Analysis of Depression in the Elderly - Case Study Example

Nursing Care Study According to the International Council of Nurses (1987 Nursing, as an integral part of the health care system, encompasses the promotion of health, the prevention of illness, and care of the physically ill, mentally ill, and disabled people of all ages, in all health care and other community settings. Within this broad spectrum of health care, the phenomena of particular concern to nurses are individual family and group responses to actual or potential health problems. These human responses range broadly from health restoring reactions to an individual episode of illness to the development of policy in promoting the long-term health of a population.” (International Council of Nurses 1987) Nursing is the use of clinical decision-making in the offering of care to facilitate individuals to get better, sustain, or recover health, to manage health issues, and to attain the top most quality of life, whatever their disease or disability, until death. The aim of nursing is to encourage wellbeing, curing, growth and development, and to avoid disease, sickness, wound, and disability. When people become ill or disabled, the point of nursing is, in addition, to reduce anguish and pain, and to allow people to comprehend and deal with with their disease or disability, its treatment and its results. When death is unavoidable, the use of nursing is to continue with the finest quality of life until its end (Beck 2010). Nurses wish to offer the highest quality care to older adult patients, but work practices or knowledge differences might stop them from using the techniques that can reduce adverse events, such as reduced mobility, pressure ulcers, and delirium. Similarly, while taking care of patients with psychological disorders, the nursing process offers distinctive challenges. Nurses managing psychiatric patients are called psychiatric nurse practitioners or mental health nurse practitioners. These nurses give patients complete psychiatric care and treatment. They assess, diagnose and deal with treatment of psychological disorders, physical-psychological conditions and substance abuse disorders (Education-portal.com 2010). Nursing the elderly psychiatric patients present the greatest challenge as such patients have physical illnesses along with psychological disorders (Antigoni & Theofanidis 2009). I encountered one such patient during my placement at the psychiatry ward with the elderly. I was among the member of the health team that was assigned to work on assessing, diagnosing and managing this patient’s condition. I will prefer not to use the patient’s real name and call him by his pseudonym, John. The reason behind this is that according to the Data Protection Act 1998 all health care professionals must abide by their professional code of conduct in respect of patient confidentiality and privacy (Juchem 2009). This means that the patient’s identity must be kept confidential so that his right of privacy of his personal and medical information is not violated (Juchem 2009). The process of nursing is a dynamic and investigative process. It is an organized and customized method to accomplish the effects of nursing care. It respects the patient’s independence and free will to make choices and be involved in nursing care. It is acknowledged by the nursing profession as a standard for offering constant nursing care that is modified according to the needs of the patients. The nurse and the patient come out as partner in a relationship built on trust and focussed towards enhancing the patient’s strong point, preserving honesty, and encouraging adaptive response to pressures of life. The process is basically divided into stages; assessment, diagnosing, planning, implementation and evaluation (Beck 2010). Assessment John, a 74-year-old widower, was admitted into the psychiatry ward after being diagnosed with mild depression on October 12, 2010. Once he was admitted into the ward, out health team was asked to assess the patient’s current condition, diagnose, plan interventions, implement interventions and evaluate. The first stage in the nursing process is the assessment in which we started with collecting information regarding the patient’s personal and medical history. This was done by conducting an interview with John in a quite private place where there was no noise and distractions. John started by telling us that his wife, Nicole, had recently passed away. He used to work at a bank but retired a few years ago. He has two daughters and one son, all of whom are married and had children of their own. None of the children lived with John. John’s son was present as well, in case, John was unable to provide us with certain information that we required. We were informed by his son that John used to be pretty active, offered help at the local community center, took part in golf