk-taking

behaviors. On the other hand, individuals in the depressed state may have thoughts of

hopelessness, decreased energy, decreased activity, increased sleeping, recurrent thoughts of

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death or suicide, etc (para. 3). Each of these three diagnoses are known to have great impact on

social and occupational functioning.

Identifiable Precipitating Factors

While conversing with this patient, I was able to help her identify multiple stressors and

behaviors that precipitated to this hospitalization. Upon meeting the patient, my first impression

was that she was very friendly, but was lacking interest in hygiene or dress – which is to be

expected of a person suffering from depression. As I began to dig deeper into her current state,

she greatly resisted any emotional topics at first. When I asked her if she could think of any

recent life stressors that may have put her back into a depressive state, she denied being able to

think of anything. With this response I had a hard time determining how I would be able to get

the patient to talk deeper into her depressive episode. With use of silence, showing interest and

digging deeper into topics, she eventually listed many identifiable stressors. For example, within

the last year this patient had experience hospitalizations for not only herself, but also her mother

and father. She explained that her and her mother we both treated for cellulitis with long-term

antibiotics. After the patient had her PICC line removed, she was again hospitalized for a clot

that had formed. Additionally, her father had recently suffered a massive heart attack followed

by two strokes, which consisted of multiple months spent in the ICU and now a long term care

facility. Not only had her family’s health been affected, but she also explained that one of her pet

dogs died from an infection. Along with this, she was experiencing a lot of guilt because she

could not afford the medical treatment her dog needed. While the patient was describing these

stressors to me, she was teary eyed and avoiding eye-contact. Therefore, I could tell that recent

disruption in the health of her family had greatly affected her. Further into our conversation, the

patient also expressed her feelings of worthlessness. She explained that she had previously
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worked as a Licensed Practical Nurse for seven years, but no longer works and currently relies

on financial support from her family and boyfriend. When I asked what lead to her current

unemployment, she explained that she is lacking motivation and her obesity has physically

impaired her. Although the patient avoided talking about life stressors in the beginning of our

conversation, I believe it was beneficial for her to identify and discuss events that lead to her

depressive episode.

History of Mental Illness

Additionally, while interacting with this patient I was able to learn a lot about herself and

her family. This thirty-year-old patient explained to me that she obtained all three of her mental

health diagnosis—Recurrent Major Depressive Episode, Anxiety and Bipolar Disorder—around

age twenty-three. Since being first diagnosed, this patient has experience two other psychiatric

hospitalizations. She explained that her medications mostly control her mood disorders, but she

finds herself experiencing a depressive episode typically once each year. This statement stood

out to me as interesting because the patient continues to relapse, even with continuous

medication treatment. I started to wonder if this was normal, if the patient was possibly non-

compliant with her medications or if there was something the treatment team was missing. While

researching the relapse rates of depressed patients on fluoxetine, I found that this occurs with

most patients. According to a study by McGrath, Steward, Quitkin, Chen, Alpert, Nierenberg,

Fava, Cheng, & Petkova (2006), results found a high rate of relapse for chronically depressed

patients taking fluoxetine. Results also showed that there was no difference in relapse between

those taking a placebo and those taking fluoxetine. In fact, relapse rates were proven greater with

specific variables including chronicity, symptom severity and the female gender (p. 1542).

Additionally, the patient mentioned that she had a lot of out-patient help in the past, but recently
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she has lost touch with her psychiatrist. Also, the patient lives with her mother, sister and

boyfriend, which all provide emotional and financial support. She denies any mental illness in

her family, but did explain that she does not get along with or even speak to her brother and his

wife. She also denied any use of illicit drugs or alcohol personally and within her household.

When asked to list her top positive and negative coping mechanisms, the patient states, “my

family, my boyfriend, eating, watching TV, playing games on my phone and smoking

cigarettes”.

