Comprehensive Health Assessment - Case Study Example

Comprehensive Health Assessment 2008 Assessment item Data collection and analysis Due: by 4pm, Monday 22nd September, 2008 Patient outline: This comprehensive health assessment is about a patient who would be referred as Ms. G throughout this assignment. For the reason of confidentiality, the identity of Ms. G. would not be revealed. It is, however, to be noted that this writer has sought consent from Ms. G. about assessing her while she was on the hospital, where she permitted this writer to interview her, to record her information, and to analyse her health records in order to complete this assignment. She has been hospitalised into this mental health unit for quite a few days, is being treated, and communicable. It was decided that this examiner approaches her. Ms. G. consented to this process immediately and was very cooperative. A comprehensive nursing assessment was completed using two assessment tools, one interview tool and the other, an objective data collection tool. Ms. G is a 17-year-old high school senior, referred for evaluation after she attempted suicide with an overdose of pills. Earlier on the night of the suicide attempt, she had a fight with her mother over a request to order pizza. Ms. G remembers her mother saying that she was a "spoiled brat" and asking whether she would be happier living elsewhere. Ms. G, feeling rejected and despondent, went to her room and wrote a note saying that she was having a mental breakdown and that she loved her parents but could not communicate with them. She added a request that her favourite glass animals be given to a particular friend. The parents, who had gone out to a movie, returned home later that evening to find their daughter comatose and immediately rushed her to the hospital Accident and Emergency. During the last couple of months, Ms. G had been crying frequently and had lost interest in her friends, school, and social activities. She had been eating more and more and had recently begun to gain weight, which her mother is very unhappy about. Ms. G says that her mother is always harping about taking care of herself. The argument on the night of her suicide attempt was about Ms. G's desire to order a pizza that her mother did not think she needed. The mother reports her daughter's recent increase in sleep and also reports that she never wants to go out with her friends or help around the house. When questioned about changes in her sleep habits, Ms. G admits that she has been feeling very tired lately and that she often feels as if there is nothing to make it worth getting out of bed. Upon evaluation, it is apparent that Ms. G, the third of three children of upper-middle-class and very intelligent parents, is struggling with a view of herself as less bright, clever, and attractive than her two siblings. She feels ignored and essentially rejected by her mother and the other sisters. Ms. G is having difficulty developing a sense of separation from her mother and an individual sense of identity. She experiences her mother's directives as interference with her efforts to express autonomy and independence. A thorough drug history was taken, and she was not on any at the time of episode. She denied any history of abusive drug use or alcohol intake. Upon presentation to the Accident and Emergency, she was immediately resuscitated and was admitted to the intensive care unit. Upon stabilization, she was transferred to the mental health unit with a diagnosing of major depression with suicidal attempt, and while she was improving on therapy, I decided to approach her to undertake a comprehensive nursing assessment in order to complete this assignment. It is to be noted that, from the records, it is evident that numerous investigations have been undertaken to rule out any medical illness in this patient. 2. Data collection process While undertaking the data collection, it was decided that the data collection will happen through two assessment tools, one interview and another objective data collection tool. The interview tool will establish the diagnosis, and since my interview process would continue for over a period of one week, another tool is necessary to quickly assess the changes in her condition during this period. As expected, treatment in the inpatient unit would cause improvement in her condition, but use of an objective data collection tool would provide an opportunity to corroborate the findings from the interview tool used (see appendix 1 and 2). Numerous assessment scales are available for assessing depression. Easily administered self-report questionnaires can be valuable detection tools. These questionnaires