Patient L.D.

Depression 1

Patient L.D. Depression

Megan M. Baril

Youngstown State University Nursing

Fall 2020
Patient L.D. Depression 2

Abstract

L.D. presents with Depression and Anxiety with a suicide attempt that brought them into the

hospital. The case study entails exploring what events brought the patient here along with

genealogical factors and predispositions that may have attributed as well. Different types of

personality disorders may fit the patient and could possibly be explored in the future as L.D.

continues to delve into their mental health and healing themselves. The importance of discharge

planning and continuity of care is evident in most mental health cases due to non-compliance

issues in those who present with different diagnoses. Goal making and outcome evaluations are

also very important to nurse and client alike to ensure positive personal mental health results and

compliance with medicines and treatments. Medicinal management is paramount in depression

cases due to the amount of time it takes for the therapeutic effects to kick in. Continuity of care

and keeping mental health a priority is crucial to getting better and dealing with your diagnosis

positively.

Keywords: Depression, Medical Management, Suicidal Ideations, Family, Cluster B,

Planning, Continuity of Care.

Patient L.D. Depression 3

Patient L.D. Depression

The patient L.D. presented to the emergency department with an overdose of Tylenol

after having relationship problems with their significant other which lead to their questioning

their future all together. L.D. is on the psych floor to get help through their crisis and is

enthusiastic about getting better and about their future including learning more about their

mental health and how to better handle it down the road. Discussing in this paper the patient’s

past psychological issues and mental health stays while also taking in their current mental state

and precipitating events we will look into possible diagnoses that may fit L.D. in the future as

their mental health unfolds.

Objective Data

L.D. presented to the emergency department on the fourth of October, two days prior to

their admission to the psychiatric floor on the sixth of October. Some laboratory tests the

emergency department ran on them on admission were acetaminophen levels, an

electrocardiogram, Albumin levels, White blood cell levels, Red blood cell levels, Thyroid

hormone levels, AST and ALTs. Of those, one of the more concerning results was the initial

acetaminophen level being 191.6 as opposed to a normal of less than 2.0. This was to be

expected though, as they had taken a bottle of Tylenol prior to arrival. The medical team treated

their Tylenol overdose with Acetylcysteine, which is the antidote to acetaminophen. Before their

admission they had already had a psychiatric diagnosis of Depression relating to their first

suicide attempt at 14 years old in their freshman year of high school. Another psychiatric

diagnosis fitted to this patient was Suicidal Ideation as they had tried to overdose on Tylenol

before coming to the hospital for treatment, and they had mentioned to the interviewers on the

date of care of their mental state on the day of the stressful event. Some safety and security
Patient L.D. Depression 4

measures maintained on the date of care were patient self-harm regulations such as no sharps on

the general floor, no shoelaces and no access to outside medications or drugs. Another safety

measure was unit restrictions to be sure that no patient is getting out that needs help and that no

person is allowed onto the unit that does not need to be there and could be a hinderance to

bettering the health of those who are there for acute treatment. The patient was being prescribed

with a wide array of PRNs including Tylenol, Haldol, Vistaril, Motrin, Trazadone, and Atarax on

the date of care, all of which help with many different items relating to their diagnosis. The

Tylenol and Motrin are used for pain relating to their physical condition and condition related to

their depression diagnosis. The signs and symptoms of depression and anxiety are treated with

Vistaril, Trazadone and Atarax with the Trazadone being used as a sleep aid to help them get to

sleep in an unfamiliar place with unexpected outcomes each day. Haldol can be used to treat

extreme moods or psychosis that some patients face when in the hospital and calms them down

when needed. All of these different medications are used in sync to promote positive mental

health and a stable condition to further their therapeutical treatments both mentally and

medicinally.

