Clinical Simulation Critical Thinking Case Study for

Depression and Suicide with Grading Rubric

Directions: Read the case study and type using 12 fonts directly into the
rubric. Save the document, print it and submit to your clinical instructor via
icollege dropbox on October 17, 2016 by 8:00 am.
Darlene, age 62 years, has been admitted to the local psychiatric facility for
inpatient treatment of depression. She became severely depressed when her
son experienced a traumatic brain injury sustained in an automobile accident 6
years ago. Since her sons accident, she has neglected to pay her bills on
time, has difficulty sleeping and difficulty concentrating, has lost interest in
eating, and has lost 30 pounds during the last year. She is complaining of
frequent headaches, generalized pain and malaise. She no longer attends the
weekly sewing club due to a lack of interest and energy. Her husband of 40
years divorced her 2 years ago.
Her home needs repairs, and she says she feels overwhelmed with completing
the maintenance required. She expresses feelings of helplessness. She states
that she is alone and no one cares. Darlene reports that she often sits
alone at night watching television and sips on a can of beer.
She has been noncompliant with pharmacologic antidepressant therapy, which
has led to her admission to an acute care psychiatric setting. She hardly
makes eye contact, slouches in her seat and wears a blank but sad expression.
She says to you, this feeling of depression is the worst thing I have had to go
through since my sons accident. I will never go through this again. I
guarantee you this will be my last episode of depression. My mother
suffered from depression and it destroyed our family.
The physician has indicated that if Darlene does not respond to medication
over the next 2-3 days, he will order ECT. Darlene has a history of
hypertension but has not been taking medication. On admission her pulse is
98, Temperature is 99.2 and blood pressure is 174/96 and her doctor
prescribes Coreg. She states she has been diagnosed with GERD and used to
take Prilosec, but she has not taken any the past six months even though she
still has symptoms of Acid Reflux. Her doctor reorders the Prilosec upon
admission. She had surgery twenty years ago to remove a benign tumor from
her left ovary.

Topic

Required
Data

Students Response

Points
Available/Ins
tructor
Comments

Introduction
(patient and
problem)

Explain who
the patient is
(Age, gender,
etc.)
Explain what
the problem
is (What was
he/she
diagnosed
with, or what
happened?)
Identify the
risk factors
that the
patient has
related to the
diagnosis.

Pathophysio Explain the

logy
disease (What
are the
symptoms?
What causes
it?)

Pt is a 62 year old female

recently admitted to an
acute care psychiatric
facility. She presents with
30 lb weight loss, difficulty
sleeping and
concentrating, feelings of
helplessness, lack of
interest in things she used
to enjoy, depressed affect,
and lack of eye contact.
Pt began experiencing
symptoms of depression 6
yrs ago after her son was
diagnosed with a TBI.
Patient is noncompliant
with medications and
states that she is lonely
and that, this will be my
last episode of
depression.
Risk factors include
gender, age, stressful
events in recent years
(divorce and sons injury),
alcohol consumption, and
noncompliance with meds.

Major depressive disorder

is characterized by
depressed mood almost
every day most of the day,
decreased interest in
almost all or all activities,
weight loss or gain,
hypersomnia or insomnia,
fatigue, feelings of
worthlessness or
inappropriate guilt,
decreased concentration,
and recurrent thoughts of
death. 5 or more of these
symptoms are present for
at least 2 weeks at a time.

10

Depression can be caused

by a plethora of factors,
including genetics,
decreased serotonin in the
brain, stressor situations,
hormone imbalances,
medication side effects,
and trauma. There is no
one cause of MDD and no
one treatment either.
History
Explain what
health
problems the
patient has
(Has she/he
been
diagnosed
with other
diseases?)
Detail any
and all
previous
treatments
(Has she/he
had any prior
surgeries or is
he/she on
medication?)

Nursing
Assessment

Pt has a history of
5
hypertension and GERD
but has not been taking
medication to treat it in
some time. She is
experiencing elevated
blood pressure and acid
reflux currently. Patient
also has been experiencing
headache, fatigue, and
malaise.
Pt is prescribed Coreg for
her blood pressure and
Prilosec for her GERD. An
antidepressant has also
been prescribed for MDD.
A benign left ovarian
tumor was surgically
removed 20 years ago.

The patients blood

List all the
pressure was 174/96,
patients
which is considered
health stats in hypertension. The
sentences
patients heart rate is 98
with specific
and temperature 99.2
numbers/level degrees F.
s (Blood
pressure,
At home, the patient has
bowel sounds, been unable to pay bills on
ambulation,
time or complete

15

etc.)
In terms of
behaviors,
thought
processes,
activities of
daily living
and ability to
function at
work and
home,
identify
objective and
subjective
signs and
symptoms of
depression
that Darlene
is exhibiting.

Related
Treatments

Explain what
treatments
the patient is
receiving
because of
his/her
disease
Since safety
is the first
concern, what
are the
appropriate
questions to
ask the
patient at this
time?
The doctor
places the
patient on

necessary household
repairs. She reports lack of
appetite and difficulty
sleeping, resulting in 30 lb
weight loss this year and
decreased amount of
sleep. She no longer
attends her sewing group
that she used to enjoy.
Objective data: 30lb
weight loss, headache,
does not pay bills on time,
does not attend group.
Subjective data: lack of
energy, lack of appetite,
difficulty sleeping,
difficulty concentrating,
slouching.

