INTRODUCTION:

. As a part of Psychiatric Nursing Clinical Posting. we are posted at NIMHANS hospital

from 01-01-2010 to 31-3-2010.As a part of Clinical rotation I was posted in Pav- I Male

closed general ward and selected the patient name Mr.Gangayya for my case presentation.

He was been diagnosed as Depression and to provide basic nursing care according to

priority needs

PATIENT PROFILE
Name of patient : Mr. Gangayya
Age : 17 years
Date of Admission : 12/1/10
Marital Status : single
Ward : child psychiatry ward
I P no : 25698
Education : PUC
Occupation : Nill
Income :
Address : kuvempunagar, bangalore.
Religion : hindu
Socio Economic Status: middle class Group
Diagnosis : Depression

INFORMANT: Client’s mother is the informant. He is staying along with patient from birth
itself. He had good intellectual and observation ability. He had moderate degree of concern
regarding the patient.
PRESENTING CHIEF COMPLAINTS
According to patient he had no problem for admitting him.
According to informant, Fearfullness, Social withdrawal5 months, 2 attempts of suicide 5
month back, Decreased food intake, and Decreased speech output from 1 month,
Decreased food intake. Decreased sleep. (Sound sleep), Not going for class, this all are
occurring after the death of the childs father

HISTORY OF PRESENT ILLNESS

Patient was apparently normal 2 month back. When he doing a computer course in
her town, he had joined the course 7 month back after studying 10, there he fell in love a
girl, but after a few days she left the boy. After few days he was depressed and discontinued
the course and came back to the house. After coming to the house his father was sick and
was admitted in the hospital, there after few days his father expired in Victoria hospital. As
it was sudden attack Mr.Nateesh was not able to cope up with the failures of the situations
and got depressed, the child has attempted for suicide, has suicidal ideations

PAST PSYCHIATRIC & MEDICAL HISTORY

This is the first episode of illness to client. He had history of social withdrawal since 2
month and suicidal ideation before 1 month. He had no history of any major illness like
hypertension, endocrine problems, metabolic problems and any other communicable or
non communicable diseases.
TREATMENT HISTORY
No treatment history available because this is the first episode.
FAMILY HISTORY
Mr.Nateesh has a positive family history of mental illness. No other family history of
medical and psychiatric problems. He family is a nuclear family and all are maintaining
good IPR with each other. During this episode of illness he is withdrawn.
FAMILY TREE
------------------------

---------------

PERSONAL HISTORY:
Perinatal history
No history of any febrile illness, medications, drugs, alcohol use, trauma to abdomen
and any physical or psychiatric illness during pregnancy. He was a wanted child. No history
about breast feeding and weaning available. The delivery was normal vaginal delivery. He
had history of measles during prenatal period. He had no birth defects.
Childhood history
Patient was brought up by his mother and father. No history available regarding
breast feeding and weaning. No history of maternal deprivation. He had temper tantrum
during his childhood period.

Educational history
Completed 10 educations and now studying a computer course. He had good
relationship with peers and teachers. He had learning problems and now had hesitance go
college. He terminated his study because he was poor in studies and was in love with a girl
as she left the place, he also discontinued his education.
Play history: Client was very happy to engage in play. He had good relationship with peer
groups.

Sexual & Marital History: He had no gender identity disorder. No sexual fantasies.
Premorbid personality: Cyclothymic personality
Interpersonal relationship
i. He had good IPR with family members, friends and superiors. He was introverted.
Now he has less involvement with peer group and others due to withdrawn
behaviour.
ii. Use of leisure time: he had no specific hobbies and interest.
iii. Family life – Not interested in family life. He was prone to anxiety and poor reaction
to stressful life events.
iv. Habit – He had no habit of day dreaming. He had no specific food fads and habits.
Environmental history
House is tiled. Disposal of waste is through dumping and open drainage.

