Nursing 432 FA Davis Mindy Wright

Nursing 432 FA Davis Mindy Wright. Erika Hightower Mindy Wright Mindy Wright | Interview the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. You said that you are experiencing some periods of sadness. Rationale Relevancy Your Answer Because the criteria for depression involve identification of symptoms of sadness, dejection, anger, guilt, helplessness, hopelessness, despondency, etc., this broad opening allows the client to start speaking about what “sadness” means to her. Relevant Relevant Client: Yes. It started about 2 months ago and I thought I could work through it myself. 2. Do you get the sensation of heart palpitations when you are feeling sad? Rationale Relevancy Your Answer Physical symptoms such as heart palpitations occur with anxiety, not depression. Irrelevant Irrelevant Client: I do not have heart palpitations. 3. Does it seem like your feelings of sadness occur at certain times of the year? (Do you feel better in the summer, for example?) Rationale Relevancy Your Answer Seasonal affective disorder is identified by seasonal variances in the depressive symptoms. The client’s symptoms have been occurring for only 2 months so it may be hard for her to quantify whether the season makes a difference. Irrelevant Irrelevant Client: Not that I know of. This has only been going on for 2 months. 4. Did something in particular happen that triggered these feelings of sadness? Rationale Relevancy Your Answer Depression can begin after a situational occurrence that is of significance to the client. It is important to understand if an event in the client’s life precipitated her symptoms. Relevant Relevant Client: Yes. These feelings started shortly after my mom died. She had been sick a long time so we knew she was dying, but I just really miss her. I don’t know why God allowed her to be that sick and suffer so much. I thought I was prepared for her death, but I continue to think about her dying and how much she suffered. 5. Have you ever experienced the feeling of a “racing heart?” Rationale Relevancy Your Answer Physical symptoms such as heart palpitations and the sensation of a “racing heart” occur with anxiety, not depression. Irrelevant Irrelevant Client: I’ve never felt like that. 6. Are you experiencing clammy hands or breaking out in a sweat when you begin feeling sad or depressed? Rationale Relevancy Your Answer Physical symptoms such as heart palpitations, the sensation of a “racing heart,” clammy hands, and breaking out in a sweat occur with anxiety, not depression. Irrelevant Irrelevant Client: I do not have clammy hands, nor do I break out in a sweat when I feel sad. 7. How long after your mother passed away did you start feeling depressed? Rationale Relevancy Your Answer Establishing a timeline for the onset of symptoms is important, as the psychiatrist will use this information to determine whether the client has acute or chronic depression. Relevant Relevant Client: Probably about a week—after the funeral, and after all of my out-of-town relatives went home. I felt like my life was empty. I would start to call or go see my mom and then would remember that she was gone. 8. How would you describe the sadness that you feel? Rationale Relevancy Your Answer It is important to understand the way the client classifies and describes her own symptoms. The psychiatrist, when determining the degree of depression, will also use this information. Relevant Relevant Client: It’s kind of hard to explain, but it’s like there is a fog around me. I can’t get motivated to do anything, and it just seems like I can’t go on like this. I just feel like I don’t have any hope left. 9. Do you find it hard to get out of bed, get showered, and get to work? Rationale Relevancy Your Answer It is not uncommon for clients with depression to experience difficulty thinking, obsessive and repetitive thoughts, negativism, and/or behaviors indicating suicidal ideation. They also commonly experience low energy level, fatigue, and listlessness. Relevant Relevant Client: Sometimes I just stay in bed in my pajamas and keep the lights all turned off. I go to work when I can, but I’ve had to call off work a few times because I feel so drained. 10. Have you taken anything to try to alleviate the symptoms? Rationale Relevanc y Your Answer With over-the-counter herbal preparations targeted at allaying depression symptoms, it is important to know if the client has tried to take anything to address the symptoms. This question also addresses whether the client has tried illicit substances to ease the symptoms. Relevant Relevant Client: No. I’ve just tried to work through it myself. 