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1
Depression Care Plan: Abigail Harris
School of Nursing, Trent University
NURS 2021: Family Focussed Practice
Professor Jaime Sims & Clinical Instructor Kathryn Taylor
June 20th, 2021
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2
Depression Care Plan: Abigail Harris
Data/Information Analysis/Rationale
(where applicable)
BACKGROUND Pt Demographics - The patient, AH, is an 86-year-old African American woman Data was collected on patient
Use report sheet to gather who was born on June 1st, 1934. demographics from Shadow
Reason for admission
information from report - She was brought into the ED by her son who expressed Health and the case overview
Chief Complaint concern, after AH experiencing physical exhaustion and on Blackboard in order to
tiredness for an extended period of time. Patient states that provide insight to the patient’s
Relevant patient history ( current and age and ethnicity, which could
past) she feels weak and tired, and doesn’t feel like getting out of
be important to consider
bed most mornings.
Social History throughout the case as age and
- The chief complaint that AH presents with is weakness and
ethnicity can increase the risk
fatigue. for various conditions.
- AH was previously diagnosed with depression 5 years ago (at
Information was also collected
age 81), after the death of her husband. Patient takes
on the patient being brought
Venlafaxine 150 mg PO daily and Zolpidem 5g PO as needed at
into the ED by her son, which
bedtime for mild insomnia. AH was also diagnosed with demonstrates that he was
hypothyroidism and diabetes at age 50. She takes 16 units of concerned for his mother’s
insulin aspart subcutaneously TID at mealtimes, 45 units of well-being, and could also be
insulin glargine subcutaneously daily. AH also takes important to consider in the
Levothyroxine 50 mcg PO once daily to treat hypothyroidism. case.
Patient was previously hospitalized at 50-years-of-age for The chief complaint was
weight loss and fatigue and was diagnosed with diabetes and determined by interviewing the
hypothyroidism. Patient also states that she has been patient, where AH revealed that
experiencing joint pain. she was experiencing fatigue
- Patient is a retired high school teacher who taught English. AH and weakness. This is important
states that she is widowed, as her husband died after a series to include, as the goal of the
of strokes 6 years ago. AH states that the onset of her nurse-client interaction is to aid
depression started after her husband died. Patient reports in mitigating the fatigue and
weakness that the patient is
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care plan abigail harris.pdfhttps://www.stuvia.com/user/docstudent96https://www.stuvia.com/user/docstudent96
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3
occasionally drinking wine but has never smoked. AH also experiencing.
reports previously being involved with her church, where she The relevant patient history was
started a knitting group, and walking her dog frequently. obtained through a
However, as of late, patient has not had the energy or desire to combination of examining
participate in these activities. Patient lives with her son and his patient orders and conducting a
family, who serve as her primary caregiver. patient interview. Obtaining
this information is important as
it identifies comorbidities or risk
factors that could be relevant to
the patient’s case. Furthermore,
this information can help
identify areas that may require
further education to promote
well-being.
The social history was also
obtained by conducting a
patient interview. This is
important to include as it can
provide insight as to the
patient’s support network,
hobbies and interests, and
examine behaviors of the
patient related to physiological
and psychosocial conditions.
PATHOPHYSIOLOGY & Provide a summary of the primary - The primary disease that the patient is admitted with is As revealed in the Shadow
ETIOLOGY disease or condition the patient is Depression, which was diagnosed at 81 years of age. AH Health assignment, many
admitted with including currently takes medication, Venlafaxine, in order to help criteria that were outlined as
treat her depression. The depression screening tool defining characteristics of
defining characteristics
revealed a score of 16, indicating that AH is experiencing depression were observed in
moderate depression. the patient such as insomnia,
fatigue, increased need for
- The patient reports that she has been having difficulty
sleep, anhedonia, weight loss,
sleeping (insomnia) and has been having an increased need
and passive thoughts of suicide.
