DOMINICA STATE COLLEGE

Faculty of Health Sciences

ASSOCIATE OF SCIENCE GENERAL NURSING

MENTAL HEALTH NUR224

Sorrowing Old Man; Vincent Van GoghINDIVIDUAL ASSIGNMENT ON MAJOR DEPRESSIVE DISORDER

Presented to

MRS. BEVERLY H. FONTAINE

by

REBEKAH ROBERTS

10BROR00498

6. 7. 2012

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CONTENTS

ACKNOWLEDGEMENTS 3

INTRODUCTION 4

SCENARIO 5

CASE STUDY 6

ETIOLOGICAL BASIS OF DISORDER 8

CONCEPT MAPPING

o SUBJECTIVE AND OBJECTIVE ASSESSMENT 10

o NURSING DIAGNOSES 11

o NURSING GOALS 12

o NURSING INTERVENTIONS 13

o NURSING OUTCOMES 14

OUTLINE OF POSSIBLE SOLUTIONS 15

CONCLUSION 17

REFERENCES 18

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ACKNOWLEDGEMENTS

The student wishes to express sincere and heartfelt gratitude to the individuals whose

assistance has made the project a successful and worthwhile endeavour.

"Although the world is full of suffering, it is also full of overcoming it."

Helen Keller

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INTRODUCTION

The nursing process, as with all aspects of nursing is integral to provision of care in

mental health nursing. This project serves to test the critical thinking and application

skills of the student. This project allows the opportunity for creative thinking, gaining

new knowledge and application of said knowledge to mental health nursing practice.

Major depressive disorder is defined in the DSM IV TR, as a mood disorder that

manifests in a change from the person's normal mood; social, occupational, educational

or other important functioning that is negatively impaired by the change in mood. This

disease is a serious illness that severely impacts one’s life as thoughts, behaviours and

activities of daily living are affected.

This disease is characterized by a combination of symptoms that interfere with a

person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities. Major

depression is disabling and prevents a person from functioning normally. Some people

may experience only a single episode within their lifetime, but more often a person may

have multiple episodes.

This disease is important to study as a nurse as the prevalence is as high as 6.7

percent in American adults with 3o% of these being severe depression, (National

Institute of Mental Health, 2012). This large number shows how important it is that such

a disease be treated and intercepted as the damages to the individual and society could

be devastating if untreated as self and social destructive behavior can be pursued.

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This project will seek to elaborate on aspects of the Nursing process to illuminate what

is to be done for a hypothetical patient suffering from this disease from diagnosis to

treatment.

SCENARIO

A. P. is a 29 year old woman who was admitted to the psychiatric unit with severe

weight loss, though she stated that she was not dieting and had thoughts of death. Her

friends had persuaded her to come as they had become worried about her daily

depressed mood, fatigue, loss of interest in normal and pleasurable activities and a

diminished ability to concentrate. She claimed that these feelings began two months

ago after the termination of a three year long relationship with her boyfriend. She also

stated that her father and maternal uncle had suffered with depression in the past.

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CASE STUDY

A. P. is a 29 year old woman who was admitted to the psychiatric unit with severe

weight loss, though she stated that she was not dieting and had thoughts of death. Her

friends had persuaded her to come as they had become worried about her daily

depressed mood, fatigue, loss of interest in normal and pleasurable activities and

diminished ability to concentrate. She claimed that these feelings began two months

ago after the termination of a three year long relationship with her boyfriend. She also

stated that her father and maternal uncle had suffered with depression in the past. She

was given the medical diagnosis of unipolar depression.

According to DSM IV TR, this disorder manifests and is diagnosed if the individual

presents with at least five of these signs and symptoms; depressed mood, diminished

interest, significant weight loss, insomnia, hypersomnia, and fatigue, feelings of

worthlessness and thoughts of death, psychomotor agitation and decreased ability to

think or concentrate. These symptoms must present nearly every day and hypersomnia

can present instead of insomnia and excessive and inappropriate guilt can present with

feelings of worthlessness. The thoughts of death reoccur with suicidal ideation, it may

not involve planning out a suicidal attempt or attempting to commit suicide.