cannot be the sole basis for making a diagnosis of major depressive episode, but they are sensitive to depressive symptoms. Clinician-completed rating scales may be more sensitive to improvement in the course of treatment and may have a slightly greater specificity than do self-report questionnaires in detecting depression. Since depressed individuals often have an unrealistic negative evaluation of their worth or have guilty preoccupations or ruminations about minor past failings. Such individuals often misinterpret neutral or trivial day-to-day events as evidence of personal defects, and they have an exaggerated sense of responsibility for untoward events. As a result they feel hopeless, helpless, worthless and powerless. The possibility of disorganized thought processes such as tangential or circumstantial thinking and perceptual disturbances such as, hallucinations, delusions should also be included in the assessment. Therefore self assessment questionnaire would not be a dependable method for assessment of this patient (Cooper JE., 2003). The Hamilton Depression Rating Scale (HAMD) is one of the most commonly used rating scales that is used to assess the range of symptoms that are most frequently observed in patients with major depression. This is not regarded as a diagnostic instrument, but is an important tool to comprehensively assess and survey the symptomatic burden of such patients. This is also known to measure the illness severity, and the reliability and validity of this tool has been psychometrically established by many studies. This scale assesses a constellation of symptoms, and the version used here contains a 24-item interview based rating scale based on further research. This is conducted as a semi-structured clinician rated interview. The Hamilton Rating Scale for Depression rates depressed mood in one item and suicidal ideation in one item. The anxiety is assessed by both one-item psychic anxiety and somatic anxiety. It considers the effect of depression on sexual function by a one-item question. It assesses loss of appetite and weight by two one-item questions. It stresses on the effect of depression on sleep and assesses insomnia with a three-item questionnaire. It does not assess the ability to think, but provides due weightage to physical symptoms, hypochondriasis, and diurnal variation in symptoms. The general psychiatric distress is an important parameter in this scale it questions depersonalization, paranoid feelings, obsession symptoms, helplessness, hopelessness, worthlessness, feelings of guilt, and insight into illness (Hamilton M., 1960). The Raskin depression rating scale is a clinician rated brief scale to assess severity of depressive symptoms with a specific focus on verbal report, behaviour, and secondary symptoms. It can be applied to adult inpatients. It can successfully assess baseline levels of depression and change in depression severity over time. The objective data is extracted from several sources, such as patient self report, information obtained during interview, and collateral information from the ward staff. The scaling happens by rating the patient's verbal report, depressed behaviour, and primarily somatic secondary symptoms of depression. Allegedly, this scale lacks specificity, but with HDRS, the yield is quite trustworthy (Raskin A, Schulterbrandt J, Reatig N, McKeon JJ., 1969). When conducting an assessment of a client with depression, it is important to maintain eye contact, to display empathic listening, and to communicate interest and concern in an unhurried manner. It is also required to focus the assessment on the client's general description or appearance; ability to communicate; mood, affect, and feelings; and behaviour. Many formal screening tools or assessment scales are available to determine the presence of mood disorder. Little evidence exists to recommend one screening method over another. Therefore, choose the method that best fits personal preference, the client population served, and the practice setting. Regardless of whether a tool, scale, or the two recommended questions are used, when completed, it is important to validate impressions with the client to avoid an incorrect interpretation of data and to allow the client time to provide any additional information that he or she deems important. Input by family members or significant others may be necessary to complete the assessment process and to determine an appropriate nursing diagnosis. The assessment occurred in two phases. In the first phase, general questions were guided after establishing a therapeutic relationship with the patient. These questions assessed presence or absence of depressive