Help with a mental health assignment

  1. 0
    Hi Everyone,

    I am currently working on an assignment for a mental health subject and am seeking advice and clarification on my direction, and would appreciate any input from any nurses that have suggestions.

    My case study has been based around a 37 year old female who was brought into A&E by her husband after an overdose of diazepam. She has been declared physically well but has been transfered to a psychiatric unit for further assessment.

    The patient has had experienced several episodes of depression over the past 5 years, following the birth of her child.

    On the ward she is not socialising with anyone and has been sitting in her room or in a corner most of the time. She has been commenced on Zoloft and stated that she has tried antidepressants before, but ceased taking them after they did not have any effect after 3 days.

    Depression has also caused several disturbances in the patients life. Her partner states she has no interest in ADL's, food, care of her child or sex. She has also not attended work for the past 3 weeks after experiencing panic attacks while she was there. A psychologist appointment was set up by her work, but she did not attend the appointment.

    NOW - I have been asked to identify 2 priority problems and state them as nursing diagnoses and give a brief rationale behind my diagnoses. My tutor has stated that they do not need to strictly fit within the NANDA diagnoses and can be in my own words.

    SO - The patient obviously has a few areas that need to be addressed such as potential for self-harm, non-compliance with medication and lack of insight into treatment, difficulty socialising and difficulty completing ADL's. However, as priorities, I have decided to go with the following:

    NURSING DIAGNOSIS 1
    ND - Potential for self-harm, and possible harm to her child
    RT -Recent history of self harm, recent decline in mental state & history of post-natal depression
    AEB - Hospital admission for overdose of diazepam

    NURSING DIAGNOSIS 2
    ND: Potential for decline in mental state
    R/T: Non-compliance with medication and treatment (psychologist)
    AEB: Lack of insight into treatment regime


    Do you think I am on the right track in terms of my diagnoses and their order of priority?

    Any comments would be much appreciated.

    Thanks

    Ben

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  2. 3 Comments...

  3. 2
    any time you are asked to problem solve you are being asked to critically think through the situation you have been given. the tool we are given to do this is the nursing process, and if used correctly and skillfully it will help you reveal not only what the problems are, but how to manage them.

    step #1 - assessment - all the assessment data has been given to you. i re-organized it so it is easier to see what is there and what can be worked with: 37 year old female brought into a&e by her husband after an overdose of diazepam and now transferred to a psychiatric unit for further assessment. has had several episodes of depression over the past 5 years, following the birth of her child. her partner states she has had no interest in adl's, food, care of her child or sex. she has not attended work for the past 3 weeks since experiencing panic attacks while she was there. a psychologist appointment was set up by her work, but she did not attend the appointment. has stopped her antidepressants before stating they had no effect after 3 days.
    symptoms on the ward:
    • not socializing with anyone
    • sitting in her room or in a corner most of the time
    medical treatment:
    • started on zoloft
    you should, as part of your understanding of depression, look up the signs and symptoms of this disorder because it was the underlying cause for her suicide attempt and needs to be addressed. having a baby causes depression in 25% of women. symptoms of depression include:
    • loss of interest in pleasure from activities that were once enjoyed - husband reported no interest in adls
    • depressed mood
    • appetite disturbances with weight loss or gain - husband report she has no interest in food
    • insomnia, inability to fall or stay asleep; excessive sleeping
    • either fatigue and loss of energy: or, psychomotor agitation and the inability to sit still
    • low self esteem, feelings of worthlessness, exaggerated or inappropriate feelings of guilt; hopelessness; emptiness
    • difficulty thinking, concentrating and making decisions, remembering; there could be delusions and hallucinations
    • recurrent thoughts of death or suicide
    • diminished or no sexual desire - reported by husband
    the doctor is doing his part in prescribing zoloft, but later in the planning phase of the nursing process the nurses will also have a part to play in responding to and treating this patient's symptoms of her depression. however, you need a nursing diagnosis to address this and finding the symptoms to go with the diagnosis is the first step in problem identification. the doctor can diagnose depression; we can't. i am also concerned about her prior history about discontinuing antidepressants do quickly because she thinks they weren't working. she needs them to help with her mood and we know that many of these antidepressants need to be taken for several weeks for their effects to become active. so, this patient needs education about the medication and why she needs to continue taking it even if it doesn't seem to be working at first.