games with his friends at least twice a week, and took pleasure in regular get-togethers with his grown children and grandchildren. But after his wife’s death, his interest in getting out and meeting people had vanished. Even though, it has been almost a years since his loss, but John has not shown any signs of improvement (Hall & Hassett 1999). Regarding the medical history of the patient, John, we were informed he was a Type II diabetes patient. His diabetes used to be under control but after the death of his wife his health gradually deteriorated. This deterioration had resulted from missing meals and often forgetting his insulin shots (Petrak, Hautzinger, Plack, Kronfeld, Ruckes, Christian, Herpertz, & Müller 2010). We were also informed that there was no family history of psychological disorders and that John did not have any history of substance-abuse. During the interview, we constantly observed John to record any discrepancies in his thought processes and his behavior. But he seemed to be cognitively functioning and was completely aware of his environment (Beck 2010). In order to check and confirm for diabetes in John, we conducted the random plasma test which is also known as the causal plasma glucose test (Trief 2007). This test was conducted to determine the blood glucose without the consideration as to when the patient had last eaten. This test, and an evaluation of symptoms, helps in the identification of diabetes (Trief 2007). After receiving the confirmation of Type II diabetes in John, we proceeded to confirm whether he was depresses or not and if he was, whether it was mild or severe. In order to check for depression, we administered a standardized depression instrument and documented the results. We used the Geriatric Depression Scale-Short Form (GDS-SF) because it takes about 5 minutes to administer, and is highly reliable and valid and is widely used with medically older adults with poor health, and also comprises of few physiological items that might be confused with physical illness (Evans & Mottram 2000). The results of the scale suggested that John was facing mild depression and any somatic complaints or medications were ruled out as reasons for depression. After the test, we performed a focused depression evaluation on John and documented the results. In this we recorded the number of symptoms; their inception; incidence/patterns; period transformation from normal mood, performance, and functioning. These symptoms included: Depressive symptoms Depressed or irritable mood, regular crying Loss of interest Weight loss Sleep trouble Fatigue/loss of energy Psychomotor slowing/agitation Reduced concentration Feelings of worthlessness/guilt Recent loss of his wife (Kurlowicz & Harvath 2008) Nursing Diagnosis After completing the tests and conducting a thorough analysis of the symptoms faced by John, we had reached our diagnosis. The diagnosis was: ‘Depression in relation to loss of interest as evidenced by recent loss of his wife and depressed or irritable mood’ Depression in elderly is a psychological phenomenon and is not a standard response to aging. Most of the people deal with growing old, and a lot of people feel content and satisfied. However, there is a predisposition among health professionals and the society in general to acknowledge lower performance and increased symptoms in older individuals. Depression tends to be denied by the existing age group of elderly people, a lot of of whom were brought up in an environment where showing feelings was not encourages, and this increases diagnostic problems. Comorbid health situations, the inclination of patients to assign physiological reasons to psychological problems, cognitive dysfunction, and numerous life events, often of loss of something or someone, all further make diagnostic process difficult (Evans & Mottram 2000). Defining characteristics Depressive symptoms Depressed or irritable mood, frequent crying Loss of interest, pleasure Weight loss Sleep disturbance Fatigue/loss of energy Psychomotor slowing/agitation Diminished concentration Feelings of worthlessness/guilt Recent loss of his wife (Kurlowicz & Harvath 2008) Related factors Loss of appetite Loneliness Expected outcome We then identified the expected outcomes individualised to John. In regards to offering nursing care, the final goal is to influence health results and enhance the patient’s health status. The expected results have to be jointly identified with the patient, and should be identified as plainly as possible. These expected outcomes also verify the success and efficiency of the nursing interventions (Beck 2010). Before defining expected outcomes, we had to understand that patient frequently look for their own treatment with goals. These goals might be expressed as reducing symptoms or enhancing functional capability. Therefore, we must appreciate the patient’s coping reaction and the