11. Have you had these kinds of feelings before in your life? Rationale Relevancy Your Answer This information is important in understanding whether the client has a history of depressive symptoms or whether this is a first incidence. Relevant Relevant Client: No. I’ve never felt like this before. In fact, I have always been a pretty happy person, so this is a strange feeling for me. 12. Do you have difficulty concentrating? Rationale Relevancy Your Answer It is not uncommon for clients with depression to experience difficulty thinking, obsessive and repetitive thoughts, negativism, and/or behaviors indicating suicidal ideation. Relevant Relevant Client: Yes, it’s hard to focus on anything. I just keep thinking about my mom and how lost I feel without her. I can’t believe God let her suffer and die. How can I enjoy life when she is no longer here? 13. Have you had any thoughts of harming yourself? Rationale Relevanc y Your Answer Any time a client is depressed it is important to establish if the client has any intention of harming herself. It is not uncommon for clients with depression to experience difficulty thinking, obsessive and repetitive thoughts, negativism, and/or behaviors indicating suicidal ideation. Relevant Relevant Client: I don’t know. Sometimes it seems like it would be easier to just give up and die. I’ve thought about killing myself. 14. Have you thought of a particular method of killing yourself? Rationale Relevanc y Your Answer Any time a client is depressed it is important to establish if the client has any intention of harming herself. It is not uncommon for clients with depression to experience difficulty thinking, obsessive and repetitive thoughts, negativism, and/or behaviors indicating suicidal ideation. Once the client has indicated that she has considered suicide, it is important to learn whether she has a specific plan in mind. Relevant Relevan t Client: Probably pills. I would rather just overdose so I don’t feel anything. Sometimes it would be nice just to go to sleep and not deal with these feelings any more. Copyright @2017 by FA Davis Mindy Wright | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Inspection • Palpation • Auscultation • Percussion It is important to maintain the client’s comfort level during the interview. When the client is in distress or is overly apprehensive or anxious, the examiner will want to make the exam as short as feasible while still gathering necessary data. Relevant Relevant Although it sounds like Mindy’s symptoms are psychological in nature, it is important to collect data that could indicate whether there are physical concerns that contribute to Mindy’s feelings. Relevant Relevant It would be important to establish a baseline. It is common for individuals with depression to experience significant weight loss or weight gain or appetite changes. Relevant Relevant Assessment Data/Patient Results: Mindy identifies that she has lost almost 18 pounds over the last 2 months. She states that she often does not feel hungry and has no energy to cook for herself. 4. Assess Mindy’s sleep patterns. Rationale Relevancy Your Answer Sleep disruptions are common with individuals experiencing depression. Relevant Relevant Assessment Data/Patient Results: Mindy identifies that she often wakes up during the night and cannot get back to sleep; she frequently feels very tired and never feels rested. 5. Assess Mindy’s self-esteem or self -concept. Rationale Relevancy Your Answer Individuals with depression often express feelings of worthlessness. Relevant Relevant Assessment Data/Patient Results: Mindy states that she often feels incompetent at home and at work. 6. Perform an abdominal assessment. Rationale Relevancy Your Answer There is no indication that Mindy is experiencing abdominal issues. Irrelevant Irrelevant Individuals with depression often experience markedly diminished interest or pleasure in social or recreational activities. Relevant Relevant Individuals with depression often attempt to address symptoms by the use of drugs or alcohol. Drugs and alcohol also contribute to the signs and symptoms of depression. Relevant Relevant There is no indication that Mindy is experiencing hallucinations or delusions. Irrelevant Irrelevant These rating scales measure the severity of depressive symptoms as well as mood, feelings of guilt, suicidal ideation, sleep disturbance, anxiety levels, and weight loss. Relevant Relevant Assessment Data/Patient Results: Mindy achieves a score of 24 on the Hamilton Depression Rating Scale. 11. Assess Mindy’s feelings related to the loss of her mother. Rationale Relevancy Your Answer Grief that is prolonged or exaggerated can result in moderate to severe depression. Relevant Relevant Assessment Data/Patient Results: Mindy identifies that she sometimes has difficulty believing that her mother is actually gone. At times she experiences anger that her mother had to suffer for so long and often finds herself crying when she thinks about her mother. 