    suicide: she has 2 risk factors: depression and prior suicide attempt. her depression is now being treated with zoloft and, my careplan would also address it. secondly, she hasn't mentioned wanting to kill herself again and she doesn't have the means (diazepam) in the facility to do that. i don't see any evidence that she would harm her child in the information that was given in the scenario and i don't know what you are basing that decision of potential harm to the child on. there is a husband in the picture watching over this family, so anticipating harm to the child makes no sense to me.

    step #2 - determining the nursing problems (nursing diagnoses) - where the patient physically is now is how you determine the problem and not where she was 2 weeks ago. she is currently at a psychiatric facility where she is being evaluated for her depression following a suicide attempt. look at the actual observations that have been made about her. she is withdrawn. in priority, i would diagnose her as:
    • social isolation r/t altered thought processes aeb not socializing with anyone and sitting in her room or in a corner most of the time
    • deficient knowledge, action of zoloft (sertraline) r/t lack of information aeb inaccurate follow through of medication instructions in the past
    • risk for suicide r/t depression and history of prior attempt

    - - - - - - - - - - - - - - -

    nursing diagnosis 1
    nd - potential for self-harm, and possible harm to her child
    rt -recent history of self harm, recent decline in mental state & history of post-natal depression
    aeb - hospital admission for overdose of diazepam
    first of all, "potential for" means an anticipated problem rather than an actual nursing problem. there would be actual nursing problems here or the patient would not be confined in a psychiatric unit.

    i do not agree that there is possible harm to the child. she didn't harm her child before.

    aebs cannot be present with anticipated problems since the problems do not exist yet. aebs must be evidence that support the nursing problem and is abnormal assessment data. a "overdose of diazepam" is a medical diagnosis. a "hospital admission" is a treatment. treatments and medical diagnoses cannot be used as evidence in aeb statements to support a nursing problem.
    nursing diagnosis 2
    nd: potential for decline in mental state
    r/t: non-compliance with medication and treatment (psychologist)
    aeb: lack of insight into treatment regime
    there is a problem with the term "mental state". what is it? how is it defined? what is a decline? how is decline defined?

    your r/t (etiology) suggests that by stopping her medication she is contributing to her detriment and trying to find negative words to put the blame on her as well. i understand your frustration with this, but i would give her the benefit of the doubt that she really didn't know how the drugs worked. when they were prescribed and she was in a depressive state she may not have been listening closely. noncompliant people, on the other hand, just don't follow doctor's orders and could care less what everyone on the healthcare team thinks. i would be hesitant to call this patient noncompliant.

    again, aebs cannot be present in anticipated problems since the problems do not exist yet. aebs must be evidence that supports the nursing problem and is abnormal assessment data. a "lack of insight into treatment regime" cannot be used to support a nursing problem that doesn't exist.

    this is an actual problem and there is a nursing diagnosis for this. what you are actually wanting to say is this diagnosis:
    nd: ineffective health care maintenance
    r/t: lack of understanding of treatment regime
    aeb: discontinuing medications before they have a chance to be effective

    better? however, above, i listed deficient knowledge, action of zoloft (sertraline) because she has now been put on a specific new drug which is an ssri and i want her to know about it, why she needs to take it, that the therapeutic effect takes up to a week or longer and that if stopped it must be discontinued gradually.
    Thanet and benjaiiimin like this.
  4. 0
    Hi,

    Thanks for your response. It is some very good information and considerations.
    I also see your point that social isolation is more of a priority than of self harm at the current point in time, as she is in a facility. Secondly, with the non compliance - I did not take into consideration that it will take a few weeks for it to work. Therefore, it is important to best help her with her depressive symptoms in the meantime.

    Thankyou, you have been a big help.

    Cheers

    Ben
  5. 0
    this is an actual problem and there is a nursing diagnosis for this. what you are actually wanting to say is this diagnosis:
    nd: ineffective health care maintenance
    r/t: lack of understanding of treatment regime
    aeb: discontinuing medications before they have a chance to be effective

    better? however, above, i listed deficient knowledge, action of zoloft (sertraline) because she has now been put on a specific new drug which is an ssri and i want her to know about it, why she needs to take it, that the therapeutic effect takes up to a week or longer and that if stopped it must be discontinued gradually.
    </blockquote>[/quote]

    should'nt the #1 nd be ineffective therapeutic management and if not why?


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