Summarize the psychiatric diagnoses

The criteria for a Major Depressive Disorder diagnosis, according to the DSM-5 is to

have five or more of the following symptoms within the same two week time period and must be

abnormal from their baseline health (American Psychiatric Association, 2013). Meaning that it

takes a lot of different signs and symptoms to be diagnosed with Major Depressive Disorder as

opposed to it just having a depressed mood or lack of energy. Of those signs and symptoms, one

should be either a depressed mood or anhedonia while there are secondary symptoms including

appetite or weight changes, sleep difficulties, psychomotor agitation or slowing, fatigue or loss
Patient L.D. Depression 5

of energy, lowered ability to concentrate or think, feelings of hopelessness, worthlessness or

excessive guilt and suicidality (Tolentino 2018). Taking all of these symptoms into mind, L.D’s

diagnosis is very serious and heavy for someone of their young age, in a very uneasy time in

their life. Suicidal Ideation is not to be taken lightly in psych patients, especially in L.D. as they

have recently had a suicide attempt and has had a past history involving suicidal ideation and

tendencies. Their suicidal ideation can be directly related to their Major Depressive Disorder

diagnosis, “severe depression was found to be linked to increased suicidality, highlighting the

importance of needing clear markers of severe depression for clinicians to identify the patients

are at risk for committing suicide” (Tolentino 2018). This just outlines the convoluted linking of

different psychiatric diagnoses and how one is often linked to another and that it can be difficult

to distinguish between each one, and to decide what factors are contributed from each one.

Identify the Stressors and Behaviors

Prior to coming into the hospital a few stressful events lead the patient to where they

ended up. A major stressor was that the patient and their significant other got into a fight at their

house which ended up with their significant other telling them that maybe they should move out

for a while and they should take a break. The patient described this as “losing their world” as

they moved to Akron with their significant other and had a job and few friends out there to lean

on. It seemed that L.D. put a lot of their mental capacity towards their relationship so once that is

at risk, their entire way of living is at risk. This may be an indicator at some other underlying

diagnoses that need to be discovered such as a personality disorder, possibly Cluster B. This is

brought up because they show a bit of histrionic and borderline with the way they described their

relationships with their family and significant other. This will be discussed more in depth in the

family history as there is an extensive one that may contribute to the patient’s current mental
Patient L.D. Depression 6

state. Continuing on with precipitating factors, they were staying with their family member when

they all of the sudden in the middle of the night needed to speak with their significant other but

they did not answer, so L.D. got in their car and began to drive there before deciding that it was

too far of a drive so they pulled over in a gas station and bought the pills that they took before

coming to the hospital. After L.D. took around thirteen to eighteen Tylenol they called their

significant other one more time and they answered and then told the patient to go to the hospital.

This also hints at a bit of histrionic personality disorder because it seems like all they wanted was

the attention of their significant other leading to take an extreme risk to do so. It can be believed

that having a lack of outside sources for support could have attributed to this hospitalization, as

the patient had all of their social leads attached to their relationship with their significant other as

opposed to reaching out to supportive friends or family more frequently to balance out their

support system.

Discuss Patient and Family History of Mental Illness

This patient has a significant personal and familial history related to mental illness both

linked to depression and suicidal ideation. The patient reported that their mother had struggled

with depression growing up and that they could see that whilst they were growing up as well,

seeing their mother struggle with her emotions. Another significant player in L.D.’s

psychological health would be their father who has a history of suicidal ideations as well as past

suicide attempts. L.D’s parents are a direct familial attachment to their diagnosis of Depression

because of their own diagnoses along with the relationships in the house and behaviors exhibited

by their parents. Growing up the patient’s father abused their mother and is even going to prison

soon for domestic assault according to the patient. All of the familial cases can be seen to

attribute something to the patient’s psychological health, “Persons with higher FLS (familial
Patient L.D. Depression 7

loading score) had higher PRS (polygenic risk score) for major depression, more severe

depression and anxiety symptoms, higher disease burden, younger age of onset, and more

neuroticism, rumination, and childhood trauma”, showing that there is a direct correlation

between L.D.’s parent’s diagnoses and theirs (Sprang 2020). There could possibly be some

cluster B within the father, being narcissistic or antisocial which could be evidenced by the abuse

and the jail sentence to be carried out. The family history of mental illness in L.D’s family is

very prevalent in their psychiatric health in that there could be some genealogic factors at play

along with learned behaviors that were seen while growing up in a home with these two

individuals.

