HESI Case Study Depression

HESI Case Study Depression Patient Assessment and Initial Interaction 1. Priority Nursing Assessment: - Determine how long the client has been hearing the voice and what it is saying. - Understanding the nature of the hallucinations is vital to assess the severity of the situation and determine any risk of self-harm. Behavioral Assessments 2. Behavior Inconsistent with Depression: - Hearing a man's voice. - Auditory hallucinations are generally more indicative of a psychotic disorder and may not be typical for depression alone. However, they may occur in psychotic depression. Consent and Involuntary Treatment 3. Justifying Short-term Involuntary Treatment: - Unable to meet basic self-care needs. - Involuntary treatment is justified when clients cannot care for themselves adequately and may be a danger to themselves or others. - States she has a plan to harm herself. - This also justifies short-term involuntary care to protect the patient. Medication Management 4. Classification of Antidepressant: - Fluoxetine (Prozac) is classified as a Selective Serotonin Reuptake Inhibitor (SSRI). - SSRIs target serotonin levels in the brain, which can improve mood. 5. Major Action of SSRIs: - Increase availability of serotonin. - SSRIs work by inhibiting the reuptake of serotonin, ensuring that more serotonin is available in the synapse. 6. Rationale for SSRI Preference Over Tricyclics: - Tricyclics are more lethal in an overdose. - SSRIs have a safer side effect profile and are less likely to cause fatal overdose compared to tricyclic antidepressants. 7. Expected Therapeutic Effectiveness Timeline: - Generally within 2 to 4 weeks. - While SSRIs can take time to show effect due to the need for neurochemical adjustments, this timeframe is typical for many patients. Side Effects to Monitor 8. Common Side Effects of SSRIs: - Gastrointestinal disturbances. - Clients taking SSRIs commonly report side effects like nausea, diarrhea, and other gastrointestinal issues, especially when starting the medication. (GI disturbances such as nausea and diarrhea, as well as genitourinary side effects such as sexual dysfunction, are common with SSRIs. SSRIs do not have significant anticholinergic, cardiovascular, or sedative side effects) 9. the client also begins an atypical antipsychotic, risperidone (Risperdal), because she reports hearing a "scary voice" upon admission. although the client remains very withdrawn and noncommunicative, the nurse must explain the purpose of Risperdal. Which explanation is best? ️"This medication will help you think more clearly." (antipsychotic medications target symptoms related to disorders of things such as psychosis and behaviors associated with agitation and disorganization or speech and behavior) the nurse is reviewing Bethany's admission lab work on the third day of hospitalization. admission labs include thyroid profile, urinalysis, chemistry panel, pregnancy test, urine drug screen, and VDRL (RPR). 10. the nurse understands that a VDRL is routinely done on admission for which reason? ️it is a screening test for syphilis (a VDRL (RPR) is a serum screening test for syphilis, which can be undetected and dormant and can cause cognitive impairment in later stages. if the screening serum test is positive, a more specific test is required to make the diagnosis of syphilis) 11. a thyroid profile is important for several reasons. what role do thyroid levels play in depression? ️hypothyroidism can lead to feeling sluggish and depressed (thyroid levels can help detect hypothyroidism, which can lead to depression) when Bethany awakens in the morning, she sits for periods of time at the edge of her bed. she does not initiate combing her hair, getting dressed, or going to breakfast. 12. which nursing intervention is important? ️help the client with daily activities (when a client is very depressed, it is necessary for the nurse to assist with daily activities because the client has decreased energy. physical care is more important with severe depression) 13. since the client has decreased energy, which intervention is best? ️plan a scheduled rest period (it is best to plan rest periods according to the client's energy level because some clients feel best in the morning and others feel best in the evening) 14. as the nurse initially communicates with Bethany, which communication technique is important? ️acknowledge the client's courage in seeking help, then offer to sit quietly with the client (offering nonjudgemental acceptance and companionship will help develop trust. acknowledging the step the client took in seeking help may restore the client's sense of control over her situation) Bethany generally declines to participate in the daily, morning community meeting, and she refuses to get out of bed. it takes a great deal of coaxing to get her awakened for meals. she often sits and stares at her tray. according to the nursing process notes, Bethany demonstrates decreased social interaction, she rarely talks, she needs assistance to her room and appears confused. Bethany only slept 30 minutes in the past 24 hours, and the daily graphics indicate that she has slept an average of 2 hours in the past week. she is eating 50% of her meals. 15. according to this data, what is the priority nursing problem? ️sleep disturbance