PHYSICAL & PHYSIOLOGIC ASSESSMENT

Vital Signs: Temperature – Normal
Pulse – 90/mt
Respiration – 20/mt
BP – 120/80 mm of Hg
General appearance:

State of nutrition – average

Personal appearance- good

Posture –straight

Emotional state- depressed

Skin and hair- child looks fair and hair is black

Head to toe examination
BODY PARTS OBSERVATION
Color is normal. Dry skin
Dry Texture. Good turgor, no edema and lesion
Skin Pink in color. Normal shape. Capillary refill good
Equal distribution of hair. No presence of alopecia and dandruff
Nails Normal Size
Hair & Scalp No puffiness, moon face etc
Head & Skull Normal visual and no double vision, ocular movements are not
Face normal. No infection & discharges.
Eye & vision No infections and discharge. Good hearing capacity. No ringing in the
ears. He had not using hearing aids.
Ears Had no frequent colds, no DNS and injury to nose or face
No halitosis, gum bleeding & hyperplasia, sore throat etc
Nose Good range of motion. No pain and neck rigidity. Ho thyroid
Mouth and throat enlargement.
Neck Normal size and shape.
Chest expansion is equal and symmetric
Thorax and chest Pale color. Soft and distended. No tenderness.
Abdomen Good range of motion. No complaints of pain and stiffness of joints.
Upper extremities No deformities. Good range of motion. No complaints of pain and
Lower extremities stiffness of joints.
No specific deformities or abnormalities found during physical
Interference examination. He had poor personal care and appearance. He was
worn shirts and 2 pants at a time during admission. No specific
medical disorders find out.

MENTAL STATUS EXAMINATION

General appearance
Facial expression – depressed
Posture – stiff
Mannerism – continuous picking up fingers and finger nails.
Dress – poor grooming
Hygiene – very poor
Motor disturbance: present (hypoactivity and negativism present. Sometime patient will
do exactly opposite when asking to do something)
Disorder of thought
A. Form of thought
a) Ambivalence present ( Patient is interacting effectively sometimes and then
he become very angry towards me)
B. Disorder of content of thought.
a) Delusion present - Persecution (Patient says “Somebody is trying to harm
me”)
b) Obsession – Present
c) Phobia – Present ( Fear of death)
d) Preoccupation – absent
e) Fantasy – absent
Remark - delusion of persecution and phobia present
Disorder of speech
1. Pressure of speech – decelerated
2. Flight of ideas – absent
3. Thought block – absent
4. Intensity – slow
5. Pitch – abnormal variation
6. Speech – decreased
7. Manner – inappropriate
8. Reaction time - slow
Disorder of perception
1. Illusion – absent
 2. Hallucination – present ( hearing voices and self talking)
Remarks – auditory hallucinations present
Disorder of affect
1. Affect – inappropriate
Subjective – Patient says “I am Happy”
Objective – facial expression reveals sadness
2. Pleasurable affect – absent. Depressed.
3. Un pleasurable affect – present
Remarks -in appropriate affect, depressed.
Disorder of memory
a. Immediate memory
Q: what you have for your breakfast?
A: Tea
b. Recent memory
Q: when did you slept during night?
A: Not answering (Looking sharply)
c. Remote memory
Q: Where did you studied?
A: Not Answering
Remarks: Patient is not responding, so it can not be assessed.
Disorder of orientation
a. Orientation to time
Q: what is the time now? (11:00AM)
A: afternoon
b. Orientation to place
Q: which place is this?
A: NIMHANS
c. Orientation to person
Q: who am I?
A: you are coming for disturbing me
Remark: Oriented to time, place and person
Insight
Q: How are you?
A: nothing. You are coming for disturb me?
Q: for what reason you came here?
A: I don’t know.
Remark: insight grade I.
Disorder of concentration
Q: Count from 100 to 10 by subtracting 10 to each
A: 100, 90, 91, 92, 93 …
Q: Count from 1 to 10
A: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12…
Remark: Concentration is impaired
Disorder of judgment
Q: what you will do when you are in a house on firing
A: Oh, I will look and see (laughing)
Remark: Judgment is impaired.
Intelligence
Q: Who is the president of India
A: I don’t know
Q: add 19 with 10
A: 29
Q: subtract 23 from 64
A: 41
Remark: Intelligence is intact.Abstract thinking
Proverb
Q: tell me the meaning of “barking dog seldom bite”
A: not responding (looking sharply)
Similarities
Q: what is the similarity between a table and a bed?
A: not responding (become angry)
Differences
 Q: what is the difference between a apple and orange
A: apple is soft and orange is juice
Remark: abstract thinking is not elicited effectively
Disorder of sleep
Present (complaints of reduced sleep since 1 week)
Summary: Eye to eye contact was developed from the beginning itself.
General remarks
Client had delusion of grandiosity and delusion of persecution. He also had disturbance in
speech, affect and thought. He is hyperactive, over talkative and easily become angry. He
had impaired concentration and abstract thinking. His orientation is not affected. He had
reduced sleep.
Diagnosis – depression.