for sleep, has been feeling fatigued, has taken less interest These criteria are consistent
in pleasurable activities (anhedonia), has recently lost 9 lbs with the DSM 5. Though the
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1
Depression Care Plan: Abigail Harris
School of Nursing, Trent University
NURS 2021: Family Focussed Practice
Professor Jaime Sims & Clinical Instructor Kathryn Taylor
June 20th, 2021
!@#()*$*(&@&(*%*&((%UDepression
!@#()*$*(&@&(*%*&((%UDepression
care plan abigail harris.pdfhttps://www.stuvia.com/user/docstudent96https://www.stuvia.com/user/docstudent96
!@#()*$*(&@&(*%*&((%UDepression
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,!@#()*$*(&@&(*%*&((%UDepression
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care plan abigail harris.pdfhttps://www.stuvia.com/user/docstudent96https://www.stuvia.com/user/docstudent96
2
Depression Care Plan: Abigail Harris
Data/Information Analysis/Rationale
(where applicable)
BACKGROUND Pt Demographics - The patient, AH, is an 86-year-old African American woman Data was collected on patient
Use report sheet to gather who was born on June 1st, 1934. demographics from Shadow
Reason for admission
information from report - She was brought into the ED by her son who expressed Health and the case overview
Chief Complaint concern, after AH experiencing physical exhaustion and on Blackboard in order to
tiredness for an extended period of time. Patient states that provide insight to the patient’s
Relevant patient history ( current and age and ethnicity, which could
past) she feels weak and tired, and doesn’t feel like getting out of
be important to consider
bed most mornings.
Social History throughout the case as age and
- The chief complaint that AH presents with is weakness and
ethnicity can increase the risk
fatigue. for various conditions.
- AH was previously diagnosed with depression 5 years ago (at
Information was also collected
age 81), after the death of her husband. Patient takes
on the patient being brought
Venlafaxine 150 mg PO daily and Zolpidem 5g PO as needed at
into the ED by her son, which
bedtime for mild insomnia. AH was also diagnosed with demonstrates that he was
hypothyroidism and diabetes at age 50. She takes 16 units of concerned for his mother’s
insulin aspart subcutaneously TID at mealtimes, 45 units of well-being, and could also be
insulin glargine subcutaneously daily. AH also takes important to consider in the
Levothyroxine 50 mcg PO once daily to treat hypothyroidism. case.
Patient was previously hospitalized at 50-years-of-age for The chief complaint was
weight loss and fatigue and was diagnosed with diabetes and determined by interviewing the
hypothyroidism. Patient also states that she has been patient, where AH revealed that
experiencing joint pain. she was experiencing fatigue
- Patient is a retired high school teacher who taught English. AH and weakness. This is important
states that she is widowed, as her husband died after a series to include, as the goal of the
of strokes 6 years ago. AH states that the onset of her nurse-client interaction is to aid
depression started after her husband died. Patient reports in mitigating the fatigue and
weakness that the patient is
!@#()*$*(&@&(*%*&((%UDepression
!@#()*$*(&@&(*%*&((%UDepression
care plan abigail harris.pdfhttps://www.stuvia.com/user/docstudent96https://www.stuvia.com/user/docstudent96
!@#()*$*(&@&(*%*&((%UDepression
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, !@#()*$*(&@&(*%*&((%UDepression
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!@#()*$*(&@&(*%*&((%UDepression
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3
occasionally drinking wine but has never smoked. AH also experiencing.
reports previously being involved with her church, where she The relevant patient history was
started a knitting group, and walking her dog frequently. obtained through a
However, as of late, patient has not had the energy or desire to combination of examining
participate in these activities. Patient lives with her son and his patient orders and conducting a
family, who serve as her primary caregiver. patient interview. Obtaining
this information is important as
it identifies comorbidities or risk
factors that could be relevant to
the patient’s case. Furthermore,
this information can help
identify areas that may require
further education to promote
well-being.
The social history was also
obtained by conducting a
patient interview. This is
important to include as it can
provide insight as to the
patient’s support network,
hobbies and interests, and
examine behaviors of the
patient related to physiological
and psychosocial conditions.
PATHOPHYSIOLOGY & Provide a summary of the primary - The primary disease that the patient is admitted with is As revealed in the Shadow
ETIOLOGY disease or condition the patient is Depression, which was diagnosed at 81 years of age. AH Health assignment, many
admitted with including currently takes medication, Venlafaxine, in order to help criteria that were outlined as
treat her depression. The depression screening tool defining characteristics of
defining characteristics
revealed a score of 16, indicating that AH is experiencing depression were observed in
moderate depression. the patient such as insomnia,
fatigue, increased need for
- The patient reports that she has been having difficulty
sleep, anhedonia, weight loss,
sleeping (insomnia) and has been having an increased need
and passive thoughts of suicide.
for sleep, has been feeling fatigued, has taken less interest These criteria are consistent
in pleasurable activities (anhedonia), has recently lost 9 lbs with the DSM 5. Though the
!@#()*$*(&@&(*%*&((%UDepression
!@#()*$*(&@&(*%*&((%UDepression
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