Major Depressive Episode: Case Study

BY: SHY WEGIEL

02/19/2014

Background
Sex: Female Age: 39 Date of Admission: 2/11/14

Income source: Stay at home mom

Spirituality: Christian Legal Status: MH4 DSM Diagnosis: I Substance Induced Mood Disorder (Methadone withdrawal symptoms. Major depression episode) Considerations r/t ethnicity or religion: None Expiration Date: 2/13/14 1030

II Deferred
III Congenital Hip Dysplasia, subclinical hypothyroidism IV Moderate stressors V Current GAF 45

History of Present Illness

39 y/o married female with history of hip dysplasia who has been treated in Kaiser Pain Clinic for many years. She has been a regimen that included methadone 40mg/day. Reports that due to her active daughters and hip dysplasia, she had frequent problems with breakthrough pain. She dealt with the pain by diverting slightly from her medication regimen. She had been seeing Doctors from Kaisers Pain Clinic. At that point she was on methadone 30mg/day. Her doctor had tried to switch her to oxytocin, which made the patient feel acutely worse. In addition her husband read on the oxytocin label that it should not be given to breastfeeding women and he did not want her to take it. Patient stopped her medication approximately a week ago. Since then she has not been able to sleep for 4 days. She has not eaten very much in 1 week. She has persistent nausea and vomiting. She also had the chills and strange prickly feeling in her body as well as increase in her pain. She did take 7 Vicodin on 2/10/14 to help alleviate some symptoms. Patient also reports progressive onset of SI since stopping her methadone regimen. Patient would like to permanently fix her pain management issues and is willing to comply with any recommendations. She denied any malicious attempt to misuse narcotic prescription but does acknowledge that due to her breakthrough pain and issues with husband has slightly diverted at times from her pain management regimen.

Patients description of illness/issues:

Patient diagnosed with a major depression episode. Patient reports feelings of depression, a lack of energy, and worthlessness. Patient reported ineffective pain management, feeling overwhelmed caring for her two young daughters, and her husbands lack of support as possible triggers related to depression. Patient self-identified her own concerns of being unable to function as a mother and wife. Patient reports not sleeping much in the last 4 days and resting for only 1 hour last night (2/11/14). Patient reported having no extended family in Hawaii, a lack of support from her husband, and a recent rekindled phone relationship with her twin sister who has similar issues with pain control and depression.

DS-IV-TR CRITERIA- Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1)depressed mood or 2) loss of interest or pleasure NOTE: Do not include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observations made by others) 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in month) or decrease or increase in appetite nearly every day. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observation by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly everyday 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproached or guilt about being sick).

8.

Diminishes ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or observed by others)

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. C. The symptoms do not meet the criteria for a mixed episode The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication), or a general medical condition (e.g., hypothyroidism) E. The symptoms are not better accounted for by bereavement (i.e., after the loss of a loves one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation).

Strengths/Weaknesses
Patients Strengths: Identified by: Nurse: Compliance with medication regimen Patient: Assertiveness in seeking help to manage pain and depression Student Nurse: Motivation to attend and participate in group meetings

Patients Limitations:
Identified by: Nurse: Med seeking behavior (lingering outside med room) Patient: Lack of family support Student Nurse: Ineffective pain management

Medications
Order: Clonidine (Catapres) 0.1mg oral BID Drug class: Therapeutic: Antihypertensive; Analgesic Pharmacologic: Adrenergic (centrally acting) Pts target sx: Management of opioid withdrawal Total 24h dose: 0.2mg Recommended range: 0.2-0.4 mg/day L M H Max: L

Current Side effects: nausea, vomiting.

Order: Pregabalin (Lyrica) 150mg oral BID Drug class: Therapeutic: Analgesics, Anticonvulsants

Pharmacologic: GABA Analogues, Nonopioid analgesics

Pts target sx: Treatment of moderate pain Total 24h dose: 300mg Recommended range: 150-300mg/day L M H Max: Max Current Side effects: SUICIDAL THOUGHTS, vomiting.

PRN Medication
Order: buprenorphine (Subutex) 2mg SL QH NTE 8 doses Drug class: Therapeutic: opioid analgesics Pharmacologic: opioid agonists/antagonists Pts target sx: PRN withdraw Total 24h dose: 16mg Recommended range: 1216 mg/day L M H Max: Max Current Side effects: nausea, vomiting. Order: Lorazepam (Ativan) 0.5mg oral TID

Drug class: Therapeutic: analgesic adjuncts, antianxiety agents, sedative/hypnotics

Pharmacologic: benzodiazepines Pts target sx: PRN anxiety Total 24h dose: 1.5mg Recommended range: 2mg-20mg/day L M H Max: L Current Side effects: headache, nausea, vomiting.