symptoms over a 2-week period that could have represented a change in previous functions that had impaired social or occupational functioning. The patient was also assessed whether she had five or more of the following symptoms occurred nearly everyday for most of the waking hours. These are depressed mood, anhedonia (inability to experience pleasure), significant weight loss or gain (more than 5% of body weight per month), insomnia or hypersomnia, increased or decreased motor activity, anergy (fatigue or loss of energy), feelings of worthlessness or inappropriate guilt (may be delusional), decreased concentration or indecisiveness, and recurrent thought of death or suicidal ideation (with or without plan) (Carpenito, L. J., 2002). The physical examination was conducted to assess posture and affect for poor or slumped posture, appearance of being older than stated age, facial expression of sadness, dejection, or episodes of weeping. Assessment also included anhedonia, inability to experience pleasure. The thought processes was assessed to identify the presence of suicidal thoughts, poor judgment, indecisiveness, impaired problem solving, poor concentration. The negative thoughts were assessed by exploring feelings for anger and irritability, anxiety, guilt, worthlessness, helplessness, and hopelessness. The physical behavior was assessed for psychomotor agitation or retardation or vegetative signs of depression. The patient wax observed for change in eating patterns, change in sleeping patterns, change in elimination patterns, change in level of interest in sex, and change in personal hygiene. Assessment for evidence of masked depression was done by assessing hypochondriasis, psychosomatic disorders. History was sought for compulsive gambling, compulsive overwork, accident proneness, eating disorders, addictive illnesses. At the end, assessment for risk of suicide was undertaken (Stuart, G.W., & Laraia, M.T., 2005). Laboratory studies were conducted to rule out other baseline illness that could have led to depression. The records revealed that the patient had Thyroid function tests and thyrotropin-releasing hormone stimulation test to detect underlying hypothyroidism, which may cause depression and DST to evaluate depression that may be responsive to antidepressant or electroconvulsive therapy (ECT). A Polysomnography was conducted to establish an increase in the overall amount of rapid-eye-movement (REM) sleep and shortened REM latency period. Additional diagnostic tests to evaluate physical conditions, such as CT scan or magnetic resonance imaging (MRI), complete blood count (CBC), chemistry panel, rapid plasma reagin (RPR), human immunodeficiency virus (HIV) test, EEG, vitamin B12 and folate levels, and toxicology studies were also conducted (O'Brien, J., & Barber, B., 2000). 3. Data analysis Cues Nursing diagnosis (ND) Validation HRSD 1, 13, 22, 23, 24 RDS I and II ND related to Hopelessness related to depressive thoughts 1. Shall assess apparent sadness representing despondency, gloom and despair (more than just ordinary transient low spirits), reflected in speech, facial expression, and posture. Rate by depth and inability to brighten up. 2. Assess reported sadness, representing reports of depressed mood, regardless of whether it is reflected in appearance or not. Includes low spirits, despondency or the feeling of being beyond help and without hope. 3. Cognitive theory describes how faulty thought patterns, including negative distortions of life experiences, produce negative self-evaluation, pessimistic thinking, and hopelessness. HRSD 4, 5, 6, 10, RDS III Disturbed Sleep Pattern related to insomnia 1. Dysfunction of circadian rhythms has been theorized to be related to depression. Abnormal sleep EEGs have been demonstrated in many individuals. Increased early morning awakening is common, as are multiple nighttime awakenings. 2. Shall assess inner tension indicated by feelings of ill-defined discomfort, edginess, inner turmoil, mental tension mounting to either panic, dread or anguish. Rate according to intensity, frequency, duration and the extent of reassurance called for. 3. Shall assess reduced sleep representing the experience of reduced duration or depth of sleep compared to the subject's own normal pattern when well. HRSD 3, 7, 9, 10, 17, 19, 24, 3 RDS I, II Risk for Injury related to hopelessness and impaired problem solving including suicide risk 1. Shall assess pessimistic thoughts representing thoughts of guilt, inferiority, self-reproach, sinfulness, remorse and ruin. 2. Shall assess suicidal thoughts representing the feeling that life is not worth living, that a natural death would be welcome, suicidal thoughts, and preparations for suicide. Suicide attempts should not in themselves influence the rating. 