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INTRODUCTION (Discuss about your patients case)

Throughout the course of our lives, we all experience episodes of stress, unhappiness, sadness, or grief. Often, when a loved one dies or we suffer a personal tragedy or difficulty such as divorce or loss of a job, we may feel depressed (some people call this "the blues"). Most of us are able to cope with these and other types of stressful events. Over a period of days or weeks, the majority of us are able to return to our normal activities. But when these feelings of sadness and other symptoms make it hard for us to get through the day, and when the symptoms last for more than a couple of weeks in a row, we may have what is called "clinical depression." The term clinical depression is usually used to distinguish the illness of depression from less difficult feelings of sadness, gloom, or the blues. Clinical depression is not just grief or feeling sad. It is an illness that can challenge your ability to perform even routine daily activities. At its worst, depression may lead you to contemplate, attempt, or commit suicide. Depression represents a burden for both you and your family. Sometimes that burden can seem overwhelming. There are several different types of clinical depression (mood disorders that include depressive symptoms):

Major depression is an episode of change in mood that lasts for weeks or months. It is one of the most severe types of depression. It usually involves a low or irritable mood and/or a loss of interest or pleasure in usual activities. It interferes with one's normal functioning and often includes physical symptoms. A person may experience only one episode of major depressive disorder, but often there are repeated episodes over an individual's lifetime. Dysthymia, often commonly called melancholy, is less severe than major depression but usually goes on for a longer period, often several years. There are usually periods of feeling fairly normal between episodes of low mood. The symptoms usually do not completely disrupt one's normal activities. Bipolar disorder involves episodes of depression, usually severe, alternating with episodes of extreme elation called mania. This condition is sometimes called by its older name, manic depression. The depression that is associated with bipolar disorder is often referred to as bipolar depression. When depression is not associated with bipolar disorder, it is called unipolar depression. Seasonal depression, which medical professionals call seasonal affective disorder, or SAD, is depression that occurs only at a certain time of the year, usually winter, when the number of daylight hours is lower. It is sometimes called "winter blues." Although it is predictable, it can be very severe. Psychotic depression refers to the situation when depression and hallucinations or delusions are experienced at the same time (co-occur). This may be the result of depression that becomes so severe that it results in the sufferer losing touch with reality. Individuals who primarily suffer from a loss of touch with reality (for example, schizophrenia) are thought to suffer from an imbalance of dopamine activity in the brain and to be at risk of subsequently becoming depressed.

Adjustment disorder is a state of distress that occurs in relation to a stressful life event. It is usually an isolated reaction that resolves when the stress passes. Although it may be accompanied by a depressed mood, it is not considered a depressive disorder. Some people believe that depression is "normal" in people who are elderly, have other health problems, have setbacks or other tragedies, or have bad life situations. On the contrary, clinical depression is always abnormal and always requires attention from a medical or mental-health professional. The good news is that depression can be diagnosed and treated effectively in most people. The biggest barriers to overcoming depression are recognition of the condition and seeking appropriate treatment.

II.

OBJECTIVE: Nurse Centered To be able to compare and contrast major depressive disorder and dysthmic disorder. To be able to describe the biology and psychodynamic explanations for depressive disorders. To be able to recognize warning signs of suicide To be able to describe intervention to prevent suicide. To be able to describe the family issues related to this disorder. PATIENTS DATA A. Patients Profile Name: GALITO, MARION ISRAEL Address: San Vicente, Urdaneta, Pangasinan Gender: Female Age: 18 years old Date of Birth: Sept. 16, 1994 Place of Birth: Urdaneta, Pangasinan Nationality: Filipino Religion: Roman Catholic Civil Status: Single Father: Marlon Galito Mother: Melisa Galito Date Admitted: April 24, 2013 (11:45 AM) Admitting Clerk: Ferdinand C. Forosan Admission Diagnosis: SEVERE DEPRESSION EPISODE WITH PSYCHOTIC SYMPTOMS B. Result of Interview (Nurse-Patient Interaction) a. Orientation Phase b.Working Phase c. Termination Phase PSYCHIATRY HISTORY

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IV.