issues that effect him (Beck 2010). Clarifying goals is a necessary measure in the therapeutic process. Therefore, our relationship with John was based upon mutually agreed goals. Once the goals were decided they were written down. Goals were written in behavioural expressions, and practically illustrated what we desired to achieve within a certain period of time. The expectations from the treatment and the short-term goals were established. These short-term goals contributed immensely in achieving the long-term goals (Beck 2010). Short-term goals At the end of two weeks John will stay out of bed and take part in activities. At the end of one week John will sleep well at night. At the end of one week John will eat properly and maintain a healthy weight. Long-term goals John will be able to successfully control his diabetes problem. John will overcome his depression through continuous treatment. John will come regularly for evaluation after leaving the hospital. John will take appropriate measures to avoid relapse of depression. Planning As soon as John’s problems were identified and diagnosed, planning of the nursing care began. At this stage, along with the members of health team, the patient and his family are involved as well. Once the goals are determined, the next task was to design a plan that would help in realizing them. After conducting a thorough analysis, the nurses decide which problem calls for priority attention or immediate focus. The stated goals show as to what is to be achieved if the identified problem is resolved. These can be the stated immediate objectives. The selected nursing action method will allow the nurse to achieve the goals that were initially determined. For example, in case of short-term goal of pursuing the patient to get out of bed, we will firmly ask the patient to get out of bed each day so that he is able to it for himself after two weeks. This is an example of the selection of the nursing action for John (Beck 2010). The planning stage also includes the therapies that will be used to treat John so that he not only overcomes the grief of his wife’s death but also manages his depression. To overcome his depression, John will be treated with the Cognitive Behavioral Therapy (CBT) (Petrak 2009). Implementation This stage of implementation in the nursing process is the real beginning of the nursing care plan. The expected outcomes and goals are accomplished by the actions of the nursing interventions. During this stage the nurse keeps on to evaluating the patient to decide whether interventions are successful (Antigoni & Theofanidis 2009). The nursing interventions are intended to avoid psychological and physical sickness and encourage, preserve, and re-establish mental and physical health. The nurse might choose interventions based on his/her amount of practice (Antigoni & Theofanidis 2009). In John’s case we decided to use the Cognitive Behavioral Therapy as it works well with elderly patients with Type II diabetes. Cognitive Behavioral Therapy is based on a programme (12 weekly sessions) intended for elderly with type 2 diabetes, comprising of cognitive and behavioral approached to conquer depression and to reduce diabetes-related misery, lessen perceived difficulties to a variety of aspects of self-management, and improve coping abilities. The main components of this therapy are psychological education, support, problem solving, enjoyable activities, activity arrangement by making use of pedometers, thought control methods, cognitive reformation, philosophical discussion, social abilities and interpersonal contact guidance, emergency intervention and crisis preparation. The existing literature suggests that the combined use of cognitive behavioral therapy and antidepressant medications result in more effective treatment of depression as compared to only using psychotherapy (Petrak 2009). Therefore, the cognitive behavioral therapy (CBT) will be used to treat John along with certain antidepressants so that John’s depression can be overcome. On the other hand, the antidepressants that will be prescribed to join will be in accordance with his diabetes problem for which he takes insulin shots. Furthermore, John will also be involved in supportive/reminiscence therapy for the bereavement of his wife so that he can overcome the death of his wife and move on with his life (Petrak 2009). Evaluation Evaluation is a nonstop phase of the nursing process. Nursing care is an ever-changing process that includes adjustment in the patient’s health condition over time, giving rise to the need of latest data and changes in the plan of care. The evaluation is the most important measure in the nursing process because it permits the nurses to determine whether the initially determined goals and expected outcomes have been met or not (Antigoni & Theofanidis 2009). During the evaluation stage, we analyzed all the previous