INVESTIGATION:
SL TEST PATIENT VALUE NORMAL VALUE REMARKS
NO
1. B Glucose 76 mg/dl 60-10 mg/dl Normal
2. B. Urea 20 mg/dl 10-50 mg/dl Normal
3. B. Creatinine 0.7 mg/dl 0.3 – 1.2 MG/dl Normal
4. T. Bilirubin 0.3 mg/dl Less than 1 Normal
5. ALP 72 u/L 40-129 U/L Normal
6. SCIOT 22 gm/Dl 8-40 U/l Normal
7. Sodium 147 mcg/L 135-148 MCG/L Normal
8. Potassium 4.5 mcg/l 3.5-5.2 mcg/l Normal
9. Chloride 110 mcg/l 95-106 mcg/l Increased

PROCESS RECORDING
OBJECTIVES
1. To establish good rapport.
2. To identify signs and symptoms of illness.

Nurse’s response Patient’s response Inference

Verbal Nonverbal
Duration 15 mts

Client lying on bed

Hello, good morning Mr. Good morning Smiling Eye contact

Santhosh. developed.

How are you?

Fine. Sitting on bed.
Why are you lying in this bed Verbal
Oh, I will go later. Smiling
constantly? Just go to out side communication
of this ward. adequate
I don’t like this
Are you happy here? Eye contact.
place. Face became
Yes. Idly . tightened.
Oh, you just leave that. Did you
It was nice. Irritated
taken your breakfast? Smiling
Yes it was ok.
How was your sleep? Smiling
Ok. When did you slept 8 ‘o clock and waken happy
on morning 5 Smiling immediate and
yesterday?
o’clock. recent memory
Who all are your family intact.
Father, mother , one Smiling
members?
In which person you have more sister and brother.

preference?
My cute sister. Smiling
Did she have any children?
Happy.
 Yes. One son. Smiling Happy.
She will bring him in
my home. I will play
with him. He is very
cute and I like him Increased speed.
Raise hand
very much. He used Flight of ideas.
to call me as uncle.
He also likes me.
Doctor came for rounds and he
went by saying bye.

MEDICATION

SL DRUGS DOES FREQ/ ACTION SIDE EFFECTS

NO ROUT
1. TRSPN 4 mg Od/ Its antipsyxholic activity may be Somnolence,
oral medicated through a crtrapyramidal
combination of dopamine type 2 symptoms,
and serotonin type 2 antagonism. headache, insomnia,
agitation, anxiety.
2. T. 25 mg Od/ It is thoughto exert its Drowsiness,
Imipramin oral antidepressant effects by dizziness excitation,
inhibiting reuptale of tremor, confusion,
norepineaphrine and serotonin hallucination,
in CNS nerve terminals anxiety, ataxia,
paresthesia, EEG
changes.
Henderson’s Basic Needs
1. Breathe normally
2. Eat and drink adequately
3. Eliminate the body waste
4. Move and maintain
desirable positions
5. Sleep and rest
6. Maintain body
temperature
7.Select suitable clothing
Patient Picture
Mr. goutham breaths normally
Mr. goutham is not interested
in eating the food
Eliminates the body waste
Moves and maintains desirable
positions
Mr. goutham looks sleepless
and restless to the new
hospital environment.
The child is maintaining the
normal body temperature
Mr. goutham is able to select
Application of theory.
 Assess the likes and dislikes of the child
 Provide food in an attractive manner
 Advise the mother to provide food according to his likes
and dislikes
 Advise the mother to provide small and frequent diets
 Advise the child’s mother to provide food in an
attractive manner
 Advise the child’s mother to provides fruits and
vegetables to increase the body strength
-
 Provide orientation of the hospital.
 Provide warm milk at night.
 Provide warm bath at night
 Provide clean and calm environment
_
 the clothes and removes dress
and but do not know to wear.