Describe the Psychiatric Evidence Based Nursing Care Provided

One of the nursing care practices provided to L.D. as well as all of the other patients is

group therapy sessions that are held on the floor all throughout the day. “Other empirically-

supported psychotherapies for depression include psychodynamic therapy, problem-solving

therapy and acceptance and commitment therapy in individual and group formats” (Voytenko

2018). A positive way to reach out to those who need counseling is all at once and together. This

way people will have a chance to listen to others struggling with similar things that they are, or

they can gain positive coping mechanisms that other people may have that they do not. Having a

sense of camaraderie when it comes to something as sensitive as your mental health can help

someone come to terms with the fact that they do have a mental illness but that it is acceptable

and that they need to know when to get help and what help to get when they do have a need for

it. Another evidence based nursing care example provided is strict and a steady flow of meds to

control their mood. L.D. needs to have their mood stable in order to progress in their mental

health and gain the different resources and help that they need to ensure that they know who to
Patient L.D. Depression 8

reach out to in the future or to be able to help themselves in their time of need if it is needed as

such.

Analyze Ethnic, Spiritual and Cultural Influences

L.D. confided in us (the interviewers) that after their first suicide attempt that they

became quite religious and would attend church services. They claimed that God helped them

feel at peace and loved when they did not feel it from those around them or even from

themselves. But, recently because of the move, L.D. has not gone to church in quite some time

but would like to get back into it as it was a major stabilization column in their life. There really

are not any ethnic or cultural influences on their psychological health beside the point that many

people around where they are from do not talk about mental health. The patient talked about that

a student they went to school with had committed suicide around the time that they had

attempted their life and how that event made them think about how they did not want to be like

him. L.D. realized that no one around there talked about their mental health until it was too late

and someone was lost, which is very common within the culture where they are from. Mental

health is something that is taboo or just not really talked about when it definitely should be,

ending the stigma is very difficult but slowly and surely more and more people are asking the

uncomfortable questions and checking in on each other as they should be to ensure the safety of

themselves and others. The cultural response around where they are from to mental health is one

of shame and guilt, people suffer alone until something happens that brings them to the edge

such as a crisis.

Evaluate the Patient Outcomes

The outcomes for this patient would be to reduce the risk of suicidal ideation or suicidal

attempts as well as maintaining a stable environment to promote positive mental health. Another
Patient L.D. Depression 9

outcome would be for the patient to be able to list and describe resources out of the hospital to

turn to if their mental health begins to decline and they need help such as but not limited to

shelters, AA meetings, Suicide hotline number, personal support persons (mother, family,

friends) or a counselor or therapist. One more outcome would be for the patient to attend normal

counseling or see a therapist as often as possible to work out other mental health issues that may

be underlying, or even just to have some stability in their life as being a college age individual

can be stressful and can be unpredictable. To evaluate these further, one would need to check in

on the patient routinely to see if they are following through with these goals. But, to evaluate the

safety in the hospital would be to be without an incident whilst the patient is admitted. Another

goal within their stay would be to routinely take their meds and attend group therapy meetings in

order to make the best of their stay and promote healthy mental standards. Getting into a

regiment whilst in the hospital is better because that will help the patient to familiarize

themselves with the medical management of their disease and give them the chance to ask

questions about their care as needed. Inpatient outcomes can be a good visualizer of how

outpatient outcomes can turn out, especially if the patient is encouraged to play a role in their

health plan.

Summarize Discharge Plans

While we may not have been there for the patient’s discharge or discharge planning there

would be similar standards to adhere by. One of which would be to have a discharge plan such as

what they plan to do right when they get out, ranging to what they plan to have done six months

from now. Maybe they plan on attending counseling sessions or therapy each week or to do self-

evaluations every week for their depression and anxiety. Making a plan with the patient before

they leave is especially important because it gives them something to lean back on once they
Patient L.D. Depression 10

leave, giving them a sense of security and assurance that they can do it! Having the confidence to

do something makes it so much easier to do it, it is half of the mental battle. Maintaining a

positive head space after discharge is important because so many people are readmitted after

thirty days because they just fall off, it is so easy to do so if one does not have the drive or

energy to do what they want to do. L.D.’s discharge plan would generally be to attend

counseling, know when to get help and where to get it and to keep up with new medicines. Being

compliant with medicine is so important with depression because it can take a few weeks for the

pharmacological effects to take place, so many will just stop taking them before they have a

chance to work. But they must also be cautious within the first few weeks because suicidal

thoughts and tendencies may still be present and another attempt may be made due to an increase

in energy but not in mood. It is important for those around the patient to monitor them closely for

any alarming signs or symptoms.