3. Kindling theory describes a process whereby external environmental stressors activate internal physiologic stress responses, which trigger the first depressive episode. Subsequent episodes can occur with less stress in response to the electrophysiologic sensitivity that was established in the brain from the initial episode. 4. Patients with major depression are at increased risk for suicide. Suicide risk should be assessed initially and throughout the course of treatment. Suicidal ideation includes thoughts that range from a belief that others would be better off if the person were dead or thoughts of death (passive suicidal ideation) to actual specific plans for committing suicide (active suicidal ideation). 5. If patient data lead to the diagnosis of Risk for Suicide, the patient should be further assessed for plan, intent, and accessibility of means (Angst, J., Angst, F., & Stassen, H. H., 1999). HSRD 13, 16, 11 RDS III Malnutrition due to decreased appetite and somatic psychic gastrointestinal symptoms 1. Assess reduced appetite representing the feeling of a loss of appetite compared with when-well. Rate by loss of desire for food or the need to force oneself to eat. 2. Assess inner tension representing feelings of ill-defined discomfort, edginess, inner turmoil, mental tension mounting to either panic, dread or anguish. Rate according to intensity, frequency, duration and the extent of reassurance called for. 3. Assess lassitude Representing difficulty in getting started or slowness in initiating and performing everyday activities. 4. Learned helplessness theory posits that a person who internalizes the belief that an unwanted event is his own fault and that nothing can be done to avoid or change it is prone to developing depression. Appendix 1 and 2 Hamilton Rating Scale for Depression For each item select the "cue" which best characterizes the patient. 1: Depressed mood (Sadness, hopeless, helpless, worthless) 0 Absent 1 These feeling states indicated only on questioning (1) 2 These feeling states spontaneously reported verbally 3 Communicates feeling states nonverbally i.e., through facial expression, posture, voice, and tendency to weep 4 Patient reports VIRTUALLY ONLY these feeling states in his spontaneous verbal and nonverbal communication 2: Feelings of guilt 0 Absent 1 Self-reproach, feels he has let people down (1) 2 Ideas of guilt or rumination over past errors or sinful deeds 3 Present illness is a punishment. Delusions of guilt 4 Hears accusatory or denunciatory voices and/or experiences threatening visual hallucinations 3: Suicide 0 Absent 1 Feels life is not worth living 2 Wishes he were dead or any thoughts of possible death to self 3 Suicide ideas or gesture 4 Attempts at suicide (any serious attempt rates 4) (4) 4: Insomnia early 0 No difficulty falling asleep 1 Complains of occasional difficulty falling asleep i.e., more than hour 2 Complains of nightly difficulty falling asleep (2) 5: Insomnia middle 0 No difficulty 1 Patient complains of being restless and disturbed during the night (1) 2 Waking during the night (any getting out of bed rates 2) (except for purpose of voiding) 6: Insomnia late 0 No difficulty 1 Waking in early hours of the morning but goes back to sleep (1) 2 Unable to fall asleep again if gets out of bed 7: Work and activities 0 No difficulty 1 Thoughts and feelings of incapacity, fatigue, or weakness related to activities, work, or hobbies 2 Loss of interest in activity, hobbies, or work (either directly reported by patient), or indirect in listlessness, indecision, and vacillation (feels he has to push self to work or activities) 3 Decrease in actual time spent in activities or decrease in productivity. In hospital, rate 3 if patient does not spend at least three hours a day in activities (hospital job or hobbies) exclusive of ward chores 4 Stopped working because of present illness. In hospital, rate 4 if patient engages in no activities except ward chores, or if patient fails to perform ward chores unassisted (4) 8: Retardation (Slowness of thought and speech; impaired ability to concentrate; decreased motor activity) 0 Normal speech and thought 2 Slight retardation at interview (2) 3 Obvious retardation at interview 4 Interview difficult 5 Complete stupor 9: Agitation 0 None 1 Playing with hands, hair, etc. (1) 2 Hand-wringing, nail biting, hair pulling, biting of lips 10: Anxiety psychic 0 No difficulty 1 Subjective tension and irritability (1) 2 Worrying about minor matters 3 Apprehensive attitude apparent in face or speech 4 Fears expressed without questioning 11: