Psychiatric Nursing Care Analysis - Research Paper Example

?Client Care Analysis The patient in this study is a 76-year-old Caucasian female. This patient recently underwent surgery for an open colon resection, which has left her with obvious physical deformities of the abdomen. As a result, she is being carefully observed for signs of clinical depression in her behavior and attitude. In order to make this determination, the theoretical description of depression is noted, followed by a comparison of the client's statements and actions to those theoretical descriptions, then an analysis of the effect of the client's behavioral stage on the possibility of depression, and finally a discussion of the relevant legal and ethical issues at hand. At the end, a discussion of nursing management techniques for patients experiencing symptoms of depression will be examined. Current Theories in the Etiology, Presentation, and Prognosis of Depression The causes of depression are complex, but are generally understood to be a combination of environmental and genetic factors, such as a traumatic life event combined with a genetic susceptibility to hormone disruption in seratonin levels, though such a connection has not been conclusively proven (Abela & Hankin, 2008; Risch et al., 2009). There is, however, a definitive correlation between “stressful” or otherwise disruptive events and the beginnings of depressive symptoms (Risch, et al., 2009). Depression is often co-morbid to an anxiety disorder or attention deficit disorder (Luby, Belden, Pautsch, Si, & Spitznagel, 2009;Goldberg, et al., 2010). When presenting independently, these disorders are also generally risk factors for depression. Depression is also often seen as a precursor to the development of senility or dementia in older adults (Brommelhoff et al., 2009). Additionally, as well as being a symptom, insomnia in older adults is considered a risk factor for depression, though this is still controversial (Fiske, et al., 2009). Depression has two core symptoms used in diagnosis which must be experienced for at least a two week period: feelings of sadness or misery without a specific reason for such feelings, and a loss of interest in previous-enjoyed activities (Goldberg, Kendler, & Sirovatka, 2010). In older adults such as the client in this report, insomnia is a widely noted symptom, which is a converse to the hypersomnia usually noted in younger adults with depression (Nutt, Wilson, & Paterson, 2008). Other symptoms include difficulty concentrating and impaired decision-making, change in appetite or eating habits, feelings of worthlessness, and thoughts of suicide (Keenan et al., 2008). Older adults, however, are less likely to display emotional symptoms, and instead present with cognitive decline, motor skills impairment, and a wider range of somatic symptoms (Fiske, Wetherell, & Gatz, 2009). The prognosis of major depressive disorder is highly variable against the length of time the initial depressive episode was present. More minor presentations of the disorder behave similarly to major depressive disorder, but the patients are likely to worsen before they improve. In one study, patients with a previous history of depressive episodes lasting longer than one year were more likely to suffer from a relapse episode that would last longer than six months. This was true even if the initial episode experienced was only minor or sub-threshold depression (Gilchrist & Gunn, 2007). Sub-threshold symptoms in older adults will generally persist for at least a year and makes the person seven times more likely to develop major depression in that time frame than those who do not exhibit such symptoms (Lyness, Chapman, McGriff, Drayer, & Duberstein, 2009). Relationship of Theories to Client Behavior Given that the client has recently undergone major surgery, she is at a higher risk for depression than most of the population. Any surgery could be considered a major life event, but an open colon resection especially would be a very stressful and possibly traumatic experience for the patient, resulting in major physical changes to the patient's appearance. This greatly increases her chances of developing depression in the months following the surgery (Risch et al., 2009). Despite her high-risk status, she does not appear to have developed serious depression. The patient is not displaying other signs or symptoms for depression that are common in older adults, such as cognitive or memory problems, nor does she seem to be suffering from motor skills impairment (Fiske, Wetherell, & Gatz, 2009). In fact, she is not showing many signs of depression at all. She takes care of her appearance and cares about her health, including the exclusion of tobacco use and alcohol consumption from her life. Despite not showing serious symptoms currently, this patient should be kept under careful observation for symptoms of depression. She is a high-risk patient, and many cases of depression in the elderly are missed due to misdiagnosis as early dementia or other cognitive disorders, or missed simply because their symptoms are very mild. As has been discussed, even sub-threshold depressive symptoms can persist for long periods of time and eventually develop into major depressive disorder, especially in older adults who have been separated from family members and their everyday lives ( Lyness, Chapman, McGriff, Drayer, & Duberstein, 2009). This patient's statements of distaste for her current physical state due indicate that she