12. Perform a suicide risk assessment. Rationale Relevancy Your Answer Individuals who are depressed are at risk for committing suicide. Relevant Relevant Copyright @2017 by FA Davis Mindy Wright | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Inspection • Palpation • Auscultation • Percussion Although it sounds like Mindy’s symptoms are psychological in nature, it is important to collect data that could indicate whether there are physical concerns that contribute to Mindy’s feelings. Relevant Relevant Assessment Data/Patient Results: Mindy’s vital signs are within normal limits. 2. Perform an abdominal assessment. Rationale Relevancy Your Answer There is no indication that Mindy is experiencing abdominal issues. Irrelevant Irrelevant Copyright @2017 by FA Davis Mindy Wright | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Inspection • Palpation • Auscultation • Percussion Although it sounds like Mindy’s symptoms are psychological in nature, it is important to collect data that could indicate whether there are physical concerns that contribute to Mindy’s feelings. Relevant Relevant Assessment Data/Patient Results: Mindy’s vital signs are within normal limits. 2. Perform an abdominal assessment. Rationale Relevancy Your Answer There is no indication that Mindy is experiencing abdominal issues. Irrelevant Irrelevant Copyright @2017 by FA Davis Mindy Wright | Assess the Patient | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. • Inspection • Palpation • Auscultation • Percussion Based on the information collected in the interview process, there is nothing to indicate that Mindy has a neurological deficit. Irrelevant Irrelevant Assessment Data/Patient Results: Mindy’s neurological assessment is normal. 2. Perform an abdominal assessment. Rationale Relevancy Your Answer There is no indication that Mindy is experiencing abdominal issues. Irrelevant Irrelevant Copyright @2017 by FA Davis Mindy Wright | Labs / Diagnostic Tests | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. Thyroid stimulating hormone (TSH) Rationale Relevancy Your Answer This test has the potential for identifying clients at risk for depression or those experiencing depression as a result of their endocrine abnormality. Relevant Relevant 2. Thyroxine, total (T4) Rationale Relevancy Your Answer Individuals with thyroid disorders can exhibit signs and symptoms of depression. Relevant Relevant Rationale Relevancy Your Answer Secondary depression may be related to electrolyte disruptions. Relevant Relevant 4. CXR (chest x-ray) Rationale Relevancy Your Answer A chest x-ray is not of value when diagnosing or treating depression. Irrelevant Irrelevant 5. ECG (electrocardiogram) Rationale Relevancy Your Answer There is no indication that Mindy has cardiac abnormalities. Irrelevant Irrelevant 6. Vitamin B12, B1 (thiamine), and B6 (pyridoxine) Rationale Relevancy Your Answer Deficiencies in the B vitamins may produce symptoms of depression. Relevant Relevant Copyright @2017 by FA Davis Mindy Wright | Clustering Assessment Data | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. When you are finished reviewing, click "Continue" to proceed to next section. 1. Cluster A Rationale Correct Answer Your Answer Rationale: Any time a client has Mindy states that, Mindy states that, expressed thoughts of killing “Sometimes it seems “Sometimes it seems himself or herself and a plan to do like it would be easier like it would be easier so, it is critical to consider this to just give up and to just give up and information in order to ensure die. I’ve thought die. I’ve thought client safety, which should be the about killing myself.” about killing myself.” primary concern. Loss of a Mindy identifies that Mindy identifies that support network can affect a she would probably she would probably client’s response to a crisis. use pills to kill herself: use pills to kill herself: “I would rather just “I would rather just overdose so I don’t overdose so I don’t feel anything.” feel anything.” Mindy states that Mindy states that sometimes it would be sometimes it would be nice just to go to nice just to go to sleep and not deal sleep and not deal with her feelings any more. Mindy identifies that she has thought about “no longer being here.” She has a plan but not the means currently or a time frame. Mindy is questioning whether her life is worth living and states that at times she cries and wants to curl up in a ball and die: “I feel like my life is over. Life seems so bleak right now.” Mindy states that she doesn’t think she can continue to enjoy life without her mom and feels as if she cannot continue to feel this way. with her feelings any more. Mindy identifies that she has thought about “no longer being here.” She has a plan but not the means currently or a time frame. Mindy is questioning whether her life is worth living and states that at times she cries and wants to curl up in a ball and die: “I feel like my life is over. Life seems so bleak right now.” Mindy states that she doesn’t think she can continue to enjoy life without her mom and feels as if she cannot continue to feel this way. 