MAJOR

DEPRESSIVE
DISORDER
BSN III-3 GROUP A-2
DEMOGRAPHIC
PROFILE
NAME: H.B
AGE: A 75 year old
GENDER: White male
EDUCATION: High school graduate
OCCUPATION: Retired; 25-year career as
a baker
RELIGION: ROMAN CATHOLIC
 Chief Complaints
“I don’t know how much longer I can go on like
this. I’ve been down in the dumps for years
and it isn’t getting any better. I’ve lost
everyone who has ever meant anything to me.
I’ve disappointed my son to the point that he’ll
never forgive me. I’ve asked God to help me
through this, but it seems that He isn’t
listening. Now my wife is telling me that I
have Alzheimer’s. Nothing is fun and I don’t
believe that life is worth living anymore.”
 FAMILY HISTORY

• Father, died from colon cancer at age 67

• Mother, died from influenza epidemic at age 24
(when patient was 2 years old)
• No known family history of depression or other
mental illness
• No biological siblings; one half-brother
PSYCHIAT
RIC
HISTORY
 HISTORY OF PRESENT
ILLNESS
 The patient is 75 y/o white male, he lost his first wife to a stroke 19 years
ago after 27 years of a “wonderful marriage”. Patient presents to the
clinic with compliant of “I don’t know how much longer I can go on like
this. I’ve been down in the dumps for years and it isn’t getting any better.
I’ve lost everyone who has ever meant anything to me. I’ve disappointed
my son to the point that he’ll never forgive me. I’ve asked God to help me
through this, but it seems that He isn’t listening. Now my wife is telling me
that I have Alzheimer’s. Nothing is fun and I don’t believe that life is worth
living anymore.” As verbalized by the patient.
 PAST MEDICAL
HISTORY
 The patient had all of the usual childhood illnesses, but has
no current non-psychiatric adult illnesses and takes no
medications.
 At age 54, he was diagnosed by neurologists with a rare eye
disorder characterized by poor peripheral vision.
 He sustained temporary deafness for six months due to the
noise of the bombings. He has had no other incidents of
trauma during his lifetime.
 PAST MEDICAL
HISTORY
 He has never been treated for any psychiatric illnesses,
although he reports a 15-year history of many periods of
intense sadness, loneliness, and guilt that have lasted
weeks to months.
 He has not had any surgeries performed and there has
been no significant travel history. The patient has no dietary
restrictions and, although he has no strict exercise
program,
 he walks every day to maintain a healthy weight. His last
tetanus booster was six years ago.
 
 MENTAL
STATUS
EXAMINATI
ON
A. Observational component  
Attitude The patient looked so down and lonely.
Appearance The patient appears tired but in no apparent
distress. His face and arms are well tanned.
His weight seems to be healthy. He has male
pattern baldness and wears bifocals.
Hygiene and grooming His hair is cut short and he is clean-shaven
and appropriately dressed
Affect Really Down.
Speech Speech is appropriately paced and content is
normal.
Thought process (logical and linear) Circumferential: patient goes through multiple
related thoughts before arriving at the answer
to a question
Insight The patient understands that he has mental
illness.
B. Direct Inquiry component  
Mood (patient's description and rating 1–10; 10 = best) Body movements/making contact with others, facial
expressions (tearfulness, sad, frowns)

Rate: 8
Hallucinations No hallucinations
Delusions No Delusions
Suicidal and violent ideation Suicidal thoughts are a major concern. The patient has a 22-
caliber rifle in the home and has considered using it to end
his life.
Cognitive exam:  

1. Orientation - The patient recognize his place in time and space

2. Register and recall (three words) - Able to recall and register the words.

3. Attention and concentration (WORLD backwards) - Attention and concentration were all good.

4. Abstraction (proverb) - Abstraction is good.

5. Current events - He knows the current events.

6. Judgment (stamped envelope) - Client shows some insight and judgment regarding her
illness and need for help.
DIAGNOSIS
 Medical Diagnosis
• Depression

Nursing Diagnosis
•Hopelessness related to losses and burdensome symptoms of
depression as evidenced by inability to establish goals, loss of
interest in life and negative ruminations