may have developed a low body image, in contrast to her earlier positive feelings about her appearance. She has stated that she does not like the results of her surgery, making such statements as “I am not happy with the idea that my gut is all open”, and “I never imagine to be walking with my colon sticking out.” Despite this, she still seems to think of herself as a good person and says she is a hard worker. When asked, she can recount the ways in which she is useful to society as a whole and a benefit specifically to her family. These positive feelings could be off-setting any negativity leading to depression, but it is also possible such positive conversations are just a cover for her currently low self-image. Depression and Developmental Stages According to Piaget’s stages of cognitive development, this patient would be at a formal operational stage based on both her abilities and her age. She has been able to demonstrate logical thinking by discussing how to deal with normal family issues (Ivancevic et al., 2011). For example, she stated “My children and his children come to help us every once in a while and I make sure I assign the tasks we want them to complete.” This indicates a high level of problem solving and logical thinking, and ensures that desired outcomes are achieved. Erikson's model of stages of development would place this patient in the ego integrity stage of psychosocial development (Evans et al., 2009). She is able to look back on her life with happiness and contentment. The patient states feelings of fulfillment in both her day-to-day life now and with her accomplishments in the past. She says that her life has benefited others and she is able see herself as having had a good and productive life. Her family, especially her children and grandchildren, are a big part of her feelings of success. Lastly, according to Kohlberg’s theory of moral reasoning, this patient would be at stage 4 of conventional morality (Lind, Hartmann, and Wakenhut, 2010). She is concerned with her duty as a wife, mother, and grandmother which according to her is to take care of her family. She is also concerned with what moral values will be passed on to the newest generations in her family. She stated “I just want to them to continue to be law-abiding citizens and good people.” She feels that up until this point she has succeeded in raising good children and in giving them the skills to raise their children successfully, and she is proud of her children and grandchildren. It is possible that the patient feels that her surgery is going to prevent her from continuing to be an active part of her family's life. She feels it is her responsibility to ensure that her children and grandchildren continue to be “good people”, but if she cannot assist them in their day-to-day lives due to her “colon sticking out”, then she will not be able to meet her responsibilities as their parent and grandparent. This could be contributing to her development of depression. If she feels that she is now suddenly failing to contribute to her family responsibilities in the ways she did in the past. she may feel somewhat useless and unwanted. Being hospitalized for such a long period of time, separate from the results of the surgery, could also be contributing to these feelings of failure to meet her responsibilities. Prior to this point in her life, she has always been available to her children to help them deal with their problems. Now, instead, she is in the hospital and a burden for them to come visit instead of a useful part of their daily lives. Legal and Ethical Issues As part of this patient's medical team, her doctors and nurses must be very careful when looking into this patient's future wishes for treatment. As she is an elderly patient with a serious illness, her care team must not let her depression stand in the way of her receiving proper care. It is common for elderly, depressed patients to request an end to life-sustaining care sooner than those patients with the same illnesses who are not depressed. It is important that if a patient requests an end to treatment, that it be done with the full knowledge of what that decision will mean, and that the care team attempt to treat the depression before such wishes are granted (Bernat, 2008). A similar situation exists with regards to the legal implications of this patient's care. While both the legal standards of informed consent and beneficence of care must be met, a clear indication of whether depression invalidates a patient's competence to make their own care decisions has no yet been made (Bernat, 2008). This patient has not yet reached the point of end-of-life care, but when she does, attention must be paid to the diagnosis of depression when the patient gives an opinion of future treatment. If she chooses not to continue life-sustaining care, it is possible there would be legal repercussions for a doctor who accedes to these wishes. Medical and Nursing Management In depression, there are two major modes of treatment. The first is the use of antidepressant medication. The second method of treatment is cognitive behavior therapy. Used in combination, most cases of even moderate to severe depression will respond to this treatment (Lichtman et al., 2008). Medications used for depression generally fall under the category of selective serotonin re-uptake inhibitors, tricyclic antidepressants, or monoamine oxidase inhibitors. However, tricyclic antidepressants and monoamine oxidase inhibitors have been found