2. Cluster B Rationale Correct Answer Your Answer Rationale: Many individuals experiencing depression express feelings related to fatigue, lack of energy, apathy, hopelessness, an inability to complete role expectations, and not feeling rested. Individuals with depression exhibit changes in normal eating patterns, diminished interest and pleasure in social or recreational activities, and sleep disruptions. Mindy states that sometimes she stays in bed in her pajamas and keeps the lights all turned off: “I go to work when I can, but I’ve had to call off work a few times because I feel so drained.” Mindy states that she feels as if she is in a fog and that she can’t get motivated to do anything. Mindy identifies that she has lost almost 18 pounds over the last 2 months. She states that she often does not feel hungry and has no energy to cook. Mindy states that sometimes she stays in bed in her pajamas and keeps the lights all turned off: “I go to work when I can, but I’ve had to call off work a few times because I feel so drained.” Mindy states that she feels as if she is in a fog and that she can’t get motivated to do anything. Mindy identifies that she has lost almost 18 pounds over the last 2 months. She states that she often does not feel hungry and has no energy to cook. Mindy exhibits a sad affect, occasionally has difficulty maintaining eye contact, and speaks very softly. Mindy states that she no longer has the energy to complete role expectations like taking care of the house or participating in activities that she used to enjoy. Mindy identifies that she feels very hopeless and alone in life. Mindy exhibits a sad affect, occasionally has difficulty maintaining eye contact, and speaks very softly. Mindy states that she no longer has the energy to complete role expectations like taking care of the house or participating in activities that she used to enjoy. Mindy identifies that she feels very hopeless and alone in life. 3. Cluster C Rationale Correct Answer Your Answer Rationale: Individuals who are experiencing a loss often identify that the grief reaction hits a crisis point when their social supports are no longer present. Individuals progress through the grief process differently, and this process can be prolonged or extreme, which may interfere with their ability to cope with grief and move on with their lives. Mindy identifies that about a week after the funeral and after all of her out-of-town relatives went home she felt like her life was empty: “I would start to call or go see my mom and then would remember that she was gone.” “Yes. It’s hard to focus on anything. I just keep thinking about my mom and how lost I feel without her. I can’t believe God let her suffer and die.” Mindy identifies that she sometimes has difficulty believing that her mother is actually gone. Mindy states that at times she experiences anger that her mother had to suffer for so long Mindy identifies that about a week after the funeral and after all of her out-of-town relatives went home she felt like her life was empty: “I would start to call or go see my mom and then would remember that she was gone.” “Yes. It’s hard to focus on anything. I just keep thinking about my mom and how lost I feel without her. I can’t believe God let her suffer and die.” Mindy identifies that she sometimes has difficulty believing that her mother is actually gone. Mindy states that at times she experiences anger that her mother had to suffer for so long and often finds herself crying when and often finds she thinks about her herself crying when mother. she thinks about her Mindy explains that mother. she thought she was Mindy explains that prepared for her she thought she was mother’s death, but prepared for her she continues to mother’s death, but think about her she continues to mother’s dying and think about her how much she mother’s dying and suffered. how much she Mindy states that she suffered. started feeling sad Mindy states that she shortly after her started feeling sad mom died and that shortly after her mom even though her died and that even mother’s death was though her mother’s expected, she is still death was expected, having difficulty she is still having coping with her loss. difficulty coping with She questions why her loss. She God allowed her questions why God mother to be that allowed her mother sick and suffer so to be that sick and much. suffer so much. Copyright @2017 by FA Davis Mindy Wright | Assign Diagnoses | Review Back Continue Answers and Rationale Your responses are displayed below. When you are finished reviewing, click "Continue" to proceed to next section. 