•Grieving related to anticipated loss and persistent feelings of

loneliness as evidenced by giving meaning of the loss and periods of
intense sadness
ANATOMY AND
PHYSIOLOGY
OF THE BRAIN
The 3 meningeal layers: dura mater (outer), arachnoid mater (middle),
and pia mater (inner) wherein this layers enclosed or cover the brain
within the bones of the cranium
The cerebrum where in it is divided into right and left
hemispheres connected by the corpus callosum. Each cerebral
hemisphere contains frontal, temporal, parietal, occipital, and
limbic lobes.
The cerebellum also is divided into right and left hemispheres,
which are connected by the vermis. Involved in the coordination of
muscle movements and maintenance of equilibrium and
proprioception.
The basal ganglia are masses of nuclei located deep in the cerebral
hemispheres that are responsible for the control of fine motor
movements, including those of the hands & lower extremities & help
regulates muscle tone
Cerebrospinal fluid (CSF) circulates in the subarachnoid space,
manufactured in the choroid plexus of the ventricular system, and
transports nutrients in the brain
The ventricular structure includes the lateral, third, and
fourth ventricles; aqueduct of Sylvius; and the foramen of
Luschka and Magendie.
Neurons are also called the information messengers. They use
electrical impulses and chemical signals to transmit information
between different areas of the brain, and between the brain and the
rest of the nervous system. 1billion neurons
Neurotransmitters are chemical messengers in the body. Their
job is to transmit signals from nerve cells to target cells. These
target cells may be in muscles, glands, or other nerves
THE SPECIFIC NEURONS THAT ARE AFFECTED IN DEPRESSION
ARE:
SEROTONIN – obsessions and compulsions
NOREPINEPHRINE – anxiety and attention
DOPAMINE – pleasure, motivation and attention
 S I
HY
O P
T H G Y
A
P OL O
CAUSES

*Unknown*

Combination of:
1. Genetics
2. Biology
3. Environment
4. Psychology
Nuerotransmitte
rs
Nuerotransmitte
rs
 Nuerotransmitte
rs

Serotoni Norepinephri
Dopamine
n ne
 Monoamine Deficiency
Theory

Serotoni Norepinephri
Dopamine
n ne
 Monoamine Deficiency
Theory

Serotoni Norepinephri
Dopamine
n
Obsessions ne Attention,
Anxiety
and Motivation
and
Compulsio , and
Attention
ns Pleasure
Monoamine Deficiency
Theory

Serotoni
n

Norepinephri
Dopamine
ne
 Monoamine Deficiency
Theory

Symptoms of
Depression

Tryptophan Serotonin
PSYCHOPHARMAC
OLOGY
FLUOXETINE 20 mg po qd
(Prozac)

-produces a slightly higher rate of mild agitation and

weight loss but less somnolence.

Side Effects

Headache, nervousness, anxiety, sedation, tremor, sexual dysfunction, anorexia, constipation,

nausea, diarrhea, and weight loss

Nursing Implications

 Administer in AM (if nervous) or PM (if drowsy).

 Monitor for hyponatremia.
 Encourage adequate fluids.
Report sexual difficulties to physician
PSYC
HO
THER
APY
1. Cognitive Therapy
2. Behavioral Therapy
3. Cognitive-Behavioral
Therapy
4. Dialect Behavior Therapy
5. Psychodynamic Therapy
6. Interpersonal Therapy
 NURSING
CARE PLAN
 Assessment
Subjective:

“I don’t know how much longer I can go on like this. I’ve been down in the dumps for years and it isn’t

getting any better. Now my wife is telling me that I have Alzheimer’s. Nothing is fun and I don’t believe that

life is worth living anymore.” As verbalized by the patient.  V/S

BP:120/80
PR: 83bpm
Objective:
RR: 16bpm
- Emotional distress BT:
- Feeling of sadness and hopelessness
- Appears tired and lack of energy
Nursing Diagnosis
Hopelessness related to losses and burdensome symptoms
of depression as evidenced by inability to establish goals,
loss of interest in life and negative ruminations
 