Nutrition & Sleep

BMI: 31.7 : Category: Obese (Height: 167.64 cm Weight: 88.9 kg)

Food & fluid intake: Normal diet- consumed 50% of meals

Bladder & bowel status: Continent. Normal bowel pattern. Sleep pattern: Difficulty falling asleep and staying asleep Total sleep/24 hrs: 1 hr Number of hrs of disruption: N/A Naps: When? None Total nap time: N/A

Lab & Studies

Date/Panels in which all values were normal: N/A Date/Any abnormal labs: N/A

Labs you would expect but were not ordered:Thyroid levels due to her subclinical hypothyroidism. She hasnt been taking levothyroxine for a 2-3 years.
Glucose readings x 24h for all diabetic pts.: N/A All drug screen findings: Urine drug Screen- + opiates

Mental Status Assessment

Behavior: Normal gait, eye contact. Affect: Appropriate to situation, restricted affect. Sensorium: Denies current AH/VH Imagery: Clean appearance. Cognition: Alert and oriented x3. Organized, linear thought process. Interpersonal relationships: No extended family in Hawaii, lack of support from husband. No friends or social network. Patients mother lives in the mainland and is a recovering alcoholic. Patient reported a recent rekindled relationship with her twin sister who is going through a similar situation. Interactive with other patients and staff. Visits physician at Kaiser Pain Clinic.

Developmental level: (Assets & barriers) Intimacy versus isolation. Patient self-identified a lack of support from her husband. Patient reported a rekindled relationship with her twin sister. Patient has no extended family or friends in Hawaii. Patient has 2 young children (2 & 5 years old).

Substance Abuse or Dependence

Drug class

Last Use

Acute intox or withdrawal sx?

Length of Time Used

Route

Usual amt.

Negative Consequences

Methadone

02/04/13

Withdrawal sx: N/V/D, insomnia

10 years

Oral

40mg/day Dependency

Problems Identified in Hospitals Master Treatment Plan

1. Suicide risk 2. Mood instability 3. Ineffective therapeutic maintenance 4. Disturbed sleep pattern 5. Impaired family functioning Current Discharge Plan: Assess for suicidal ideation, implement TM33 assessment as needed, develop a pain management plan, identify a support system, management of stressors related to depression, attend family therapy, set up an appointment at the Kaiser Pain Clinic. Nursing interventions you performed this shift (Include safety and teaching!): Assess for suicidal ideation, contract for safety, therapeutic 1:1 conversation, identification of stressors and coping mechanisms, encouraged group and milieu participation.

Prioritized Patient Needs

1. P: Risk for self-directed violence

E: Patient reports recent suicidal ideation, lack of personal and social resources, methadone dependence, and a major depressive episode. Patient admitted for Major depressive episode with a TM33 score of 5.
S: Maintain safe environment, assess for current suicidal ideation, perform TM33 assessment

as needed, and verbally contract for safety.

2. P: Ineffective Pain Management E: Patient identified ineffective pain control as one of her stressors related to depression. Patient self-identified the need to withdrawal from methadone and develop an alternative pain management plan. S: Assess for pain and breakthrough pain. Administration of Catapress, Lyrica, and PRN Subutex. Educate patient on nonpharmacologial pain management methods (such as: deep breathing, distraction). Encourage patient to maintain a log of pain symptoms, medication (names, doses, time), and her response.

3. P: Disturbed sleep pattern

E: Patient reports not sleeping very much in 4 days and only sleeping for 1 hour last night (02/11/14). S: Promote sleep by reducing stimuli (e.g., decreasing noise, lowering light), PRN Ambien. Maintain normal sleep schedule. 4. P: Lack of support system E: Patient self-identified an inefficient support system. She has no extended family in Hawaii. She reported a lack of support from her husband and having no friends. Patient recently rekindled a relationship with her twin sister who has similar problems. S: Encouraged group and milieu participation. Provide information on community support groups and resources. Refer to family counseling.

Key Factors

High Risk

Moderate Risk

No Precautions
Agrees to tell staff if feeling unsafe.

SUICIDE/SELF-HARM RISK ASSESSMENT

Current admission precipitated by suicide attempt: Yes = 2 Points No = 1 Point
RNs subjective appraisal of risks: Patient replies not trustworthy, several non-verbal cues 4 Patient replies questionably trustworthy, at least one non-verbal cue 3 Patient replies trustworthy 0

Agrees to inform staff if feeling unsafe

Unwilling to agree Or Unable to agree due to impaired reality testing (e.g., hallucinations, delusions, dementia, delirium, dissociation) 2

States is able to inform staff if unable to maintain safety, but is ambivalent and/or guarded

0
No Plan

Suicide Plan

Has plan with actual OR potential access to planned method 2 Highly lethal plan (e.g., gun hanging, jumping, carbon monoxide)

Has plan without access to planned method 1 Low lethality of plan

0 Low lethality of plan (e.g., superficial scratching, head banging, pillow over face, biting, holding breath) 0 No elopement risk 0 No current suicidal thoughts 0 No previous attempts 0 0-2 symptoms present