Nursing Care

Before I talked with the patient one-on-one in the common area, I did attend a group

therapy session that the patient also attended. The ‘group’ was a general review of how the day

went and whether patients had met their goals for the day. My female patient was very quiet

during the group and kept to herself, unless prompted to respond. The goal she had set for the

day was to attend at least two group therapy sessions. She did accomplish this with the help of

some encouragement from members of the treatment team. Also as a nursing student, I was able

to practice providing education on her diagnoses, medications, tobacco use and diet. For

example, I explained to her that her history and current use of tobacco could be causing her

anxiety. According to a study by Johnson, Cohen, Pine, Klein, Kasen, & Brook (2000), results

showed that twenty percent of people who smoked during adolescents developed generalized

anxiety disorder during adulthood (p. 2348). Also, I was able to use research to explain to her

that her weight could be contributing to her obesity and vice versa. The results from a study by

Luppino, Wit, Bouvy, Stijnen, Cuijpers, Penninix & Zitman (2010) found a reciprocal

correlation between depression and obesity. I explained that this means obesity increases the risk

of depression and depression increases the risk of obesity (p. 220). Another educational topic we
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discussed regarding her medications included administration, timing, dosage, side effects and

more. Also, I made sure to ask the patient for her approval and thoughts about the doctors

increasing her daily dose of fluoxetine. Additionally, as a nursing student I made sure to

maintain a safe and therapeutic milieu. For example, I attended group therapy meetings, kept

continuous observation on patients and more. The entire mental health floor maintains this

milieu in various ways, such as remaining a ‘locked’ floor, searching patients’ belongings,

withholding potentially dangerous weapons, following a structured schedule, allowing the use of

the phone, promoting set visiting hours, checking on patients every fifteen minutes, promoting

trust and so much more.

Influences

There are multiple ethnic, spiritual and cultural influences present within the patient’s

life—both positive and negative. First of all, she lives with her mother, sister and boyfriend. She

explained to me that this is beneficial because they support her in multiple aspects, but it also

makes her feel worthless. This is because she feels as if she is not an independent person who

can fully care for herself. Along with this, she explained that they are living in poverty and

receive support from the government with finances and healthcare. This further makes the patient

feel less independent. When I asked her if she was religious or not, she denied any spiritual

influences and explained that it was just not part of her family’s beliefs. Later, she did further

reveal that she occasionally wishes she had been exposed to the benefits of religion, since they

could have been positive coping mechanism for dealing with her emotions. When I offered to

help find religious groups that she could join, the patient explained that she does not have any

motivation or energy to do so. Another aspect of the patient I asked of her was about diet and

exercise. The patient explained that she has does not have any motivation for these as well.
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Additionally, the patient added that she eats what the family provides, which consists of mostly

fast food, junk food and frozen meals.

Outcomes

At first, the patient was hesitant to consider weight loss and smoking cessation, stating “it

is not even worth trying”. After presenting her the results from the two previously mentioned

studies, the patient seemed increasingly interested returning to a healthy weight and stopping her

smoking habit. Additionally, the patient responded well to our discussion about the difference

between positive and coping mechanisms. Once the education was complete, the patient was able

to state three positive coping mechanisms for herself, including talking with her family, taking a

walk with her dog and playing games on her phone.

Discharge Plans

The underlying goal of any in-patient psychiatric unit is to stabilize and maintain the

safety of patients in preparation for discharge. For this female patient there was two main plans

in place to ensure readiness for discharge. First, the doctors wanted to stabilize the patient with

her current medications and increase the dose of her fluoxetine. The inpatient stay is very

beneficial for the patient, doctors and nurse to evaluate the effects of increasing a medication.

During the day of my care, the patient was reporting a positive response to the dosage increase

and denying any adverse effects. Additionally, both the patient and treatment team wanted to

make sure that she had established out-patient care and help before discharge. While reading the

chart I read that social work was in contact with a behavioral health company called ‘Psycare’ to

establish out-patient counseling and medication management. These two plans are very

important for any patient, especially this one, in avoiding relapse and even readmission.
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Prioritized NANDA Nursing Diagnoses

The following is a list of prioritized NANDA Nursing Diagnoses that the patient had been

assigned during this hospital stay. Each contains a goal that is measurable and within a specific

timeframe and one nursing interventions to promote goal attainment.