8. Maintain bodily Is able to maintain cleanliness

cleanliness and grooming alone needs help and
assistance

9. Avoid dangers in the Mr. goutham d is conscious

environment about the dangers of the
environment

10. Communicate with others Mr. goutham is showing  Develop good rapport with the child
to express emotions, needs reaction towards  Use calm and soothening approach while caring the
fears or opinions hospitalization and she is child
scared of personnel with  Avoid speaking loudly, avoid shouting
apron.
NURSING DIAGNOSIS

1. High risk for self harm related to depressed mood, feelings of worthlessness,

anger turned inward to self.

2. Dysfunctional grieving related to real or perceived loss, bereavement over

loads.

3. Low self esteem related to learned helplessness, feelings of abandonment by

significant others.

4. Powerlessness related to dysfunctional grieving process, life style of

helplessness.

5. Spiritual distress related to dysfunctional grieving over loss of valued object.

6. Alteration in sleeping pattern related to suicidal thoughts

7. Alteration in nutrition less than body requirement related to loss of appetite.

ASSESSMENT NURSING GOAL PLANNING RATIONALE INTERVENTIONS EVA
DIAGNOSIS ATIO
SUBJECTIVE Risk for suicide Reduce the ---Ask Client directly “have ---The risk of suicide ---Client told that he Clien
DATA relaxed to risk of self you though about harming your is greatly increased doesn’t want to live, will
Client , told that he depressed mood, harm or self in any way? If so what do if the Client has because her life is harm
doesn’t want to feelings of injury. you plan to do? Do you have the developed a plan and useless and worthless. herse
live, because his worthlessness, means to carry out this plan? particularly it means
life is useless and anger turned in exist for the Client to
worthless. ward on the self. ---Create a safe environment for execute the plan. ---Created a safe
the Client. ---Client safely is a environment for the
OBJECTIVE nursing priority. Client.
DATA ---Formulate a short term verbal --- A degree of the ---A degree of the
Client looks very or written contract that the responsibility for his responsibility for his or
sad and depressive Client will not harm self. or her safety is given her safety is given to
mood. to client. client.
---Maintain a close observation ---Observation helps
---Maintained a close
of Client. to find out any
observation of Client.
suicidal behaviour.

---Involvement in ---Encourage the client

---Encourage the client to interaction helps to to become involved
SUBJECTIVE Low self esteem Improve the become involved with staff and build self-esteem. with staff and other
DATA related learned Client’s self other clients in the therapy clients
Patient says that he helplessness, esteem. through interactions and ---Give the Client
is separated from feeling of completion of responsibilities. ---Positive feedback positive feed back for
his parents because abandonment by ---Give the Client positive feed helps to identify completion of
of illness and feels significant others. back for completion of responsibilities.
depressed. He says responsibilities. meaning in behaviour. ---Teach assertiveness
that his and communication
 ---Encourage Client to recognize ---it will helps for technique. Clien
relatives make fun areas to change and provide effective interaction. ---Promote attendances will
of him and feels assistances towards these in therapy groups that able
shame to stay in the efforts. ---it is a form of offer Client simple attem
hospital. He says ---Teach assertiveness and reinforcement for the methods of new
that he needs others communication technique. client. accomplishment. activ
help. ---Promote attendances in witho
therapy groups that offer Client fear
Objective data. simple methods of ---Assessed stages of failu
Client is not doing accomplishment. fixation in grief
activities in a process. (2nd stage)
normal pattern.