Precipitating Event and Predisposing Event (Genetic Influences, Past Experiences, Existing Condition). HISTORY OF THE PRESENT ILLNESS According to patient: No data was gathered from the since he was non-conversant at the time of interview. According to informant: Four months PTA, the patient had an abortion and underwent dilatation and curettage. After the operation, the patient was noticed to be non-conversant and preferred to be alone most of the time. The patient was also to be talking alone and telling to her family that shes feeling san and alone. Patient also had poor sleep and had suicidal thoughts. No consult was done. No medications were taken. The symptoms persisted until 2 months PTA, the family decided to seek consult, patient was then given Sertraline 50mg/tab tablet OD at HS, Diphenhydramine 50mg/cap 1 capsule OD at HS and Risperidone 2mg/tab 1 tablet OD at HS. 1 month PTA, the symptoms persisted and patient had auditory hallucinations and delusions that a prince is waiting for her. Patient also tries to escape and insists that she wars to go out of the house. Patient had good sleep and appetite but the patient does not want to take her medications. 1 week PTA, the symptoms persisted and the patient had an episode of trying to hurt herself using a barbeque stick. No medications were taken due to refusal of the patient to take her medications. She also hurts her sibling every time they try to restrain her when she wants to escape the house. Persistence of the symptoms prompted the family to seek another consult. The were advised for admission, hence patient was admitted. PAST MEDICAL HISTORY No previous history of hospitalization due to general medical condition. 4 months patient underwent Dilatation and Curettage, but was not hospitalized. No fall and accidents. Allergies to drugs like antibiotics and paracetamol. No history of drug use. FAMILY HISTORY POSITIO N Mother NAME AG E 37 GENDE R Male EDU. ATT. WORK HEALTH CONDITIO N Apparently well

Marion G.

College Unemploye Undergrad d .

Mother Siblings

Marieta G. 39 1. Mariel 19

Female Female

Com. Sci. 2nd Year HS

Unemploye d Unemploye d

Heart and Renal Px Apparently well

2. Patient 3. Mario 16 Male 4th Year student Apparently n HS well st 4. Maree 13 Female 1 Year student Apparently n HS well No family history of Asthma, DM, CA, and HPN (+) Psychiatric illness and mental d/o maternal side(aunt of the mother) PERSONAL, SOCIAL and ENVIRONMENTAL HISTORY The patient was born via NSD at Urdaneta Hospital. She started to study at age 7 at grade 1. She was an average student, who has many friends. Patient was a BSA college student, stopped due to financial constraints. She then applied and worked as a sales lady at manila. After 1 year she went home for home for no apparent reason. No maltreatment was noted. Presently she is unemployed. She had a total of 7 boyfriends, last boyfriend was last December 2012, and was then pregnant for 2 months. V. MENTAL HEALTH ASSESSMENT A. Physical Assessment a. Sensation b. Elimination c. Locomotion d. Fluid e. Posture f. Aeration g. Circulation h. Integumentary i. Nutrition j. General Appearance

During nurse-patient interaction, the patients grooming was good. She displayed eye contact but doesnt displayed interest on the topic (blank stare). B. Psychological Assessment a. General Presentation a. Appearance
The patient had seen well groom and young. She dress appropriately according to age and sex. She also had seen healthy and good posture and normal way walk or gait.

b. General Behavior

The patient does not show mannerism, combative actions, twitching, hand and feet wringing and rubbing but she is clumsy and having psychomotor retardation (patient is less moving and cooperative to the daily activities.

c. Attitude Towards the examiner Attitude is a position of the body or manner of carrying oneself. It is a position or posture of the body appropriate to or expressive of an action, emotion. The patient does not cooperation in the whole duration of duty and not able to answers most of questions asked to him and cant participates in all activities. It was also observed that she was not going out with other patient and student nurse. Every time she sense that the door will be open, she tried to go out. b. State of Consciousness
During my interaction to the patient I had observed that she is not aware of anything happened on her surrounding and looks like wandering.

c. Attention
As I observed to the patient, every time we interact, the patient focus during the interaction is less effective because she is easily destructive to stimuli around her and the cooperation that the patient is attend is short or absent. Example conversation: Nurse: Kamusta ka na? Patient: Patient kept on silent and blank staring Nurse: Alam mo ba kong asan ka at bakit ka andito? Patient: The same response

d. Speech During interaction with the patient, the patient is kept on silence and it seemed to be that shes afraid of something. e. Orientation
The patient is aware to her name, age, and when she is born, the place and their home address but when I asked her about the current time, she is not response and remained mute following other questions. Example conversation: Nurse: Ano po pangalan mo? Patient: Marion

Nurse: Ilan taon ka na? Patient: 18 na Nurse: san ka pinanganak? Patient: Urdaneta, Pangasinan Nurse: Galing naman, alam na alam ah..eh anong oras na ngayon at anong araw ngayon? Patient: Mute and blank staring

f. Mood and Affect A severe reduction in emotional expressiveness. People with depression and schizophrenia often show flat affect. A person with schizophrenia may not show the signs of normal emotion, perhaps may speak in a monotonous voice, have diminished facial expressions, and appear extremely apathetic. The patient sometimes shows flat affect during the whole interaction. g.Form of Thought
As presented the example above, I think it is hard for me to determine the main idea that she might poses to express because of the mute behavior of the patient the conversation but I taught it is a form of thought (flight of idea), because I felt that she want to jump the topic from another topic.

