INTRODUCTION: . As a part of Psychiatric Nursing Clinical Posting.

we are posted at NIMHANS hospital

from 01-10-2010 to 31-10-2010.As a part of Clinical rotation I was posted in Pav- I Male closed general ward and selected the patient name Mr. goutham 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 Age Date of Admission Marital Status : Ward I P no Education Occupation Income Address Religion : : : : : : kuvempunagar, Bangalore. Hindu middle class Group Depression : : : : Mr. goutham 17 years 12/1/10 single child psychiatry ward 25698 PUC Nil

Socio Economic Status: Diagnosis :

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, Fearfulness, 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 child s 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.Goutham 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.Goutham 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 ------------------------

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PERSONAL HISTORY: Prenatal 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 He Completed SSLC 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: Cyclothymiacs 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 behavior. ii. iii. Use of leisure time: he had no specific hobbies and interest. 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 Hair & Scalp Head & Skull Face Eye & vision Normal Size No puffiness, moon face etc Normal visual and no double vision, ocular movements are not normal. No infection & discharges. 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 Mouth and throat Neck Good range of motion. No pain and neck rigidity. Ho thyroid enlargement. Normal size and shape. Chest expansion is equal and symmetric Thorax and chest Abdomen Upper extremities Lower extremities Pale color. Soft and distended. No tenderness. Good range of motion. No complaints of pain and stiffness of joints. No deformities. Good range of motion. No complaints of pain and 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 (hypo activity 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 2. Flight of ideas 3. Thought block 4. Intensity 5. Pitch 6. Speech 7. Manner 8. Reaction time decelerated absent absent slow abnormal variation decreased inappropriate 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 cannot 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 NO 1. 2. 3. 4. 5. 6. 7. 8. 9. B Glucose B. Urea B. Creatinine T. Bilirubin ALP SCIOT Sodium Potassium Chloride 76 mg/dl 20 mg/dl 0.7 mg/dl 0.3 mg/dl 72 u/L 22 gm/Dl 147 mcg/L 4.5 mcg/l 110 mcg/l 60-10 mg/dl 10-50 mg/dl 0.3 1.2 MG/dl Less than 1 40-129 U/L 8-40 U/l 135-148 MCG/L 3.5-5.2 mcg/l 95-106 mcg/l Normal Normal Normal Normal Normal Normal Normal Normal Increased TEST PATIENT VALUE NORMAL VALUE REMARKS

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

Nurse s response

Patient s response Verbal Nonverbal

Inference

Duration 15 mts Client lying on bed Hello, good morning Mr. Santhosh. How are you? Why are you lying in this bed constantly? Just go to out side of this ward. Are you happy here? I don t like this place. Yes. Idly . Oh, you just leave that. Did you taken your breakfast? How was your sleep? Ok. When did you slept yesterday? 8 o clock and waken on morning 5 o clock. Who all are your family members? In which person you have more Father, mother , one sister and brother. Smiling Smiling It was nice. Yes it was ok. Smiling happy immediate and recent memory intact. Face became tightened. Smiling Irritated Fine. Oh, I will go later. Sitting on bed. Smiling Verbal communication adequate Eye contact. Good morning Smiling Eye contact developed.

preference? Did she have any children?

My cute sister.

Smiling Happy. Happy.

Yes. One son. She will bring him in my home. I will play with him. He is very cute and I like him very much. He used to call me as uncle. Doctor came for rounds and he went by saying bye. He also likes me.

Smiling

Raise hand

Increased speed. Flight of ideas.

MEDICATION

SL NO 1.

DRUGS

DOES

FREQ/ ROUT

ACTION

SIDE EFFECTS

TRSPN

4 mg

Od/ora Its antipsychotic activity may be l medicated through a combination of dopamine type 2 and serotonin type 2 antagonisms.

Somnolence, crtrapyramidal symptoms, headache, insomnia, agitation, anxiety. Drowsiness, dizziness excitation, tremor, confusion, hallucination, anxiety, ataxia, paresthesia, EEG changes.

2.

T. Imipramin e

25 mg

Od/ora It is thought exert its l antidepressant effects by inhibiting reuptake of norepineaphrine and serotonin in CNS nerve terminals

Henderson s Basic Needs 1. Breathe normally

Patient Picture Mr. goutham breaths normally

Application of theory.

2. Eat and drink adequately

Mr. goutham is not interested in eating the food

y y y y y y

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

3. Eliminate the body waste 4. Move and maintain desirable positions 5. Sleep and rest

Eliminates the body waste Moves and maintains desirable positions Mr. goutham looks sleepless and restless to the new hospital environment. y y y y -

Provide orientation of the hospital. Provide warm milk at night. Provide warm bath at night Provide clean and calm environment

6. Maintain body temperature

The child is maintaining the normal body temperature

7.Select suitable clothing

Mr. goutham is able to select the clothes and removes dress and but do not know to wear. Is able to maintain cleanliness alone needs help and assistance Mr. goutham d is conscious about the dangers of the environment y y y

8. Maintain bodily cleanliness and grooming

9. Avoid dangers in the environment

10. Communicate with others Mr. goutham is showing to express emotions, needs reaction towards fears or opinions hospitalization and she is scared of personnel with apron.

Develop good rapport with the child Use calm and soothening approach while caring the child Avoid speaking loudly, avoid shouting

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 SUBJECTIVE DATA Client , told that he doesnt want to live, because his life is useless and worthless. OBJECTIVE DATA Client looks very sad and depressive mood.