Any individual suffering with major depressive disorder like A. P, can be effectively

treated with a mix of medication therapy and psychotherapy. The nurse’s responsibility,

in A. P’s, case would be to firstly establish a therapeutic relationship with the client

based on mutual trust and respect which forms the basis for a successful treatment

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regime. The nurse would assist in recovery and illness management by facilitating

adherence to medication regime, open rapport and communication with patient,

relatives and other members of the health team to promote a team approach.

Psychotherapy is a beautiful method which produces great results and no physiological

side effects to the patient. Interpersonal and cognitive behavioural therapy would be

ideal in this case, to assist her to solve problems in relationships that may have caused

the problem and to understand and eventually eliminate negative and unrealistic

thoughts about herself that contributes to depression.

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ETIOLOGICAL BASIS OF DISORDER

Major depressive disorder or unipolar depression is a medical illness that causes a

persistent feeling of sadness and loss of interest, it can cause result in physical

symptoms that can persist for weeks or more and can increase in strength gradually.

These symptoms can interfere with daily functioning and cause distress for both the

person with the disorder and those who care about him or her.

According to DSM IV TR, major depressive disorder can stem from genetic, biological,

psychological and environmental factors. According to ADAM Medical Encyclopaedia,

(2012) many researchers believe major depression is caused by chemical changes in

the brain. This may be due to a problem with your genes, or triggered by certain

stressful events. More likely, it's a combination of both. Studies show that first degree

relatives of people with depression have a higher incidence of the illness. Situational

and environmental factors can exacerbate a depressive disorder in significant ways.

These factors can include lack of support system, stress, problems in relationships

illness in self or loved one, legal difficulties, financial struggles, and job problems.

According to the National Institute of Mental Health, 2012; longstanding theories about

depression suggest that important neurotransmitters are out of balance in depression,

but it has been difficult to prove this. Magnetic resonance imaging (MRI), have shown

that the brains of people who have depression look different than those of people

without depression. The parts of the brain involved in mood, thinking, sleep, appetite,

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and behaviour appear different. But these images do not reveal why the depression has

occurred.

This causes manifests in A.P, who has an immediate family history of the disorder. A

break up of a serious relationship acted as a trigger along with her genetic factors and

brought about the major depressive episode.

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CONCEPT MAPPING

SUBJECTIVE AND OBJECTIVE ASSESSMENT

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SUBJECTIVE

ASSESSMENT

OBJECTIVE

ASSESSMENT

Family history and health

history

Psychological assessment,

patient’s thoughts on self

Information on Present

illness using COLDSPA

Interview with family

and friends

Laboratory tests to eliminate

other disorders

Rorshach, sentence

completion or other

psychological test for

diagnosis

Possible stressors in life

Drug/ alcohol and

medication use

Lifestyle factors; diet, exercise,

coping level

NURSING DIAGNOSES

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FIRST SECOND THIRD

Imbalanced nutrition:

less than body

requirements

Related to disinterest in

self care

As evidenced by

severe weight loss

Secondary to

unipolar

depression

Related to cognitive

impairment

Ineffective coping

As evidenced by

patient’s behaviour

Risk for violence, self

directed

As evidenced by

patient’s

verbalisation

Related to impaired

cognitive function

Secondary to depressed mood

NURSING GOALS

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first diagn

osis

Client will gain 2 pounds per week for the next 3 weeks.Client will exhibit no signs or symptoms of malnutrition by time of discharge from treatment

second

diagnosis

that patient will exhibit postive mood displays 48 hours after commencement of treatment regime.that during hospitalization patient will identify coping strategies to manage illness.

third diagn

osis

that the patient will not harm herself during hospitalisation

NURSING INTERVENTIONS

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Keep strict documentation of patient's intake, output, and calorie count.