h.Thought Content
I observed to the patient that every time the door is open, she is always been near to the door holding her things and also the mute behavior during interaction.

i. Perception
According to her mother, the patient displayed misperception to the sound. An auditory hallucination that have been noted prior to hospitalization. The patient told hinihintay ako ng prince sa labas every time she tried to escape from their home.

j. Judgement
During the 3rd day of conversation, I tried to remotivate the patient through helping to increase self perception toward treatment. I told to her that: Nurse: adding kong gusto mong gumaling at makalabas dito, sana makipagcooperate ka lang, kasi sana sayo din yan nakasalalay, ang paggaling mo. Patient: Silent and kept on staring Nurse: naiintindihan mo po ba ako? Tandaan mo, nasa sayo ang paraan para gumaling ka

Patient: The same response These conversation might implied that the patient have poor judgement because she kept on silent and blank staring and remember, commonly people, whey they answer question like these, they will answer properly and accurately.

k.Memory
Recent: Nurse: Kamusta ka na, naalala mo pa ba ako? Patient: Patient kept on silent and staring Nurse: kamusta tulog mo? Patient: The same response Conversation indicates that the patient had low recent memory status. Remote: Nurse: kaylan ka pinanganak? Saang eskwelahan ka nag-aral? Nagtrabaho ka nab a? Immediate: After the patient takes her breakfast and medicine, I asked her if she know that she had already taken her breakfast and medicine. The patient response by turning her head up and down (suggesting yes).

VI.

l. Intellectual Functioning TREATMENT MODALITIES

Psychotherapy Psychotherapy ("talk therapy") involves working with a trained therapist to figure out ways to solve problems and cope with depression. It can be a powerful intervention, even producing positive biochemical changes in the brain. Three major approaches are commonly used to treat clinical depression. In general, these therapies take weeks to months to complete. Each has a goal of alleviating your symptoms. More intense psychotherapy may be needed for longer when treating very severe depression or for depression with other psychiatricsymptoms. Interpersonal therapy (IPT): This helps to alleviate depressive symptoms and helps you develop more effective skills for coping with social and interpersonal relationships. IPT employs two strategies to achieve these goals.

The first is education about the nature of depression. The therapist will emphasize that depression is a common illness and that most people can expect to get better with treatment. The second is defining your problems (such as abnormal grief or interpersonal conflicts). After the problems are defined, the therapist is able to help set realistic goals for solving these problems. Together you will use various treatment techniques to reach these goals. Cognitive behavioral therapy (CBT): This helps to alleviate depression and reduce the likelihood it will come back by helping you change your way of thinking. In CBT, the therapist uses three techniques to accomplish these goals.

Didactic component: This phase helps to set up positive expectations for therapy and promote your cooperation. Cognitive component: This helps to identify the thoughts and assumptions that influence your behaviors, particularly those that may predispose you to being depressed. Behavioral component: This employs behavior-modification techniques to teach you more effective strategies for dealing with problems. Behavioral therapy (BT): This helps to modify your depressive behaviors through highly structured, goal-oriented therapy. BT uses three techniques to accomplish these goals.

Functional analysis of behavior: This helps to define the behaviors that will be targeted for change. Selection of specific techniques: Various techniques can be employed to help modify the selected behavior, including relaxation training, assertiveness training, role-playing, and time-management tips. Monitoring behavior: Progress and program effectiveness can be monitored by logs and records you keep. VII. PSYCHIATRIC NURSING CARE PLAN VIII. PASYCHOPHARMACOLOGY IX. DISCHARGE PLANNING and HEALTH EDUCATION A. Medication The following are the home medications that will be taken by the patient: SERTRALINE 50mg/tab 1 tab OD at HS RISPERIDONE 2mg/tab 1 tab OD at HS BIPERIDEN 2mg/tab 1 tab OD at AM HALOPERIDOL 5mg deep IM as needed for refusal to take Oral Risperidone with BP precautions HALOPERIDON 10mg + DIPHENHYDRAMINE 50mg, deep IM PRN for severe psychotic agitation. Maximum of 3 doses with interval of 1 hour per dose, with BP precautions B. Economic Status The patient is belongs to a middle class family that they able to eat trice a day. C. Health Education D. Out Patient (follow-up) Depending on the severity of your depression, you will see your health-care provider more frequently, perhaps as often as every week or every other week, for the first six to eight weeks after the initial diagnosis of depression.

Be sure to tell your health-care provider about any medication side effects or urges to hurt yourself or others E. Diet