phases to decide whether the expected outcomes for John have been met or not. Looking at John now, it can be suggested that the cognitive behavioral therapy along with the prescribed antidepressants has proven successful as John has gradually started coming back towards his normal. The short-term goals have been achieved as John gets out of bed each day and takes part in different activities. Moreover, he is able to sleep well at night and eats well so that he can maintain a health weight. Similarly, the long-term goals are slowly being achieved as well as John has successfully controlled his diabetes problem. Furthermore, after 12 months CBT, the sessions have been cut down to one session per month for the long-term phase trial. Thus, evaluation operates as a feedback instrument for assessing the quality of care provided. It will point towards the problems of the patient have been overcome, which need to be re-assessed, planned and implemented again and re-evaluated (Trief 2007). As high level of technology is typically not needed in the care of cognitively dysfunctional elderly patients, these individuals might be the initial patients nursing students are assigned to care for (Beck 1996). Even though, elderly people do not require high tech care, but their nursing care can be very demanding for the nursing students (Neilson, Peet, Poole, & Ledsham 1996). The reason behind this is that elderly patients seem to be more vulnerable due to which the students might feel sadness and empathy (Neilson, Peet, Poole, & Ledsham 1996). On the other hand, due to their deteriorating health and psychological problems, they might be resistant to the treatment which would result in frustration among the nursing students (Neilson, Peet, Poole, & Ledsham 1996). Taking care of elderly with psychological disorders offers nursing students with challenges that they need to overcome to become better at what they do (Neilson, Peet, Poole, & Ledsham 1996). In the present case scenario, John, the patient was not resistant towards the treatment; rather, after a few days into the treatment, he started participating in the activities himself. On the other hand, as he was old and his wife had recently passed away I felt sadness for him which was overcome by joy once he started getting his life back. After working on this case, I have decided to work with elderly patients with psychological disorders in the future. Treating John has helped me gain immense knowledge about the different phases that are involved and the amount of care the nurse has to provide in order to help the patient get back to his life. Furthermore, patients like John, who face both physiological and psychological problems present a great challenge, which I would like to take in my future practice. Works Cited Antigoni, Fountouki and Theofanidis, Dimitrios. “Depression in the Elderly: Limits and Challenges - a Nursing Perspective.” International Journal of Caring Science. 2.3 (2009): 108-117 Beck, C. T. “Nursing students experiences caring for cognitively impaired elderly people.” Journal of Advanced Nursing. 23.5 (1996): 992-998. Beck, Jyoti. “Nursing Process in Psychiatric Nursing.” 28 July 2010. Psychiatric Nursing. 30 October 2010. http://www.nursingplanet.com/pn/nursing_process_ psychiatric_ nursing.html Education-portal.com. 1 November 2010. Psychiatric Nurse Practitioner Career Info and Education Requirements. 1 November 2010. Evans, Mavis and Mottram, Pat. “Diagnosis of Depression in Elderly Patients.” Advances in Psychiatric Treatment. 6. (2000): 49-56. Hall, Kathryn A. and Hassett, Anne M. “Assessing and Managing Old Age Psychiatric Disorders in Community Practice.” The Medical Journal of Australia. (1998). 30 October 2010. International Council of Nurses. 1987. Position statement. Geneva: ICN. Juchem, Brett. Data Protection Laws for Personal Health Information in the UK and Europe. 1 July 2009. Bright Hub. 30 October 2010. Kurlowicz, Lenore H. and Harvath, Theresa A. “Nursing Standard of Practice Protocol: Depression.” January 2008. Consult GeriRN.org. 30 October 2010. Neilson, Trish, Peet, Malcom, Poole, Jacqui and Ledsham, Robert. “Does the Nursing Care Plan help in the management of psychiatric risk?” Journal of Advanced Learning.24.6 (1996): 1201-1206. 30 October 2010. Petrak, Frank, Hautzinger, Martin, Plack, Kristin Kai Kronfeld, Kristin, Ruckes, Christian, Herpertz, Stephan and Müller, Matthias J. “Cognitive Behavioral Therapy in Elderly Type 2 Diabetes Patients with Minor Depression or Mild Major Depression: Study Protocol of A Randomized Controlled Trial (MIND-DIA)”. BMC Geriatrics. 10.21 (2010). Petrak, Frank. Cognitive Behavioral Therapy in Elderly Type 2 Diabetes Patients with Minor Depression or Mild Major Depression. 23 July 2009. 30 October 2010. Trief, Paula M. “Depression in Elderly Diabetes Patients”. Western Research of Nursing Research. 20.2 (2007): 71-75. Read More