Patient is receiving an
antidepressant medication
while in the inpatient
facility and may be given
ECT if the medication is
not effective.
The patient should be
asked about suicidal
ideation and plans for a
suicide attempt.
While the patient is on
suicide precautions, the
nurse should be sure that
the patient does not have
anything they could harm
themselves with
(shoelaces, pencils,
alcohol, etc.). They should
also be sure that patient
swallows medication and

20

suicide
precautions.
What is the
nurses role
and
interventions
for carrying
out this
order?
What
teaching does
the nurse
need to give
the patient
related to
mixing
alcohol and
medications
for
depression?
What lab
tests should
the nurse
expect the
doctor to
order?
The
patient
asks
what
should
she
expect from
ECT?
What
teaching
should
the
nurse provide
to the patient
related
to
before, during
and after the
ECT?
What

does not save it for a

possible overdose. Patient
will be monitored closely
ranging from constant
contact to 15 minute
checks. The nurse is to
ensure that the patient
remains safe.
Most psychiatric
medications, including
antidepressants, interact
negatively with alcohol.
Patients on
antidepressants should
avoid alcohol.

Labs the physician may

obtain are CBC, Chem 7,
vitamin B and D levels,
hormone levels.
The nurse should let the
patient know what ECT is
and why it is used. Before
and after ECT, the nurse
should remind the patient
that short-term memory
loss post treatment is very
common and temporary.
Be sure the patient knows
that they will not be awake
during the procedure and
will not feel anything. A
headache may occur
immediately after each
session but any other pain
is unlikely.

The drugs used in ECT

drugs administration include

Nursing
Diagnoses
Goals,
Intervention
s and
Rationales

are used in
the
administratio
n of ECT.

atropine sulfate, propofol

or another short acting
anesthetic, succinylcholine
chloride, and oxygen.

List the 5
priority ones
for this
patient. List
in this order:
(1) Diagnosis,
goals,
interven-tions
and rationale
(2) ditto, etc.

1. Risk for suicide. Client

will not harm self. Client
will be observed closely
and a safe environment
will be created. Patient
will be asked about any
intent for self harm and
will form a no self harm
contract with staff. These
interventions will be
implemented because the
risk of suicide is decreased
when the patient has a
safe environment and
constant observation.
2. Imbalanced nutrition:
less than body
requirements. Client will
not lose any more weight
and will gain 4 pounds by
discharge. Client will be
given high calorie snacks
and meals at frequent,
regular intervals. Patients
with depression may
forget to eat so regular
eating intervals may
increase the amount
consumed by patient.
3. Insomnia. Patient will
increase amount of sleep
by one hour each week
until 7-9 hours per night is
reached. Medications may
be given to promote sleep
and bedtime routines
should be maintained. A
routine will let the body

30

know it is time for sleep

and medications can help
initially to promote rest.
4. Complicated grieving.
Patient will express
feelings about her sons
TBI and verbalize
behaviors associated with
normal grieving. Trusting
relationship between the
patient and staff must be
established, client should
be encouraged to express
feelings in numerous ways,
grief stages should be
taught. These
interventions will help the
patient to open up and let
the grieving process heal
her.
5. Hopelessness. Patient
will express acceptance for
things she cannot control.
Stressors and coping
mechanisms should be
identified and patient
should be encouraged to
express feelings. By
understanding coping
mechanisms and how they
are effective or ineffective,
the patient will be able to
choose effective ones
when needed.
Medications

The patient
was started
on sertraline
(Zoloft). What
patient
teaching
should be
done with the
patient

Zoloft may cause dry

mouth, diarrhea, or
decreased libido. It should
be taken in the morning to
prevent insomnia at night.
It should not be mixed
with alcohol. If you begin
to have suicidal thoughts
you should contact your

10

regarding the
sertraline?
The patients
friend, who is
a Registered
Nurse, came
to visit and
told the
patient that a
life
threatening
event
associated
with taking,
Zoloft, a SSRI
is serotonin
syndrome.
The patient
asks you to
explain this to
her so she
can really
understand.
What would
you tell the
patient?
What patient
teaching
related to
medication
should the
nurse
provided
related to
Coreg and
Prilosec?

Recommend
ation

What should
the nurse
teach the
patient to do

physician immediately.
Serotonin syndrome can
occur if two
antidepressants
particularly SSRIs, SNRIs,
and MAOIs, are taken
together. The brain will
have too much serotonin
and may cause
restlessness, tachycardia,
and tremors. The patient
should not take anything
not prescribed by the
physician and should
notify her physician if any
symptoms of serotonin
syndrome occur.
Coreg: The patient should
change positions slowly to
prevent a drastic drop in
blood pressure. Patient
should take blood pressure
daily and record in a log.
Patient should be taught
how to take their pulse
and call the physician if it
drops below 60.
Prilosec: Take before
meals. Drink plenty of
water. Notify physical of
black stools or consistent
GI upset.

Take meds as prescribed,

even when feeling better.
Attend support group.

in the future
to continue
recovery?