Lethality of Plan

2 Elopement Risk High elopement risk 2 Constant suicidal thoughts Suicidal Ideation 2 Attempt History Past attempts of highly lethality 2

1 Low elopement risk 1 Intermittent or fleeting suicidal thoughts 1 Past attempts of low lethality 1

TOTAL SCORE: ___4___ = PRECAUTION LEVEL: Moderate Risk = 4 9 Assessed by (RN): Shy WegielKCCSN
Date: 02/12/14 Time: 0925

Symptoms (Circle all present) Hopelessness Helplessness Anhedonia Guilt/Shame Anger/Rage Impulsivity
Current Morbid Thoughts (e.g., reunion fantasies, preoccupation with death)

5-6 symptoms present

3-4 symptoms present

2 Constantly 2

1 Frequently 1

0 Rarely 0

Priority # 1 Assess for suicidal ideation and contract for safety CARE PLAN Nursing Diagnosis: Risk for self-directed violence related to lack of personal and social resources, recent suicidal ideation, methadone dependence, and major depressive episode. P: Risk for self-harm E: Patient reports intermittent suicidal ideation. Patient admitted for Major depressive episode with a TM33 score of 5. S: Maintain safe environment, assess for current suicidal ideation, perform TM33 assessment as needed, and verbally contract for safety. LT goal: Patient will manage depression stressor (pain) by meeting with physician and creating a pain management plan by 02/14/14. ST goal: Patient will verbally contract for safety on 02/12/13.
Intervention & Frequency
Conduct a suicide assessment as necessary to ensure the patients safety and to prevent harm to the patients or others. Scientific Rationale Fortinash, K.M., Holoday-Worret, P.A. (2012). Psychiatric Mental Health Nursing. (5th ed.). St. Louis: Mosby. Patients with mania and depression need to be assessed for suicidal thinking.

Care Plan

Evaluation

Patient admits to intermittent thoughts of hurting herself but has no current plan. Patient denies any previous suicide attempts or having any current suicidal ideation. Completed suicide risk assessment, patient has a TM33 score 4. Maintain a safe, harm free environment This intervention requires that the nurse conduct an Observed patients environment, paying close through close and frequent observations assessment of the patients environment to determine if attention to any objects that could be to minimize the patents risk for self-harm there are items or physical space issues that could facilitate potentially harmful. No items needed or violence. removal. self-harm. Patients with depression may require close observation to ensure safety. Establish rapport and demonstrate Create a connection with patients help them to Initiated a 1:1 conversation with patient. communicate with the nurse. respect for the patient to facilitate the Patient reported feelings of hopelessness, patients willingness to communicate his anergia, anxiousness, and worthlessness. or her thoughts and feelings Patient reported her own concerns of being unable to function as a mother and wife due to her ineffective pain management and depression.

Identify the patient social support system, and encourage the patient to use it to minimize isolation and loneliness and to provide assistance with monitoring the illness and treatment. Assess the patients cognitive and perceptual processes to ascertain the existence of hallucinations or delusions that are troubling or harmful to the patient. Encourage the patient to attend therapeutic groups and thinking with the support of others.

Support from loved ones conveys caring and concern and helps to promote functioning.

Patients with depression can become psychotic with delusional thinking or hallucinations. These experiences can be potentially harmful when patients respond to these altered thinking and perceptual experiences. Depressed patients may not be energized or motivated to attend activities. Group support and input from other patients can help to clarify or raise issues that involving thinking and perspective.

Discussed patients support system. Patient reported having no extended family in Hawaii, a lack of support from her husband, no friends, and a recent rekindled phone relationship with her twin sister who has similar issues with pain control and depression. Patient selfidentified the need to attend family therapy with her husband to facilitate communication and support. Patient denies any current visual or auditory hallucinations.

Patient attended all group meetings with moderate participation. Patient interacted with other patients and staff. No self-isolation.

Identify sources of eternal stress and assist the patient with coping with the in a more effective manner to minimize stressors and to promote adaptive coping mechanisms.

As patients with depression improve, identifying coping strategies that help them to deal with external stressors can prevent or minimize future episodes.

Patient reported ineffective pain management, feeling overwhelmed caring for her two young daughters, and her husbands lack of support as possible triggers related to depression. Patient self-identified the need to communicate with her physician from the pain clinic to create a pain management plan. Patient self-identified the need to withdraw from opiates and explore alternative pain control methods, such as nonopioid analgesic. Patient agreed to a verbal contract for safety. Patient agreed to notify staff is she feels that she wants to harm herself.

Develop a verbal or written contract stating that the patient will not act on impulse to do self-harm. Review and update the contract as needed.

The patient benefits from talking about suicide ideation with trusted staff. A written or verbal agreement establishes permission to discuss the subject, makes a commitment not to act on impulse, and defines a plan of action in case impulse occurs.

The End