1. Cluster A Rationale Correct Answer Your Answer True Risk for Suicide Risk for Suicide 2. Cluster B Rationale Correct Answer Your Answer True Hopelessness Hopelessness 3. Cluster C Rationale Correct Answer Your Answer True Risk for Complicated Risk for Complicated Grieving Grieving Copyright @2017 by FA Davis Mindy Wright | Nursing Outcomes / Individualized Goals | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. The client will not harm herself. Rationale Relevancy Your Answer Rationale: The client’s safety should be a primary concern. The client has identified that she has thought about killing herself and has identified her plan; therefore, this should be addressed. Risk for Suicide Risk for Suicide 2. The client will verbalize a measure of hope and acceptance of life and situations over which she has no control. Rationale Relevancy Your Answer Rationale: Identifying areas of life that clients can realistically control can give them a feeling of having some control over their lives and thus a sense of hope for the future. Hopelessnes s Hopelessne ss 3. The client will verbalize normal behaviors associated with grieving. Rationale Relevancy Your Answer Rationale: Assisting clients with identifying the normal grieving process will promote an understanding of the stages of grief and the individual’s progress. Complicated Grieving Complicated Grieving 4. The client is able to understand basic communications in interactions with caregivers. Rationale Relevancy Your Answer Rationale: There is no indication that this client has communication difficulties. None 5. The client will verbalize which social behaviors are appropriate and which are inappropriate. Rationale Relevancy Your Answer Rationale: There is no indication that the client is experiencing difficulty socializing appropriately with peers or coworkers. None 6. The client distinguishes actual from perceived stimuli and interprets her environment accurately. Rationale Relevancy Your Answer Rationale: There is no information to suggest that the client is in danger of injuring herself as a result of delusions or hallucinations. None Copyright @2017 by FA Davis Mindy Wright | Nursing Interventions / Activities | Review Back Continue Answers and Rationale Your responses and feedback are displayed below. For more information regarding feedback, click "Help". When you are finished reviewing, click "Continue" to proceed to next section. 1. Identify stressors in Mindy’s life that contributed to the current crisis. Rationale Relevancy Your Answer Rationale: Identification of contributing factors to the client’s current crisis will assist with planning appropriate nursing interventions. Hopelessness Hopelessnes s 2. Exhibit an accepting attitude and encourage Mindy to verbalize her feelings, even those of anger, which initially may be deflected toward the nurse. Rationale Relevancy Your Answer Rationale: An accepting attitude will assist with building a therapeutic, trusting relationship. Complicated Grieving Complicated Grieving 3. Perform a suicide risk assessment on Mindy on a regular basis. Rationale Relevancy Your Answer Rationale: The client’s risk of suicide increases if she has developed a plan. Risk for Suicide Risk for Suicide 4. Encourage Mindy to discuss the coping mechanisms that she has used successfully in the past. Rationale Relevancy Your Answer Rationale: Identification of client strengths can encourage the client to continue to utilize those strengths and coping strategies to overcome the current crisis. Hopelessnes s Hopelessnes s 5. Help Mindy to realistically identify areas of her life that she can control. Rationale Relevancy Your Answer Rationale: The client’s current emotional crisis may interfere with her current ability to problem solve. Providing assistance will aid with the client’s realistic view of life events that are within her control. Hopelessnes s Hopelessne ss 6. Encourage Mindy to seek out supportive family, friends, or professionals when feeling as if she might harm herself. Ask the client if she can commit to a no-harm contract. Rationale Relevancy Your Answer Rationale: It is important that clients assume responsibility for their personal safety as soon as possible. Risk for Suicide Risk for Suicide 7. Teach Mindy the normal stages of grief and behaviors that are common in each stage. Rationale Relevancy Your Answer Rationale: Knowledge of the normal grieving process will assist the client in developing a comfort level with her feelings. Complicated Grieving Complicated Grieving 8. Normalize Mindy’s feelings and behaviors and encourage her to recognize that the grief process differs for every individual. Rationale Relevancy Your Answer Rationale: Validating the client’s feelings as she moves through the grieving process will enable her to feel comfortable discussing her feelings and progress through Complicated Grieving Complicate d Grieving the grief process. 9. Encourage Mindy to express her feelings, including anger, and accept those feelings in a nonjudgmental way. Rationale Relevancy Your Answer Rationale: Clients may be able to resolve feelings if they are allowed to express themselves in a safe environment. Risk for Suicide Risk for Suicide Copyright @2017 by FA Davis