Prioritized List of all Actual Diagnoses

There are definitely many nursing diagnoses that apply to Depression, but here are actual

ones (imminent problems already happening):

Self-neglect related to depression and cognitive impairment as evidenced by

nonadherence to health activities.

Death anxiety related to feelings of lack of self-worth as evidenced by reports deep

sadness

Social Isolation related to ineffective coping as evidenced by absence of supportive

significant other(s)

Chronic sorrow related to unresolved grief as evidenced by reports feelings of sadness

Fatigue related to physiological demands as evidenced by lack of energy

Patient L.D. Depression 11

List of Potential Nursing Diagnoses

There are also many nursing diagnoses that may not be currently happening, but pose a

major risk:

Risk for suicide related to grieving and hopelessness r/t disrupted family life as evidenced

by vocalization of concerns

Risk for self-mutilation related to disturbed interpersonal relationships as evidenced by

vocalization of concerns

Risk for complicated grieving related to lack of previous resolution of former grieving

response as evidenced by decreased sense of wellbeing.

Conclusion

In summation, L.D. is a young individual who needs some help getting their life on track

as well as dealing with underlying mental health issues both through both medicinal routes and

counseling or therapy. Having a lack of support at this time in their life alongside having a

pivotal fight with their only support person on hand, caused the patient to go into a crisis and

attempt to take their own life. The way they went about trying to take their life and the events

preceding it make one wonder whether or not they have some other underlying personality

diagnoses that may pop back up later on in life as crises come and go. This underlying disorder

may be cluster B personality disorder which has been evidenced by seeking attention and falling

very deeply “in love” very quickly, while it may just truly be a shallow relationship that they

build up in their head. The couple had just began dating earlier this year but already lives

together away from where they are normally from. A lot of factors had to do with the patient’s

crisis but the nurses helping them utilized psychiatric evidence based nursing care to provide for
Patient L.D. Depression 12

L.D. and focusing on discharge goals and medical management will positively impact their

disease process and provide them with the tools to do right by themselves and their mental

health.
Patient L.D. Depression 13

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Arlington, VA

Sprang, E. D., Maciejewski, D. F., Milaneschi, Y., Elzinga, B. M., Beekman, A. T., Hartman, C.
A., . . . Penninx, B. W. (2020). Familial risk for depressive and anxiety disorders:
Associations with genetic, clinical, and psychosocial vulnerabilities. Psychological
Medicine, 1-11. doi:10.1017/s0033291720002299
https://www.cambridge.org/core/services/aop-cambridge-
core/content/view/E48CB3FAAF084061C759CB440D2E8398/S0033291720002299a.pdf/
familial_risk_for_depressive_and_anxiety_disorders_associations_with_genetic_clinical_a
nd_psychosocial_vulnerabilities.pdf

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 Criteria and Depression Severity: Implications
for Clinical Practice. Frontiers in Psychiatry, 9. doi:10.3389/fpsyt.2018.00450
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6176119/

Videbeck, S. L., & Videbeck, S. L. (2014). Psychiatric-mental health nursing. 6th edition.
Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Voytenko, V., Nykamp, L., Achtyes, E., Stoyanov, R., Anderson, K., Thomas, S., . . .
Wyngarden, N. (2018). Evidence-based practice guideline for the treatment of adult
patients with depressive disorders. Part I: Psychiatric management. Psychiatr Psychol Klin,
18(3), 234-241. http://psjd.icm.edu.pl/psjd/element/bwmeta1.element.psjd-d4733664-46f4-
4868-90b8-aa96ec73eae7
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Case Study Comment Sheet 4842

Student Name_____________________________________

Pt Identifier______________

Date(s) of Care_____________

__________ Objective Data presentation the patient, treatments, medications

_ _________ Discuss patient / family history of mental illness

___________ Identify stressors and behaviors that precipitated current hospitalization

___________ Summarize the psychiatric nursing interventions with rationales

___________ Evaluate patient outcomes for nursing care provided

___________ Analyze ethnic, spiritual and cultural influences that impact care of the patient

__________ Summarize discharge plans and community care

__________ Actual nursing diagnoses, prioritized, using R/T and a.e.b.

___________ List of potential nursing diagnoses

___________ Conclusion paragraph

____________ Style, spelling, grammar, clarity, organization, APA format

Patient L.D. Depression 15
Patient L.D. Depression 16