1. Risk for suicide r/t expression of suicidal thoughts and hopelessness

 Goal: Pt will identify three resources to contact when feeling suicidal before

discharge.

 Intervention: Nurse will assist patient in identifying family, friends and

community resources available.

2. Adult failure to thrive r/t depression AEB unemployment, lack of motivation regarding

health and diet

 Goal: Pt will take at least one shower each day spent on the mental health unit.

 Intervention: Nurse will provide patient with supplies needed for ADLs.

Potential NANDA Nursing Diagnoses

The following is a list of potential NANDA Nursing Diagnoses for this patient. Each contains a

goal that is measurable and within a specific timeframe and two nursing interventions to promote

goal attainment.

1. Hopelessness r/t stress AEB lack of motivation, decreased eye contact, sleep pattern

disturbance

 Goal: Patient will list 3 purposes in life by end of shift.

 Intervention: Nurse will assist patient by promoting discussion on this topic.

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2. Social Isolation r/t ineffective coping AEB dull and sad affect, rare eye contact, seeking to

be alone

 Goal: Patient will attend at least two group therapy sessions each day spent on

mental health unit.

 Intervention: Nurse will walk patient to group therapy sessions.

3. Ineffective health maintenance r/t lack of ability to make good judgements AEB lack of

interest in improving health behaviors

 Goal: Patient will eat at least one vegetable and one fruit during each meal.

 Intervention: Nurse will help patient determine healthy options when picking from

menu.

4. Chronic low Self-Esteem r/t repeated unmet expectations AEB frequent lack of success in

life events, hesitant to try new things, lack of eye contact, reports feelings of shame and

guilt

 Goal: Patient will list three positive qualities of self each night before bed.

 Interventions: Nurse will supply patient with list of positive affirmations to read.

5. Readiness for enhanced knowledge r/t expressed interest in smoking cessation

 Goal: Patient will identify three smoking cessation methods by end of shift.

 Interventions: Nurse will administer prescribed smoking cessation medications

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Reference Sheet

Ackley, B.J., Ladwig, G.B. (2014). Nursing Diagnosis Handbook: An Evidence-Based Guide to

Planning Care (10th Edition). Maryland Heights, Missouri: Elsevier.

Bressert, S. (2017). Depression Symptoms (Major Depressive Disorder). Psych Central.

Retrieved on October 9, 2017, from

https://psychcentral.com/disorders/depression/depression-symptoms-major-depressive-

disorder/

Johnson, J.G., Cohen, P., Pine, D.S., Klein, D.F., Kasen, S., & Brook, J.S. (2000, November 8).

Association Between Cigarette Smoking and Anxiety Disorders during Adolescents and

Early Adulthood. Journal of American Medical Association, 284(18), 2348-2351.

Luppino, F.S., Wit, L.M., Bouvy, P.F., Stijnen, T., Cuijpers, P., Penninix, B., and Zitman. F.G.

(2010, March 1). Overweight, Obesity & Depression. American Medical Association,

2010;67(3):220-229.

McGrath, P.J., Steward, J.W., Quitkin, F.M., Chen, Y., Alpert, J. E., Nierenberg, A. A., Fava,

M., Cheng, J., Petkova, E. (2006, September). Predictors of Relapse in a Prospective

Study of Fluoxetine Treatment of Major Depression. The American Journal of

Psychiatry, 2006;163(9):1542-1548.

The National Institute of Mental Health (NIMH). (March 2016). Anxiety Disorders. Retrieved

from https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml

The National Institute of Mental Health (NIMH). (April 2016). Bipolar Disorder. Retrieved from

https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
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Townsend, M. (2015). Psychiatry Mental Health Nursing: Concepts of Care in Evidence-Based

Care (8th Edition). Philadelphia, PA: F.A. Davis.