---Accurate baseline
Subjective data Improve the ---Assess stages of fixation in data is required in ---Developed trust, Clien
Dysfunctional
Client says “ god is Client’s grief process. order to plan accurate showed empathy will
grieving related to
cheating me” functional care. concern and able
real or perceived
abilities and ----Developing trust unconditional positive verba
loss, overloads.
Subjective data: should ---Develop trust, show empathy provide the basic for regard. norm
The Client told, that behave concern and unconditional therapeutic ---Helped the client beha
she is not interested normality. positive regard. relationships. with honest review of assoc
in eating food. ---Only when the relationship with lost d wit
---Help Client with honest Client is able to see object. griev
review of relationship with lost both positive and and b
object. negative aspects prog
related to the lost on
objects. resol
---Teach normal behavior ---To develop the n.
associated with grieving. positive attitude.
 Clien
will
Subjective data ---Providing Client ---Taught the normal able
Client , told that he Improve the ---Allow Client in participate in with choices will behavior associated solve
doesn’t want to Powerlessness Client’s goal setting and decision increase the feelings with grieving. prob
live, because her related to problem making regarding own care. of control. to tak
life is useless and dysfunctional solving ---Ensure the goals are realistic --- Realistic goals will ---Allowed the client in contr
worthless. grieving process abilities. and the Client is able to identify avoid setting Client up participate in goal life
life style of areas of life situation that are for further failure. setting and decision situa
Objective data helplessness. realistically under control --- It may help Client making regarding own .
Client looks very ---- Encourage Client to to accept what cannot care.
sad and depressive verbalize feelings about areas be changed. ---Ensured the goals
mood. that are not within her ability to --- To promote trust in are realistic
control. relationship.
---Be accepting and non-
judgmental when Client express
anger and bitterness toward god,
stay with Client.

Subjective data Reduce ---Encourage the client to ---Catharsis can Clien

Client , told that he client’s ventilate feelings related to provide relief and put will
doesn’t want to spiritual meaning of own existence in the life back into realistic expre
live, because his distress. face of current. perspective. achie
Spiritual distress
life is useless and ---Ensure the client that he or ---increases spiritual ent o
related to
worthless. she is not alone when feeling well being. supp
dysfunctional
inadequate in the search of life’s ---Encouraged the and
grieving over loss
Objective data of valued object. answer. client to ventilate perso
Client looks very feelings related to satisf
sad and depressive ---Provide food in a small meaning of own on fr
mood. quantity and at a time but existence in the face of spirit
frequently. current. pract
---Ensured the client
that he or she is not
alone when feeling
inadequate in the
search of life’s answer.

Subjective data:
Client says “I am
feeling not well. I Alteration in Maintain the ---Ask choice of food and serve increase digestion and ---Provided food in a The
have fatigue and nutrition less than Client’s in an attractive manner. palatability. small quantity and at a quan
not able to do any body requirement nutritional ---Serve food when every one is time but frequently. of fo
thing”. related to loss of and fluid eating. ---serving in attractive ---Served food when intak
Objective data: appetite. status. ---Be with the patient when he is manner improve every one is eating. impr
Look weak eating food. attitude. ---Be with the patient
Poor food intake ---Talk about his success and when he was eating
Dry mouth and good behavior while the patient ---to ensure whether food.
tongue. is eating. client is taken food. ---Told about his
---Pursue the patient to eat full ---improve self success and good
meal. esteem. behavior while the
---Give plenty of fluids and
roughage, green leafy
vegetables and salad.
patient is eating.
---to ensure ---Pursue the patient to
recommended daily eat full meal.
intake. ---Given plenty of
---To maintain fluids and roughage,
nutritional status. green leafy vegetables
and salad
PSYCHO EDUCATION & REHABILITATION

Explained the patient regarding various measures to do at home

DIET

 Explained him about the importance of balanced diet & explained to him about the
diet pattern which should be followed
 Explained to his relatives to give diet according to the choice of the patient and if
he is unable to take food help him to eat

DRUG

 Explain to him and to his family members regarding the importance of drug therapy
 Explained to the relatives about the drug how often it should be given and about the
action of each drug
 Explain to him and to his relatives not to stop the drug without the prescription of
doctor and to continue drug as prescribed by doctors.

FAMILY SUPPORT

 Explain to family members about the king of illness the patient is suffering from and
about his social productive abilities
 Educate the relatives to persuade the patient to maintain his personal hygiene, take
diet, participate in daily care activities and to accept the treatment
 Explain about the types of jobs the client can perform
 Encouraged the relatives to keep supportive the patient and not to over protect and
show rejection towards patient

SOCIALIZATION

 Encourage him to go day care center and to interact with others

 Allowed him to sit with others and encouraged him to talk to neighbor patients
 Encourage his good performance in the group
 Encourage him to spend more time with others
FOLLOW UP

Explain to the patient that the disease can’t be cured completely. Only we have to control
this. So you must continue drugs as prescribed by doctor and come for follow up regularly
as prescribed by doctor.