Case Study 1: The Client with Depression (Peripartum onset): Marie Clinician Role: Admitting Nurse: Inpatient Mother and Baby Unit. Identifying information: Marie is a 31-year-old married woman referred to the Inpatient Mother and Baby Unit by her GP. She is a practising Catholic and has worked as a secretary for 9 years at a local private school as the office manager. Marie lives with her husband, Ron, and their 10-week-old daughter, Nicole, in their own home. Presenting Complaint: Marie states, “I’m not coping at all with the baby; I’m sad and upset all the time, and I’m a bad mother”. History of Present Problem: Marie states that over the past 10 weeks (since the birth of Nicole), she has experienced increasing dysphoria, anhedonia, feelings of guilt and worthlessness, intense crying, social isolation, and has struggled to bond / care for her daughter. Marie sleeps 10 to 15 hours per night, experiencing no difficulty falling asleep or middle-of-the-night or early-morning awakening. Her appetite has diminished during the past 2 months, with a reported weight loss of 8 kilograms. She eats erratically, usually snacks, and meals are prepared by her husband and mother. She has not been able to provide effective care to her daughter, cook, or do household chores and generally spends the day in bed. She has had become increasingly insular and has avoided social contact, tending to avoid friends and family who have come to call: she has not attended the Mothers group meetings that her MCH nurse had linked her into. Marie describes no interests or involvements outside the home, except for weekly attendance at Church. Her husband and mother have assumed the primary care for Nicole however with her husband due to return to work in 2/52 this is becoming a concern for the family. Mornings are the most difficult for Marie — she feels increased anxiety, has difficulty breathing, and cries a lot. She describes feeling disconnected from Nicole and describes increased guilt and a sense of being a ‘failure’ as a mother. She admits to occasional suicidal ideation in the form of a passive wish to be dead in hopes of relieving her emotional pain. She denies a history of suicide attempts or current suicidal plan. She denies alcohol or drug abuse. Current life stressors reported by Marie include: • Her brother’s death in a car accident 6 months ago. Marie had not seen him in 1.5 years and expresses guilt that they were not close.
• Her sister’s surgery for cancer 5 months earlier. Whilst she has made a good recovery Marie is fearful that she will die in the near future.
• The transition to parenthood and caring for Nicole. Marie and Ron had been planning for their first child for some time and had been very excited about the impending change in their lives. Her pregnancy and birth had gone well though she had struggled to breastfeed, eventually giving up after 5 weeks of trying. Marie feels very guilty about this and thinks she should have tried harder.
• Loss of her sense of role / structure she had gained from her job. Marie had been in her role for many years, was well like and respected and was very committed to the job. She stopped work when 32 weeks pregnant and has struggle to organise her time since then. Past Psychiatric History: Marie has had no prior hospitalisation or community psychiatric treatment. She denies previous episodes of depression. There is no history of mania or hypomania. Pre-morbid Personality: Marie describes herself as being hard-working, kind, well organised and committed to her job before becoming unwell. When asked further about work she says she was very hard-working, motivated to do well at work, able to pal and organised complex tasks and shows pride in her ability to see jobs through to a successful completion. She also reports a strong sense of loyalty to family and close friends, willing to go out of her way to help others. Medical History: Marie’s only physical ailment is borderline hypertension, with a significant family history of same [though it is not treated by medication]. Family History: Marie’s father died from a myocardial infarction at the age of 52, 10 years ago. Marie’s brother, who died 6 months ago in a MCA, was 28 years old. Her sister is 37 years old and is divorced with two daughters, ages 7 and 9; she was recently diagnosed with cervical cancer though is in remission at present. Marie believes her maternal grandmother was depressed but knows no details about this. Social and Developmental History: Marie is the middle child of three siblings. Her mother’s labour and delivery with her were normal, and developmental milestones (talking, walking, etc.) were reached at an early age. She denies any maladaptive behaviours or experiencing unusual stresses as a child. Academically, Marie was an A student throughout her educational experience. She had friends at school and in the community and did not date until after high school. She completed a 3 year business degree. Marie has work in an administration role with the same organisation since graduation, and she has worked her way up to office manager. Marie was raised in rural Victoria and lived there until she was 22, at which time she moved to Melbourne to marry Ron. They initially focused on establishing their careers and buying a house before deciding to try for a baby approximately 18 months ago. Marie describes her 9-year marriage as good but states they both take it for granted at times. She and Ron were very excited about becoming a ‘family’. Marie is a practising Catholic, attending weekly mass and occasional confession.