NURSING DIAGNOSIS Risk for suicide relaxed to depressed mood, feelings of worthlessness, anger turned in ward on the self.

GOAL Reduce the risk of self harm or injury.

PLANNING ---Ask Client directly have you though about harming your self in any way? If so what do you plan to do? Do you have the means to carry out this plan? ---Create a safe environment for the Client. ---Formulate a short term verbal or written contract that the Client will not harm self. ---Maintain a close observation of Client.

RATIONALE ---The risk of suicide is greatly increased if the Client has developed a plan and particularly it means exist for the Client to execute the plan. ---Client safely is a nursing priority. --- A degree of the responsibility for his or her safety is given to client. ---Observation helps to find out any suicidal behavior. ---Involvement in interaction helps to build self-esteem.

INTERVENTIONS ---Client told that he doesnt want to live, because her life is useless and worthless.

EVALU ATION Client will not harm herself.

---Created a safe environment for the Client. ---A degree of the responsibility for his or her safety is given to client. ---Maintained a close observation of Client. ---Encourage the client to become involved with staff and other clients ---Give the Client positive feed back for completion of responsibilities. ---Teach assertiveness and communication

SUBJECTIVE DATA Patient says that he is separated from his parents because of illness and feels depressed. He says that his

Low self esteem related learned helplessness, feeling of abandonment by significant others.

Improve the Clients self esteem.

---Encourage the client to become involved with staff and other clients in the therapy through interactions and completion of responsibilities. ---Give the Client positive feed back for completion of responsibilities.

---Positive feedback helps to identify meaning in behavior.

relatives make fun of him and feels shame to stay in the hospital. He says that he needs others help. Objective data. Client is not doing activities in a normal pattern.

---Encourage Client to recognize areas to change and provide assistances towards these efforts. ---Teach assertiveness and communication technique. ---Promote attendances in therapy groups that offer Client simple methods of accomplishment.

---it will helps for effective interaction. ---it is a form of reinforcement for the client.

technique. ---Promote attendances in therapy groups that offer Client simple methods of accomplishment.

---Assessed stages of fixation in grief process. (2nd stage)

Client will be able to attempts new activities without fear of failure.

Subjective data Client says god is cheating me

Improve the Dysfunctional Clients grieving related to functional real or perceived abilities and loss, overloads. should Subjective data: The Client told, that behave she is not interested normality. in eating food.

---Assess stages of fixation in grief process.

---Develop trust, show empathy concern and unconditional positive regard. ---Help Client with honest review of relationship with lost object.

---Teach normal behavior associated with grieving.

---Accurate baseline data is required in order to plan accurate care. ----Developing trust provide the basic for therapeutic relationships. ---Only when the Client is able to see both positive and negative aspects related to the lost objects. ---To develop the positive attitude.

---Developed trust, showed empathy concern and unconditional positive regard. ---Helped the client with honest review of relationship with lost object.

Client will be able to verbalize normal behavior associate d with grieving and begin progressi on resolutio n.

Subjective data Client , told that he doesnt want to live, because her life is useless and worthless. Objective data Client looks very sad and depressive mood.

Powerlessness related to dysfunctional grieving process life style of helplessness.

Improve the Clients problem solving abilities.

---Allow Client in participate in goal setting and decision making regarding own care. ---Ensure the goals are realistic and the Client is able to identify areas of life situation that are realistically under control ---- Encourage Client to verbalize feelings about areas that are not within her ability to control. ---Be accepting and nonjudgmental when Client express anger and bitterness toward god, stay with Client.

Client will be ---Providing Client ---Taught the normal able to with choices will behavior associated solve increase the feelings with grieving. problems of control. to take --- Realistic goals will ---Allowed the client in control of avoid setting Client up participate in goal life for further failure. setting and decision situations --- It may help Client making regarding own . to accept what cannot care. be changed. ---Ensured the goals --- To promote trust in are realistic relationship.

Subjective data Client , told that he doesnt want to live, because his life is useless and worthless.

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

Reduce clients spiritual distress.

---Encourage the client to ventilate feelings related to meaning of own existence in the face of current. ---Ensure the client that he or she is not alone when feeling inadequate in the search of lifes

---Catharsis can provide relief and put life back into realistic perspective. ---increases spiritual well being. ---Encouraged the

Client will express achievem ent of support and

Objective data Client looks very sad and depressive mood.

answer. ---Provide food in a small quantity and at a time but frequently.

client to ventilate feelings related to meaning of own existence in the face of current. ---Ensured the client that he or she is not alone when feeling inadequate in the search of lifes answer.

personal satisfacti on from spiritual practices.

Subjective data: Client says I am feeling not well. I have fatigue and not able to do any thing. Objective data: Look weak Poor food intake Dry mouth and tongue.

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

Maintain the Clients nutritional and fluid status.

---Ask choice of food and serve in an attractive manner. ---Serve food when every one is eating. ---Be with the patient when he is eating food. ---Talk about his success and good behavior while the patient is eating. ---Pursue the patient to eat full meal.

increase digestion and palatability. ---serving in attractive manner improve attitude. ---to ensure whether client is taken food. ---improve self esteem.

---Provided food in a small quantity and at a time but frequently. ---Served food when every one is eating. ---Be with the patient when he was eating food. ---Told about his success and good behavior while the

The quantity of food intake improved

---Give plenty of fluids and roughage, green leafy vegetables and salad.

---to ensure recommended daily intake. ---To maintain nutritional status.

patient is eating. ---Pursue the patient to eat full meal. ---Given plenty of fluids and roughage, 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.