Anxiety somatic 0 Absent Physiological concomitants of anxiety, such as: 1 Mild 2 Moderate Gastrointestinal (dry mouth, wind, indigestion, diarrhea, cramps, belching) (2) 3 Severe 4 Incapacitating Cardiovascular (palpitations, headaches) Respiratory (hyperventilation, sighing) Urinary frequency Sweating 12: Somatic symptoms gastrointestinal 0 None 1 Loss of appetite but eating without staff encouragement. Heavy feelings in abdomen 2 Difficulty eating without staff urging; requests or requires laxatives or medication for bowels or medication for G.I. symptoms (2) 13: Somatic symptoms general 0 None 1 Heaviness in limbs, back or head. Backaches, headache, muscle aches. Loss of energy and fatigability (1) 2 Any clear-cut symptom rates 2 14: Genital symptoms 0 Absent Symptoms such as: 1 Mild Loss of libido 2 Severe Menstrual disturbances 15: Hypochondriasis 0 Not present (0) 1 Self-absorption (bodily) 2 Preoccupation with health 3 Frequent complaints, requests for help, etc. 4 Hypochondriacal delusions 16: Loss of weight A: When rating by history 0 No weight loss 1 Probable weight loss associated with present illness (1) 2 Definite (according to patient) weight loss B: On weekly ratings by ward psychiatrist, when actual weight changes are measured 0 Less than 1 Ib weight loss in week 1 Greater than 1 Ib weight loss in week (1) 2 Greater than 2 Ib weight loss in week 17: Insight 0 Acknowledges being depressed and ill 1 Acknowledges illness but attributes cause to bad food, climate, overwork, virus, need for rest, etc. 2 Denies being ill at all (2) 18: Diurnal variation AM PM 0 0 Absent If symptoms are worse in the morning or evening, note which it is and rate severity of variation 1 1 Mild 1 PM 2 2 Severe 19: Depersonalization and derealization 0 Absent 1 Mild Such as: 2 Moderate Feeling of unreality(2) 3 Severe Nihilistic ideas 4 Incapacitating 20: Paranoid symptoms 0 None (0) 1 Suspiciousness 2 3 Ideas of reference 4 Delusions of reference and persecution 21: Obsessional and compulsive symptoms 0 Absent (0) 1 Mild 2 Severe 22: Helplessness 0 Not present 1 Subjective feelings which are elicited only by inquiry (1) 2 Patient volunteers his helpless feelings 3 Requires urging, guidance, and reassurance to accomplish ward chores or personal hygiene 4 Requires physical assistance for dress, grooming, eating, bedside tasks, or personal hygiene 23: Hopelessness 0 Not present 1 Intermittently doubts that things will improve but can be reassured 2 Consistently feels hopeless but accepts reassurances 3 Expresses feelings of discouragement, despair, pessimism about future, which cannot be dispelled (3) 4 Spontaneously and inappropriately perseverates: I'll never get well or its equivalent 24: Worthlessness (Ranges from mild loss of esteem, feelings of inferiority, self-deprecation to delusional notions of worthlessness) 0 Not present 1 Indicates feelings of worthlessness (loss of self-esteem) only on questioning 2 Spontaneously indicates feelings of worthlessness (loss of self-esteem) 3 Different from 2 by degree. Patient volunteers that he is no good, inferior etc. (3) 4 Delusional notions of worthlessness i.e., I am a heap of garbage or its equivalent Hamilton M. (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56 Raskin Depression Scale Rate each of the following according to the degree of severity below: 1 = Not at all 2 = Somewhat 3 = Moderately 4 = Considerably 5 = Very much 1. 3 Verbal report: Feels blue, talks of feeling helpless or worthless, complains of loss of interest, may wish to be dead, reports of crying spells. II. 4 Behavior: Looks sad, cries easily, speaks in a sad voice, psychomotor retardation, lacking energy III. 3 Secondary symptoms of depression: insomnia/hypersomnia, dry mouth, GI complaints, suicide attempt recently, change in appetite, cognitive problems Raskin A, Schulterbrandt J, Reatig N, McKeon JJ., (1969) J Nerv Ment Dis 1969; 148(1):87-98. Reference List Angst, J., Angst, F., & Stassen, H. H. (1999). Suicide risk in patients with major depressive disorder. Journal of Clinical Psychiatry, 60(Suppl. 2), 57-62. Carpenito, L. J. (2002). Handbook of nursing diagnosis (9th ed.). Philadelphia: Lippincott Williams & Wilkins. Cooper JE., (2003). Measuring psychopathology. Psychol Med. 2003;33:749-750 Hamilton M. (1960) A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56 O'Brien, J., & Barber, B. (2000). Neuroimaging in dementia and depression. Advances in Psychiatric Treatment, (6), 109-119. Raskin A, Schulterbrandt J, Reatig N, McKeon JJ., (1969) J Nerv Ment Dis 1969; 148(1):87-98. Stuart, G.W., & Laraia, M.T. (2005). Principles and practice of psychiatric nursing (7th ed.). St. Louis: Mosby. Read More