encourage intake of regular healthy meals and foods high in fiber

Weigh patient daily.

encourage patient to engage in diversional therapy and instruct on coping mechanisms

therapeutic relationship will be utilized to carry out interpersonal psychotherapy with patient to focus on strengths and positive traits

increase and mobilize support systems by carrying out group therapy

medication will be administered to patient as prescribed

monitor client for risk of harming self and others and intervene as necessary

document, report and record patient's status regularly

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NURSING OUTCOMES

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patient has gained 2 pounds per week in the last threeweeks.Client exhibits no signs or symptoms of malnutrition by time of discharge from treatment

fi rs t d ia g n o s is

patient exhibits postive mood displays 48 hours after commencement of treatment regime.during hospitalization patient identifies coping strategies to manage illness.

s e c o n d d ia g n o s is

the patient has not harmed herself during hospitalisation

th ird d ia g n o s is

OUTLINE OF POSSIBLE SOLUTIONS

Medical and nursing management of a patient with major depressive disorder must

include both pharmacotherapy and psychotherapy.

According to Encarta Encyclopaedia, 2008; antidepressant medications appear to work

by altering the levels of serotonin, norepinephrine, and other neurotransmitters in the

brain and they generally take at least two to three weeks to become effective.

Monoamine oxidase inhibitors, selective serotonin reuptake inhibitors and tricyclics are

usually used in treatment plans.

Tricyclics, named for their three-ring chemical structure, include amitriptyline (Elavil),

imipramine (Tofanil) and desipramine (Norpramin). Side effects of tricyclics may include

drowsiness, dizziness upon standing, blurred vision, nausea, insomnia, constipation,

and dry mouth.

MAOI’S include isocarboxazid (Marplan), phenelzine (Nardil), and tranylcypromine

(Parnate) and include much the same side effects as tricyclics.

SSRI’S include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). These

drugs generally produce fewer and milder side effects than do other types of

antidepressants, although SSRIs may cause anxiety, insomnia, drowsiness, headaches,

and sexual dysfunction.

As major depression is more severe than other types longer term psychotherapy is

necessary for treatment. The most effective are cognitive-behavioural therapy,

interpersonal therapy and psychodynamic therapy. Cognitive –behavioural therapy

assumes that depression stems from unhealthy, negative and irrational thoughts about

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one’s self and future and thus seeks to improve one’s outlook of self by teaching

understanding and elimination of negative thoughts about self.

In Interpersonal therapy the therapist or counselor helps a person resolve problems in

their relationships with others that may have caused the depression. The subsequent

improvement in social relationships and support helps alleviate the depression.

Psychodynamic therapy views depression as the result of internal unconscious conflicts

and thus the therapist focuses on past experiences and the resolution of childhood

conflicts. Psychoanalysis is an example of this.

Electro Convulsive therapy, though not used in Dominica is used to treat severe

depression in persons not responding to pharmaceutical and psychological treatment.

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CONCLUSION

Mood disorders especially major depressive disorder severely affects the lives of the

persons suffering from it as well as their loved ones. Treatment of this disease is

intensive and requires proper planning and participation of all members of the health

team. Completing this project has given me the information necessary to care for a

patient with such a disorder. This project has given me insight into mood disorders and

treatment modalities for such which will undoubtedly enhance my clinical and practical

experience and practice.

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REFERNECES

All Psych Online. (2012). DSM IV TR; Unipolar Depression. (2011). Retrieved from

http://allpsych.com/disorders/mood/majordepression.html

Encarta Encyclopaedia. (2008). Depression (Psychology). Microsoft Corporation

(2008).

PubMed Health. (2012). ADAM Encyclopaedia, Depressive Disorder, 2012.

Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001941/

National Institute of Mental Health, (2012). Depression, 2012. Retrieved from

http://www.nimh.nih.gov/health/publications/depression/what-are-the-different-

forms-of-depression.shtml

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