to have cardiotoxic effects as well as causing wide-spread side effects. Patients on medications for depression must be closely monitored for compliance, as up to 25% of depressed patients stop their medication in the first six months due to unwanted side effects or their belief that the medication is not effective (Lichtman et al., 2008). This non-compliance is most often seen in patient that experience symptoms of feeling worthless or having cognitive impairments (Little, 2009). Cognitive behavioral therapy is also used to control depression, as it is more successful in combination with medication than medication alone. Additionally, some patients may seek a non-drug treatment alternative (Lichtman et al., 2008). However, in the cases where the condition does not respond to treatment with medication, there is little evidence that the condition will improve significantly with therapy, either (Little, 2009). Some patients have what is considered treatment-resistant depression, where after several months of treatment with cognitive behavioral therapy and medication the condition still has not improved. This is often due to non-compliance with medication, the existence of a co-morbid psychiatric or somatic condition, or possibly an additional substance abuse issue. If the co-morbid condition is not also treated, it can be difficult to treat the depressive symptoms; somatic causes of depression will often not respond to specific anti-depressant medication (Little, 2009). As a nursing diagnosis, most patients experiencing depression fall under “ineffective coping.” The symptoms of depression, such as a change in appetite or sleeping habits, fall under the defining characteristics of ineffective coping. Additionally, many of the risk factors for depression, such as the diagnosis of a serious illness or a personal crisis, are related factors in the nursing diagnosis of ineffective coping (Gulanick & Myers, 2011). Interventions for a patient experiencing ineffective coping generally involve opportunities for the patient to express emotional distress. The first step is to create a working relationship with the patient, and offer opportunities for the patient to express their feelings. The nurse should express understanding and acceptance of the patient's feelings without providing “false reassurances” that “everything will be fine,” especially in the case of serious illness (Gulanick & Myers, 2011). On-going intervention involves helping the patient to deal with the situation that has led them to this state. Help them deal with the situation in smaller pieces by setting reasonable short-term goals, and provide only the information the patient needs or wants regarding specific procedures. Point out situations where the patient is succeeding or has accomplished a goal. Discourage the patient from making decisions or attempting to problem-solve while under severe stress, as this will only exacerbate the patient's inability to cope (Gulanick & Myers, 2011). Conclusion The presence of depression in an elderly patient shortly after a major surgery is unsurprising, and the patient should be closely monitored for signs and symptoms of depression. These signs and symptoms were noted on a theoretical basis, and were then compared to the patient's behaviors to make a distinction of the patient's risk of depression. The patient's developmental stage was analyzed and the possible ethical and legal implications of the patient's condition were provided. Finally, a description of the nursing management techniques for a patient experiencing these symptoms was listed. This patient is high-risk for depression and ineffective coping, but does not at this time seem to be experiencing these problems. References Abela, J. R. Z., & Hankin, B. L. (2008). Handbook of depression in children and adolescents: Guilford Press. Bernat, J. L. (2008). Ethical issues in neurology: Lippincott Williams & Wilkins. Brommelhoff, J. A., Gatz, M., Johansson, B., McArdle, J. J., Fratiglioni, L., & Pedersen, N. L. (2009). Depression as a risk factor or prodromal feature for dementia? Findings in a population-based sample of Swedish twins. Psychol Aging, 24(2), 373-384. doi: 2009-08094-010 [pii]10.1037/a0015713 Evans, N. J., Forney, D. S., Guido, F. M., Patton, L. D., & Renn, K. A. (2009). Student Development in College: Theory, Research, and Practice: John Wiley & Sons. Fiske, A., Wetherell, J. L., & Gatz, M. (2009). Depression in older adults. Annu Rev Clin Psychol, 5, 363-389. doi: 10.1146/annurev.clinpsy.032408.153621 Gilchrist, G., & Gunn, J. (2007). Observational studies of depression in primary care: what do we know? BMC Fam Pract, 8, 28. doi: 1471-2296-8-28 [pii]10.1186/1471-2296-8-28 Goldberg, D., Kendler, K. S., & Sirovatka, P. J. (2010). Diagnostic issues in depression and generalized anxiety disorder: refining the research agenda for DSM-V: American Psychiatric Association. Gulanick, M., & Myers, J. L. (2011). Nursing care plans : diagnoses, interventions, and outcomes (7th ed.). St. Louis, Mo.: Elsevier Mosby. Ivancevic, T. T., Jovanovic, B., Jovanovic, S., Djukic, M., Djukic, N., & Lukman, A. (2011). Paradigm Shift for Future Tennis: The Art of Tennis Physiology, Biomechanics and Psychology: Springer. 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Interaction Between the Serotonin Transporter Gene (5-HTTLPR), Stressful Life Events, and Risk of Depression. JAMA: The Journal of the American Medical Association, 301(23), 2462-2471. doi: 10.1001/jama.2009.878 Read More