Mood behavior
 
Neuroadaptations in stress and reward circuits in the brain

Neutrophic disturbance

Psychomotor agitation

High level of suffering and functional impairment

Restructing for repetitive negative imagery

Hopelessness related to losses and burdensome symptoms

of depression
 Planning
Short Term Goal:
-After 3 days of Nursing intervention the patient will express his feelings,
verbalized a sense of improvement toward resolution of hope and
acceptance of life events over which he has no control.
Long Term Goal:
-After one week of Nursing intervention, the patient will demonstrate
independent problem-solving techniques to take control over life,
communicate well to discuss with those irrational thought about self and life
circumstances and does not verbalized or demonstrate suicidality.
 Nursing Interventions
Independent:
 Assessment
- Assess individual signs of hopelessness.
 Therapeutic
- Allow the patient to express feelings and perceptions
- Assist the patient determine aspect of life that are under his control.
- Aid the patient determine aspects of life events that are not within his ability
to control. Discuss feelings related with this lack of control.
 Educative
- Educate the patient about crisis intervention services such as suicide hotlines
and other resources.
Dependent:
 Assessment
- Assess the client’s previous level of cognitive functioning (from client,
family, past medical records).
 Therapeutic
- Administer antidepressants as indicated.
 Educative
- Instruct patient if there is side effects or adverse effects to the drug.
Interdependent/
Collaborative
 
 Assessment
- Assess what spiritual practices have offered comfort and
meaning to the client’s life when not ill.
 Therapeutic
- Cognitive behavioral therapy (CBT)
 Educative
- Educate patient about depression and emphasize that there
are effective methods available for relief of symptoms.
 Evaluation
Short Term Goal:
-After 3 days of Nursing intervention the patient expressed his feelings and
verbalized a sense of improvement toward resolution of hope and
acceptance of life events over which he has no control.
Long Term Goal:
-After one week of Nursing intervention, the patient demonstrated
independent problem-solving techniques to take control over life. He
communicated well in discussing with irrational thought about his self and
life circumstances and did not verbalized or demonstrate suicidality.
Assessment
Subjective:
 
“I don’t know how much longer I can go on like this and it isn’t getting any better. I’ve lost
everyone who has ever meant anything to me. I feel very much alone, and extremely sad “as
verbalized by the patient.
 
 
Objective:
 Restlessness
 Unusually tired and lack of energy   V/S
 Emotional distress BP:120/80
 Impaired Concentration PR: 83bpm
 Trouble falling asleep RR: bpm
BT:
• Recurring thoughts of death or suicide
 Nursing Diagnosis

-Grieving related to anticipated loss and persistent feelings of

loneliness as evidenced by giving meaning of the loss and
periods of intense sadness
Inference
Persisntent and intensefeelings of sadness

Neuroadaptations in stress and reward circuits in the brain

Neutrophic disturbance

Psychomotor agitation
 
 
High level of suffering and functional impairment

Restructing for repetitive negative imagery

Grieving related to anticipated loss

 Planning
(Short Term Goal Evaluation)
-After 4 days of nursing intervention the patient will verbalize a sense of
improvement toward resolution of hope and grief in the subsequent time and
demonstrate independent problem-solving techniques to take control over life, and
does not verbalize or demonstrate suicidality.
 
(Long Term Goal Evaluation)
-After 1 week of nursing intervention the patient will be able to express feelings
and acceptance of life events over which he has no control and reframe positive
behavior in life circumstances that leads to being optimistic one
 Nursing Interventions
Independent

- Ask the patient about the losses that happen in his or her life. Discuss
how the patient view them
Therapeutic
- Help the client identify negative thinking/thoughts. Teach the client to
reframe and/or refute negative thoughts.
- Assume active role in initiating communication. 
Educative
- Educate patient about depression and emphasize that there are
effective methods available for relief of symptoms.
Dependent

Assessment
- Assess the phase of grieving being experienced by the patient and significant
others
Therapeutic
- Administer antidepressants as indicated
- Allow the patient to express feelings and perceptions
Educative
- Discuss and educate patient the normal stages of grief and accept the reality of
related feelings such as guilt, anger, and powerlessness.
- Teach/ encourage client to write a journal expressing thoughts and reflections
daily.
Interdependent/Collaborative

Assessment
- Assess what spiritual practices have offered comfort and meaning to the
client’s life when not ill
Therapeutic
- Express hope to the patient with realistic comments about the patient’s
strengths and resources.
- Keep a regular sleep/wake time
- Counseling including cognitive-behavioral therapy (CBT)
Educative
- Acknowledge the patient’s need to review the loss experience.
 Evaluation
(Short Term Goal Evaluation)
-After 4 days of nursing intervention the patient, verbalized a sense of
improvement toward resolution of hope and grief in the subsequent time and
demonstrate independent problem-solving techniques to take control over life, and
did not verbalized or demonstrate suicidality.
 
(Long Term Goal Evaluation)
-After 1 week of nursing intervention the patient expressed feelings and
acceptance of life events over which he has no control and reframe positive
behavior in life circumstances that led to being optimistic one
 THANK YOU
FOR
LISTENING! :D