Despite her husband’s encouragement, she does not attend Church social groups or participate in any other outside activity. Mental Status Examination General Appearance: Marie is an underweight woman who is appropriately dressed, although with an mildly unkempt appearance. She presents with a downcast, averted gaze. Speech: Marie speaks slowly and quietly with a flat tone. Her responses to questions are delayed but her thinking is goal-directed. Thought Content: Themes of worthlessness, helplessness, guilt, hopelessness, and somatic concerns predominate, as well as a pervasive sense of being a failure as a mother. Affect and Mood: Affect is constricted, with mood sad and depressed. Marie frequently engages in intense bouts of crying. Motor Behaviour: Posture is rigid, slumped slightly forward, with few spontaneous movements. Perceptions: There is no evidence of delusions or hallucinations. Suicide Potential: The wish for death is present, but there is no active suicidal intent or plan. Orientation: Marie is oriented to person, place, and time. Concentration: Concentration is impaired, as evidenced by an inability to do Serial 7’s accurately and a digit span of 4 forward, none backward. Recent and Remote Memory: Marie’s recent memory is intact, with three of three objects recalled after 5 minutes. She is able to describe accurately events from the past. Insight and Judgement: Marie has insight into her illness though she is feels angry that it has happened to her. Her judgment is intact. Formulation of Impression Marie presents with a 10-week history of depressed mood; anhedonia; feelings of worthlessness, guilt, hopelessness, and helplessness, suicidal ideation; withdrawn behaviour and impaired functioning; decreased concentration; somatic preoccupations; and decreased appetite and weight loss following the birth of her first child. Symptoms are consistent with that of a [major] post natal depression with melancholia. Marie’s preoccupation with worthlessness, her suicidal ideation, and her marked functional impairment, all occurring in the context of recently having a baby on a background of other losses, are suggestive of bereavement in addition to her major depression. Traditional Nursing Diagnostic Focus The following nursing diagnoses for Marie M. are derived from the assessment data gathered:
• Mood Disturbance
• Dysfunctional Grieving
• Risk for Self-directed Violence
• Self-esteem Disturbance
• Self-care Deficit
• Social Isolation
• Altered Nutrition. Additional nursing diagnoses that may apply to the person with depression include, Altered Thought Processes, Sleep Pattern Disturbance, Anxiety and Sensory-perceptual Alterations. HONOs Scoring Domain Results 1. Overactive, aggressive, disruptive behaviour. 0 1 2 3 4 2. Non-accidental self-injury. 0 1 2 3 4 3. Substance use and misuse. 0 1 2 3 4 4. Cognitive problems. 0 1 2 3 4 5. Physical illness or disability problems. 0 1 2 3 4 6. Hallucinations or delusions. 0 1 2 3 4 7. Depressed mood. 0 1 2 3 4 8. Other mental health issues. 0 1 2 3 4 9. Relationships. 0 1 2 3 4 10. Activities of daily living. 0 1 2 3 4 11. Problems with living conditions. 0 1 2 3 4 12. Problems with occupation and activities. 0 1 2 3 4 Results Key: see Assignment Information package. DSM-5 diagnosis for the Client with a Major Depressive Disorder (Perinatal Onset) The DSM-5 diagnosis for Marie is as follows:
• Major Depressive Disorder (Moderate), single episode with perinatal onset (296.22). Planning The Nursing Care Plan for Marie illustrates how nursing diagnoses guide the development of goals and therapeutic interventions. Ideally, the nurse collaborates with the client in planning care. This can be difficult to do with the depressed person who is feeling hopeless, helpless, and unmotivated. The nurse’s communication of the firm belief in the clients capacity, ability, resourcefulness and potential for recovery is critical in empowering the client to begin the journey towards recovery. Equally the nurse’s communication of the firm belief that the client will feel better with time can often be enough to engage the client in at least going along with the care plan. Setting practical, reasonable, manageable, short-term goals that the client can accomplish without much difficulty is important in fostering a sense of hope and improved self-esteem. The nurse should expect that with the amotivated psychotic client, early interventions may need to be aimed at “doing for” the client [after accurate identification of those abilities that remain intact vs. those that are compromised].
The care plan will also need to include consideration regarding the involvement/capacity of family, friends and other significant supports care of her daughter], but the expectation should be that the client will gradually assume more independent functioning as their mental state improves. Implementation Nursing interventions are guided by the nursing care plan. For the depressed client, priority needs to be given to preventing self-harm through ongoing assessment of suicide potential and maintenance of a safe environment. In addition, improving and maintaining physical health are important foci of care for the depressed client, who is likely to have an altered nutritional status and disturbed sleeping pattern. Monitoring for side effects of somatic treatments for depression is equally important to maintain biological integrity. The depressed client is often socially isolated and withdrawn. Involving the client in individual and group interactions in the hospital unit will decrease his or her isolation and foster a sense of self-worth. As the client’s symptoms of depression respond to the psychotherapeutic and somatic interventions implemented, psycho-education becomes feasible. Clients should be educated about the type of depression they have, as well as its possible causes. Specifically, the contribution of both neurobiological and psychosocial factors to the onset of depressive illness should be discussed. Informing the client of the signs and symptoms of depression is important so that recurrence can be identified early. Education regarding the maintenance of medication regimens should be conducted. Evaluation Evaluation of the client’s responses to nursing interventions should be ongoing. Questions the nurse might ask to evaluate the effectiveness of the nursing process with the depressed client include the following:
• Does the client describe an improvement in mood and energy level?
• Is there any evidence of suicidal ideation?
• Has the client learned new, more effective ways of expressing feelings?
• Has the verbalisation of self-deprecatory ideas diminished?
• Is the client initiating interactions with others?
• Has the client’s appetite improved? Has he or she gained weight?
• Has the client experienced any improvement in her subjective experience of parenthood / connecting with her daughter? In asking these and other questions, the nurse reflects on his or her own observations; on the observations of other team members and the client’s family; and, of utmost importance, on the client’s description of his or her own experience.
|Number of Pages||6 (1650 words)|
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